Centre for Population Health SciencesUniversity of Edinburgh

A systematic review of the effectiveness of policies and interventions to reduce socio-economic inequalities in smoking among adults.Final Report May 2013

Amanda AmosTamara BrownStephen Platt

SILNE - Tackling socio-economic inequalities in smoking: learning from natural experiments by time trend analyses and cross-national comparisons

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Project team

Amanda Amos, Professor of Health Promotion

Tamara Brown, Research Fellow

Stephen Platt, Professor of Health Policy Research

Centre for Population Health Sciences

School of Molecular, Genetic and Population Health Sciences

The University of Edinburgh

Medical School

Teviot Place

Edinburgh

Scotland

EH8 9AG

Phone: (+44)-(0)131-650-3237

Fax: (+44)-(0)131-650-6909

Acknowledgements

The project team would like to thank members of the SILNE project and members of the European

Network for Smoking and Tobacco Prevention (ENSP) who helped in the search for grey literature.

In particular we would like to thank Gera Nagelhout, researcher at STIVORO and Maastricht

University (CAPHRI), the Netherlands for identifying four Dutch reports on mass media campaigns

and kindly providing synopses in English.

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Table of Contents

EXECUTIVE SUMMARY.............................................................................................................. 5

1 INTRODUCTION................................................................................................................... 10

1.1 Background...................................................................................................................................... 10

1.2 Aims and objectives.......................................................................................................................... 12

2 METHODS............................................................................................................................... 12

2.1 Search strategy................................................................................................................................. 12

2.2 Study selection................................................................................................................................. 13Study selection process.................................................................................................................................13Inclusion criteria............................................................................................................................................14Data extraction..............................................................................................................................................16Quality assessment........................................................................................................................................16Data synthesis...............................................................................................................................................16

3 RESULTS................................................................................................................................. 18

3.1 Introduction..................................................................................................................................... 18

3.2 Smoking restrictions in workplaces, enclosed public places, cars and homes.....................................213.2.1 Smoking restrictions in workplaces.................................................................................................243.2.2 Smoking restrictions in enclosed public places...............................................................................333.2.3 Smoking restrictions in cars.............................................................................................................54

3.3 Increases in price/tax of tobacco products........................................................................................64

3.4 Controls on advertising, promotion and marketing of tobacco..........................................................85

3.5 Mass media campaigns..................................................................................................................... 943.5.1 Mass media cessation campaigns...................................................................................................973.5.2 Mass media campaigns to promote calls to Quitlines and use of NRT..........................................119

3.6 Multiple policies............................................................................................................................. 131

3.7 Settings based interventions........................................................................................................... 1363.7.1 Community....................................................................................................................................1373.7.2 Workplace.....................................................................................................................................1413.7.3 Hospitals........................................................................................................................................143

3.8 Population-level cessation support interventions............................................................................1463.8.1 National Quitlines..........................................................................................................................1463.8.2 UK NHS Smoking Cessation Services.............................................................................................1463.8.3 New Zealand General Practice Smoking Cessation Services..........................................................152

4 DISCUSSION........................................................................................................................ 154

4.1 Future research............................................................................................................................... 165

5 CONCLUSIONS.................................................................................................................... 166

6 REFERENCES....................................................................................................................... 168

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7 APPENDICES....................................................................................................................... 177

7.1 Appendix A Search strategies: electronic searches, handsearching and searching for grey literature 177

7.2 Appendix B WHO European countries and other stage 4 countries..................................................189

7.3 Appendix C Inclusion/exclusion form..............................................................................................190

7.4 Appendix D Included studies...........................................................................................................192

7.5 Appendix E Excluded studies........................................................................................................... 203

7.6 Appendix F Data extraction.............................................................................................................207

7.7 Appendix G Quality assessment......................................................................................................426

7.8 Appendix H Equity Impact...............................................................................................................433

7.9 Appendix I Summary of Equity Impact.............................................................................................480

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EXECUTIVE SUMMARY Smoking is the single most important preventable cause of premature mortality in

Europe and a major cause of inequalities in health. Adult smoking prevalence in the

EU is declining but the social gradient in smoking is not. Reducing inequalities in

smoking is therefore a key public health priority.

Some progress has been made in tobacco control in many EU countries in recent

years. However, there is considerable variation in the strength and

comprehensiveness of tobacco control policies and their implementation.

While there is good evidence on which tobacco control policies are effective in

reducing adult smoking, little is known about what is effective in reducing

inequalities in smoking.

The aim of this report was to undertake a systematic review of the effectiveness of

population-level policies and interventions to reduce socioeconomic inequalities in

smoking in adults.

The systematic review included primary studies involving adults (aged 18 years and

older), published between January 1995 and January 2013, which assessed the impact

of population-level policies and interventions by socioeconomic status (SES).

The search strategy included searches of 10 electronic databases, papers ‘in press’ in

four key journals, and contacting tobacco control experts for grey literature.

Any type of tobacco control or other policy intervention, of any length of follow-up,

with at least one smoking-related outcome was included, such as quit attempts,

intentions to quit, exposure to second-hand smoke (SHS) and social norms/attitudes,

was included.

All primary studies based in a WHO Europe country or non-European countries at

stage 4 of the tobacco epidemic were eligible. SES variables included education,

income and occupation.

A quality assessment tool was adapted to enable appraisal of the diverse range of

intervention types and study designs encompassed in the included studies. The results

are presented in the form of a narrative synthesis and according to intervention type.

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

assessed as either being: positive (reduced inequality), neutral (no difference by

SES), negative (increased inequality), mixed (equity impact varied by SES measure

and/or gender, setting, country and/or outcome measure) or unclear (not possible to

assess the equity impact).

One hundred and sixteen studies were included which evaluated 129

interventions/policies. Electronic searches produced 93 studies and 23 studies were

identified through hand-searching, grey literature, key reviews and contacting

experts.

There was considerable variation in study design and quality. More than half the

studies were carried out in the USA. Eighteen studies were carried out in the UK,

mostly assessing the impact of smokefree legislation and NHS smoking cessation

services, and eight in the Netherlands. This limited geographical coverage raises

concerns about the generalisability and potential transferability to, or relevance for,

countries in Europe with different social and cultural contexts and/or levels of

tobacco control.

The types of interventions/policies included were: smoking restrictions in cars,

homes, workplaces and other public places (44 studies); increases in the price/tax of

tobacco products (27); controls on advertising, promotion and marketing of tobacco

(9); mass media campaigns including promoting the use of quitlines and NRT (30);

multiple policy interventions (4); settings-based interventions including community,

workplace and hospital (7); and population-level cessation support interventions (8).

Eight studies included more than one type of policy/intervention.

Only one relevant study of non-tobacco control interventions and polices (e.g.

education, employment, social policy) was identified.

The equity impacts of the 129 included interventions/policies were: 33 positive, 35

neutral, 38 negative, 6 mixed and 17 unclear.

Twenty-six of the 29 neutral equity impact studies showed similar beneficial impacts

across SES groups. Three studies, all community-based, found no significant

intervention effect for any SES group.

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Some trends in equity effect by type of intervention/policy emerged. Over half of the

studies of increases in the price/tax of cigarettes were associated with a positive

equity impact. More than half the smokefree policy/legislation studies (these included

voluntary and partial smokefree policies) were associated with a negative equity

impact, making up the bulk of the negative studies. There were no negative studies

for controls on advertising, marketing and promotion of tobacco products. Four of the

six studies of UK NHS cessation services had a positive equity impact. There was no

clear trend for the equity impact of mass media campaign studies.

Smokefree policies and legislation (44 studies) - The evidence suggests that partial,

voluntary or regional adoption of smokefree policies can increase socioeconomic

inequalities in protection from secondhand smoke (SHS) exposure. The recent

increase in smokefree policies in bars, restaurants and workplaces in Australia,

Canada, UK and USA has had a positive equity impact, reducing inequalities in

policy coverage by SES, with low SES worksites and public places catching up in

adopting total smokefree policies.

National comprehensive smokefree legislation reduces SHS exposure, increases quit

attempts and has positive population health effects. By definition such policies have a

positive equity impact in removing inequalities in policy coverage. However, only

two of the 22 studies that evaluated national smokefree legislation demonstrated an

overall positive equity impact using other outcome measures. The national smokefree

legislation in Scotland, Wales and Northern Ireland did not displace smoking into the

home. Although smoking restrictions in the car and home increased following this

legislation, there was no change in smoking-related inequality. SES differences

remained, with a greater proportion of lower SES adults smoking in the car/home.

Price and tax increases (27 studies) - The majority of studies on price/tax increases

on cigarettes were associated with a positive equity impact and had the most

consistent of all the policy results. Overall, lower SES adults appear more responsive

to price/tax increases in terms of larger price elasticities compared with higher SES

adults in respect of reducing prevalence and/or consumption. Most of the

econometric studies did not measure longer-term effects on quitting, cross-border

sales or smokers’ price reducing strategies which may differ by SES.

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Controls on advertising, marketing and promotion (9 studies) - Most of the studies

were on health warnings and found that they had neutral (3) or positive (2) equity

effects. Only three studies looked at restrictions on marketing and were associated

with neutral equity impacts.

Mass media cessation campaigns (18 studies) - There was no consistent equity

impact for these studies, but only three studies had an overall positive equity impact.

A Dutch multimedia campaign targeted at smokers with an intention to quit smoking

and with a focus on lower educated smokers, was associated with a positive equity

impact for campaign awareness. A tobacco control paid media campaign in the US

was associated with a more rapid decline in smoking prevalence among low SES

women. The EX mass media campaign (TV element) increased cessation-related

cognitions only among those with less than a high-school education and increased

quit attempts only among those with less than a high-school education.

Different types of media messages appeared to have differential impacts by SES,

with some limited evidence that emotionally evocative, testimonial and graphic

messages were more likely to be equity positive. The media format of the campaign

and the mechanisms of engagement also varied by SES.

Mass media quitline and NRT campaigns (12 studies) - all the studies found increases

in calls to quitlines. However, the equity impact was inconsistent, though three of the

five positive equity impact studies promoted free NRT.

Multiple policies (4 studies) - The evidence suggests that different elements of

multiple policies may impact differentially by SES. For example, people with lower

incomes were more affected by cigarette tax increases, whereas people with higher

incomes may have been more affected by voluntary smokefree policies. The evidence

also suggests that, within and across different SES groups, the impact of multiple

tobacco control policies can vary by age, gender and the type of smoking-related

outcome.

Settings-based interventions (7 studies) - the types of interventions included were

very variable in approach and had inconsistent equity impacts. The only intervention

in the review to address wider social determinants of inequality (community

approach) had no impact on quitting rates.

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Comprehensive smoking cessation services (8 studies) – Four of the six UK NHS

smoking cessation services studies had a positive equity impact. These studies found

that the relatively higher reach of services among low SES smokers more than

compensated for the relatively lower quit rates in low SES smokers. The UK

smoking cessation service is unique in Europe in the extent of its population

coverage. However, these findings may be relevant to increasing the positive equity

impact of cessation support in other European countries. A study of a General

Practitioner delivered smoking cessation service in New Zealand was effective in

reducing smoking prevalence, but there was no evidence of a significant impact on

area-based inequalities (neutral equity impact). The only quitline study produced an

unclear equity impact.

While 116 studies were identified, only limited conclusions can be drawn about

which types of tobacco control interventions are likely to reduce inequalities in

smoking. The clearest and most consistent evidence of a positive equity impact was

for price/tax increases.

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1 INTRODUCTION1.1 BackgroundSmoking prevalence rates differ substantially within European countries according to

people’s educational level, occupational class and income level; and smoking is a major

cause of socioeconomic inequalities in mortality in the European Union (EU). The patterning

of smoking by socioeconomic status (SES) within a country reflects the stage of the tobacco

epidemic in that country. In general smoking is initially taken up by higher SES groups,

followed by lower SES groups. Higher SES groups are then the first to show declines in

smoking, followed by lower SES groups.1 The tobacco epidemic is also gendered in that men

first take up smoking, followed by women.2 Most countries in the EU are characterised as

being in the fourth (last) stage of the epidemic. In these countries lower SES groups have

higher rates of smoking prevalence, higher levels of cigarette consumption and lower rates of

quitting.3;4 Some EU countries are at a slightly earlier stage. This is reflected in the

differential patterning of smoking by SES and gender, where the clear relationship between

low SES and smoking found in men is only starting to emerge in women.

Since the 1990s, many European countries have intensified tobacco control policies and

introduced measures such as legislation on smokefree public places, bans on tobacco

promotion and tax increases. There is good evidence on what is effective in reducing adult

smoking amongst the general population. A review of the international evidence by the

World Bank in 20035 identified six cost-effective policies which they concluded should be

prioritised in comprehensive tobacco control programmes:

price increases through higher taxes on cigarettes and other tobacco products including measures to combat smuggling

comprehensive smokefree public and work places better consumer information including mass media campaigns comprehensive bans on the advertising and promotion of all tobacco products, logos

and brand names large, direct health warnings on cigarette packs and other tobacco products treatment to help dependent smokers stop, including increased access to medications

These priorities have been endorsed by World Health Organisation (WHO)6 and form the

basis of the Framework Convention on Tobacco Control (FCTC), the first international

public health treaty.7

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What is much less certain is how ‘real world’ policies and interventions that reduce overall

smoking prevalence within the general population impact on socioeconomic inequalities in

smoking. Tackling these socioeconomic inequalities in smoking is central to reducing the

health inequalities gap and is the fundamental underpinning aim of the “SILNE” project,8

funded by the EU entitled: “Tackling socioeconomic inequalities in smoking: learning from

natural experiments by time trend analyses and cross-national comparisons”. The SILNE

project is a three-year European project co-ordinated by the University of Amsterdam,

Department of Public Health, Academic Medical Centre, the Netherlands, with financial

support from the European Commission Seventh Framework Programme; ‘Developing

methodologies to reduce inequities in the determinants of health’ programme (grant

agreement no. 278273). The SILNE project involves twelve European partners who will

deliver the seven work packages which make up the project. This systematic review is part

of Work Package 6 of the SILNE project.

Few reviews have addressed the equity impact of tobacco control measures; two key reviews

have previously been carried out on the equity impact of tobacco control interventions.9;10 In

2008 the Centre for Reviews and Dissemination (CRD) at the University of York, published

a systematic review of the equity impact of tobacco control on young people and adults,9

focussing on population-level interventions (not individual smoking cessation interventions)

published up to January 2006. In 2010 the Department of Health’s Policy Research

Programme, through the Public Health Research Consortium (PHRC), funded a study of

tobacco control and inequalities in health in England.10 This study included a review of the

evidence on the efficacy of interventions to reduce adult smoking amongst

socioeconomically deprived populations, which built on the CRD review and included

evidence published from January 2006 until November 2010. It included both population

level interventions and individual level cessation support interventions. The PHRC review

concluded that there was limited evidence to inform tobacco control policy and interventions

that are aimed at reducing socioeconomic inequalities in smoking behaviour.

While considerable progress has been made in tobacco control in many countries in the EU

in recent years, there is considerable variation in the strength and comprehensiveness of

tobacco control policies and their implementation.11 However, while overall smoking

prevalence is reducing; the social gradient is not. Addressing inequalities in smoking is a key

public health priority, starting with improving our understanding of the equity impact of

existing policies and interventions.

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1.2 Aims and objectivesThe overarching aims of Work Package 6 are to undertake a systematic review of the

effectiveness of policies and interventions to reduce socioeconomic inequalities in smoking

among youth and adults, and to assess the implications of this evidence for understanding the

effects of such policies and interventions in countries within the EU. This report focuses on

the findings of the systematic review of the effectiveness of population-level policies and

interventions to reduce socio-economic inequalities in smoking among adults. Population-

level control interventions have been defined as ‘those applied to populations, groups, areas,

jurisdictions or institutions with the aim of changing the social, physical, economic or

legislative environments to make them less conducive to smoking’12. The report’s objectives

are to identify and review the strengths and limitations of the published evidence on the

effectiveness of policies at the population level to reduce smoking amongst

socioeconomically deprived populations as compared to higher socioeconomic groups, and

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

a The 4 stages of the tobacco epidemic are described: Stage 1, characterized by low uptake of smoking and low cessation rates; Stage 2, characterized by increases in smoking rates among women and an increase to 50% or more among men; Stage 3, typified by a marked downturn in smoking prevalence among men, and a plateau and then gradual decline in women; and Stage 4, marked by further declines in smoking prevalence among men and women, with numbers of new smokers starting to decrease. Richmond, R. Addiction 2003;98 (5).

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2 METHODS2.1 Search strategy A comprehensive search strategy was developed to encompass studies published from

January 1995 to May 2012. The search included published papers identified through

searches of relevant electronic databases, and papers pending publication identified through

handsearching of key journals, and contacting key tobacco control experts. A database of

relevant references was produced using Reference Manager 12 software package and details

of the search strategies, including hand-searching and searching for grey literature, are in

Appendix A.

The following databases were searched:

BIOSIS

CINAHL Plus

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

EMBASE

ERIC

Conference Proceedings Citation Index

MEDLINE

PsycINFO

Science Citation Index Expanded

Social Science Citation Index

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This search was supplemented by hand-searching of four key journals from January 2012 to

the end of July 2012 to identify articles ‘in press’ published on the journals’ websites:

Addiction

Nicotine and Tobacco Research

Social Science and Medicine

Tobacco Control

Three key reviews were also searched for relevant primary studies: the York review,9 the

PHRC review,10 and a report by the US Surgeon General on Preventing Tobacco Use Among

Youth and Young Adults12 which was published during the production of this review.

Bibliographies of included studies were also searched for further relevant studies. Members

of SILNE and members of the ENSP were asked to identify any relevant studies not

identified by the extensive searching of the electronic databases and the handsearching.

Update search

The electronic search strategy was rerun in all the databases used in the initial search to

identify studies published between May 2012 and end of December/start of January 2013. In

February 2013, the same four key journals were hand-searched to identify articles published

on the journals’ websites but not yet listed in electronic databases. See appendix A for

details.

2.2 Study selection

Study selection process

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Articles retrieved from the searches were screened by title and abstract, to identify potentially

relevant studies. An initial screen of the first 200 references imported into Reference Manager

from MEDLINE were screened by title and abstract by two reviewers (AAb and TBc) to clarify

inclusion and exclusion criteria and establish consistency. The remaining references were screened

by title and abstract by one reviewer (TB) and checked by a second reviewer (AA). A second

screen of full text articles was then carried out by one reviewer (TB) and checked by a

second reviewer (AA). Any disagreements between reviewers were resolved by discussion at

each stage and, if necessary, a third reviewer (SPd) was consulted.

b AA=Amanda Amos, c TB=Tamara Brown, dSP=Stephen Platt

c

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Inclusion criteriaAll primary study designs based in a WHO European country or non-European country at

stage 4 of the tobacco epidemic were eligible for inclusion (see Appendix B for list of

included countries).

The inclusion ages for the youth review were 11-25 years and, for the adult review, 18+

years. Smoking uptake continues until around the age of 25 years which is why this cut-off

was chosen for the youth review. However, many adult focussed interventions target

smokers aged 18 years and older. Thus 18 years and older was used to categorise adult

interventions. In the rare cases where studies straddled both age categories, they were

included in both the youth and adult reviews.

In order to assess the equity impact of tobacco control measures in the general population,

we included both population-level policies and interventions, and individual-level

interventions which aimed to reduce adult smoking or to prevent youth starting to smoke.

Studies of population-level policies and interventions cover secondhand smoke (SHS)

exposure by SES, the strength or reach of policy coverage by SES, and the impact by SES of

the 'voluntary' adoption/spread/strength of smokefree policies, i.e., where countries do not

have comprehensive legislation.

In order to be included an article must have assessed the equity impact of a tobacco control

intervention or policy, and have presented results with a differentiation between high and

low socioeconomic groups. In other words, the review only included studies which reported

differential smoking-related outcomes for at least two socioeconomic groups.

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Any type of tobacco control policy/intervention or other type of policy (eg social,

education), of any length of follow-up, with any type of smoking-related outcome was

included. A broad range of smoking related outcomes, either self-reported or

observed/validated, was included: initiation and cessation rates, quit attempts, intentions to

smoke/quit, prevalence, exposure to SHS, policy reach, social norms/attitudes, use of

quitting services and sources of smoking (i.e. vending machines).

Socioeconomic variables included income, education, and occupational social class, area-

level socio-economic deprivation (including neighbourhood and school-level SES), housing

tenure, subjective social status and health insurance.

A measure of SES had to be reported in the abstract of the electronic references in order to

be included. Evidence identified through handsearching, searching of key reviews, or

contacting experts, could be included if a measure of SES was reported in the main body of

the text even if the abstract did not report that SES was assessed. If grey literature, such as

reports not published as journal articles, was identified by experts as assessing equity impact

then this evidence could be included even if the abstract did not report that SES was

assessed. In addition, such reports not written in English were included if an English

synopsis was provided (and otherwise met the inclusion criteria). Only studies published

since 1995 in full-text and in English language were included. No settings were excluded.

See Appendix C for inclusion/exclusion form.

The SILNE review excluded interventions targeted exclusively at one socioeconomic group

and also excluded studies which reported only socio-demographic data (without any

socioeconomic data). For example, ethnicity alone was not considered to be an appropriate

indicator of SES for this review as the smoking patterns associated with ethnicity differ from

one country to another. Interventions that focused solely on tobacco products other than

cigarettes (e.g. cigars, smokeless tobacco, waterpipes) or tobacco replacement products were

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

solely on outcomes for providers of a smoking cessation intervention were excluded unless

results were also reported for high versus low socioeconomic participant groups. Papers

reporting study protocol and design only without reporting the impact of the intervention or

policy were excluded.

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Data extractionData from the included studies were extracted by one reviewer (TB) and independently

checked by another reviewer (AA). Data relating to population characteristics, study design

and outcomes were extracted into data extraction forms. Data from studies presented in

multiple publications were extracted and reported as a single study with all other relevant

publications listed in the report. Data extraction from non-English reports (grey literature)

was limited because it was derived from an English synopsis provided by an expert;

therefore the synopsis is reported directly in the text (not in data extraction tables).

Quality assessmentAll included studies were assessed for methodological quality by one reviewer (TB) and

independently checked by another reviewer (SP). The exception to this was non-English

reports (grey literature); where any reference to quality was derived from an English

synopsis and reported directly in the text. Methodological quality was assessed by adapting

the method used in the York review.9 Each study was assessed on a scale of quality of

execution using the six item checklist of quality of execution adapted from the criteria

developed for the Effective Public Health Practice Project in Hamilton, Ontario.13 Certain

items of quality are not applicable to all study designs, for example, randomisation and

comparability are not applicable to cross-sectional study designs. We added a new criterion

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

generalisable at a national, regional, or local level.

Data synthesisGiven the variations in study methodologies, intervention types and outcome measures, the

results are presented in the form of a narrative synthesis and according to intervention type.

In order to provide a simple basis for comparing the methodology of each study a typology

of study designs was devised (Table 1).

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Table 1 Typology of study designsCode Study design

1.0 Population-based observational1.1 Cross-sectional 1.2 Repeat cross-sectional1.3 Cohort longitudinal 1.4 Econometric analyses (cross-sectional data)2.0 Intervention-based observational2.1 Single intervention (before and after, same participants)2.2 Single intervention with internal comparison2.3 Comparison between different types of intervention3.0 Intervention-based experimental3.1 Randomised controlled trial (individual or cluster)3.2 Non-randomised controlled trial3.3 Quasi-experimental trial4.0 Qualitative4.1 Cross-sectional4.2 Repeat cross-sectional4.3 Longitudinal

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The equity impact of each population-level intervention/policy is summarised by adapting a

model used in the York review14:

The null hypothesis that for any given socio-economic characteristic related to education, occupation or income, there is no social gradient in the effectiveness of the intervention i.e. a neutral equity impact.

The hypothesis of a positive equity impact defined as evidence that groups such as lower occupational groups, those with a lower level of educational attainment, the less affluent, those living in more deprived areas, are more responsive to the intervention.

The hypothesis of a negative equity impact defined as evidence that groups such as higher occupational groups, those with a higher level of educational attainment, the more affluent, or those who live in more affluent areas are more responsive to the intervention.

The main strengths and limitations of each study, particularly internal and external validity,

are considered when discussing the equity impact of each intervention. Particular attention is

given to the issue of generalisability: to what extent are results from interventions and

policies carried out in various countries transferable across Europe despite differences in

tobacco control policies, socioeconomic conditions, and other factors? We draw conclusions

about the strengths and weaknesses of the current evidence of the impact of tobacco control

and other policy interventions on reducing socioeconomic inequalities in smoking in youths

and adults (equity impact) and identify the most effective and promising interventions.

3 RESULTS3.1 IntroductionA total of 116 studies (from 119 papers) were included in the review of adult population-

level policies/interventions.

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The initial electronic search produced 12,605 references after duplicates were removed. Two

hundred and eighty-seven references were identified as potentially relevant to the reviews

and 286 references were successfully obtained as full-text journal articles. Of these 286 full-

text articles, 115 were included and 171 were excluded. See Figure 1 for flow chart of study

inclusion. Eighty-three (81 studies) of the 119 papers focused on adult population-level

interventions and were included in this adult review from the initial searching of the

electronic database. In addition twenty-four papers (23 studies) were identified through

hand-searching, searching of grey literature, key reviews and contacting experts. An update

of the electronic searches were carried out in 2013 which identified a further twelve relevant

studies published up until January 2013. Appendix D contains bibliographic details for all

the included adult population-level policies/interventions including details of source. The

details of studies that were excluded at the stage of screening of full-text articles (n=51) are

listed in Appendix E with reasons for exclusion.

The findings of these 116 included studies are presented by intervention type. A summary of

studies by design and type of policy/intervention are summarised in Table 2. Population-

level policies/interventions (which aimed to change social norms, smoking behaviour and/or

access to tobacco) included: smoking restrictions in cars, workplaces and other public places

including bars and restaurants; increases in price/tax of tobacco products; controls on

advertising, promotion and marketing of tobacco; mass media campaigns including

campaigns promoting the use of quitlines; multiple policy interventions; settings based

interventions; population-level cessation support interventions. Data extraction tables and

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

respectively. A table of the equity impact can be found in Appendix H and a summary of the

equity impact is in Appendix I.

Figure 1 Study selection flow chart

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**119 papers for 116 studies

22

Electronic search May 2012

Titles and abstracts screened

n = 12,605

excluded from title and abstract

n = 12,318

Full papers ordered n = 287

screenedn = 286

excluded (full-text) n = 171

includedn = 115

adult policy includedn = 83

update electronic search*n = 12

handsearch, reviews, expertsn = 24

total number adult policy studies

n = 116**

update electronic search January 2013

titles and abstractsn = 1309

update full papers screened

n = 44

update includedn = 12*

update excluded n = 32

Table 2 Summary of studies by intervention type*Intervention type Number

of studies

Smoking restrictions in workplaces, enclosed public places, cars and homes 44Increases in price/tax of tobacco products 27Controls on advertising, promotion and marketing of tobacco 9Mass media campaigns – cessation 18Mass media campaigns - quitlines and NRT 12Multiple policies 4Settings based interventions (community, workplace, hospitals) 7Population-level cessation support interventions 8* 8 studies were included in more than one intervention type

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3.2 Smoking restrictions in workplaces, enclosed public places, cars and homes.

Introduction

Studies assessing the socio-economic impact of smoking restrictions were split into three

categories. The first category (3.2.1) includes studies that looked at workplace specific

smoking restrictions and the impact on workers. The second category (3.2.2) includes studies

that looked at the impact of wider smoking restrictions in enclosed public places (including

workplaces) on the wider population (which might also have included workers). This second

category also includes studies which looked at the impact of smokefree policies on peoples

smoking restrictions and smoking behaviour in the home. The third category (3.2.3) includes

studies that looked at the impact of voluntary restrictions in cars. Smokefree vehicle laws

exist in some countries and support for such policies is increasing.

One study evaluated the socioeconomic impact of national smokefree policy15 and another

the adoption of local clean air ordinances16and both included separate results for workplace

settings and other public places. Therefore for these two studies the results for workplace

settings are included in the ‘smoking restrictions in workplaces’ section (3.2.1) and results

for non-workplace settings are included in the ‘smoking restrictions in workplaces’ section

(3.2.2).

Within the first two categories the studies have been split into two sub-sections:

(i) Adoption and coverage of smokefree workplace policies by SES - these are

correlational studies which cover countries, states or regions where smokefree

workplace policies were either voluntary or include several states or regions some

of which had voluntary and others which had compulsory smokefree workplace

policies

(ii) Impact of introducing smokefree policies by SES - these are intervention studies

which look at the impact of smokefree policies introduced at the national, local or

individual workplace level.

24

The studies within each sub-section were grouped according to a logic model of expected

outcomes associated with smoke-free legislation developed by Haw et al. which is based on

an evaluation strategy to assess the expected short-term, intermediate and long-term

outcomes of legislation on smoking in enclosed public places.17 The model (Figure 2)

includes eight key outcome areas; knowledge and attitudes, environmental tobacco smoke

(ETS)/SHS exposure, compliance, culture, smoking prevalence and tobacco consumption,

tobacco-related morbidity and mortality, economic impacts on the hospitality sector and

health inequalities.

25

Short-term Intermediate Long-term 0-2 mths > 2 –12 mths > 12 mths

Expected Outcomes

Implementation of smoke-free

legislation

Enforcement of smoke-free legislation

Increasing awareness 1 of health risks of ETS, change in attitudes towards ETS exposure

Reduction in exposure to ETS 2 Reduced ETS exposure

Increasing compliance with 3 smoke-free legislation

Sustained compliance with smoke-free legislation

Increasing support for 4 legislation and change in

smoking cultures

Reduction in smoking prevalence and tobacco consumption 5

Reduction in tobacco-related morbidity and mortality 6

Reduction in costs to health service of tobacco-related

illness

Variable economic impact on 7 hospitality sector

Reduction in 8 health inequalities

health inequalities

Sustained cultural change

Figure 2 Logic model for Smoke-free legislation

26

Logic Model of Expected Outcomes

Associated with Smoke-free legislation

3.2.1 Smoking restrictions in workplaces

Overall, fifteen studies were included as assessing the socio-economic impact of smoking

restrictions in the workplace; thirteen studies were set exclusively in workplaces and two

studies included workplace settings.

Thirteen studies18-30 assessed the socio-economic impact of smoking restrictions exclusively

in workplaces, the majority of studies evaluated local/regional adoption of legislation (either

enforced or voluntary) and two studies assessed the impact of national workplace smoking

bans.25;30 Studies were conducted mainly in the USA, but also Belgium,25 Scotland,23,

Sweden22 and the Netherlands.30 The SES variables used within the majority of studies were

occupation and education, although income was also used as well as poverty level (family

income divided by family size).26

Outcomes included policy adoption, implementation, coverage and enforcement; SHS/ETS

exposure (cotinine levels or self-report); smoking prevalence; and changes in smoking

behaviour including quit rates and quit attempts. Some studies evaluating SHS exposure only

included non-smokers and one study only included non-smokers that were not exposed to

SHS at home.18 Two studies included female workers only.26;28Two studies included both

workplace and home smoking restrictions.26;29

Of the thirteen workplace specific studies; four studies were single cross-sectional surveys,

eight studies used a repeat cross-sectional design, and one study included qualitative

data.23Only five of the 13 study samples were assessed as representative of the study

populations. In ten of the 13 studies it was unclear whether the observed effects were

attributable to the workplace smoking restrictions/intervention that was under investigation.

Findings from three of the studies could be generalisable on a national scale and two studies

were generalisable to the region of study.

(i) Adoption and coverage of smokefree workplace policies by SES

This section first considers studies that have looked at the adoption (i.e. diffusion) of

smokefree policies by SES, then those that have looked at the impact in terms of SHS

exposure or other smoking related variables, and finally, studies which have looked at the

relationship between workplace smokefree policy coverage and smokefree policies in the

home. The studies are ordered beginning with national studies, then regional studies and

finally, local studies.

27

A cross-sectional study using the optional tobacco module of the 2001 Behavioral Risk

Factor Surveillance System (BRFSS) examined workplace smoking policy coverage in over

44,000 indoor workers in 25 US states in 2001.19 Overall, 70.9% of respondents reported

working under a smokefree workplace policy, ranging from 60.4% (Kentucky) to 84.5%

(Alaska). Non-smokers were most likely to report a smoke-free environment (74.4%),

followed by occasional smokers (67.9%) and daily smokers (58.2%). Household income

was inversely related to the odds of working in a non-smokefree environment; the likelihood

of being protected by a smokefree work policy was significantly lower among workers who

earned less than $50,000 annually. Education, even after adjusting for all other factors

including income, was strongly associated with the absence of a smokefree workplace

policy. Workers with less than a high school education and workers with a high school

diploma or General Educational Development (GED) were 3.46 and 2.49 times more likely,

respectively, than college graduates to report working in a non-smokefree environment.

Workers in South or Midwest regions were less likely to have a smokefree work policy

compared to workers in Northeast or West, which indicates that other factors as well as SES

influenced workplace smoking policy coverage.

A study which used the Tobacco Use Supplement to the Current Population Survey

supplements (1993 to 1999) examined trends in smokefree workplace policies among

approximately 254,000 indoor workers employed in 38 major occupations in the USA, with

a particular focus on the 6.6 million workers employed in the food preparation and service

occupations.27 It should be noted that analyses were not adjusted for smoking status of

workers. Among all workers, the proportion reporting a smokefree policy increased 37%

between 1993 and 1996 but less than 9% from 1996 to 1999, suggesting a significant

slowing in the adoption rate of such policies. This trend was evident for each of the three

major occupational groups (white collar, blue collar, service workers). Blue collar and

service workers showed the largest percentage gains in smokefree policy coverage between

1993 and 1999 but continued to lag significantly behind their white collar counterparts with

barely a majority reporting a smokefree workplace policy in 1999 compared with more than

three-quarters of white collar workers. Amongst workers who reported a smokefree work

policy; non-compliance was higher among blue collar and service workers than among white

collar employees. However, only a relatively small percentage of workers in all occupational

categories reported that someone had violated their smoke-free policy during the previous

two weeks and non-compliance did not appear to be a significant issue.

28

A repeat cross-sectional study using Tobacco Use Supplements to the Current Population

Surveys (1995 to 1996 and 1998 to 1999) evaluated clean indoor air policies in nearly 6000

indoor workers in Wisconsin, USA.21The percentage of US indoor workers working under a

smokefree policy increased from 64% in 1995/1996 to 69% in 1998/1999. Smokefree

policies in Wisconsin had not progressed as much as other US states; Wisconsin was 29 th

best in the USA in 1993 and 1996 but 37 th in 1999. In Wisconsin the percent of indoor

workers working under a smokefree policy increased from 62% in 1995/1996 to 65% in

1998/1999. Residents with less than a high school education or with a high school diploma,

as well as residents making less than $15,000 were much more likely to work in an

environment where smoking was permitted or unregulated. Smoking prevalence was

generally higher among people in occupations with a lower percentage of workers covered

by a smokefree workplace policy. There are relatively small numbers in some of the

education and income subgroups which might make the estimates unstable.

Another repeat cross-sectional study using Tobacco Use Supplements to the Current

Population Surveys (1992 to 2002) examined trends in official workplace smoking policies

for indoor working environments in approximately 10,000 workers in North Carolina,

USA.24 North Carolina ranked 35th for the proportion of its workforce reporting a smokefree

place of employment in 2001/2002. The proportion of workers reporting a smokefree policy

doubled between 1992 and 2002. Less than a third of the state’s workforce was smokefree in

1992/1993, but by 2001/2002, slightly more than two-thirds reported this level of protection.

Blue-collar (55.6%, CI +/-5.5) and service workers (61.2%, CI +/-8.4), especially males,

were less likely to report a smokefree worksite than white-collar workers (73.4%, CI +/-2.6).

29

The study did not account for the smoking status of workers, which may have confounded

results. In addition, at the time of the study there was a pre-emptive state law specific to

North Carolina which might have limited the progress of smokefree policies and any impact

on equality, and limited the generalisability of the study findings to North Carolina. 24 The

study authors state that in 1993, the state legislature passed a law that required state-

controlled buildings to set aside 20% of their space for smoking and prohibited local

regulatory boards from enacting stronger provisions unless the legislation was enacted

before the state law would take effect in October 1993. A total of 105 local ordinances were

in effect by the October date, 89 of which had been fast tracked to beat the deadline. A legal

challenge to one ordinance led to a subsequent ruling which invalidated almost all of the 89

newly enacted ordinances, forcing most communities to suspend legal enforcement of their

ordinances.

A cross-sectional study examined the pattern of, and socioeconomic factors associated with,

the adoption of clean indoor air (CIA) ordinances in 332 Appalachian communities16 with at

least 2000 residents, in 6 states; Alabama, Georgia, Kentucky, Mississippi, South Carolina,

and West Virginia. Fewer than 20% of the 322 communities had adopted a comprehensive

workplace, restaurant, or bar ordinance. Most ordinances were weak, achieving on average

only 43% of the total possible points. The percentage that completed high school was related

to the presence of workplace clean air policies in Appalachian communities outside West

Virginia. Adjusting for state and county, a 1% increase in high school completion rate was

associated with a 10% increase in both the odds of a workplace policy and the odds of at

least 1 policy (workplace or restaurant).

A cohort study using data from 2006/7 (Wave 5) and 2007/8 (Wave 6) International Tobacco

Control Four County Survey15(Australia, Canada, UK, USA) assessed socioeconomic and

national variations in the prevalence, introduction, retention, and removal of smokefree

policies in various indoor environments, including homes, worksites, bars, and restaurants

(see section 3.2.2). An important strength of this study is that it uses the same survey in four

countries and makes international comparisons. In the period between Waves 5 and 6

comprehensive smokefree legislation (worksites, bars and restaurants) was introduced in

England, and several states in Australia either implemented or strengthened smokefree

polices in these environments.

30

In terms of smokefree worksite policies; overall, the proportion of current smokers who

reported that smoking was not allowed (total ban) was greatest among respondents from

Canada in Wave 5 (current: 88.2%) and the UK in Wave 6 (current: 96.1%; former: 98.2%).

The US had the lowest proportion of respondents with such a policy at both Waves (76.8%

and 75.9%). Among former smokers the proportion with a total ban at Wave 5 was highest in

the US (92.7%) but lowest at Wave 6 (83.0%). The proportion of current smokers with a

total ban increased with increasing SES in Canada and the US in Wave 5 but no trends were

apparent in Wave 6. Between Waves, the introduction of a total ban significantly increased

with decreasing SES among current smokers in Canada, the US and UK. No consistent

association was observed across all countries with regard to either the presence or

introduction of total smoking bans in workplaces.

Thus the study found that while current smokers with higher SES were more likely to have

total worksite smoking bans, the rate of the adoption of such bans over this one year period

was comparable by SES group. Also there was no consistent association in current or former

smokers between SES and total bans in bars and restaurants. The authors concluded that the

recent proliferation of smokefree policies in these locations had led to a reduction, indeed

removal, in disparities in coverage by SES as low SES worksites and public places were

catching up in the adoption of total smoking bans. They therefore had a positive equity

impact.

A cross-sectional study explored trends in cotinine levels in over 8000 US non-smoking

workers not exposed to SHS at home, by occupational groups, using data from the National

Health and Nutrition Examination Surveys (NHANES III) over 14 years from 1988 to

2002.18 For the overall population, there was a significant decrease in cotinine levels (0.16

ng/mL; 80% relative decrease) over time which ranged from 0.08 to 0.30 ng/mL (67% to

85% relative decrease). The largest absolute reductions in cotinine levels were in blue-collar

and service occupations; the negative slope in cotinine levels for blue-collar service and

service workers (0.21 and 0.22 ng/mL, respectively; 72% and 76% decreases) were

significantly greater than the slope for white-collar workers (0.13 ng/mL; 76%). Although

the study excluded workers exposed to SHS at home, SHS exposure from other settings such

as bars and restaurants cannot be ruled out.

31

A study investigated the sociodemographic distribution of workplace exposure to SHS in

Sweden, using the Scania Public Health Survey 2000 which was based on a sample of

24,922 randomly selected persons born from 1919 to 1981 and living in Scania.22 13,604

persons responded to the questionnaire, representing a 59% response rate. The prevalence of

SHS at work was higher among men (26.4%) than among women (20.8%), although regular

smoking was higher among women (21.1%) than among men (17.0 %). Regular smokers

had a higher risk of SHS exposure at work than non-smokers. The exposure to SHS at work

was highest among men in skilled manual work and women in unskilled manual work and

persisted after adjusting for age, country of origin, and smoking patterns. Male skilled

manual workers and female unskilled manual workers had higher adjusted odds ratios (OR

4.0, 95% CI: 3.1 – 5.3 and OR 3.2, 95% CI: 2.2 – 4.7, respectively) of SHS exposure than

non-manual high-level employees. The survey included only workers living in Scania, the

southernmost province of Sweden and so study results might not be generalisable to the

entire Swedish workforce.

A repeat cross-sectional study using Tobacco Use Supplements to the Current Population

Surveys from 1992 to 1993, estimated the impact of workplace smoking restrictions on the

prevalence and intensity of smoking among all indoor workers (approximately 98,000) and

various demographic and industry groups.20 The percentage of indoor workers subject to a

100% smokefree policy was 46.7%. Nearly 67% were subject to smoking restrictions in their

immediate work area but were allowed to smoke in some common areas. The percentage of

indoor workers subject to no work area or common area restrictions was 18.9%.

32

The survey results showed a consistent pattern: the more restrictive the workplace policy, the

greater the decline in smoking. Moving from no smoking restrictions to a smokefree

workplace decreased the prevalence of smoking by 5.7 percentage points (95% CI = 4.9 to

6.5) which represents a 22.8% reduction in smoking prevalence compared to the sample

mean; and reduced daily consumption among the remaining smokers by 2.67 cigarettes (95%

CI = 2.28 to 3.05) which represents nearly a 14% decrease in average daily cigarette

consumption. Maintaining work area bans but allowing smoking in common areas reduced

the impact of work area bans by half. For these workplaces, there was a 2.6 percentage point

decrease in the prevalence of smoking and a decline of 1.48 cigarettes in the average daily

consumption (95% CI = 1.08 to 1.89). Partial workplace and common area bans had no

statistically significant effects on the prevalence of smoking. However, these restrictions

decreased daily consumption among remaining smokers (those who do not quit smoking) by

0.57 cigarettes (95% CI = 0.05 to 1.08).

Indoor workers with postgraduate education had both a lower prevalence of smoking and a

lower daily consumption. Although the percentage point declines in the prevalence of

smoking in response to a smokefree environment were fairly uniform across educational

groups, as a percentage of current rate of smoking, the largest effects (percentage decline)

were for workers with a college degree (28.4% decline) and the least for high school

dropouts (13.7% decline). However, the opposite was true for the effects of the smoking ban

on average daily consumption. Those with less than a high school degree had the largest

decline, both in absolute terms (3.90 cigarettes) and as a percentage of average daily

consumption (19.4%). Those with a college degree decreased daily consumption by an

average of 1.69 cigarettes, a 9.3% decrease. The sample of indoor workers was more

educated than the sample of all workers and so the equity impact may not be generalisable to

the entire workforce.

33

Another study which used the Tobacco Use Supplement to the Current Population Survey

supplements (1998/9 and 2000/1) examined the association between workplace smoking

policies and home smoking restrictions with current smoking among approximately 80,000

working women.26 About 11.1% of women reported no workplace smoking policy.

Workplace policies were associated with distance from the poverty level; 61.5% below the

poverty level were covered by full workplace restrictions, compared to 76.6% of those 150%

+ above the poverty level. 19.1% of those below the poverty level had no workplace

smoking policy, compared to just 10% of the 150%+ group. Workplace smoking policies

were not associated with a quit attempt in the past year for any of the poverty level

categories.

A study assessed differences in the likelihood of exposure to SHS at home and at work

among an ethnically diverse sample of approximately 2300 non-smoking women aged 40

and older in the United States in 1997.28 The analysis of SHS exposure and smoking

restrictions at work was further restricted to include only employed women, resulting in a

sample size of 1100. The study excluded women without a telephone at home; these women

could have been more exposed to SHS. Nearly 40% of the respondents had an annual income

of $20,000 or less. Income was excluded from the final model due to the high proportion of

missing cases (16.7%) and its collinearity with educational level.

Among employed women, 19.2% were exposed to SHS at work, and 22% were employed at

worksites that allowed smoking in some or all work areas. Exposure to SHS at work was

substantially higher for women who worked where smoking was allowed in some (adjusted

OR 15.1, 95% CI 10.2, 22.4) or all (adjusted OR 44.8, 95% CI 19.6, 102.4) work areas.

Exposure to SHS at work was higher among women with some high school education

(adjusted OR 2.8, 95% CI 1.5, 5.3) and high school graduates (adjusted OR 3.1, 95% CI 1.9,

5.1) and marginally so for those with some college (adjusted OR 1.5, 95% CI 0.9, 2.5).

34

A study compared how adoption and enforcement (self-reported smoke exposure) of

smokefree policies differed for Asian-American women by educational status, using the

California Tobacco Use Surveys for Chinese and Korean Americans (CCATUS and

KCATUS).29The response rate to the survey was low; 52% for Chinese Americans and 48%

for Korean Americans and included approximately 1900 women, nearly 60% had less than

$30,000 annual income. The study authors stated they aimed to assess the impact of

California’s smoke-free social norm campaign (with Asian community and in-language

outreach) but this was established in 1988; over a decade before the survey was conducted

(2003), making it difficult to isolate the specific impacts of this campaign.

Lower-educated and higher-educated women had similar proportions of smoke-free policies

for indoor work (90%) however; lower-educated women were more likely than higher-

educated women to report exposure during the past 2 weeks at an indoor workplace

(OR=2.43, 95% CI= 1.30, 4.55, p=0.005), even after controlling for ethnicity, smokefree

policy, knowledge about the health consequences of secondhand smoke exposure, and

acculturation.

(ii) Impact of introducing smokefree policies by SES

In March 1993 the Belgian Public Health Department published a Royal Decree to structure

and regulate smoking habits in the workplace. According to the Royal Decree, companies

were obliged to ‘take measures against the harmful consequences of smoking at the

worksite’. A study25 assessed the impact of this decree, through mailed questionnaires, to

evaluate the implementation of health policy recommendations to 3543 randomly selected

Belgian companies from the ‘Trends Top 20,000’ companies.

In 1990, 773 companies (22%) and in 1993, 890 companies (25%) responded to the

questionnaire. A total of 325 (9%) companies responded to both the 1990 and 1993

questionnaires. Comparison of the 1990 and 1993 dataset regarding the influence of the anti-

smoking campaigns on smoking policy shows that despite the media attention and the

promulgation of the Royal Decree by the Public Health Department, no major changes were

observed. Only restrictions on smoking in cafeterias (p = 0.0001) and in meeting rooms (p =

0.02) were implemented. The relation between companies’ turnover and the willingness to

offer a worksite smoking cessation programme (WSCP) was not observed in 1990 but

became significant in 1993. Companies with a very high turnover reported more willingness

to offer a WSCP in 1993 (67% in 1993 versus 54% in 1990).35

A significant relation was observed between the blue/white collar worker ratio and its impact

on company’s smoking policy in 1990. Companies employing mostly white collar workers

compared with companies employing mostly blue collar workers reported being more able to

offer time (p = 0.001), meeting rooms (p = 0.001) and to subsidize a WSCP (p = 0.001).

Companies employing mostly white collar workers were willing more often to offer a WSCP

(p = 0.02). Companies employing mostly blue collar workers had a stricter non-smoking

policy (p = 0.003).

In 1993 a significantly higher percentage of companies with a high number of white collar

compared with companies with a high number of blue collar workers were reported more

able to offer time (p = 0.00001), meeting rooms (p = 0.001), having already organised a

WSCP (p = 0.00001), to subsidize a WSCP (p = 0.00001) and to offer a WSCP (p = 0.0002).

A lower percentage of companies with a high number of blue collar compared with

companies with a high number of white collar workers tended to offer a worksite

information program (p = 0.02).

When comparing survey data from 1990 and 1993: the difference regarding a more strict

smoking policy between companies employing mostly blue collar (12% total non-smoking

policy) and companies employing mostly white collar (2% total non-smoking policy) which

was significant in 1990 has disappeared in 1993 (7% in a ‘mostly blue collar’ company

versus 4% in a ‘mostly white collar’ company).

It is unclear how comprehensive this decree was or how strictly it was enforced. The 1993

Royal Decree31 regarding smoking in workplaces issued by the Minister of Employment

states:

“[Tobacco use] must be based on mutual tolerance, respect of individual liberties, and courtesy. If necessary, the employer must take additional technical measures [ventilation systems] in order to eliminate the annoyance caused by environmental tobacco smoke.”

This indicates that there was likely to have been variability in adoption and enforcement of

the decree. The response rate to the questionnaire in 1990 and 1993 was related to the

companies’ turnover (12% in low to 30% in high turnover) and to the blue/white collar ratio

(13% in high ratio to 26% in low ratio). This differential response rate might invalidate study

findings. In addition, the study evaluated the impact of the new law only 3 months post

implementation which might not be sufficient time to assess impact.

36

A study in the Netherlands30 examined whether a national workplace partial smoking ban in

2004 reduced exposure to SHS and inequalities in SHS exposure. The ban applied to all

workplaces except the hospitality industry (employees in restaurants, pubs, bars, and

discotheques were excluded from this ban). The data source was the Continuous Survey of

Smoking Habits (CSSH) Dutch internet survey, and included over 11,000 non-smoking

workers. SHS exposure decreased among all employees and low-educated employees (at

higher risk before the ban); 52.2% still reported being exposed post-legislation. Lower-

educated workers were twice as likely to be exposed as those workers with a higher level of

education. There were significant differences between educational subgroups and the

decrease in SHS exposure since the national smoking ban. OR between low and middle, pre

and post-legislation: 1.61 (1.23-2.10); 1.21 (1.16-1.47); OR low v high educated: 2.29 (1.74-

3.01); 2.17 (1.91-2.45).

The authors of the study argue that the workplace smoking ban was limited because it

excluded the hospitality industry and employers were also permitted to offer designated

smoking rooms at work. The internet sample might not be representative of the general non-

smoking working population in the Netherlands. Any positive response to exposure was

coded as ‘exposed’ during the survey; dichotomising responses in such a manner could have

led to over-stating exposure. The brief period of data collection pre-ban offered less seasonal

variability compared to data collect post-ban. In addition, education is a difficult measure of

SES to compare across generations and internationally, more so for this study because there

was no definition provided for ‘low, middle, high’ education.

A study which examined the implications of moving from a voluntary smoking code to a

smoking ban at Edinburgh University, UK used a postal questionnaire which was completed

by 997 staff members (27.8% of the sample) and qualitative interviews with a purposive

sample of 30 staff members.23Across the staff groups (smoke less, smoke more, quit, no

change) the proportions were as follows: Academic and related 39 (36.8%), 3 (2.8%), 17

(16.0%), 47 (44.3%); Clerical / secretarial 30(42.2%), 1 (1.4%), 6 (8.4%), 34 (47.9%);

Technical 25 (51.0%), 2 (4.1%), 6 (12.2%), 16 (32.7%); Manual 76 (45.2%), 15 (8.9%), 7

(4.2%), 70 (41.7%). Significant differences were found in quit rates between academic and

related staff and manual staff (16.0% vs. 4.2%) and in increase in smoking between

academic and related and manual staff (2.8% vs. 8.9%). The largest response categories for

academic and related and clerical / secretarial staff was 'no change' and for technical and

manual staff was 'smoke less'.

37

3.2.2 Smoking restrictions in enclosed public places

A total of twenty-nine studies assessed the socio-economic impact on the wider population

(not just workers) of smoking restrictions in enclosed public places; three studies16;32;33

evaluated local/regional adoption and coverage of smokefree legislation and 24 studies

examined the impact of introducing smokefree policies: four studies34-37 of regional

smokefree legislation and 22 studies15;38-59 of national smokefree legislation. Six studies

evaluated national smokefree legislation alongside other types of policies.40;54-58

Studies were conducted in several countries including Australia, Canada, England, France,

Germany, Ireland, Italy, Netherlands, New Zealand, Scotland, USA and Wales. One study

used data from 18 European countries including Finland, Sweden, Denmark, England,

Ireland, Netherlands, Belgium, Germany, France, Italy, Spain, Portugal, Slovakia, Hungary,

Czech Republic, Lithuania, Latvia and Estonia.56

Settings included bars, restaurants and hospitals. SES variables used within the studies

included area deprivation, occupational class, education and household income. Outcomes

varied and included: policy adoption and coverage; compliance with smokefree legislation

and social norm data; smoking prevalence and odds ratios for smoking; SHS exposure

measured by cotinine levels and particulate matter, and self-report; smoking behaviour

including consumption and quitting; health impacts including acute myocardial infarctions

and coronary events; perceived respiratory and sensory symptoms. Qualitative data included

the impact of changes in physical spaces from smokefree legislation. Two studies evaluated

the impact of national smokefree legislation and measured children’s reports of parental

smoking behaviour in cars and in homes.46;47

Four studies were single cross-sectional surveys, sixteen studies used a repeat cross-sectional

design (one of which is classed as econometric study40 design 1.4, as price elasticities were

reported), five studies were prospective longitudinal cohorts, one study used a before-and-

after design with the same participants at follow-up, and three studies were qualitative. Only

eleven of the 27 study samples were assessed as representative of the study populations; one

UK cohort reported a response rate of 72% for the original data source but applied various

exclusions to the data and excluded participants from ethnic minorities.45

38

Four of the five cohort studies43;45;58;59had an attrition rate of at least 30%, and three of the

cross-sectional studies had relatively small numbers within some subgroups.35;36;38For

fourteen of the studies it was not possible to be confident that the observed effects were

attributable to the intervention under investigation mainly due to other tobacco control

legislation which occurred concurrently. Findings from ten studies could be generalisable on

a national scale (one study45 might not be generalisable to ethnic minority groups within the

UK), and one study32 was generalisable to the region of study. All members of one

cohort43were participating in a clinical trial of aspirin in people at moderately increased risk

of cardiovascular events and so the results of the trial are specific to this trial population.

(i) Adoption and coverage of smokefree policies by SES

Three studies16;32;33 evaluated local/regional adoption of smokefree legislation and were all

cross-sectional studies based in the USA. Freestanding bars were excluded from two

studies16;33 as they were not covered by ordinances. It should be noted that the three studies

assumed that protection from SHS exposure was provided by regulations rather than

measuring the actual level of protection, however the presence of a regulation should

correlate with reduced exposure.

One study of 351 cities and towns in Massachusetts, USA examined the diffusion of

smokefree restaurant regulations.32 Over 10 years (1993 to 2004) prior to statewide ban, only

36% of the total population of Massachusetts was covered by local regulations that protected

them from SHS exposure in restaurants. The proportion of college graduates in

Massachusetts protected from SHS in restaurants in their own town was consistently

between 2 and 7 percentage points greater than the proportion of non-graduates who were

protected. Just prior to the statewide smoking ban, 40% of college graduates were protected

compared to 33% of non-graduates. There was also substantial disparity in protection from

SHS by individual poverty status; protection from SHS exposure was higher for those living

above the poverty line.

39

Another cross-sectional study also based in Massachusetts33 identified and quantified

differences in sociodemographic characteristics of communities relative to the strength of

351 local restaurant smoking regulations obtained from a database maintained by the

Massachusetts Tobacco Control Progam (MTCP) at one time-point in 2002. Three measures

of the strength of ordinances were developed: strong equalled smokefree, medium equalled

separate ventilated areas for smoking, and weak equalled designated smoking areas or no

restrictions. Towns with Board of Health funding by the MTCP were nearly 5 times more

likely to adopt strong regulations and more than 11 times more likely to adopt medium

regulations. In bivariate analyses, local smokefree restaurant regulations were significantly

more likely to be adopted by towns with a higher proportion of college graduates, and a

higher per capita income. Strength of regulation was not significantly related to household

income or poverty level. In multivariate analyses, education and per capita income became

insignificant. The study authors stated this might be explained by another significant

measure which was ‘agreeing with the 1992 ballot to create the MTCP’ which was highly

correlated with both education (r=0.90) and per capita income (r=0.74).

A cross-sectional study examined the pattern of, and socioeconomic factors associated with,

the adoption of clean indoor air (CIA) ordinances in 332 Appalachian communities16 with at

least 2000 residents, in 6 states; Alabama, Georgia, Kentucky, Mississippi, South Carolina,

and West Virginia. Appalachia is characterized by widespread poverty and, in addition,

study findings might not be generalisable to smaller Appalachian communities. Policy

coverage was evaluated in 2008 through web-based search and contacting of city halls for

CIA ordinances. Separate logistic regression models were fitted to West Virginia and

communities within the other five states because West Virginia differed from the other states

as the majority of its communities had an ordinance. The CIA strength ratings were not

adjusted to account for the state CIA laws, however the laws in these states were very weak.

Fewer than 20% of the 322 communities had adopted a comprehensive workplace,

restaurant, or bar ordinance. Most ordinances were weak, achieving on average only 43% of

the total possible points. The percentage that completed high school was related to the

presence of restaurant clean air policies in Appalachian communities outside West Virginia.

Adjusting for state and county, a 1% increase in high school completion rate was associated

with a 9% increase in the odds of a restaurant policy and a 10% increase in the odds of at

least 1 policy (workplace or restaurant).

40

Univariate logistic regression models revealed no associations between county

characteristics and CIA ordinances in West Virginia, with the exception of a significant

negative relationship between median income and presence of a restaurant policy (a $1000

increase in median income was associated with a 12% decrease in the odds of a restaurant

policy, likelihood ratio P=.033). A 1% increase in the percentage that completed high school

was associated with an average increase of 0.9% in points achieved for CIA strength ratings.

The analysis was repeated for the West Virginia counties, though no significant relationships

were found.

(ii) Impact of introducing smokefree policies by SES

Twenty-four studies examined the impact of introducing smokefree policies: four studies34-37

of regional/statewide smokefree legislation and 20 studies15;38-45;48-59 of national smokefree

legislation. Six studies evaluated national smokefree legislation alongside other types of

policies.40;54-58

A before-and-after study using International Tobacco Control Europe Surveys48 investigated

how successful national level smokefree hospitality industry legislation was in reducing

smoking in bars; assessed individual smokers predictors of smoking in bars post-ban;

examined country differences in predictors; and examined differences between education

levels. Studied countries were Ireland, France, Netherlands and Germany. While the partial

smokefree legislation in the Netherlands and Germany was effective in reducing smoking in

bars (from 88% to 34% and from 87% to 44%, respectively), the effectiveness was much

lower than the comprehensive legislation in Ireland and France which almost completely

eliminated smoking in bars (from 97% to 3% and from 84% to 3% respectively).

41

Smokers from Ireland and France were younger and less educated than smokers from the

Netherlands and Germany. Smokers with a low educational level were more likely than

smokers with a high educational level to smoke in bars post-ban. Highly educated smokers

from the Netherlands who were supportive of a partial ban were less likely to smoke in bars

post-ban (OR highly educated = 0.53, 95% CI = 0.26 to 1.08). Moderately educated smokers

from the Netherlands who often or sometimes thought about the harm of smoking to others

were less likely to smoke in bars (OR moderately educated = 0.54, 95% CI = 0.34 to 0.88).

Societal approval of smoking was a stronger predictor of smoking in bars among highly

educated smokers (OR highly educated = 2.87, 95% CI = 1.01 to 8.18). Low and moderately

educated smokers from Germany who very often thought about the harm of smoking to

others were borderline significantly less likely to smoke in bars (OR low educated = 0.14,

95% CI = 0.02 to 1.15; OR moderately educated = 0.23, 95% CI = 0.05 to 1.11).

A repeat cross-sectional study examined patron responses to the California smokefree bar

law in 199835 in three telephone surveys; 3-months, 8-months and 2.5 years post-law.

Approval of the law rose from 59.8% to 73.2% (OR 1.95; 95% Cl:1.58 to 2.40). Self-

reported non-compliance decreased from 24.6% to 14.0% (OR 0.50; 95% CI:0.30 to 0.85).

The likelihood of visiting a bar or of not changing bar patronage after the law was

implemented increased from 86% to 91% (OR1.76: 95% CI:1.29 to 2.40). Respondents who

approved of the law were more likely to be more highly educated or have a household

income of at least $60,001. Patrons with higher income or educational attainment tended to

report they were “more likely” to visit bars or to report “no change” in their patronage.

Patrons with an income of at least $60,001 were less likely to perceive non-compliance.

Response rates ranged between 28 to 32% and so the study sample was not representative of

the population. Also, because of their willingness to complete the survey, the respondents

selected may be inclined to support the law.

Three studies evaluated the socio-economic impact of national comprehensive smokefree

legislation on reducing exposure to SHS. One study measured salivary cotinine levels,

another study measured particulate matter and one study used self-reported exposure.

42

A repeat cross-sectional study in England53 used salivary cotinine data from the Health

Survey for England that were collected in 7 of 11 annual surveys (1998 to 2008) to examine

trends in, and predictors of, SHS exposure among non-smoking adults to determine whether

exposure changed after the introduction of smokefree legislation in 2007, and whether these

changes varied by SES and by household smoking status. Exposure declined markedly from

1998 to 2008 (the proportion of participants with undetectable cotinine was 2.9 times higher

in the last 6 months of 2008 compared with the first 6 months of 1998 and geometric mean

cotinine declined by 80%). There was a significant fall in exposure after legislation was

introduced adjusting for pre-legislative downward trends and potential confounders (the odds

of having undetectable cotinine were 1.5 times higher [95% CI: 1.3, 1.8] and geometric

mean cotinine fell by 27% (95% CI:17%, 36%).

Significant reductions in SHS exposure were not, however, seen in those living in lower-

social class households or homes where smoking occurred inside on most days. Social class

was a significant determinant of SHS exposure; the odds of having undetectable cotinine

decreased with declining SES status with the lowest levels in social class IV and V [29%

lower than social class I and II, 95% CI: 21, 35] and in adults with no qualifications (19%

lower than those with a higher education qualification, 95% CI: 11, 26). Significant impacts

of the smokefree legislation were observed among those from social classes I to III. The

odds of having undetectable cotinine were 1.8 (95% CI: 1.4, 2.3) times higher among those

in social classes I and II and 1.5 (95% CI: 1.1, 1.9) times higher among those in social

classes III after the legislation, whereas geometric mean cotinine levels fell by 37% (95%

CI: 24%, 48%) and 23% (95% CI: 6%, 37%) respectively.

43

A repeat cross-sectional study in England, Scotland and Wales 52 evaluated the effects of

national smokefree legislation on air pollution levels in bars. The intervention included

discreet sampling of air quality in bars by researchers and also 26 personal exposure shift

samples for non-smoking bar workers from Scotland and England recruited to wear personal

air quality monitors. Particulate matter <2.5 mm in diameter (PM2.5) levels prior to

smokefree legislation were highest in Scotland (median 197 µg m-3), followed by Wales

(median 184 µg m-3) and England (median 92 µg m-3). All three countries experienced a

substantial reduction in PM2.5 concentrations following the introduction of the legislation

with the median reduction ranging from 84 to 93%. Personal exposure reductions were also

within this range. Bars located in more deprived postcodes had higher PM2.5 levels prior to

the legislation. Linear trend in the change in PM2.5 by deprivation category, suggested more

deprived areas experienced greater percentage reduction in PM2.5 levels up to 12 months

post-implementation when compared to more affluent areas, although there were higher

levels of PM2.5 at baseline for more deprived areas.

One study evaluated the impact of a statewide smokefree law enacted in July 2010 in

Wisconsin, USA, on smoking behaviours in and out of the home with an Annual Survey of

the Health of Wisconsin (SHOW).36 Six hundred and thirty-four adults were surveyed before

the ban and 434 after the ban. Participants who lived in an area with a workplace or complete

public smoking ban prior to the statewide ban were excluded from the analysis. Smoke-free

legislation in Wisconsin decreased reported exposure to tobacco smoke outside the home,

and at work. The smoking ban was associated with a reduction of participants reporting

exposure to smoke outside the home (from 55% to 32%; P<0.0001).

Participant exposure to tobacco smoke outside the home improved among both education

groups, and all income groups (<$30,000 per year; $30,000 to $59,000 per year; >/=$60,000

per year) but it was decreased further in the highest income group (family income >$60,000

per year). Participants being exposed to smoke at work significantly reduced only for middle

income group. Smokefree legislation not associated with change in smoking prevalence but

analyses were weakened by small sample size. The number of current smokers in the SHOW

data was only 167, a number that limits the statistical power of the study when it comes to

analysing the effects of the law on smoking prevalence and on the behaviours of current

smokers. The results of the study might be specific to the residents of Wisconsin and not

generalisable to the general population.

44

Ten studies (three qualitative) evaluated the socio-economic impact of national smokefree

legislation using self-reported quitting behaviour, smoker status, and/or prevalence as the

outcome measures. An interrupted time-series analyses of 11 annual cross-sectional surveys

(1999 to 2010) estimated the impact of the 2005 smokefree law in Italy42 which prohibited

smoking in all public place including workplaces. Changes in both smoking prevalence and

cessation were particularly marked immediately before or just after the introduction of the

2005 policy, whereas in the following years rates tended to be similar to those of the period

before the policy was introduced. Among both low and high-educated males, smoking

prevalence decreased by 2.6% (P = 0.002) and smoking cessation increased by 3.3% (P =

0.006) shortly after the ban, but both measures tended to return to pre-ban values in the

following years. The absolute difference in smoking prevalence between highly and low-

educated males widened slightly over the whole time-period. Time trends in the quit ratio

mirrored those in smoking prevalence for males.

Among low-educated females, the ban was followed by a 1.6% decrease (P = 0.120) in

smoking prevalence and a 4.5% increase in quit ratios (P < 0.001). However, these

favourable trends reversed over the following years. Among high-educated females, trends

in smoking prevalence and cessation were not altered by the ban. A different pattern

emerged for the female quit ratio: the policy was associated with an immediate 2.6%

increase in quit ratio (P = 0.050), but the change in time trends (b = -0.6% per year) was not

significant at the 0.05 level. However, the immediate effect of the policy was more

favourable among low-educated females than among the higher educated, with a 4.5%

increase in quit ratios among low-educated females, p < 0.001. Long-term trends clearly

favoured the higher educated (b = 0.7% for the interaction term between education and

time). As a result, educational differences in quit ratios widened over time.

The results of this study might not be entirely attributable to the smokefree law; in Italy the

price of cigarettes rose by about 65% between 1999 and 2010, and the largest relative

increase occurred between 2003 and 2005. In addition, a national mass media anti-smoking

campaign was carried out in 2009.

45

A cohort of participants in an RCT of Aspirin for Asymptomatic Atherosclerosis43 were

evaluated to investigate trends in smoking cessation before and after the introduction of

smokefree legislation in Scotland which prohibited smoking in enclosed public places and

workplaces in 2006. The Scottish smokefree legislation was associated with an increase in

the rate of smoking cessation in the 3-month period immediately prior to its introduction

(5.1% quit in the 3-months prior to legislation implementation, far higher than any other 3-

month period). Overall quit rates in the year the legislation was introduced and the

subsequent year were consistent with a gradual increase in quit rates prior to the introduction

of the legislation. Odds of quitting increased annually (OR 1.09 95% CI: 1.05 to 1.12).

There was no evidence of an association between the Scottish Index of Multiple Deprivation

(SIMD) and the probability of attempting to quit, or feeling influenced to quit. However,

smokers from more affluent areas were more likely to have a positive perception of the

legislation compared with more deprived communities. The cohort was participating in a

clinical trial which might have influenced their smoking behaviour and their attitudes

towards the smokefree legislation. Therefore the findings of this study might not be

generalisable to the general population.

A repeat cross-sectional study in England44used national household surveys (2007 to 2008)

to determine the impact of smokefree legislation implemented in 2007, on quit attempts and

intentions. The smokefree legislation was associated with a significant, temporary, increase

in the percentage of smokers attempting to quit. One in five smokers who quit after the ban

said they had been influenced by the ban. There was no evidence of any significant

difference in quit attempts by social grade, but only six months of pre-legislation data were

examined.

46

A study45 used Millennium Cohort Study (MCS) data for parents of children born between

September 2000 and January 2002, to investigate parental smoking behaviours in England

and Scotland after Scottish smokefree legislation in 2006, and inequalities in maternal

smoking behaviour between the two countries. No smokefree legislation in England occurred

during the data collection period. Various inclusion/exclusion criteria were applied to the

MCS data; only singleton births to white British/Irish mothers who participated in all three

contacts and lived in England or Scotland at first and third contact were studied. Excluded

were mothers who were pregnant at any contact, main respondents who were not female, and

partners who were not male. Smoking behaviours among parents with young children

remained relatively stable.

There was a higher rate of smoking cessation between contact 1 (when child was 9 months

old), and contact 3 (when child was 5 years old) among mothers in England who had higher

household income, higher occupational class, or left school at an older age. There was no

significant relationship for these factors in Scotland; where quitting smoking was similar

across social groups, whether defined by occupation, education or income. The socio-

economic gradient in quitting smoking in Scotland has flattened slightly following the

smokefree legislation. However mothers from disadvantaged circumstances were still more

likely to smoke, start smoking or report smoking in the home. Lower SES was associated

with higher rates of maternal smoking uptake and smoking in the home in both England and

Scotland (p<0.05).

This study showed higher attrition rate among non-smokers (40% of those who only

responded at contact point 1 smoked compared to 29% who participated in the first and third

contacts), however non-response weights were included in all analyses. It should be noted

that a range of other tobacco control policies were implemented during this time. The results

may not be applicable to ethnic minority groups with England and Scotland and may be

specific to parents of young children.

47

A cohort study using data from 2006/7 (Wave 5) and 2007/8 (Wave 6) International Tobacco

Control Four County Survey15(Australia, Canada, UK, USA) assessed socioeconomic and

national variations in the prevalence, introduction, retention, and removal of smokefree

policies in various indoor environments, including homes, worksites (see section 3.2.1), bars,

and restaurants. An important strength of this study is that it uses the same survey in four

countries and makes international comparisons. In the period between Waves 5 and 6

comprehensive smokefree legislation (worksites, bars and restaurants) was introduced in

England, and several states in Australia either implemented or strengthened smokefree

polices in these environments.

In terms of smokefree bar policies; overall, the proportion of both current and former

smokers who reported that smoking was not allowed in any indoor area of local bars (total

ban) was greatest among respondents from Canada in Wave 5 (current: 83.6%; former:

83.0%) and those from the UK in Wave 6 (current: 97.1%; former: 95.3%). Between Waves

5 and 6, relative increases of 79.7% and 50.6% were observed in the proportion of current

smokers with a total ban in the UK and Australia, respectively. Similar increases were also

observed among former smokers in these two countries (UK: 81.1%; Australia: 45.3%). No

consistent association with SES was observed across countries with regard to either the

presence or introduction of total smoking bans in bars.

In terms of smokefree restaurant policies; overall, the proportion of both current and former

smokers who reported that smoking was not allowed in any indoor area of local restaurants

(total ban) was greatest among respondents from Canada in Wave 5 (current: 91.5%; former:

92.7%) and the UK in Wave 6 (current: 97.1%; former: 98.2%). The proportion of

respondents with such a policy was lowest among those from the UK in Wave 5 (current:

27.5%; former: 32.0%) and the US in Wave 6 (current: 65.0%; former: 60.9%). Between

Waves 5 and 6, relative increases of 71.7% and 67.4% were observed among current and

former smokers in the UK, respectively. No consistent association by SES was observed

across countries with regard to either the presence or introduction of total smoking bans in

bars.

48

Thus the study found that while current smokers with higher SES were more likely to have

total worksite smoking bans, the rate of the adoption of such bans over this period was

comparable by SES group. Also there was no consistent association in current or former

smokers between SES and total bans in bars and restaurants. The authors conclude that the

recent proliferation of smokefree policies in these locations has led to a reduction, indeed

removal, in disparities in coverage by SES as low SES worksites and public places are

catching up in the adoption of total smoking bans. They therefore had a positive equity

impact.

A national population survey assessed the effects of the implementation of a workplace

smoking ban in January 2004 in the Netherlands and the extension to the hospitality industry

in July 2008.49 The study used seven years of data from the Dutch Continuous Survey of

Smoking Habits (DCSSH), an internet-based survey (n=18,000 per year) to examine

smoking prevalence, quit attempts and successful quitting.

There was a slight, significant, decrease in smoking prevalence between 2001 and 2007

(OR=0.97, p<0.001). The workplace ban was followed by a decrease in smoking prevalence

in 2004 (OR=0.91, p<0.001), with prevalence lower in the first half of the year than the

second, suggesting some relapse. The hospitality ban had no significant influence on

smoking prevalence (OR=0.96, p=0.127). Quit attempts were higher following the

workplace ban (33% (2004) v 27.7% (2003), p<0.001), and hospitality ban (26.3% in 2008,

v 24.1% in 2007, p=0.013). Seasonal variations in quit rates also support the effectiveness of

both smokefree policies. There were significant increases in successful quit attempts

following both smokefree policies.

In terms of impact by SES; the workplace ban led to more successful quit attempts among

higher educated smokers (OR=0.35, p<0.001) than medium (OR=0.41, p<0.001) or lower

OR=0.74, p=0.052). The hospitality industry ban had a larger effect on quit attempts among

frequent bar visitors (OR = 1.48, P = 0.003) than on non-bar visitors (OR = 0.71, P = 0.014),

and more frequent bar visitors were more likely to be higher educated, as well as younger,

male, and employed (all p<0.001). The Dutch smoking bans were implemented in

conjunction with a tax increase and a mass media smoking cessation campaign, so it is

difficult to tease out any separate effects of the workplace ban and the hospitality industry

ban.

Three qualitative studies37;41;50;51evaluated the impact of smokefree legislation. 49

One study50;51 explored whether, and in what ways national smokefree legislation affected

smokers’ experience of stigma in four areas in Scotland selected to provide urban and rural,

affluent and deprived communities. The intervention included thematic analyses of semi-

structured interviews in two socioeconomically advantaged and two disadvantaged localities

at three time points, one pre-legislation and two post-legislation (2005 to 2007), and also

observational data recorded in public places. Smokers’ narratives in the disadvantaged

localities described more decreases in consumption and successful quitting than those in the

affluent localities. Participants’ narratives suggested that a range of factors underlay the

decreases in consumption and most of these were connected to the environmental constraints

of smokefree legislation and the nature of any newly created public social spaces for

smoking. There appears to have been a more substantial change in deprived areas, because

the advantaged areas already had reasonably comfortable accommodation for smokers

outside, and opinion changed from being opposed to the ban to accepting it and following it.

Smokers in disadvantaged areas said they abided by the law to support the licensee, and

rushed cigarettes because they were worried about their drink. These smokers might visit

public places less because of the ban. Smokers in advantaged areas said that they smoked

less, or quicker, because going outside interrupted social activity, and because of concerns

over the stigma of being seen smoking. While some described how they were able to re-

create convivial social groups in the new smoking places, for example, where there was

comfortable and sheltered provision, others particularly in disadvantaged communities

described limited or no outside provision for smokers. Thus, the sense of separation was

compounded by a loss of comfort, particularly in poor weather with an implicit and real loss

of status compared with their pre-legislation position.

This qualitative study provides an in-depth analysis which showed that there might be some

unintended negative consequences of the smokefree legislation. It is unlikely that the study

sample was representative of the community as a whole and it is unclear whether the study

areas were typical of each urbanisation/affluence category.

50

Another qualitative study, also set in Scotland, explored how management, customers and

workers from across the social spectrum received and responded to the new measures

following the smokefree legislation.41 Ten bar proprietors, 16 bar workers and 44 customers

were interviewed in eight Scottish community bars in three contrasting study communities

located in one local authority area over 12 months. Bars in deprived study communities

tended to show lower compliance and less support for the legislation compared with the

relatively affluent community, but there were exceptions to this. Three factors were

particularly important in explaining variance between bars: smoking norms, management

competency and management attitudes towards the ban. Smoking norms and management

attitude were related to social disadvantage.

The small number of bars studied means that the study does not provide a representative

view of the licensed trade across Scotland. The strength of the study is derived from the

multiple perspectives offered by interviewing customers, bar workers and proprietors

operating in the same study sites. Study authors argue that the generalisability of the results

arises from the reliability of the compliance and enforcement concepts and their value to

assessment in a wider range of settings.

A Canadian qualitative study37 explored the effects of SHS policies on a purposive sample

of 47 men and women. Participants were classed as low income or non-low income

according to their self-reported combined family income before deductions. Interview and

focus group transcripts were analysed and recurring themes were identified, paying

particular attention to gendered factors and income levels. Three key themes included:

reshuffling and relocating where people smoke; SHS management and the impact on social

relations and interactions; disparities in the effect of policies and management of SHS.

51

The majority of participants thought that people living on a low income would be more

vulnerable to SHS, face more smoking-related challenges and be less likely to benefit from

SHS policies. Participants noted that smokers tend to be poor and have fewer resources to

afford healthier options, experience more stress and anxiety, and are more likely to use

smoking as a coping mechanism. Participants noted that some people living on a low income

use smoking to cope with mental illness, and therefore face more barriers to reducing or

quitting smoking. Participants thought that people living on a low income tend to be

surrounded by more smokers, and also that smoking restrictions are less likely to be

regulated. Participants thought that low income neighbourhoods or housing areas often lack

access to private outdoor space, creating challenges for those individuals trying to reduce

their smoking or SHS exposure.

The study authors recruited a small purposive sample specific to Vancouver, Canada, and

not based on smoking status. Study authors were unable to recruit men living on a low

income to attend a focus group, and only one non-low income woman turned up for a focus

group.

A cross-sectional study34 using data from the 2004 New York City Health and Nutrition

Examination Survey (NYCHANES) estimated the prevalence of smoking and SHS exposure

among 1,767 non-smoking adults in New York City (NYC) compared to a national dataset

(2003/2004 National Health and Nutrition Examination Survey), following comprehensive

smokefree workplace and enclosed public place legislation in NYC in 2003. Although the

smoking prevalence in NYC was lower than that found nationally (23.3% vs. 29.7%, p

< .05), the proportion of non-smoking adults in NYC with elevated cotinine levels was

greater than the national average (56.7% vs. 44.9%, p < .05).

Smoking prevalence in both the NYC and U.S. populations was higher in those earning less

than $20,000 per year. Nationally, those with less than a high school education had a

significantly higher smoking prevalence than those with at least a high school education. In

NYC, the effect of education on smoking prevalence did not reach statistical significance (p

< .10). However, in NYC, those with less than a high school education were 64% more

likely than those with at least a high school education to have an elevated cotinine level. The

overall NYCHANES survey response rate was only 55%, in addition, NYC residents might

face unique exposure to SHS due to the density of the urban environment, which both limit

study findings.

52

Three studies evaluated the impact of smokefree bans on health outcomes. One repeat cross-

sectional study examined Acute Myocardial Infarction (AMI) admissions to Christchurch

Public Hospital in New Zealand before and after (2003 to 2006) the implementation of the

smokefree Environments Act in 2004.38 The smokefree legislation was associated with a 5%

reduction in AMI admissions. The 55 to 74 age group recorded the greatest decrease in

admissions (9%) and this figure rose to 13% among never smokers in this group. The effects

of area deprivation increased the reduction to 21% among 55 to 74 year olds living in more

affluent (quintile 2) areas (RR 0.76; CI 0.59–0.97). Overall however, the statistical

association of changing levels of AMI admissions with smoking status and with deprivation

was not consistently significant. Long-term secular trends in AMI admissions might have

accounted for some of this change and new diagnostic criteria for AMI was also introduced

during the time of the study.

A repeat cross-sectional study evaluated changes in acute coronary event rates (2000 to

2005) in residents of Rome39 in relation to the 2005 ban on smoking in all indoor places. The

study included both out-of-hospital deaths and hospitalised cases. The reduction in acute

coronary events was statistically significant in 35 to 64 year-olds (11.2%, 95% CI 6.9% to

15.3%) and in 65 to 74 year-olds (7.9%, 95% CI 3.4% to 12.2%) after the smoking ban.

People aged 35 to 64 years living in low socioeconomic census blocks (socioeconomic

positions [SEP] 1 to 5, 1=low, 5=high) appeared to have the greatest reduction in acute

coronary events after the smoking ban with significantly reduced ORs for SEP 3, 4 and 5 but

not 1 and 2; but there was no evidence of a statistically significant interaction. The study did

account for several time-related potential confounders, including particulate matter air

pollution, temperature, influenza epidemics, time trends, and total hospitalization rates.

However study authors noted that the implementation of new diagnostic criteria and changes

in daily doses of statins during the study period could have partially accounted for decreases

in acute coronary events.

53

A cohort study before and after smokefree legislation in England and Scotland59 determined

whether workers’ attitudes towards the change in their working conditions might be linked to

the change in health they report. Data sources were the Bar workers Health and

Environmental Tobacco Smoke Exposure (BHETSE) for Scotland and the Smokefree Bars

07 for England. The study used a convenience sample of 548 bar workers in participating

bars from a random sample of bars in Glasgow, Edinburgh and Aberdeen; and small towns

in Aberdeenshire and the Borders areas of Scotland, central London and Liverpool;

Northumbria and Cumbria; and Newcastle-upon-Tyne.

There were a lower proportion of bars in England agreeing to participate compared to

Scotland (18% England; 45% Scotland) and a significantly higher proportion of bar workers

in England compared to Scotland were lost to follow-up. Analyses of reported health

symptoms were limited to 180 bar workers that did not have a cold at baseline or follow-up;

only 69 of the 253 baseline bar workers were in the low SES group (school level education).

There was no difference in the initial attitudes towards smokefree legislation between those

working in Scotland and England. The proportion of people reporting any symptoms was

significantly reduced from baseline to one year, in both England (76% vs. 49%) and

Scotland (81% vs. 67%), with similar patterns being evident for both countries. However,

the size of the reduction in symptom prevalence in Scotland was lower than in England.

Attitude towards smokefree legislation was not found to be related to change in reported

symptoms for bar workers in England (Respiratory, p = 0.755; Sensory, p = 0.910). In

Scotland there was suggestion of a relationship with reporting of respiratory symptoms (p =

0.042), where those who were initially more negative to smokefree legislation experienced a

greater improvement in self-reported health. For the majority of the questions, bar workers

who were educated to degree level and higher were significantly more positive towards the

smokefree legislation than those who did not continue with education after school. Level of

education did not significantly effect change in symptoms reported. There was no

association between smoking status and change in reported health. There was no evidence

that bar workers who were initially more supportive of the smokefree legislation were more

likely to report improvements in health. In summary, bar workers of all SES appeared to

benefit from smokefree legislation in terms of perceived health.

54

Six studies40;54-56evaluated the impact of smokefree legislation alongside other policies, and

reported the impact of smokefree legislation separately, mainly on smoking prevalence. One

study evaluated the impact of smokefree legislation in New York City (NYC)54, two

studies40;55 evaluated national smokefree legislation (one for women only55) and one study

used data on smokefree legislation from 18 European countries.56

A US study54 determined the impact of comprehensive tobacco control measures in New

York City beginning in 2002 (cigarette tax increases, Smoke-free Air Act (SFAA) 2002, free

NRT, tobacco control media campaign). During the 10 years preceding the 2002 programme,

smoking prevalence did not decline in New York City. From 2002 to 2003, smoking

prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%,

(P=.0002) approximately 140000 fewer smokers). Smoking declined among all education

levels. Groups that experienced the largest declines in smoking prevalence included residents

in the lowest and highest income brackets and residents with higher educational levels.

The decrease was more pronounced among low-income women (an 18.1% decrease, from

21.6% to 17.8%; P=.009). Significant decreases in smoking were found among residents

with more than a high school education (a 12.4% decrease, from 19.3% to 16.9%; P=.01).

Declines were also large among residents with annual family incomes of less than $25000 (a

12.6% decrease) or $75000 or more (a 13.4% decrease). In 2003, former smokers who had

quit within the past year were more likely to have low incomes compared with former

smokers who had quit more than 1 year previously (43.6% vs 32.0%, p=.0001). High-

income residents were more likely than low-income residents to report that the SFAA

reduced their exposure to ETS (53.3% vs 41.9%, P<.0001).

A US study55 examined the association between smoking and tobacco control policies

(increase in cigarette price, tobacco control media campaigns, clean air laws) among women

of low SES, using four waves of data between 1992 and 2002 from the TUS. Clean air laws

were represented by an index of state level clean air regulations. States with ‘‘no smoking

allowed (100% smoke free)’’ were counted as 100% of the effect, with ‘‘no smoking

allowed or designated smoking areas allowed if separately ventilated’’ as a 50% effect, and

with ‘‘designated smoking areas required or allowed’’ as a 25% effect. Separate indices by

type of law were used, and an aggregate weighted index, with worksite laws weighted by

50%, restaurant laws by 30%, and laws for other public places by 20%.

55

Smokefree legislation (clean air laws) was associated with a marginal effect on current

smoking. Over the period 1992–2002, current smoking among low education women was

inversely related to the index of clean air laws, with an odds ratio of 0.91 (0.80, 1.03), but

was significant only in the medium education female sub-population, with an odds ratio of

0.88 (0.83, 0.94). However, only in the 2001/02 model do clean air laws seem to play a part

for the medium education female sample, although the confidence intervals around the

estimates for each survey wave overlap for this group. It should be noted that most of the

developments in clean air regulations at the state level occurred after 2001.

A US study40used data from the February 2002 panel of the Tobacco Use Supplement of the

Current Population Survey (54,024 individuals representing the US population aged 15–80)

to evaluate the effect of strong clean indoor air laws (100% ban) and cigarette prices on

smoking participation and consumption. Clean indoor air laws and cigarette prices were

independently associated with significant reductions in smoking participation and

consumption. The effect of clean indoor air laws on smoking status (OR 0.66) was larger

than the effect of cigarette prices over the range of prices at which they found smokers to be

price sensitive (OR 0.83 for $2.91 to $3.28). Established patterns of education and income

disparity in smoking were largely unaffected by either clean indoor air laws or price in terms

of both mean effects and variance. The study authors concluded that strong clean indoor air

laws and price increases appear to benefit all SES groups equally in terms of reducing

smoking participation and consumption and are generally neutral with regard to health

disparities.

One European study examined the extent to which tobacco control policies (increase in

cigarette price, advertising bans, public place bans, campaign spending, health warnings)

were correlated with smoking cessation, in eighteen European countries.56 Log-linear

regression analyses were used to explore the correlation between national quit ratios and

scores (total and sub scores by separate policy) on the Tobacco Control Scale (TCS). The

SES variable was the Relative Index of Inequality (RII); the RII assesses the association

between quit ratios and the relative position of each educational group, and can be

interpreted as the risk of being a former smoker at the very top of the educational hierarchy

compared to the very lowest end of the educational hierarchy.

56

The study found large variations in quit rate and RII between countries. Quit rates were

positively associated with TCS score; more developed tobacco control policies were

associated with higher quit rates. More educated smokers were more likely to have quit than

lower educated, for men and women. There was a larger absolute difference between high

and low educated adults for 25-39 year olds. The regression coefficient for the association

between national quit ratios and sub score for public place bans, on TCS was 0.94 (-2.43 to

5.89) for men and 0.41 (-3.84 to 5.26) for women. However, no consistent differences were

observed between higher and lower educated smokers regarding the association of quit ratios

with score on the TCS. Strong conclusions cannot be drawn because of various study

limitations; the survey was conducted before the TCS was devised, and before some were

policies enacted, so the study results might underestimate the impact of recent smoking

policies. In addition, the study only examined the association between ex-smokers and

presence of policies, rather than changes in smoking prevalence post-implementation.

A US study57 examined the impact of smokefree legislation (and cigarette excise taxes) on

tobacco use among households with children aged six to seventeen years of age. Household

tobacco use was defined as any member of the household using tobacco. Data sources

included the National Survey of Children’s Health 2003 (N = 67,607) and 2007 (N =

62,768). The study is a comparison of methods study in which the authors focus on causal

inference model results. A smoke-free legislation total score for each state was constructed

from the National Cancer Institute’s State Cancer Legislative Database, which measured the

scope and strength of smoke-free legislation across seven domains from zero (none) to 32

(very strong) and coded in 10 unit increments: government worksites (scoring 0–5); private

worksites (0–5); schools (0–5); childcare facilities (0–5); restaurants (0–4); retail stores (0–

4); recreational/cultural facilities (0–4). From 2001 to 2005, 18 US states strengthened

smokefree legislation with a mean increase of 13.3 (SE 1.8; range 1–28). In 2005, the mean

smokefree legislation total score was 12.0 (SE 1.3; range 0–32).

57

In adjusted causal inference models there was no effect of smokefree legislation on

household tobacco use. In adjusted cross-sectional models, a higher smokefree legislation

total score was associated with a lower prevalence of household tobacco use. The interaction

between smokefree legislation and household income was only significant for households at

the 100–199 % Federal poverty level but not at 0–99 % Federal poverty level or above 199%

federal poverty level. Smokefree legislation was not associated with an overall reduction in

household tobacco use. However, the measure used (household tobacco use) would not have

picked up any changes in individual household members’ smoking if one member of the

household was still using tobacco.

A cohort study58 in the Netherlands examined age and educational inequalities in smoking

cessation due to the implementation of a national smokefree hospitality industry legislation.

The study assessed three interventions which were all implemented at the same time and also

included a national tobacco tax increase and a national mass media smoking cessation

campaign. Three survey waves of the International Tobacco Control (ITC) Netherlands

Survey, 2008 (before) and 2009 and 2010 (after) were used. Dutch smokers (having smoked

at least 100 cigarettes in their lifetime and currently smoking at least once per month) aged

15 years and older were recruited from a probability-based web database and 78% responded

to the first survey. Analyses were restricted to respondents who participated in all three

survey waves, did not quit during the 2008 and 2009 surveys and answered all survey

questions.

In total, 65.6% reported having visited a drinking establishment that had some form of

smoking restriction. Higher educated smokers were more exposed to the smokefree

legislation. Exposure to the smokefree legislation had a significant positive association with

attempting to quit smoking in the univariate analyses, but not with successful smoking

cessation. In the multivariate analyses, the association between exposure to the smokefree

legislation with attempting to quit smoking remained significant (OR:1.11; 95% CI:1.01–

1.22; p=0.029). There were no overall age or educational differences in successful smoking

cessation after the implementation of the smokefree legislation.

58

The follow-up rate was 70%. However the study authors’ report that almost half of the

sample was either lost to follow-up or did not answer all questions. These respondents were

younger; less addicted and had more intention to quit smoking. Therefore, the results may

not be fully generalisable to the broader population of Dutch smokers.58However this study

did measure exposure to each policy and measured the effects of each policy.

Three studies investigated voluntary smokefree home policies by SES. 36;46;47

One study36 evaluated the impact of a statewide smokefree law enacted in July 2010 in

Wisconsin, USA, on voluntary smokefree home policies by SES.36 Six hundred and thirty-

four adults were surveyed before the ban and 434 after the ban. Participants who lived in an

area with a workplace or complete public smoking ban prior to the statewide ban were

excluded from the analysis. Smoke-free legislation in Wisconsin increased the number of

participants who reported having strict no-smoking policies in their households and

decreased reported exposure to tobacco smoke inside the home. The smoking ban was

associated with a reduction of participants reporting exposure to smoke at home (13% to 7%;

P=0.002) and an increased percentage of participants with no-smoking policies in their

households (from 74% to 80%; P=.04).

Participants being exposed to smoke at home were significantly reduced only for the highest

income group and the higher education group. Participants having a strict ban in the home

were significantly increased only for the highest income group and the higher education

group. Smokefree legislation was not associated with change in smoking prevalence but

analyses were weakened by the small sample size. Although this study is specific to the

residents of Wisconsin, it is the only included study that directly evaluated the impact of

smokefree legislation in public places on home smoking by SES. This study suggests that a

statewide smoking ban does beneficially impact voluntary home smoking policies, but only

for higher SES adults, suggesting a negative equity impact in this setting.

Two further studies were included which measured parental smoking in homes by proxy (via

children’s reports).

59

The changes in child exposure to environmental tobacco smoke (CHETS) study was

included: CHETS Wales46 and a CHETS UK study.47 The CHETs studies applied repeat

cross-sectional class-based surveys, in order to explore the impact of smokefree legislation

on 11 year old children’s exposure to SHS. In addition the CHETS Wales46 study measured

children’s estimates of adult smoking prevalence and parental smoking in cars and in homes.

The CHETS UK study47 pooled data from the Scottish, Welsh and Northern Irish CHETS

studies to examine socioeconomic patterning in children’s reports of parental restrictions on

smoking in cars and in homes.

Results for the home are included in the previous section (3.2.2) and results for cars are

reported in this section (3.2.3). Individual data from the Welsh46 study is described

separately and is also included in the pooled analyses of UK data along with data from

Scotland and Northern Ireland.47 Participants were non-smokers (self-reported non-smokers

providing saliva samples containing <15ng/ml cotinine) in their final year at 304 primary

schools in Scotland (n = 111), Wales (n = 71) and Northern Ireland (n = 122).47 The pooled

data was adjusted for country and age, and clustering was accounted for. The data set

comprised 10, 867 children (5347 baseline/5520 follow-up), average age was 11.2 years.

SES varied significantly between survey years, with affluence being higher at follow-up

survey.

In the CHETS Wales46 study children were asked to identify whether parent figures (mother,

father, stepfather or mother’s partner, and stepmother or father’s partner) smoked in the

home. Multinomial regressions were used to assess change in home-smoking restrictions.

The CHETS Wales46 study showed that parental smoking in the home and perceived

smoking prevalence were highest among children from low SES households. In 2007 the

percentage of homes with neither parent smoking (reported by children) were 48.9% for low

SES (as measured by Family Affluence Scale), 65.5% for medium SES and 72.4% for high

SES. In 2008 the percentage of homes with neither parent smoking were 49.9% for low SES,

67.3% for medium SES and 78.1% for high SES.

60

Parental smoking in the home and children’s estimates of adult smoking prevalence declined

only among children from higher SES households following smokefree legislation. The

percentage of children from higher SES households perceiving that nearly all adults in Wales

smoked halved, while estimates remained stable for lower SES children. The study authors

report that lower SHS exposure in high-SES children following smokefree legislation might

be explained by lower levels of parental smoking in the home among higher SES parents

after smokefree legislation.

The CHETS UK study47 measured smoking restrictions in the car and home as well as

parental smoking. Children were asked whether smoking was allowed inside their home. In

all countries, and the combined data set, as SES increased, the likelihood of partial or no

home smoking restrictions (compared with full smoking restrictions), decreased significantly

even after adjustment for parental smoking. There was no change in inequality following

legislation. Following legislation, 26.3% of children scoring 1 on FAS reported living in a

fully smoke-free home, climbing to 72.0% for those scoring 9.

3.2.3 Smoking restrictions in cars

Four studies investigated voluntary smokefree car policies by SES46;47;60;61

One US study60 examined smoking behaviour in terms of imposition of smoking rules in cars

with children present, amongst smoking parents in the US, in the context of no ban. The

study used baseline data from 10 control sites (in 8 US states) from a cluster RCT ‘Clinical

Efforts Against Secondhand Smoke Exposure’ which was an intervention to address parental

tobacco use within the paediatric clinic setting. The study sample were parents or legal

guardians who accompanied a child to the visit; were at least 18 years old; spoke English;

had smoked at least a puff of a cigarette in the past 7 days and completed a baseline

enrolment survey for which they received $5 cash.

Parents who smoked were asked about smoking behaviours in their car and receipt of smoke-

free car advice at the visit. Parents were considered to have a “strictly enforced smoke-free

car policy” if they reported having a smoke-free car policy and nobody had smoked in their

car within the past 3 months. The measure of SES used was level of education (high school

or less versus some college or college graduates). Analyses were limited to parents who

smoked and who reported having a car that they owned or travelled in frequently, it was

unclear how representative this study sample was of the general population.

61

Twenty-nine percent of 795 parents reported a smokefree car policy and 48% reported that

smoking occurred with children present in the car. Fourteen percent of smoking parents

reported being asked if they had a smoke-free car, and 12% reported being advised to have a

smoke-free car policy by a paediatric health care provider. Of those who smoked with

children present in the car, only 5% were counselled about having a smoke-free car. No

significant association was found between parents education level and having a strictly

enforced smokefree car policy. However, parents of children aged less than one year were

more likely to have strict smoke-free car policies if they were college educated (OR:2.42;

95% CI: 1.21 to 4.83, p = 0.013). Strict smoke-free car policies were more common when

parents were both light smokers (smoked 10 cigarettes or less per day) and college educated

(OR: 2.88; 95% CI: 1.24 to 6.66, p = 0.013).

A New Zealand observational study observed smoking prevalence in vehicles61 and

differences between high and low areas of deprivation and over time. The study evaluated

the point prevalence of smoking and of SHS exposure in moving vehicles and compared

these prevalence’s between two areas of contrasting socioeconomic status and over time. In

New Zealand, all workplace vehicles accessible by the public have been required to be

smoke-free since 1990 and during 2006 to 2008 there was a Government-funded smoke-free

vehicles media campaign.

A total of 149,886 vehicles were observed in 20 days in a high SES area (Wainuiomata,

NZDep deciles 7-9) and a low SES area Karori NZDep deciles 1-4). The mean point

prevalence of smoking in vehicles at both sites combined was 3.2% (95% CI 3.1% to 3.3%).

Of those vehicles with smoking, 4.1% had children present. Smoking point prevalence in

vehicles was 3.9 times higher in the area of high deprivation than in the area of low

deprivation (95% CI 3.6 to 4.2). The same pattern was seen for vehicles with only the driver

at 3.6 times (95% CI 3.4 to 4.0), in vehicles with other adults at 4.0 times (95% CI 3.4 to

4.7) and in vehicles with children at 10.9 times (95% CI 6.8 to 21.3), with all results adjusted

for vehicle occupancy.

62

Compared with data collected in the 2005 study at the same two observation sites, there was

an absolute reduction in the point prevalence of smoking in vehicles of 1.1 percentage points

(RR relative to the former 1.3, 95% CI 1.2 to 1.5). The relative reduction over time in the

area of low deprivation was 1.2 times greater than in the area of high deprivation (95% CI

1.0 to 1.6). There was an absolute reduction in the point prevalence of smoking in the

presence of others in vehicles between 2005 and 2011 of 0.2 percentage points (RR relative

to the former 1.3, 95% CI 1.1 to 1.6). The relative reduction over time of smoking in the

presence of others in the low-deprivation area was 1.3 times greater than that for the high-

deprivation area (95% CI 0.8 to 2.1).

Inter-observer variation between observer pairs was assessed (k values were (1) 0.99 for any

smoking, (2) 0.87 for other adults in vehicles with smoking and (3) 0.80 for children in

vehicles with smoking). Occupants appearing to be aged 12 years or younger were classified

as children; otherwise they were recorded as adults and so this was a subjective judgement

made by the observers. The study sample may not be fully representative of smoking in

vehicles in the Wellington region (or for elsewhere in New Zealand). In addition, as the

author states; point prevalence of smoking might underestimate the true population

prevalence of smoking in vehicles. Although a smoke-free vehicles media campaign took

place prior to the study, the study does not evaluate the impact of this campaign on smoking

in vehicles.

Two further studies were included which measured parental smoking in cars by proxy (via

childrens reports).

The changes in child exposure to environmental tobacco smoke (CHETS) study was

included: CHETS Wales46 and a CHETS UK study.47 The CHETs studies applied repeat

cross-sectional class-based surveys, in order to explore the impact of smokefree legislation

on 11 year old children’s exposure to SHS. In addition the CHETS Wales46 study measured

children’s estimates of adult smoking prevalence and parental smoking in cars and in homes.

The CHETS UK study47 pooled data from the Scottish, Welsh and Northern Irish CHETS

studies to examine socioeconomic patterning in children’s reports of parental restrictions on

smoking in cars and in homes.

63

Results for the home are included in the previous section (3.2.2) and results for cars are

reported in this section (3.2.3). Individual data from the Welsh46 study is described

separately and is also included in the pooled analyses of UK data along with data from

Scotland and Northern Ireland.47 Participants were non-smokers (self-reported non-smokers

providing saliva samples containing <15ng/ml cotinine) in their final year at 304 primary

schools in Scotland (n = 111), Wales (n = 71) and Northern Ireland (n = 122).47 The pooled

data was adjusted for country and age, and clustering was accounted for. The data set

comprised 10, 867 children (5347 baseline/5520 follow-up), average age was 11.2 years.

SES varied significantly between survey years, with affluence being higher at follow-up

survey.

In the CHETS Wales46 study children were asked, “While you were in a car yesterday was

anyone smoking there?”46 Binary logistic regression models examined car-based smoking.

The study showed that car-based SHS exposure was highest among children from low SES

households. The percentage of children reporting SHS exposure in a car the previous day

remained at 7% before and after the smokefree legislation.

In 2007 percentages of children reporting car-based exposure to SHS exposure was 8.8%

(n=69) for low SES (as measured by Family Affluence Scale), 6.5%% (n=79) for medium

SES and 5.4% (n=58) for high SES. Among the lower SES group, percentages of children

reporting car-based exposure increased slightly from 7.4% (n = 31) pre-legislation to 10.6%

(n = 38) post-legislation. Among the medium-SES group, exposure remained almost

unchanged, at 6.3% (n = 38) pre-legislation and 6.6% (n = 41) post-legislation. However,

among the high-SES group, exposure declined from 6.3% (n = 33) to 4.6% (n = 25). The

changes in car-based SHS exposure were not statistically significant for any of the three SES

subgroups, however the changes did increase between group differences from 1% pre-

legislation to 6% post-legislation.

The CHETS UK study47 measured smoking restrictions in the car and home as well as

parental smoking. Children were asked ‘Are people allowed to smoke in your car, van or

truck?’ Car-based smoking declined and reached significance in the pooled UK sample

before and after adjustment for parental smoking. There was no change in inequality

following legislation. Percentages reporting that smoking was not allowed in their car ranged

from 51.7 (least affluent) to 83.0% (most affluent). Following the smokefree legislation in

the UK, smoking restrictions in the car increased. Post-legislation changes were not

patterned by SES but socioeconomic differences remained. 64

3.2.4 Summary of smoking restrictions in workplaces, enclosed public places, cars and,

homes

Forty-four studies evaluated the adoption/coverage or and/or the impact of smoking

restrictions in workplaces and enclosed public places.

Summary of smoking restrictions in workplaces

Fifteen studies assessed the socioeconomic impact of smoking restrictions, 13 studies were

set exclusively in workplaces and two studies included workplace settings. The majority of

studies evaluated local or regional adoption of smoking restrictions, either enforced or

voluntary, within the USA. Two studies assessed the impact of national workplace smoking

restrictions in Belgium25 and in the Netherlands30, and one study assessed the impact of

moving from a voluntary to an enforced smoking ban within a UK university.23The majority

of studies were cross-sectional surveys, of which five US-based studies used the same survey

data source; the Tobacco Use Supplement to the Current Population Survey, from various

years. One study included qualitative interviews following adoption of a smoking ban within

a university.23 Findings from three of the studies could be generalisable on a national scale,

although some study findings might be specific to indoor workers and working women.

The evidence shows that, where the adoption of policies is voluntary,, significant inequalities

exist in policy coverage and SHS exposure among workers according to SES. In general, the

higher the level of income or education or occupational status, the greater the odds of

working in a smokefree environment and the stronger the workplace smoking restrictions.

The lower the level of income, education and occupation, the greater the smoking prevalence

and the greater the SHS exposure. Smoking prevalence was generally higher among workers

in occupations with a lower percentage of workers covered by smokefree workplace policy.

Stricter non-smoking policies were associated with greater declines in smoking prevalence.

One study20 found that declines in prevalence were similar across educational groups, though

the largest effects were in the highest educational groups (negative equity effect). However,

declines in consumption were greater in the low educational groups (positive equity effect).

Qualitative interviews showed that a smoking ban can contribute to and sustain social

inequalities among staff. These inequalities in adoption and coverage of workplace smoking

policies by SES was also found, in the US, to be related to inequalities in the adoption of

smokefree policies at the regional and community levels, with lower SES communities less

likely to have adopted clean air ordinances.

65

An ITC study of Australia, Canada, UK, and USA15 found that while current smokers with

higher SES were more likely to have total worksite smoking bans, the rate of the adoption of

such bans over a one year period (2006/7-2007/8) was comparable by SES group. The

authors conclude that the recent proliferation of smokefree policies in these locations has led

to a reduction in disparities in coverage by SES, as low SES worksites and public places are

catching up in the adoption of total smoking bans and therefore having a positive equity

impact.

The only study assessing the impact of a worksite smoking policy which showed positive

benefits in terms of equity of exposure to SHS, was also the only study that just included

workers that were both non-smokers and not exposed to SHS smoke at home, which means

that they are probably not representative of all workers.18 The study showed that inequalities

in SHS workforce exposure might be diminishing with the increased adoption of clean

indoor laws in the USA; measured by serum cotinine levels. Blue-collar non-smoking

workers that were not exposed to SHS at home continued to have the highest cotinine levels

but experienced the largest absolute reductions. 18

Only two studies evaluated national smokefree legistation (partial) and both studies failed to

show a reduction in inequalities in SHS exposure. Neither of the national smoking policies,

in Belgium or the Netherlands, were comprehensively implemented or enforced. Following a

national workplace smoking decree in Belgium, companies with a high blue/white collar

ratio were less likely to implement health policy recommendations. However, responses to

the study survey were significantly lower amongst companies with a low blue/white collar

ratio. Both before and after implementation of the national workplace smoking ban in the

Netherlands; lower-educated non-smoking workers were twice as likely to be exposed as

those with a higher level of education. There was a significant difference both for differences

between educational subgroups and the decrease in exposure since ban.

Three studies focussed on women workers only and also evaluated exposure in the home.

However, none of these studies directly evaluated the influence of workplace smoking policy

on home smoking policy by SES. These studies highlight the importance of measuring other

sources of SHS exposure, including the home, especially when the smoking in the home is

associated with quit attempts for women of all poverty levels26 but possible disparity in

enforcement of home smoking bans by SES.29

Summary of smoking restrictions in enclosed public places66

The evidence relating to the socioeconomic impact on the wider population of smokefree

restrictions in enclosed public places is derived from 29 mainly cross-sectional studies.

Three studies evaluated local/regional adoption of smokefree legislation, 22 studies

evaluated national smokefree legislation and four studies evaluated the impact of

comprehensive legislation in a state or city.

Evidence from three studies of local/regional adoption of smokefree legislation in the USA,

showed a negative equity impact in terms of policy adoption, with lower SES communities

having significantly less policy coverage in restaurants and bars. The evidence suggests that

partial or voluntary local adoption of smokefree legislation has the potential to increase

socioeconomic disparity in terms of protection from SHS exposure.

Overall, national comprehensive smokefree legislation reduces SHS exposure, increases quit

attempts and has positive health effects within the general population. By definition,

comprehensive national smokefree legislation also has a positive equity effect in terms of

removing inequalities in policy coverage. However, only two of the 22 studies15;52 that

evaluated national smokefree legislation using other outcome measures demonstrated a

positive overall equity impact. The recent proliferation of smokefree policies in bars,

restaurants and workplaces across Australia, Canada, UK and USA have had a positive

equity impact; by reducing disparities in policy coverage by SES, as low SES worksites and

public places catch up in adopting total smoking bans.15 A study52 based in England, Wales

and Scotland, showed that bars in more deprived areas experienced a greater percentage

reduction in PM2.5 levels up to 12 months post-implementation of national comprehensive

smokefree legislation, compared to more affluent areas, although there was higher levels of

PM2.5 at baseline for the more deprived areas.

Of the 22 studies that evaluated national smokefree legislation, nine studies showed equal

effectiveness by SES (neutral equity impact) and five studies showed a negative equity

impact. In three studies the equity impact was unclear and in another study the equity impact

was mixed according to outcome. All four studies that evaluated the impact of

comprehensive legislation in a state or city showed a negative equity impact.

One of the few studies that measured SHS exposure using a biochemically validated

outcome (salivary cotinine) showed that although SHS exposure was significantly reduced

following national smokefree legislation in England; significant beneficial impacts were

observed only among those from social classes I to III.53 67

Support for smokefree legislation was stronger among higher SES.33;35;43 One international

study48 of the same participants before and after smokefree legislation was introduced in

Ireland, France, Germany and the Netherlands, showed that smokers with a low educational

level were more likely than smokers with a high educational level to smoke in bars post-ban.

The evidence on the equity impact in terms of quitting and smoking behaviour was mixed.

For example, two studies did not demonstrate a significant association between SES and the

probability of attempting to quit43;44 ie a neutral equity impact, and one study showed a

‘flattening’ of the socioeconomic gradient in quitting smoking among parents of young

children in Scotland (but not in England) following the smokefree legislation.45 However,

within the same study; lower SES was associated with higher rates of maternal smoking

uptake and smoking in the home in both Scotland where the legislation had been introduced

and in England where smokefree legislation had not been introduced during the time of the

study. In the Netherlands 49 the workplace smoking ban (2004) and the hospitality smoking

ban (2008) were associated with significant increases in quit attempts and successful quit

attempts; but this was more apparent amongst higher SES, producing a negative equity

effect.

One study evaluated the impact of a statewide smokefree law enacted in July 2010 in

Wisconsin, USA, on smoking behaviours in and out of the home with an Annual Survey of

the Health of Wisconsin (SHOW).36 Participant exposure to tobacco smoke outside the home

improved in both education groups and in all income groups but the greatest decrease was in

the highest income group (family income >$60,000 per year).

Six studies evaluated the impact of smokefree legislation alongside other types of policies. 40;54-56;57;58 A regional smokefree ban in NYC was associated with an unclear equity impact;

smoking declined among all education levels and groups that experienced the largest

declines in smoking prevalence included residents in the lowest and highest income brackets

and residents with higher educational levels.54 Another US study40 found both strong clean

indoor air laws (100% ban) and cigarette prices were independently associated with

significant reductions in smoking prevalence and consumption. Established patterns of

education and income disparity in smoking were largely unaffected by strong clean indoor

air laws. The study authors concluded that clean indoor air laws appear to benefit all SES

groups equally in terms of reducing smoking prevalence and consumption, producing a

neutral equity effect.

68

Another US study55 showed that smokefree legislation (clean air laws) was associated with a

marginal effect on current smoking. Over the period 1992–2002, current smoking among

low education women was inversely related to the index of clean air laws, but was

significant only in the medium education female subpopulation and varied over time. In a

European study56 no consistent differences were observed between higher and lower

educated smokers regarding the association of quit ratios with score on the TCS. The

regression coefficient for the association between national quit ratios and sub-score for

public place bans, on TCS was not significant and did not vary significantly between high

and low education adults.

A US study57 examined the impact of smokefree legislation (and cigarette excise taxes) on

tobacco use among households with children aged six to seventeen years of age. Two

methods of analyses resulted in inconsistent results for whether smokefree legislation was

associated with an overall reduction in household tobacco use. In addition, the interaction

between smokefree legislation and household income was only significant for households at

the 100–199 % Federal poverty level but not at 0–99 % Federal poverty level or above 199%

Federal poverty level.

A cohort study in the Netherlands58 examined age and educational inequalities in smoking

cessation due to the implementation of a national tobacco tax increase. Higher educated

smokers were more exposed to the smokefree legislation and the association between

exposure to smokefree and attempting to quit was significant but was not significant for

successful smoking cessation, so the equity impact was neutral in terms of prevalence.

The national smokefree legislation in Italy42 was associated with beneficial short-term effects

for all males and for low-educated females. However there were limited long-term effects on

inequalities in smoking behaviour. The absolute difference in smoking prevalence between

high and low-educated males widened slightly over the whole time-period. Long-term trends

clearly favoured the higher educated females and educational differences in quit ratios

widened over time. Overall the Italian smokefree legislation had a negative equity impact.

69

Evidence from three qualitative studies based in Scotland showed a mixed equity impact of

the national smokefree legislation; bars in deprived study communities tended to show lower

compliance and less support for the national smokefree legislation compared with the

relatively affluent community. Smoking norms were related to social disadvantage and was

one of three factors which explained variation in compliance between bars.41 Post-legislation

changes in smoking behaviour were most apparent in disadvantaged localities. Smokers’

narratives in the disadvantaged localities described more decreases in consumption and

successful quitting than those in the affluent localities.51 However, smokers from both

deprived and affluent communities perceived the smokefree legislation to have increased the

stigmatization of smoking.50 A small qualitative study specific to Vancouver, Canada 37

explored the perceived effects of SHS policies. The physical, social, and economic barriers

low income women and men encounter to reducing smoking and smoke exposure were

viewed as possibly reinforcing or intensifying health-related disparities.

Three studies that reported on longer-term health outcomes showed a neutral equity impact.

Evidence from two studies38;39 did not show a consistently significant association between

national smokefree legislation and SES in terms of heart health, despite statistically

significant risk reduction for certain SES area deprivation quintiles within specific age

groups. A cohort study in England and Scotland59 showed that bar workers of all SES groups

appeared to benefit from smokefree legislation in terms of perceived health. Higher SES bar

workers had more positive attitudes towards the legislation, but level of education did not

significantly effect change in respiratory or sensory symptoms reported.

Three studies of smoking in the home were included. One study 36 suggests that a statewide

smoking ban does beneficially impact voluntary home smoking policies, but only for higher

SES adults, suggesting a negative equity impact of smokefree legislation on voluntary home

smoking restrictions. The CHETS Wales46 study suggests that the smokefree legislation in

Wales benefitted only high-SES parents and was potentially associated with increased

socioeconomic disparity in terms of parental smoking in the home (negative equity). The

CHETS UK study47 showed a neutral equity impact because there was no change in

inequality in parental smoking in the home following smokefree legislation. Following the

smokefree legislation in the UK, smoking restrictions in the home increased. Post-legislation

changes were not patterned by SES and socioeconomic differences remained. The smokefree

legislation in Scotland, Wales and Northern Ireland did not appear to displace smoking into

the home.

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Summary of smoking restrictions in cars

Four studies of smoking in cars were included: two investigated smoking in cars in the

context of no smokefree vehicle legislation, and two evaluated any impact of national

smokefree public places legislation on parental smoking in cars.

One study60 examined smoking behaviour in terms of imposition of smoking rules in cars

with children present, amongst smoking parents in the US, in the context of no ban. Parental

education level was not significantly associated with strictly enforced smokefree car policy

on its own, only significant in interaction with child age and amount smoked. College

educated parents of children aged less than one year were more likely to have strict smoke-

free car policies. A New Zealand study61 observed a decrease in smoking prevalence in

vehicles over time that was relatively greater in lower SES areas than in higher SES areas.

However, smoking prevalence and thus exposure to SHS within vehicles remained higher in

more deprived areas. It should be noted that it was unclear whether either of these studies 60;61

had representative study samples and results which can be generalisable on a national scale,

which weakens any equity impact.

The CHETS Wales study46 suggests that the smokefree public places legislation was

associated with increased socioeconomic disparity (negative equity) in terms of parental

smoking in cars. However, this conclusion is tentative because there were relatively few

children reporting car-based exposure at both time points, with changes in percentage

exposure based on small changes. The CHETS UK study47 showed a neutral equity impact

because, although smoking restrictions in the car increased following the smokefree

legislation, there was no change in SES inequalities in parental smoking in the car. The

smokefree public places legislation in Scotland, Wales and Northern Ireland did not appear

to displace smoking into the car.

No studies were identified which evaluated the equity impact of smokefree vehicle laws.

However, support for smokefree vehicle laws is increasing and these four studies, two

studies of smoking in cars in the context of no smokefree vehicle legislation, and two studies

of national smokefree public places legislation on parental smoking in cars, provide some

evidence for inequalities in smoking in vehicles in the absence of smokefree vehicle laws.

3.3 Increases in price/tax of tobacco products

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A total of twenty-seven studies40;54-58;62-82 assessed the socio-economic impact of increases in

the price and/or taxation of cigarettes. Studies were conducted mainly in the USA (n=16),

but also Canada (n=3), Australia (n=2), France (n=3), Ireland (n=1) and the Netherlands

(n=1). One study evaluated the impact of a range of tobacco control policies across 18

European countries.56 The SES variables used within the majority of studies were income

and education, although occupation and area-level deprivation were also used infrequently.

The majority of studies evaluated the effects of price/tax across the general population of

smokers. However, one study focused on people who were HIV-positive, another study

focussed on pregnant women, and one study focused on parents of children aged six to

seventeen years. Four of the studies54;65;74;79 included in this section evaluated elements of the

‘New York City 5 Component Tobacco Control Programme’.

Outcomes measured were generally similar across studies and mainly included price/tax

elasticity (the change in the percentage of persons smoking relative to a 1% change in

cigarette price), smoking prevalence and consumption, but also smoking behaviour including

product-related (e.g. changing to a cheaper brand) and smoking-related changes, quit

attempts and reasons for smoking. One study79 used over-the-counter pharmacy sales of

nicotine patch and gum products and one study measured the impact of price increase on

calls to quitlines.80

Twelve of the studies included econometric modelling (study design 1.4) which combined

repeat cross-sectional (mainly) or longitudinal survey data with inflation-adjusted prices for

a packet of cigarettes to produce price elasticities. Four studies were single cross-sectional

surveys, six studies assessed repeat cross-sectional survey data, four studies used

longitudinal cohort data including pharmacy sales data collected in real time over two years,

and one study was qualitative.

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Thirteen of the 27 study samples were assessed as representative of the study populations

with findings that are generalisable on a regional or national scale. The findings from three

studies were applicable to specific subpopulations only, including one study of HIV-positive

smokers, one study of pregnant women smokers and one study of parents only. The majority

of studies used credible data collection methods. In all but two studies58;76 attrition rates or

numbers of participants in each survey wave were acceptable. However in three studies some

of the SES subgroups were relatively small68;73;75In the majority of studies it was unclear

whether the observed effects were directly attributable to increases in the price and/or

taxation of cigarettes; econometric studies model potential effects of increases in price/tax

rather than directly ‘observing’ findings.

A Canadian econometric study62 used cohort data from the Canadian National Population

Health Survey to examine the impact of cigarette taxes on smoking prevalence. The higher

and middle income groups were less likely to be smokers than the low income group.

Individuals with post-secondary education were less likely to smoke than those with less

than secondary education. While the tax elasticity of the high income group (−0.202) was

larger than the low income group (−0.183), it was not statistically significant. The low

educated group were more tax sensitive than the high educated group. Tax elasticities by

education level were: less than secondary (−0.555), secondary (−0.218), some post-

secondary (−0.018) and post-secondary (−0.042). This study showed a positive equity

impact when education was measured but a neutral equity impact when income was

measured. Pictorial warning labels were introduced during the study period and may have

influenced smoker’s behaviour and so study findings cannot be attributed solely to increases

in cigarette tax.

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A US econometric study evaluated the responses in the National Health Interview Survey to

increases in cigarette prices by race/ethnicity, income and age groups and showed a positive

equity impact.65 Lower-income populations were more likely to reduce or quit smoking than

those with higher incomes. The total price elasticity was –0.29 (-0.20 prevalence, -0.09

consumption) for lower-income persons compared with –0.17 (-0.05 prevalence, -0.12

consumption) for higher income persons. This paper contained a summary report of the

study and the editor noted that smokers with family incomes equal to or below the study

sample median were more likely to respond to price increases by quitting than smokers with

family incomes above the median (e.g., 10% quitting compared with 3% quitting in response

to a 50% price increase). The analysis did not control fully for other factors unrelated to

price (e.g., differences between states in social and policy environments) that could reduce

demand and be confounded with the state’s excise tax level.

Another US econometric study examined whether cigarette taxes were progressive using

data from the Current Population Survey’s Income Supplements and Tobacco Use Survey.66

Increasing tobacco taxation had a small narrowing effect on socio-economic inequalities in

smoking. Total price elasticities were -0.37 (-0.243 prevalence, -0.127 consumption) for

low-income, -0.35 (-0.196 prevalence, -0.105 consumption) for middle-income, and -0.20 (-

0.115 prevalence, -0.083 consumption) for high-income groups. Higher income individuals

were less price-sensitive; however the difference was less than the standard error between

groups. A $1 rise in taxation would cause a decline of approximately 2.3 percentage points

in the low-income group, 1.7 percentage points in the middle income group and 0.8

percentage points in the high income group.

However, the study authors concluded that, higher prevalence of smoking among low

income groups meant that the benefit or taxation was outweighed by the tax burden borne by

non-quitters. The tax rise would absorb 1.9% of the median income of low income smokers,

and 0.7% and 0.3% for the mid and high income smokers. The disparity was even wider

once the increase in cessation was accounted for.

A US econometric study67 investigated the responsiveness of older adult smokers (45 to 59

years) to large (at least 50 cents per pack) cigarette tax rises using the Behaviour Risk Factor

Surveillance Survey. Twenty-two tax increases were included, from 18 states between 2000

and 2005. The study findings showed that a relatively large state tax increase was associated

with a large narrowing of education and income-related smoking disparities.

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The tax increases were associated with greater responses among low-educated smokers. $1

increase would reduce the fraction of low-educated smokers by over 10%, and only 3%

among those with more than high school education. Price participation elasticities were -0.43

for low-educated smokers and -0.12 for higher educated smokers. A similar pattern was seen

by income. A rise of $1 would reduce fraction of low-income smokers by about 10% and

high income by 2%. Low-income individuals, defined as those living in households with

annual incomes of less than $35,000, are found to quit at a much higher rate in response to

higher taxes than their counterparts from higher income households. Price participation

elasticities were -0.39 for low-income group (<$35,000) and -0.12 for high income group

($>35,000).

A US econometric study69 evaluated the effect of cigarette price increases by pooling data

from 14 years (1976-1980, 1983, 1985, and 1987-1993) from the National Health Interview

Survey. Adults with income at or below the median income were more than four times as

price-responsive as those with income above the median; total price elasticity was significant

at -0.43 (-0.21 prevalence, -0.22 consumption) and not significant at -0.10 (0.01 prevalence,

-0.11 consumption) respectively. Study authors did not report what the actual median income

was set which makes it difficult to compare findings with other similar studies.

A US econometric study70 examined the relationship between cigarette pack price and

smoking prevalence using data from the Behavioural Risk Factor Surveillance System for

1984 through to 2004. Increased real cigarette pack price overtime was associated with a

marked decline in smoking among higher-income but not among lower-income persons.

Although the pre-Master Settlement Agreement (MSA) association between cigarette pack

price and smoking revealed a larger elasticity in the lower- versus higher-income persons (-

0.45 vs -0.22), the post-MSA association was not statistically significant for either income

group.

Although smoking declined over the 20-year period, the gaps in smoking prevalence among

the income groups have widened. The proportion of lower-income persons smoking from

1984 to 1996 was 27.7%, increasing to 28.6% from 1997 to 2004; for higher-income persons

smoking declined from 23.9% to 21.6%. The study showed no evidence that increased

cigarette prices reduced disparities in smoking prevalence, with some indication of

increasing difference in smoking prevalence between the low income group and the high

income group.

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It appeared that the high income group responded to prices reaching a threshold (c.$2.50)

and had no further price responsiveness. So despite the widening of inequality the absolute

gap of smoking probability narrowed as price increased (between lowest income and other

income). Unfortunately the paper only reported price elasticities for lowest income group

against all other income groups although the figure on smoking prevalence reports

prevalence by lowest, second, third and highest income quartiles. On balance, this study

findings show a neutral equity impact.

A Canadian econometric study71 investigated the overall magnitude of the demand response

to price and also the difference in response by socioeconomic level, using Statistics

Canada/Health Canada Canadian Tobacco Use Monitoring survey (CTUMS) for years 2000

through 2005. Those with less than a completed high school education level experienced

declines in smoking that were just slightly above the average, those with completed high

school and college level experienced declines considerably below the average, and those

with university level experienced declines in excess of the average. For those with university

level education, prevalence declined by 30% while consumption declined by more than 40%.

The elasticities for high school and college graduates were approximately −0.3, while

smokers with less than high school appeared to be less responsive to price movements with a

median elasticity of −0.22. These elasticities take into account the impact of price on both

participation and quantity decisions. None of these estimates was in the region of unity, and

there was no evidence of either a declining elasticity value moving from a low to high

education group or a higher elasticity value for the lower group. Cumulative frequency

distributions for all smokers for each year showed a downward shift in these distributions

over time, indicating that continuing smokers were progressively smoking stronger

cigarettes. While the higher education group saw little change in choice of cigarette, the

lowest income group has, although pack choice does not necessarily translate to smoking

intensity.

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A Canadian econometric study72 estimated elasticities in the context of widespread

smuggling and explored the price sensitivity of smoking by income group. Excluding

smuggling provinces and using expenditure data suggested bias from using legal prices

instead of illegal prices paid through smuggling was quite modest because elasticities were

similar (elasticity not accounting for smuggling -0.72, excluding smuggling provinces -0.47,

using data expenditure elasticity -0.45). The elasticities were based on consumption rather

than prevalence data. Using expenditure data, it appeared that almost all of the response of

consumption to price changes occurred through reductions in consumption and not through

quitting smoking (using data expenditure elasticity -0.45, and conditional expenditure was -

0.43 excluding smuggling). Therefore, although this study showed a positive equity impact

for reaction to price it is based on changes in cigarette consumption and not in quitting

smoking.

Study findings showed that lower income groups spent a much larger share of their incomes

(4%) on cigarettes than higher income groups (1% for highest income quartile). There was a

pattern of much higher price elasticities for the lowest income groups than for the highest

income groups either by dividing the data using after-tax income quartiles or by

consumption quartiles, showing that the lowest income group is much more price sensitive

than higher income groups.

Divided by after-tax income quartiles, there is a much larger price elasticity of demand

among the lowest income smokers. In the bottom income quartile, there is no effect of higher

taxes on cigarette spending, with an estimated elasticity of demand close to −1. This

elasticity falls to −0.45 in the second quartile, and then to −0.31 in the third quartile before

rising again to −0.36 in the top quartile. The drop between the lowest income quartile and

the other three quartiles is a statistically significant one, whereas the differences in

elasticities within the top three quartiles are not statistically significant. Divided by

consumption quartiles the elasticity pattern is similar, except that the big drop-off is between

the second and third quartiles (this drop is statistically significant), while the difference in

elasticities between the first and second quartiles and the third and fourth quartiles are not

statistically significant.

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An Irish study73 used retrospective cohort data to investigate the role of tobacco taxes from

1960 to 1998, in starting and quitting smoking. The data was derived from a single cross-

sectional survey on women’s knowledge, understanding and awareness of lifetime health

needs, but mainly focussed on hormone replacement therapy as part of an unpublished MA

thesis at the University College Dublin. Higher tax levels were associated with earlier

cessation. Taxation had the strongest effect on cessation among those with the lowest

education, and an equal impact on those with other levels of education. The results were

tentative because of the potential for recall bias (going back 40 years in some cases), also

during the study period 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 tax.

A US study74 used data from the New York City (NYC) Department of Health and Mental

Hygeine survey to evaluate the impact of New York City’s April 2002 increase (13%) in the

state cigarette excise tax. Response was recorded in the survey by asking individuals “How

has the increase in cigarette prices (since April 3) affected your smoking?” The final sample

represented only 64% of eligible households and the data was collected at one time-point

shortly after the increase in tax. Response to recent taxation was only one minor part of the

survey which included detailed questions on current smoking practices, exposure to SHS and

smoking cessation practices.

Lower household income was independently predictive of current smoking. US born college

graduates were less likely to smoke than other New Yorkers. Internet purchases were more

common among those with a college education or higher compared with those with a high

school education or less (4.1% VS. 1.1%, P=.003), although this finding was not linked to

the response to the state tax increase but part of examination of smoking practices.

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In response to the 13% price increase; nearly one in four smokers reported reducing their

cigarette consumption shortly after the tax increase, whereas 2.8% of smokers reported

quitting smoking. In addition, 5.6% of all recent smokers (smoked cigarettes in the past 3

months) indicated that they had thought about quitting, 4.0% tried to quit, and 2.8% quit

smoking in response to the 39-cent price increase. When asked specifically about their

response to the state tax increase, 21.9% of individuals who had smoked cigarettes in the

past 3 months reported that they had reduced the number of cigarettes they smoked in

response to price increase. This response varied by income level, from 27.2% of those with

low incomes (<$25,000) to 11.0% of those with high incomes (>$50,000) (P < .0001). Quit

attempts were associated with lower income although again this was not linked to the

response to the state tax increase but part of general examination of cessation practices.

Study authors conclude that tax evasion through cross-border and internet cigarette

purchases could blunt the effectiveness of local tax increases and argue for a national

cigarette tax increase.

A French study75used mixed-methods, including both national repeat cross-sectional data and

in-depth interviews, to examine the social differentiation of smoking and why low-income

smokers are less sensitive to price increases. Data was derived from six telephone surveys

conducted by the National Institute for Prevention and Health Education between 2000 and

2008 and in-depth interviews with 31 ‘poor’ smokers. Subjective social status was used

based on financial status and consistency was checked using neighbourhood socio-

demographic profile and respondent’s education and occupational status. Occupational class

was also used as a measure of SES.

Study findings showed a negative equity impact; the difference in smoking prevalence by

occupational class widened; prevalence among executive managers and professionals fell

after the cigarette prices had begun to increase, whereas manual groups showed a smaller,

later, and temporary decline (prevalence increased again soon after).

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‘Poor’ smokers were aware of their addiction and of its financial cost. All spoke of stress-

relief, several spoke of ‘little moment of happiness’, and that smoking filled voids with

nothing else to do, and compensated for loneliness or emotional problems. Many felt it was

the only joy they had left. Concerning reactions to the cigarette price increase, about one

third of ‘poor’ smokers and ‘other’ smokers reduced their cigarette consumption, but poor

smokers were more likely to turn to cheaper or hand-rolled cigarettes (50% did so, versus

33% for other smokers). ‘Poor’ smokers were significantly more likely to smoke

automatically, less likely to smoke for social reasons, more likely to relieve stress and take

mind of worries, less to aid concentration.

The study authors concluded that smokers in low occupational groups and of low-income

were less likely to respond to tobacco control measures due to the harsh living environment

which acts to sustain their attachment to smoking, despite understanding the costs. The study

findings are only tentative, and the validity of these findings is weakened by the relatively

small sample of the manual group in most of the survey years.

A French cohort study also by Peretti et al76 investigated how HIV-infected smokers reacted

to a sharp increase in cigarette price and showed a negative equity impact.. In France, the

price of cigarettes doubled between 1997 and 2007 (from US$4 to US$8 approximately).

The French cohort study APROCO-COPILOTE investigated biomedical and

sociobehavioural characteristics of HIV-1 positive individuals who started an antiretroviral

therapy including protease inhibitors. Participants were enrolled between 1997 and 1999 in

47 French hospital departments delivering specialized care for HIV/AIDS patients, and

prevalence data was collected over ten years (1997 to 2007).

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Participants were grouped by type of transmission (infection through intravenous drug use

(IDU), homosexual intercourse, heterosexual intercourse or other). There were striking

differences across transmission groups regarding socio-demographic background and

smoking prevalence. The IDU group was characterised by a lower socioeconomic status, a

higher smoking prevalence and a smaller decrease in this prevalence over the period 1997 to

2007. The homosexual group had a higher socioeconomic status, an intermediate smoking

prevalence in 1997, and the highest rate of smoking decrease. In the dynamic multivariate

analysis, smoking remained correlated with indicators of socioeconomic disadvantage and

with infection through IDU. Aging and cigarette price increase had a negative impact on

smoking among the homosexual group, but not for the IDU group. In both univariate and

multivariate analyses, smoking remained much more prevalent among the IDU group and, to

a lesser extent among patients with a lower educational level as well as those who were

unemployed or on income support during follow-up. In multivariate analysis only, smoking

was significantly more prevalent among patients who never worked, as well as among those

with an intermediate level of occupation.

It should be noted that the smoking prevalence observed among HIV-infected patients

between 1997 and 2007 was higher than that measured in the French general population

during the same period. Study results are generalisable to HIV infected smokers having

antiretroviral therapy.

A US econometric study77 estimated how changes in state cigarette taxes affected the

smoking behaviour of pregnant women using the Natality Detail File, an annual census of

births in the US (1989 to 1995). The results indicated that highly educated pregnant women

were most responsive to changes in cigarette taxes and that increase in cigarettes tax had a

negative equity impact for this specific subpopulation. This group of pregnant women had

higher price elasticities than the general population; the participation price elasticity of

demand for this sample was 3 to 4 times the estimate for the general adult population.

Women at lower education levels (high school or less) had higher than-average smoking

rates for their subgroups but lower-than-average responsiveness to tax changes. Price

elasticities were ‘less than high school’ -0.30, ‘High school’ -0.49, ‘Some college’ -0.86,

‘College’ -3.39. The study authors also regressed cigarette consumption data, producing

price elasticity for consumption of 0.03; indicating that the effect of cigarette tax is mainly

on smoking participation.

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An Australian econometric study78 examined the effect of price on cigarette smoking

prevalence across three income groups in the five largest cities of Australia (Sydney,

Melbourne, Brisbane, Perth, and Adelaide) and showed a positive equity impact. Data was

derived from the Roy Morgan Single Source; a weekly omnibus survey by Roy Morgan

Research, an Australian market research company.

Between January 1991 and December 2006 smoking prevalence decreased from 28.2% to

19.7%, and price increased from $3.39 to $11.60. In the beginning of the period, the age-

adjusted prevalence in the low-, medium-, and high-income groups were 36.5%, 28%, and

21.5%, respectively. At the end of the study period, the prevalence had decreased to 28.4%,

21.8%, and 16.6%, respectively. Real price and prevalence were negatively associated. Price

elasticity in the lowest income group (<AU $18,000) was -0.32, but only -0.04 and -0.02 in

the medium and high income groups. One Australian dollar increase in price was associated

with a decline of 2.6%, 0.3%, and 0.2% in the prevalence of smoking among low-, medium-,

and high-income groups, respectively. There was a clear gradient in the effect of income on

prevalence that diminished at higher levels of price.

The study did include controls for several other policies enacted during the survey period;

televised antismoking advertising, the availability of nicotine patches by prescription, the

availability of nicotine replacement therapy by over-the-counter sale, the availability of

bupropion by prescription, the introduction of six bold rotating health warnings on cigarette

packs, the ban of most forms of tobacco sponsorship, and addiction (both myopic and

rational). The survey covered 61% of the adult population, but only in metropolitan areas

and so generalisability of the study findings to rural areas is unknown. The study focused on

only two cigarette brands which held 38% of the market in 2003; it is unclear if this was

sufficient to capture valid results across all cigarette brands.

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A retrospective survey63 examined smoker’s perceptions of the impact of statewide tobacco

taxes in Massachusetts, USA. Respondents were assigned to one of three mutually exclusive

categories: (1) did not respond to taxes (2) cut costs by reducing number smoked or changed

to cheaper brand (3) considered quitting. Lower income smokers were three times more

likely than higher income smokers to report cutting the costs of smoking and twice as likely

to consider quitting as opposed to having no response to the price increase. Lower income

smokers were significantly more likely than higher income smokers to respond to an

increase in cigarette prices. The lower the household income, the greater the impact of the

price increases on the respondent’s decision to quit. Household income was not related to the

choice between cutting costs and considering quitting. There appeared to be a positive equity

impact on smoking behaviour associated with a statewide tobacco tax increase. It should be

noted that 46% of continuing smokers denied having any of the three potential reactions to

the price increase and so the study could have failed to measure an important variable.

A US cohort study (Minnesota Adult Tobacco Survey) estimated the prevalence of the use of

price-minimizing strategies in a cohort of current smokers living in Minnesota, immediately

following the federal tobacco tax increase in 2009 and showed a negative equity impact

because strategies used by participants differed according to SES.64 Overall, 78% of

participants used at least one price minimizing strategy in 2009 to save money on cigarettes.

About 53% reported buying from less expensive places, 49% used coupons or promotions,

42% purchased by the carton, and 34% changed to a cheaper brand.

The lowest income group was significantly more likely than the highest income group to

report buying cigarettes from cheaper places, buying a cheaper brand, and rolling their own

cigarettes. The middle - income groups (annual household income between $25,000 and

$75,000) were significantly more likely than the highest income group to report buying

cigarettes from cheaper places, using coupons or promotions, and buying cartons instead of

packs. Participants who reported buying cartons instead of packs to save money were less

likely to attempt to quit smoking in the following year and cut back on cigarette

consumption. Having some college education, having an annual household income between

$25,000 and $75,000 were significantly associated with higher odds of using at least one

price-minimizing strategy; having less than high school education, having annual household

income less than $75,000, were significantly associated with higher number of strategies

used. Participants who used more strategies were less likely to cut back on their cigarette

consumption.

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An Australian study using repeat cross-sectional date from the Cancer Institute NSW’s

Tobacco Tracking Survey tracked smoker’s responses to the increasing price of cigarettes

after a tax increase in 2010 and showed a positive equity impact. 68 Overall, 47.5% of

smokers made smoking-related changes and 11.4% made product-related changes without

making smoking-related changes. The proportion of smokers making only product-related

changes decreased with time, while smoking-related changes increased with time. Low- or

moderate-income smokers (versus high-income) were more likely to make smoking-related

changes compared to no changes.

Smokers with less than high school education were more likely to have cut down, thought

about quitting or started using loose tobacco than those with a tertiary education, and those

with a high school or technical college education were also more likely to have started using

loose tobacco than those with tertiary education. Smokers with lower incomes (<$40 000)

were more likely to have cut down, changed to a lower price brand or started to use loose

tobacco than those with higher incomes, and those with a moderate income were more likely

to have changed to a lower priced brand.

A greater proportion of smokers from low SES neighbourhoods switched to lower-priced

brands than those from moderate–high SES neighbourhoods. However, these low-income,

less-education smokers were no more likely to engage in these practices without also

reporting some positive changes in their smoking-related behaviours. Study authors

conclude that the effect of increasing cigarette prices on smoking did not appear to be

mitigated by using cheaper cigarette products or sources.

A US study80 aimed to examine the impact on 16 state quitlines, before (2008) and after

(2009) a federal cigarette excise tax increase from 39 cents to $1.01 per pack. Smokers in

participating states represented 24% of smokers in US (2009). The study also included a

seven-month follow up from four state quitlines based on random samples of quitline

participants. Tobacco control varied between states but all quitlines provided mailed support

materials, a single reactive (inbound) counselling call to all tobacco users, and three or four

additional outbound calls to select groups. Some state quitlines referred insured tobacco

users to cessation benefits offered through their health plan or employer. All but four states

offered at least some free NRT depending on the state-approved eligibility criteria.

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Overall, there was a 23.5% increase in total call volume when comparing December 2007–

May 2008 (84,541 calls) to December 2008–May 2009 (104,452 calls). The tax effect on call

volumes had returned to the before tax levels in May 2009. Participant quit rates did not

differ significantly before versus after the tax increase (controlled for age, gender, race,

education, chronic condition, amount smoked, how heard about quitline, and state). More

quitline callers in 2009 compared with 2008 had less than a high school education (61.0% vs

58.6%, p=0.007). Quit rates at seven months did not differ before versus after tax, however

this was not reported by SES. The authors stated that more callers with the same quit rate

indicated an increase in the total number of successful quitters. The magnitude of the

differences before and after tax was small. The impact of the federal tax increase cannot be

analysed separately from other excise tax increases and other changes in state and local level

tobacco control policies. In summary, the tax increase was associated with a positive equity

impact for smokers in these 16 US states in terms of calls to the state quitlines, but quit rates

did not differ after the tax increase and whether the quit rate differed by SES is not reported.

A US study81 estimated how smoking prevalence, daily cigarette consumption, and share of

annual income spent on cigarettes varied by annual income (less than $30,000; $30,000–

$59,999; and more than $60,000), both nationally and New York. New York state had the

highest cigarette excise tax ($4.35) compared with the national average of $1.46 per pack.

The average price per pack was $7.95 in New York compared with $5.21 nationally. Data

sources were the New York Adult Tobacco Survey (NY ATS) and national Adult Tobacco

Survey (NATS) from 2010 to 2011. Participants were 7,536 adults and 1,294 smokers from

New York and 3,777 adults and 748 smokers nationally.

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Overall, smoking prevalence was lower in New York (16.1%) than nationally (22.2%) and

was strongly associated with income in New York and nationally (P<0.001). Smoking

prevalence ranged from 12.2% to 33.7% nationally and from 10.1% to 24.3% from the

highest to lowest income group. The relationship between the percentage of income spent on

cigarettes and income level differed significantly between New York and the United States.

Percentage of income spent on cigarettes increased in New York over time for smokers

overall, from 6.4% in 2003–2004 to 12.0% in 2010–2011 p<0.001, as the state cigarette

excise tax increased from $1.50 to $4.35. Percentage of income spent on cigarettes more

than doubled for the lowest income category, increasing from 11.6% in 2003-2004 to 23.6%

in 2010-2011 (P<0.01) and 14.2% nationally. This percentage also increased for the middle

income group from 4.0% to 5.4% (P<0.01), but not for the highest income group. The

middle-income group spent 5.4% of their income on cigarettes in New York and 4.3%

nationally. Smokers in the highest income group spent 2.2% of their income on cigarettes in

New York and 2.0% nationally.

Daily cigarette consumption was not related to income either nationally or in New York. The

study also showed that self-reported daily cigarette consumption, adjusted for

underreporting, was considerably higher than taxable cigarette sales, suggesting that tax

avoidance was significant in New York State with an estimated 6.8 cigarettes per smoker per

day being purchased outside of New York’s tax jurisdiction. This might have weakened any

impact of the cigarette excise tax increase.

Smoking prevalence was lower in New York compared to national prevalence but the pattern

was the same: the prevalence of smoking was inversely related to income in New York State

and in the US, with a less pronounced relationship in New York. Lower SES smokers in

New York spent a significantly larger portion of their income on cigarettes and continued to

smoke at a higher rate than higher SES.

In summary this study showed a neutral equity impact for smoking prevalence, although

results are specific to New York. The percentage of income spent on cigarettes did not

significantly increase over time for high income smokers but did for low income. Lower

income smokers in New York State have not had a greater response to higher taxes than

smokers with higher incomes.

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A French study82 evaluated persistent smokers’ retrospective reactions (n=621) to increasing

cigarette prices (persistent smokers were defined as smokers who did not quit because of

such increases). Twenty-four percent of persistent smokers did not change their smoking

habits at all, 31% only reduced the cost of smoking (they neither reduced their consumption

nor tried to quit) and 45% tried to give up smoking or reduced their consumption (they also

frequently reduced the cost of smoking). Twenty-nine percent attempted to quit smoking.

Smokers who had completed a university degree more frequently reduced only the cost of

smoking rather than attempted to quit or smoke less (OR = 1.8) and were much more likely

to have shown no reaction (OR=3.0). Wealthier smokers more frequently reported no

reaction at all to the price increase rather than attempted to quit or smoke less (OR=2.4

among those earning at least 1500 euros/month). The equity impact appeared positive in

terms of quit attempts and reduced consumption although the study only focuses on smokers

who did not quit.

Seven studies evaluated the impact of increases in price/tax of tobacco products alongside

other policies, and reported the impact of increases in price/tax separately.

A US study54 determined the impact of comprehensive tobacco control measures in New

York City beginning in 2002 (cigarette tax increases, Smoke-free Air Act (SFAA) 2002, free

NRT, tobacco control media campaign). During the 10 years preceding the 2002 programme,

smoking prevalence did not decline in New York City. From 2002 to 2003, smoking

prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%, p =

0.0002, approximately 140000 fewer smokers). Smoking declined among all education

levels. Groups that experienced the largest declines in smoking prevalence included residents

in the lowest and highest income brackets and residents with higher educational levels.

Residents with low incomes (<$25000 per year) or with less than a high school education

were more likely than those with high incomes (>$75 000 per year) and those with a high

school education or higher to report that the tax increase reduced the number of cigarettes

they smoked (income: 26% [low] vs 13.0% [high], p = 0.0002; educational attainment:

27.5% [lower] vs 19.3% [higher], p = 0.009). However, authors reported that between 2002

and 2003 the proportion of cigarettes purchased outside New York City doubled, reducing

the effective price increase by a third.

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Another study79 also assessed the impact of the same tobacco control programme in New

York City using over-the-counter pharmacy sales of nicotine patch and gum products in

approximately 30% of all pharmacies in New York City. SES tertiles based on income were

used to determine pharmacy location.

There was a 27% increase in nicotine patch sales during the week of the state tax increase

and a 50% increase during the week of the city tax increase. These percentages gradually

declined over the ensuing weeks. Sales of nicotine gum increased by 7% and 10% following

the rise in state and city cigarette taxes, respectively, but these increases generally did not

persist for a period as long as the increases in nicotine patch sales. Pharmacies in low income

areas generally had larger and more persistent increases in sales of nicotine patch and gum

products in response to tax increases than those in higher-income areas. Cigarette taxes were

associated with increased sales of nicotine patch and gum products which can be viewed as a

proxy for quit attempts, in New York City, particularly in low-income areas. It should be

noted that the tobacco control programme in New York City also included the Smoke-free

Air Act (SFAA) 2002, free NRT, and a tobacco control media campaign; as well as cigarette

tax increases which is the focus of this study.

A US study55 examined the association between smoking and tobacco control policies

(price, media campaigns, clean indoor air laws) among women of low SES using four waves

of data between 1992 and 2002 from the TUS. Between 1992 and 2002, smoking prevalence

declined more rapidly among low-education compared to medium and high education

women. Moreover, evidence showed that compared with higher educated women, low

education women responded with greater positive effect to certain policy measures,

particularly price.

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A US study40used data from the February 2002 panel of the Tobacco Use Supplement of the

Current Population Survey (54,024 individuals representing the US population aged 15–80)

to evaluate the effect of strong clean indoor air laws (100% ban) and cigarette prices on

smoking participation and consumption. Clean indoor air laws and cigarette prices were

independently associated with significant reductions in smoking participation and

consumption. The effect of clean indoor air laws on smoking status (OR 0.66) was larger

than the effect of cigarette prices over the range of prices at which we found smokers to be

price sensitive (OR 0.83 for $2.91 to $3.28). Established patterns of education and income

disparity in smoking were largely unaffected by either clean indoor air laws or price in terms

of both mean effects and variance. Study authors concluded that clean indoor air laws and

price increases appear to benefit all SES groups equally in terms of reducing smoking

participation and consumption and are generally neutral with regard to health disparities.

A study of the impact of various tobacco control policies on education-related inequalities in

eighteen countries in Europe, including Eastern Europe and Baltic countries56 found that

price increases had a stronger association with national quit ratios than any other type of

tobacco control policy (i.e. countries with price increases had higher smoking cessation

rates). The regression coefficient for the association between national quit ratios and sub

score for price was 2.08 (-0.36 to 8.48) for men and 2.07 (-1.09 to 8.66) for women. There

was a significant positive association between quit ratio and price for high SES aged 40-59

years. However; high and low educated groups seem to benefit equally from the nationwide

tobacco control policies. No consistent differences were observed between higher and lower

educated smokers regarding the association of quit ratios with score on Tobacco Control

Scale (TCS). Strong conclusions cannot be drawn however because of various study

limitations; the survey was conducted before the TCS was devised, and before some policies

enacted so might underestimate the impact of recent smoking policies. In addition, the study

only examines the association between ex-smokers and presence of policies, rather than

changes in prevalence post-implementation. The study authors state that the a possible

reason for not finding a difference in impact between high and low education groups, might

be because they measured prevalence instead of consumption level; arguing that an increase

in price mainly reduces the number of cigarettes smoked rather than smoking prevalence

rates.

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A US study57 examined the impact of cigarette excise taxes (and smokefree legislation) on

tobacco use among households with children aged six to seventeen years of age. Data

sources included the National Survey of Children’s Health 2003 (N = 67,607) and 2007 (N =

62,768). From 2003 to 2007, 40 states raised cigarette excise taxes with a mean increase of

54.5 cents (SE 6.4; range 7–175). In 2005, the mean tax was 84.7 cents (SE 7.9; range 5–

246). The study is a comparison of methods study in which the authors focus on causal

inference model results.

In adjusted causal inference models every $1.00 increase in cigarette excise tax between

2001 and 2005 was associated with a 4 percentage point decrease in household tobacco use

between 2003 and 2007 (p = 0.008). There was a significant interaction between cigarette

tax and household income: cigarette tax increases were associated with reductions in

household tobacco use for lower income households (100–399% of the Federal poverty

level) but not at 0–99 % Federal poverty level or 400 % Federal poverty level or greater.

A cohort study in the Netherlands58 examined age and educational inequalities in smoking

cessation due to the implementation of a national tobacco tax increase, national smokefree

hospitality industry legislation and a national mass media smoking cessation campaign, all

implemented during the same time period. Three survey waves of the International Tobacco

Control (ITC) Netherlands Survey, 2008 (before) and 2009 and 2010 (after) were used.

Dutch smokers (having smoked at least 100 cigarettes in their lifetime and currently smoking

at least once per month) aged 15 years and older were recruited from a probability-based

web database and 78% responded to the first survey. Analyses were restricted to respondents

who participated in all three survey waves, did not quit during the 2008 and 2009 surveys

and answered all survey questions.

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Exposure to the price increase was assessed in terms of smokers reporting that they paid

more for their cigarettes in the 2009 survey than in the 2008 survey. 82.4% reported having

paid more for their cigarettes in the 2009 survey than in the 2008 survey. Higher educated

smokers were more exposed to the price increase. Exposure to the price increase was not

associated with significant increased odds of quit attempts or successful smoking cessation

in any SES group. Exposure to the price increase only predicted successful smoking

cessation among young respondents. There were no significant educational inequalities in

successful smoking cessation after the implementation of the price increase. It is worth

noting that prices only increased by eight percent. The follow-up rate was 70% however the

study authors’ report that almost half of the sample was either lost to follow-up or did not

answer all questions. These respondents were younger; less addicted and had more intention

to quit smoking. Therefore, the results may not be fully generalisable to the broader

population of Dutch smokers.58

Summary of increase in price/tax of tobacco products

Twenty-seven studies were included which evaluated the equity impact of increases in the

price or tax of cigarettes; seven of which evaluated the impact alongside other tobacco

control policies.40;54-58;79 The majority of studies evaluated the effects of price/tax across the

general population of smokers. However, one study focused on people who were HIV-

positive, another study focussed on pregnant women, and one study focused on parents of

children aged six to seventeen years.

The majority of studies included income and/or education as a measure of SES. Outcomes

measured were generally similar across studies and mainly included smoking prevalence and

price/tax elasticity. Elasticity was based on smoking prevalence and/or consumption data.

One study used pharmacy sales data79 and one study measured the impact of price increase

on calls to quitlines.80

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Thirteen of the 27 study samples were assessed as representative of the study populations

with findings that are generalisable on a national or regional scale. In the majority of studies

it was unclear whether the observed effects were directly attributable to increases in the price

and/or taxation of cigarettes. Econometric studies modelled the potential effects of increases

in price/tax rather than directly ‘observing’ findings. Two studies attempted to measure

actual exposure to the policy/intervention: one European study explored the correlation

between national quit ratios and scores (total and sub scores by separate policy) on the

Tobacco Control Scale (TCS)56; and in the other study respondents were asked how much

they paid for their cigarettes at their last purchase and increases in reported price were used

as a measure of exposure to the price increase.58

Overall, increase in the price/tax of tobacco products was associated with decreases in

smoking prevalence across the general population. The majority of studies also demonstrated

that increases in the price/tax of cigarettes are associated with larger reductions in smoking

prevalence and/or consumption of smoking for lower SES groups compared with higher SES

groups. Fourteen of the twenty-seven studies demonstrated a positive impact55;63;65-69;72-74;78-

80;82 on equity; six studies demonstrated a neutral equity impact,40;56;58;70;71;81 in one study the

equity impact was mixed depending on SES measure62 and in two studies the equity impact

was unclear.54;57 Four studies showed a negative impact on equity.64;75-77 However this group

of ‘negative’ equity studies included two studies of distinct population subgroups; HIV-

positive adults76 and pregnant women.77

Two studies showed inconsistent equity results according to type of SES measure. One of

these studies showed that smokers living in higher neighbourhood deprivation were more

likely to report a product-related change in response to a price/tax increase but not more

likely to also report a smoking-related change, whereas smokers of lower income and lower

education were more likely to report both product and smoking-related changes compared

with higher income and higher education smokers.68 Another one of these studies showed

positive equity results when education was measured but neutral impact when income was

measured.62

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There was also some inconsistency in equity results depending on the type of outcome

measure used. One study showed a neutral effect on equity in terms of price elasticity but

also suggested the gap in smoking prevalence between income groups had widened over

time.70 In the case of one econometric study 66 both relative and absolute changes were

considered; the study authors stated that the absolute change in smoking prevalence was

similar among high- and low-income consumers, which implied the relative change was

much larger among the former.

One study showed a positive equity impact in terms of increasing calls to quitlines amongst

lower SES smokers but no change in callers’ quit rates following a cigarette tax increase.80

Another study showed a negative impact in terms of exposure to price increases but no effect

(in any SES) groups in terms of reducing smoking prevalence.58

Seven studies40;54-58;79 evaluated the impact of increases in price/tax of tobacco products

alongside other tobacco control policies and appeared to show either equal equity impact or

positive equity impact. In two cases the equity impact was unclear: a US study57 examined

the impact of cigarette excise taxes (and smokefree legislation) on tobacco use among

households with children aged six to seventeen years of age. An increase in excise tax was

associated with an overall reduction in household tobacco use, but this reduction was not

consistent across all income levels.  There was no significant reduction in tobacco use in the

poorest households or in the least poor households. To the extent that the interaction term

(income) was significant, it is reasonable to conclude that there was some change in the

distribution of risk of tobacco use by household SES, but the equity impact is unclear

because the reduction in tobacco use was not consistent across all income levels. 

In another study54 the equity impact was unclear because although smoking declined among

all education levels, groups that experienced the largest declines in smoking prevalence

included people in the lowest and highest income brackets.

A study of the impact of various tobacco control policies on education-related inequalities in

eighteen countries in Europe, including Eastern Europe and Baltic countries56 found that

price increases had a stronger association with national quit ratios than any other type of

tobacco control policy (i.e. countries with price increases had higher smoking cessation

rates). However; high and low educated groups seem to benefit equally from the nationwide

tobacco control policies; producing a neutral equity effect.

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Interestingly, a US study40 evaluated the effect of strong clean indoor air laws (100% ban)

and cigarette prices on smoking participation and consumption and found both policies to be

independently associated with significant reductions in smoking participation and

consumption. The effect of clean indoor air laws on smoking status was larger than the effect

of cigarette prices over the range of prices at which we found smokers to be price sensitive.

Established patterns of education and income disparity in smoking were largely unaffected

by price in terms of both mean effects and variance and therefore appeared to have a neutral

equity impact; benefitting all SES groups equally.

A US study55 examined the association between smoking and tobacco control policies (price,

media campaigns, clean indoor air laws) among women of low SES using four waves of data

between 1992 and 2002 from the TUS. Between 1992 and 2002, smoking prevalence

declined more rapidly among low-education compared to medium and high education

women. Moreover, evidence showed that compared with higher educated women, low

education women responded with greater positive effect to certain policy measures,

particularly price.

A US multifaceted study79 using over the counter sales of nicotine patch and gum products

showed that pharmacies in low income areas generally had larger and more persistent

increases in response to tax increases than those in higher-income areas. However it is

uncertain how sales of nicotine products translate into actual successful quitting outcome.

A cohort study in the Netherlands58 examined age and educational inequalities in smoking

cessation due to the implementation of a national tobacco tax increase. Higher educated

smokers were more exposed to the price increase but the price increase was not effective in

reducing overall smoking prevalence and so the equity impact was neutral.

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Four studies showed a ‘negative equity impact’; three of which included at least two

measures of SES, all showing negative results.64;75-77 However this group of ‘negative’

studies included two studies of distinct population subgroups; HIV-positive adults76 and

pregnant women.77 Interestingly, this group of ‘negative’ studies also included distinctly

different study designs; two cohort studies64;76 and one qualitative study.75 HIV-positive

smokers appear to be a particularly vulnerable subgroup, where smoking was significantly

more prevalent amongst the poorest adults. In the case of pregnant women; those at lower

education levels had higher than average smoking rates but lower-than-average

responsiveness to tax changes. However,, in nearly all cases, pregnant women were found to

be more responsive to higher cigarette taxes than the general adult population.77 A qualitative

study tentatively (due to small study size) concluded that low SES smokers were less likely

to respond to cigarette price increases.75 The qualitative study used subjective social status

based on financial status as the SES variable and so this is distinct from other measures of

income used in the other included studies. However, it helps to explain the reasons why

‘poor’ smokers may be less likely to respond to price increase through quitting.

Overall, within the general population, lower SES adults appear more responsive to price/tax

increases in terms of larger price elasticities compared with high SES adults. However

smoking prevalence is greater in lower SES adults compared with higher SES adults, and the

prevalence gap in smoking disparities may be widening. Larger price elasticities amongst

lower SES adults might be capturing short-term effects which do not translate into increased

quitting amongst lower SES adults. In addition, cross-border sales or smuggling were not

accounted for in most econometric studies which could have biased the results. Lower SES

adults might be more likely than higher SES adults to mitigate the effects of price or tax

increases by switching to cheaper brands or bulk buying.

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A panel of experts who assessed the effectiveness of tax and price policies in tobacco control

in 201083 concluded that there was sufficient evidence of the effectiveness of increased

tobacco excise taxes and prices in reducing overall tobacco consumption and prevalence of

tobacco use. The experts also concluded that there was strong but not sufficient evidence

that lower income populations are more responsive to tax and price increases compared with

higher income groups within high-income countries; and limited evidence that lower income

populations are more responsive to tax and price increases compared with higher income

groups within low- and middle-income countries. This review does not analyse the data

according to income level of country but does add to the evidence base by showing that a

majority of studies demonstrate greater responsiveness to tax/price increases in lower SES

groups, through reduced smoking prevalence and consumption.

3.4 Controls on advertising, promotion and marketing of tobaccoNine studies were included which evaluated the effects of controls on advertising, promotion

and marketing of tobacco. Three studies examined the impact of restrictions on tobacco

advertising, promotion and marketing; including marketing restrictions84 and advertising

bans85;86. Five studies evaluated the impact of warning labels alone87-90 one of which

examined the effect of including the word “Quitline” beside the telephone number.91 One

study examined the extent to which a range of tobacco control policies (increase in cigarette

price, advertising bans, public place bans, campaign spending, health warnings) were

correlated with smoking cessation, in eighteen European countries.56

One study84 examined the effectiveness of tobacco marketing regulations in the UK, Canada,

Australia, and the USA, on exposure to different forms of product marketing, and differences

in exposure across different SES groups. The study used seven waves of data collected

between 2002 and 2008 as part of the International Tobacco Control (ITC) Four Country

Survey. Respondents lost to attrition (number not stated) were replenished at each wave and

all respondents who participated in at least one of the seven survey waves were included in

the present study, giving a total of 21,615 individuals (5251 in the UK, 5265 in Canada,

4806 in Australia, and 6293 in the US). A 35-minute telephone survey to evaluate the

psychosocial and behavioural impact of various national-level tobacco control policies on

marketing regulations was undertaken with 21,615 adult smokers (5251 in the UK, 5265 in

Canada, 4806 in Australia, and 6293 in the US). Since 2002, various tobacco marketing

regulations have been enacted in the United Kingdom (UK), Canada, Australia and the

United States. Self-reported exposure was assessed through salience of pro-smoking

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marketing i.e. overall awareness and the total number of channels (max 15) through which

marketing was noticed.

There were differences between counties both in the type and extent of marketing

restrictions at baseline and those that were introduced during this period. Awareness was

related to the extent of restrictions, being highest in the US and lowest in Australia. In

general, the introduction and implementation of additional tobacco marketing regulations

were associated with significant reductions in smokers’ reported awareness of pro-smoking

cues, among all SES groups, and the observed reductions were greatest immediately

following the enactment of regulations with awareness reduction occurring more slowly in

subsequent years. While tobacco marketing regulations have been effective in reducing

exposure to certain types of product marketing there still remain gaps in each country,

especially with regard to in-store marketing and price promotions.

Changes in reported awareness were generally the same across different SES groups. Out of

68 possible SES differences in the four countries only 5 SES differences were statistically

significant. These exceptions included awareness of billboard advertising and arts

sponsorships in the UK reducing more sharply among those in the high SES group relative to

those in the low SES group immediately following the enactment of the Tobacco

Advertising and Promotion Act 2002.

In each of the four countries, the high SES groups experienced greater reductions in the total

number of channels through which they reported being aware of tobacco marketing

compared to the low SES groups. However, at baseline, the high SES groups in each country

were exposed to more marketing channels than were the low SES groups. The study authors

argue therefore that the significant SES group differences should not be interpreted as an

indicator that marketing regulations had differential impacts on different SES groups. By the

end of the study period there was no significant difference by SES in the number of channels

that smokers reported being aware of tobacco marketing. Therefore the introduction of

restrictions on tobacco advertising and marketing had a neutral equity effect measured by

exposure.

The strength of this study is the comparison between four countries; however other policy

changes within studies across the study period might have also influenced reported

awareness. For example, in the UK, national legislation prohibiting smoking in worksites,

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bars, and restaurants was implemented during this time might have influenced awareness of

tobacco marketing. Also the study did not assess the extent of exposure or its effect by SES.

Single field observation85 of a random sample of 129 licensed tobacco retailers in 2010

assessed retailer compliance with Food and Drug Administration (FDA) regulations on

tobacco sales and advertising practices, including point-of-sale advertisements, in two

distinct Columbus, Ohio neighbourhood groups by income. Practices considered out of

compliance with FDA regulation were: sales of loose cigarettes, offering free items with

cigarette or smokeless tobacco (ST) purchase, and self-service access to cigarette or ST

products. No outlets were out of compliance by selling loose cigarettes or offering free items

with cigarette purchase. Less than 10% of sampled outlets were out of compliance by

offering self-service access to cigarettes, which did not differ by neighbourhood income.

While there was no significant difference between low and high income neighbourhoods

regarding the number of advertisements on site or inside shops, there were significantly

fewer advertisements on the buildings in high income areas (1.1 vs 1.9, P<0.05).

Three observational audits86 of 302 randomly selected stores (milk bars, convenience stores,

newsagents, petrol station, supermarket) evaluated compliance with legislation which

restricted cigarette displays in retail outlets, including a point-of-sale display ban, and

assessed prevalence of pro- and anti-tobacco elements in stores pre- and post-legislation

(October 2010 and December 2011) in Melbourne, Australia by Socio-Economic Indexes for

Areas (SEIFA) index of disadvantage. Overall, the prevalence of anti-tobacco signage

increased and pro-tobacco features decreased between audits for every store type and

neighbourhood SES. Mid-SES stores had consistently lower scores than low- and high-SES

stores for non-mandated anti-tobacco signage but not mandated signage.

A European study examined the extent to which tobacco control policies (increase in

cigarette price, advertising bans, public place bans, campaign spending, health warnings)

were correlated with smoking cessation, in eighteen European countries.56 Log-linear

regression analyses were used to explore the correlation between national quit ratios and

scores (total and sub scores by separate policy) on the Tobacco Control Scale (TCS). The

SES variable was the Relative Index of Inequality (RII); the RII assesses the association

between quit ratios and the relative position of each educational group, and can be

interpreted as the risk of being a former smoker at the very top of the educational hierarchy

compared to the very lowest end of the educational hierarchy.

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The study found large variations in quit rate and RII between countries. Quit rates were

positively associated with TCS score; more developed tobacco control policies were

associated with higher quit rates. More educated smokers were more likely to have quit than

lower educated, for men and women. There was a larger absolute difference between high

and low educated adults for 25-39 year olds. The regression coefficient for the association

between national quit ratios and sub-score for advertising bans, on TCS was 1.33 (1.11 to

8.02) for men and 1.59 (1.39 to 8.67) for women.

No consistent differences were observed between higher and lower educated smokers

regarding the association of quit ratios with score on the TCS. A comprehensive advertising

ban showed the next strongest associations with quit ratios (after price) in most subgroups

(not low SES aged 40-59 or low SES women aged 25-39 years). Strong conclusions cannot

be drawn because of various study limitations; the survey was conducted before the TCS was

devised, and before some were policies enacted, so the study results might underestimate the

impact of recent smoking policies. In addition, the study only examined the association

between ex-smokers and presence of policies, rather than changes in smoking prevalence

post-implementation.

Warning labels

An internet-based study in the Netherlands90 examined the self-reported perceived impact of

the effect of health warnings on cigarette packs and to determine whether these effects

differed for subgroups of smokers, using cross-sectional data from the Continuous Survey of

Smoking Habits (June 2002 to June 2003). 3,937 (31%) of the original sample were

smokers, and 3318 (84.3%) had noticed a change to health warnings and were asked further

questions. An EU Directive meant that as of 30 September 2002, the front of cigarette

packets in EU countries were required to have one of two health warnings, covering 30% of

the surface. The back of the packet must contain one of 14 different health warnings,

covering 40% of the surface. On 1 May 2002 the new health warning labels came into effect

in The Netherlands.

Across the survey period, 3318 (84.3%) said they had noticed changes to the health

warnings. This percentage was higher in the 3 months directly after the introduction (90%)

compared with the months April to June of 2003 (81% p<0.001). Of all smokers, 14%

indicated they were less inclined to purchase cigarettes as a result of the new warnings;

31.8% said they prefer to buy packets without the new warnings; and 10.3% said they

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smoked less because of the new warnings. A strong dose-response relationship was

observed, e.g. the higher the intention the greater the impact of the warnings. 17.9% reported

that warnings made them more motivated to quit; multivariate analysis showed that those

intending to quit smoking within one month had a higher change of reporting that they

smoked less because of new warnings (OR 7.89), independent of other variables.

There were no significant differences in level of education for respondents in reported

change in smoking behaviour. More respondents with medium level of education (19.4%)

reported being more motivated to quit than those of high (18.3%) or low levels (15.8%)

p<0.001). More respondents with a higher level of education (35.5%) reported a preference

for buying packs without the new warning compared to those of low (28%%) or medium

levels 31%. There was no significant difference between education levels in inclination to

buy the new packs. As the study only surveyed smokers who had noticed the new health

warning labels, this sample might be more motivated to change their smoking behaviour

compared to the overall general population. In addition it was unclear in this internet-based

survey was representative of the general population in the Netherlands.

A European study examined the extent to which tobacco control policies (increase in

cigarette price, advertising bans, public place bans, campaign spending, and health warnings)

were correlated with smoking cessation, in eighteen European countries.56 The regression

coefficient for health warnings was -0.40 (-7.32 to 2.31) for men and -0.42 (-9.51 to 3.43)

for women.

A cohort study in New Zealand91 examined how recognition of a national quitline number

changed after new health warnings were required on tobacco packaging. The study used data

from the New Zealand ‘arm’ of the International Tobacco Control Policy Evaluation Survey

which differed somewhat from other ITC samples as the smokers involved were New

Zealand Health Survey (NZHS) participants. NZHS respondents were invited at end of

NZHS to participate in this study. Wave 1 (March 2007 and February 2008) respondents

were exposed to text-based warnings with a quitline number but no wording to indicate that

it was the “Quitline” number. Wave 2 (March 2008 and February 2009) respondents were

exposed to pictorial health warnings (PHWs) that included the word “Quitline” beside the

number as well as a cessation message featuring the Quitline number and repeating the word

“Quitline.”

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The introduction of the new PHWs was associated with a 24 absolute percentage point

between-wave increase in Quitline number recognition (from 37% to 61%, p < .001) and a

matched odds ratio of 3.31, 95% CI = 2.63 to 4.21. A majority (range 58.0%–65.5%) of all

five quintiles of socioeconomic deprivation using a small area measure recognized the

Quitline number in Wave 2. The increase between the waves was lowest in the most

deprived quintile (p < .001), though this group had the highest level of recognition at

baseline. For individual deprivation, the increase was highest in the second-to-least deprived

group and lowest in the most deprived group. For area and individual-level deprivation, the

most deprived had the highest level of recognition in Wave 1 and the lowest level of

recognition at Wave 2 (though in the latter, the differences were not significantly different).

Recognition increased from a minority of respondents to a majority for all deprivation levels

(using small area and individual measures), and financial stress (unable to pay any important

bills on time and not spending on household essentials). The overall response rate for this

study was 32.6% and the attrition was 32.9%, therefore results might not be representative or

generalisable to the overall general population of New Zealand.

Two studies evaluated the impact of the new pictorial health warnings for tobacco packages

which were among the first regulations following the introduction of the Family Smoking

Prevention and Tobacco Control Act in 2009 which granted the Food and Drug

Administration (FDA) authority to regulate tobacco products. Cigarette packages are

required to display one of nine colour graphic (i.e., pictorial) warnings on the top 50% of the

“front” and “back” of cigarette packages. Both studies used online research panels and

although the pictorial warnings replicated the new FDA warning the intervention conditions

did not mirror real life exposure to cigarette packaging.

A web-based RCT87 evaluated the potential impact of the nine new pictorial warning labels

compared with text-only labels using a purposive sample of U.S. adult smokers from diverse

racial/ethnic and socioeconomic subgroups in 2011. The U.S. Family Smoking Prevention

and Tobacco Control Act of 2009 required updating of the existing text-only health warning

labels (HWLs) on tobacco packaging with nine new warning statements accompanied by

pictorial images. 1,665 participants assigned to the control condition were exposed to one of

nine text-only HWLs, and 1,706 participants in the experimental condition were exposed to

one of nine pictorial HWL with the same text messages as in the control condition.

Participants viewed the labels and reported their reactions.

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There were significantly stronger reactions for the pictorial condition for each outcome:

salience (b = 0.62, p<.001); perceived impact (b = 0.44, p<.001); credibility (OR = 1.41,

95% CI = 1.22-1.62), and intention to quit (OR = 1.30, 95% CI = 1.10-1.53). Individuals

with a high school education or less compared with higher educated individuals had stronger

responses for perceived impact and salience. There were no significant differences in

reactions across income categories. No significant results were found for interactions

between condition and education or income. The only exception concerned the intention to

quit outcome, where the condition-by-education interaction was nearly significant (p =

0.057). There was a stronger effect for the pictorial condition versus the text-only condition

among individuals with moderate education compared with higher educated groups. The

study sample was unlikely to be representative of the study population because the

recruitment rate and survey completion rates were low. In addition, there were significant

differences between intervention groups at baseline for SES and smoking behaviour.

Another web-based quasi-randomised trial88 evaluated the efficacy of the 36 proposed FDA

warnings for each of the nine “statements” or health effects specified in the Act.

Respondents rated each warning while the image appeared on screen, one at a time, and then

ranked the warnings within a set on overall effectiveness. Comparisons on specific elements

indicated that warnings were perceived as more effective if they were: full colour (vs. black

and white), featured real people (vs. comic book style), contained graphic images (vs. non-

graphic), and included a quitline number or personal information. Association between

index ratings scores and both education and income were not significant. The most effective

ratings performed equally well across SES groups. Due to a technical flaw in the program,

the second set of health warnings assigned to respondents was not assigned at random and so

the number of participants who viewed each set of warnings not balanced. There were

relatively few (less than 200) participants in the low SES sub-groups (income and

education).

A European study89 examined the effectiveness of text only health warnings among daily

cigarette smokers in France (n = 1,532), Germany (n = 1,305), the Netherlands (n = 1,788)

and the UK (n = 1,788. The International Tobacco Control Policy Evaluation Project

produced data from single survey waves in each of the four countries between 2007 and

2008. At the time of the study the European Commission required tobacco products sold in

the EU to display standardized text health warnings. Smokers rated the health warnings on

warning salience, thoughts of harm and quitting and forgoing cigarettes; and a labels impact

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index (LII) was used to score results. Scores on the LII differed significantly across

countries. Scores were highest in France, lower in the UK, and lowest in Germany and the

Netherlands. Impact tended to be highest in countries with more comprehensive tobacco

control programmes.

Across all countries, scores were significantly higher among low income smokers (i.e. rated

warnings more effective), with no significant interaction between country and income. There

was a main effect of education, as well as a country by education interaction. Although

scores on the LII tended to be higher among smokers with low to moderate education in

France, Germany and the Netherlands, the opposite trend was observed in the UK. The

impact of the health warnings was highest among smokers with lower incomes and smokers

with low to moderate education (except the UK in the case of education) suggests that health

warnings could be more effective among low SES groups. This European study was

representative and enables cross-country comparisons. However, France and the UK now

have pictorial health warnings rather than text-only warnings.

Summary of controls on advertising, promotion and marketing of tobacco

Of the nine studies which evaluated the effects of controls on advertising, promotion and

marketing of tobacco, five studies evaluated the impact of warning labels alone. The effects

of controls on advertising, promotion and marketing of tobacco were equally effective in

seven studies (neutral equity impact) and had a positive equity impact in two studies

including EU text-only health warnings and the addition of quitline number to new pictorial

health warnings. The representativeness of the majority of the study samples is unclear and

limits the generalisability of the results which may weaken the potential equity impact.

In general, tobacco marketing regulations were associated with significant reductions in

smokers’ reported awareness of pro-smoking cues, among all SES groups in nationally

representative samples from the UK, Canada, Australia, and the USA.84 The observed

reductions were greatest immediately following the enactment of regulations, with

awareness reducting more slowly in subsequent years. Changes in reported awareness were

generally the same across different SES groups. The introduction of restrictions on tobacco

advertising and marketing had a neutral equity effect measured by exposure. It is unknown

whether the extent of exposure differed by SES or whether there were any differences by

SES in the impact of change in exposure. While tobacco marketing regulations have been

effective in reducing exposure to certain types of product marketing there still remain gaps in

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coverage, especially with regard to in-store marketing and price promotions. It is unclear

whether these gaps have a differential impact by SES.

It is unclear how change in ‘intermediate’ outcomes, such as awareness, recognition,

motivation and preferences, translate into change in smoking prevalence and the impact of

such longer-term changes on equity. Compliance with restrictions on sales and general and

point-of-sale advertising was associated with a neutral equity impact as there was no

significant difference in compliance by SES. However this evidence was derived from two

regional studies85;86 and it is unclear whether this outcome is generalisable to other regions

and how this outcome impacts on smoking prevalence. A European study56 found that

comprehensive advertising bans had the next strongest association with quit ratios (after

price) in most subgroups (not low SES aged 40-59 or low SES women aged 25-39 years).

Pictorial health warnings were associated with greater impact than text only warnings and

were equally effective across SES groups, with two studies suggesting a neutral equity

impact. There were two studies which evaluated EU text only warning labels. Findings from

a Netherlands study of EU text only warning labels showed neutral equity impact and a

European study showed positive equity impact. There were no significant differences in

changes in smoking behaviour by education level, following new EU text health warnings,

amongst an internet-based sample of smokers motivated to quit in the Netherlands. A

European study showed variation in impact of EU text only health warnings across countries

depending on type of SES measure used. Overall there was a positive equity with the impact

highest among smokers with lower incomes and smokers with low to moderate education

(except the UK in the case of education), suggesting that text only health warnings could be

more effective among low SES groups. However, France and the UK now have pictorial

health warnings. Another European study which evaluated a range of tobacco control

policies including health warnings showed a lack of significant effect for health warnings.

Quitline number recognition included with new pictorial health warnings, increased across

all SES groups in New Zealand, and the gap in quitline number recognition between the least

and most deprived groups narrowed, indicating a positive equity effect. It is unclear how

quitline number recognition translates into quitting.

3.5 Mass media campaigns

Introduction

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Mass media interventions in tobacco control encompass a range of different types of media,

sources and messages. These include paid advertising, earned media (e.g. through advocacy),

press releases and events such as no smoking days, and direct marketing through television,

radio, newspapers, magazines, cinema, billboards, posters, leaflets, internet and other digital

media (e.g. texts, viral marketing). Mass media campaigns aim to impact directly on

smoking behaviour (e.g. increase unaided quit attempts, increase call to quitlines) and/or

changing social norms relating to smoking (e.g. to support policy action, reduce the

desirability and acceptability of smoking).

Niederdeppe et al92 undertook a systematic review which compared media campaign

effectiveness by SES. In order to understand how, and at what point, media campaigns

might differ in effect by SES, the study authors adapted a logic framework (Figure 3).

According to the logic framework, differences in effect between SES groups can occur

during exposure to a media campaign, in motivational response, and finally, in longer-term

behavioural response to a media campaign. Therefore, when interpreting the data from

studies of media campaigns, we group results in terms of message recall/awareness, seeking

information/treatment, attempting to quit, and, finally, sustained quitting.

Studies showing lower levels of exposure or response or abstinence/quitting in lower SES

compared with higher SES are summarised as likely to increase inequality (negative equity

impact). Studies showing equivalent levels of exposure and response and

abstinence/quitting, between low SES compared with higher SES groups, are summarised as

maintaining inequality (neutral equity impact). Studies showing higher levels in at least one

stage (exposure or response or abstinence/quitting) without lower levels at another stage,

between low and high SES groups, are summarised as reducing inequalities (positive equity

effect).

Twenty-nine studies were identified and included interventions using multiple media

formats, television campaigns, unpaid for media and the internet. Eighteen studies evaluated

a range of mass media campaigns, nine studies focused specifically on mass media to

promote the use of quitlines and three studies used mass media to promote the use of NRT.

One study was included in both the ‘mass media’ section and the subsection ‘mass media to

increase the use of NRT because the study included both a concurrent Quit & Win contest

and NRT giveaway.93 Studies of quitline campaigns were only included if they reported on

the impact of the mass media element in terms of reach and/or impact at the population level.

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Figure 3 Logic framework for Mass Media Campaigns

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3.5.1 Mass media cessation campaigns Fifteen studies55;58;93-105 were included which evaluated the effects of mass media cessation

campaigns. In addition four Dutch reports106-109 were included that were obtained through

grey literature searching and English synopses are provided separately. The results of one

Dutch report107 are discussed alongside a published paper of the same study.58 Therefore in

total, eighteen studies were included that evaluated mass media cessation campaigns. The

findings from one study, the EX campaign, were reported in two papers.101;102 Studies were

conducted mainly in the USA, but one study was set in Croatia97 and one in Russia.94 All the

studies used education as a measure of SES and some studies also used income.

The types of mass media used varied between studies: three studies used multiple media

formats. This included a Croatian national ‘smoke out day’ media campaign on the first day

of Lent.97 A cohort study in the Netherlands examined age and educational inequalities in

smoking cessation due to the implementation of a national tobacco tax increase; national

smokefree hospitality industry legislation and a national mass media smoking cessation

campaign, all implemented during the same time period.58 One study evaluated the impact of

paid media campaigns alongside cigarette prices and clean air regulations and the types of

media campaigns are not detailed within the paper; states were included as having a media

campaign if the state ‘spent more than 70% of the CDC goals in 2001 and 2002’.55

Four studies assessed Quit & Win campaigns using multiple media formats including press,

television and radio: a Russian-based ‘Quit & Win’ campaign,94 a Canadian Quit & Win

incentive-based intervention95 plus a ‘Quit Kit’, a Dutch Quit & Win campaign in the

Netherlands110 and a US concurrent Quit & Win contest and NRT giveaway.93

Seven studies used mainly TV advertisements: a television-based anti-tobacco media

campaign using graphic imagery of the health effects of smoking,96 a comparison of

different types of anti-tobacco television adverts in Massachusetts,98 television smoking

cessation adverts in Wisconsin,100 EX, a US-based branded national smoking cessation

media campaign designed to promote cessation in the USA,101;102 an Australian study103

sought to identify modifiable factors that increased the efficiency of antismoking TV

advertisements in terms of reach and recall, a US study104 assessed the impact of emotional

and/or graphic antismoking TV advertisements on quit attempts, and a New York Media

Tracking Survey Online 105examined SES variation in response to different types of

television smoking cessation advertisements.

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One study used online internet advertising to promote a web-based cessation programme,99.

Outcomes measured were generally similar across studies and included uptake of the

campaign, smoking prevalence, smoking abstinence, quit attempts, campaign awareness,

recall and interest, recruitment, and cessation-related cognitions.

One study compared different interventions (Quit & Win, NRT or both), eight studies were

prospective cohorts, one study used single cross-sectional data and five studies used repeat

cross-sectional data. Only four of the fifteen study samples were assessed as representative

of the study populations, with findings that are generalisable on a regional or national scale.

The majority of studies used credible data collection methods. In seven studies the attrition

rates were either low or unclear. In four studies it was unclear whether the observed effects

were directly attributable to the mass media campaigns, either because the mass media

campaign was an element of a broader tobacco control programme or the study validity was

compromised in some other way.

Multiple media formats

A study based in Croatia97 evaluated the impact on smokers behaviour of ‘Smoke out day’

using cross-sectional data from anonymous surveys carried out over one week, in people’s

homes. Over 2000 participants aged 15 years and over, were selected from radio and

television subscribers in the Republic of Croatia. This was the first national ‘smoke out day’

media campaign, carried out on the first day of Lent as part of the ‘Say yes to no smoking’

campaign. The activity was connected with an event of cultural and religious significance for

the majority of the Croatian people (88% of the population are Roman Catholic) and was

also supported by other religious communities, governmental, and non-governmental

associations. Various strategies were used (intense media campaign, round tables, stands,

public events at main town squares, activities in nurseries, schools, and work places). The

aim of these simultaneous activities was to reach the target population, i.e. smokers, in the

phase of contemplation about quitting smoking regardless of age, gender, or duration of

smoking.

Nearly 93% of selected listeners and viewers responded and were interviewed. In the total

analysed sample 1,822 (85.0%) had heard of the activity and 1,608 (75.0%) knew the exact

date of the “Smoke out day.” Among smokers, 27% had given up smoking on that day and

16% declared they would not smoke during Lent. Among smokers, 141 (15.6%) participants

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had primary school education, 579 (64.1%) had secondary school education, 71 (7.9%) had

university education, and 112 (12.4%) were students. The analysis of abstainers according to

the level of education showed that the largest group of abstainers (abstinence for one day)

was those with secondary school education (59.1%), followed by primary school educated

(20.4%) and those with university education (16.8%). However, the study did not compare

the quit rates by SES group or provide details of relative uptake by SES. The summary

equity impact was therefore unclear.

A US study55 evaluated the impact of paid media campaigns alongside cigarette prices and

clean air regulations. The types of media campaigns are not detailed within the paper; states

were included as having a media campaign if the state ‘spent more than 70% of the CDC

goals in 2001 and 2002’. The study examined the association between smoking and media

campaigns among women of low SES using four waves of data between 1992 and 2002 from

the TUS. Between 1992 and 2002, smoking prevalence declined more rapidly among low-

education compared to medium and high education women. Moreover, evidence showed that

compared with higher educated women, low education women responded with greater

positive effect to certain policy measures, including mass media. The authors concluded that

media campaigns may reduce prevalence among women with low education. In a state with

a media campaign, low education women’s odds ratio for smoking was 0.86 for women of

low education, 0.89 for women with medium education and 0.93 (non-significant) for

women with high education. Generally, the association between the media variable and

smoking prevalence declined in the more recent survey waves.

The mass media campaign appeared effective for lower SES women, however the study is

limited because exposure to mass media campaigns was based on whether a state of

residence funded a comprehensive tobacco control programme with a significant media

component (there was no examination of individual level exposure). There was no

description of the types of media campaigns involved, and which were the most effective

(either the mode of intervention or locations). The positive effects might not be due to the

mass media component and may even be the consequence of changing social norms. In

addition, there were a number of tobacco control policies that were introduced during this

period which may have influenced the results.

A cohort study in the Netherlands examined age and educational inequalities in smoking

cessation due to the implementation of a national tobacco tax increase; national smokefree

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hospitality industry legislation and a national mass media smoking cessation campaign, all

implemented during the same time period.58 Three survey waves of the International

Tobacco Control (ITC) Netherlands Survey, 2008 (before) and 2009 and 2010 (after) were

used. Dutch smokers (having smoked at least 100 cigarettes in their lifetime and currently

smoking at least once per month) aged 15 years and older were recruited from a probability-

based web database and 78% responded to the first survey. Analyses were restricted to

respondents who participated in all three survey waves, did not quit during the 2008 and

2009 surveys and answered all survey questions (n=962).

From April 2008 until January 2009, a mass media smoking cessation campaign ‘There is a

quitter in every smoker’ ran on television, radio, print and internet. This campaign was

designed to stimulate smokers to quit smoking and focussed on smokers with low to

moderate educational levels aged 20–50 years. 83.1% of participants reported having

experienced one or more parts of the national mass media smoking cessation campaign.

Smokers from different educational levels were reached equally (no difference in levels of

exposure) by the mass media smoking cessation campaign (the campaign did not reach low

to moderate educated smokers more than high educated smokers). Exposure to the cessation

campaign had a significant positive association with attempting to quit smoking in the

univariate analyses, but not with successful smoking cessation and was not significant in the

multivariate analyses. There were no overall educational differences in successful quitting

after the implementation of the national mass media smoking cessation campaign.

The follow-up rate was 70%. However, the study authors’ report that almost half of the

sample was either lost to follow-up or did not answer all questions. These respondents were

younger; less addicted and had more intention to quit smoking. Therefore the results may not

be fully generalisable to the broader population of Dutch smokers.58However this study did

measure exposure to each policy and measure the effects of each policy. In summary, a

Dutch, targeted multi-media campaign had equal reach by SES, but was not effective in

reducing prevalence (in any SES subgroup).

An evaluation report of the same Dutch multimedia campaign (‘There is a quitter in every

smoker’) was identified through contacting experts and an English synopsis was provided. A

larger sample size (n=1,573) was analysed in the report107 than in the published paper. 58 The

report also assesses a sponsored television show that was part of the campaign called ‘Ik wed

dat ik het kan’ (‘I bet I can do it’). In the television show, groups of smokers were followed

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in their attempts to quit smoking successfully. The campaign was designed to stimulate

smokers to quit smoking and had a special focus on smokers with low to moderate education

levels, aged 20 to 50 years. Low education included primary education, lower vocational

education; ‘middle education group’ included general secondary education and secondary

vocational education; ‘high education group’ included general and higher education, higher

professional education and university education (bachelor), and university education

(doctoral). The evaluation report showed that the ‘There is a quitter in every smoker’

campaign had positive effects on communication about smoking cessation, but only among

higher educated smokers. The ‘I bet I can do it’ television show had positive effects on quit

intention among low educated smokers.

English synopsis of three Dutch mass media campaigns using multiple media formats

(grey literature)

Three Dutch mass media campaigns, all using multiple media formats were included which

evaluated SES differences in campaign effects. The campaigns are reported in chronological

order beginning with the earliest campaign.

A mass media campaign109 on television, radio, and the internet; entitled ‘Nederland start

met stoppen / Nederland gaat door met stoppen’ (‘The Netherlands starts quitting / The

Netherlands continues with quitting’) ran from November 2003 to the beginning of 2004. A

representative sample of smokers aged 16 to 70 years old participated in a longitudinal web-

based survey with eight survey waves between September 2003 and May 2005. In the first

survey, 3,411 respondents participated. Of this group, 1,305 respondents participated also in

the last survey (62% attrition rate). There was also a concurrent workplace campaign and a

‘children copy’ (the behaviour of parents) campaign.

The aim of the campaign was to stimulate smokers to attempt to quit smoking as a New

Year’s Resolution. The campaign consisted of sponsored amusement programs and short

communications within existing amusement programmes and informative programmes. The

‘higher education’ group included (hoger algemeen voortgezet onderwijs (HAVO) meaning

higher general secondary education, voortgezet wetenschappelijk onderwijs (VWO) meaning

secondary science education; college and university education), the ‘middle education

group’ included vocational training and the ‘low education group’ included secondary

school, lower vocational education, and primary education.

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There was no differential effect of the campaign on several psychosocial determinants of

smoking cessation between lower and higher educated smokers. There were positive effects

of the campaign for quit intention, attitude towards smoking cessation, social norms, and

interpersonal communication about smoking cessation. The study examined both quit

attempts and successful quitting, but positive effects of the campaign were only found for

successful quitting. Successful quitting was self-reported and it was not specified how long

people should be quit. Adults with lower education were less likely to successfully quit. This

Dutch multimedia campaign109was associated with an unclear equity impact because

although positive effects were reported for several psychosocial determinants of smoking

cessation between lower and higher educated smokers, adults with lower education were less

likely to successfully quit.

A mass media campaign108 called ‘Rokers verdienen ‘n beloning’, de 24-uur-niet-rokenactie

(‘Smokers deserve an award’, the 24-hour-no-smoking intervention) ran in 2006 in the

Netherlands. The intervention was announced on posters, flyers, local newspapers, banners

on websites, with press releases, and radio spots. It included a web-based survey with one

questionnaire after the intervention was performed among a representative group of smokers.

2,800 smokers were asked to participate and 2,140 answered the survey (76% response rate).

There was also a web based survey of 920 intervention respondents. Smokers were

encouraged to stop smoking for 24 hours and to register for participation. Participants filled

in a web-based survey, on which they immediately got personalised feedback aimed at

increasing self-efficacy and intention to quit. Participants were rewarded with a magazine of

their choice and the chance to win a television.

People with lower school or lager beroepsonderwijs (LBO) meaning junior secondary

education are classified in the ‘lower wealth group’. Persons with middelbaar algemeen

voortgezet onderwijs (MAVO) meaning secondary school education; HAVO meaning higher

secondary general education; middelbaar beroepsonderwijs (MBO) meaning middle-level

applied (vocational) education; or pre-university education; are classified in the ‘middle

wealth group’. Persons with college or university education were classified in the ‘highest

wealth group’.

The 24 hour no-smoking intervention had greater reach in the higher socioeconomic groups

which was measured using awareness of the campaign. The middle SES group had the

highest rate of registration for participation in the 24-hour no-smoking day. Effects on

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smoking cessation were not studied, only on willingness to quit. There was no significant

difference between the low and high SES groups on willingness to stop smoking by

awareness of the campaign and by participation. The 24 hour no-smoking intervention108

which included a web-based survey and personalised feedback aimed at increasing self-

efficacy and intention to quit, was associated with a negative equity impact for campaign

reach.

A Dutch mass media campaign106 ran from December 15, 2010 until March 2011 and was

called ‘Echt stoppen met roken kan met de juiste hulp’ (‘Really quitting smoking can be

done with the right help’). There was a television and radio commercial, banners, social

media, posters and flyers, and messages in newspapers and magazines. The target group was

smokers with an intention to quit smoking in the future, with a focus on lower educated

smokers. The goal of the mass media campaign was to make smokers aware of the fact that

smoking cessation is more successful with the right cessation aids and that the combination

of pharmacotherapy and behavioral therapy is reimbursed as of January 2011.

A representative sample of smokers aged 18 years and older participated in a longitudinal

web-based survey, with two waves before the campaign and two surveys after the campaign.

The first survey was sent in September 2010 to 4,338 potential respondents, of which 2,763

participated in the survey (64% response rate). The second survey was in December 2010, in

which 1,811 respondents of the first survey participated (34% attrition rate). The third survey

was in March 2011 and 1,694 respondents participated (39% attrition rate). The fourth

survey was in June 2011 and 1,429 respondents participated (48% attrition rate).

Smokers with low (lower education, lower vocational and MAVO meaning secondary school

education) and secondary (HAVO meaning higher secondary general education and

vocational) education belonged to the group of ‘less educated’ and smokers who had

completed college or university training among the ‘highly educated’ group. Lower educated

smokers reported more often that they had heard from the campaign than higher educated

smokers. This Dutch multimedia campaign106 targeted at smokers with an intention to quit

smoking in the future, with a focus on lower educated smokers, was associated with a

positive equity impact for campaign awareness.

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Mass media Quit & Win campaigns

Four studies evaluated Quit & Win campaigns, one in Russia, one in Canada and one in the

Netherlands. A US study93 examined a concurrent Quit & Win contest plus NRT.

A Russian study94 examined the sociodemographic and motivation of participants in the

Novosibirsk Quit and Win Campaign, organised by the Institute of Internal Medicine in

Russia since 1994. Registered participants were interviewed a year after each campaign from

1998 to 2004. The Quit and Win Campaign is an international antismoking campaign

initiated by the WHO. Any adult aged 18 years or older who smoked at least one cigarette a

day during the previous year and who wanted to quit could participate. The Quit and Win

Campaign is conducted at same time in each country, all participants are asked to abstain

from 1st May to 29th May and the campaign ends on International Non-Smoking Day which

is the 31st May. Abstinence is biochemically confirmed and participants who did not smoke

may take part in the drawing of the prize. The international prize is 10,000 US$ and there are

also six regional prizes (2,500 US$) which were raffled between winners from participating

countries.

Overall, 90% did not smoke during the month of campaign and 40% did not smoke in the

following year. The number of people intending to stop smoking completely increased from

year to year. Follow-up questionnaires were used to measure participants intentions before

the campaign; participant’s intentions to quit entirely, were 77% in 1996 and 87% in 2002.

In 1998, 32% of participants had higher education, compared with 43% in 2000, and 30% in

2002. In 1998, 28% of participants had secondary professional education, compared with

27% in 2000, and 27% in 2002. In 1998, 15% of participants had secondary school

education, compared with 16% in 2000, and 13% in 2002. In 1998, 2000 and 2002 about

10% had primary education. The majority of participants were men; 84% were men in 1996

and 76% were men in 2002. In 2002 only 3% of participants were supported by medical

professionals in their quit attempt and 90% reported that they did not use any nicotine

replacement therapies. These findings are likely to be different from other countries. The

study only analysed uptake of the campaign by educational level, and did not analyse

abstinence by educational level nor make any comparisons with the SES of smokers in the

general population. Campaign uptake by SES appeared stable across time; the higher the

education level the higher the participation, and so in terms of uptake of the campaign the

equity impact appears negative.

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A Canadian study95 evaluated the impact of a Quit & Win incentive-based intervention plus a

‘Quit Kit’ that was developed to help daily smokers to quit smoking. Quit & Win Challenge

participants were 231 adult daily smokers (minimum average of 10 cigarettes per day)

residents from two of the four Eastern Ontario counties (Frontenac, Lennox & Addington)

who entered the Quit and Win contest in January 1995. A cohort group of comparison adult

daily smokers were selected by random telephone survey (n = 385) from the same regions as

well as two neighbouring counties (Hastings, Prince Edward). Both cohorts were followed

up for one year.

Enrolled adult smokers pledged to quit smoking for a designated period of time. In

exchange, they were entered into a lottery with a cash prize of $1,000 and secondary prizes

of lesser values. The initiative was promoted through the local print and radio media, as well

as through the distribution of leaflets. A contest winner, who was required to be smokefree

in the month leading up to the prize ceremony, was selected by random draw approximately

three months after the contest was initiated. The winner was asked to provide the name of a

"buddy" to be contacted to verify smokefree status. Those who enrolled in the contest were

also given the educational Quit Kit, which contained a letter of encouragement, information

on cessation methods, a list of local cessation programmes, tips on maintaining a smoke-free

status and a refrigerator magnet with the telephone number of a health unit information line.

After one year, 19.5% of Quit & Win participants reported that they were smokefree (self-

reported 6 months continuous abstinence), whereas less than 1% of the random comparison

group had quit. A participation rate of 0.83% combined with the cessation rate produced an

impact rate of 0.17% (extrapolates to 1 in 8 smokers led to quit due to Quit & Win contest).

Compared with the random survey group, Quit and Win participants tended to be more

educated at baseline. There was no significant association between level of education or

occupation and cessation at one year. In summary, lower SES smokers were not reached as

well by the Quit & Win campaign but there were no differences in cessation by education

level at one year, leading to a negative equity impact. The response rates and the one-year

follow-up rates in both groups were high, however the results may be specific to this region

of Canada. In addition 87% of Quit & Win participants were actively trying to quit at

baseline (and were more likely to have quit at one year) so the results may be relevant only

to a highly motivated subpopulation.

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A Quit and Win campaign in the Netherlands110 took place in May 2005 and the main

objective was to encourage respondents to abstain from smoking for at least one month.

Recruitment of participants was promoted on a national as well as regional level using radio,

newspapers, campaign posters and brochures.

In total, five supportive e-mail messages were sent to the participants. Participants were

offered the opportunity to receive computer-tailored cessation advice, support from a

telephonic coach, and they could enrol in an e-mail counselling programme, all of which

were provided by the Dutch Foundation on Smoking and Health (STIVORO). Participants

were also asked to name a buddy, whom they could call upon for support during their

cessation attempt. Other cessation support included NRT and bupropion. After one month,

prize winners (first prize: €1.000 and 11 regional prizes of €450) were randomly selected

from a pool of successful quitters and were obliged to undergo biochemical verification of

smoking abstinence.

Quit & Win contestants were significantly more likely to be from medium and high educated

groups than the control group of non-contestants. At one month abstinence rates were 35.4%

in Quit & Win contestants and 10.9% in control participants (OR 4.70; 95% CI:3.02 to 7.31)

when all non-respondents were classed as smokers. At 12 months abstinence rates were

11.9% in Quit & Win contestants and 2.9% in control participants (OR 2.46; 95% CI:1.64 to

3.68). One-month abstinence was significantly predicted by use of buddy support and Quit

and Win e-mail messages. Quit and Win e-mail messages remained a significant predictor

for continuous abstinence at 12 months. Participants with a higher education were more

likely to maintain their quit attempt for the entire contest month. Higher education was a

significant predictor of cessation at one month (OR = 1.199; 95% CI: 1.032 to 1.393) but did

not predict continuous abstinence at 12 months (OR=1.109; 95% CI: 0.895 to 1.374). There

were no analyses of recruitment method, use of buddy system or other types of cessation

support by SES. In summary, the Netherlands Quit & Win contest was associated with a

negative equity impact based on reach and short-term quit rates.

A US study93 examined a concurrent Quit & Win contest and NRT giveaway in Erie and

Niagara counties in the western New York region. Smokers could enrol in both or either

programme (combined group). Daily smokers (at least 10 cigarettes per day) were offered

the opportunity to win prizes including $1000 if they stopped smoking for the month of

January 2003 with a quit date of 1st January. NRT vouchers were redeemable at pharmacies

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for a 2-week supply of nicotine gum or patch. Media coverage included a press conference,

newspaper and television coverage. $35,000 was spent on radio advertisements aired on 6

local radio stations. The focus was mainly on the Quit & Win contest – people were

informed of free NRT giveaway when they telephoned the New York State Quitline. Both

interventions were marketed to minority populations (African American and Latino) using

newspaper, churches and community sites.

Random samples of 341 Quit & Win participants (40%) and 314 (46%) NRT voucher and

230 (100%) combination group were selected for follow-up at 4 to 7 months from the 1 st

January 2003, by telephone survey. Follow-up rates were 60-64%, with 204, 179 and 143

participants follow-up for Quit & Win, NRT and combination groups, respectively. The 3

intervention groups were compared with smokers in the same region using Erie-Niagara

Tobacco Use Survey (ENTUS), to determine reach. At follow-up the self-reported quit rates

were similar across the three intervention groups: 25 to 30%. Compared with smokers in

region, those enrolled in the three interventions had significantly more years of formal

education. However there was no significant difference in 7-day point prevalence of

smoking by education group. It was unclear how representative the regional cohort of

smokers was in the ENTUS survey, and in addition, smokers in all three intervention groups

were heavier smokers than in general population (20-21 vs 17 cigarettes per day). In

summary, the Quit & Win contest and concurrent NRT giveaway had lower reach among

less educated smokers in two regions in the US, all 3 interventions were associated with a

25-30% quit rate which did not differ by educational level.

Television advertisements

A US study96 assessed the effect of two mass media campaigns (2006) on smoking

prevalence among New York City (NYC) residents, using data from the NYC Department of

Health and Mental Hygiene (DOHMH) annual health surveys from 2002 to 2006. Gross

ratings points (GRPs) were used to measure exposure to the campaign; GRPs are an

industry-specific standardized measure of the broadcast frequency and audience reach of a

campaign. For example, 100 GRPs are equal to one exposure in the given period. An

extensive, television-based anti-tobacco media campaign using graphic imagery of the health

effects of smoking focused on increasing smokers’ motivation to quit. Advertisements

included testimonials from sick and dying smokers and graphic images of the effects of

smoking on the lungs, arteries, and brains of smokers. Advertisements included diverse

messages in both English and Spanish. The television campaign broadcast for 23 of 40 117

weeks during January through to October 2006, with 100 to 600 GRPs per week, for a total

of approximately 6,500 GRPs. The New York State Department of Health also aired a

separate, simultaneous statewide television-based anti-tobacco media campaign that included

NYC. The campaign included advertisements featuring graphic images of the effects of

smoking and emphasizing the effects of SHS on children. The broadcasts equated to

approximately 4,400 GRPs in NYC from January through December 2006. Thus, in total,

New York City adult smokers were exposed to nearly 11,000 GRPs during this 1-year

period, equating to the average viewer in NYC seeing an advertisement approximately 110

times over the year.

The smoking prevalence among NYC residents decreased significantly from 21.5% in 2002

to 18.4% in 2004 (p<0.001). From 2004 to 2005, smoking prevalence did not change

significantly among NYC residents overall. In 2006, the year during which television

advertisements were aired, smoking prevalence did not change significantly among NYC

residents overall (17.5% in 2006 compared with 18.9% in 2005, p=0.055). The total decrease

associated with NYC’s comprehensive programme from 2002 to 2006 was 19%, an average

annual decrease of 5%. From 2002 to 2004 decreases in prevalence were demonstrated in all

education subgroups. The smoking prevalence among those with less than a college

education was higher than among those with more education and the percentage change in

smoking prevalence from 2002 to 2006 was significantly higher in those with more

education compared with those with less than a college education. From 2005 to 2006, no

significant changes occurred within education subgroups.

The 2006 DOHMH media campaign was part of a tobacco-control programme which

consisted of increased taxation in 2002, establishment of smoke-free workplaces in 2003,

public and health-care–provider education, cessation services, and rigorous evaluation.

Therefore it is difficult to tease out the specific contribution of the media campaign impact

on smoking prevalence. In terms of equity impact, in 2006, the year the television adverts

were aired, smoking prevalence did not change significantly overall or between educational

subgroups, the equity impact is summarised as neutral.

A US cohort study98 assessed which types of mass media messages might reduce disparities

in smoking prevalence among disadvantaged population subgroups. The study used a

cumulative measure of SES: high school education or lower and household income of

$50,000 or less was classed as ‘low SES’. More than $50,000 household income and at least

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college education was classed as ‘high SES’ and all others as ‘medium SES’. Data source

was the first two waves of UMass Tobacco Study, a longitudinal survey of Massachusetts

adults designed to investigate responses to the Massachusetts Tobacco Control Program.

Television adverts of varying intensity were aired in the two years prior to data collection in

2003/2004. 20.2% were highly evocative personal testimonials, 13.4% emotional but not

testimonials, 11.2% testimonials but not highly emotional and 53.7% not highly emotional or

testimonials.

On average, smokers were exposed to more than 200 antismoking ads during the 2-year

period, as estimated by televised gross ratings points (GRPs). The odds of having quit at

follow-up increased by 11% with each 10 additional potential ad exposures (per 1000 points,

odds ratio [OR]=1.11; 95% confidence interval [CI]=1.00, 1.23; P<.05). Greater exposure to

ads that contained highly emotional elements or personal stories drove this effect (OR=1.14;

95% CI 1.02, 1.29; P<.05), comparison ads show no significant effect (OR=0.93).

The study authors reported no significant variation in exposure to the advertisements by

SES. At follow-up (approximately 26 months from baseline), 12.9% of low SES smokers

had quit compared to 18.2% of mid and 19.2% of high SES smokers. The likelihood of

quitting for each 10 additional potential exposures to an emotionally evocative or personal

testimonial ad, adjusting for all co-variates, increased for respondents in the low-SES group,

the mid-SES group (highest increase), and the undetermined-SES group. By contrast,

smokers in the high-SES group showed a decreased likelihood of quitting with each 10

additional potential exposures to these types of ads.

The TV advertisements overall appeared to have a neutral equity impact in terms of exposure

but a negative equity impact in terms of quit rates as the odds of quitting were higher in the

mid and high SES groups compared to the low SES group. However, the highly emotional or

personal testimonial advertisements were more effective with the low, mid and undetermined

SES groups compared to the high SES groups for increasing the likelihood of quitting

smoking. The authors argue that using such advertisements may contribute to reducing

socioeconomic disparities in smoking. However the role of the ‘underdetermined’ SES group

might have undermined the significance of the intervention impact. Response rates and

attrition were relatively low (response rate 46%, follow up rate 56%) which might have

reduced the representativeness of the study sample and the generalisability of the study

findings.

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A US study100 examined whether the impact of a televised smoking cessation advertising

campaign differed by education or income levels. The campaign formed part of the

Wisconsin Tobacco Control and Prevention Programme. Televised smoking cessation

advertisements were aired most weeks between May 2002 and December 2003. The

advertisements highlighted the dangers of SHS and included personal testimonials, or keep

trying to quit messages (KTQ), and aimed to promote Quitline calls. Subsets of both types of

adverts were targeted at low SES groups. Data were collected before and after the media

campaign a statewide sample of 452 adult smokers who were interviewed in 2003 to 2004

and followed up 1 year later in the Wisconsin Behavioural Health Survey.

At one year, 42% had made a quit attempt and 13% were abstinent. Overall, neither KTQ

nor secondhand smoke ad recall was associated with quit attempts or smoking abstinence at

one year. KTQ ads were significantly more effective in promoting quit attempts among

higher- versus lower-educated populations. There was a positive relationship between KTQ

advert recall and quit attempts for the higher educated group (college degree), but a negative

relationship for the lower educated group (high school diploma or less). There was no

relationship between KTQ recall and income. No differences were observed for SHS ads by

the smokers' education or income levels.

The equity impact overall was unclear for this study, there was potentially neutral equity

impact in terms of smoking abstinence at one year and negative equity impact in terms of

quit attempts related to the KTQ ad. However results can only be tentative because the type

of ad message appeared to have a differential impact and the impact also appeared to vary

depending on type of SES outcome measure. There was a small initial sample size, plus a

low rate of enrolment (29%) into the study, and a greater loss to follow up among the less

educated.

Two papers evaluated the EX national media campaign, one examined the association

between awareness and quit attempts and the other evaluated cessation-related cognitions

and quit attempts. 101;102 Both papers use survey data from the first six-months of the national

campaign. The survey had an overall response rate of 48% among known eligible

households and a 73% follow-up rate. The summary equity impact for the EX campaign was

positive.

The EX campaign was a branded mass media campaign to promote cessation among lower

income and blue collar smokers of diverse race/ethnicity, aged 25 to 49 years, who were 120

interested in quitting. The campaign was based on behaviour change theory, and included

formative research with the target audience. Using an empathic tone, the EX campaign

encourages smokers to "relearn" life without cigarettes. Smokers are asked to identify their

personal smoking triggers (e.g. drinking coffee, or driving a car) and work to disassociate

smoking from these daily activities. EX advertising is delivered through television, radio, the

Internet, and other channels. Television advertising was placed during programming popular

with smokers and aired during different times of the day to increase exposure among shift

workers, (large segment of the target audience). Advertising was also aired to match the high

interest of smokers in sports events. Radio advertisements were aired during African-

American and Hispanic programming (small proportion in Spanish language), as well as on

country and classic rock stations.

One paper101 examined whether changes in cessation-related cognitions mediated the rela-

tionship between awareness of a national mass-media smoking cessation campaign, the EX

campaign, and quit attempts in 3,571 current smokers in 2008. A majority of respondents

were seriously thinking of quitting at baseline, with 15.6% expressing an intention to quit

within 30 days and 51.6% within six months. 85% of the sample was aged between 25 and

49 years. At the six-month follow-up, 46.5% had confirmed awareness of the EX campaign

(measured by awareness of TV adverts). The direct effect of EX awareness on quit attempts

was 0.031 (SE = 0.01), which indicated that EX awareness increased the probability of

reporting a quit attempt at follow-up by approximately 3%. Altogether, the model explained

approximately 18% of the variance in quit attempts at follow-up. Data suggested that there

were both a direct effect of confirmed awareness of EX on quit attempts as well as an indi-

rect effect mediated by positive changes in cessation-related cognitions. Only respondents

with less than a high-school education showed a statistically significant effect of EX

awareness on quit attempts, and this effect was both direct (0.082, SE = 0.04) and indirect

(0.017, SE = 0.01), therefore showing a positive equity effect.

The study author’s hypothesis was that EX awareness manifested in changes in quit

behaviour through initial modification of cessation-related cognitions. The data, however,

did not fully support this hypothesis. While there was a statistically significant effect of EX

awareness on quit attempts mediated through cessation-related cognitions, the larger effect

of EX awareness on quit behaviour was not mediated through cessation related cognitions.

Furthermore, the mechanism underlying how EX awareness promotes quit attempts differed

across education subgroups.

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Another linked paper102 assessed the effectiveness of the EX campaign, focussing on TV

advertising only, across racial/ethnic and educational subgroups of 4067 current smokers in

2008. EX campaign awareness differed significantly by education, with higher awareness

observed among those with higher educational attainment (41.0% weighted estimate for

college degree vs. 30.2% for less than high school diploma, summary p value = .002). EX

was significantly related to a higher cognitions index score at 6-month follow-up only

among respondents who had achieved less than a high school education (OR = 2.6, p =

.037). Baseline cognition index score was consistently predictive of follow-up cognition

index score for all educational strata at the p < .000 level. A statistically significant

relationship between confirmed awareness of EX and having made a quit attempt at follow-

up was observed among those with less than high school education (OR = 2.1, p = .016).

Among smokers with less than a high school education, confirmed awareness of the EX

campaign more than doubled their odds of having more favourable cognitions about quitting

smoking at 6-month follow-up, and doubled their odds of having made a quit attempt during

the study period.

The Cancer Institute New South Wale’s Tobacco Tracking Survey103 (CITTS) sought to

identify modifiable factors that increased the efficiency of anti-smoking TV advertisements

in terms of reach and recall. Over 13,000 adult smokers and recent quitters were interviewed

between 2005 and 2010. Income and education variables were combined into dummy

variables indicating low, middle or high SES. Postcodes were used with the Socio-Economic

Indices for Areas (SEIFA) to indicate neighbourhood SES.

TV advertisements broadcast more at higher levels or in more recent weeks were more likely

to be recalled. Advertisements were more likely to be recalled in their launch phase than in

following periods. Controlling for broadcasting parameters, advertisements higher in

emotional intensity were more likely to be recalled than those low in emotion. Also

emotionally intense advertisements required fewer GRPs to achieve high levels of recall than

lower emotion advertisements. There was some evidence for a diminishing effect of

increased GRPs on recall.

Neighbourhood SES was not significant in univariate analyses. In order to ascertain if the

effects of broadcasting parameters on recall were moderated by advertisement type, the

multivariate models were run with interaction terms between advertisement type (low

emotion, high emotion graphic imagery and high emotion narrative) and broadcasting

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parameters (GRPs, broadcasting recency, launch phase). High SES but not moderate SES

had increased OR for recall compared to low SES (OR 1.11, 95% CI: 1.04 to 1.18, p=0.001).

High SES and moderate SES had decreased OR for recall compared to low SES (OR 0.90,

95%CI: 0.84 to 0.97, p=0.001; and OR 0.89 95% CI: 0.83 to 0.96, p=0.002 respectively.

The individual composite measure of SES (income and education) but not neighbourhood

measure of SES showed significant associations with recall and recognition. The impact of

TV advertisements on recall was in the opposite direction to the impact of recognition and

also recall and recognition outcomes differed between high and moderate SES (compared to

low SES). High SES adult smokers/recent quitters were more likely to readily recall TV anti-

smoking advertisements from memory than low SES. High and moderate SES adult

smokers/recent quitters were less likely to recognise specific advertisements currently or

recently on air (last 4 weeks) compared to low SES. This inconsistency between outcomes

means any equity impact of these TV advertisements is unclear.103The study analyses do not

inform as to whether the type of advertisements varied in impact between SES groups.

A US study104 assessed the impact of emotional and/or graphic anti-smoking TV

advertisements on quit attempts in the past 12 months among 8780 adult smokers in New

York State. Smokers saw an average of three emotional and/or graphic (defined as such by

interrater agreement 0.81 to 1.00) and three comparison advertisements (defined as not

emotional and/or graphic) per month across the study period (2003 to 2010). Of the 142

study advertisements, 98 (69%) were comparison and 44 (31%) were emotional and/or

graphic.

The overall response rate to the survey was 40% which limits generalisability of the study

results. Exposure to emotional and/or graphic advertisements was positively associated with

making quit attempts among smokers overall. Exposure to advertisements without strong

negative emotions or graphic images had no effect. Recalling at least one emotional or

graphic advertisement recently was associated with a 29% increase in the odds of making a

quit attempt (p<0.05), whereas each additional 5000 GRPs of exposure to emotional and/or

graphic advertisements in the past year was associated with a 38% increase in the odds of

making a quit attempt (p<0.01). Education was not a predictor of quit attempts, income was

marginally signifıcant in the confırmed recall model.

Exposure to all types of advertisements and to emotional and/or graphic advertisements was

positively associated with making quit attempts by income and education. Smokers with 123

incomes of >/=$30,000, and smokers with some college education or beyond were more

likely to make a quit attempt if they reported recall of advertisements (all types). Recall of

emotional and/or graphic advertisements was associated with making a quit attempt for

smokers with incomes <$30,000 and those with a high-school degree or less (p<0.05).

Exposure to the comparison advertisements, as measured by past year GRPs and confırmed

recall, was not associated with quitting for any group of smokers.

A New York Media Tracking Survey Online105 examined SES variation in response to

different types of television smoking cessation advertisements in adult smokers in five waves

over two years (2007 to 2009). Participants included adult smokers who resided in either

New York or media markets within New Jersey where the New York Tobacco Control

Program purchased advertising time. A key feature of the survey included exposing

participants to videos of a random selection of specific anti-smoking advertisements via

online multimedia tools. Participants were showed a number of ads from five main

categories: (1) Why-Graphic (10 ads), (2) Why-Testimonial (15 ads), (3) How (7 ads, only

one of which used a personal testimonial), (4) Anti-Industry (4 ads), and (5) Secondhand

Smoke (9 ads). Secondhand Smoke advertisements were excluded from analyses. Outcomes

included aided advertisements recall and perceived advertisement effectiveness.

Participants recalled Why-Testimonial advertisements at higher rates than advertisements

using the other three themes. Participants perceived Why-Graphic advertisements as more

effective than the three other advertisement themes. In terms of recall there was a significant

interaction between How advertisements (vs. Why-Testimonial) and income; and significant

interactions between both Why-Graphic and How advertisements (vs. Why-Testimonial) and

education. The interactions between How advertisements and income/education were not

robust to the inclusion of both interaction terms. Stage of change did not interact with

advertisement theme: did not change the size or significance of the coefficients for the

interaction between Why-Graphic advertisements or How advertisements (vs. Why-

Testimonial) and education on aided ad recall. Why-Testimonial advertisements had the

highest and How advertisements had the lowest ad recall across all levels of education. This

difference was greatest at low levels of education. For example, among those with 10 years

of education, the model predicted 71% recall of Why-Testimonial advertisements vs. 33%

recall of How advertisements. Among those with 20 years of education, the model predicts

67% recall of Why-Testimonial advertisements vs. 40% recall of How advertisements.

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In terms of effectiveness there was significant interactions between How advertisements (vs.

Why-Graphic advertisements) and income, and How advertisements (vs. Why-Graphic

advertisements) and education, respectively. How advertisements (vs. Why-Graphic) and

income was not robust to the inclusion of interactions with education. There were significant

interaction between How advertisements and the contemplation stage, although in the

opposite direction of what would be expected based on the theory. The inclusion of

interactions between advertisement theme and stage of change did not substantially alter the

size or significance of the interaction between How advertisements and education. Why-

Graphic advertisements had the highest level of perceived effectiveness. This value was

higher than How advertisements across all levels of education. Once again, however, the

difference was most pronounced at low levels of education. It should be noted that the New

York survey sample was not representative of the broader population of smokers in New

York, New Jersey or elsewhere because the internet-based sample was skewed toward

White, affluent and educated smokers.

Internet advertisements

A US feasibility study99 examined the potential of online advertising compared with

traditional advertising, to recruit smokers to cessation treatments. Online advertisements

were placed on national and local websites and search engines between December 2004 and

October 2006 to promote QuitNet’s web-based cessation program and state run telephone

quitlines in Minnesota and New Jersey. The advertising campaigns were managed by

Healthways QuitNet, including negotiation of contracts with online advertising partners.

The advertisements invited the user to click to receive more information. Clicking on the ad

took the user to a landing page where he or she read a brief description of three cessation

treatment options: (1) 24/7 online support, (2) telephone counselling, or (3) telephone and

online support. If users selected the first option, they were taken immediately to the state-

sponsored QuitNet website where they were prompted to register and begin using the

website. If the individuals selected the second or third option, they were asked to fill out an

online quitline referral form, which provided a quitline counsellor with basic contact

information; individuals selecting option three were then directed to the state-sponsored

QuitNet website to register. As a comparison group, registration were extracted data on all

individuals who joined QuitNet during the study period in response to all other forms of

advertising (ie, not an online ad), such as billboards, TV and radio ads, outdoor ads (e.g. bus

shelters), direct mail and physician referrals.125

A total of 130,214 individuals responded to advertising during the study period: 23,923

(18.4%) responded to traditional recruitment approaches and 106,291 (81.6%) to online ads.

Of those who clicked on an online ad, 9655 (9.1%) registered for cessation treatment: 6.8%

(n = 7268) for Web only, 1.1% (n = 1119) for phone only, and 1.2% (n = 1268) for Web and

phone. Online ads recruited more men, young people and those with a high school degree or

less (24.6% v 23.2%, p<0.02) than traditional media. Banner adverts, rather than actively

searching for cessation assistance, was a source of significantly more smokers with high

school education or less (26.3% vs 23.9%, P = .03). Compared to traditional media,

humorous online ads were significantly more likely to recruit those with a high school

degree or less (26.8%, p<0.01). Humorous ads were also the only creative approach that was

effective in recruiting smokers with lower levels of education.

This feasibility study shows the potential of online advertising on uptake and recruitment of

lower SES groups, with banner ads driving much of the effect and effectiveness limited to

one type of advertisement (humorous). Although engagement was not analysed by SES, the

subsequent level of engagement with the advertised cessation website was significantly

lower (although relatively small difference) among those recruited online, compared with

traditional media responders, but the authors argued that this was such a small difference that

it would be clinically insignificant.

Summary of Mass Media Cessation Campaigns

Fifteen mass media campaigns were included which evaluated the effectiveness by SES, plus

three Dutch grey literature reports, totalling eighteen studies.

Three studies showed a positive equity impact, including one Dutch study106 found from

searching the grey literature. This Dutch multimedia campaign106 targeted at smokers with an

intention to quit smoking in the future, with a focus on lower educated smokers, was

associated with a positive equity impact for campaign awareness. A tobacco control paid

media campaign in the US was associated with a more rapid decline in smoking prevalence

among low SES women. One campaign (the EX campaign) showed a positive equity impact.

The EX mass media campaign (TV element) increased cessation-related cognitions only

among those with less than a high-school education and increased quit attempts only among

those with less than a high-school education.

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Two studies showed equal effectiveness by SES, a television-based anti-tobacco media

campaign in the US was associated with decreased smoking prevalence across all SES

groups. A mass media smoking cessation campaign in the Netherlands called ‘There is a

quitter in every smoker’ which ran on television, radio, print and internet showed equal reach

by SES and no significant educational inequalities in successful smoking cessation.

Five studies demonstrated a negative equity impact, including four Quit & Win campaigns

and a Dutch 24 hour no-smoking intervention. A Quit & Win campaign in Russia only

reported uptake by SES, which appeared stable across time, the higher the education levels

the higher the participation. The study did not report abstinence by SES nor make any

comparisons with the SES of smokers in the general population. Lower SES Canadian

smokers were not reached as well by a Quit & Win campaign but there were no differences

in cessation by education level at one year, leading to a negative equity impact. A Dutch

Quit & Win campaign including behavioural support and pharmacotherapy significantly

increased abstinence rates at one month and 12 months compared to control. Non-contestants

were more likely to be lower educated than contestants. Higher education was a significant

predictor of cessation at one month but did not predict continuous abstinence at 12 months.

In summary, the Netherlands Quit & Win contest was associated with a negative equity

impact based on reach and short-term quit rates.

A Quit & Win contest and concurrent NRT giveaway had lower reach among less educated

smokers in two regions in the US, and all three interventions (including a combined group)

were associated with a 25-30% quit rate which did not differ by educational level. A Dutch

24 hour no-smoking intervention108 which included a web-based survey and personalised

feedback aimed at increasing self-efficacy and intention to quit, was associated with a

negative equity impact for campaign reach.

Equity impact was unclear in six studies due to the following reasons: type of outcome

reported (i.e. uptake by SES); measure of exposure; where impact was more pronounced in a

‘middle’ SES group; where there was inconsistency between outcome measures; where

outcome differed between SES groups even despite similar exposure to the policy; or where

differences in effect were more pronounced although the effect was similar across all SES

groups. One Dutch multimedia campaign109was associated with an unclear equity impact

because although positive effects were reported for several psychosocial determinants of

smoking cessation between lower and higher educated smokers, adults with lower education

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were less likely to successfully quit. These issues were also impacted by the lack of

representativeness of most of the study samples and also in some cases low attrition.

Two US studies98;104 found that the equity impact varied depending on which types of

messages were used and these two studies were classed as ‘mixed’ equity impact. Highly

emotional and personal testimony ads were more effective with low SES groups in one

study98 and emotional or graphic ads with low SES smokers in the other study.104

Mass media campaigns targeted at low SES smokers did not show consistently more

beneficial results for low SES compared with campaigns targeted at the general population.

The type of outcomes measured varied, but were mainly stage one and stage two outcomes

according to the logic framework; such as campaign awareness, recall and interest (stage 1)

and recruitment, quit attempts and one-day abstinence (stage 2). Some studies reported the

impact of mass media campaigns in terms of longer term outcomes, including smoking

prevalence and abstinence and there was no apparent pattern of effectiveness according to

stage or type of outcome reported. It is unclear how short or intermediate outcomes translate

into reduction in smoking prevalence and other health outcomes, and the impact of such

longer term changes on equity.

Different types of media messages appear to have differential impact by SES, and multiple

media formats may lead to equity benefit. A Dutch study105 showed that all smokers

(particularly those with low education) recalled advertisements on ‘how to quit’ less often,

and perceived them as less effective, than advertisements using graphic imagery or personal

testimonials on ‘why quit’. Differences in readiness to quit between higher and lower

educated populations did not explain why thematic differences in recall and response were

more pronounced among smokers with the lowest levels of education. A study exploring

differences in smokers’ perceptions of the effectiveness of cessation media messages111

found that advertisements using a ‘why quit’ message with either graphic images or personal

testimonials were perceived as more effective than the other advertisement categories (how

to quit and anti-industry).

This review adds to the evidence included in the Niederdeppe review100and suggests that the

type of media message, the media format of the campaign and the mechanisms of

engagement vary by SES.

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3.5.2 Mass media campaigns to promote calls to Quitlines and use of NRT

Mass media campaigns to promote calls to Quitlines

Nine studies91;112-119 were included which evaluated the effects of mass media campaigns to

promote the use of quitlines. Four studies were based in the USA112;113;115;118 one in

England,116 one in Canada,119 one in New Zealand,91 and two studies114;117 assessed callers to

the same quitline in Victoria, Australia across different time periods. One of these studies113

evaluated the use of free nicotine patches rather than using paid media to increase the use of

a Quitline in Oregon. Another study used TV, radio and newspapers to launch a programme

of 2-weeks free NRT.115 In both studies NRT was accessed through calling a quitline and so

these two studies are assessed in ‘mass media campaigns to promote the use of quitlines’. A

Canadian study119examined the reach and effectiveness of free 5 weeks mailed NRT (patches

or gum) via a quitline and included brief telephone advice among the first 14,000 eligible

Ontario residents who were smokers motivated to quit and who called a toll-free quitline. A

cohort study in New Zealand91 examined how recognition of a national quitline number

changed after new health warnings were required on tobacco packaging.

Three studies evaluated mass media advertising targeted at specific sub-populations; one

media campaign was targeted at low-income Latino smokers112 one at young smokers in

England116 and one at lower SES smokers in Australia.114 Two studies of the Victorian

quitline in Australia114;117 focused on the impact of television advertising alone, whereas the

majority of the other studies assessed the impact of multimedia campaigns to promote the

use of quitlines including billboards, radio, magazine and cinema advertising, one study also

used unpaid media.

All studies reported characteristics of the quitline callers and four studies reported

quitting/abstinence.112;115;116;119 One study112 assessed television gross rating points but did not

directly measure the association between campaign exposure and quitline calls. The two

studies of the Victorian quitline in Australia114;117 directly measured exposure to ads and calls

to quitline adjusting for covariates, using Target Audience Rating Points.

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Four studies used educational level as the SES variable and two of these studies also

included income.118;119Two studies114;117 based on data from the same quitline in Australia

used an area level indicator of SES as did the New York study;115 and the English study116

used occupational social class as a measure of SES. One study used small area deprivation,

individual deprivation, and financial stress as measures of SES.91

Four studies used cross-sectional data one of which used repeat cross-sectional data. Two

studies used cohort data91;116, one study compared free NRT plus brief advice through a

quitline to a no-intervention control cohort (study design 2.3), and two studies used quasi-

experimental designs.112;115 Only one of the studies was assessed as representative of the

study populations with findings that are generalisable on a regional scale; which is surprising

given these are national quitlines.

Four of the studies could be assessed for attrition rates/numbers in each survey wave, of

which one study had low response rates 44.1% and 50.4% among pre and post-campaign

Latinos.112 Another study116 randomly selected only 905 of 6038 for 2-month recall survey

and only 473 (of 905) interviews were achieved at 11 months post-baseline. A fresh sample

(n = 951) was randomly drawn from the 5133 baseline log sheets with telephone numbers

that had not been used for the two month recall study. This provided an additional 257

respondents. Thus a total of 730 respondents were interviewed one year after their initial call

to Quitline which represented a relatively small number of the initial sample. In another two

studies attrition was low.91;119 In another study113 there were 920 in the baseline sample but

less than 200 in the educational subgroups. In the majority of studies the observed effects

were directly attributable to the mass media campaigns, either because the calls to the

quitlines were evaluated before and after the campaign or because exposure to the campaign

was directly measured.

Multimedia formats

130

One study used a quasi-experimental design to evaluate the impact of a media campaign for

the Colorado Quitline targeting Spanish-speaking smokers.112 Advertisements in Spanish

were aired on Spanish-language television channels, radio and at cinemas in majority-Latino

neighbourhoods. The advertisements delivered ‘positive, supportive and encouraging’

messages and modelling of quitting through actors portraying key family members (relating

to the important cultural value of familismo). Although there was no direct measure of

campaign exposure, it was estimated that 79.8% of households were exposed to campaign

messages, an average of 12 times each. Quitline calls among Latino smokers increased by

57.6% over the three month campaign period, with Latino callers significantly more likely to

be younger, uninsured and of lower education status. 42.5% of callers during the intervention

had less than high school education, compared to 22.2% pre-intervention. 56.0% uninsured,

compared to 40.5% pre-intervention. Callers during the campaign were also significantly

more likely to report remaining abstinent at 6-month follow up (18.8% post-intervention,

9.6% preintervention, p=0.04). Quit rates by SES are not reported.

Although the survey response rates increased pre and post campaign for Latinos, the rates

were still relatively low; 44.1% and 50.4% among pre and post-campaign Latinos, and

54.3% and 52.7% among pre and post-intervention non-Latinos. Individuals lost to follow up

were typically younger and uninsured, less likely to have completed the program, and less

likely to have requested a second NRT shipment. The media intervention had a positive

equity impact on calls to the quitline but the impact on overall quit rates is not known.

A quasi-experimental study set in New York City (NYC)115 assessed the effectiveness of a

programme of free NRT to improve smoking cessation. In 2003, the New York City

Department of Health and Mental Hygiene (NYC DOHMH), announced the availability of

free six-week courses of NRT patches to the first 35 000 eligible smokers to call the New

York State Smokers’ Quitline. All major metropolitan newspapers and television and radio

stations reported the programme launch. Neighbourhood-specific media and promotional

efforts were used to reach populations with the highest prevalence of heavy smokers. Six

months after treatment, smoking status was assessed in 1305 randomly sampled NRT

recipients and a non-randomly selected comparison group of eligible smokers who, because

of mailing errors, did not receive the treatment.

An estimated 5% of all adults in New York City who smoked ten cigarettes or more daily

received NRT; most (64%) recipients were non-white, foreign-born, or resided in a low-

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income neighbourhood. Of individuals contacted at six months, more NRT recipients than

comparison group members successfully quit smoking (33% vs 6%, p<0·0001), and this

difference remained significant after adjustment for demographic factors and amount

smoked (odds ratio 8·8, 95% CI 4·4–17·8). NRT recipients who received counselling calls

were more likely to stop (246 [38%] vs 189 [29%], adjusted odds ratio 1·5; 95% CI, 1·1–

1·9) than those who did not. Similar proportions of NYC heavy smokers and NRT recipients

resided in low-income neighbourhoods. Neighbourhood income level and educational

attainment were not associated with quit success.

Of the people in the random sample, about 60% of NRT recipients participated in the 6-

month follow-up survey, compared to a 31% response rate for the non-random comparison

group (eligible callers who did not receive NRT). New York City implemented this

programme at a time when new smoke-free workplace legislation and increased taxation on

cigarettes focused public attention on cessation. However, the mass media promotion

campaign appeared equally effective across all SES.

A Canadian study119examined the reach and effectiveness of free 5 weeks mailed NRT

(patches or gum) via a quitline and included brief telephone advice among the first 14,000

eligible Ontario residents who called a toll-free quitline, who smoked at least 10 cigarettes

per day and were willing to make a quit attempt within 30 days. The Smoking Treatment for

Ontario Patients (STOP) Study was compared with population-based estimates of smoker

characteristics from a concurrent Ontario Tobacco Survey (OTS) study of smokers from the

same general population. A sub cohort of the OTS was matched to STOP participants to

assess effectiveness. The STOP study was launched in January 2006. Region-specific media

promotion was used to increase the reach in more remote regions of the province with a high

prevalence of smoking. The response rate for STOP was 48% (n=5261) and 42% had

complete follow-up data and were assessed.

The percentage of STOP participants reporting abstinence after 6 months was 21.4%,

relative to 11.6% in the no-intervention cohort (rate ratio of 1.84;95% CI 1.79 to 1.89), with

30-day point prevalence of 17.8% and 9.8% for the intervention and nointervention cohorts,

respectively (rate ratio 1.81; CI 1.75 to 1.87). Compared with all adult Ontario smokers

STOP participants were more likely to have less than high school education. The lowest

income group was associated with a lower percentage of self-reported quit at the time of

interview in bivariate analyses. In multivariate analyses neither education nor income was

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significantly related to self-report at least one serious quit attempt within 6 months, being

quit at the time of interview, or 30-day quit point prevalence. In summary, mailed NRT

showed a positive equity impact in terms of reach, was equally effective in significantly

increasing quit rates across all SES groups and therefore had an overall positive equity

effect.

An English study116 evaluated the impact of a 3-month TV and advertising campaign

supported by advertorials (adverts that look like editorial) in women's magazines. The

television advertisements were targeted at young smokers (aged 16-24 years) and aimed to

challenge their reasons for smoking and provide them with reasons to quit. In contrast to

previous campaigns, the TV adverts adopted a hard hitting testimonial approach. The radio

and magazine adverts were aimed at a slightly wider audience and were intended to provide

support and encouragement to those who want to quit. All adverts included the freephone

Quitline number.

The study evaluated the impact of a telephone helpline (Quitline) with additional support

(written information) on callers who used the service during a mass media campaign. 3019

of 18,873 log sheets were randomly selected and compared with all smokers in the general

population in England; callers were more likely to be women, to be in the age groups 25-34

or 35-44 years, to come from households with children under the age of 16 years, and to be

heavy smokers (smoke 20 or more cigarettes a day). Of 6038 callers who had left telephone

numbers to be contacted, 730 were follow-up at one year (12%). Compared with callers at

baseline, women, those aged 35 and over, those with moderate consumption levels (10-19

cigarettes a day), and more long term smokers were overrepresented in the one year recall

sample. Quitline received around half a million calls in the course of one year, representing

4.2% of the total population of adult smokers in England.

At one year the social class profile of callers to the helpline reflected the social class profile

of all adult smokers; 63% of the sample were of manual occupations or unemployed

compared with 61% of the adult smoker population. At one year 22% (95% CI; 18.4% to

25.6%) of smokers reported that they had stopped smoking. Assuming that those who refuse

to take part in the one year follow up were continuing smokers and a further 20% of reported

successes would fail biochemical validation, this yielded an adjusted quit rate of 15.6%

(95% CI 12.7% to 18.9%) at one year. 25% (17.05 to 32.95) of social classes ABC1 and

21% (13.52 to 28.48) social classes C2DE stopped smoking at one year; manual and

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unemployed ex-smokers were more likely to relapse at one year compared with non-manual

ex-smokers. Information on social class was not available at baseline and so it is not possible

to conclude about the reach of the mass media campaign, although the difference in relapse

suggest the campaign was less effective in the long-term in lower SES smokers.

A US study118 compared characteristics of new callers to a national reactive telephone

helpline with those in a control population of adult current smokers in the US (2002)

National Behavioral Risk Factor Surveillance Study and the 1999-2001 National Health

Interview Study. Mass media advertising campaigns using health consequences messages

directed homogeneously across all population segments were used to boost helpline usage.

Based upon an independent survey report of 432 callers, billboards were noted to be the most

common method (49.6%) for the users to learn about the helpline, followed by radio

(12.5%), television (10.6%), and word of mouth (7.6%).

A convenience sample of 890 eligible adult smokers participated (98.9%), mostly from the

Midwestern and Southern states who called the helpline during January 2003 and October

2005. There was significant overrepresentation of poorer and less educated smokers who

used this national reactive telephone helpline, when compared with the general adult

population of smokers across the United States.

There were issues with study validity; the study findings were based on a convenience

sample not sampled by a stratified design across the entire United States. Participants were

mostly from the Midwestern and Southern states so results may not be generalisable across

US. Further, all comparisons between the two populations were based on crude or

unadjusted prevalence rates. The study did not take into account the secular trends in

smoking behaviour during the period 1999 to 2005. In addition, helpline callers were more

likely to represent the contemplation stage of behavioural change than the general population

of smokers. The study did not directly measure TV advertising exposure amongst callers to

the helpline.

Television advertisements

An Australian study114 examined the efficacy of 13 different types of mass media

advertisements in driving lower SES smokers aged 18 to 39 years, to utilise quitlines over

two years (2006 to 2008). Each person within the target population was exposed 88.39 times,

and rates of exposure were similar across ad types. After all significant covariates were

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included, (including the introduction of smokefree pubs and clubs legislation) increases in

anti-smoking advertising TARPs were significantly associated with the number of quitline

calls (Rate Ratio = 1.070, 95% CI 1.020 to 1.122, P = 0.005). Higher emotion narrative ad

exposure had the strongest association with quitline calls, increasing call rates by 13% for

every additional ad exposure per week (per 100 points, rate ratio = 1.132, P = 0.001).

The Victorian quitline received a significantly higher rate of calls from high SES (RR =

4.177, P < 0.001) and mid-high SES (RR = 1.804, P < 0.001) smokers compared with those

from the low SES group, but call rates from mid low SES smokers (RR = 0.869, P < 0.001)

were significantly lower than those from the low SES smokers. There was no interaction

between TARPs and SES group (P = 0.223). There were greater increases in calls to the

quitline from lower SES groups when higher emotion narrative ads were on air compared

with when other ad types were on air. In summary, there was a neutral equity impact,

although there was an over-representation of Quitline calls from the high SES group,

Quitline calls increased by the same degree across each SES group. Higher emotion narrative

anti-smoking ads may potentially contribute to reducing socio-economic disparities in calls

to the quitline through maximizing the responses of the lower SES smokers.

An Australian antismoking TV media campaign117 assessed the impact of anti-tobacco

television advertising on call rates to a Quitline in Victoria, and socioeconomic variations in

call rates. The TV campaign predominantly featured hard-hitting advertisements on the

health risks of smoking, and promotion of a telephone Quitline. Adverts were shown

irregularly over 169 week period; in 88 weeks there were no adverts, in 42 weeks there was a

‘medium’ volume of adverts, and in 39 weeks there was a ‘ high’ volume of adverts aired.

Attempts were made to tailor adverts to low SES groups, including placement and content.

Study participants were television viewer in Victoria who responded to the TV

advertisements by calling the Quitline and requesting a Quit Pack. Quitline calls were

tracked between January 2001 and March 2004 and linked to callers postcodes; SES

quintiles were derived from the Index of Socioeconomic Disadvantage.

Exposure to TV adverts led to higher Quitline call-rates across all five SES quintiles. Call

rates increased almost universally by 2.5-2.7 times in all five quintiles. SES and call rates

were inversely associated; the adjusted call rate was 57% (95% CI 45% to 69%) higher in

the highest than the lowest SES quintile. The call rates gradient appeared to be very similar

across SES groups. The trend in calls appeared to be very similar across SES categories,

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indicating no interaction between TARPs and SES in their effect on the volume of calls.

There was no evidence of an interaction of time with SES, suggesting that SES differentials

in call rates were stable in the study period.

The study showed that TV advertising of a Quitline can have an equal effect in terms of

prompting people of all SES levels to seek help by calling a Quitline. However, an equal

increased response rate meant that there was no reduction in the relatively lower rates of

calls in the lower SES quintiles and so the summary equity impact is neutral.

Earned media

A US study113 evaluated the use of free nicotine patches rather than using paid media to

increase the use of a Quitline in Oregon. The study evaluated whether a multicomponent

campaign which promoted the Oregon Free Patch Initiative (FPI) in 2004, could generate

and sustain incoming call volumes to the Oregon Tobacco Quitline, (ORQL) more

efficiently than paid media advertising. Twelve of the 22 health plans contacted, agree to

promote the Free Patch Initiative (FPI) and included health maintenance organizations (both

Medicaid and non-Medicaid), preferred provider organizations, and indemnity-based plans.

The promotional plan, utilizing Roger’s Diffusion of Innovation theory, targeted health

plans, local policy makers, media sources, and referral sources, such as healthcare providers.

Word-of-mouth advertising was also encouraged using a free patch card, which could be

handed out to tobacco users. Six weeks prior to the public launch, information about the

initiative was disseminated by e-mailing and sending letters to public and private sector

partners. The ORQL paid for media (TV commercials) during the preinitiative period, but

not during the initiative.

A sample, six months prior to the launch, was utilized as the comparison group. In three

months, the FPI achieved free news media coverage, generated a 12-fold increase in calls to

the ORQL, sustained a two-fold increase in calls for 5 months after the FPI, and reached

1.3% of all Oregon smokers in 3 months. If these volumes were sustained, the annualized

reach would be 5.2%. Between October and December 2004, the top two specific sources of

hearing about the ORQL identified were TV news (17.1%) and family or friends (16.2%). In

the pre-initiative sample, the two top sources of hearing about the ORQL identified at

registration were TV/commercial (19.3%) and a Medicaid letter (17.9%).

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The pre- and post-launch cohorts differed on major demographic characteristics including

education; 56.2% ‘high school or less education’ vs 54.2% after launch; 36% ‘some college’

before and 35.3% after; ‘college graduate or more’ 7.8% before and 10.5% after. The media

campaign increased calls from ‘college graduate or more’ but not ‘some college’ nor ‘high

school or less’. The study does not provide details of the relative uptake by SES. In terms of

equity based on caller educational level, the media campaign was associated with a negative

equity impact. Within 6 months of the FPI, 2 of the 22 health plans decided to add tobacco

cessation phone counselling as a member benefit. These Health Plan system changes that

occurred during the initiative may have influenced call rates.

Quitline number on cigarette packets

A cohort study in New Zealand91 examined how recognition of a national quitline number

changed after new health warnings were required on tobacco packaging. The study used data

from the New Zealand ‘arm’ of the International Tobacco Control Policy Evaluation Survey

which differed somewhat from other ITC samples as the smokers involved were New

Zealand Health Survey (NZHS) participants. NZHS respondents were invited at end of

NZHS to participate in this study. Wave 1 (March 2007 and February 2008) respondents

were exposed to text-based warnings with a quitline number but no wording to indicate that

it was the “Quitline” number. Wave 2 (March 2008 and February 2009) respondents were

exposed to pictorial health warnings (PHWs) that included the word “Quitline” beside the

number as well as a cessation message featuring the Quitline number and repeating the word

“Quitline.”

Quitline number recognition increased across all SES groups and the gap in quitline number

recognition between the least and most deprived groups narrowed. The overall response rate

for this study was 32.6% and the attrition was 32.9%, therefore results might not be

representative or generalisable to the overall general population of New Zealand.

Mass media campaigns to promote use of NRT

Three US studies93;120;121 were included which evaluated the effects of mass media

campaigns to promote the use of NRT.

The 2008 Nicotine Patch and Gum Program (NPGP) was a 16-day programme which used

geographic information system (GIS) analyses to monitor the large scale distribution of

nicotine replacement therapy (NRT) in New York City (NYC).120 The intake data were

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analysed in two ways, as the percent of NYC current smokers enrolled (through intake

reporting) and the geographic density of enrolment (through mapping). Population estimates

for current smokers were based on self-reported data from the Community Health Survey.

All campaign messages directed interested smokers to call 3-1-1 during the publicised dates.

Applicants were notified of programme eligibility by letter; eligible callers received the

appropriate NRT package (determined by the number of cigarettes smoked per day), while

ineligible callers received a letter with a referral to other cessation services. Two days before

the end of the NPGP, the NYC Department of Health and Mental Hygiene issued a press

release announcing that there was only 48 hours left to call for NRT. The complete intake

data were electronically passed from 3-1-1 to the NYC DOHMH daily for analysis,

reporting, and mapping.

In 2006 the adult smoking prevalence in NYC was 17.5%, representing 1,065,000 smokers.

More than 32,000 smokers applied for the 2008 NPGP and almost 30,000 (92.1%) were

found eligible. Almost all of the applicants and enrollees (99.6%) had geocodable addresses.

The primary sources of referral reported by all NPGP enrollees were TV commercials

(66.5%), followed by recruitment letters (11.2%), word of mouth (9.5%), and radio

commercials (5.2%). Overall, 2.8% of NYC smokers enrolled in the programme. Low

income adults had high enrolment percentages: 3.3% of NYC current smokers enrolled

compared to 2.5% from middle income neighbourhoods and 2.6% from high income

neighbourhoods. Adults with less than a high school education had high enrolment: 3.6% of

NYC smokers compared to 2.7% for high school graduates; 2.7% for ‘some college’ and

1.2% for college graduates. Neighbourhoods varied in the percentage of smokers enrolled,

ranging from 1.2 to 5.1%, with the low and medium income neighbourhoods having more

enrollees compared to high income neighbourhoods. This study of a large scale distribution

of NRT programme showed a positive impact in terms of reach and uptake by low SES

smokers. GIS provided near real-time assessment of participation patterns and the impact of

media and outreach strategies and it is one of the few studies to assess reach of an NRT

programme. However results might be specific to NYC neighbourhoods.

A US study93 examined a concurrent Quit & Win contest and NRT giveaway in Erie and

Niagara counties in the western New York region. Smokers could enrol in both or either

programme (combined group). Daily smokers (at least 10 cigarettes per day) were offered

the opportunity to win prizes including $1000 if they stopped smoking for the month of

January 2003 with a quit date of 1st January. NRT vouchers were redeemable at pharmacies

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for a 2-week supply of nicotine gum or patch. Media coverage included a press conference,

newspaper and television coverage. $35,000 was spent on radio advertisements aired on 6

local radio stations. The focus was mainly on the Quit & Win contest – people were

informed of free NRT giveaway when they telephoned the New York State Quitline. Both

interventions were marketed to minority populations (African American and Latino) using

newspaper, churches and community sites.

Random samples of 341 Quit & Win participants (40%) and 314 (46%) NRT voucher and

230 (100%) combination group were selected for follow-up at 4 to 7 months from the 1 st

January 2003, by telephone survey. Follow-up rates were 60-64%, with 204, 179 and 143

participants follow-up for Quit & Win, NRT and combination groups, respectively. The 3

intervention groups were compared with smokers in the same region using Erie-Niagara

Tobacco Use Survey (ENTUS), to determine reach. At follow-up the self-reported quit rates

were similar across the three intervention groups: 25 to 30%. Compared with smokers in

region, those enrolled in the three interventions had significantly more years of formal

education. However there was no significant difference in 7-day point prevalence of

smoking by education group. It was unclear how representative the regional cohort of

smokers was in the ENTUS survey, and in addition, smokers in all three intervention groups

were heavier smokers than in general population (20-21 vs 17 cigarettes per day). In

summary, the Quit & Win contest and concurrent NRT giveaway had lower reach among

less educated smokers in two regions in the US, all 3 interventions were associated with a

25-30% quit rate which did not differ by educational level.

A US study121 evaluated the impact of a multimedia campaign to promote a Nicotine

Replacement Therapy (NRT) giveaway between May 3rd and June 6th 2006 in New York

City (NYC). Smokers could enrol via a free non-emergency government information line

and eligible callers received four weeks of NRT patches. The Nicotine Patch Program (NPP)

was advertised via a multimedia campaign (TV/radio/print in English & Spanish) from

January to October 2006, including testimonials from dying/sick smokers, and graphic

images of smoking’s impact. The NPP was assessed by random telephone survey of adult

smokers in NYC (n=1000) conducted in 2006 in English or Spanish. The study aimed to

aimed to improve understanding of: (1) awareness of the 2006 Nicotine Patch Program

(NPP) among New York City (NYC) smokers; (2) differences in sociodemographic

characteristics among those who reported a desire to participate compared to those who did

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not; (3) perceived barriers and reasons for not wanting to participate; and (4) suggested

outreach methods for future giveaways and media campaigns.

Programme awareness was 60% overall, with most awareness coming from TV advertising

(62%) followed by word-of mouth (19%) and radio advertisements (14%). Interest among

those who hadn’t heard of the programme was 54%. Reported awareness was significantly

lower for the highest income group ($75,000 or more) and for the highest education (college

graduate) group. Populations with lower levels of income and education expressed more

interest in the programme compared to groups with higher levels of income and education.

Compared to 37% of respondents with an annual income of $75,000 or more, 56% of

respondents each earning less than $25,000 (p=0.04) and $25,000 to less than $50,000

(p=0.03) reported program interest. Sixty-three percent of those with less than a high school

education (p=0.04) and 67% of high school graduates (p<0.001) reported program interest,

compared to 43% of college graduates.

Summary equity impact for awareness and interest in the programme was positive however,

there was no SES evaluation of the other research questions (3) perceived barriers and

reasons for not wanting to participate; and (4) suggested outreach methods for future

giveaways and media campaigns. Response and co-operation rates were low; 14% screening

response rate to the survey and 56% (n=602) completed the survey. The study extrapolated

data from a very small population to make assertions about a huge, diverse city. There was

no assessment of the representativeness of the sample of either smokers or NYC as a whole.

The study was likely to over-estimate the number of potential users given the hypothetical

question on interest (those reporting interest would significantly outweigh the number of

actual users). Programme awareness estimates might also be overestimates, because study

authors note that the NPP was tied to a larger social marketing campaign around quitting

smoking.

Summary of mass media campaign to promote the use of quitlines and use of NRT

Nine studies used mass media to promote the use of quitlines and three studies used mass

media to promote use of NRT. In general, the evidence of effectiveness of mass media

campaigns to promote the use of quitlines in terms of equity was inconsistent.

Mass media smoking cessation advertising campaigns to promote the use of quitlines were

associated with increases in calls to telephone helplines for quitting smoking. Three of the

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nine studies showed greater effectiveness for lower SES smokers compared with higher SES

smokers.91;112;118;119. One US study found higher calls to quitlines (motivational response,

stage 2) and a New Zealand study found greater recognition of a quitline number on cigarette

packs (recall, stage 1). It is unclear how quitline number recognition might translate into

quitting. A Canadian study of a mass media campaign and provision of free NRT by mail

following a brief telephone intervention showed a positive equity impact in terms of reach,

was equally effective in significantly increasing quit rates across all SES groups and

therefore had an overall positive equity impact.

Three studies showed equal effectiveness (neutral impact) in terms of calls to quitlines by

SES114;117and in quit rates. 115 Higher emotion narrative anti-smoking ads may potentially

contribute to reducing socio-economic disparities in calls to quitlines through maximizing

the responses of the lower SES smokers. Two studies showed lower effectiveness for low

SES groups, in terms of calls to quitlines113and smoking relapse.116 An English study116

evaluated the impact of a 3-month TV and advertising campaign, showed that manual and

unemployed ex-smokers were more likely to relapse at one year compared with non-manual

ex-smokers.116 It was not possible to conclude about the reach of the mass media campaign,

although the difference in relapse rates, suggests the campaign was less effective in the long-

term in lower SES smokers.

Three US studies93;120;121 were included which evaluated the effects of mass media

campaigns to promote the use of NRT. A multimedia campaign to promote awareness of a

nicotine patch giveaway was associated with a positive equity impact: there was significantly

lower reported awareness of the nicotine patch giveaway for the highest income and

education groups.121 Another study (by the same first author) of a large-scale distribution of

NRT showed a positive impact in terms of reach: low income and low education smokers

had higher participation rates. Among neighbourhoods with high smoking prevalence, lower

income neighbourhoods had higher enrolment compared to higher income neighbourhoods.

Geographic information system analyses provided near real-time assessment of participation

patterns and the impact of media and outreach strategies and it is one of the few studies to

assess reach of an NRT programme. However the results from this study might be specific

to NYC neighbourhoods. A US Quit & Win contest with a concurrent NRT giveaway had

lower reach among less educated smokers in two regions in the US, all 3 interventions were

associated with a 25-30% quit rate which did not differ by educational level.

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3.6 Multiple policies Four studies54;56;122;123 which examined the impact of multifaceted policies were included,

two54;56 of which also reported results for separate policies and are reported in the relevant

sections of this review.

Three studies used repeat cross-sectional data, one study used USA data54 and two studies

were set in the Netherlands.122;123 One study used single cross-sectional data from 18

European countries.56 The two Dutch studies had large study samples and used the same

internet-based survey source. All four studies used education as an SES variable; one study

used the relative index of inequality (RII)56 and one Dutch study122 also used household

income.

All studies examined the impact of multifaceted tobacco control policies; including

smokefree workplace and enclosed public places legislation, increases in price/tax of

cigarettes, tobacco control campaign spending, advertising bans, health warnings, and mass

media smoking cessation campaigns. Outcomes included smoking prevalence, self-reported

behavioural responses to policies, smoking consumption, smoking initiation ratios, quit

attempts, and quit ratios. Most of the studies examined trends in data; the study in 18

European countries56 used log-linear regression analyses to explore the correlation between

national quit ratios and scores (both total and sub scores by individual policy) on the

Tobacco Control Scale (TCS).

A US study54 determined the impact of comprehensive tobacco control measures in New

York City (NYC) beginning in 2002 (cigarette tax increases, Smoke-free Air Act (SFAA)

2002, free NRT, tobacco control media campaign). During the 10 years preceding the 2002

programme, smoking prevalence did not decline in NYC. From 2002 to 2003, smoking

prevalence among NYC adults decreased by 11% (from 21.6% to 19.2%, (P =.0002)

approximately 140000 fewer smokers). Smoking declined among all education levels.

Groups that experienced the largest declines in smoking prevalence included residents in the

lowest and highest income brackets and residents with higher educational levels.

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High-income people were more likely than low-income people to report that the SFAA

reduced their exposure to ETS (53.3% vs 41.9%, P<.0001). Residents with low incomes

(<$25000 per year) or with less than a high school education were more likely than those

with high incomes (>$75 000 per year) and those with a high school education or higher to

report that the tax increase reduced the number of cigarettes they smoked (income: 26%

[low] vs 13.0% [high], P=.0002; educational attainment: 27.5% [lower] vs 19.3% [higher],

P=.009). The authors concluded that the data suggest that people with lower incomes may

have been more affected by the increase in taxation, whereas people with higher incomes

may have been more affected by greater awareness of the dangers of SHS and smokefree

legislation.

A Dutch study123 explored how the combination of a workplace smoking ban and two tax

increases influenced the smoking behaviour of the general population (>32,000) using repeat

cross-sectional survey data from the internet-based Dutch Continuous Survey of Smoking

Habits. Survey respondents were grouped into those who had paid work and those that

didn’t, in order to control for exposure to the workplace smoking ban.

There were no significant changes in the percentage of quit attempts among those with or

without paid work. For respondents with paid work, the combination of a smoking ban and 2

tax increases led to a decrease in the number of cigarettes per day and in the prevalence of

daily smoking. For respondents without paid work, there was no significant effect on any of

the outcome parameters.

For paid workers, there was no significant change (OR: 0.87) in the likelihood of daily

smoking among the respondents interviewed in the one month (January 2004) in which the

ban without additional tax increases was in force, although the OR was similar to the other

interventions. The effects of the first (OR: 0.86) and second tax increase (OR: 0.85) after the

ban on daily smoking were significant and in the expected direction. Among those without

paid work, the tax increases had no significant effect on the likelihood of daily smoking.

However, in terms of effect size, there was little difference between those with and without

paid work in the effect of the first (OR: 0.86 vs. OR: 0.87) and second (OR: 0.85 vs. OR:

0.94) tax increase. In both paid and unpaid groups, there was no evidence that the effect of

the measures on smoking was moderated by the respondent’s level of education.

Study authors argue that lack of significant effect for the workplace smoking ban amongst

paid workers, despite a relatively strong effect, might have been due to lack of statistical 143

power, and that due to the short time span in which the effect of the workplace smoking ban

alone could be measured (1 month); the influence of the workplace-smoking ban is likely to

be incorporated in the effects found for the first and second tax increase and so the individual

policy elements should not be teased out, but evaluated in combination. There is the

possibility that the study sample was not representative, particularly of those not in paid

work.

Another Dutch study122 examined trends in socioeconomic inequalities in smoking

prevalence, consumption, initiation, and cessation between 2001 and 2008, also using repeat

cross-sectional survey data from the internet-based Dutch Continuous Survey of Smoking

Habits. Several tobacco control policies were implemented; in 2002 text warning labels for

cigarette packages were introduced, in 2002 there was a tobacco advertising ban, in 2003 a

youth access law, in 2004 smoke-free workplace legislation was implemented which was

extended in 2008 to include the hospitality industry. Tax increases were implemented in

2001, 2004, and 2008. Intensive national mass media smoking cessation campaigns ran in

2003, 2004, and 2008.

While inequalities in smoking prevalence were stable among Dutch men, they increased

among women, due to widening inequalities in both smoking cessation and initiation.

Among men, educational inequalities widened significantly between 2001 and 2008 for

smoking consumption only.

Lower educated respondents were significantly more likely to be smokers, smoked more

cigarettes per day, had higher initiation ratios, and had lower quit ratios than higher educated

respondents. Income inequalities were smaller than educational inequalities and were not all

significant, but were in the same direction as educational inequalities. Among women,

educational inequalities widened significantly between 2001 and 2008 for smoking

prevalence, smoking initiation, and smoking cessation. Among low educated women,

smoking prevalence remained stable between 2001 and 2008 because both the initiation and

quit ratio increased significantly. Among moderate and high educated women, smoking

prevalence decreased significantly because initiation ratios remained constant, while quit

ratios increased significantly. It should be noted that there was evidence of an increase in

respondents to the survey with higher incomes over time.

One study examined the extent to which tobacco control policies (increase in cigarette price,

advertising bans, public place bans, campaign spending, health warnings) were correlated 144

with smoking cessation, in eighteen European countries.56 Log-linear regression analyses

were used to explore the correlation between national quit ratios and scores (total and sub

scores by separate policy) on the TCS.

The study found large variations in quit ratios (ratio of the number of ex-smokers divided by

the number of ever-smokers (current + former smokers)) and RII between countries. Quit

ratios were positively associated with TCS score; more developed tobacco control policies

were associated with higher quit ratios. More educated smokers were more likely to have

quit than lower educated, for men and women. There was a larger absolute difference

between high and low educated adults for 25-39 year olds. Policies related to cigarette price

showed the strongest association with quit ratios, a comprehensive advertising ban showed

the next strongest association with quit ratios and health warnings were negatively associated

with quit ratios.

There was significant positive association between quit ratio and price for high SES men and

women aged 40-59 years. There was significant positive association between quit ratio and

advertising bans for high SES men and women across both age groups and low SES men

aged 25-39 years. However, no consistent differences were observed between higher and

lower educated smokers regarding the association of quit ratios with score on the TCS.

Strong conclusions cannot be drawn because of various study limitations; the survey was

conducted before the TCS was devised, and before some were policies enacted, so the study

results might underestimate the impact of recent smoking policies. In addition, the study

only examined the association between ex-smokers and presence of policies, rather than

changes in smoking prevalence post-implementation.

Summary of multiple policies

Four cross-sectional studies54;56;122;123 examined the equity impact of multiple tobacco control

policies; including smokefree workplace and enclosed public places legislation, increases in

price/tax of cigarettes, tobacco control campaign spending, advertising bans, health

warnings, and mass media smoking cessation campaigns.

On the whole, these multifaceted tobacco control policies were associated with a neutral

equity impact. High and low SES groups seem to benefit equally from nationwide tobacco

control policies. In one European-wide study, more developed tobacco control policies were

associated with higher quit rates. Policies related to cigarette price showed the strongest

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association with quit ratios; significant associations with price were found for high education

males and females aged 40-59 years. A comprehensive advertising ban showed the next

strongest association with quit ratios; the association was stronger in the higher educated

group compared to the lower educated group in most age/sex groups.

Evidence suggests that different elements of these multiple policies may impact

differentially by SES. For example, people with lower incomes were more affected by the

cigarette tax increase, whereas people with higher incomes may have been more affected by

greater awareness of the dangers of SHS and smokefree legislation.

Evidence also suggests that within and across different SES groups; impact of multiple

tobacco control policies varies by age, gender, and according to the type of smoking-related

outcome that is measured. One Dutch study showed that initiation ratios (ratio of ever

smokers to all respondents) amongst low SES women increased and amongst moderate/high

educated women initiation rates did not change. Quit ratios (ratio of former smokers to ever

smokers) increased in all SES groups but overall, educational inequalities widened amongst

women for smoking prevalence due to the differences in initiation ratios between SES

groups.

3.7 Settings based interventions Seven studies124-130 were included which evaluated the impact of settings based interventions.

Four studies126-129 did not focus on smoking alone, but on broader inequalities related to

lifestyle (diet, physical activity, and smoking) and the wider environment (unemployment,

education, crime and the physical environment). Two studies were cancer prevention

initiatives (diet and smoking) set in manufacturing worksites in Massachusetts, USA;

WellWorks and WellWorks-2 which were developed by the same research group.126;127

WellWorks-2 integrated health promotion with occupational health and safety issues. The

New Deal for Communities (NDC) in England128 aimed to improve conditions in some of

most deprived neighbourhoods in the country. The Hartslag Limburg Intervention129 was a

five year community cardiovascular risk reduction lifestyle intervention programme in the

Netherlands.

Two community-based studies focussed on reducing smoking; one targeting African-

American smokers in low income and moderate income areas in four sites in the north-

eastern and south-eastern parts of the United States124 and one study targeting women,

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particularly low-income women of childbearing age in two rural counties in Vermont and

New Hampshire, USA.125

One study looked at the association between tobacco control policy and quit rates and the

influence of education level, within alcohol-addicted hospital in-patients in Germany.130

Measures of SES included education, income-level of areas, household income; and

occupation for the two worksite studies. The two worksite studies and the NDC study

reported an equity focus although both smoking interventions targeted lower-income adults

(African-American and American women of childbearing age). All studies except one

reported quit or abstinence rates, one study also reported smoking initiation rates129 and one

study reported smoking prevalence and quit attempts.124

Six studies compared results with a control group and two125;129 of these studies were

assessed as having comparable groups at baseline. One study used repeat cross-sectional

samples to observe changes in behaviour125 and two studies observed changes within a

cohort compared to an external comparison cohort128;129 One study was quasi-experimental in

design124and two studies were RCTs of worksite health promotion interventions -

‘WellWorks’ and ‘WellWorks-2’ - that included stopping smoking.126;127 However both of

these RCTs were not assessed according to an intention to treat (ITT) method. A seventh

study did not have a control group and applied a pre-post design with parallel cross-sectional

assessments.130

In the WellWorks126 study a random sample of workers were selected both at baseline and at

follow-up and completion rate of the surveys was 61% and 62% respectively, however the

paper focuses on those workers who responded to both surveys. In WellWorks-2127 15 out of

41 eligible worksites agreed to participate; the response rate of workers was 80% (range 64

to 92%) at baseline and 65% (range 31 to 89%) at follow-up. The study used both cross-

sectional data and an embedded cohort of respondents for analyses. In both RCTs126;127 it was

unclear how representative the study samples were of the study population, whether the

intervention and control groups were comparable, and if the attrition rates were acceptable.

Only one125 of the seven study samples were assessed as representative of the study

populations, with findings that are generalisable on a regional scale. The majority of studies

used credible data collection methods. The two worksite studies and the hospital-based study

did not have acceptable levels of attrition. With the exception of the NDC initiative (where

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there was overlap between intervention and comparator sites) and the hospital-based study, it

is likely that the observed effects were directly attributable to the community-based

intervention.

3.7.1 CommunityTwo broad health inequalities studies set in the community included the New Deal for

Communities (NDC) in England128 and the Hartslag Limburg Intervention in the

Netherlands.129

The New Deal for Communities (NDC) area-based initiative128 aimed to improve conditions

in some of the most deprived neighbourhoods in England and reduce the gap between them

and the rest of the country. There were 39 NDC areas, each with a budget of approximately

£50 million with which to address five specific outcome areas (health, unemployment,

education, crime and the physical environment) over 10 years. It was unique in this review in

targeting a broad range of social determinants of inequality. A longitudinal survey of 10 390

residents in NDC areas and 977 residents in comparator areas was undertaken with follow-

up at two years (2002 to 2004).

Small overall improvements were seen on all domains in NDC areas but similar

improvements were also seen in comparator areas. More than 10% of residents quit smoking

in NDC areas. At baseline there were large differences by education for smoking between

the intervention and control sites, and these differences widened over the two-year follow-

up. In NDC areas, higher educational groups were more likely to stop smoking. NVQ1 is up

to general certificate of secondary education (GCSE) level and NVQ4 is up to degree level.

The odds ratio for quitting smoking in the NDC areas for NVQ 1-2 was 1.14 (95% CI: 0.86

to 1.50) and for NVQ 3-5 was 1.49 (95% CI: 1.14 to 1.95). The odds ratio for quitting

smoking in the comparator areas for NVQ 1-2 was 0.55 (95% CI: 0.23 to 1.32) and for NVQ

3-5 was 1.48 (95% CI: 0.57 to 3.87). In summary, adults with higher education were more

likely to quit smoking within NDC group but there was no significant difference between

NDC areas and comparator areas, so in terms of equity there was no intervention effect.

The attrition rate was 27% in the intervention group and 28% in the comparator group at two

years. The comparator areas had a slightly lower proportion of residents with no educational

qualifications (33% versus 39%) which may indicate that the comparator areas were slightly

less deprived than their NDC counterparts. There was considerable overlap of area-based

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initiatives in NDC areas and it is likely that interventions were underway in some of the

similarly deprived comparator areas.

The Hartslag Limburg Intervention in the Netherlands129 was a five year community

cardiovascular risk factor reduction lifestyle intervention programme, encouraging people to

reduce their fat intake, be physically active, and stop smoking. It was an umbrella project

with two strategies, one at population level and the other targeted at deprived communities.

790 interventions were implemented (9 were anti-smoking interventions). Almost 50% of the

interventions took place in deprived areas. Examples of interventions were nutrition parties;

debt assistance (people with debts are taught to cook a healthy meal on a small budget);

printed guides showing walking and cycling routes; a daily TV guided aerobics programme,

including information about the health advantages of exercising; and anti-smoking

campaigns using billboards, posters, and leaflets.

To evaluate the programme, a longitudinal survey was undertaken with follow-up at five

years (1998 to 2003) of 2356 participants in experimental area (Maastricht), and 758 in

control area (Doetinchem). The participants in the intervention were involved in a previous

health monitoring study, and so were likely to be more health conscious than the general

population. Follow-up rate was over 80% in both intervention and comparator areas. At five

years, 6.5% of men and 5.8% women in the intervention group quit smoking compared to

5.8% men and 5.9% women in the control group. Initiation of smoking was 3.2% men and

3.3% women in the intervention group, and 2.3% men and 3.2% women in the control

group. All changes were significant for within group changes and there were no significant

differences between intervention and control groups. Smoking quit rates by low versus

median/high education was 6.2% vs 6.1% in the intervention group and 5.8% vs 5.9% in the

control group. Smoking initiation by low versus median/high education was 2.2% vs 4.3% in

the intervention group and 2.0% vs 3.7% in the control group. There were no significant

between intervention and control by educational level.

Two community-based studies focussed on reducing smoking; one targeting African-

American smokers in low income and moderate income areas124 and one study targeting low-

income American women of childbearing age.125

A community-based intervention124 targeted 2,644 black smoking households in four sites in

the north-eastern and south-eastern parts of the United States. A sample of 520 smokers was

randomly drawn from the baseline cohort for the six-month follow-up. For the twelve-month 149

follow-up a random sample of 490 smokers were selected from the original cohort

(excluding those individuals who had participated in the six-month follow-up). At the

eighteen-month follow-up survey (1989 to 1990), 2096 members of the original cohort left

were followed up. The community as a whole (both the active and the passive areas) were

exposed to a mass media campaign designed to promote readiness to quit smoking. The

active intervention included area-based educational interventions to reduce smoking. The

community-based intervention was centred on the health belief and diffusion of innovation

models.

At 18 months, there was a 41.5% greater point prevalence rate of non-smoking in the active

versus the passive intervention areas which was statistically significant. At 18 months, 1344

baseline smokers were re-interviewed in the active intervention groups combined, and the

point prevalence of non-smoking was 16.7% while it was 11.8% in the passive groups

combined, an absolute difference of 4.9 percent. Significant beneficial changes were also

observed for the intervention for quit attempts in the previous six months, number of

smokefree days and number of cigarettes smoked. The moderate income areas tended to

show a smaller percentage change in smoking outcomes in the intervention versus control

groups, than did the lower income areas, although the differences were not significant. The

exception to this was the greater percentage reduction in the number of cigarettes smoked.

Education was not significantly related to outcome variables. Within the paper there was no

specific outcome data by income area and income areas were not defined in any detail and so

it is difficult to ascertain what the impact of the intervention was by area SES.

One community-based intervention ‘Breathe Easy’ aimed to reduce the prevalence of

cigarette smoking among women with special emphasis on lower-income women of

childbearing age, among whom smoking was most prevalent.125 Two counties in Vermont

and two counties in New Hampshire, USA were assessed pre-intervention and post-

intervention using random-digit-dialled telephone surveys over four years (1989 to 1994).

Social cognitive theory, the transtheoretical model of behaviour change, diffusion of

innovation theory, and communications theory guided the intervention. Community

organization approaches to create coalitions and task forces to develop and implement a

multicomponent intervention with a special focus on providing support to help women quit

smoking. A community coordinator formed a local planning group, each county's planning

group formed a coalition, and each coalition recruited volunteers to serve on 5 working

groups: support systems, health professionals, educators, worksites, and mass media.

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In the intervention counties, compared with the comparison counties, the odds of a woman

being a smoker after 4 years of programme activities were 0.88 (95% CI = 0.78, 1.00,

p=0.02); women smokers' perceptions of community norms about women smoking were

significantly more negative and the quit rate in the past 5 years was significantly greater

(25.4% vs 21.4%; P=0.002). Quit rates were significantly higher in the intervention counties

among women with household annual incomes of $25 000 or less (14.6±2.0) compared with

control counties (22.6±2.3), p<0.01. There was no significant difference in 5 year quit rates

between intervention and control with household income >$25,000.

The response rates were 79.1% for the baseline survey and 89.9% for the year 5 survey of

eligible households. The mass media campaign was used in the context of a comprehensive

community programme including telephone counselling, support groups, primary care

interventions, cessation classes, workplace initiatives, health fairs and public events – and so

it is difficult to tease out independent effects of any separate component of the intervention.

3.7.2 WorkplaceTwo ‘linked’ RCTs evaluated worksite cancer prevention initiatives ‘WellWorks’126 and

‘WellWorks-2’127 which targeted behavioural risk factors including smoking in workers in

worksites in Massachusetts, USA. In the earlier trial (WellWorks) one worksite in each

matched pair was randomly assigned to the intervention and the other to the control group.

61% of worksites completed surveys at baseline (range by worksite was 36 to 99%), and

62% completed surveys at follow-up (range by worksite was 43 to 92%). The three

occupation groups were; ‘skilled and unskilled labourer (blue collar workers)’ ‘office work’

and ‘professional, managerial and administrative work’.

The intervention consisted of a whole worksite cancer prevention initiative, particularly

tailored for blue-collar workers, targeting behavioural risk factors (diet and smoking) and

exposure to job-related hazards in 2386 workers in 24 predominantly manufacturing

worksites. Three key intervention elements targeted health behaviour change: (1) joint

worker management participation in programme planning and implementation (2)

consultation with management on work-site environmental change (3) health education

programmes. The study length was 5 years (1989 to 1994) and the smoking outcome was 6-

month self-reported abstinence.

No significant effects were observed for smoking cessation; six-month smoking abstinence

rates were 15% in the intervention worksites and 9% in control worksites controlling for 151

worksites (p=0.123). When worksite was removed from the model, the OR for the

intervention effect was 1.83 (p=0.04). The intervention impact by job category was not

significant, though there was a trend with 6-month abstinence rate for skilled and unskilled

labourers 17.9% in the intervention sites and 9.0% in the control sites. For office workers

abstinence was 5.1% in control sites vs 2.5% in intervention sites, for professionals and

managers abstinence was 18.6% in control and 14.2% in intervention sites (abstinence rates

higher in control). Thus the intervention had no significant impact and no equity effect

(neutral equity impact).

It should be noted that this study focuses on the cohort of workers who completed both

baseline and follow-up surveys (62%) and that there were a differentially low proportion of

smokers and office workers which may have impacted on the abstinence results. Compared

with those responding only at baseline; the cohort had higher percentage of skilled and

unskilled labourers (49 vs 43%) and lower smoking prevalence (23% vs 26%). Members of

the cohort were less likely to have college degrees (26% vs 30%) but more likely to have

some college education (37% vs 32%).

The later study (WellWorks-2), similarly tailored to address needs of blue collar workers

consisted of a worksite health promotion integrated with an occupational health and safety

intervention (HP/OHS Group; seven worksites) compared with a worksite health promotion

only intervention (HP Group; eight worksites). It included interventions at the individual,

organisational, and environmental levels of influence and was conducted between 1997 and

1999. Worksites ranged in size from 424 workers to 1585 workers (mean: 741 per site).

Types of manufacturing at the worksites included adhesives, food, technology, jewellery,

motor controls, paper products, newspaper, abrasives, automobile parts, and metal

fabrication. 5156 workers responded to both the baseline and final survey; there was an

‘embedded cohort’ of 880 smokers at baseline who responded to the final survey.

‘Hourly wage earners’ were classified as blue collar workers and ‘paid on salary’ as white

collar workers. The primary smoking outcome was self-reported abstinence for six months

prior to the survey. Current smokers were defined as having smoked at least 100 cigarettes in

their lives and defined themselves as current smokers. For all smokers the quit rates were

higher in the HP/OHS condition compared to the HP group, but the difference was not

statistically significant; 11.3% vs 7.5% respectively, p=0.17. Smoking quit rates among

hourly workers in the HP/OHS condition more than double those in the HP condition (11.8%

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vs. 5.9%; p=0.04). There were no differences in quit rates between intervention groups for

salaried workers. Smoking quit rates among salaried workers in the HP/OHS condition was

9.9% vs 12.7% in the HP condition p=0.63. Thus the intervention appeared to have a

positive equity impact.

In WellWork-2 the unit of randomization and intervention was the worksite, while the unit

of measurement was the employee. Of 41 eligible worksites, 15 agreed to participate which

is a 37% response rate. Response rate to the baseline cross-sectional survey was 80%, the

response rate to the final survey was 65%. It was unclear how many smokers at baseline in

the ‘embedded cohort’ did not respond to the follow-up survey. It was also unclear which

differences in baseline characteristics between groups were adjusted for in analyses. The

measure of blue and white collar workers used in the WellWorks-2 study might not transfer

to other types of business.

Although both WellWorks and WellWorks-2 were RCTs; quit rates were not assessed in all

smokers randomised to each intervention. In addition, participating worksites might not be

representative of general population of worksites of this size and type of business.

3.7.3 HospitalsOne study looked at the association between tobacco control policy and quit rates and the

influence of education level, within alcohol-addicted in-patients in Germany.130 The study

explored the influence of tobacco control policies in German in-patient substance abuse

treatment centres on the smoking status of alcohol-addicted patients at discharge. Patients

were recruited consecutively in a 6-month period starting June 2005, 774 (65.7%) alcohol-

addicted in-patient smokers were followed up in 37 treatment centres. The mean duration of

treatment was 12.9 weeks. The majority of the centres were located in the western part of

Germany. One fourth of the recruited patients were female, the mean age of the patients was

42 years. The majority of the patients were not employed and had an education of less than

12 years. The mean smoking prevalence of patients at admission was 84% varying between

65% and 100%.

The Institutional tobacco control policy contained seven elements regarding Restrictions,

Enforcement, Assessment of smokers, Smoking cessation offers, Non-smoker protection,

Activities, and Training of Employees. The questionnaire consisted of scores up to an

optimal 100, for seven policy areas and was developed using published material and piloted.

Retest reliability was acceptable in 5 of 7 areas (r=0.61 to r=0.81) and in 2 areas the retest 153

reliability was ≤0.5. The tobacco control policy questionnaire was anonymous and answered

by the director of each treatment centre.

There was a small but significant effect of centres’ tobacco control policy on patients’

smoking cessation. A total of 39/774 in-patients that were smokers at admission (N=774)

were non-smokers (7-day prevalence) at discharge. This equals an abstinence rate of 3.3%

(intent-to-treat-analysis) respectively 5.0% (exclusion of drop outs). Abstinence rates varied

between centres within the range of 0% to 23%. Lower tobacco dependency predicted non-

smoking status at discharge (OR=0.84, 95% CI= 0.71 to 0.99). Comprehensiveness of

smoking restrictions (OR=1.03, 95% CI=1.00 to 1.07) and intensity of smoking-related

training of employees (OR=1.02, 95%CI=1.00 to 1.03) were significant predictors for the

variance in quit rates between the centres. Significant individual predictors for quitting

included educational status (OR=1.86, 95%CI=1.25 to 2.75), with higher education

predicting non-smoking status at discharge.

The study sample was a very specific population of smokers whose quit rates were relatively

low and the effects of the tobacco control policy were small. It was unclear how

representative the study sample was; compared with the general German population the

education of the sample was lower and the unemployment higher. There might have been

some selection bias as the majority of the treatment centres were self-selected and was only

one-fifth of all German in-patient substance abuse treatment centres. In addition attrition rate

was relatively high; 34% of the smokers dropped out of the study.

Summary of settings based interventions

There were seven settings based interventions: four community, two workplace and one

hospital based intervention. Two of the community based and both workplace interventions

focused on broader inequalities related to lifestyle and the wider environment.

Two studies demonstrated positive equity impacts; a workplace intervention integrating

health promotion with occupational health and safety efforts significantly improved smoking

quit rates among blue-collar manufacturing workers compared to health promotion alone, in

Massachusetts, USA. The ‘Breathe Easy’ community intervention which targeted lower-

income women produced higher quit rates amongst these women after four years.

Three interventions showed neutral effects for SES; a cancer prevention workplace

intervention showed that job category was significantly associated with smoking but there 154

were no significant effects of the intervention for smoking cessation, and intervention by job

category interaction was not significant. A community-based intervention targeting African-

American smokers showed that education was not significantly related to smoking outcomes

at 18 months. The community-based Hartslag Limburg Intervention did not reduce smoking

or prevent starting smoking in the general population or among low SES adults in the

Netherlands.

Two studies showed a negative equity impact. The NDC initiative in England, which was the

only intervention in the whole review to address the wider social determinants of inequality,

showed differences by education for smoking widened over the two-year follow-up. The

initiative did not demonstrate a beneficial effect, either overall or for lower SES. Residents

with lower education experienced the least favourable health profiles at baseline and the

smallest improvements. In a hospital-based study of alcohol addicted patients, at a time

when Germany did not have comprehensive smokefree hospitals; tobacco control policy

within substance-abuse treatment centres was likely to have had a negative equity impact,

with higher education predicting non-smoking status at discharge. There were two predictive

areas of tobacco control policy (restrictions and employee training) while an overall

effectiveness of the tobacco control policy could not be proven.

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3.8 Population-level cessation support interventions

3.8.1 National QuitlinesA New Zealand study131 evaluated reach of a quitline using repeat cross-sectional data from

the New Zealand Health Survey (NZHS) as part of The International Tobacco Control Policy

Evaluation Survey (ITC Project). It should be noted that another study91 is included within

this review (which examined the effect of including the word “Quitline” and the telephone

number to new pictorial health warning labels of cigarette packets) that uses the same

participant data.

A complex sample design included systematic boosted sampling of the Māori, Pacific, and

Asian populations. The initial wave (2007 to 2008) included 2,438 adult participants,

between-wave attrition of 32.9% resulted in 923 respondents in wave 2 (2008 to 2009).

Quitline use in the last 12 months rose from 8.1% (95% CI = 6.3%–9.8%) in Wave 1 to

11.2% (95% CI = 8.4% to 14.0%) at Wave 2. There was higher usage with increasing small

area deprivation (p = .04 for trend) and for higher ratings in one of the two measures of

financial stress “not spending on household essentials”. The overall response rate was

32.6%, and results were weighted to adjust for the complex study design and high level of

non-response. The weighting process may not have fully adjusted for nonresponse bias,

potentially affecting the generalizability of the findings to all NZ smokers.

In summary, one study was identified which evaluated reach of a national Quitline, and

found that SES was not significantly associated with Quitline usage. The equity impact was

unclear because of inconsistency of outcome between SES measures, uncertainty about how

quitline calls translates to smoking prevalence, and lack of representativeness of study

sample.

3.8.2 UK NHS Smoking Cessation ServicesThe UK is the only country in the world to have established comprehensive local smoking

cessation services which are available to smokers free as part of NHS. This state-reimbursed

stop smoking service provides behavioural support and pharmacotherapy. Thus, while

services are delivered at the individual level (either one-to-one or in groups), because of their

national comprehensive coverage they can also be regarded as a population-level policy

intervention.

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Six studies of UK NHS stop smoking services (SSSs) which reported the reach of these

services were included. Articles were only included if they reported on the impact of the

SSSs in terms of reach and/or impact at the population level. An early study of NHS

SSS’s132aimed to evaluate the reach of the service and quit rates at four weeks in 76 of 99

health authorities in England during 2000/2001. One cross-sectional study examined the

reach of NHS SSSs in Spearhead (deprived) areas and impact on inequalities in smoking in

England.133 Another cross-sectional study evaluated the prevalence of smoking status,

provision of advice and referral to NHS SSSs and whether trends differed by deprivation

group across the UK.134 Another study135 examined the impact of an NHS SSS rolling-group

drop-in service in a cohort of clients in Liverpool and Knowsley (England) over a year.

Another cross-sectional study136 assessed the impact of the Quality and Outcomes

Framework (QOF) on the recording of smoking targets in primary care medical records in

the UK. A ‘grey literature’ report evaluated the NHS SSSs in Scotland.137

A study of NHS SSS’s132aimed to evaluate the reach of the service and quit rates at four

weeks in 76 of 99 health authorities in England during 2000/2001 when the service was

relatively new. There was considerable variation in outcomes across the health authorities

including those sampled and not sampled.

A wide range of service characteristics (individual sessions, stronger service relationships,

service operating at full capacity, smoking cessation co-ordinator hours, location of service)

were significantly associated with the outcome measures: reach, absolute success, cessation

rate, and loss to follow up. A number of area characteristics were also significantly

associated with outcome measures. Area characteristics accounted for a large proportion of

the variation in reach (81%) and the absolute number of successful self-reported four week

quits (79%). Study authors argue this is due to the service being more developed and better

funded in HAZ areas. Service characteristics were substantially more important in

accounting for the cessation rate (78%) and loss to follow up (98%).

Cessation services based in health action zones (HAZ, areas of high deprivation) reached

140% more smokers compared to other more affluent areas, and the number of people who

reported quitting at four weeks was 90% greater in HAZ areas. However, there was an

inverse relationship between reach and cessation rates (the number of smokers who reported

quitting at four weeks as a percentage of those setting a quit date). Cessation rates were

lower in deprived areas compared with more advantaged areas. Typically the cessation rate

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in an area with an upper quartile deprivation score was 6% lower than that in an area in the

lower quartile. Services operating in deprived areas were more likely to lose clients between

setting a quit date and reporting outcomes at four weeks. The study did not assess the overall

equity impact of the services (ie whether the higher reach in deprived areas compensated for

lower quit rates). Therefore the equity impact is unclear.

One study133 examined the impact of NHS SSSs in Spearhead areas which are officially

designated as the most disadvantaged local authority areas in England and account for about

30% of the adult population. Estimates of smoking prevalence were compared with national

monitoring data from the NHS SSSs to evaluate reach of services and impact on inequalities.

Self-reported 4-week quit rates were lower in disadvantaged areas (52.6%) than elsewhere

(57.9%) (p<0.001), but the proportion of smokers being treated was higher (16.7% compared

with 13.4%) (p<0.001). Overall, the proportion of all smokers who were estimated to have

quit at 4 week and 52 week follow up was higher in the Spearhead areas (8.8% and 2.2%)

than elsewhere (7.8% and 1.9%) (p<0.001). Assuming 75% of 4 week quitters would relapse

(across all areas) within one year, the absolute and relative rate gaps in smoking prevalence

between Spearhead areas and others were estimated to fall by small but statistically

significant amounts from 5.2 and 1.215 (CIs: 1.216 to 1.213) to 5.0 and 1.212 (CIs: 1.213 to

1.210) between 2003-4 and 2005-6. The study found that although disadvantaged groups had

proportionately lower quitting success rates than their more affluent neighbours, services

were treating many more clients in disadvantaged communities. Overall, therefore, the net

effect of service intervention was to achieve a greater proportion of quitters among smokers

living in the most disadvantaged areas. In summary, NHS SSSs were having a slight

narrowing i.e. positive effect on inequalities in smoking prevalence.133

One study134 investigated smoking prevalence, provision of advice and referral to NHS SSSs

within the UK and whether trends differed by deprivation group. In April 2004, a General

Medical Services contract was introduced into UK primary health care that included

financial incentives to record smoking status and to provide smoking cessation support. The

study134 used the QRESEARCH database to confirm a recent acceleration in smoking

reduction found using survey data, and also describe the recording of smoking status,

provision of smoking advice, and referral to SSSs in patients registered in primary care in the

UK. It also aimed to investigate whether these trends differed between sex, age, and

deprivation groups. Data sources were cross-sectional samples from 2001/2 and 2006/7 of

2.7 million patients from 525 general practices.

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The proportion of people with smoking status recorded increased by 32.9% (2001/2002:

46.6% to 2006/2007: 79.5%). A large overall increase in the provision of smoking cessation

advice (2001/2002: 43.6% to 2006/2007: 84.0%) and referral to SSSs (2001/2002: 1.0% to

2006/2007: 6.6%) was also observed. The proportion of people who smoked (with a

recorded smoking status) reduced by 6.0% (2001/2002: 28.4% to 2006/2007: 22.4%). The

decrease in the proportion of people who smoked was greatest among patients in the most

deprived areas (7.2%) and the youngest patients (16–25 years: 7.1%). In 2006/2007, more

than twice as many patients in deprived areas smoked as those in affluent areas (most

deprived: 33.8%; most affluent: 14.1%).

In 2001/2002, patients in deprived areas (who had been recorded as smokers in the last 12

months) received the most smoking cessation advice (P<0.001). However, in 2006/2007,

similar proportions from the most affluent and most deprived groups were provided with

smoking cessation advice. In 2001/2002, patients in deprived areas were more likely to be

referred to SSSs (P<0.001). In 2006/2007, those living in the most deprived areas were most

likely to be referred. Large increases in the number of patients referred to SSSs were also

found (P<0.001), most particularly among those in the most deprived areas.

In summary, a greater proportion of lower SES smokers were more likely to be referred to a

SSS and this has increased over time. The absolute gap between low and high SES in terms

of smoking prevalence appeared to be increasing whilst the relative gap was getting smaller.

The study used a large representative dataset of UK adults. There were a larger number of

non-smokers being recorded over time which could have overestimated decreases in the

prevalence of smokers but it is unlikely that any potential overestimation varied across SES

groups. During the time period of the study there was a range of smoking cessation

initiatives introduced as part of a multifaceted government policy to reduce inequalities in

smoking. These initiatives included mass media campaigns, increases in cigarette tax,

increased action to reduce tobacco smuggling and the Tobacco Advertising and Promotion

Act 2002. The study authors do not attribute any specific intervention to the observed

effects.

An English study135 assessed long term outcomes of a drop-in rolling-group model of

behavioural support for smoking cessation: the Roy Castle Lung Cancer Foundation Fag

Ends NHS Stop Smoking Service in Liverpool and Knowsley, UK. ‘Fag Ends’ is an

alternative intervention approach with support centred on drop-in rolling groups. Quit date

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can be different for attendees and can be determined by the client. There are no waiting lists,

no appointments and no requirement to be referred by a third party, although referral systems

are in place. Weekly sessions run continuously. Clients can attend as many sessions as they

wish and can continue to attend even if they relapse.

The study collected data from clients who accessed the service during a ten week period in

2009. In terms of reach, the study sample135 was particularly disadvantaged, 68% resided in

the most deprived decile of the English Index of Multiple Deprivation (positive equity). ‘Fag

Ends’ clients were drawn from particularly disadvantaged groups when compared to the

general population. Only 20% had finished their education after age 16, whereas in England

49% had qualifications obtained after age 16 in 2009. Nearly two-thirds were eligible for

free prescriptions, whereas 50% of the general population were eligible. A third were long-

term unemployed, whereas the General Lifestyle Survey 2008 estimate for UK over-16s

unemployment was 4.2%.

In terms of effectiveness, in general, more affluent clients were significantly more likely to

be quitters at 12 months (negative equity impact). The study135 was only able to

biochemically validate quit status of approximately two-thirds of the clients. A composite

measure of affluence in the multivariate analysis found that affluent smokers had

significantly higher quit rates (OR 1.33 p<0.001). In the bivariate analysis quit rates were

significantly higher in those living in affluent areas, those who owned their home and those

who were not entitled to free prescriptions. However, there was no significant difference by

educational status and there was no clear pattern by occupational status. The overall equity

impact was therefore ‘mixed’.

The Liverpool and Knowsley region has high economic and social disadvantage, Liverpool

is the most disadvantaged local authority in England. Rolling-group drop-in services are

attended by approximately 3% of NHS SSS clients who set a quit date138 and so although this

type of NHS SSS might be particularly effective at reaching lower SES (positive equity

impact), it is a relatively small proportion of services users who access this particular type of

NHS SSS.

Another UK study136 assessed the impact of the QOF (April 2004) on the recording of

smoking targets in primary care medical records. The data source was the Health

Improvement Network (THIN) database which included over six million patients’ records

from 446 practices throughout the UK. The introduction of the QOF was associated with a 160

significant increase in the recording of smoking status and cessation advice. There was a

greater recording of smoking status and cessation advice with advancing Townsend score

(greater deprivation). Multivariate analyses for 2008 showed that more deprived patients

were 35% more likely to have their smoking status recorded (OR 1.35, 95% CI 1.21-1.49,

p<0.001) and 20% more likely to have cessation advice recorded (OR 1.20, 95% CI 1.10-

1.30, p<0.001), than those least deprived.

The smokefree legislation was introduced around the same time as the QOF which may have

confounded study results. The study reports intermediate outcomes for smoking (recording

status and advice) which do not show how the intervention impacts on smoking prevalence.

Other studies have found that lower SES smokers are less likely to be successful when they

attempt to quit smoking, even after accessing support from a SSS.

The report of NHS Smoking Cessation Service Statistics (Scotland)137 1st January to 31st

December 2011 provides an analysis of Scottish NHS SSSs uptake and outcomes during

2011. This is the sixth annual release of statistics from the minimum dataset monitoring in

Scotland, produced by Information Services Division (ISD) Scotland. For the first time, the

2012 annual report included statistics on successful ‘self-reported’ one month quits by

Scottish Index of Multiple Deprivation (SIMD) and also as a percentage of total estimated

adult smokers.

Those living in the most deprived communities (equivalent to SIMD 1-2) account for an

estimated 31% of adult smokers in Scotland and for 37% of quit attempts made in NHS

SSSs in 2011. One month quit outcomes by SIMD reveal that the lowest quit rates were in

the most deprived areas (1-2) and the highest quit rates in the least deprived areas (9-10).

However, in terms of overall numbers of quitters the most deprived areas (1-2) still

accounted for the largest numbers of quitters of all the deprivation deciles.

Most importantly, combining reach (of all smokers in an area) with quit rates at one month,

showed that the percentage of successful quitters was greater in the most deprived SIMD

area 1 (4.2%) compared with least deprived SIMD area 10 (3.4%). This report therefore

shows a positive equity impact of the SSSs in Scotland. However there is the possibility of

systematic bias in the results, there was a greater percentage of ‘lost to follow-up/smoking

status unknown’ in the more deprived SIMD areas than the least deprived SIMD areas.

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3.8.3 New Zealand General Practice Smoking Cessation Services

A New Zealand study139 evaluated the impact of a behavioural and pharmacological smoking

cessation programme “Preparation Education Giving up and Staying smoke free’’ (PEGS)

which targeted more deprived areas and was delivered by General Practitioners to 11,000

patients over six years who resided in the Christchurch urban area. PEGS is an educational

smoking cessation intervention with different types of counselling and literature based on

patients level of readiness to quit. The ‘most ready’ participants are also offered NRT and to

nominate a quit date. The delivery of the programme is not consistent across practices but in

general, face-to-face support was given when the patient collected NRT from the practice

every one or two weeks. The NRT was heavily subsidised by the Ministry of Health for up to

three months. Enrolees were followed up by their GP six months after their enrolment.

There was little difference in utilisation of the programme between the highest and lowest

deprivation areas as a proportion of the city’s smoking population (22.0% for least deprived

quintile and 20.7% for most deprived quintile). However, the quit rate for the least deprived

neighbourhoods was 36.1% compared to 25.6% for the most deprived areas. Assuming those

lost to follow-up were smokers the quit rate was 25.2% in the least deprived areas compared

with 17.5% in the most deprived areas.

The study estimated that the actual gap in smoking prevalence between the most and least

affluent neighbourhoods was reduced by 0.2 percentage points (15.6% to 15.4%), but

relative gap widened from 2.81 to 2.84 OR due to the PEGS programme. The population-

level effect was small and non-significant. Although the programme was effective in

reducing smoking prevalence, there was no evidence of a significant impact on area

inequalities (neutral equity impact).

Summary of population-level cessation support interventions

UK NHS SSSs appear to be reaching relatively more disadvantaged than advantaged

smokers and, although low SES service users have lower quit rates, the higher reach is more

than compensating for this. Thus, the net overall effect is a narrowing of relative inequality

in terms of smoking prevalence between adults of the lowest and highest SES, i.e. a positive

equity effect. The one study to assess the equity impact of a behavioural and

pharmacological smoking cessation programme (PEGS) delivered by General Practitioners

and targeted at more deprived areas ,was effective in reducing smoking prevalence however

there was no evidence of a significant impact on area inequalities (neutral equity impact).

162

The one study to assess the equity impact of a national quitline, in New Zealand, produced

unclear findings.

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4 DISCUSSION

The review presented in this report has systematically assessed the available evidence on the

impact of population-level tobacco control and other policy interventions on socioeconomic

inequalities in adult smoking. One hundred and sixteen studies were included which have

evaluated the impact of population-level policies/interventions, on smoking-related

outcomes in adults by SES, measured by a range of indicators including income, occupation,

education and area deprivation. 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

Considerable attempts were made to include published and ‘in press’ studies as well as ‘grey

literature’. The search included searching key reviews, handsearching to identify ‘in press’

articles from four key journals, and contacting European tobacco control experts and asking

them to provide any other relevant peer reviewed articles (non-English language) or grey

literature. However, it is possible that some relevant studies might have been missed which

had not been published in the peer reviewed literature and/or which were not published in

English. In addition a pragmatic decision was taken to exclude studies published prior to

1995.

The inclusion criteria for the systematic review were intentionally wide in order to gather the

broadest possible range of evidence that could inform equity-orientated policies. Any type

of tobacco control or other policy intervention, of any length of follow-up, with a relvant

smoking-related outcome was included. Thus, this review goes beyond the previous CRD

and PHRC reviews in searching for non-tobacco control interventions and polices (e.g.

education, social policy) which assessed any smoking-related equity impacts. A broad range

of smoking related outcomes, either self-reported or observed/validated, was included:

initiation and cessation rates, quit attempts, intentions to smoke/quit, prevalence, exposure to

SHS, policy reach, social norms/attitudes and use of quitting services. Studies were included

which did or did not have a specific equity focus. In order to include as much relevant

evidence as possible, many of the primary studies included in this review would not meet the

criteria used by other systematic reviews. However, ‘pure’ experimental designs are often

either not feasible or inappropriate for evaluating certain types of tobacco control policies

and interventions, such as smokefree legislation and national media campaigns.

164

A further inclusion criterion was that a measure of SES had to be reported within the abstract

of a paper. It is possible that papers which undertook analyses by SES were not included

because these analyses were not mentioned in their abstract. An example of this is

econometric studies where an outcome is elasticity (i.e. affordability according to income).

All potentially relevant econometric studies might not have been identified as the abstracts

might not have reported a measure of SES, although by their very nature these econometric

studies are relevant to this review. It was not feasible to include all papers which report SES

anywhere in the main body of the paper in such a broad encompassing review as this.

However, such as search might be worth undertaking in future reviews in respect of a small

number of topic/policy areas to see if any more relevant evidence is captured and whether

this differs from that found in the original review.

Socioeconomic variables included income, education, occupational social class, area-level

socio-economic deprivation and subjective social status. These SES variables do not

encompass all disadvantaged people, who might have been captured by including other

measures of SES, such as ethnicity. In addition, the socioeconomic conditions captured by

SES measures, such as income, education and occupation, can vary widely between

countries across Europe.

Studies targeted at low SES sub-populations that did not report differential smoking-related

outcomes for at least two socio-economic groups were excluded because, although they can

potentially provide useful information about uptake and impact within specific lower SES

groups, they cannot provide information about any equity impact.

We developed a new quality assessment tool, an adapted version of previously used tools,

which was designed to enable us to assess the quality of the diverse range of types of

interventions and study designs encompassed in the included studies. Given the variations in

study methodologies, intervention types and outcome measures, the results were presented in

the form of a narrative synthesis and according to intervention type. In order to provide a

simple basis for comparing the methodology of each study, a typology of study designs was

devised.

We also adapted a model to assess the equity impact of each intervention/policy. A study

was classed as associated with a positive equity impact when low SES groups, such as lower

occupational groups, those with a lower level of educational attainment, the less affluent or

those living in more deprived areas, were more responsive to the intervention/policy. A

study was classed as associated with a neutral equity impact when there was no social 165

gradient in the effectiveness of the intervention/policy as measured by SES. This could mean

that both lower and higher SES groups benefitted equally from the intervention/policy or that

the intervention/policy was not effective in any SES group. A study was classed as

associated with a negative equity impact when high SES groups were more responsive to the

intervention/policy.

The equity impact of each study policy/intervention was derived ‘on balance’, taking into

account quality issues, such as internal and external validity, generalisability and

transferability.

4.2 Strengths and limitations of the available evidence

A relatively large number of studies were identified and included within this systematic

review. The majority of the evidence concerns the effectiveness of smoking restrictions in

enclosed public places (44), increases in price/tax of tobacco products (27) and mass media

campaigns (30). A relatively small number of studies were included for other types of

interventions/policies including the effects of controls on advertising, promotion and

marketing of tobacco (9); multiple policies (4); settings-based interventions (7) and

population-level cessation support interventions (8). Despite searching for non-tobacco

control interventions and polices (e.g. education, social policy) which assessed any smoking-

related equity impacts, only one study (community approach) was identified.

There was considerable variation in the type of designs and quality of the studies. A large

proportion of the studies were from the USA, which raises concerns about their

generalisability and potential transferability to, or relevance for, countries in Europe which

have different social and cultural contexts and/or different levels of tobacco control. In

addition, there was a lack of consistency in respect of the reported outcome measures and

length of follow-up within most policy or intervention types.

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The summary of the equity impact of policies/interventions was derived ‘on balance’.

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

complicated by some studies having multiple outcomes or multiple measures of SES which

varied in equity impact. In other cases the same SES measure or outcome varied by gender,

setting or country. In these cases the equity impact was classed as ‘mixed’. In some cases it

was not possible to assess the equity impact and these types of studies were classed as

‘unclear’. Whether exposure was measured in relative or absolute terms could also influence

the equity impact results.

4.3 Main findings and conclusions

There were 116 studies which reported smoking-related outcomes by SES included in the

review. The initial electronic search produced 12,605 references, of which 81 studies met

the inclusion criteria. A further twenty-three studies were identified through hand-searching,

searching of grey literature, key reviews and contacting experts. An update of the electronic

searches and journal handsearching was carried out in January 2013 which identified a

further twelve relevant studies.

The literature was international, with more than half the studies being carried out in the

USA. Eighteen studies were carried out in the UK and eight in the Netherlands. A few

studies were based in multiple countries. Other study countries included Australia, Belgium,

Canada, Croatia, France, Germany, Italy, New Zealand, Sweden and Russia. Most of the

British studies assessed the impact of smokefree legislation and the NHS smoking cessation

services.

The types of interventions/policies included were: smoking restrictions in cars, homes,

workplaces and other public places (44); increases in the price/tax of tobacco products (27);

controls on advertising, promotion and marketing of tobacco (9); mass media campaigns

including call to promote the use of quitlines and NRT (30); multiple policy interventions

(4); settings-based interventions including community, workplace and hospitals (7); and

population-level cessation support interventions (8). Eight studies were included in more

than one type of policies/intervention category.

4.3.1 Equity impact

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Out of the 116 included studies there were 129 different types of policies that were evaluated

and the equity impact was as follows: 33 ‘positive’ policies, 35 ‘neutral’ policies, 38

‘negative’ policies, 6 ‘mixed’ policies and 17 ‘unclear’ policies (Appendix I). It is important

to point out that the 35 ‘neutral’ policies indicate that these policies have benefits for adults

across all SES groups. Only three of these ‘neutral’ policies showed no significant effect of

the intervention for any SES group and these three studies were community-based.

Thirty-three policies showed the potential to produce a positive equity impact i.e. to reduce

inequalities in adult smoking. These ‘positive’ policies included one study of smokefree

workplace legislation, two studies of national smokefree legislation in enclosed public

places, fourteen studies of increasing the price/tax of tobacco products, two studies of

controls on advertising, promotion and marketing of tobacco, three studies of anti-tobacco

mass media campaigns, five studies of mass media smoking cessation advertising campaigns

to promote the use of quitlines, two settings-based interventions (community, workplace)

and four studies of the UK NHS smoking cessation services. One of these ‘positive’ policies 91 was included in both the ‘mass media’ section and the ‘mass media to promote the use of

quitlines’. One study had a positive equity impact for mass media and price policies but an

unclear equity impact for smokefree legislation.55

Some trends in equity effect by type of tobacco control intervention/policy emerged from the

data. More than half of the studies of smokefree legislation were associated with a negative

equity impact and make up the bulk of the ‘negative’ studies. However, these include a large

number of studies that looked at the equity impact of voluntary policies. The majority of the

studies of policies to increase the price/tax of cigarettes were associated with a positive

equity impact. There were no ‘negative’ studies for controls of advertising, marketing and

promotion of tobacco products. The mass media campaigns were associated with

inconsistent equity impacts. Four of the six studies of NHS smoking cessation services had a

positive equity impact.

4.3.2 Equity impact by type of tobacco control policy/intervention

Smoking restrictions in workplaces, enclosed public places, cars and homes

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The 44 studies which assessed the equity impact of smoking restrictions and smokefree

policies varied considerably in terms of the scope, setting and comprehensiveness of the

policies being assessed. These ranged from voluntary workplace and/or public places

smoking polices to partial national legislation covering workplaces to comprehensive

smokefree national legislation covering all enclosed public places. The evidence shows that,

irrespective of the country, where the adoption of smokefree policies is voluntary, there are

significant inequalities in policy coverage and SHS exposure among workers according to

SES. In general, the higher the level of income or education or occupational status, the

greater the odds of working in a smokefree environment and the stronger the workplace

smoking restrictions. The lower the level of income, education and occupation, the greater

the smoking prevalence and the greater the SHS exposure in the workplace. The evidence

also suggests that partial or voluntary local adoption of smokefree legislation has the

potential to increase socioeconomic inequalities in terms of protection from SHS exposure.

Statewide/regional rather than national comprehensive legislation also has the potential to

increase socioeconomic inequality. For example, several US studies found that more

deprived communities were slower in adopting smokefree polices for public places than

more affluent communities.

Only one of fifteen studies assessing the impact of voluntary worksite smoking policies

demonstrated a positive equity impact in terms of exposure to SHS. This study included

workers who were both non-smokers and not exposed to SHS smoke at home, which means

that they are probably not representative of all workers.18 The study showed that inequalities

in SHS workforce exposure (measured by serum cotinine levels) might be diminishing with

the increased adoption of clean indoor laws in the USA. Blue-collar non-smoking workers

who were not exposed to SHS at home continued to have the highest cotinine levels but

experienced the largest absolute reductions.18

Overall, national comprehensive smokefree legislation was found to reduce SHS exposure,

increases quit attempts and have positive health effects within the general population. By

definition such legislation is equity positive as it removes the inequalities in protection from

SHS found in studies which looked at voluntary policies. However, in terms of equity impact

on other smoking-related outcomes, only two of the 22 studies15;52 that evaluated national

smokefree legislation demonstrated an overall positive equity impact. Nine studies showed a

neutral equity impact and five showed a negative equity impact. In three studies the equity

impact was unclear and in another study the equity impact was mixed according to outcome.

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The recent proliferation of smokefree policies in bars, restaurants and workplaces across

Australia, Canada, UK and USA has had a positive equity impact by reducing disparities in

policy coverage by SES, as low SES worksites and public places catch up in adopting total

smoking bans.15 A study52 based in England, Wales and Scotland, showed that bars in more

deprived areas experienced a greater percentage reduction in PM2.5 levels up to 12 months

post-implementation of national comprehensive smokefree legislation, compared to more

affluent areas, although there were higher levels of PM2.5 at baseline for the more deprived

areas.

The comprehensive smokefree legislation in Scotland, Wales and Northern Ireland did not

appear to displace smoking into the car or the home and was not patterned by SES in pooled

analyses. Two of the three studies on the impact of public places smoking legislation on

voluntary home smoking restrictions found a negative impact and one was associated with a

neutral impact. The CHETS UK study47, for example, showed that although smoking

restrictions in the car and in the home increased following the smokefree legislation, there

was no change in inequalities in parental smoking in the car or in the home (socioeconomic

differences remained).

No studies which evaluated the equity impact of smokefree vehicle laws were identified.

However, support for smokefree vehicle laws is increasing and this review provides some

evidence of inequalities smoking in vehicles in the absence of smokefree vehicle laws.

Increases in price/tax of tobacco products

Overall, increase in the price/tax of tobacco products was associated with decreases in

smoking prevalence across the general population. Fourteen of the twenty-seven

studies55;63;65-69;72-74;78-80;82 of increases in the price/tax of cigarettes were associated with larger

reductions in smoking prevalence and/or consumption for lower SES groups compared with

higher SES groups, demonstrating a positive equity impact. Six studies demonstrated a

neutral equity impact,40;56;58;70;71;81 in one study the equity impact was mixed depending on

SES measure62 and in two studies the equity impact was unclear.54;57 Four studies showed a

negative impact on equity.64;75-77 However this group of ‘negative’ equity studies included

two studies of distinct population subgroups: HIV-positive adults76 and pregnant women.77 In

addition, most of these studies were from the US.

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Overall, within the general population, lower SES adults appear more responsive to price/tax

increases in terms of larger price elasticities compared with high SES adults. However,

larger price elasticities amongst lower SES adults might be capturing short-term effects

which do not translate into increased sustained quitting amongst lower SES adults.

In addition, cross-border or black-market sales were not accounted for in most econometric

studies which could have biased the results. Cross-border sales may be patterned by SES

and issues of cross-border sales may have more relevance to some European countries than

others. Included studies suggest that lower SES adults might be more likely than higher SES

adults to mitigate the effects of price or tax increases by switching to cheaper or stronger

brands or bulk buying. A recent study140 examining socioeconomic and country variations in

cross-border cigarette purchasing among adult smokers showed that cross-border cigarette

purchasing was more often reported by smokers with higher education and income.

Furthermore, cross-border cigarette purchasing is more common in European regions

bordering countries with lower cigarette prices.

A panel of experts who assessed the effectiveness of tax and price policies in tobacco control

in 201083 concluded that there was sufficient evidence of the effectiveness of increased

tobacco excise taxes and prices in reducing overall tobacco consumption and prevalence of

tobacco use. They also concluded that there was strong but not sufficient evidence in high-

income countries that lower income populations are more responsive to tax and price

increases compared with higher income groups. Our review adds to the evidence base by

showing that a majority of studies demonstrate greater responsiveness to tax/price increases

in lower SES groups, through reduced smoking prevalence and consumption.

Controls on the advertising, promotion and marketing of tobacco

Few studies have looked at the equity impact of wider restrictions and bans on advertising

and promotion. Of the nine studies which assessed the effects of controls on advertising,

promotion and marketing of tobacco, five looked only at the impact of health warning on

packets. Seven studies found a neutral equity impact (i.e. were equally effective in all SES

groups). The two studies with a positive equity impact were on EU text-only health warnings

and the addition of a quitline number to new pictorial health warnings.

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A European study showed variation in impact of EU text only health warnings across

countries depending on type of SES measure used. Overall there was a positive equity with

the impact highest among smokers with lower incomes and smokers with low to moderate

education (except the UK in the case of education), suggesting that text only health warnings

could be more effective among low SES groups. However, France and the UK now have

pictorial health warnings. Quitline number recognition included with new pictorial health

warnings, increased across all SES groups in New Zealand, and the gap in quitline number

recognition between the least and most deprived groups narrowed, indicating a positive

equity effect. It is unclear how change in ‘intermediate’ outcomes (reported in most of these

studies), such as awareness, recognition, motivation and preferences, translate into change in

smoking prevalence and the equity impact of any such longer term changes.

Mass media campaigns including campaigns to promote the use of Quitlines and NRT

There was no consistent equity impact for either mass media cessation campaigns or

campaigns promoting quitlines or free NRT. Three studies of mass media cessation

campaigns showed a positive equity impact. A tobacco control paid media campaign55 in the

US was associated with a more rapid decline in smoking prevalence among low SES

women. The EX mass media campaign (TV element) increased cessation-related cognitions

only among those with less than a high-school education and increased quit attempts only

among those with less than a high-school education. A Dutch multimedia campaign106

targeted at smokers with an intention to quit smoking in the future, with a focus on lower

educated smokers, was associated with a positive equity impact for campaign awareness.

The equity impact was unclear in six studies due to the following reasons: type of outcome

reported; measure of exposure; where impact was more pronounced in a ‘middle’ SES

group; where there was inconsistency between outcome measures; where outcome differed

between SES groups even despite similar exposure to the policy; or where differences in

effect were more pronounced although the effect was similar across all SES groups. These

issues were also impacted by the lack of representativeness of most of the study samples and

in some cases also low attrition. Five studies demonstrated a negative equity impact,

including four Quit & Win competitions and a Dutch 24 hour no-smoking intervention.

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The type of outcomes measured varied, but were mainly stage one and stage two outcomes

according to the logic framework; such as campaign awareness, recall and interest (stage 1)

and recruitment, quit attempts and one-day abstinence (stage 2). Some studies reported the

impact of mass media campaigns in terms of longer-term outcomes, including smoking

prevalence and abstinence and there was no apparent pattern of effectiveness according to

stage or type of outcome reported. It is unclear how short or intermediate outcomes translate

into reduction in smoking prevalence and other health outcomes, and the impact of such

longer-term changes on equity.

Different types of media messages appear to have differential impact by SES and multiple

media formats may lead to equity benefit. A Dutch study105 showed that all smokers

(particularly those with low education) recalled advertisements focused on how to quit less

often, and perceived them as less effective, than advertisements using graphic imagery or

personal testimonials to convey why to quit. A study exploring differences in smokers’

perceptions of the effectiveness of cessation media messages111 found that advertisements

using a ‘why to quit’ strategy with either graphic images or personal testimonials were

perceived as more effective than the other advertisement categories (how to quit and anti-

industry). A further US study of paid media campaigns98 showed that highly emotional or

personal testimonial advertisements were more effective with the low, mid and undetermined

SES groups compared to the high SES groups for increasing the likelihood of quitting

smoking.

Mass media campaigns to promote the use of quitlines were associated with increases in

calls. However, only two of the nine studies found a positive equity effect91;112 in terms of

calls to quitlines and recognition of a quitline number on cigarette packs. Promoting free

NRT had more consistent positive equity effects. A Canadian study119 of a mass media

campaign and free NRT showed a positive equity impact in terms of reach and was equally

effective in increasing quit rates across all SES groups. Two of the three studies of mass

media to promote the use of NRT showed positive equity impacts in terms of awareness or

reach.120;121

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This review adds to the evidence included in the Niederdeppe review100and suggests that the

type of media message, the media format of the campaign and the mechanisms of

engagement vary by SES. A mass media campaign using multiple media formats, targeted at

lower SES groups, as part of an overall comprehensive tobacco control programme, has the

potential to impact positively on smoking inequalities.

Multiple policies

Four studies54;56;122;123 examined the equity impact of multiple tobacco control policies;

including smokefree workplace and enclosed public places legislation, increases in price/tax

of cigarettes, tobacco control campaign spending, advertising bans, health warnings, and

mass media smoking cessation campaigns. On the whole, these multifaceted tobacco control

policies were associated with a neutral equity impact. High and low SES groups seem to

benefit equally from nationwide tobacco control policies. In one European-wide study, more

developed tobacco control policies were associated with higher quit rates. Policies related to

cigarette price showed the strongest association with quit ratios and this mirrors the results

found from studies of individual interventions/policies.

Evidence suggests that different elements of these multiple policies may impact

differentially by SES. For example, people with lower incomes were more affected by

cigarette tax increases, whereas people with higher incomes may have been more affected by

greater awareness of the dangers of SHS and smokefree legislation. Evidence also suggests

that, within and across different SES groups,, the impact of multiple tobacco control policies

can vary by age, gender and the type of smoking-related outcome that is measured.

Settings based interventions

There were seven settings based interventions: four community-based, two workplace and

one hospital based intervention. The types of interventions included in these studies varied

considerably in their scope and approach; thus, the observed inconsistency in equity impact

is perhaps unsurprising. The evidence for any specific setting was insufficient to be able to

draw firm conclusions. The only intervention in the whole review to address wider social

determinants of inequality, the New Deal for Communities (NDC) in England128 had no

impact on the smoking outcome (quitting rates). The other community based intervention in

the Netherlands.129 also found no impact on smoking across all SES groups.

174

Two studies demonstrated positive equity impacts. A workplace intervention126 integrating

health promotion with occupational health and safety efforts significantly improved smoking

quit rates among blue-collar manufacturing workers compared to health promotion alone, in

Massachusetts, USA. The US ‘Breathe Easy’ community intervention125 which targeted

lower-income women produced higher quit rates amongst these women after four years.

Population-level cessation support interventions

The UK is the only country to have established comprehensive local smoking cessation

services which are free to smokers. This state-reimbursed stop smoking service provides

behavioural support and pharmacotherapy. Because of their national comprehensive

coverage these services can be regarded as a population-level policy intervention. The

services are particularly targeted at disadvantaged communities. Four of the five relevant

studies found a positive equity impact. These services are reaching relatively more

disadvantaged (than advantaged) smokers and, although these low SES service users have

lower quit rates, the higher reach more than compensates for this. Thus, the net overall effect

is a narrowing of relative inequality in terms of smoking prevalence between adults of the

lowest and highest SES, i.e. a positive equity effect.

One New Zealand study assessed the equity impact of a behavioural and pharmacological

smoking cessation programme (PEGS) delivered by General Practitioners, targeted at more

deprived areas, which was effective in reducing smoking prevalence. However there was no

evidence of a significant impact on area inequalities (neutral equity impact).

The only study to evaluate the reach of a national Quitline found that SES was not associated

with Quitline use. The equity impact was unclear because of inconsistency of outcome

between SES measures, uncertainty about how quitline calls translates to smoking

prevalence, and lack of representativeness of the study sample.

4.1 Future researchIt was not feasible to include in this review all papers which reported impact by SES

anywhere in the main body of the paper. However, a wider-ranging search might be worth

undertaking in a future study in respect of a small number of topic/policy areas, in order to

ascertain whether any more relevant evidence is captured and how this differs from the

evidence found in this review.

175

Studies targeted at low SES sub-populations that did not report differential smoking-related

outcomes for at least two socio-economic groups were excluded because, although they can

potentially provide useful information about uptake and impact within specific lower SES

groups, they cannot provide information about any equity impact. However, these types of

studies could increase understanding about the mechanisms of change and how more

effectively to target/tailor policies and interventions.

Given the relatively small number of identified studies that included equity analyses, another

potentially fruitful way to develop the evidence base would be to perform secondary

analyses of relevant datasets where SES data have been collected but not reported within

published papers. Consideration might be given to studies evaluating wider non-tobacco

control public policies, such as Spearhead and Sure Start in the UK, as well as tobacco

control policies. Another option would be to explore in cessation studies intermediate

outcome measures along the path to quitting, such as reduction in consumption.

A final suggestion would be to investigate whether findings are sensitive to different

measures of SES within and across studies included within this systematic review. This

might help us to increase our understanding of mechanisms of change.

176

5 CONCLUSIONS

One hundred and sixteen studies were included in this systematic review of the effectiveness

of population-level policies and interventions to reduce socio-economic inequalities in

smoking among adults. Despite searching for non-tobacco control interventions and polices

(e.g. education, employment, social policy) which assessed any smoking-related equity

impacts, only one relevant study was identified. Over a third of the studies assessed

smoking restrictions and smokefree polices, with approximately a quarter focusing on mass

media campaigns and a quarter on increases in the price/tax of tobacco products.

There was considerable variation in the type of designs and quality of the studies. A large

proportion of the studies were from the USA, which raises concerns about their

generalisability and potential transferability to, or relevance for, countries in Europe which

have different social and cultural contexts and/or different levels of tobacco control.

Among the included policies, 26% had a positive equity impact, 27% had a neutral equity

impact and 29% had a negative equity impact. It is important to point out that most of the

policies/interventions associated with a neutral equity effect had equal benefits for all SES

groups. Only three of these ‘neutral’ studies showed no significant effect of the intervention

for any SES group.

Limited conclusions can be drawn from these 116 studies about which types of tobacco

control interventions are likely to reduce inequalities in smoking. While the evidence base

has increased significantly since the previous PHRC review10 particularly in relation to

smokefree policies, no substantially new or significantly different findings or conclusions

have emerged.

177

The most consistent policy/intervention in terms of positive impact on reducing smoking

inequalities was price/tax rises. Overall, national comprehensive smokefree legislation

reduces SHS exposure, increases quit attempts and has positive health effects within the

general population. While comprehensive national smokefree polices remove inequalities in

protection from SHS in the workplace and enclosed public places, only two studies found a

positive equity impact on other smoking-related outcomes. This may be due to a lag effect in

terms of the impact on smoking behaviour (e.g. through changing social norms, which are a

long-term process) and the increased relative importance of SHS exposure in the home and

car, which is higher among low SES groups. Mass media campaigns had inconsistent effects,

which is perhaps to be expected given the diversity of messages, media formats and levels of

exposure in the studies. However, there is some emerging evidence that certain types of mass

media messages are more effective in low SES groups. The provision of free NRT might

also be more effective in low SES groups. A mass media campaign using multiple media

formats, with emotionally engaging or graphic messages, targeted at lower SES groups, as

part of an overall comprehensive tobacco control programme, appears to have the potential

to positively impact on smoking inequalities. Evidence from the UK NHS smoking cessation

services also indicates that cessation services effectively targeted at low income smokers can

have a positive equity impact by more than compensating for the lower quit rates in low SES

groups. This is an important finding: the previous PHRC review found that all types of non-

targeted cessation support have a negative equity effect as low SES smokers using such

support have lower quit rates than high SES smokers.

Given these previous findings, it is not surprising that the evidence suggests that different

elements of multiple policies (e.g. tax, smokefree) may impact differentially by SES. The

impact of multiple tobacco control policies also may vary by age, gender and the type of

smoking-related outcome.

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(107) Nagelhout GE, Willemsen MC, van den Putte B, Crone MR, de VH. International Tobacco Control (ITC) policy evaluation project. Evaluatie 'In iedere roker zit een stopper' campagne. Tweede nameting. 2009. Den Haag, the Foundation for Public Health and Smoking STIVORO.

(108) Wiebing MA, Bot SM, Willemsen MC. Rokers verdienen 'n beloning', de 24-uur-niet-rokenactie. Blootstelling, deelname en effect op stopbereidheid bij hoge en lage welstandsgroepen. Tijdschrift voor Gezondheidswetenschappen 2010; 88:435-441.

(109)van den Putte B, Yzer MC, Ten Berg BM, Steevels RMA. Nederlands Start Met Stoppen / Nederlands Gaat Door Met Stoppen. Evaluatie van de STIVORO campagnes rondom de jaarwisseling 2003-2004. 2005. Amsterdam, Universiteit van Amsterdam.

(110)van Osch L., Lechner L, Reubsaet A, Steenstra M, Wigger S, de VH. Optimizing the efficacy of smoking cessation contests: an exploration of determinants of successful quitting. Health Education Research 2009; 24(1):54-63.

(111) Davis KC, Nonnemaker JM, Farrelly MC, Niederdeppe J. Exploring differences in smokers' perceptions of the effectiveness of cessation media messages. Tobacco Control 2011; 20: 26-33.

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(113) Deprey M, McAfee T, Bush T, McClure JB, Zbikowski S, Mahoney L. Using free patches to improve reach of the Oregon Quit Line. Journal of Public Health Management and Practice 2009; 15(5):401-408.

(114) Durkin SJ, Wakefield MA, Spittal MJ. Which types of televised anti-tobacco campaigns prompt more quitline calls from disadvantaged groups? Health Education Research 2011; 26(6):998-1009.

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(116) Owen L. Impact of a telephone helpline for smokers who called during a mass media campaign. Tobacco Control 2000; 9(2):148-154.

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187

7 APPENDICES7.1 Appendix A Search strategies: electronic searches, handsearching

and searching for grey literatureElectronic searches

Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1946 to May 04 2012, search date 09/05/2012; also Ovid MEDLINE(R) 1946 to January week 3, 2013, search date 23/01/2013

1. smoking/2. smoking cessation/3. tobacco/4. "Tobacco Use Disorder"/5. nicotine/6. tobacco, smokeless/7. tobacco use, cessation/8. (smokers or smoker).ti,ab.9. cigar$.mp.10. smoking.ti,ab.11. or/1-1012. smoking cessation/13. tobacco use, cessation/14. tobacco use, cessation products/15. smoking/pc16. smoking/dt17. smoking/th18. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (ban or bans or prohibit$ or restrict$ or discourage$)).ti,ab.19. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (workplace or work place or work site or worksite)).ti,ab.20. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (public place$ or public space$ or public area$ or office$ or school$ or institution$)).ti,ab.21. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (legislat$ or government$ or authorit$ or law or laws or bylaw$ or byelaw$ or bye law$ or regulation$)).ti,ab.22. ((tobacco free or smoke free) adj3 (hospital or inpatient or outpatient or institution$)).ti,ab.23. ((tobacco-free or smoke-free) adj3 (facilit$ or zone$ or area$ or site$ or place$ or environment$ or air)).ti,ab.24. ((tobacco or smok$ or cigarette$) adj3 (campaign$ or advertis$ or advertiz$)).ti,ab.25. ((billboard$ or advertis$ or advertiz$ or sale or sales or sponsor$) adj3 (restrict$ or limit$ or ban or bans or prohibit$)).ti,ab.26. (tobacco control adj3 (program$ or initiative$ or policy or policies or intervention$ or activity or activities or framework)).ti,ab.27. ((smok$ or tobacco) adj (policy or policies or program$)).ti,ab.28. ((retailer$ or vendor$) adj3 (educat$ or surveillance$ or prosecut$ or legislat$)).ti,ab.29. test purchas$.ti,ab.30. voluntary agreement$.ti,ab.31. health warning$.ti,ab.32. ((tobacco or cigarette$) adj3 (tax or taxes or taxation or excise or duty free or duty paid or customs)).ti,ab.33. ((cigarette$ or tobacco) adj3 (packaging or packet$)).ti,ab.34. ((cigarette$ or tobacco) adj3 (marketing or marketed)).ti,ab.35. ((cigarette$ or tobacco) adj3 (price$ or pricing)).ti,ab.

188

36. point of sale.ti,ab.37. vending machine$.ti,ab.38. (trade adj (restrict$ or agreement$)).ti,ab.39. (contraband$ or smuggl$ or bootleg$ or cross border shopping).ti,ab.40. (tobacco control act or clean air or clean indoor air).ti,ab.41. ((reduce$ or prevent$) adj3 (environmental tobacco smoke or passive smok$ or secondhand smok$ or second hand smok$ or SHS)).ti,ab.42. ((population level or population based or population orientated or population oriented) adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.43. (community adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.44. ((sale or sales or retail$ or purchas$) adj3 (minors or teenage$ or underage$ or under-age$ or child$)).ti,ab.45. (youth access adj3 restrict$).ti,ab.46. (smoking cessation or cessation support).ti,ab.47. (smokefree or smoke-free or smoke free).ti,ab.48. ((stop$ or quit$ or reduc$ or give up or giving up) adj3 (cigarette$ or tobacco or smoking)).ti,ab.49. quit attempt$.ti,ab.50. tobacco quit.ti,ab.51. quit rate$.ti,ab.52. (quitline$ or quit line$ or quit-line$).ti,ab.53. ((smok$ or tobacco or nicotine or cigarette$) adj2 (abstinence or cessation)).ti,ab.54. or/12-5355. (socioeconomic or socio economic or socio-economic).ti,ab.56. inequalit$.ti,ab.57. depriv$.ti,ab.58. disadvantage$.ti,ab.59. educat$.ti,ab.60. (social adj (class$ or group$ or grade$ or context$ or status)).ti,ab.61. (employ$ or unemploy$).ti,ab.62. income.ti,ab.63. poverty.ti,ab.64. SES.ti,ab.65. demographic$.ti,ab.66. (uninsur$ or insur$).ti,ab.67. minorit$.ti,ab.68. poor.ti,ab.69. affluen$.ti,ab.70. equity.ti,ab.71. (underserved or under served or under-served).ti,ab.72. occupation$.ti,ab.73. (work site or worksite or work-site).ti,ab.74. (work place or workplace or work-place).ti,ab.75. (work force or workforce or work-force).ti,ab.76. (high risk or high-risk or at risk).ti,ab.77. (marginalised or marginalized).ti,ab.78. (social$ adj (disadvant$ or exclusion or excluded or depriv$)).ti,ab.79. exp socioeconomic factors/80. exp public assistance/81. exp social welfare/82. vulnerable populations/83. or/55-8284. 11 and 5485. 83 and 8486. limit 85 to (abstracts and english language and yr="1990 -Current")

189

Embase; Excerpta Medica Database Guide, 1980 to 2012 Week 18, search date 09/05/2012; also 1980 to 2013 week 3, search date 23/01/2013

1. smoking/2. smoking cessation/3. tobacco/4. nicotine/5. tobacco, smokeless/6. "smoking and smoking related phenomena"/7. cigarette smoking/8. cigarette smoke/9. tobacco smoke/10. (smokers or smoker).ti,ab.11. cigar$.mp.12. smoking.ti,ab.13. or/1-1214. smoking cessation program/15. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (ban or bans or prohibit$ or restrict$ or discourage$)).ti,ab.16. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (workplace or work place or work site or worksite)).ti,ab.17. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (public place$ or public space$ or public area$ or office$ or school$ or institution$)).ti,ab.18. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (legislat$ or government$ or authorit$ or law or laws or bylaw$ or byelaw$ or bye law$ or regulation$)).ti,ab.19. ((tobacco free or smoke free) adj3 (hospital or inpatient or outpatient or institution$)).ti,ab.20. ((tobacco-free or smoke-free) adj3 (facilit$ or zone$ or area$ or site$ or place$ or environment$ or air)).ti,ab.21. ((tobacco or smok$ or cigarette$) adj3 (campaign$ or advertis$ or advertiz$)).ti,ab.22. ((billboard$ or advertis$ or advertiz$ or sale or sales or sponsor$) adj3 (restrict$ or limit$ or ban or bans or prohibit$)).ti,ab.23. (tobacco control adj3 (program$ or initiative$ or policy or policies or intervention$ or activity or activities or framework)).ti,ab.24. ((smok$ or tobacco) adj (policy or policies or program$)).ti,ab.25. ((retailer$ or vendor$) adj3 (educat$ or surveillance$ or prosecut$ or legislat$)).ti,ab.26. test purchas$.ti,ab.27. voluntary agreement$.ti,ab.28. health warning$.ti,ab.29. ((tobacco or cigarette$) adj3 (tax or taxes or taxation or excise or duty free or duty paid or customs)).ti,ab.30. ((cigarette$ or tobacco) adj3 (packaging or packet$)).ti,ab.31. ((cigarette$ or tobacco) adj3 (marketing or marketed)).ti,ab.32. ((cigarette$ or tobacco) adj3 (price$ or pricing)).ti,ab.33. point of sale.ti,ab.34. vending machine$.ti,ab.35. (trade adj (restrict$ or agreement$)).ti,ab.36. (contraband$ or smuggl$ or bootleg$ or cross border shopping).ti,ab.37. (tobacco control act or clean air or clean indoor air).ti,ab.38. ((reduce$ or prevent$) adj3 (environmental tobacco smoke or passive smok$ or secondhand smok$ or second hand smok$ or SHS)).ti,ab.39. ((population level or population based or population orientated or population oriented) adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.40. (community adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.

190

41. ((sale or sales or retail$ or purchas$) adj3 (minors or teenage$ or underage$ or under-age$ or child$)).ti,ab.42. (youth access adj3 restrict$).ti,ab.43. (smoking cessation or cessation support).ti,ab.44. (smokefree or smoke-free or smoke free).ti,ab.45. ((stop$ or quit$ or reduc$ or give up or giving up) adj2 (cigarette$ or tobacco or smoking)).ti,ab.46. tobacco quit.ti,ab.47. quit attempt$.ti,ab.48. quit rate$.ti,ab.49. (quit line$ or quitline$ or quit-line$).ti,ab.50. ((smok$ or tobacco or nicotine or cigarette$) adj2 (abstinence or cessation)).ti,ab.51. or/14-5052. (socioeconomic or socio economic or socio-economic).ti,ab.53. inequalit$.ti,ab.54. depriv$.ti,ab.55. disadvantage$.ti,ab.56. educat$.ti,ab.57. (social adj (class$ or group$ or grade$ or context$ or status)).ti,ab.58. (employ$ or unemploy$).ti,ab.59. income.ti,ab.60. poverty.ti,ab.61. SES.ti,ab.62. demographic$.ti,ab.63. (uninsur$ or insur$).ti,ab.64. minorit$.ti,ab.65. poor.ti,ab.66. affluen$.ti,ab.67. equity.ti,ab.68. (underserved or under served or under-served).ti,ab.69. occupation$.ti,ab.70. (work site or worksite or work-site).ti,ab.71. (work place or workplace or work-place).ti,ab.72. (work force or workforce or work-force).ti,ab.73. (high risk or high-risk or at risk).ti,ab.74. (marginalised or marginalized).ti,ab.75. (social$ adj (disadvant$ or exclusion or excluded or depriv$)).ti,ab.76. exp socioeconomics/77. public assistance/78. welfare, social/79. exp social status/80. social security/81. vulnerable population/82. or/52-8183. 13 and 5184. 82 and 8385. limit 84 to (abstracts and english language and yr="1990 -Current")

191

PsycInfo (OVID) 1987 to May Week 1 2012, search date 10/05/2012; also 1987 to January week 3 2013, search date 23/01/2013

1. exp tobacco smoking/2. exp smoking cessation/3. nicotine/4. tobacco, smokeless/5. (smokers or smoker).ti,ab.6. tobacco.ti,ab.7. nicotine.ti,ab.8. cigar$.mp.9. smoking.ti,ab.10. or/1-911. exp smoking cessation/12. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (ban or bans or prohibit$ or restrict$ or discourage$)).ti,ab.13. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (workplace or work place or work site or worksite)).ti,ab.14. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (public place$ or public space$ or public area$ or office$ or school$ or institution$)).ti,ab.15. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (legislat$ or government$ or authorit$ or law or laws or bylaw$ or byelaw$ or bye law$ or regulation$)).ti,ab.16. ((tobacco free or smoke free) adj3 (hospital or inpatient or outpatient or institution$)).ti,ab.17. ((tobacco-free or smoke-free) adj3 (facilit$ or zone$ or area$ or site$ or place$ or environment$ or air)).ti,ab.18. ((tobacco or smok$ or cigarette$) adj3 (campaign$ or advertis$ or advertiz$)).ti,ab.19. ((billboard$ or advertis$ or advertiz$ or sale or sales or sponsor$) adj3 (restrict$ or limit$ or ban or bans or prohibit$)).ti,ab.20. (tobacco control adj3 (program$ or initiative$ or policy or policies or intervention$ or activity or activities or framework)).ti,ab.21. ((smok$ or tobacco) adj (policy or policies or program$)).ti,ab.22. ((retailer$ or vendor$) adj3 (educat$ or surveillance$ or prosecut$ or legislat$)).ti,ab.23. test purchas$.ti,ab.24. voluntary agreement$.ti,ab.25. health warning$.ti,ab.26. ((tobacco or cigarette$) adj3 (tax or taxes or taxation or excise or duty free or duty paid or customs)).ti,ab.27. ((cigarette$ or tobacco) adj3 (packaging or packet$)).ti,ab.28. ((cigarette$ or tobacco) adj3 (marketing or marketed)).ti,ab.29. ((cigarette$ or tobacco) adj3 (price$ or pricing)).ti,ab.30. point of sale.ti,ab.31. vending machine$.ti,ab.32. (trade adj (restrict$ or agreement$)).ti,ab.33. (contraband$ or smuggl$ or bootleg$ or cross border shopping).ti,ab.34. (tobacco control act or clean air or clean indoor air).ti,ab.35. ((reduce$ or prevent$) adj3 (environmental tobacco smoke or passive smok$ or secondhand smok$ or second hand smok$ or SHS)).ti,ab.36. ((population level or population based or population orientated or population oriented) adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.37. (community adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.38. ((sale or sales or retail$ or purchas$) adj3 (minors or teenage$ or underage$ or under-age$ or child$)).ti,ab.39. (youth access adj3 restrict$).ti,ab.40. (smoking cessation or cessation support).ti,ab.

192

41. (smokefree or smoke-free or smoke free).ti,ab.42. ((stop$ or quit$ or reduc$ or give up or giving up) adj3 (cigarette$ or tobacco or smoking)).ti,ab.43. quit attempt$.ti,ab.44. tobacco quit.ti,ab.45. quit rate$.ti,ab.46. (quitline$ or quit line$ or quit-line$).ti,ab.47. ((smok$ or tobacco or nicotine or cigarette$) adj2 (abstinence or cessation)).ti,ab.48. or/11-4749. (socioeconomic or socio economic or socio-economic).ti,ab.50. inequalit$.ti,ab.51. depriv$.ti,ab.52. disadvantage$.ti,ab.53. educat$.ti,ab.54. (social adj (class$ or group$ or grade$ or context$ or status)).ti,ab.55. (employ$ or unemploy$).ti,ab.56. income.ti,ab.57. poverty.ti,ab.58. SES.ti,ab.59. demographic$.ti,ab.60. (uninsur$ or insur$).ti,ab.61. minorit$.ti,ab.62. poor.ti,ab.63. affluen$.ti,ab.64. equity.ti,ab.65. (underserved or under served or under-served).ti,ab.66. occupation$.ti,ab.67. (work site or worksite or work-site).ti,ab.68. (work place or workplace or work-place).ti,ab.69. (work force or workforce or work-force).ti,ab.70. (high risk or high-risk or at risk).ti,ab.71. (marginalised or marginalized).ti,ab.72. (social$ adj (disadvant$ or exclusion or excluded or depriv$)).ti,ab.73. exp socioeconomic status/74. poverty/75. disadvantaged/76. or/49-7577. 10 and 4878. 76 and 7779. limit 78 to (english language and abstracts and yr="1990 - 2012")

193

Cochrane Library 2012 (Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects; Cochrane Central Register of Controlled Trials; Health Technology Assessment Database), search date 10/05/12; also January 2012 to December 2012, search date 29/04/13.

#1 MeSH descriptor Smoking, this term only#2 MeSH descriptor Tobacco Use Cessation explode all trees#3 MeSH descriptor Tobacco explode all trees#4 MeSH descriptor Tobacco Use Disorder, this term only#5 MeSH descriptor Nicotine, this term only#6 (smoking or smokers or smoker or tobacco or cigar* or nicotine)#7 (#1 OR #2 OR #3 OR #4 OR #5 OR #6)#8 (smok* or anti-smok* or tobacco or cigarette*) near3 (ban or bans or prohibit* or restrict* or discourage*)#9 (smok* or anti-smok* or tobacco or cigarette*) near3 (workplace or work place or worksite)#10 (smok* or anti-smok* or tobacco or cigarette*) near3 (public next place*)#11 (smok* or anti-smok* or tobacco or cigarette*) near3 (public next space)#12 (smok* or anti-smok* or tobacco or cigarette*) near3 (public next area*)#13 (smok* or anti-smok* or tobacco or cigarette*) near3 (office* or school* or institution*)#14 (smok* or anti-smok* or tobacco or cigarette*) near3 (legislat* or government* or authorit* or law or laws or bylaw* or byelaw* or bye-law* or regulation*)#15 (tobacco-free or smoke-free) near3 (hospital* or inpatient* or outpatient* or institution*)#16 (tobacco-free or smoke-free) near3 (facility* or zone* or area* or site* or place* or environment* or air)#17 (tobacco or smok* or cigarette*) near3 (campaign* or advertis* or advertiz*)#18 (billboard* or advertis* or advertiz* or sale or sales or sponsor*) near3 (restrict* or limit* or ban or bans or prohibit*)#19 (tobacco next control) near3 (program* or initiative* or policy or policies or intervention* or activity or activities or framework)#20 (smok* or tobacco) next (policy or policies or program*)#21 (retailer* or vendor*) near3 (educat* or surveillance or prosecut* or legslat*)#22 test next purchas* in All Fields or (voluntary next agreement*)#23 (sale or sales or retail* or purchas*) near3 (minors or teenage* or underage* or under-age* or child*)#24 (youth near3 access) near3 restrict*#25 health next warning*#26 (tobacco or cigarette*) near3 (tax or taxes or taxation or excise or duty-free or duty-paid or customs)#27 (cigarette* or tobacco) near3 (packaging or packet*)#28 (cigarette* or tobacco) near3 (marketing or marketed)#29 (cigarette* or tobacco) near3 (price* or pricing)#30 "point of sale"#31 vending next machine*#32 trade near3 (restrict* or agreement*)#33 contraband* or smuggl* or bootleg* or (cross-border next shopping)#34 "tobacco control act" or "clean air" or "clean indoor air"#35 reduce* near3 "environmental tobacco smoke" or (passive next smok*) or (secondhand next smok*) or (second next hand next smok*) or SHS#36 prevent* near3 "environmental tobacco smoke" or (passive next smok*) or (secondhand next smok*) or (second next hand next smok*) or SHS#37 (population next level) near3 (intervention* or prevention or policy or policies or program* or project*)#38 (population next based) near3 (intervention* or prevention or policy or policies or program* or project*)#39 (population next orientated) near3 (intervention* or prevention or policy or policies or program* or project*)

194

#40 (community next level) near3 (intervention* or prevention or policy or policies or program* or project*)#41 (community next based) near3 (intervention* or prevention or policy or policies or program* or project*)#42 (community next orientated) near3 (intervention* or prevention or policy or policies or program* or project*)#43 (community next oriented) near3 (intervention* or prevention or policy or policies or program* or project*)#44 smoking next cessation or cessation next support#45 smokefree or smoke-free or smoke next free#46 (stop* or quit* or reduc* or give next up or giving next up) near3 (cigarette* or tobacco or smoking)#47 quit next attempt*#48 tobacco next quit#49 quit next rate*#50 quitline* or quit-line* or quit next line*#51 (smok* or tobacco or nicotine or cigarette*) near2 (abstinence or cessation)#52 (#8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46 OR #47 OR #48 OR #49 OR #50 OR #51)#53 socioeconomic or socio next economic or socio-economic#54 inequalit*#55 depriv*#56 disadvantage*#57 educat*#58 social next (class* or group* or grade* or context* or status)#59 employ* or unemploy*#60 income#61 poverty#62 SES#63 demographic*#64 insur* or uninsur*#65 minorit*#66 poor#67 affluen*#68 equity#69 underserved or under next served or under-served#70 occupation*#71 work next site or worksite or work-site#72 work next place or workplace or work-place#73 work next force or workforce or work-force#74 high next risk or high-risk or at next risk#75 marginalised or marginalized#76 social* next (disadvant* or exclusion or excluded or depriv*)#77 MeSH descriptor Socioeconomic Factors explode all trees#78 MeSH descriptor Public Assistance, this term only#79 MeSH descriptor Social Welfare, this term only#80 MeSH descriptor Vulnerable Populations, this term only#81 (#53 OR #54 OR #55 OR #56 OR #57 OR #58 OR #59 OR #60 OR #61 OR #62 OR #63 OR #64 OR #65 OR #66 OR #67 OR #68 OR #69 OR #70 OR #71 OR #72 OR #73 OR #74 OR #75 OR #76 OR #77 OR #78 OR #79 OR #80)#82 (#7 AND #52)#83 (#81 and #82), from 1990 to 2012

195

Science Citation Index Expanded, Social Sciences Citation Index, Conference Proceedings Citation Index (Science, and Social Science & Humanities), in Web of Science hosted on ISI Web of Knowledge, search date 10/05/12; also 1st May 2012 to 31st December 2012, search date 29/04/13.

(TS=(smoking or smokers or smoker or tobacco or cigar* or nicotine) AND TS=(abstinence or cessation or quit*) AND TS=(socioeconomic or socio economic or socio-economic)) AND Language=(English), Timespan=1990-2012

BIOSIS Previews hosted on ISI Web of Knowledge, search date 10/05/12(TS=(smoking or smokers or smoker or tobacco or cigar* or nicotine) AND TS=(abstinence or cessation or quit*) AND TS=(socioeconomic or socio economic or socio-economic)) AND Language=(English), Timespan=1990-2012; also January 2012 to December 2012, search date 29/04/13.

CINAHL Plus (EBSCO host) search date 10/05/12; also 1st May 2012 to 31st December 2012, search date 29/04/13.

S8 S5 AND S9, Limiters - Published Date from: 19900101-20121231S9 S6 OR S7 OR S8 S8 TX social* W1 (disadvantage* or exclusion or excluded or depriv*)S7 TX social W1 (class* or group* or grade* or context* or status)S6 (MH "Socioeconomic Factors") OR "SOCIOECONOMIC" OR (MH "Poverty") OR "POVERTY" OR "EQUITY"S5 S1 OR S2 OR S3 OR S4S4 TX (stop* or quit* or reduc* or give up or giving up) W3 (cigarette* or tobacco or smoking)S3 TX Smoking W1 cessationS2 (MH "Tobacco, Smokeless") OR (MH "Tobacco Abuse Control (Saba CCC)") OR (MH "Risk Control: Tobacco Use (Iowa NOC)") OR (MH "Passive Smoking")S1 (MH "Smoking Cessation Programs") OR (MH "Smoking Cessation") OR (MH "Smoking Cessation Assistance (Iowa NIC)")

ERIC (EBSCO Host) search date 11/05/12; also 1st May 2012 to 31st December 2012, search date 29/04/13.

S10 S8 and S9S9 S4 or S5 or S6 or S7S8 S1 or S2 or S3S7 AB Socioeconomic OR AB Poverty OR AB equityS6 ((DE "Socioeconomic Background" OR DE "Socioeconomic Influences" OR DE "Socioeconomic Status") OR (DE "Poverty")) AND (DE "Disadvantaged Environment" OR DE "Economically Disadvantaged" OR DE "Socioeconomic Influences")S5 TX social* W1 (disadvantage* or exclusion or excluded or depriv*)S4 TX social W1 (class* or group* or grade* or context* or status)S3 TX (stop* or quit* or reduc* or give up or giving up) W3 (cigarette* or tobacco or smoking)S2 TX Smoking W1 cessationS1 DE SMOKING

196

Handsearching:

1. Addiction 2012 volume 107 issues 1 to 8 (August 2012) and Early View, search date 31/7/12; also ‘Accepted Articles’, ‘Early View’, search date 14/2/13 and 2012 volume 107 issues 12 and S2, volume 108 issues 1 to 2 search date 18/2/13.

2. Nicotine and Tobacco Research 2012, volume 14, issues 1 to 6, search date 30/7/12; also 2013 volume 15 issues 1 to 3 and ‘Advance Access’ search date 18/2/13.

3. Social Science and Medicine 2012, volume 74 issues 1 to 12, volume 75 issues 1 to 7, articles ‘in press’ search date 31/7/12; also 2013 volumes 74 to 82 ‘in progress’, and ‘articles in press’, search date 18/2/13.

4. Tobacco Control 2012, volume 21, issues 1 to 4, ‘online first’ search date 31/7/12; also volume 21 issue 6, volume 22 issues 1 to 2 and ‘online first’, search date 18/2/13.

197

Searching for grey literature

23/11/12Dear All,

As you know, ENSP is an Associated Partner in the SILNE project (http://www.ensp.org/node/738).

In order to support the implementation of Work Package 6: Review & Synthesis by Amanda Amos and Tamara Brown, our colleagues from the University of Edinburgh, and help them to identify any grey literature, we would be grateful if you could inform them of any such literature that they may be able to include in their review, particularly government reports that they may not have identified through their searching.

They are now at the stage where they have a complete list of included studies both for the review of youth policies and the review of adult policies. Please see the attached inclusion/exclusion criteria. Attached are also the reference lists of these studies.

Amanda and Tamara are specifically interested in any reports of the socio-economic impact of policies which are written in non-English and which an English synopsis could be provided.

Please do not hesitate to contact them should you need any further clarification:

Tamara BrownResearch FellowCentre for Population Health SciencesUniversity of EdinburghTeviot PlaceEdinburghEH8 9AGScotland, UKTel: 0131 650 3237Fax: 0131 650 6909Email: tbrown23@staffmail.ed.ac.uk

It would be great if you could not remain simply silent. So, even if you have no available information, a simple negative reply would be appreciated. The deadline is 31/12/12.

Thanking you in advance,

Best regardsFrancisFrancis GrognaSecretary GeneralENSP - European Network for Smoking and Tobacco Prevention

198

10/12/12

To all members of SILNE,

I am pleased to tell you that the youth report for Work Package 6: Review & Synthesis is nearly complete and the adult policy review is well under way.

Amanda and I look forward to presenting the initial results of these reviews when we all meet in Brussels in January.

Do you know of any grey literature that we may be able to include in our review, particularly government reports that we may not have identified through our searching? We are specifically interested in any reports of the socio-economic impact of policies which are written in non-English and which an English synopsis could be provided.

I attach reference lists of included studies both for the review of youth policies and the review of adult policies. I also attach our inclusion/exclusion criteria.

Our deadline for receiving literature is 31/12/12.

Please let me know if you require any further information and I look forward to some hopeful replies and meeting you again in January.

Very best wishes Tamara

Tamara Brown Research Fellow Centre for Population Health Sciences University of Edinburgh Teviot Place Edinburgh EH8 9AG Scotland, UK Tel: 0131 650 3237 Fax: 0131 650 6909 Email: tbrown23@staffmail.ed.ac.uk

199

7.2 Appendix B WHO European countries and other stage 4 countriesAlbania AndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandIsraelItalyKazakhstanKyrgyzstanLatviaLithuaniaLuxembourgMaltaMonacoMontenegroNetherlandsNorwayPolandPortugalRepublic of MoldovaRomaniaRussian FederationSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTajikistanThe Former Yugoslav Republic of MacedoniaTurkeyTurkmenistanUkraineUnited Kingdom of Great Britain and Northern IrelandUzbekistanOther stage 4 countries: Australia, United States, New Zealand, Canada

200

7.3 Appendix C Inclusion/exclusion formRef ID FIRST AUTHOR YEAR

CODE

ANSWER TYPE QUESTION

1 population Is the study population 11 years of age or older?2 Is it based in a WHO European country or non-

European country at stage 4 of the tobacco epidemic?

3 intervention/policy

Is it an intervention or policy to reduce adult smoking or to prevent youth starting to smoke?

4 socio-economic inequalities

Does it report outcomes for high vs. low socio-economic group?*

What type of study design is it? (highlight) Review RCT Non-randomised controlled study Observational cohort Qualitative Other

What type of intervention is it? (highlight) taxation/pricing tobacco advertising and marketing bans smoking cessation support smoke free policies (public places, workplaces, home) school-based interventions mass media campaigns community programmes educational policies social and welfare policies employment policies multifaceted lifestyle interventions/policies (not just smoking cessation) other

What type of SES indicator does it report? (highlight) Income Education Occupational social class Area-level socio-economic deprivation Housing tenure Subjective social class Health insurance Proxy measures for youth, i.e. Free School Meals, Family Affluences Scale (FAS)

What type of outcomes does it report? (highlight) quit rates initiation rates changes in initiation/cessation or abstinence rates uptake and reach use of quitting aids/services smoking status (self-reported/validated) number of quit attempts exposure

201

prevalence changing attitudes passive smoking policy reach/awareness/comprehensiveness attitude/social norms intentions to smoke sources (i.e. vending machines) second hand smoke exposure other

What is the length of follow up? (highlight)<3 months3 months6 months12 monthsOther Is the interventionYouth or adult or both? (highlight) Individual support or population/policy or both? (highlight)

What is the type of analyses? Population-level or individual level or both? (highlight)*INCLUDE? YES/NO/UNCLEAR (highlight)*To be included a paper must be rated as YES to 1 + 2 + 3 + 4

REVIEWER COMMENTS

202

7.4 Appendix D Included studiesReference SourceAlekseeva NV, Alekseev OL, Chukhrova MG. Some psychosocial aspects of smoking: 10-year experience in "Quit & Win" campaigns in Novosibirsk. Alaska Medicine 2007; 49(2:Suppl):Suppl-4.

MEDLINE

Arheart KL, Lee DJ, Dietz NA, Wilkinson JD, Clark JD, III, LeBlanc WG et al. Declining trends in serum cotinine levels in US worker groups: the power of policy. Journal of Occupational & Environmental Medicine 2008; 50(1):57-63.

MEDLINE

Azagba S, Sharaf M. Cigarette taxes and smoking participation: evidence from recent tax increases in Canada. International Journal of Environmental Research & Public Health 2011; 8(5):1583-1600.

MEDLINE

Bains N, Pickett W, Laundry B, Mercredy D. Predictors of smoking cessation in an incentive-based community intervention. Chronic Diseases in Canada 2000; 21(2):54-61.

MEDLINE

Barnett R, Pearce J, Moon G, Elliott J, Barnett P. Assessing the effects of the introduction of the New Zealand Smokefree Environment Act 2003 on acute myocardial infarction hospital admissions in Christchurch, New Zealand. Australian & New Zealand Journal of Public Health 2009; 33(6):515-520.

MEDLINE

Bauld L, Chesterman J, Judge K, Pound E, Coleman T, English Evaluation of Smoking Cessation Services (EESCS). Impact of UK National Health Service smoking cessation services: variations in outcomes in England. Tobacco Control 2003; 12(3):296-301.

PHRC

Bauld L, Judge K, Platt S. Assessing the impact of smoking cessation services on reducing health inequalities in England: observational study. Tobacco Control 2007; 16(6):400-404.

MEDLINE

Bauld L, Ferguson J, McEwen A, Hiscock R. Evaluation of a drop-in rolling-group model of support to stop smoking. Addiction 2012.

HANDSEARCH

Biener L, Aseltine RH, Jr., Cohen B, Anderka M. Reactions of adult and teenaged smokers to the Massachusetts tobacco tax. American Journal of Public Health 1998; 88(9):1389-1391.

MEDLINE

Burns EK, Levinson AH. Reaching Spanish-speaking smokers: state-level evidence of untapped potential for QuitLine utilization. American Journal of Public Health 2010; 100:Suppl-710.

MEDLINE

Bush T, Zbikowski S, Mahoney L, Deprey M, Mowery PD, Magnusson B. The 2009 US federal cigarette tax increase and quitline utilization in 16 states. Journal of environmental and public health 2012; Article ID 314740, doi:10.1155/2012/314740.

EMBASE

Cantrell J, Vallone DM, Thrasher JF, Nagler RH, Feirman SP, Muenz LR et al. Impact of Tobacco-Related Health Warning Labels across Socioeconomic, Race and Ethnic Groups: Results from a Randomized Web-Based Experiment. PLoS ONE 2013; 8(1):e52206.

EXPERT

203

Centers for Disease Control and Prevention (CDC). Response to increases in cigarette prices by race/ethnicity, income, and age groups--United States, 1976-1993. Morbidity & Mortality Weekly Report 1998; 47(29):605-609.

MEDLINE

Centers for Disease Control and Prevention (CDC). Decline in smoking prevalence--New York City, 2002-2006. Morbidity & Mortality Weekly Report 2007; 56(24):604-608.

MEDLINE

Cesaroni G, Forastiere F, Agabiti N, Valente P, Zuccaro P, Perucci CA. Effect of the Italian smoking ban on population rates of acute coronary events. Circulation 2008; 117(9):1183-1188.

MEDLINE

Choi K, Hennrikus D, Forster J, St Claire AW. Use of Price-Minimizing Strategies by Smokers and Their Effects on Subsequent Smoking Behaviors. Nicotine & Tobacco Research 212; 14(7):864-870.

HANDSEARCH

Civljak M, Ulovec Z, Soldo D, Posavec M, Oreskovic S. Why choose Lent for a "smoke out day?" Changing smoking behavior in Croatia. Croatian Medical Journal 2005; 46(1):132-136.

MEDLINE

Colman GJ. Vertical equity consequences of very high cigarette tax increases: If the poor are the ones smoking, how could cigarette tax increases be progressive? Journal of Policy Analysis and Management 2008; 27(2).

PSYCINFO

Czarnecki KD, Goranson C, Ellis JA, Vichinsky LE, Coady MH, Perl SB. Using geographic information system analyses to monitor large-scale distribution of nicotine replacement therapy in New York City. Preventive Medicine 2010; 50(5-6):288-296.

MEDLINE

Czarnecki KD, Vichinsky LE, Ellis JA, Perl SB. Media campaign effectiveness in promoting a smoking-cessation program. American Journal of Preventive Medicine 2010; 38(Suppl 3):S333–S342.

MEDLINE

Darity WA, Chen TT, Tuthill RW, Buchanan DR, Winder AE, Stanek E et al. A multi-city community based smoking research intervention project in the African-American population. International Quarterly Community Health Education 2006; 26(4):323-336.

MEDLINE

DeCicca P, McLeod L. Cigarette taxes and older adult smoking: evidence from recent large tax increases. Journal of Health Economics 2008; 27(4):918-929.

MEDLINE

Delnevo CD, Hrywna M, Lewis MJ. Predictors of smoke-free workplaces by employee characteristics: who is left unprotected? American Journal of Industrial Medicine 2004; 46(2):196-202.

MEDLINE

Deprey M, McAfee T, Bush T, McClure JB, Zbikowski S, Mahoney L. Using free patches to improve reach of the Oregon Quit Line. Journal of Public Health Management Practice 2009; 15(5):401-408.

MEDLINE

Deverell M, Randolph C, Albers A, Hamilton W, Siegel M. Diffusion of local restaurant smoking regulations in Massachusetts: identifying disparities in health protection for population subgroups. Journal of

MEDLINE

204

Public Health Management Practice 2006; 12(3):262-269.

Dinno A, Glantz S. Tobacco control policies are egalitarian: a vulnerabilities perspective on clean indoor air laws, cigarette prices, and tobacco use disparities. Social Science Medicine 2009; 68(8):1439-1447.

MEDLINE

Donath C, Metz K, Chmitorz A, Gradl S, Piontek D, Floter S et al. Prediction of alcohol addicted patients' smoking status through hospital tobacco control policy: A multi-level-analysis. Drugs: Education, Prevention & Policy 2009; 16(1): 53-70.

PSYCINFO

Dunlop SM, Perez D, Cotter T. Australian smokers' and recent quitters' responses to the increasing price of cigarettes in the context of a tobacco tax increase. Addiction 2011; 106(9):1687-1695.

MEDLINE

Dunlop SM, Perez D, Cotter T. The natural history of antismoking advertising recall: the influence of broadcasting parameters, emotionalintensity and executional features . Tobacco Control Online First. 2012.

HANDSEARCH

Durkin SJ, Biener L, Wakefield MA. Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups. American Journal of Public Health 2009; 99(12):2217-2223.

MEDLINE

Durkin SJ, Wakefield MA, Spittal MJ. Which types of televised anti-tobacco campaigns prompt more quitline calls from disadvantaged groups? Health Education Research 2011; 26(6):998-1009.

MEDLINE

Eadie D, Heim D, MacAskill S, Ross A, Hastings G, Davies J. A qualitative analysis of compliance with smoke-free legislation in community bars in Scotland: implications for public health. Addiction 2008; 103(6):1019-1026.

MEDLINE

Ellis JA, Gwynn C, Garg RK, Philburn R, Aldous KM, Perl SB et al. Secondhand smoke exposure among nonsmokers nationally and in New York City. Nicotine & Tobacco Research 2009; 11(4):362-370.

MEDLINE

Farrelly MC, Evans WN, Sfekas AE. The impact of workplace smoking bans: results from a national survey. Tobacco Control 1999; 8(3):272-277.

MEDLINE

Farrelly MC, Bray JWPTWT. Response by Adults to Increases in Cigarette Prices by Sociodemographic Characteristics. Southern Economic Journal 2001; 68(1):156-165.

YORK

Farrelly MC, Duke JC, Davis KC, Nonnemaker JM, Kamyab K, Willett JG et al. Promotion of smoking cessation with emotional and/or graphic antismoking advertising. American Journal of Preventive Medicine 2012; 43(5): 475– 482.

EMBASE

Farrelly MC, Nonnemaker JM, Watson KA. The Consequences of High Cigarette Excise Taxes for Low-Income Smokers. PLoS ONE 2012; 7(9):e43838.

EMBASE

205

Federico B, Mackenbach JP, Eikemo TA, Kunst AE. Impact of the 2005 smoke-free policy in Italy on prevalence, cessation and intensity of smoking in the overall population and by educational group. Addiction 2012.

HANDSEARCH

Ferketich AK, Liber A, Pennell M, Nealy D, Hammer J, Berman M. Clean indoor air ordinance coverage in the Appalachian region of the United States. American Journal of Public Health 2010; 100(7):1313-1318.

EBSCO HOST

Fowkes FJI, Stewart MCW, Fowkes FGR, Amos A, Price JF. Scottish smoke-free legislation and trends in smoking cessation. Addiction 2008; 103(11): 1888–1895.

EMBASE

Franks P, Jerant AF, Leigh JP, Lee D, Chiem A, Lewis I et al. Cigarette prices, smoking, and the poor: implications of recent trends. American Journal of Public Health 2007; 97(10):1873-1877.

MEDLINE

Frick RG, Klein EG, Ferketich AK, Wewers ME. Tobacco advertising and sales practices in licensed retail outlets after the Food and Drug Administration regulations. Journal of Community Health: The Publication for Health Promotion and Disease Prevention 2012; 37[5]: 963-967.

PSYCINFO

Frieden TR, Mostashari F, Kerker BD, Miller N, Hajat A, Frankel M. Adult tobacco use levels after intensive tobacco control measures: New York City, 2002-2003. American Journal of Public Health 2005; 95(6):1016-1023.

MEDLINE

Gospodinov N, Irvine I. Tobacco taxes and regressivity. Journal of Health Economics 2009; 28(2):375-384.

MEDLINE

Graham AL, Milner P, Saul JE, Pfaff L. Online advertising as a public health and recruitment tool: comparison of different media campaigns to increase demand for smoking cessation interventions. Journal of Medical Internet Research 2008; 10(5):e50.

MEDLINE

Gruber J, Sen A, Stabile M. Estimating price elasticities when there is smuggling: the sensitivity of smoking to price in Canada. Journal of Health Economics 2003; 22(5):821-842.

MEDLINE

Guse CE, Marbella AM, Layde PM, Christiansen A, Remington P. Clean indoor air policies in Wisconsin workplaces. Wisconsin Medical Journal 2004; 103(4):27-31.

MEDLINE

Guzman A, Walsh MC, Smith SS, Malecki KC, Nieto JF. Evaluating effects of statewide smoking regulations on smoking behaviors among participants in the survey of the health of Wisconsin. Wisconsin Medical Journal 2012; 111(4):2012.

EMBASE

Hackshaw L, McEwen A, West R, Bauld L. Quit attempts in response to smoke-free legislation in England. Tobacco Control 2010; 19(2):160-164.

MEDLINE

Hammond D, Reid JL, Driezen P, Boudreau C. Pictorial health EMBASE

206

warnings on cigarette packs in the united states: An experimental evaluation of the proposed FDA warnings. Nicotine and Tobacco Research 2013; 15(1): 93–102.

Hawk LW, Jr., Higbee C, Hyland A, Alford T, O'Connor R, Cummings KM. Concurrent quit & win and nicotine replacement therapy voucher giveaway programs: participant characteristics and predictors of smoking abstinence. Journal of Public Health Management & Practice 2006; 12(1):52-59.

MEDLINE

Hawkins SS, Cole TJ, Law C. Examining smoking behaviours among parents from the UK Millennium Cohort Study after the smoke-free legislation in Scotland. Tobacco Control 2011; 20(2):112-118.

MEDLINE

Hawkins SS, Chandra A, Berkman L. The impact of tobacco control policies on disparities in children's secondhand smoke exposure: a comparison of methods. Maternal and child health journal 2012; 16: S70-77).

EMBASE

Hemsing N, Greaves L, Poole N, Bottorff J. Reshuffling and relocating: the gendered and income-related differential effects of restricting smoking locations. Journal of environmental and public health 2012; Article ID 907832, doi:10.1155/2012/907832.

EMBASE

Hiscock R, Pearce J, Barnett R, Moon G, Daley V. Do smoking cessation programmes influence geographical inequalities in health? An evaluation of the impact of the PEGS programme in Christchurch, New Zealand. Tobacco Control 2009; 18(5):371-376.

PHRC

Hitchman SC, Mons U, Nagelhout GE, Guignard R, McNeill A, Willemsen MC et al. Effectiveness of the European Union text-only cigarette health warnings: findings from four countries. European Journal of Public Health 2012; 22(5):693-699.

MEDLINE

Kasza KA, Hyland AJ, Brown A, Siahpush M, Yong HH, McNeill AD et al. The effectiveness of tobacco marketing regulations on reducing smokers' exposure to advertising and promotion: findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research & Public Health 2011; 8(2):321-340.

MEDLINE

King BA, Hyland AJ, Borland R, McNeill A, Cummings KM. Socioeconomic variation in the prevalence, introduction, retention, and removal of smoke-free policies among smokers: findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research & Public Health 2011; 8(2):411-434.

MEDLINE

Levy DT, Mumford EA, Compton C. Tobacco control policies and smoking in a population of low education women, 1992-2002. Journal of Epidemiology & Community Health 2006; 60:Suppl-6.

MEDLINE

Linsey Galbraith GHIS. NHS Smoking Cessation Service Statistics (Scotland) 1st January to 31st December 2011. 1-40. 2012. ScotPHO.

GREY LITERATURE

207

MacCalman L, Semple S, Galea KS, van TM, Dempsey S, Hilton S et al. The relationship between workers' self-reported changes in health and their attitudes towards a workplace intervention: lessons from smoke-free legislation across the UK hospitality industry. BMC Public Health 2012; 12:324.

EMBASE

Madden D. Tobacco taxes and starting and quitting smoking: does the effect differ by education? Applied Economics 2007; 39:613-627.

PHRC REVIEW

Metzger KB, Mostashari F, Kerker BD. Use of pharmacy data to evaluate smoking regulations' impact on sales of nicotine replacement therapies in New York City. American Journal of Public Health 2005; 95(6):1050-1055.

MEDLINE

Miller N, Frieden TR, Liu SY, Matte TD, Mostashari F, Deitcher DR et al. Effectiveness of a large-scale distribution programme of free nicotine patches: a prospective evaluation. Lancet 2005; 365(9474):1849-1854.

MEDLINE

Moore GF, Currie D, Gilmore G, Holliday JC, Moore L. Socioeconomic inequalities in childhood exposure to secondhand smoke before and after smoke-free legislation in three UK countries. Journal of Public Health 2012; 34(4):599-608.

EXPERT

Moore GF, Holliday JC, Moore LA. Socioeconomic patterning in changes in child exposure to secondhand smoke after implementation of smoke-free legislation in Wales. Nicotine & Tobacco Research 2011; 13(10):903-910.

MEDLINE

Mostashari F, Kerker BD, Hajat A, Miller N, Frieden TR. Smoking practices in New York City: the use of a population-based survey to guide policy-making and programming. Journal of Urban Health 2005; 82(1):58-70.

MEDLINE

Moussa KM, Lindstr+Âm M, +ûstergren P. Socioeconomic and demographic differences in exposure to environmental tobacco smoke at work: the Scania Public Health Survey 2000823. Scandinavian Journal of Public Health 2004; 32(3):194-202.

EBSCO HOST

Nabi-Burza E, Regan S, Drehmer J, Ossip D, Rigotti N, Hipple B et al. Parents smoking in their cars with children present. Pediatrics 2012; 130(6):e1471.

EMBASE

*Nagelhout GE, Willemsen MC, van den Putte B, Crone MR, de VH. International Tobacco Control (ITC) policy evaluation project. Evaluatie 'In iedere roker zit een stopper' campagne. Tweede nameting. 2009. Den Haag, the Foundation for Public Health and Smoking STIVORO.

GREY LITERATURE

Nagelhout GE, Willemsen MC, de VH. The population impact of smoke-free workplace and hospitality industry legislation on smoking behaviour. Findings from a national population survey. Addiction 2011; 106(4):816-823.

MEDLINE

Nagelhout GE, Mons U, Allwright S, Guignard R, Beck F, Fong GT et al. Prevalence and predictors of smoking in "smoke-free" bars. Findings

MEDLINE

208

from the International Tobacco Control (ITC) Europe Surveys. Social Science & Medicine 2011; 72(10):1643-1651.

Nagelhout GE, de Korte-de Boer D, Kunst AE, van der Meer RM, de Vries H, van Gelder BM, Willemsen MC. Trends in socioeconomic inequalities in smoking prevalence, consumption, initiation, and cessation between 2001 and 2008 in the Netherlands. Findings from a national population survey. BMC Public Health 2012; 303.

EXPERT

*Nagelhout GE, Crone MR, van den Putte B, Willemsen MC, Fong GT, de VH. Age and educational inequalities in smoking cessation due to three population-level tobacco control interventions: findings from the International Tobacco Control (ITC) Netherlands Survey. Health Education Research 2013; 28(1):83-91.

EXPERT

Niederdeppe J, Fiore MC, Baker TB, Smith SS. Smoking-cessation media campaigns and their effectiveness among socioeconomically advantaged and disadvantaged populations. American Journal of Public Health 2008; 98(5):916-924.

MEDLINE

Niederdeppe J, Farrelly MC, Nonnemaker J, Davis KC, Wagner L. Socioeconomic variation in recall and perceived effectiveness of campaign advertisements to promote smoking cessation. Social Science & Medicine 2011; 72(5):773-780.

MEDLINE

Owen L. Impact of a telephone helpline for smokers who called during a mass media campaign. Tobacco Control 2000; 9(2):148-154.

MEDLINE

Parry O, Platt S. Smokers at risk: implications of an institutionally bordered risk-reduced environment. Health & Place 2000; 6(2):117-123.

MEDLINE

Patel V, Thomson G, Wilson N. Objective measurement of area differences in 'private' smoking behaviour: observing smoking in vehicles. Tobacco Control 2011; Online First, published on December 1, 2011 as 10.1136/tobaccocontrol-2011-050119.

HANDSEARCH

Peretti-Watel P, Constance J. "It's all we got left". Why poor smokers are less sensitive to cigarette price increases. International Journal of Environmental Research & Public Health 2009; 6(2):608-621.

MEDLINE

Peretti-Watel P, Villes V, Duval X, Collin F, Reynes J, Sobel A et al. How do HIV-infected smokers react to cigarette price increases? Evidence from the APROCO-COPILOTE-ANRS CO8 Cohort. Current HIV Research 2009; 7(4):462-467.

MEDLINE

Peretti-Watel P, L'haridon O, Seror V. Responses to increasing cigarette prices in France: How did persistent smokers react? Health Policy 2012; 106(2):169-176.

EXPERT

Plescia M, Malek SH, Shopland DR, Anderson CM, Burns DM. Protecting workers from secondhand smoke in North Carolina. North Carolina Medical Journal 2005; 66(3):186-191.

MEDLINE

Razavi D, Vandecasteele H, Primo C, Bodo M, Debrier F, Verbist H et al. Improving cancer prevention at the worksite: how are Belgian

MEDLINE

209

companies dealing with smoking regulations? Psycho-Oncology 1997; 6(3):204-211.

**Richardson A, Cullen J, Mowery P, McCausland K, Vallone DE-MA, Richardson Aao. The path to quit: How awareness of a large-scale mass-media smoking cessation campaign promotes quit attempts. Nicotine & Tobacco Research 2011; .13(11).

PSYCINFO

Ringel JS, Evans WN. Cigarette taxes and smoking during pregnancy. American Journal of Public Health 2001; 91(11):1851-1856.

MEDLINE

***Ritchie D, Amos A, Martin C. "But it just has that sort of feel about it, a leper"--stigma, smoke-free legislation and public health. Nicotine & Tobacco Research 2010; 12(6):622-629.

MEDLINE

***Ritchie D, Amos A, Martin C. Public places after smoke-free--a qualitative exploration of the changes in smoking behaviour. Health & Place 2010; 16(3):461-469.

MEDLINE

Schaap MM, Kunst AE, Leinsalu M, Regidor E, Ekholm O, Dzurova D et al. Effect of nationwide tobacco control policies on smoking cessation in high and low educated groups in 18 European countries. Tobacco Control 2008; 17(4):248-255.

MEDLINE

Secker-Walker RH, Flynn BS, Solomon LJ, Skelly JM, Dorwaldt AL, Ashikaga T. Helping women quit smoking: results of a community intervention program. American Journal of Public Health 2000; 90(6):940-946.

MEDLINE

Semple S, van TM, Galea KS, MacCalman L, Gee I, Parry O et al. UK smoke-free legislation: changes in PM2.5 concentrations in bars in Scotland, England, and Wales. Annals of Occupational Hygiene 2010; 54(3):272-280.

MEDLINE

Shavers VL, Fagan P, Alexander LA, Clayton R, Doucet J, Baezconde-Garbanati L. Workplace and home smoking restrictions and racial/ethnic variation in the prevalence and intensity of current cigarette smoking among women by poverty status, TUS-CPS 1998-1999 and 2001-2002. Journal of Epidemiology and Community Health 2006; 60(Suppl II):ii34–ii43

MEDLINE

Shopland DR, Anderson CM, Burns DM, Gerlach KK. Disparities in Smoke-Free Workplace Policies among Food Service Workers. Journal of Occupational and Environmental Medicine 2004; 46(4):347-356.

EMBASE

Siahpush M, Wakefield M, Spittal M, Durkin S. Antismoking television advertising and socioeconomic variations in calls to Quitline. Journal of Epidemiology and Community Health 2007; 61(4):298-301.

MEDLINE

Siahpush M, Wakefield MA, Spittal MJ, Durkin SJ, Scollo MM. Taxation reduces social disparities in adult smoking prevalence. American Journal of Preventive Medicine 2009; 36(4):285-291.

MEDLINE

Simpson CR, Hippisley-Cox J, Sheikh A. Trends in the epidemiology of smoking recorded in UK general practice. British Journal of General

MEDLINE

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Practice 2010; 60(572):e121-e127.

Sims M, Mindell JS, Jarvis MJ, Feyerabend C, Wardle H, Gilmore A. Did smokefree legislation in England reduce exposure to secondhand smoke among nonsmoking adults? Cotinine analysis from the Health Survey for England. Environmental Health Perspectives 2012; 120(3):425–430.

EMBASE

Skeer M, George S, Hamilton WL, Cheng DM, Siegel M. Town-level characteristics and smoking policy adoption in Massachusetts: are local restaurant smoking regulations fostering disparities in health protection? AM J PUBLIC HEALTH 2004; 94(2):286-292.

MEDLINE

Sood A, Andoh J, Rajoli N, Hopkins-Price P, Verhulst SJ. Characteristics of smokers calling a national reactive telephone helpline. American Journal of Health Promotion 2008; 22(3):176-179.

MEDLINE

Sorensen G, Stoddard A, Hunt MK, Hebert JR, Ockene JK, Avrunin JS et al. The effects of a health promotion-health protection intervention on behavior change: the WellWorks Study. American Journal of Public Health 1998; 88(11):1685-1690.

MEDLINE

Sorensen G, Stoddard AM, LaMontagne AD, Emmons K, Hunt MK, Youngstrom R et al. A comprehensive worksite cancer prevention intervention: behavior change results from a randomized controlled trial (United States). Journal of Public Health Policy 2003; 24(1):5-25.

MEDLINE

Stafford M, Nazroo J, Popay JM, Whitehead M. Tackling inequalities in health: evaluating the New Deal for Communities initiative. Journal of Epidemiology and Community Health 2008; 62(4):298-304.

MEDLINE

Stamatakis KA, Brownson RC, Luke DA. Risk factors for exposure to environmental tobacco smoke among ethnically diverse women in the United States. Journal of Womens Health & Gender-Based Medicine 2002; 11(1):45-51.

MEDLINE

Taggar JS, Coleman T, Lewis S, Szatkowski L. The impact of the Quality and Outcomes Framework (QOF) on the recording of smoking targets in primary care medical records: cross-sectional analyses from The Health Improvement Network (THIN) database. BMC Public Health 2012; 12:329.

EMBASE

Tang H, Cowling DW, Lloyd JC, Rogers T, Koumjian KL, Stevens CM, Bal DG. Changes of Attitudes and Patronage Behaviors in Response to a Smoke-Free Bar Law. American Journal of Public Health 2003; 93:611-617.

YORK REVIEW

Tong EK, Tang H, Tsoh J, Wong C, Chen MS, Jr. Smoke-free policies among Asian-American women: comparisons by education status. American Journal of Preventive Medicine 2009; 37(2S):S144–S150.

MEDLINE

**Vallone DM, Niederdeppe J, Richardson AK, Patwardhan P, Niaura R, Cullen J. A national mass media smoking cessation campaign: effects by race/ethnicity and education. American Journal of Health Promotion

MEDLINE

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2011; 25(5): S38-S50.

Van den Putte B, Yzer MC, Ten Berg BM, Steevels RMA. Nederlands Start Met Stoppen / Nederlands Gaat Door Met Stoppen. Evaluatie van de STIVORO campagnes rondom de jaarwisseling 2003-2004. 2005. Amsterdam, Universiteit van Amsterdam.

GREY LITERATURE

Van Osch L, Lechner L, Reubsaet A, Steenstra M, Wigger S, de Vries H. Optimizing the efficacy of smoking cessation contests: an exploration of determinants of successful quitting. Health Education Research 2009;24(1):54-63.

PHRC

Verdonk-Kleinjan WMI, Knibbe RA, Tan FES, Willemsen MC, de Groot HN, de VH. Does the workplace-smoking ban eliminate differences in risk for environmental tobacco smoke exposure at work? Health Policy 2009; 92(2-3):197–202.

EMBASE

Verdonk-Kleinjan WMI, Verdonk-Kleinjan WMI. Effects of a workplace-smoking ban in combination with tax increases on smoking in the Dutch population. Nicotine & Tobacco Research 2011;13(6):412-418.

PSYCINFO

Wendel-Vos GCW, Dutman AE, Verschuren WMM, Ronckers ET, Ament A, van AP et al. Lifestyle Factors of a Five-Year Community-Intervention Program. The Hartslag Limburg Intervention. American Journal of Preventive Medicine 2009; 37(1):50-56.

EMBASE

Wiebing MA, Bot SM, Willemsen MC. Rokers verdienen 'n beloning', de 24-uur-niet-rokenactie. Blootstelling, deelname en effect op stopbereidheid bij hoge en lage welstandsgroepen. Tijdschrift voor Gezondheidswetenschappen 2010; 88:435-441.

GREY LITERATURE

Willems RA, Willemsen MC, Nagelhout GE, Smit ES, Janssen E, van den Putte B et al. Evaluatie van de 'Echt stoppen met roken kan met de juiste hulp' campagne. 2012. Maastricht, Universiteit Maastricht.

GREY LITERATURE

Willemsen MC. The new EU cigarette health warnings benefit smokers who want to quit the habit: results from the Dutch Continuous Survey of Smoking Habits. European Journal of Public Health 2005; 15(4):389-392.

YORK REVIEW

Wilson N, Weerasekera D, Borland R, Edwards R, Bullen C, Li J. Use of a national quitline and variation in use by smoker characteristics: ITC Project New Zealand. Nicotine & Tobacco Research 2010;12 (Suppl-84):S78-S84.

MEDLINE

Wilson N, Weerasekera D, Hoek J, Li J, Edwards R. Increased smoker recognition of a national quitline number following introduction of improved pack warnings: ITC Project New Zealand. Nicotine & Tobacco Research 2010; 12 (Suppl-1): S72–S77.

MEDLINE

Zacher M, Germain D, Durkin S, Hayes L, Scollo M, Wakefield M. A Store Cohort Study of Compliance Witha Point-of-Sale Cigarette Display Ban inMelbourne, Australia. Nicotine and Tobacco Research 2013; 15(2):

HANDSEARCH

212

444-449.

Zawertailo L, Dragonetti R, Bondy SJ, Victor C, Selby P. Reach and effectiveness of mailed nicotine replacement therapy for smokers: 6-month outcomes in a naturalistic exploratory study. Tobacco Control Online First 2012.

HANDSEARCH

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7.5 Appendix E Excluded studiesReference Reason for exclusionAhrens D, Uebelher P, Remington PL. Evaluation of community and organizational characteristics of smoke-free ordinance campaigns in 15 Wisconsin cities. Preventing Chronic Disease 2005; 2(3):1-9.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Alexander LA, Crawford T, Mendiondo MS. Occupational status, work-site cessation programs and policies and menthol smoking on quitting behaviors of US smokers. Addiction 2010; 105(Suppl-1): 95–104.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Anger S, Kvasnicka M, Siedler T. One last puff? Public smoking bans and smoking behavior. Journal of Health Economics 2011; 30(3):591-601.

Does not report outcomes for high versus low socio-economic group

Brenner H, Born J, Novak P, Wanek V. Smoking behavior and attitude toward smoking regulations and passive smoking in the workplace. A study among 974 employees in the German metal industry. Preventive Medicine 1997; 26(1):138-143.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Burns EK, Levinson AH, Deaton EA. Factors in Nonadherence to Quitline Services: Smoker Characteristics Explain Little68. Health Education & Behavior 2012; 39(5):596-602.

Did not report reach by SES

Centers for Disease Control and Prevention (CDC). State-specific prevalence of current cigarette smoking among adults and the proportion of adults who work in a smoke-free environment--United States, 1999. Morbidity & Mortality Weekly Report 2000; 49(43):978-982.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Deason LM, Adhikari SB, Clopton TM, Oches B, Jensen C. The Ohio Cross-Cultural Tobacco Control Alliance: understanding and eliminating tobacco-related disparities through the integration of science, practice, and policy. American Journal of Public Health 2010; 100:(Suppl-5): S240–S245.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Delnevo CD, Hrywna M, Foulds J, Steinberg MB. Cigar use before and after a cigarette excise tax increase in New Jersey. Addictive Behavior 2004; 29(9):1799-1807.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke – focus is cigar use

Eek F, Ostergren PO, Diderichsen F, Rasmussen NK, Andersen I, Moussa K et al. Differences in socioeconomic and gender inequalities in tobacco smoking in Denmark and Sweden; a cross sectional comparison of the equity effect of different public health policies. BMC Public Health 2010; 10:9.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Emmelin M, Weinehall L, Stenlund H, Wall S, Dahlgren L. To be seen, confirmed and involved--a ten year follow-up of perceived health and cardiovascular risk factors in a Swedish community intervention programme. BMC Public Health 2007; 7:190.

Does not report outcomes for high versus low socio-economic group – for smoking outcomes

Fujishiro K, Stukovsky KDH, Roux AD, Landsbergis P, Burchfiel C. Occupational gradients in smoking behavior and exposure to workplace environmental tobacco smoke: The multi-ethnic study of atherosclerosis. Journal of Occupational and Environmental Medicine 2012; 54(2):136–145.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Germain D, Durkin S, Scollo M, Wakefield M. The long-term decline of adult tobacco use in Victoria: changes in smoking initiation and quitting over a quarter of a century of tobacco control. Australian & New Zealand Journal of Public Health 2012; 36(1):17-23.

Does not link with specific intervention/policy. Does not report outcomes for high versus low socio-economic group on/policy, did not report.

Gilpin EA, Pierce JP. The California Tobacco Control Program and potential harm reduction through reduced cigarette consumption in continuing smokers. Nicotine & Tobacco Research 2002; 4:Suppl-66.

Reports changes in daily prevalence by SES but no analysis or discussion by policy

Hunt MK, Lederman R, Stoddard AM, LaMontagne AD, McLellan D, Combe C et al. Process evaluation of an integrated health

Does not report outcomes for high versus low socio-economic group

214

promotion/occupational health model in WellWorks-2. Health Education & Behavior 2005; 32(1):10-26.Hyland A, Higbee C, Travers MJ, Van DA, Bansal-Travers M, King B et al. Smoke-free homes and smoking cessation and relapse in a longitudinal population of adults. Nicotine & Tobacco Research 2009; 11(6):614-618.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Kaplan GA, Siefert K, Ranjit N, Raghunathan TE, Young EA, Tran D et al. The health of poor women under welfare reform. American Journal of Public Health 2005; 95(7):1252-1258.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Keller PA, Christiansen B, Kim SY, Piper ME, Redmond L, Adsit R et al. Increasing consumer demand among Medicaid enrollees for tobacco dependence treatment: the Wisconsin "Medicaid covers it" campaign. American Journal of Health Promotion 2011; 25(6):392-395.

Does not report outcomes for high versus low socio-economic group

Lando HA, Pechacek TF, Pirie PL, Murray DM, Mittelmark MB, Lichtenstein E et al. Changes in adult cigarette smoking in the Minnesota Heart Health Program. American Journal of Public Health 1995; 85(2):201-208.

Does not report outcomes for high versus low socio-economic group

Levy DT, Romano E, Mumford E. The relationship of smoking cessation to sociodemographic characteristics, smoking intensity, and tobacco control policies. Nicotine & Tobacco Research 2005; 7(3):387-396.

Does not report outcomes for high versus low socio-economic group

Licht A, Hyland A, O'Connor R, Chaloupka F, Borland R, Fong T et al. The impact of socio-economic status and price minimizing behaviors on smoking cessation: Findings from the international tobacco control (ITC) four country survey. American Journal of Epidemiology Conference: 3rd North American Congress of Epidemiology Montreal, QC Canada 2011; 173(pp S285):01.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Lock K, Adams E, Pilkington P, Duckett K, Gilmore A, Marston C. Evaluating social and behavioural impacts of English smoke-free legislation in different ethnic and age groups: implications for reducing smoking-related health inequalities. Tobacco Control 2010; 19(5):391-397.

Does not report outcomes for high versus low socio-economic group

Luk R, Cohen JE, Ferrence R, McDonald PW, Schwartz R, Bondy SJ. Prevalence and correlates of purchasing contraband cigarettes on First Nations reserves in Ontario, Canada. Addiction 2009; 104(3):488-495.

Not based in a WHO European country or non-European country at stage 4 of the tobacco epidemic – specific to First Nations reserves

Martinez-Sanchez JM, Gallus S, Zuccaro P, Colombo P, Fernandez E, Manzari M et al. Exposure to secondhand smoke in Italian non-smokers 5 years after the Italian smoking ban. European journal of public health 2012; 22(5):707-712.

No baseline comparison (prior to ban).

McLellan DL. Intended and unintended consequences: Effects of state cigarette price on smoking and current, binge, and heavy drinking by demographic group. Dissertation Abstracts International Section A: Humanities and Social Sciences 2012; 72(8-A): 2991.

Abstract focuses on tobacco control impacts on alcohol behaviour rather than smoking

Mindell JS, Wardle H. Using the Health Survey for England to monitor the effect on non-smokers and on inequalities of smokefree legislation. European Journal of Cardiovascular Prevention and Rehabilitation Conference: EuroPRevent 2010 Prague Czech Republic 2010; 17(pp S4):May.

Conference abstract only

Minov J, Karadzinska-Bislimovska J, Vasilevska K, Nelovska Z, Risteska-Kuc S, Stoleski S et al. Smoking among macedonian workers five years after the anti-smoking campaign. Arhiv za Higijenu Rada i Toksikologiju 2012; 63(2):01.

Does not link with specific intervention/policy.

Monteiro CA, Cavalcante TM, Moura EC, Claro RM, Szwarcwald CL. Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003). Bulletin of the World Health Organization 2007; 85(7):527-534.

Not based in a WHO European country or non-European country at stage 4 of the tobacco epidemic - Brazil

Moore K, Borland R, Yong HH, Siahpush M, Cummings KM, Thrasher JF et al. Support for tobacco control interventions: Do

Cessation survey related to attitudes to tobacco control.

215

country of origin and socioeconomic status make a difference? [References]. International Journal of Public Health 2012;57(5):777-786. Nierkens V, Kunst AE, Vries HD, Voorham TAJ, Stronks K. Reach and effectiveness of a community program to reduce smoking among ethnic Turkish residents in Rotterdam, the Netherlands: A quasi-experimental design. Nicotine and Tobacco Research 2013; 15(1):112-120.

Neither participation nor outcome analysed by SES.

Okechukwu C, Bacic J, Cheng K-W, Catalano R. Smoking among construction workers: The nonlinear influence of the economy, cigarette prices, and antismoking sentiment. Social Science and Medicine 2012; 75(8):1379-1386.

Analysis does not compare by education level (un/employment).

Osypuk TL, Subramanian SV, Kawachi I, Acevedo-Garcia D. Is workplace smoking policy equally prevalent and equally effective among immigrants? Journal of Epidemiology & Community Health 2009; 63(10):784-791.

Does not report outcomes for high versus low socio-economic group

Paulik E, Maroti-Nagy A, Nagymajtenyi L, Rogers T, Easterling D. Support for population level tobacco control policies in Hungary. Central European Journal of Public Health 2012; 20(1):Mar.

Cross-sectional data related to attitudes to Tobacco Control, no intervention

Peng L, Ross H. The impact of cigarette taxes and advertising on the demand for cigarettes in Ukraine. Central European Journal of Public Health 2009; 17(2):93-98.

Does not report outcomes for high vs. low socio-economic group

Pereira A, Sa E Sousa, Morais De AM, Filipe AL, Carvalho R, Todo-Bom A et al. The Portuguese national asthma survey-prevalence of tobacco smoke and tobacco smoke exposure at home in the general Portuguese population. Allergy: European Journal of Allergy and Clinical Immunology Conference: 30th Congress of the European Academy of Allergy and Clinical Immunology Istanbul Turkey 2011; 66(pp 82):June.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Phillips G, Renton A, Moore DG, Bottomley C, Schmidt E, Lais S et al. The Well London program - a cluster randomized trial of community engagement for improving health behaviors and mental wellbeing: baseline survey results. Trials 2012; 13.

Only baseline data, no intervention.

Pierce JP, Gilpin EA, Farkas AJ. Can strategies used by statewide tobacco control programs help smokers make progress in quitting? Cancer Epidemiology, Biomarkers & Prevention 1998; 7(6):459-464.

Does not report outcomes for high versus low socio-economic group

Pisinger C, Vestbo J, Borch-Johnsen K, Jorgensen T. Smoking cessation intervention in a large randomised population-based study. The Inter99 study. Preventive Medicine 2005; 40(3):285-292.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Regidor E, Pascual C, Gutierrez-Fisac JL. Increasing the price of tobacco: economically regressive today and probably ineffective tomorrow. European Journal of Cancer Prevention 2007; 16(4):380-384.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Reid JL, Hammond D, Driezen P. Socio-economic status and smoking in Canada, 1999-2006: has there been any progress on disparities in tobacco use? Canadian Journal of Public Health Revue Canadienne de Sante Publique 2010; 101(1):73-78.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Schopfer DW, Whooley MA, Stamos TD. Hospital compliance with performance measures and 30-day outcomes in patients with heart failure. American Heart Journal 2012; 164(1):80-86.

Uses composite measures so cannot disentangle effect on smoking.

Smit ES, Hoving C, Cox VC, de vH. Influence of recruitment strategy on the reach and effect of a web-based multiple tailored smoking cessation intervention among Dutch adult smokers493. Health education research 2012; 27(2):191-199.

Does not compare reach of either recruitment strategy withsmokers in general population. Does not report outcomes byintervention group, by SES.

Szatkowski L, Coleman T, McNeill A, Lewis S. The impact of the introduction of smoke-free legislation on prescribing of stop-smoking medications in England. Addiction 2011; 106(10):1827-1834.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke - focus on tobacco replacement products

216

Szilagyi T. Higher cigarette taxes--healthier people, wealthier state: the Hungarian experience. Central European Journal of Public Health 2007; 15(3):122-126.

Does not report outcomes for high versus low socio-economic group

Tangari AH, Tangari AH, Burton Ssue, Andrews JCc, Netemeyer RG. How do antitobacco campaign advertising and smoking status affect beliefs and intentions? Some similarities and differences between adults and adolescents. Journal of Public Policy & Marketing 2007; 26(1):60-74.

Does not report outcomes for high versus low socio-economic group

Tzelepis F, Paul CL, Walsh RA, Wiggers J, Knight J, Lecathelinais C et al. Telephone recruitment into a randomized controlled trial of quitline support. American Journal of Preventive Medicine 2009; 37(4):324-329.

Not population-level cessation support

Veeranki S, Mamudu H, Johnson T. Epidemiology of smoke free policies in the United States. American Journal of Epidemiology Conference: 3rd North American Congress of Epidemiology Montreal, QC Canada 2011; 173(S330):01.

Conference abstract only

Verkleij SP, Adriaanse MC, Verschuren WM, Ruland EC, Wendel-Vos GC, Schuit AJ. Five-year effect of community-based intervention Hartslag Limburg on quality of life: a longitudinal cohort study. Health & Quality of Life Outcomes 2011; 9:11.

Does not report outcomes for high versus low socio-economic group

Voigt K. Nonsmoker and "Nonnicotine" Hiring Policies: The Implications of Employment Restrictions for Tobacco Control83. American Journal of Public Health 2012; 102(11):2013-2018.

No specific employment restriction policy is evaluated

Wehby GL, Courtemanche CJ. The heterogeneity of the cigarette price effect on body mass index. Journal of Health Economics 2012; 31(5):719-729.

Focuses on impact on BMI not smoking.

Widome R, Jacobs DR, Jr., Schreiner PJ, Iribarren C. Passive smoke exposure trends and workplace policy in the Coronary Artery Risk Development in Young Adults (CARDIA) study (1985-2001). Preventive Medicine 2007; 44(6):490-495.

Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke

Woodall AA, Woodall AA. The partial smoking ban in licensed establishments and health inequalities in England: Modelling study. British Medical Journal 2005; .331(7515).

Does not report outcomes for high versus low socio-economic group

217

7.6 Appendix F Data extraction

218

Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Arheart 2008CountryUSADesign Cross-sectional surveyObjectiveTo explore trends in cotinine levels in US workers by occupational/industrial and race/ethnicity-gender sub-groups.SES variablesOccupational status using both categories from the National Centre for Health Statistics (NCHS) and National Occupational Research Agenda at the National Institute on Occupational Safety and Health (NIOSH):Analysesregression

Data sourcesThe National Health and Nutrition Examination Surveys (NHANES III); 1988 to 1991, 1991 to 1994, 1999 to 2000, 2001 to 2002.Participant selectioncomplex sampling strategy, randomly selected households, NHANES sampling scheme was not based on occupational categoryParticipant characteristics8105 non-smoking workers (confirmed by cotinine levels) and reported not exposed to SHS at home and 18 years of age and older across the four survey periods Intervention smoke-free workplace policiesLength of study14 years; 1988 to 2002Outcomescotinine levels

General population For the entire sample, there was a significant decrease in cotinine levels (0.16 ng/mL; 80% relative decrease) over time. Decreases from 1988 to 2002 ranged from 0.08 to 0.30 ng/mL (67% to 85% relative decrease).SES Largest absolute reductions in: blue-collar and service occupations; construction/manufacturing industrial sectors.NCHS occupational groups: The decline in cotinine levels ranged from 0.10 to 0.22 ng/mL (71% to 76% relative decrease). The negative slope in cotinine levels for blue-collar service and service workers (0.21 and 0.22 ng/mL, respectively; 72% and 76% decreases) were significantly greater than the slope for White collar workers (0.13 ng/mL; 76%). All reductions were significant (except for farm workers which had a small subgroup sample size (n = 81)).NIOSH industrial sector groups: the decrease in cotinine levels ranged from 0.09 to 0.23 ng/mL (73% to 85% relative decrease). The negative slope in cotinine levels for the Construction sector (0.23 ng/mL; 77% decrease) was significantly greater than the slope for Agriculture (0.09 ng/ml; 75%), health care , and Service sectors. The Manufacturing sector (0.22 ng/mL; 85% decrease) had a larger negative slope than Health care (0.11 ng/mL;73%) and Service sectors (0.13 ng/ml;76%). Transportation=0.19 ng/mL; 76%)Author’s conclusion of SES impactAll worker groups had declining serum cotinine levels. Most dramatic reductions occurred in sub-groups with the highest before cotinine levels, thus disparities in SHS workforce exposure are diminishing with increased adoption of clean indoor laws. large differences

Internal validityan unknown proportion of the NHANES participants had not worked the day before they provided blood samples for cotinine analysis, therefore reported levels may underestimatethe amount of occupational exposure to SHS. NHANES did not include questions about other forms of SHS exposure such as visiting bars and restaurants, where smoking may still be still permitted; this might lead to an over-estimate of occupational SHS exposure.External validity

Validity of author’s conclusionThe use of cotinine levels and self-reported no SHS exposure in the home makes it more likely that the observed effects were a result of smokefree workplace policies but SHS exposure from other settings cannot be ruled out.

219

Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places

in cotinine levels in worker subgroups persist; including those employed in the constructionsector, and blue-collar workers who continue to have the highest cotinine levels.

220

Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places Author, year Barnett 2009CountryNew ZealandDesign Before and after study (different participants)Objectiveto examine Acute Myocardial Infarction (AMI) admissions in Christchurch, New Zealand before and after the implementation of the smokefree legislation in 2004 SES variablesNeighbourhood social deprivation; the socio-economic profile of eachCensus Area Unit (CAU) was identified using the 2006 New Zealand DeprivationIndex and on this basis the CAUs were classified according to their quintile ranking on the index.AnalysesPoisson regression was used to calculaterate ratios by comparing for AMI ratesof hospital admissions

Data sourcesAMI hospital admissions to Christchurch Public Hospital and census dataParticipant selectionfirst admissions for AMI within the study timeframe originating in Christchurch CityParticipant characteristics3,079/6928Intervention New Zealand Smokefree Environments Act 2003 implemented in Dec 2004Length of study3 years – Jan 2003 to Dec 2006OutcomesAMI hospital admissions

General population The introduction of the smokefree legislation was associated with a 5% reduction in AMI admissions. The 55 to 74 age group recorded the greatest decrease in admissions (9%) and this figure rose to 13% among never smokers in this group. Reductions were more marked for men.SES Adding the effects of area deprivation increased the reduction to 21% among 55 to 74 year olds living in more affluent (quintile 2) areas. Only among the 55 to 74 year age group does the RR analysis give a hint that admissions may be falling in less deprived areas with quintile 2 being statistically significant (RR 0.76; CI 0.59–0.97). Overall however, the statistical association of changing levels of AMI admissions with smoking status and with deprivation was not consistently significant.Author’s conclusion of SES impactAt this early stage following the smokefree legislation, there are hints emerging of a positive impact on AMI admissions but these suggestions cannot yet be treated with certainty.

Internal validity

External validityUnclear if data from one hospital can be generalisable to rest of the countryValidity of author’s conclusionAuthors discuss other potential influences as well as smokefree legislation including possible long-term secular trends and new diagnostic criteria for AMI

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Details Method Results Comments

Smoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Cesaroni 2008CountryRome, ItalyDesign Repeat cross-sectionalObjectiveTo evaluate changes in acute coronary event rates in residents of Rome in relation to the smoking banSES variablessmall-area index of deprivation (education, occupation, home ownership, family composition, and nationality) to create a composite index of socioeconomic position (SEP), distributed in quintiles.Analysescomputed annual standardized rates and estimated rate ratios by comparing the data from prelegislation and post legislation

Data sourcesResidents of Rome between 35 and 84 years of age Participant selectionout-of-hospital deaths and hospitalized cases; hospitalizations for acute coronary events from all discharge reports of residents of Rome (35 to 84 years of age) between 2000 and 2005 that listed a principal diagnosis of “acute myocardial infarction” (as subsequently defined) and “other acute and subacute forms of ischemic heart disease”. Participant characteristicsSee participant selectionIntervention Ban on smoking in all indoor public places January 2005Length of study5 years, 2000 to 2004 and 2005OutcomesAcute coronary events

General population The prevalence of smoking decreased from 34.9% to 30.5% in men and from 20.6% to 20.4% in women. Cigarette sales also decreased in Rome in 2005 compared with 2004 (-5.5%). The average concentrations of PM10 decreased (from 46 _g/m3 in 2000 to 39 _g/m3 in 2005), as did the number of days per year that PM10 rose above 50 _g/m3 (144 days in 2000 versus 73 in 2005).The reduction in acute coronary events was statistically significant in 35- to 64-year-olds (11.2%, 95% CI 6.9% to 15.3%) and in 65- to 74-year-olds (7.9%, 95% CI 3.4% to 12.2%) after the smoking ban. No evidence was found of an effect among the very elderly.SES people aged 35 to 64 years living in low socioeconomic census blocks appeared to have the greatest reduction in acute coronary events after the smoking ban with significantly reduced ORs for SEP 3,4 and 5 but not 1and 2. There was no evidence of a statistically significant interaction between SEP and smokefree legislation.Author’s conclusion of SES impactEvidence indicates that a comprehensive ban could contribute effectively to the reduction of inequalities in health.

Internal validityTook into account several time-related potential confounders, including particulate matter air pollution, temperature, influenza epidemics, time trends, and total hospitalization rates. External validity

Validity of author’s conclusionImplementation of new diagnostic criteria and changes in daily doses of statins during study period could partially account for decreases in acute coronary events observed in this study.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Delnevo 2004Country25 states, USADesign Cross-sectionalObjectiveTo examine recent data from 25 states regarding workers’ protection via workplace smoking policies and focuses particularly on predictors of which workers are at risk of ETS exposure at the worksite.SES variablesEducation, household incomeAnalysesLogistic regression

Data sourcesThe optional tobacco module on the 2001 Behavioral Risk Factor Surveillance System (BRFSS) was administered by 25 states.Participant selectionBRFSS is a state-based random digit dial telephone survey of the adult population. The data from the 25 states were pooled. Across all 25 states, the median response rate was 51.3% and ranged from 33.3 to 70.8%Participant characteristics44,357 adults who reported that they are employed for wages and work indoors most of the time.Intervention Smokefree workplace policy; defined a smoke-free policy as a policy that prohibited smoking in the common, public, and work areas of the workplace.Length of study2001 onlyOutcomesPolicy coverage

General population Overall, 70.9% of respondents reported working under a smoke-free workplace policy. ranging from 60.4 (Kentucky) to 84.5% (Alaska). SES Household income was inversely related to the odds of working in a non smoke-free environment.Education, even after adjusting for all other factors including income, was strongly associated with the absence of a smokefree workplace smoking policy. Workers with less than a high school education and workers with a high school diploma or GED were 3.46 and 2.49 times more likely, respectively, than college graduates to report working in a non smoke-freeenvironment. Author’s conclusion of SES impactThe likelihood of being protected by a smoke-free workplace policy was significantly lower among workers who earned less than $50,000 annually, or had a high school education or less

Internal validityworking in a smoke-free environment was associated with a worker’s smoking status; nonsmokers were most likely to report a smoke-free environment(74.4%), followed by occasional smokers (67.9%) and everyday smokers (58.2%). Absence of a smokefree policy by education level was controlled for income race and gender but not smoking status?External validityWorkers in South or Midwest or less likely to have a smokefree work policy compared to workers in Northeast.Data from only 25 states: Data reported by region may not capture all states normally considered to be part of a region and may not be representative of the entire US workforce.Validity of author’s conclusion

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Details Method Results Comments

Smoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Deverell 2006Country351 cities and towns in Massachusetts, USADesign Repeat cross-sectionalObjectiveTo examine the diffusion of smokefree restaurant regulations and identify socioeconomic and racial/ethnic disparities in SHS exposure in restaurantsSES variablesTown-level SEP as measured by percentage of towns adult population with a college degree and living below the poverty lineAnalysesProportion of population protected divided by total population of Massachusetts, bivariate

Data sourcesLocal smokefree ordinances, classified into strong=no smoking and other = restricted smoking, and the US censusParticipant selectionn/aParticipant characteristics6,349,097 adultsIntervention Decade of transition from no 100% smokefree restaurant regulations to statewide ban on smoking in restaurants and barsLength of study10 years, January 1993 to July 2004OutcomesLocal regulation adoption of smokefree regulation

General population Over 10 years prior to statewide ban, only 36% of total population was covered by local regulations that protected them from SHS exposure in restaurantsSES The proportion of college graduates in Massachusetts protected from SHS in restaurants in their own town was consistently between 2 and 7 percentage points greater than the proportion of nongraduates who were protected. Just prior to the statewide smoking ban 40% of college graduates were protected compared to 33% of nongraduates. There was also substantial disparity in protection from SHS by individuals poverty status (protection higher for those living above poverty line)Author’s conclusion of SES impactPrior to the statewide ban there was substantial disparity in protection against SHS exposure based on educational status.

Internal validityBivariate analyses makes it difficult to tease out which SES is most important (measured education, poverty, rural area, race/ethnicity)External validity

Validity of author’s conclusionStudy addresses a theoretical level of protection from SHS exposure provided by regulations rather than actual level of protection but presence of regulation should correlate with reduced exposure. Towns with higher proportion of college educated were more likely to support legislation.

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Details Method Result CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Dinno 2009CountryUSADesignSingle cross-sectionalObjectiveTo consider disparities in tobacco control both by evaluating possible differences in the effects of clean indoor air laws and cigarette prices by different social circumstances, and by establishing whether vulnerabilities exist for smoking participation and consumption and, if so, whether these vulnerabilities covary with tobacco control policies.SES variables Education, household incomeAnalysesMultilevel modelling

Data sourcesFebruary 2002 panel of the Tobacco Use Supplement of the Current Population Survey (54,024 individuals representing the US population aged 15–80). Data on strong clean indoor air laws in effect at time of interview were obtained from the American Lung Association’s State of Tobacco Control 2002 and local ordinances from the American Nonsmokers’ Rights Foundation Local Tobacco Control Ordinance database; price from the average state cigarette prices per pack from The Tax Burden on TobaccoParticipant selectionNon-institutionalized civilian individuals in 266 counties in 50 states plus the District of Columbia. Participant characteristics54,024 self-respondents aged 15 to 18 yearsIntervention Strong clean indoor air laws and cigarette prices.Strong clean indoor air laws include 100% prohibition without exception of smoking in public and private workplaces (including non-hospitality work sites like manufacturing and office sites among others), restaurants (with and without attached bars), and bars and taverns.Length of studyFebruary 2002Outcomes Smoker statusConsumptionSmoking elasticities

General population Clean indoor air laws and cigarette prices are independently associated with reductions in smoking.Independent associations of strong clean indoor air laws were found for current smoker status (OR 0.66, 95% CI 0.60, 0.73), and consumption among current smokers (-2.36 cigarettes/day, 95% CI -2.43, -2.29).Cigarette price was found to have independent associations with both smoking and consumption, an effect that saturated at higher prices. The odds ratio for smoking for the highest versus lowest price over the range where there was a price effect, was 0.83. Average consumption declined (-1.16 cigarettes/day) over the range of effect of price on consumption.The effect of clean indoor air laws on smoking status (OR 0.66) was larger than the effect of cigarette prices over the range of prices at which we found smokers to be price sensitive (OR 0.83 for $2.91 to $3.28).SES Established patterns of education, income, and race/ethnic disparity in smoking are largely unaffected by either clean indoor air laws or price in terms of both mean effects and variance.Author’s conclusion of SES impactClean indoor air laws and price increases appear to benefit all SES groups equally in terms of reducing smoking participation and consumption and are generally neutral with regard to health disparities.

Internal validityThe household response rate for the February 2002 CPS was 93%.External validityOne of few studies to look at separate impact of smokefree legislation and priceValidity of author’s conclusionvalid

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Details Method Results Comments

Smoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Eadie 2008CountryScotlandDesign Before and after qualitative studyObjectiveto explore how management, customersand workers from across the social spectrum received and responded to the new measures during the 12 months following the banSES variablesSocial grade based on the occupation of the household’s chief wage-earnerAnalysesEthnographic case study combining unobtrusive semi-structured observation and in-depth interviews (minimal cueing). Interviews were recorded digitally and audio-files transcribed for thematic analysis.

Data sourcesEight Scottish community bars in three contrasting study communities located in one local authority areaParticipant selectionIn two areas, all the community bars in the study area were recruited to take part, while in the third covert visits were made to all licensed premises in the area to identify those with a local customer base. Bar customers were recruited door-to-door from within the local community and interviews conducted in the customer’s home. Sample stratified to broadly represent the smoking and gender profile of each study bar using baseline observation data as a guide.Participant characteristicsTen bar proprietors, 16 bar workers and 44 customers InterventionIndividual and paired interviews were conducted with a cohort of bar customers and bar staff (proprietors and bar workers) over two and three stages, respectively, to provide multiple perspectives on compliance, enforcement and acceptance of the smokefree legislationLength of study12 monthsOutcomesCompliance with ban

General population All eight study bars endeavoured to enforce the ban, but with varying enthusiasm. Compliance varied, with violations more prevalent in those bars serving deprived communities. Most violations occurred in peripheral areas and generally went unchallenged. Six bars reported some form of complicit behaviour with staff and customers smoking together, either in the entrance area or during ‘lock-ins’ when access to the bar was restricted to regular customers.SES Bars in deprived study communities tended to show lower compliance and less support for the legislation compared with the relatively affluent community, but there were exceptions to this. Three factors were particularly important in explaining variance between bars: smoking norms, management competency and management attitudes towards the ban. Smoking norms and management attitude were related to social disadvantageAuthor’s conclusion of SES impactEvidence suggests a need for targeted support for bars serving deprived communities where a pro-smoking culture remains entrenched, to help ensure that the major gains already achieved are retained and built upon

Internal validityStrength in the multiple perspectives offered by interviewing customers, bar workers and proprietors operating in the same study sites.Data collection restricted in one of the eight bars (refusal by proprietor to participate in post-ban follow-up stages and to facilitate access to staff)External validityThe small number of bars involved means that the study does not provide a representative view of the licensed trade across Scotland Validity of author’s conclusionauthors argue that the generalizability of the results arises not from the sample’s representativeness, but from the reliability of the compliance and enforcement concepts and their value to assessment in a wider range of settings

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Ellis 2009CountryNew York City, USADesign cross-sectional survey with control comparisonObjectiveTo estimate prevalence of smoking and SHS exposure among non-smoking adults in New York CitySES variablesEducation and incomeAnalysesmultivariate logistic regression

Data sources2004 NYC Health and Nutrition Examination Survey and the 2003 to 2004 National Health and Nutrition Examination Survey Participant selectionNYCHANES: three-stage cluster sampling Participant characteristicsadult non-smokers; NYCHANES: ( n = 1,767 adults aged 20 years or older); NHANES: ( n = 4,476 adults aged 20 years or older)Intervention comprehensive smokefree workplace legislation 2003Length of study12 monthsOutcomesSmoking prevalence Secondhand smoke exposure (cotinine)

General population Compared with national adult population characteristics (as reported in NHANES), more NYC adults were foreign born (51.3% vs. 15.2%), had less than a high school education (26.6% vs. 18.2%), and had an annual income of less than US$20,000 (32.4% vs. 23.6%).Although the smoking prevalence in NYC was lower than that found nationally (23.3% vs. 29.7%, p < .05), the proportion of nonsmoking adults in NYC with elevated cotinine levels was greater than the national average overall (56.7% vs. 44.9%, p < .05) and was higher for most demographic subgroups. SES Smoking prevalence by population subgroups demonstrated a generally consistent pattern: smoking prevalence in both the NYC and U.S. populations was higher in those earning less than $20,000 per year. Nationally, those with less than a high school education had a significantly higher smoking prevalence than those with at least a high school education. In NYC, the effect of education did not reach statistical significance ( p < .10).In general, NYC nonsmokers were significantly more likely to have elevated cotinine levels than their U.S. counterparts, except for adults aged 60 years or older, White females, Black males, and those with an annual income below $20,000. In NYC, those with less than a high school education were 64% more likely than those with at least a high school education to have an elevated cotinine level.Author’s conclusion of SES impactIn summary, we found, unexpectedly, that a greater proportion of NYC adults are exposed to SHS than are adults nationally, despite lower levels of smoking. Sociodemographic

Internal validityNHANES: overall response rate was 69% (4,742/6,916), NYCHANES: overall survey response rate of 55%. Thus, reported estimates may be biased. However, all data reported were weighted using information on age, gender, race/ethnicity, income, education, language spoken at home, and household size to correct for bias related to these factors.Study strength is that it is an assessment of SHS exposure conducted at the community level using a biologically measured indicator.External validityNYC residents might face unique exposure to SHS due to the density of the urban environment which limits study findings to NYCValidity of author’s conclusionvalid

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places

differences in the NYC population account only partially for the observed higher prevalence of SHS exposure. The higher prevalence across racial/ethnic and socioeconomic strata in NYC compared with nationally suggests that SHS exposure in dense, urban settings may be elevated, although the concentration of the SHS exposure may be lower than that found nationally.

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Details Method Results Comments

Smoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Farrelly 1999CountryUSADesign Repeat cross-sectionalObjectiveTo estimate the impact of workplace smoking restrictions on the prevalence and intensity of smoking among all indoor workers and various demographic and industry groups.SES variablesEducation, industryAnalysesMultivariate probit models (prevalence), ordinary least squares models (consumption)

Data sourcesTobacco use supplements to the September 1992, January 1993, and May 1993 Current Population Surveys of 97,882 indoor workers who were not self-employed.Participant selectionSample of indoor workers n=97,882Participant characteristicsThe indoor sample was roughly the same age, was more educated, had a higher percentage of females, and had a lower fraction of minorities than the sample of all workers. In all, 24 471 indoor workers (25.0%) smoked at the time of the survey, and smokers reported smoking 19.2 cigarettes a day. These numbers are only slightly lower than the estimates for the full workforce. Intervention Workplace smoking policies; four main types of workplace programme were defined: (1) 100% smoke-free environments, (2) work area bans in which smoking is allowed in some common areas, (3) bans in some but not all work and common areas, and (4) minimal or no restrictionsLength of studySeptember 1992 to May 1993OutcomesSmoking prevalenceconsumption

General population 46.7% of workers were subject to a 100% smoke-free policy, nearly 67% were subject to smoking restrictions in their immediate work area but were allowed to smoke in some common areas. The percentage of indoor workers subject to no work area or common area restrictions was 18.9%.Moving from no smoking restrictions to a smoke-free workplace decreased the prevalence of smoking by 5.7 percentage points (95% CI = 4.9 to 6.5) and reduced daily consumption among the remaining smokers by 2.67 cigarettes (95% CI = 2.28 to 3.05). The former result is a 22.8% reduction in smoking prevalence compared to the sample mean, while the latter represents a nearly 14% decrease in average daily cigarette consumption. Maintaining work area bans but allowing smoking in common areas reduced the impact of work area bans by half. For these workplaces, we observed a 2.6 percentage point decrease in the prevalence of smoking and a decline of 1.48 cigarettes in the average daily consumption (95% CI = 1.08 to 1.89). Partial workplace and common area bans had no statistically significant effects on the prevalence of smoking. However, these restrictions decreased daily consumption among remaining smokers (those who do not quit smoking) by a modest 0.57 cigarettes (95% CI = 0.05 to1.08). These results show a consistent pattern: the more restrictive the workplace policy, the greater the decline in smoking. SES Those with postgraduate education had both a

Internal validityEducation sample was limited workers aged 25 and older, when many have completed their education.External validityThe indoor sample was more educated than the sample of all workers. Validity of author’s conclusionvalid

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lower prevalence of smoking and a lower daily consumption. Although the percentage point declines in the prevalence of smoking in response to a smoke-free environment were fairly uniform across educational groups, as a percentage of current rate of smoking, the largest effects (percentage decline) were for workers with a college degree (28.4% decline) and the least for high school dropouts (13.7% decline). However, the opposite is true for the effects of the smoking ban on average daily consumption (19.4%). Those with less than a high school degree had the largest decline both in absolute terms (3.90 cigarettes) and as a percentage of average daily consumption (19.4%). Those with a college degree decreased daily consumption by an average of 1.69 cigarettes, a 9.3% decrease.Author’s conclusion of SES impactSmoke-free workplace policies reduce the prevalence and intensity of smoking. Furthermore, we found these policies to be an effective tool for reducing smoking among more and less educated people.

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Details Method Results Comments

Smoking restrictions in enclosed public placesAuthor, year Federico 2012CountryItalyDesign Interrupted Time-Series of 11 cross-sectional surveysObjectiveTo estimate the immediate as well as the longer-term impact of the 2005 smoke-free law in Italy on the smoking behaviour of adult subjects, and to assess if the impact differed by educational group.SES variablesEducation; highly educated subjects were those who held at least a high school degree (level 3 of the International Standard Classification of Education), while the remaining subjects were classified as low-educated.Analysessegmented linear regression

Data sources11 multi-purpose yearly surveys ‘Aspects of everyday life’, carried out by the National Institute of StatisticsParticipant selectionFor bigger municipalities cluster sampling was used, with households being the primary sampling units. A two-stage sampling was used for smaller municipalities.Participant characteristics29,000 to 36,000 subjects each year, aged 20–64 yearsIntervention 10th January 2005 Italian smoke-free law prohibited smoking in all public and work-placesLength of study12 years; 1999 to 2010 except 2004OutcomesQuit ratios

General population The prevalence of current smoking in the overall population decreased over time, while the quit ratio increased. Changes in both prevalence and cessation of smoking were particularly marked immediately before or just after the introduction of the 2005 policy, whereas in the following years values tended to be similar to those of the period before the policy was introduced. A clear decline over the whole time-period is observed for the number of cigarettes smoked daily, from 15.0 in 1999 to 13.1 in 2010.SES Among both low and high educated males, smoking prevalence decreased by 2.6% (P = 0.002) and smoking cessation increased by 3.3% (P = 0.006) shortly after the ban, but both measures tended to return to pre-ban values in the following years. The absolute difference in smoking prevalence between highly and low-educated males widened slightly over the whole time-period. Time trends in the quit ratio mirror those in smoking prevalence for males.Among low-educated females, the ban was followed by a 1.6% decrease (P = 0.120) in smoking prevalence and a 4.5% increase in quit ratios (P < 0.001). However, these favourable trends reversed over the following years. Among highly educated females, trends in smoking prevalence and cessation were not altered by the ban. A different pattern emerged for the female quit ratio: the policy was associated with an immediate increase in quit ratio (b = 2.6%, p = 0.050), but the change in time trends (b = -0.6% per year) was not significant at the 0.05 level. However, the immediate effect of the policy was

Internal validityData for 2004, which were used only to obtain descriptive statistics, were derived from a different survey.External validityExcludes institutionalised population. Validity of author’s conclusionResults may not be entirely attributable to smokefree law. In Italy the price of cigarettes rose by about 65% between 1999 and 2010, and the largest relative increase occurred between 2003 and 2005. In addition national mass media anti-smoking campaign carried out in 2009.Authors state reduced compliance or adaptation to the ban may have contributed to reduced social pressure to quit smoking among current smokers as well as to smoking relapse among former smokers.

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more favourable among low-educated females than among the higher educated, with a 4.5% increase in quit ratios among low-educated females, p < 0.001. Long-term trends clearly favoured the higher educated (b = 0.7% for the interaction term between education and time). As a result, educational differences in quit ratios widened over time.Author’s conclusion of SES impactThe impact of the Italian smoke-free policy on smoking and inequalities in smoking was short-term. Smoke-free policies may not achieve the secondary effect of reducing smoking prevalence in the long term, and they may have limited effects on inequalities in smoking.

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Details Method Results Comments

Smoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Ferketich 2010CountryAppalachia, USADesign Cross-sectionalObjectiveto examine the pattern of, and socioeconomic factors associated with, adoption of clean indoor air ordinances inAppalachia.SES variablesPercentage completed high school education, per capita income, median income, percentage poverty, and unemployment rate (average of yearly percentage reported between 1998 and 2007).Analysesmixed-effects logistic regression

Data sourcesWeb-based search and contacting of city halls for CIA ordinances. US Census Bureau and the US Bureau of Labor Statistics.Participant selection

Participant characteristics332 Appalachian communities with at least 2000 residents, in 6 states; Alabama, Georgia, Kentucky, Mississippi, South Carolina, and West Virginia.Intervention Clean indoor air (CIA) ordinances; in all 6 states, there are weak statewide CIA laws in place that do not prohibit smoking in restaurants, bars, and many other workplaces. However, the statewide CIA laws in these states also do not prohibit local communities from passing stronger CIA ordinances. Revised rating system for CIA local ordinances developed by local authorities could range from 0 to 13.Length of studyJune through August of 2008OutcomesPolicy coverage in workplaces, restaurants and bars

General population Fewer than 20% of the 322 communities had adopted a comprehensive workplace, restaurant, or bar ordinance. Most ordinances were weak, achieving on average only 43% of the total possible points.SES Both the percentage who completed high school and unemployment rate were related to the presence of workplace and restaurant clean air policies in Appalachian communities outside West Virginia. Adjusting for state and county, a 1% increase in high school completion rate was associated with a 9% increase in the odds of a restaurant policy and a 10% increase in both the odds of a workplace policy and the odds of at least 1 policy (workplace or restaurant).By contrast, we observed a negative relationship between the presence of an ordinance and unemployment rate: a 1% increase in unemployment rate was associated with an approximate 50% decrease in the odds of a restaurant policy, or either a workplace or restaurant policy. We observed the same relationship for workplace policies, though it was not significant at the .05 level. Univariate logistic regression models revealed no associations between county characteristics and CIA ordinances in West Virginia, with the exception of a significant negative relationship between median income and presence of a restaurant policy (a $1000 increase in median income was associated with a 12% decrease in the odds of a restaurant policy, likelihood ratio P=.033).A 1% increase in the percentage who completed high school was associated with an average increase of 0.9% in points achieved for

Internal validityFitted separate logistic regression models to West Virginia and communities within other 5 states because West Virginia differed from the other states as majority of its communities had an ordinance.Did not adjust the ratings to account for the state CIA laws. However the laws in these states were very weak, achieving only 26% of the total possible points.Freestanding bars were excluded as not covered by ordinances.External validityAppalachia is characterized by widespread poverty. Census data used might have been outdated for use in this study. Might not be generalisable to smaller Appalachian communities.Validity of author’s conclusion

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strength ratings, and a 1% increase in unemployment corresponded to an average decrease of 10.5% after adjustment for state. The analysis was repeated for the West Virginia counties, though no significant relationships were found.Author’s conclusion of SES impactCIA efforts in these states should be statewide, because, clearly, leaving the effort to local communities does not result in a large number of strong local CIA ordinances. Communities with a higher unemployment rate were less likely and those with a higher education level were more likely to have a strong ordinance.

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Details Method Result CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor , year Fowkes, 2008 CountryScotlandDesignCohort ObjectiveTo investigate trends in smoking cessation before and after the introduction of Scottish smoke-free legislation and to assess the perceived influence of the legislation on giving up smoking and perceptions of the legislation in smokers.SES variablesScottish Index of Multiple Deprivation (Cat 1=high, Cat 5=low)AnalysesLogistic regression

Data sourcesParticipants of Aspirin for Asymptomatic Atherosclerosis RCTParticipant selection1087 current smokers and 54 who restarted during study period (n=1141 out of 3350). Also subgroup of 474 of 631 (75.1%) current smokers the year prior to legislation completed questionnaire about the legislation’s impact (no sig differences to original study population).Participant characteristics50-75 year olds from central Scotland at moderately increased risk of cardiovascular events. 33% male, mean age 60.9, SIMD1-5 = 13%, 11%, 15%, 25%, 36%InterventionSmoke-free legislation in Scotland prohibiting smoking in almost all enclosed public places and work places (26th March 2006).Length of studyApril 1998 to December 2007OutcomesCessation (three month abstinence).Perception of legislation and its impact measured on an 11-point scale.

General population The Scottish smoke-free legislation was associated with an increase in the rate of smoking cessation in the 3-month period immediately prior to its introduction. Overall quit rates in the year the legislation was introduced and the subsequent year were consistent with a gradual increase in quit rates prior to introduction of the legislation.Odds of quitting increased annually (OR 1.09 95% CI: 1.05 to 1.12). 5.1% quit in 3 months prior to legislation implementation, far higher than any other 3-month period.In the subgroup completing the questionnaire (n = 474); 57 (12%) quit following between June 2005 and May 2007and 43.9% of these said that the smoke-free legislation had helped them to quit. Bi-modal perceptions of the legislation’s impact on their decision to quit (20% rated influence as between 2 and 8/10), 56% rated the legislation’s as having between 0 and 4/10 influence. 22.5% tried to quit following legislation, 66% of whom were influenced to do so by the ban. 70% of current smokers considered the ban to be positive.SES No association between area of residence or SIMD with the probability of attempting to quit, or feeling influenced to quit. Smokers from more affluent areas more likely to have a positive perception of the legislation compared with more deprived communities (p=0.01).Author’s conclusion of SES impactSocio-economic status was not related to smoking cessation, but individuals from more affluent communities were more positive about the legislation.

Internal validityGeographic measure of SES can be misleading.Reliance on patient recall of date they quit/began smoking.Small sample size.External validityBased on participants in an existing trial – therefore sample already more health-literate and more likely to respond positively to legislation? Also participation in the trial might have influence smoking behaviourValidity of author’s conclusionData on socio-economic impact of smoking status not presented, but assumed to be accurate.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Frieden 2005CountryNew York City, USADesign Repeat cross-sectionalObjectiveto determine the Impact of comprehensive tobacco control measures in New York CitySES variableseducationAnalysesUnivariate and multivariate

Data sourcesAnnual New York State Behavioral Risk Factor Surveillance System (BRFSS), New York City Department of Health and Mental Hygiene (DOHMH) conducted a population-based, random-digit dialed telephone community health surveyParticipant selectionrandomly selectedParticipant characteristicsadult New York City resident Intervention 1. April and July 2002 state and city tax

increases raised the cost of a pack of cigarettes by approximately 32%, to a retail price of approximately $6.85

2. 2002 Smoke-Free Air Act (SFAA) became effective in March 2003 eliminated existing exemptions to make virtually all indoor workplaces, including restaurants and bars, smokefree.

3. April 2003 nicotine-patch distribution program began providing free 6-week courses (coupled with brief telephone counseling) to 34 000 of the city's heavy smokers

4. Expansion of educational efforts such as publications and advertisements in broadcast and print media, emphasized the health risks of environmental tobacco smoke and the benefits of quitting. There was also extensive media coverage of the debate regarding smoke-free workplace legislation.

Length of study

General population During the 10 years preceding the 2002 program, smoking prevalence did not decline in New York City; within a year of implementation of the new policies, a large, statistically significant decrease occurred. From 2002 to 2003, smoking prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%, (P=.0002) approximately 140000 fewer smokers).Increased taxation appeared to account for the largest proportion of the decrease; however, between 2002 and 2003 the proportion of cigarettes purchased outside New York City doubled, reducing the effective price increase by a third.SES Smoking declined among all education levels. The decrease was more pronounced among low-income women (an 18.1% decrease, from 21.6% to 17.8%; P=.OO9). Significant decreases in smoking were found among people with more than a high school education (a 12.4% decrease, from 19.3% to 16.9%; P=.O1). Declines were also large among people with annual family incomes of less than $25000 (a 12.6% decrease) or $75000 or more (a 13.4% decrease).In 2003, former smokers who had quit within the past year were more likely to have low incomes compared with former smokers who had quit more than 1 year previously (43.6% vs 32.0%, p=.0001).Residents with low incomes (<$25000 per year) or with less than a high school education were more likely than those with high incomes (>$75 000 per year) and those with a high school education or higher to report that the tax increase reduced the number of cigarettes they

Internal validityResponse rates per wave among contacted households were 64%, 59%, and 64% respectively for three waves of data collection 2002 to 2003.ORs significantly reduced for smoking, only for people in income <$25,000 and ‘some college’ education.External validityAnalyses of education level were restricted to adults aged 25 years and olderValidity of author’s conclusionValid, but respondents' attribution of the impact of various control measures on their smoking behaviour may not be accurate.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places

May 2002 to November 2003; The 2002 community health survey was considered to be the preintervention sample, and the 2 surveys conducted in 2003 were combined and treated as the postintervention sample.OutcomesSmoking prevalenceOR for smokingResponse to tax increaseResponse to workplace smoking ban

smoked (income: 26% [low] vs 13.0% [high], P=.0002; educational attainment: 27.5% [lower] vs 19.3% [higher], P=.OO9).High-income people were more likely than low-income people to report that the SFAA reducedtheir exposure to ETS (53.3% vs 41.9%, P<.0001).Author’s conclusion of SES impactGroups that experienced the largest declines in smoking prevalence included people in the lowest and highest income brackets and people with higher educational levels.Our data suggest that people with lower incomes may have been more heavily affectedby the increase in taxation, whereas people with higher incomes may have been more affected by greater awareness of the dangers of environmental tobacco smoke and expansion of smoke-free workplace legislation.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Guse 2004CountryWisconsin, USADesign Repeat cross-sectionalObjectiveTo describe the nature and extent of workplace ETS exposures in WisconsinSES variablesEducation, income, occupationAnalysesBivariate regression

Data sourcesCurrent Population Survey tobacco supplements; 25% in person interviews, 75% telephone interviewsParticipant selectionNo detailsParticipant characteristics5933 (1995 to 1996) and 5674 (1998 to 1999) aged 16 years+Intervention Workplace clean indoor air policiesLength of study1995 to 1996 and 1998 to 1999 surveysOutcomesSmoking prevalenceWorkplace policy coverage

General population % US indoor workers working under a smokefree policy increased from 64% in 1995 to 1996 to 69% in 1998 to 1999. In Wisconsin the percent of indoor workers working under a smokefree policy increased from 62% in 1995 to 1996 to 65% in 1998 to 1999.SES Residents with less than a high school education or with a high school diploma as well as residents making less than $15,000 are much more likely to work in an environment where smoking is permitted or unregulated.Smoking prevalence was generally higher among people in occupations with a lower percentage of workers covered by smokefree workplace policy.About 80% of indoor workers working under a smokefree policy work are in professional specialities, protective services and technicians, compared to 22% of farmers and 50% machine operators and assemblers.Author’s conclusion of SES impactThere are socioeconomic differences in exposure to SHS in terms of occupation, income and education.

Internal validitySmall numbers in some subgroups make estimates unstableExternal validitySurvey represents civilian non-institutionalised population. Smokefree policies in Wisconsin have not progressed as much as other US states – 29th best in country in 1993 and 1996but 37th in 1999.Validity of author’s conclusion

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Details Methods Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor , year Guzman 2012CountryWisconsin, USADesignRepeat cross-sectional (before and after)ObjectiveTo evaluate the impact of smokefree legislation on smoking behaviours in and out of the homeSES variables Education level: high school education or level; some college education or higher). Family income: (<$30,000 per year; $30,000 to $59,000 per year; >/=$60,000 per year).AnalysesChi-square tests were used to compare proportions and two-tailed t tests were used for comparison of means. Appropriate sample weighting was applied based on survey strata and cluster structure. Logistic regression models were used to estimate crude and adjusted odds ratios of exposure to smoking variables comparing SHOW participants recruited after and before the state smoking ban.

Data sourcesAnnual Survey of the Health of Wisconsin (SHOW).Participant selectionRandomly selected, 2-stage cluster samplingParticipant characteristicsN = 1341 aged 21-74 years, 20.4% excluded from analyses (exposed to ban prior to statewide ban), 634 surveyed before ban and 434 after banIntervention 2009 Wisconsin Act, a statewide smoke-free law enacted in July 2010Length of study2008 to 2010Outcomes Being current smoker,Participants being exposed to smoke outside home,Participants being exposed to smoke at work,Participants being exposed to smoke at home,Participants having a strict ban in the home,

General populationSmoke-free legislation in Wisconsin increased the number of participants who reported having strict no-smoking policies in their households and decreased reported exposure to tobacco smoke outside the home, inside the home, and at work.The smoking ban was associated with a reduction of participants reporting exposure to smoke outside the home (from 55% to 32%; P<0.0001) and at home (13% to 7%; P=0.002). The new legislation was associated with an increased percentage of participants with no-smoking policies in their households (from 74% to 80%; P=.04).Smokefree legislation not associated with change in smoking prevalence but analyses weakened by small sample size. SES The results were stronger among participants who were wealthier, and more educated.IncomeParticipant exposure to tobacco smoke outside the home improved among all income groups but it was decreased further in the highest income group (family income >$60,000 per year). Participants being exposed to smoke at home was significantly reduced only for highest income group. Participants having a strict ban in the home was significantly increased only for the highest income group.

Internal validityParticipants who lived in an area with a workplace or complete public smoking ban prior to the statewide ban were excluded from the analysis.The number of current smokers in the SHOW data was only 167, a number that limits the statistical power of the study when it comes to analysing the effects of the law on smoking prevalence and on the behaviours of current smokers.External validitySpecific to Wisconsin residents.Validity of author’s conclusionOne of very few (if any) studies to look at impact of smokefree on home smoking by SES.

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Details Methods Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places

Participants being exposed to smoke at work significantly reduced only for middle income group.EducationBoth education groups significantly reduced exposure to smoke outside the home. Participants being exposed to smoke at home was significantly reduced only for higher education group. Participants having a strict ban in the home was significantly increased only for the higher education group.Author’s conclusion of SES impactParticipants with a family income greater than $60,000 per year also reported the largest reduction in exposure to smoke outside and inside the home, while the middle income group ($30,000-$59,999 per year) reported the largest reduction in exposure to smoke at work. The reduction in exposure to smoke outside the home and at work was about the same in both education groups but a larger reduction was seen in exposure to smoke at home in the group with a college education or higher. Those in the higher education group were also more likely to have a strict no-smoking ban in the home.

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Details Method Result CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor , year Hackshaw, 2010 CountryEngland, UKDesignRepeat cross-sectionalObjectiveTo determine the impact of smokefree legislation on quit attempts and intentions.SES variables Occupational classAnalysesSPSS version 13.1; categorical and continuous data were analysed using x2 tests and t tests, respectively.

Data sourcesNational household surveys, Smoking Toolkit study (monthly, face-to-face, computer-assisted, interviews).Participant selectionRandom location sampling method for over 16yrs. The sample was weighted to match census data on demographics. Subsample for current smokers, or have smoked in the last year (n=10560)Participant characteristicsMean age 41, 52% male. Average cigarette consumption – 13.45cpd. Occupational grades: AB=16.3%, C1 25%, C2 24.1%, D 22.5%, E 12.1%. Authors report there were no statisticallysignificant differences between respondents to the 2007 and to the 2008 surveys according to gender, age, social grade and daily cigarette consumption.InterventionNational smoke free legislation enforced in July 2007.Length of study January 2007 to December 2008OutcomesIntention to quit Influence of the ban on quit attempts.

General population 8.6% quit attempts in Jul/Aug-07, (5.7% equivalent period in 2008). Partially off-set by fewer quitters in Sep/Nov-07.2007 also shows significantly higher percentage of smokers making quit attempts in Jan/Mar-07.March-07 saw a significant increase in intention to quit before the ban, which fell by June (18% in March, 7% in June). Coincided with a significant rise in those planning to quit once the ban had been enforced (7% in March to 16% in June).One in five who quit after the ban said they’d been influenced by the ban. SES No significant difference in quit attempts by social grade. Intention to quit not discussed by social grade.Author’s conclusion of SES impactSmoke-free legislation was associated with a significant, temporary, increase in the percentage of smokers attempting to quit. This was true across all social grades. May not necessarily lead to a reduction in smoking-related health inequalities, but did not widen them.

Internal validityNon-response rate not discussed.Self-reported quit attempts likely to be higher than actual – no indication of attempts turning in to short-term cessation.Other tobacco control policies within the time period may have influenced the outcomes, only No Smoking Day discussed.Only examine six months of pre-legislation data, unclear whether quit attempts around the ban are different from the equivalent months in 2006.External validityLarge national household surveyValidity of author’s conclusionQuit attempts are generally more successful in more advantaged social groups, so although the influence has been equal across groups it is likely that the net outcome is a widening of inequality.

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Details Method Result CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, yearHawkins 2011CountryEngland and Scotland DesignCohort ObjectiveTo investigate parental smoking behaviours in England and Scotland after Scottish smokefree legislation, and inequalities in maternal smoking behaviour between the two countries.SES variables Occupational class, household income, educationAnalysesLogistic regression

Data sourcesMillennium Cohort Study (MCS) data for parents of children born between Sep-00 and Jan-02. First contact when child was 9 months old, third contact at 5 years old, 99.6% of these in Scotland took place post-legislation. 72% response rate to MCS.Participant selectionOnly studied singleton births to white British/Irish mothers who participated in all three contacts and lived in England or Scotland at first and third contact. Excluded if mother was pregnant at any contact, main respondent was not female, or partner was not male. In the final sample (4661), 3757 fathers were resident in England and 904 in Scotland.Participant characteristicsSocio-demographic variables from first contact used. 32% of mothers held managerial or professional jobs, 49% left education at or before age of 16, 13% lone parents, 60% employed, mean age at birth 29, no sig differences between England and Scotland. One quarter had income of £33k or higher, sig more English households had income above £22k (56% v 50%, p=0.03)InterventionSmokefree public places introduced in Scotland on March 26th 2006. No smokefree legislation in England during data collection period.Length of study2000 to 2007OutcomesSmoking behaviour at child’s age 9 months and 5 years.

General population No significant differences between countries in parental smoking or smoking in the home at 5 years, when adjusted for smoking at 9 months.Light smoking parents less likely to quit in Scotland than in England, no difference for heavy smokers. After adjusting for socio-demographics mothers in Scotland were less likely to start smoking by the child’s 5th birthday than in England (6.2% vs 7.3% respectively).SESHigher rate of smoking cessation between contact 1 and contact 3 among mothers in England who have higher household income, higher occupational class, left school at an older age, or gave birth later. No significant relationship for these factors in Scotland.Lower SES associated with higher rates of maternal smoking uptake and smoking in the home in both countries (p<0.05).Author’s conclusion of SES impactSmoking behaviours among parents with young children have remained relatively stable. In England quitting was also sociallypatterned, but socio-economic gradient in quitting smoking in Scotland has flattened slightly following the smokefree legislation. Smokefree legislation appears to encourage quitting across all socioeconomic groups, and does not appear to widen health inequalities.

Internal validityInitial data point several years before the introduction of legislation, during a period of continual change in tobacco control policy, difficult to isolate the impact of smokefree legislation. 45% of respondents in Scotland were surveyed within six months of the legislation. Self-reported smoking behaviour, possible differences in misreporting due to differences in smoking stigma.Higher attrition rate among non-smokers (40% of those who only responded at contact point 1 smoked compared to 29% who participated in the first and third contacts).Non-response weights were included in all analyses.No apparent threshold to define a smoker, e.g. smoked at least 100 cigarettes in lifetime, or regular smoker rather than occasional.External validityResults may not be applicable to ethnic minority groups.Validity of author’s conclusionDifficult to attribute any of the findings to smokefree legislation, given the range of other tobacco control policies implemented between the two data collection points.

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Smoking in the home measured from ‘Does anyone smoke in the same room as [Cohort child] nowadays?’Smoking one cigarette per day classified as smoker, 10 or more per day classified as heavy smoking.

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Details Method Result CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Hawkins 2012CountryUSADesignRepeat cross-sectionalObjectiveTo examine the impact of cigarette excise taxes and smoke-free legislation on tobacco use among households with school-age children and adolescents as well as disparities in children’s secondhand smoke exposure.SES variables Total combined family income during the past calendar year before taxes. A household’s percentage of the federal poverty level was calculated from household size and income. Highest level of education in the household wasconstructed by comparing education of the mother and father: less than/high school graduate or more than high school graduateAnalysescompared the results from models using causal inference techniques (differences in differences) to those from cross-sectional models using ordinal least squares regressions models

Data sourcesNational Survey of Children’s Health, state-level cigarette excise taxes, smoke-free legislation total score (0 [none]–32 [very strong]) in 2001 and 2005 (National Cancer Institute’s State Cancer Legislative Database).Participant selectionNot stated Participant characteristicsfamilies of 6–17-year-olds from the 2003 (N = 67,607) and 2007 (N = 62,768)Intervention Cigarette excise taxes and smoke-free legislation.From 2003 to 2007 40 states raised cigarette excise taxes with a mean increase of 54.5 cents (SE 6.4; range 7–175). In 2005, the mean tax was 84.7 cents (SE 7.9; range 5–246). From 2001–2005, 18 states strengthened smoke-free legislation with a mean increase of 13.3 (SE 1.8; range 1–28). In 2005, the mean smoke-free legislation total score was 12.0 (SE 1.3; range 0–32).Length of studyJanuary 2003 – July 2004 and repeated separate sample April 2007 – July 2008.Outcomes Household tobacco use

General populationIn adjusted causal inference models every $1.00 increase in cigarette excise tax between 2001 and 2005 was associated with a 4 percentage point decrease in household tobacco use between 2003 and 2007 (p = 0.008); however, there was no effect of smoke-free legislation on household tobacco use.In adjusted cross-sectional models, a higher smoke-free legislation total score was associated with a lower prevalence of household tobacco use.SES Cigarette tax increases but not smokefree legislation total score, were associated with reductions in household tobacco use for lower income households (100–399 % of the federal poverty level) using casual inference techniques.Cigarette tax increases and smokefree were associated with reductions in household tobacco use for lower income households.Author’s conclusion of SES impactStronger tobacco control policies decreased tobacco use among households with school-age children and adolescents; however, which policy reduced parental smoking depended on the modelling approach used. In causal inference models we found that stronger cigarette excise taxes decreased household tobacco use, particularly for families with children from lower income groups, but smoke-free legislation did not change tobacco use. In cross-sectional models we showed that a higher smoke-

Internal validityHousehold tobacco use as a proxy for children’s secondhand smoke exposure. Two year lag between tax and smokefree policies and outcomes.External validityNational survey data used which should be generalisable to US parentsValidity of author’s conclusionThis is a comparison of methods study in which authors focus on causal inference model results. Aim of increasing cigarette tax is to reduce prevalence of smoking and aim of smokefree legislation is to protect from SHS exposure.

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free legislation total score, indicating stronger policies or a greater coverage of policies, was associated with a lower prevalence of household tobacco use. Results suggest that increasing cigarette excise taxes may help reduce disparities by influencing parental smoking behaviours for the most at-risk children.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor , year Hemsing 2012CountryVancouver, CanadaDesignqualitativeObjectiveTo explore the effects of SHS policies on diverse group of men and womenSES variables low income or not low income according to their self-reported combined family income before deductions, using the Low-IncomeCut-Offs (LICOs) from Statistics Canada for 2004, and based on Vancouver population size (500,000+)AnalysesQualitative analysis (NVivo 8) software was utilized to analyse interview and focus group transcripts. Recurring themes were identified, paying particular attention to gendered factors and differences between women and men, and income levels. Data associated with each specific theme were organized under each code. Preliminary themes were discussed and reviewed in a team meeting, and themes further refined

Data sourcesTelephone interview with 21 women (9 low income) and 19 men (9 low income), and focus groups with one group of 3 low income women, one group of 3 non-low-income men, and one non-low-income womanParticipant selectionRecruited via advertisements in universities, coffee shops, hospitals, local media, and Craigslist (a free online classified advertisement). Purposive sample, Participant characteristicsN=47, exposed to SHS daily or almost daily and who were 19 years and olderIntervention Smokefree legislation, interviews and focus groups were semi-structured conducted by a trained female interviewer over the phone, and the focus groups by a trained, female facilitator in a meeting room at BC Women’s Hospital (transportation vouchers and child care reimbursement were offered). Participants received gift cards to local retailers as honorarium for their participation, in the amount of $20 for the phone interviews and $40 for the focus groups. All interviews and groups were recorded and transcribed,

General populationN/ASES The majority of participants thought that people living on a low income would be more vulnerable to SHS, face more smoking-related challenges and be less likely to benefit from SHS policies.Participants noted that smokers tend to be poor and have fewer resources to afford healthier options, experience more stress and anxiety and are more likely to use smoking as a coping mechanism. Some people living on a low income use smoking to cope with mental illness, and therefore face more barriers to reducing or quitting smoking.Participants thought that people living on a low income tend to be surrounded by more smokers, and also that smoking restrictions are less likely to be regulated. Low income neighbourhoods or housing areas often lack access to private outdoor space, creating challenges for those individuals trying to reduce their smoking or SHS exposure.Author’s conclusion of SES impactWomen and men living on a low income are more likely to live in more crowded areas, with more smokers and less safe, open spaces. These physical constraints limit opportunities to avoid SHS exposure in spite of increasing restrictions. The physical, social, and economic barriers low

Internal validityUnable to recruit men living on a low income to attend a focus group, and only met with one non-low-income woman for a focus group.Unequal number of smokers and non-smokers - sampling was not performed based on smoking statusExternal validitySmall study sample specific to Vancouver.Validity of author’s conclusion

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places

Length of studyMarch 2010 and February 2011Outcomes 3 key themes:Reshuffling and Relocating Where People Smoke;SHS management and the impact on social relations and interactions;Disparities in the effect of policies and management of SHS.

income women and men encounter to reducing smoking and smoke exposure may reinforce or intensify health-related disparities. Smoking in low-income areas may be normalized, smoking restrictions less enforced, and individuals experiencing the many stresses associated with living on a low income may find it difficult to quit

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Details Method Results Comments

Smoking restrictions in cars, homes, workplaces and enclosed public places

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Author, year King 2011CountryCanada, the United States, the UnitedKingdom, and AustraliaDesign Prospective cohort studyObjectiveTo assess socioeconomic and national variations in the prevalence, introduction, retention, and removal of smoke-free policies in various indoor environments, including homes, worksites, bars, and restaurants. A secondary objective was to identify sociodemographic predictors of these policy-related indicators by environment type.SES variablesSelf-reported education and annual household income were used to create composite measure of SES.AnalysesBivariate analyses, multiple logistic regression.

Data sources2006 and 2007 Waves 5 and 6 of the International Tobacco Control Four Country SurveyParticipant selectionRecruited by probability sampling methods in each of the four countries. In subsequent follow-up surveys of the cohort, recruited samples are replenished after attrition to ensure a sample size of at least 2,000 per country at each Wave. Participants were identified using stratified random digit dialling and interviews were conducted using computer assisted telephone interview (CATI) software by multiple research firms.Participant characteristics8,245 current and former adult smokers who were interviewed as part of Wave 5 of the ITC-4 survey between October 2006 and February 2007 (Canada, n = 2,023; the US, n = 2,034; the UK, n = 2,019; and Australia, n = 2,169). Intervention Telephone interviews with current smoker (reported smoking daily, weekly, or monthly at the time of survey) and former adult smokers (either remained quit since the time of last survey Wave completion or who made an attempt to stop smoking since the time of last survey Wave completion and was also quit for a month or more at the time of current survey Wave).Length of study12 monthsOutcomespresence, introduction, and removal of smoke-free policies in homes, worksites,

General population Smokefree bar policies:Overall, the proportion of both current and former smokers who reported that smoking was not allowed in any indoor area of local bars (total ban) was greatest among respondents from Canada in Wave 5 (current: 83.6%; former: 83.0%) and those from the UK, where a national ban on smoking in indoor public places was implemented between Waves, in Wave 6 (current: 97.1%; former: 95.3%). Between Waves 5 and 6, relative increases of 79.7% and 50.6% were observed in the proportion of current smokers with a total ban in the UK and Australia, respectively. Similar increases were also observed among former smokers in these two countries (UK: 81.1%; Australia: 45.3%).Smokefree restaurant policies:Overall, the proportion of both current and former smokers who reported that smoking wasnot allowed in any indoor area of local restaurants (total ban) was greatest among respondents from Canada in Wave 5 (current: 91.5%; former: 92.7%) and the UK, where a national ban on smoking in indoor public places was implemented between Waves, in Wave 6 (current: 97.1%; former: 98.2%). In contrast, the proportion of respondents with such a policy was lowest among those from the UK in Wave 5 (current: 27.5%; former: 32.0%) and the US in Wave 6 (current: 65.0%; former: 60.9%). Between Waves 5 and 6, relative increases of 71.7% and 67.4% were observed among current and former smokers in the UK, respectively.Smokefree worksite policies:Overall, the proportion of current smokers who reported that smoking was not allowed in any indoor area of their worksite (total ban) was greatest among respondents from Canada in Wave 5 (88.2%) and those from the UK, where

Internal validityBetween September 2007 and February 2008, a total of 5,866 of these participants (71.1%) were successfully re-interviewed in Wave 6 (Canada, n = 1,459, 72.1%; the US, n = 1,291, 63.5%; the UK, n = 1,484, 73.5%; and Australia, n = 1,632, 75.2%). In addition, another 2,329 individuals were recruited as part of the Wave 6 replenishment sample (Canada, n = 556; the US, n = 711; the UK, n = 523; and Australia, n = 539).External validityFindings from each of the four countries can be compared as same survey used. Validity of author’s conclusionIn the UK, national legislation prohibiting smoking in worksites, bars, and restaurants was implemented between data collection waves which may have influenced results.

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bars, and restaurants a national ban on smoking in indoor public areas was implemented between Waves, in Wave 6 (96.1%). The US had the lowest proportion at both Waves (Wave 5: 76.8%; Wave 6: 75.9%). Among former smokers, the proportion of respondents with such a policy in Wave 5 was the greatest in the US (92.7%), but lowest in Wave 6 (83.0%). Following stratification by SES, the proportion of current smokers with a total smoking ban in the worksite increased with increasing SES in Canada and the U.S. in Wave 5, but no significant trends were apparent in Wave 6. In the UK, the proportion of former smokers with a total smoking ban in the worksite increased with increasing SES in Wave 5. Between Waves, the introduction of a total ban among continuing smokers significantly decreased with increasing SES in Canada, the U.S. and the U.K.SES No consistent association was observed between SES and the presence or introduction of bans in worksites, bars, or restaurants. Current smokers with higher SES were more likely to have a total smoking ban in the workplace; however, the rate of smoke-free policy adoption in the workplace was comparable by SES group.Author’s conclusion of SES impactThe lack of socioeconomic differences in public workplace, bar, and restaurant smoke-free policies suggest these measures are now equitably distributed in these four countries. although smoke-free workplaces have previously been more common in high SES occupations, this disparity appears to have disappeared. On balance, the evidence indicates that smoke-free policies in public places are not being implemented differentially by the socioeconomic status of smokers.

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Details Method Result CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Levy, 2006 CountryUSADesignRepeat cross-sectionalObjectiveTo examine association between smoking and tobacco control policies among women of low SES.SES variables Not completed high school or no high school degree or GEDAnalysesmultivariate logistic models,

Data sourcesTobacco Use Supplement, four waves between 1992 and 2002. Sample nationally representative of non-institutionalised civilian population over the age of 15. Participant selectionFemales grouped by education level (less than high school, high school or higher, bachelor’s degree). Low education males included as a reference population. Sample varies between 176,452 and 228,552.Participant characteristicsMajority white, with increasing Hispanic proportion in later surveys. Majority 25 year olds or over. Over 40% from the South, approx. 20% each from the Midwest, Northeast and West.Low educated female constitutes between 21.6 and 26.6% of each survey, mid-educated 19.3-22.4%, high educated are 7.3 to 9.2% Intervention cigarette prices, clean air regulations, and tobacco control media campaigns, Clean air laws were represented by an index of state level clean air regulations. States with ‘‘no smoking allowed (100% smoke free)’’ were counted as 100% of the effect, with ‘‘no smoking allowed or designated smoking areas allowed if separately ventilated’’ as a 50% effect, and with ‘‘designated smoking areas required or allowed’’ as a 25% effect. We used separate indices by type of law, and settled on an aggregate weighted index, with worksite laws weighted by 50%, restaurant laws by 30%, and laws for other public places by 20%. Media campaign exposure measured at the state level rather than individual, and youth

General population impactSmoking prevalence declining across all categories.SES Price:As price increased the OR of low-education female smoking fell, but influence varies over survey waves. Only lower than 1 in 1992-3 and 2001-02. Med-higher educated groups less responsive. Media:In a state with a media campaign low education women’s OR=0.86, medium education = 0.89, high = 0.93 (non sig). Low education men also significantly less likely to smoke (0.92) Generally, the association of the media variable and smoking prevalence declines in the more recent survey waves.Smokefree legislationMarginal effect on current smoking. Over the period 1992–2002, current smoking among low education women is inversely related to the index of clean air laws with an odds ratio of 0.91 (0.80, 1.03), but is significant only in the medium education female subpopulation, with an odds ratio of 0.88 (0.83, 0.94). However, only in the 2001/02 model do clean air laws seem to play a part for the medium education female sample, although the confidence intervals around the estimates for each survey wave overlap for this group.Author’s conclusion of SES impactLow education women particularly responsive to media and price increases especially in comparison with high education women. Tax increases can play an important role. Tax increases and media

Internal validityNo before and after, simply tracks the association between policy and prevalence. Fail to adjust for confounding individual characteristics.Small sample sizes at some state levels.External validityMost of the developments in clean air regulations at the state level occurred after 2001.A number of tobacco control policies were introduced during this period as well as changing social norms and increasing awareness, all of which may have influenced the results. Data is now one, in some cases nearly two, decades out of date. Covers a substantial Hispanic population that wouldn’t exist in the UK.No description of the types of media campaigns involved, and which were the most effective (either the mode of intervention or locations) in order to replicate the study.Validity of author’s conclusionNo examination of individual level exposure, or whether media campaigns were actively influencing people to change their smoking behaviour. Outcome may simply be the consequence of changing social norms in these populations.

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campaigns coded as half a media campaign. Length of study1992 to 2002Outcomes Individual use, attitudes towards smoking and clean air laws, and smoking bans at home or work.

messages may reduce prevalence among women with low education. Health-SES relationship not irreversible.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor , year MacCalman 2012CountryEngland and ScotlandDesignCohort, before and after SFLObjectiveTo determine whether workers’ attitudes towards the change in their working conditions (SFL) may be linked to the change in health they report.SES variables Highest attained education (School, college, university or postgraduate)AnalysesRegression

Data sourcesBar workers Health and Environmental Tobacco Smoke Exposure – BHETSE (Scotland), and Smokefree Bars 07 (England)Participant selectionRandom sample of bars from Glasgow, Edinburgh and Aberdeen; and small towns in Aberdeenshire and the Borders areas of Scotland, central London and Liverpool; Northumbria and Cumbria; Newcastle-upon-Tyne.Convenience sample of bar workers in participating bars.Participant characteristicsN=548, bar workersIntervention UK smokefree legislation (SFL)Length of study1 year,Outcomes attitudes towards SFL and the presence of respiratory and sensory symptoms

General populationThere was no difference in the initial attitudes towards SFL between those working in Scotland and England. The proportion of people reporting any symptoms was significantly reduced from baseline to 1 year, in both England (76% vs. 49%) and Scotland (67% vs. 87%), with similar patterns being evident for both countries. However, the size of the reduction in symptom prevalence in Scotland was lower than in England.Attitude towards SFL was not found to be related to change in reported symptoms for bar workers in England (Respiratory, p = 0.755; Sensory, p = 0.910). In Scotland there was suggestion of a relationship with reporting of respiratory symptoms (p = 0.042), where those who were initially more negative to SFL experienced a greater improvement in self-reported health.SES For the majority of the questions bar workers who were educated to degree level and higher were significantly more positive towards the legislation than those who did not continue with education after school. Education did not significantly effect change in symptoms reported.Author’s conclusion of SES impactInitial attitude did not have an effect on the change in symptoms reported by those in England. There was, however, a relationship between the change in

Internal validity72/159 bars agreed to participate in Scotland (45%) and 46/253 (18%) in England. Same questionnaire used for both the Scottish and English studies. A higher proportion of bar workers in England were lost to follow-up (p<0.001), especially those from London and Newcastle while there was a slightly lower proportion of those from Aberdeen lost to follow-up. 295/548 lost to follow-up (54%, 65% in England and 49% in Scotland). Analyses of reported health symptoms limited to 180 bar workers (did not have a cold at baseline or follow-up. Only 138 bar workers in low SES group (school level education).External validitylower proportion of bars in England agreeing to participate (18% England; 45% Scotland),Validity of author’s conclusionValid – no association between smoking status and change in reported health. No evidence that bar workers who were initially more supportive of SFL

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places

reported respiratory symptoms and initial attitude in Scotland. The biggest improvement in respiratory symptoms, from baseline to year 1, was reported by those who were initially negative towards the SFL. Initial attitude is more likely to be associated with the symptoms reported initially, with those who were initially more positive towards the legislation being more likely to report no symptoms than those who had a negative attitude.

were more likely to report improvements in health. So no evidence of this type of selection bias, and all bar workers of all SES likely to benefit from SFL in terms of perceived health.

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Details Method Results CommentsSmoking restriction in cars, homes, workplaces and other public placesAuthor, year Moore 2011CountryPrimary schools, WalesDesign Repeat cross-sectional ObjectiveTo assess socioeconomic patterning in changes in salivary cotinine concentrations, reports of parental smoking in the home and car and estimates of population-level smoking prevalence following introduction of smoke-free legislationSES variablesFamily Affluence Scale (bedroom occupancy, car ownership, holidays, computer ownership)AnalysisMultinomial logistic regression analysis accounting for clustering and adjusted for age, year and time of data collection.Analyses are limited to children living with parents, a parent and step-parent or a single parent, and who completed the FAS (smoking questionnaire n = 1,555/1,528; salivary cotinine n = 1,397/1,390 pre/post-legislation). Cotinine analyses are limited to children classified as non-smokers [i.e., who both reported being a non-smoker

Data sourcesCHETS Wales studyParticipant selectionIn 2007, 1,611 pupils of an eligible 1,761 pupils within 75 schools completed the smoking questionnaire (91.5%), compared with 1,605 of an eligible 1,775 children within the same 75 schools in 2008 (90.4%). In total, 1,447 children pre-legislation (82.2% of those eligible) and 1,461 children post-legislation (82.3% of those eligible) from 71 schools provided useable saliva samplesParticipant characteristicsMean age 11 years. Pre-legislation, 422 (27.1%), 606 (39.0%), and 527 (33.9%) of children were assigned to low-, medium-, and high-SES tertiles, respectively. Post-legislation, a slightly smaller proportion of children were assigned to the low-SES group (n = 360, 23.6%), with 621 (40.6%) and 547 (35.8%) assigned to medium- and high-SES groups, respectively. InterventionNational smokefree legislationLength of study1 yearOutcomesSalivary cotinine levelsParental smoking in the home

General populationThere was no significant increase in inequality in the relative likelihood of a child’s sample containing a high level of cotinine (RRR = 1.03; 95% CI = 0.91–1.17).SES The likelihood of providing a sample containing an undetectable level of cotinine increased significantly after legislation among children from high [relative risk ratio (RRR) = 1.44, 95% CI = 1.04–2.00,p=0.03] and medium SES households (RRR = 1.66, 95% CI = 1.20–2.30, p<0.01), while exposure among children from lower SES households remained unchanged (RRR=0.93, 95% CI=0.62-1.40, p=0.72).In 2007 the percentage of homes with neither parent smoking (reported by children) were 48.9% for low SES, 65.5% for medium SES and 72.4% for high SES. In 2008 the percentage of homes with neither parent smoking were 49.9% for low SES, 67.3% for medium SES and 78.1% for high SES.The percentage of children reporting SHS exposure in a car the previous day remained at 7% before and after the smokefree legislation. In 2007 percentages of children reporting car-based exposure to SHS exposure was 8.8% (n=69) for low SES, 6.5%% (n=79) for medium SES and 5.4% (n=58) for high SES. Among the lower SES group,

Internal validityBiochemical measure of smoking. No significant differences between characteristics of pre- and post-legislation samples, nor were there significant differences between those providing useable saliva samples and those providing only questionnaire responses.Required imputation of random values for 47% of cases which limits reliability.External validityGeneralisability limited by narrow age group and analyses restricted to children attending school and living with parents, a parent and step-parent or a single parent. Childrens reports of parental smoking in the home and in the car are only proxy measures.Validity of author’s conclusionThe impact of comprehensive smoking bans may differ depending on the pre-ban level of exposure and the balance between sources of exposure i.e. public places v home.

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Details Method Results CommentsSmoking restriction in cars, homes, workplaces and other public placesand provided saliva with a cotinine concentration <15 ng/ml (n = 1,362/1,364)].

Car-based SHS exposure

Intervention detailsQuestionnaire plus cotinine assay

percentages of children reporting car-based exposure increased slightly from 7.4% (n = 31) pre-legislation to 10.6% (n = 38) post-legislation. Among the medium-SES group, exposure remained almost unchanged, at 6.3% (n = 38) pre-legislation and 6.6% (n = 41) post-legislation. However, among the high-SES group, exposure declined from 6.3% (n = 33) to 4.6% (n = 25). The changes in car-based SHS exposure were not statistically significant for any of the three SES subgroups, however the changes did increase between group differences from 1% pre-legislation to 6% post-legislation.Parental smoking in the home, car-based SHS exposure, and perceived smoking prevalence were highest among children from low SES households. Parental smoking in the home and children’s estimates of adult smoking prevalence declined only among children from higher SES households.Author’s conclusion of SES impactPost-legislation reductions in SHS exposure were limited to children from higher SES households. Children from lower SES households continue to have high levels of exposure, particularly in homes and cars, and to perceive that smoking is the norm among adults.Children’s SHS exposure did not worsen for any SES subgroup after introduction of legislation in Wales. However, the

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unanticipated reductions in children’s SHS exposure following legislation appear limited to children from more affluent households in Wales, whose exposure was already significantly lower prior to legislation, leading to increased socioeconomic disparity.

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Details Method Results CommentsSmoking restriction in cars, homes, workplaces and other public placesAuthor, year Moore 2012CountryPrimary schools, Scotland, Northern Ireland, WalesDesign Repeat cross-sectional ObjectiveTo pool data from 3 countries in order to assess socioeconomic patterning in SHS exposure and parental restrictions on smoking in homes and cars before and after smokefree legislationSES variablesFamily Affluence Scale (bedroom occupancy, car ownership, holidays, computer ownership)AnalysisMultinomial logistic regression analysis accounting for clustering and adjusted for age and country. Binomial logistic regression for car-based smoking.

Data sourcesCHETS Scotland, Northern Ireland and Wales studies, questionnaire plus cotinine assayParticipant selectionOf 586 schools approached, 320/304 (54/51%) participated at baseline/follow-up.Participant characteristics10 867 non-smokers (self-reported nonsmokers providing saliva samples containing <15 ng/ml cotinine) in their final year at 304 primary schools in Scotland (n = 111), Wales (n = 71) and NI (n = 122).Intervention National smokefree legislation prohibiting smoking in enclosed public places and workplaces (Scotland March 2006, Wales March 2007, Northern Ireland (NI) April 2007Length of studyOne yearOutcomesSalivary cotinine levelsSmoking restrictions in the homeSmoking restrictions in the car

General population Relative risk of children’s samples containing no detectable cotinine increased significantly following legislation. Percentages of children with undetectable concentrations increased from 31.0 (n = 1715) to 41.0% (n = 2251) following legislation overall, and from 20.1 to 34.2, 44.9 to 51.0 and from 38.6 to 42.9% in Scotland, Wales and NI, respectively. Relative risk of providing a sample containing a ‘high’ cotinine concentration also increased significantly. SES Relative risk of children’s samples containing no detectable cotinine increased significantly as SES increased, whilst the relative risk of samples containing a ‘high’ cotinine concentration fell. These associations were almost identical in all countries, remaining significant after entry of terms for parental smoking and private smoking restrictions.This inequality appears to have widened following legislation (in the combined data set and trend in individual countries), with percentages of samples above the limit of detection ranging from 96.9 to 38.2% for the least and most affluent children, respectively, after legislation. Gradients for higher exposure levels remained relatively unchanged.In all countries, and the combined data set, as SES increased, the likelihood of partial

Internal validityBiochemical measure of smoking. Children reported on smoking restrictions in homes and cars.SES varied significantly between survey years (affluence higher at follow-up).External validityGeneralisability limited by narrow age group and analyses restricted to children attending school and living with parents, a parent and step-parent or a single parent. However pools data from 3 CHETS studies.Childrens reports of parental restrictions in the home and in the car are only proxy measures.Validity of author’s conclusionValid. Impact may differ between individual countries because baseline cotinine concentrations differed between countries. Difficult to compare results by SES pertaining to individual countries with other CHETS papers because analyses are different.

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Details Method Results CommentsSmoking restriction in cars, homes, workplaces and other public places

or no home smoking restrictions (rather than full smoking restrictions), decreased significantly, whilst the odds of smoking being allowed inside the family car also decreased significantly. Following legislation, 26.3% of children scoring 1 on FAS reported living in a fully smoke-free home, climbing to 72.0% for those scoring 9. Percentages reporting that smoking was not allowed in their car ranged from 51.7 (least affluent) to 83.0% (most affluent). These trends remained after adjustment for parental smoking No change in inequality following legislation for home and car-based smoking restrictions (socioeconomic patterning remained stable).Author’s conclusion of SES impactSocioeconomic inequality in the likelihood of a child’s sample containing detectable traces of cotinine increased. Hence, declines in exposure occurred predominantly among children with low exposure before legislation, and from more affluent families. Substantial socioeconomic gradients in proportions of children with higher SHS exposure levels remained unchanged. Post-legislation changes in smoking restrictions in cars or homes were not patterned by socioeconomic status.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Moussa 2004CountryScania, SwedenDesign Cross-sectionalObjectiveTo investigate the sociodemographic distribution of workplace exposure to ETS in a Swedish working population sample in order to assess the potential contribution of ETS exposure to health inequalities.SES variablesOccupation; High-level non-manual employees, medium-level non-manual employees, low-level non-manual employees, skilled manual workers, unskilled manual workers, self-employed persons (a very heterogeneous group), and students.Analysesmultivariable regression

Data sourcesScania Public Health Survey 2000 was based on a sample of 24,922 randomly selected persons born from 1919 to 1981 and living in Scania (population 1.14 million), the southernmost province of Sweden.Participant selection13,604 persons responded to the questionnaire, representing 59% of those contacted for the study.Participant characteristics8,270 working individualsIntervention Workplace ETS Length of studyNovember 1999 to February 2000.OutcomesETS exposure

General population The prevalence of ETS at work was higher among men (26.4%) than among women (20.8 %), although regular smoking was higher among women (21.1%) than among men (17.0 %). Regular smokers had a higher risk of ETS exposure at work than non-smokers.SES The exposure to ETS at work was highest among men in skilled manual work and womenin unskilled manual work. The higher risk of exposure among individuals in the aforementioned groups persisted after adjusting for age, country of origin, and smoking patterns.Male skilled manual workers and female unskilled manual workers had higher adjusted odds ratios (OR 4.0, 95% CI: 3.1 – 5.3 and OR 3.2, 95% CI: 2.2 – 4.7, respectively) of ETS exposure than non-manual high-level employees.Author’s conclusion of SES impactIndividuals in lower socioeconomic groups experienced a higher risk of ETS exposure at work than other such groups. ETS should be recognized as a factor contributing to health inequalities.

Internal validityAge and smoking habits were adjusted for in analyses.External validitySample is from Scania only and may not be generalisable to whole of Sweden.Validity of author’s conclusionValid

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor , year Nabi-Burza 2012

Age (years)26% (n=214) aged less than 1 year;35% (n=288) aged 1 to 4 years;19% (n=158) aged 5 to 9 years);18% (n=147) aged 10 years or over

SettingPaediatric clinics in 8 US states

Study design Cross-sectional study

ObjectiveTo determine prevalence and factors associated with strictly enforced smoke-free car policies among smoking parents.

SES variableeducation (high schoolor less versus some college or collegegraduates)

Study analysisLogistic regression

Data sourcesBaseline data collected at paediatric practices enrolled in the control arm of a cluster, randomized controlled trial, Clinical Effort Against Secondhand Smoke Exposure.

Participant selectionParticipants were eligible to enrol in the study if they had accompanied a child to the office visit, had smoked at least a puff of a cigarette in the past 7 days, were the parent or legal guardian of the child seen that day, were at least 18 years old, and spoke English. Enrolled parents received $5 in cash for completing the baseline enrolment survey.Screening continued until 100 eligible parents were enrolled at each practice.

Participant characteristics817/981 parents reported having a car. The majority (70%) of the parents were in the age group 25 to 44 years, 77% were females, mostly mothers (98% vs 2% legal guardians), and 68% were non-Hispanic whites. Many parents (42%) had only a high school degree, and 16% had completed college. Most of the children (60%) were covered by Medicaid

OutcomesSmokefree car policy

Intervention detailsQuestionnaire of smoking behaviour in cars and home

General population impactOf 795 parents, 73% reported that someone had smoked in their car in the past 3 months. Less than 1 in 3 parents who had a smoke-free car policy reported that it was violated in the past 3 months. Of the 562 parents who did not report having a smoke-free car policy, 48% reported that smoking occurred with children present in the car. Approximately one-fifth of all enrolled parents reported being asked by a paediatric health care provider about their smoking status. Only 14% of smoking parents reported being asked if they had a smoke-free car, and 12% reported being advised to have a smoke-free car policy by a paediatric health care provider.

Impact by SES variableNo association between parent’s age, race and ethnicity, education, and intention to quit smoking with having a strictly enforced smokefree car policy.Exploratory analyses assessed possible interactions between the 4 parent demographic variables (age, gender, race, and education) and the 3 significant predictors of car policy (child’s age, number of cigarettes smoked per day by the parent, and having another smoker at home). Parent gender and education interactedwith child’s age: parents of children aged <1 year were more likely to have strict smoke-free car policies if they

Internal validityUnable to ascertain how representative the study sample was. Self-reported outcome data.

External validitySample excludes non-car owners. Sample is derived from 8 US states. Validity of author’s conclusionEducated was not significantly associated with smokefree car policy on its own, only significant in interaction with child age and amount smoked.

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were female (OR: 3.00 [95% CI: 1.22–7.38], P = .016) or college educated (OR:2.42 [95% CI: 1.21–4.83], P = .013). Strict smoke-free car policies were more common when parents were both light smokers (smoked 10 or less cigarettes per day) and college educated (OR: 2.88 [95% CI: 1.24–6.66], P = .013).

Author’s conclusion of SES impactCollege educated parents of children aged <1 year were more likely to have strict smoke-free car policies.

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Details Method Results Comments

Smoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Nagelhout 2011aCountryIreland, France, the Netherlands, GermanyDesign Before and after study (same participants)Objectiveto investigate how successful the smoke-free hospitality industry legislation was in reducing smoking in bars; assess individual smokers predictors of smoking in bars post-ban; to examine country differences in predictors; to examine differences between education levels.SES variableseducationAnalysesmultivariate regression mediation analyses

Data sourcesInternational Tobacco Control (ITC) Europe SurveysParticipant selectionProbability sampling methods with fixed line telephone numbers selected at random from the population of each country. The Netherlands sample differed in that most respondents were surveyed using web interviewing (n = 1668 of baseline sample of 2072) instead of telephone interviewing. The Dutch web sample was drawn from a large probability-based database with respondents who had indicated their willingness to participate in research on a regular basis.Participant characteristics3147 adult smokers (Ireland n = 573, France n = 820, the Netherlands n = 1034 (telephone n = 185, web n = 849), Germany n = 720).Intervention smoke-free hospitality industry legislationLength of studyVaried between countries, approx. 12-24 monthsOutcomesPrevalence, predictors of smoking in bars

General population while the partial smoke-free legislation in theNetherlands and Germany was effective in reducing smoking in bars (from 88% to 34% and from 87% to 44%, respectively), the effectiveness was much lower than the comprehensive legislation in Ireland and France which almost completely eliminated smoking in bars (from 97% to 3% and from 84% to 3% respectively). Smokers, who were more supportive of the ban, were more aware of the harm of SHS, and who had negative opinions of smoking were less likely to smoke in bars post-ban. Support for the ban was a stronger predictor in Germany.SES Smokers from Ireland and France were younger and less educated than smokers from the Netherlands and Germany. Smokers with a low educational level were more likely than smokers with a high educational level to smoke in bars post-ban.Highly educated smokers from the Netherlands who were supportive of a partial ban were less likely to smoke in bars post-ban (OR highly educated = 0.53, 95% CI = 0.26 to 1.08). Moderately educated smokers from the Netherlands who often or sometimes thought about the harm of smoking to others were less likely to smoke in bars (OR moderately educated = 0.54, 95% CI = 0.34 to 0.88). Societal approval of smoking was a stronger predictor of smoking in bars among highly educated smokers (OR highly educated = 2.87, 95% CI = 1.01 to 8.18). Low and moderately educated smokers from Germany who very often thought about the harm of smoking to

Internal validityRespondents who did not visit bars after the implementation (n = 985) and respondents who had quit smoking (n = 606) were excluded from analysis. Younger smokers had lower follow-up rates. Since younger smokers were more likely to smoke in bars post-ban, this could have led to an underestimation of the point estimates of smoking in bars post-ban.72.5% follow-up - rates were considerably higher for the Netherlands web survey (80.1%) than the Netherlands telephone survey (73.7%) and the telephone surveys in the other countries (Ireland 71.8%, France 71.0%, Germany 66.1%).The survey months and years and the time intervals between waves and between the ban and post-ban waves were different between countries, there were demographic differences between countries and the interviewing methods were different for the ITC Netherlands survey.External validityFindings from each of the four countries can be compared as same survey used.Validity of author’s conclusionvalid

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others were borderline significantly less likely to smoke in bars (OR low educated = 0.14, 95% CI = 0.02 to 1.15; OR moderately educated = 0.23, 95% CI = 0.05 to 1.11).Author’s conclusion of SES impactSHS harm awareness was a stronger predictor among less educated smokers in the Netherlands and Germany. This suggests that smoking in bars post-ban can be decreased among lower SES smokers by communicating about the harm of smoking to others. This is especially urgent for the Netherlands, where only 1 percent of low educated smokers thinks very often about the harm of their smoking to others (compared to 19% of Irish, 17% of French, and 9% of German low educated smokers).

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Details Method Result CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Nagelhout 2011bCountryThe NetherlandsDesignCross-sectionalObjectiveTo study the impact of implementing smoke-free workplace and hospitality industry legislation on smoking behaviour.SES variables Education (low: primary and lower secondary, medium: mid-secondary and secondary vocational, high: senior secondary school, (pre-)university and higher professional).Employment (employed or ‘not employed for at least two days a week’)AnalysesMultivariate logistic regression

Data sourcesDutch Continuous Survey of Smoking Habits (DCSSH), a continuous cross-sectional population survey, running from 2001-2008. The DCSSH is conducted by TNS NIPO (Amsterdam, the Netherlands) for the Dutch expert centre on tobaccocontrol (STIVORO)Participant selectionAged 15 or over, randomly selected from regular participants in internet-based research, 18,000 surveyed each year (total=144733).Participant characteristicsNo significant differences between years or pre/post 2008 hospitality ban.Weighted by age, gender, education, working hours, region, urbanisation and household size to make the sample representative of Dutch population over 15 years old.21% of responses contained no information on income.Intervention Workplace smoking ban in the Netherlands, introduced in 2004, and a hospitality industry smoking ban introduced in 2008.

General population There was a slight, significant, decrease in prevalence between 2001 and 2007 (OR=0.97, p<0.001). Workplace ban was followed by a decrease in smoking prevalence in 2004 (OR=0.91, p<0.001), with prevalence lower in the first half of the year than the second, suggesting some relapse.Hospitality ban had no significant influence on prevalence (OR=0.96, p=0.127).Quit attempts higher following the workplace ban (33% (2004) v 27.7% (2003), p<0.001), and hospitality ban (26.3% in 2008, v 24.1% in 2007, p=0.013). Seasonal variations in quit rates also support effectiveness of both smokefree policies.Significant increases in successful quit attempts following both policies.SES Workplace ban led to more successful quit attempts among higher educated smokers (OR=0.35, p<0.001) than medium (OR=0.41, p<0.001) or lower OR=0.74, p=0.052).

Internal validityUnable to infer causality from cross-sectional data.All data is self-reported.Do not disclose the characteristics of the surveyed population from which the weighted study data was extrapolated.External validityPopulation exposed to a number of concurrent tobacco control policies during study period, including three tax rises, national media campaigns, warning labels, advertising ban and a youth access law. Similar population structure to England, with similar recent history in tobacco control policies. Legislation poorly enforced in some areas.Validity of author’s conclusionDisagree with the equal impact of the smokefree hospitality legislation. There is no significant difference in quit attempts pre-ban, but post-ban higher educated smokers are more likely to attempt to quit than low educated smokers (p=0.022).

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Length of study2001 to 2008Outcomes Smoking prevalence, quit attempts (and success).

No variation in impact of hospitality ban by SES.The hospitality industry ban had a larger effect on quit attempts among frequent bar visitors (OR = 1.48, P = 0.003) than on non-bar visitors (OR = 0.71, P = 0.014). More frequent bar visitors more likely to be higher educated, as well as younger, male, and employed (all p<0.001).Author’s conclusion of SES impactWorkplace smoking ban had a greater impact on smoking behaviour than a hospitality industry ban. The latter only appeared to increase quit attempts rather than change smoking prevalence.Hospitality industry bans have the potential to increase cessation in all socio-economic groups.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor , year Nagelhout 2013CountryThe NetherlandsDesignCohortObjectiveTo examine age and educational inequalities in smoking cessation due to the implementation of a tobacco tax increase, smoke-free legislation and a cessation campaign.SES variables Education, low (primary education and lower pre-vocational secondary education), moderate (middle pre-vocational secondary education and secondary vocational education) and high [senior general secondary education, (pre-) university education and higher professional education].AnalysesUnivariate and multivariate logistic regression. All analyses were weighted by age and gender to be representative of the adult smoker population in the Netherlands.

Data sourcesThree survey waves of the International Tobacco Control (ITC) Netherlands Survey, 2008 (before) and 2009 and 2010 (after)Participant selectionRecruited from a probability-based web databaseParticipant characteristicsN=1820/2331 (78.1%) in first survey, 1447 in second survey and 1275 in third survey. Analyses restricted to respondents who participated in all three survey waves (n=1176). And excluded 128 who had quit during 2008 and 2009 surveys, n=1048 and then answered all questions, n=962.Dutch smokers (having smoked at least 100 cigarettes in their lifetime and currently smoking at least once per month) aged 15 years and olderIntervention Tobacco tax increase, smoke-free hospitality industry legislation and mass media cessation campaign (all at national level) implemented during the same time period in the Netherlands in 2008. The Dutch cessation campaign focused on smokers with low to moderate educational levels.Length of study2008 – 2010

General populationCessation: 281 out of 962 respondents (29.3%) had tried to quit smoking between the 2009 and 2010 surveys. At the 2010 survey, 86 out of 962 respondents (8.9%) had successfully quit smoking. There were no significant age inequalities in successful smoking cessation. Smokers aged 15–39 years were more likely to attempt to quit smoking.Exposure:In total, 82.4% reported having paid more for their cigarettes in the 2009 survey than in the 2008 survey, 65.6% reported having visited a drinking establishment that had some form of smoking restriction and 83.1% reported having experienced one or more parts of the campaign. Smokers aged 15–24 years were more exposed to the smoke-free legislation, whereas smokers aged 25–39 years were more exposed to the cessation campaign.Exposure to the smoke-free legislation and to the cessation campaign had a significant positive association with attempting to quit smoking in the univariate analyses, but not with successful smoking cessation. In the multivariate analyses, only the association between exposure to the smoke-free legislation with attempting to quit smoking remained significant [odds ratio (OR)=1.11, 95% confidence interval (95% CI)=1.01–1.22, P=0.029]. Exposure to the price

Internal validity70% follow-up rateExternal validityPrices increased by only 8%. Smokefree legislation was weak, not well implemented and issues with compliance.Study authors report that almost half of the sample was either lost to follow-up or did not answer all questions. These respondents were younger, less addicted and had more intention to quit smoking. Therefore, our results may not be fully generalizable to the broader population of Dutch smokers.Validity of author’s conclusionSmokefree, price, mass media campaigns were not associated with reduction in prevalence of smoking.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places

Outcomes Exposure,Quit attempts,7-day point prevalence (successful quitters)

increase only predicted successful smoking cessation among young respondents.SES Exposure: Higher educated smokers were more exposed to the price increase and the smoke-free legislation.Smokers from different educational levels were reached equally by the mass media campaign.Cessation: There were no significant educational inequalities in successful smoking cessation.Author’s conclusion of SES impactThere were no overall ages or educational differences in successful smoking cessation after the implementation of the three interventions.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Parry 2000CountryEdinburgh University, ScotlandDesign Qualitative and cross-sectional sampleObjectiveTo examine the implications of a smoking ban at the universitySES variablesOccupationAnalysesQualitative data – from questionnaires and interviews – were transcribed, then thematically explored and analysed.

Data sourcesPostal survey and qualitative work was undertaken as part of an evaluation of the smoking ban commissioned by the University. It included analysis of policy documentation, a questionnaire, qualitative interviews and participant observation.Participant selectionQuestionnaire – Respondents were identified from the January 1998 salary register. Questionnaires were personally addressed to respondents and sent through the University internal mail system. Each respondent received a preaddressed envelope and instructions to return completed questionnaires via the University internal mail service. 997 people (27.8% of achieved sample) wrote comments on the blank page of the questionnaires. Qualitative interviews – a purposive sample of 30 staff members pre- and post-implementation of the policy. Participant characteristicsPostal survey: Number:= 3531,Gender: 1675M (46.6%), 1898F(52.8%), 19 Unknown (<1%) Occupation: Academic (1355), Academic related (419), Clerical / secretarial (825), Technical(469), Manual (524) Significant differences in reported smoking between the different occupational groups within the University: Academic 188 of 1765(10.7%), Clerical / secretarial 134 of 802 (16.7%), Technical 67 of 457 (14.7%), Manual 223 of 507 (44%), Missing data 61. There was a significant variation in smoking prevalence by

General population Of 151 (15.5%) indicated that they smoked during the working day prior to the ban, 51 (5.2%) smoked but not during the day and 775 (79.3%) were non-smokers. No information on smoking was available for 20 respondents.Day time smokingDo not smoke now 36 (9.1%), Smoke less 170 (43.1%), Smoke more 21 (5.3%), No change 167(42.4%)Overall pattern of smokingDo not smoke now 21 (6.5%), Smoke less 77 (23.8%), Smoke more 45 (13.9%), No change 180 (55.7%)Smoking outside workDo not smoke now 19 (5.9%), Smoke less 35 (10.9%), Smoke more 70 (21.7%), No change 198 (61.5%) Of those still smoking during the working day 35(8.2%) had reduced smoking outside work since the ban. 70(16.4%) smoked more and 198(46.5%) had not changed.Relocation of smoking2648 of 3448 (76.8%) of respondents reported an increase of smoking on University property outside buildings. 2756 of 3435 (80.29%) noted an increase in smoking specifically on entrances and steps to University buildings.Quality of airNo change, 2419 of 3529 (68.5%), Improvement1069 of 3529(30.3%), Deterioration 41 of 3529(1.2%). Data on quality of air by smoking statusnot extracted.Change in working patterns3278 (91.3%) reported no change in the amount of time spent in the main work area before the „official‟ beginning of the work day, 3226(89.8%) reported no change in working late, 3124(87.5%) no change at lunch times and 3254 (90.6%) no change during actual working

Internal validity

External validityDifferences between the University sample and national samples are discussed.Validity of author’s conclusionrestrictions on smoking in workplaces may be more effective for staff in higher occupational grades.

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gender (Males 225 of 1653 (15.4%) vs. Females 354 of 1862 (19.0%), p= 0.005). Smoking rates did not differ by age.Interviewees: included members of the University court, those involved in the process of implementation, union officials, student representatives and attendees at support and implementation classes.Intervention Workplace smoking ban: Prior to the intervention smoking at the University was guided by a voluntary code discouraging smoking in communal areas. Those with their own offices were allowed to smoke provided they kept their doors shut and those sharing offices were expected to respect the wishes of their colleagues. Reserved smoking areas were provided in some restaurant facilities and designated smoking rooms were provided at the discretion of heads of department.The smoking policy, banning smoking in University buildings and University vehicles was introduced on 1 October 1997. The smoking policy applies to all staff, students, outside contractors and visitors to the University of Edinburgh. The policy is supported by University disciplinary procedures for staff and through faculty representation for students. Three exceptions to the ban are licensed premises, some selected residential accommodation for students and University grounds (provided entrances to buildings are not obstructed). The decision to move from a voluntary code to a smoking ban was

hours. 76 (17.8%) of smokers stated that they spent less time in their work area during working hours since the ban was introduced compared to 6 (0.2%) of non-smokers. 122 (32.2%) of smokers and 14 (0.5%) of non-smokers indicated they spent less time in their main work area at lunch time since the ban. 84 (19.7%) smokers and 4(0.1%) nonsmokers claimed to spend less time at work before the official start to the day and 70 (16.7%) smokers and 8 (0.3%) non-smokers stayed late less often than before the ban. When data on respondents who used to smoke during the day but subsequent to the ban claimed to be nonsmokers were excluded the level of reported change in the amount of time spent in the main work area rose further (data not extracted).Desire to quitOf the 358 respondents (84.0%) who still smoked during the day 43 (12.0%) expressed an interest in changing smoking behaviour through the uptake of support from the University or elsewhere.Perception of rule breaking445 (15.2%) of non-smokers felt that the ban was only partially working or not working at all in personal offices. Of the non-smokers 724 (24.8%) claimed the ban was not wholly effective in corridors and foyers.Attitudes to smoking3125/3947 (89.4%) agreed it was important forthe University to have a policy on smoking.223/405 (55.1%) of those who had smoked during the day prior to the ban, 135/178 (75.8%) of those smoking outside the working day prior to the ban and 2720/2862 (95.0%) of non-smokers were in favour of a policy (chi-squared = 664.4, df=4, p<0.001). 1919/3516 (54.6%) felt that a University smoking policy should allow for

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taken by the University Court without prior consultation with staff or students. Two years' warning was given during which time the University devised a programme of publicity, education and the provision of support for smokers. No smoking classes were held during work hours and run by a smoking consultant commissioned by the University.Length of studyMarch and April 1998OutcomesRelocation of smoking (Survey)Quality of air (Survey)Change in working patterns (Survey)Desire to quit (Survey)Perception of rule breaking (Survey)Attitudes to smoking (Survey)

designated smoking areas within University buildings. There were significant differences in opinion according to smoking status Qualitative: The high visibility of smokers following the ban raised awareness about the problems faced by smokers among non-smoking staff members. Smoking bans can be divisive in pitching non-smoker against smoker at work.‟SES OCCUPATION426 of 612 (69.6%) respondents who smoked did so during the day before the ban. At six months 170 smoked less, 21 smoked more, 36 had quit and for 167 there had been no change, 32 had missing data. Across the staff groups (smoke less, smoke more, quit, no change) the proportions were as follows: Academic and related 39 (36.8%), 3 (2.8%), 17 (16.0%), 47 (44.3%); Clerical / secretarial 30(42.2%), 1 (1.4%), 6 (8.4%), 34 (47.9%); Technical 25 (51.0%), 2 (4.1%), 6 (12.2%), 16 (32.7%); Manual 76 (45.2%), 15 (8.9%), 7 (4.2%), 70 (41.7%). Significant differences were found in quit rates between academic and related staff and manual staff (16.0% vs. 4.2%) and in increase in smoking between academic and related and manual staff (2.8% vs. 8.9%). The largest response categories for academic and related and clerical / secretarial staff was 'no change' and for technical and manual staff was 'smoke less' (p values not reported).Author’s conclusion of SES impactThe University smoking policy did not impact equally upon all members of the organisation and was experienced as divisive contributing towards and sustaining social inequalities among staff.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Patel 2011CountryWellington, New ZealandDesign single-observer data collectionObjectiveto (a) refine and use methods to measure the point prevalence of smoking and of secondhand smoke exposure in moving vehicles and (b) compare these prevalence’s (1) between two areas of contrasting socioeconomic status and (2) over timeSES variablesThe two observation sites represented high and low areas of socioeconomic deprivation (small area deprivation index).AnalysesMonte Carlo simulations

Data sourcesobservationalParticipant selectionSite selection criteria included high traffic flows, low traffic speeds and good visibility of vehicle occupants (at both sites, observers were approximately only 1-2 meters distance from the passing vehicles). The average flow was 935 vehicles per hour over the observation periods.Participant characteristics149 886 vehicles, Wainuiomata NZDep deciles 7-9 (high SED) and Karori deciles 1-4 (low SED)Intervention Solo observers on the roadside observed vehicles at two sites in the Wellington region over 15 km apart by road. Observations at both sites were made during high traffic periods (7:30-9:30 and 16:00-18:00) on 20 weekdays during February to April 2011 that were not in school holidays. Two consecutive pairs of observers were used, one for 9 days and one for 11 days. Observers held a mechanical counter in one hand to count the total number of vehicles that fitted the sample frame (regardless of whether smoking was observed or not). For each vehicle with observed smoking, the observer recorded on a pre-formatted data sheet: the presence of smoking, the presence of other adults than the smoker

General population A total of 149 886 vehicles were observed in 20 days. The mean point prevalence of smoking in vehicles at both sites combined was 3.2% (95% CI 3.1% to 3.3%). Of those vehicles with smoking, 4.1% had children present.SES Smoking point prevalence in vehicles was 3.9 times higher in the area of high deprivation than in the area of low deprivation (95% CI 3.6 to 4.2). The same pattern was seen for vehicles with only the driver at 3.6 times (95% CI 3.4 to 4.0), in vehicles with other adults at 4.0 times (95% CI 3.4 to 4.7) and in vehicles with children at 10.9 times (95% CI 6.8 to 21.3), with all results adjusted for vehicle occupancy.Compared with data collected in the 2005 study at the same two observation sites, there was an absolute reduction in the point prevalence of smoking in vehicles of 1.1 percentage points (RR relative to the former 1.3, 95% CI 1.2 to 1.5). The relative reduction over time in the area of low deprivation was 1.2 times greater than in the area of high deprivation (95% CI 1.0 to 1.6). There was an absolute reduction in the point prevalence of smoking in the presence of others in vehicles between 2005 and 2011 of 0.2 percentage points (RR relative to the former 1.3, 95% CI 1.1 to 1.6). The relative reduction over time of smoking in the presence of others in the low-deprivation area was 1.3 times greater than that for the high-deprivation area (95% CI 0.8 to 2.1).Author’s conclusion of SES impactAdults and children from high deprivation areas

Internal validityInter-observer variation between observer pairs was assessed (k values were (1) 0.99 for any smoking, (2) 0.87 for other adults in vehicles with smoking and (3) 0.80 for children in vehicles with smoking). Occupants appearing to be aged 12 years or younger were classified as children; otherwise they were recorded as adults. This is a subjective judgement made by the observers.External validityCompares results with similar study with smaller sample size (16055) conducted in 2005 but the 2005 study is not referenced.Results may not be fully representative of smoking in vehicles in the Wellington region (or for elsewhere in New Zealand).Validity of author’s conclusionAs author states – point prevalence may underestimate true population prevalence of smoking in vehicle trips.Government-funded smoke-free vehicles media campaign during 2006 to 2008 and all workplace vehicles accessible by the public have been required to be smoke-free since 1990.

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and the presence of children. Observers swapped observation points every 2 days.Length of studyFebruary to April 2011Outcomesobserved point prevalence of smoking in vehicles

are much more likely to be exposed to secondhand smoke.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Plescia 2005CountryNorth Carolina, USADesign Repeat cross-sectionalObjectiveTo examine trends in official workplace smoking policies for indoor working environments in North CarolinaSES variablesOccupational statusAnalysesTrends in the state are compared with trends nationally and among select surrounding states.

Data sources40-item Tobacco Use Supplement to the Census Bureau’s Current Population Survey. The Supplement was conducted over four time periods, 1992-1993, 1995-1996, 1998-1999, 2001-2002.Participant selectionMonthly CPS sample consists of approximately 56,000 eligible housing units in 792 sampling areas. Participant characteristics10,773 15 years of age or older and (1) employed either full- or part-time at the time of interview, (2) employed outside the home but not self-employed, (3) not working outdoors or in a motor vehicle, (4) not traveling to different buildings or sites, and (5) not working in someone else’s home.Intervention Smokefree workplace policiesLength of study10 years, 1992 to 2002OutcomesSmokefree workplace coverage

General population North Carolina ranks 35th in the proportion of its workforce reporting a smoke-free place of employment. The proportion of workers reporting such a policy doubled between 1992 and 2002. Less than a third of the state’s workforce was smoke-free in 1992-1993, but by 2001-2002, slightly more than two thirds were reporting this level of protection.SES Blue-collar (55.6%, CI +/-5.5) and service workers (61.2%, CI +/-8.4), especially males, were less likely to report a smoke-free worksite than white-collar workers (73.4%, CI +/-2.6).Author’s conclusion of SES impactWhile some progress has been made in North Carolina to protect workers from secondhand smoke, significant disparities exist.

Internal validityResponse rates to the NCI Tobacco Use Supplement are between 85-89%. Multivariate analyses would have provided evidence of any independent variables associated with workplace smoking policy. Study does not account for smoking status of workers which may have confounded results.External validityTrends in the state are compared with trends nationally and among select surrounding states.Validity of author’s conclusionopportunities to protect North Carolina workers from the health effects of SHS are limited by a pre-emptive state law specific to North Carolina

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Razavi 1997CountryBelgiumDesign Repeat cross-sectionalObjectiveTo assess changes in attitudes and in policies towards smoking in Belgian companies between October 1990 and June 1993, in order to evaluate the impact due to the media inputs and to the promulgation of this decree.SES variablesOccupation; blue and white collarAnalysesChanges in the companies’ attitudes between 1990 and 1993 were analysed using the McNemar test for paired data

Data sourcesTrends Top 20,000, a dataset containing information about the economic and financial situation of the most important Belgian companies.Mailed questionnaire to 3543 Belgian companiesParticipant selectionOut of the 20,000, 3543 companies were randomly selected using stratified method.In 1990, 773 companies (22%) and in 1993, 890 companies (25%) responded to the questionnaire. A total of 325 (9%) companies responded to the 1990 and 1993 questionnaires.Participant characteristicsQuestionnaire received by personnel manager and general manager Intervention In March 1993 the Belgian Public Health Department published a Royal Decree to structure and regulate smoking habits in the workplace, in order to reduce the health risks due to passive smoking.Length of study3 years, October 1990 and June 1993Outcomesdesignation of smoke free areas (SFA); willingness to offer a worksite information program (WIP); willingness to offer a worksite smoking cessation program (WSCP); willingness to subsidize a WSCP; willingness to offer a WSCP during working hours; willingness to offer a meeting room for a WSCP and actual

General population Comparison of the 1990 and 1993 dataset regarding the influence of the antismoking campaigns on smoking policy, shows that despite the media attention and the promulgation of the Royal Decree by the Public Health Department, no major changes are observed. Apparently only restriction of smoking in the cafeteria (p = 0.0001) and in meeting room (p = 0.02) have been implemented. Moreover the organization of WSCP has been more frequently reported.The relation between companies’ turnover and the willingness to offer a WSCP which was not observed in 1990 became significant in 1993. Companies with a very high turnover reported more willing to offer a WSCP in 1993 (67% in 1993 versus 54% in 1990).SES 1990: A significant relation is observed between the blue/white collar worker ratio and its impact on company’s smoking policy. Companies employing mostly white collar workers compared with companies employing mostly blue collar workers reported being more able to offer time (p = 0.001), meeting rooms (p = 0.001) and to subsidize a WSCP (p = 0.001). Companies employing mostly blue collar workers have a stricter non-smoking policy (p = 0.003). Companies employing mostly white collar workers are willing more often to offer a WSCP (p = 0.02).1993: A significantly higher percentage of companies with a high number of white collar compared with companies with a high number of blue collar workers are reported more able to offer time (p = 0.00001), meeting rooms (p = 0.001), having already organized a WSCP (p =

Internal validityThe response rate to the questionnaire in 1990 and 1993 is related to the companies’ turnover (12% in low to 30% in high turnover) and to the blue/white collar ratio (13% in high ratio to 26% in low ratio).External validityEvaluated impact of new law only 3 months post implementation – may not be sufficient time to assess impact.Validity of author’s conclusionDifferential response rates may invalidate conclusions?

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organization of a WSCP. 0.00001), to subsidize a WSCP (p = 0.00001) and to offer a WSCP (p = 0.0002). A lower percentage of companies with a high number ofblue collar compared with companies with a high number of white collar workers tend to offer a WIP (p = 0.02).Comparison between 1990 and 1993:The difference regarding a more strict smoking policy between companies employing mostly blue collar (12% total non smoking policy) and companies employing mostly white collar (2% total non smoking policy) which was significant in 1990 has disappeared in 1993 (7% in a ‘mostly blue collar’ company versus 4% in a ‘mostly white collar’ company (Table 2). In 1993 companies with mostly white collar employees reported being more likely to have already organized a WSCP compared with 1990.Author’s conclusion of SES impactSmall companies and companies with a high blue/white collar ratio were less able to implement health policy recommendations.There was a tendency towards a recommended smoking policy in companies with a low blue/white collar ratio.

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Smoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Ritchie 2010aRitchie 2010bCountry4 localities in ScotlandDesign qualitative longitudinal case studies using semi-structured interviews in 2 socioeconomically advantaged and 2 disadvantaged localities at three time points, one pre-legislation and two post legislation.Objectiveto explore whether and in what ways the smoke-free legislation affected smokers’ experience of stigmaSES variablesrange of indices, including SES and smoking rates among adults and during pregnancyAnalysesthematic analysis of narrative accounts

Data sourcesInterviews in four contrasting locales between October 2005 and March 2007, and observational data recorded in public places.Participant selectionFour areas selected to provide both urban and rural, affluent and deprived communities.Purposively sampled panel recruited within the localities by trained interviewers using a variety of methods including door knocking, opportunistic street recruitment, and visiting community venues. Predefined quotas were used, based on three primary criteria (smoking status, age, and gender) and three secondary criteria (children younger than12 years in the household, use of licensed premises, and employment outside the home).Participant characteristics20 male and 20 female current and recent ex-smokers (quit in the previous 12 months) aged 18 years and older.Urban Disadv (D1) Mostly social grade E, Adult smoking rate 50.7%Suburban Adv (A1) 48.1% A-B, 18.8% Semi-rural Disadv (D2) 23% E, 38%Semi-rural Adv (A2) 30.5% AB, 21%Intervention National smokefree legislation in Scotland. Smoking was banned in enclosed public places, including pubs and restaurants in Scotland in March 2006.The interviews used topic guides that

General population Pre-legislation there are more outdoor facilities for smokers and a lower rate of smoking in pubs, some already smokefree. Disadvantaged communities less supportive of the ban, some hoped that it would help them quit.Smokers perceived the smoke-free legislation to have increased the stigmatization of smoking. By separating, albeit temporarily, those who were smoking from those who were not had led to increased felt stigma. This had led to a social milieu that fostered self-labeling and self-stigmatization by smokers of their own smoking behaviour, even when they were not smoking. While there was little reported direct discrimination, there was a loss of social status in public places. Smokers attempted to ameliorate stigmatization by not smoking outside, reducing going out socially, joining in the stigmatization of other smokers, and/or acknowledging the benefits of smokefree environments.SES Smokers in disadvantaged areas say they abide by the law to support the licensee, and rush cigarettes because they’re worried about their drink. Also may visit public places less because of the ban.Smokers in advantaged areas say that they smoke less, or quicker, because going outside interrupts social activity, and because of concerns over the stigma of being seen smoking.While some described how they were able to re-create convivial social groups in the new smoking places, for example, where there was comfortable and sheltered provision, others

Internal validity88% follow-up rateExternal validityRecruited interviewees to fill quota, unlikely to be representative of the community as a whole.No indication of whether the localities are typical of each urbanisation/affluence category.Validity of author’s conclusionAppears to have been a more substantial change in deprived areas, because the advantaged areas already had reasonably comfortable accommodation for smokers outside, and opinion changed from being opposed to the ban to accepting it and following it.

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explored participants’ smoking behaviour and/or exposure within the context of their daily lives; their beliefs and understandings of second hand smoke; regulation of smoking within the home; awareness, understandings, and attitudes toward the legislation; and any changes in smoking patterns and consumption. Participants described their smoking behaviour in a typical 24-hr period using an adapted version of the “life grid,” which annotated the number of cigarettes smoked over the course of a day in terms of when, where, and in what social context smoking occurred. All interviews were recorded and transcribed. Participants received £15 for each interview.Length of studyMaximum 15 monthsOutcomesChanges in smoking behaviour and changes in physical spaces

particularly in disadvantaged communities described limited or no outside provision for smokers. Thus, the sense of separation was compounded by a loss of comfort, particularly in poor weather with an implicit and real loss of status compared with their prelegislation position.Author’s conclusion of SES impactBehavioural changes in localities were shaped by environmental constraints as well as the social context.There are unintended negative consequences of smokefree legislation for some which suggest that tobacco control strategies need to consider how smokers who experience increased stigmaare supported by public health to address their smoking while continuing to create smoke-free environments.

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Details Method Result CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Schaap, 2008 Country18 European countries; Finland, Sweden, Denmark, England, Ireland, Netherlands, Belgium, Germany, France, Italy, Spain, Portugal, Slovakia, Hungary, Czech Rep., Lithuania, Latvia, EstoniaDesignCross-sectionalObjectiveTo examine the extent to which tobacco control policies are correlated with smoking cessation, especially among lower education groupsSES variables Education; relative index of inequality (RII). The RII assesses the association between quit ratios and the relative position of each educational group, can be interpreted as the risk of being a former smoker at the very top of the educational hierarchy compared to the very lowest end of the educational hierarchyAnalysesLog-linear regression analyses to explore the correlation between national quit ratios and the national score on the Tobacco Control Scale (TCS).

Data sourcesNational health surveys. 100,893 respondents over 18 countries.Participant selectionSelection process varies. Non-response rate between 13.4 and 49% depending on country. Participant characteristicsIreland has most developed tobacco control policy, Latvia least. Intervention Joosens and Raw’s tobacco control scale used as a proxy, with some analysis by individual policies including:Price, advertising bans, public place bans, campaign spending, health warningsLength of studyYear 2000, except Germany and Portugal = year 1998-9.Outcomes Quit ratios

General population Large variations in quit rate and RII between countries.Quit rates positively associated with tobacco control scale score. Policies related to cigarette price showed the strongest association with quit ratios. A comprehensive advertising ban showed the next strongest associations with quit ratios in most subgroups. Health warnings negatively associated with quit rates. Regression coefficient 2.08 (-0.36 to 8.48) for men and 2.07 (-1.09 to 8.66) for women for price.Regression coefficient 1.33 (1.11 to 8.02) for men and 1.59 (1.39 to 8.67) for women for advertising bans.Regression coefficient 0.94 (-2.43 to 5.89) for men and 0.41 (-3.84 to 5.26) for women for public place bans.Regression coefficient 0.54 (-3.05 to 6.17) for men and 0.54 (-3.52 to 6.41) for women for campaign spending.Regression coefficient -0.40 (-7.32 to 2.31) for men and -0.42 (-9.51 to 3.43) for women for health warnings.A ‘stripped’ analysis focusing on price, health warnings and treatment (excluding recent policy developments) supported the main findings.SES Quit rates positively associated with tobacco control scale score. More educated smokers more likely to have quit than lower educated, for men and women. Larger absolute difference between high and low educated for 25-39 year olds. However no consistent differences were found between quit

Internal validityNon-response percentages ranged from about 15% in Italy and Spain up to 49% in Slovakia, while percentages in most other countries were between 20% and 35%.Survey conducted before tobacco control scale devised, and before some policies enacted so may underestimate the impact of recent policies.Difficult to draw conclusions about causality as study only examines the association between ex-smokers and presence of policies, rather than changes in prevalence post-implementation.Occasional smokers excluded from all analyses.External validityIncluded data from Eastern Europe and Baltic countries. Limited analyses to the adult population aged 25–59 years.Difficulty in drawing conclusions from multiple nations with varying average standards of education, definition of ‘highly educated’ likely to vary for some nations. Validity of author’s conclusionConclusion is consistent with the data presented; however it’s difficult to draw strong conclusions about the impact of any one intervention given the methodological limitations discussed above.

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ratios in high and low educated groups and tobacco control scale score.Policies related to cigarette price showed the strongest association with quit ratios. Significant positive association between quit ratio and price for high SES aged 40-59 years.A comprehensive advertising ban showed the next strongest associations with quit ratios in most subgroups (not low SES aged 40-59 or low SES women aged 25-39 years. Health warnings negatively associated with quit rates. Author’s conclusion of SES impactHigh and low educated groups seem to benefit equally from nationwide tobacco control policies. More developed tobacco control policies are associated with higher quit rates.

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Details Method Results Comments

Smoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Semple 2010CountryScotland, England, WalesDesign Before and after studyObjectiveTo evaluate the effect of smokefree legislation on air pollution levels in barsSES variablesPostcode data of bar location – area level deprivation scoresAnalysesRegression analysis of PM2.5 concentrations measured discreetly for at least 30 minutes in >300 bars

Data sourcesRandom selection of bars using a database of bars generated from online business directories from selected regions and urban areas in each country.Participant selectionn/aParticipant characteristicsn/aIntervention Discreet sampling of air quality in bars by researchers and also 26 personal exposure shift samples for non-smoking bar workers from Scotland and England recruited to wear TSI SidePak AM510 Personal Aerosol MonitorsLength of studyUp to 12 months post implementation Outcomesparticulate matter <2.5 mm in diameter (PM2.5)

General population PM2.5 levels prior to smoke-free legislation were highest in Scotland (median 197µg m-3), followed by Wales (median 184 µg m-3) and England (median 92 µg m-3). All three countries experienced a substantial reduction in PM2.5 concentrations following the introduction of the legislation with the median reduction ranging from 84 to 93%. Personal exposure reductions were also within this range.SES Bars located in more deprived postcodes had higher PM2.5 levels prior to the legislation. Linear trend in the change in PM2.5 by deprivation category, which suggests more deprived areas experienced greater percentage reduction in PM2.5 levels up to 12 months post-implementation when compared to more affluent areas, although higher levels of PM2.5 at baseline for more deprived areas.Author’s conclusion of SES impactLegislation in all three countries produced improvements in indoor air quality.

Internal validityVariation in number, location and timing of visits to bars across the three projects.External validitycommon protocol for air sampling across studies and large data set.Validity of author’s conclusionThe amount of variability in the percentage reduction in PM2.5 concentrations that was explained by deprivation category was low this could either be due to the SES measure used or SES had no significant influence on legislative changes.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Shavers 2006CountryUSADesign Repeat cross-sectionalObjectiveTo examine the association between workplace smoking policies and home smoking restrictions with current smoking among womenSES variablesPoverty level: at or below the poverty line, 100-124% of the poverty level, 125-149% of the poverty level, 150% or more above the poverty level.AnalysesMultivariate logistic regression

Data sourcesTobacco Use Supplement to the Current Population Survey supplementsParticipant selectionResponse rate approx. 80%, multistage probability sampling design. Employed women aged 18-64, based on nationally representative survey data. Proxy respondents and respondents missing smoking-related survey data excluded.Participant characteristicsN=82966, Majority white, education and income vary significantly by ethnicity. African Americans, American Indians/Alaskans, and Hispanics all significantly more likely to live in poverty (16.8-19.6%), 7.1% overall. White females most likely to be smokers (22.7%). Intervention Workplace and home smoking policiesLength of study1998-9 and 2000-1OutcomesPolicy coverage/restrictions,Quit attemptsWorkplace:Not permitted in any area, permitted in common areas only, permitted in work area only, permitted in all areas, no policy, other.Home: Not permitted anywhere, permitted in some places/times, permitted anywhere at any time.

General population Almost 66% prohibit smoking anywhere in the home. 11.1% report no workplace smoking policy.Current smoking and heavy smoking (20+ cigarettes per day) significantly associated with permitting smoking anywhere in the home for all poverty levels.Lower adjusted odds ratio for quit attempts among those who permit smoking anywhere in the home for all poverty level categories except for women who were 125%–149% of the poverty level. In contrast, workplace smoking policies were not associated with a quit attempt in the past year for any of the poverty level categories.SES Workplace policies are associated with distance from the poverty level, 61.5% below the poverty level are covered by full workplace restrictions, compared to 76.6% of those 150%+ above the poverty level. 19.1% of those below the poverty level have no workplace smoking policy, compared to just 10% of the 150%+ group.Home smoking policies show the same trend: 56.3% of people below the poverty line don’t permit smoking anywhere, and 21.3% allow smoking anywhere; compared to 67.3% and 14.8% of the most advantaged group. Author’s conclusion of SES impactVariance in exposure to ETS among employed women; those further from the poverty line more likely to be covered by restrictions on smoking in the workplace and home. Home smoking policies were more consistently associated with a lower prevalence of current smoking irrespective of poverty status or race/ethnicity

Internal validityCross-sectional data, unable to infer any causal relationship.External validityWorking women only.Validity of author’s conclusionValid

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places

than workplace policies.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Shopland 2004CountryUSADesign Repeat cross-sectionalObjectiveTo examine recent trends in smoke-free workplace policies among the major occupational groups in the United States with a particular focus on the 6.6 million workers employed in the food preparation and service occupations.SES variablesOccupational class; white collar, blue collar, service workers.AnalysesStandard errors, which were used in computing the 95% confidence intervals (CI), were produced using the CPS design effect adjustments developed by the Bureau of the Census.

Data sourcesCensus Bureau’s Current Population Survey Tobacco Use Supplement September 1992, January 1993, and May1993 and repeated the same months in 1995–1996 and 1998–1999.Participant selectionThe monthly CPS sample consists of approximately 56,000 eligible housing units in 792 sampling areas. Response rates to the CPS labor force core questionnaire are approximately 95% and 84% to 89% for the NCI Supplements.Participant characteristics254,059 indoor workers employed in 38 major occupations. Individuals must have been 18 years of age or older and 1) employed either full- or part-time at the time of the interview, 2) employed outside the home but not self-employed, 3) not working outdoors or in a motor vehicle, 4) not traveling to different buildings or sites, and 5) not working in someone else’s home.Intervention smoke-free workplace policiesLength of study6 years; 1993 to 1999OutcomesPolicy coveragePrevalence

General population Among all workers, the proportion reporting a smoke-free policy increased 37% between 1993 and 1996 but less than 9% from 1996 to 1999, suggesting a significant slowing in the adoption rate of such policies. This trend was evident for each of the 3 major occupational groups.SES Blue collar and service workers showed the largest percentage gains in smoke-free policy coverage between 1993 and 1999 but continuedto lag significantly behind their white collar counterparts with barely a majority reporting a smoke-free workplace policy in 1999 compared with more than three fourths of white collar workers.Trends in Smoke-Free Workplace Policy Coverage Among Indoor U.S. Workers, by Type of Worker andPercent Increase in Coverage Between 1993 and 1999:All U.S. workers 46.5 (+/-0.4) 1993; 63.7 (+/-0.5) 1996; 69.3 (+/-0.4) 1999; 49% increaseWhite collar workers 54.1 (+/-0.5) 1993; 71.7 (+/-0.5) 1996; 76.3 (+/-0.4) 1999; 41% increaseBlue collar workers 28.3 (+/-1.0) 1993; 45.4 (+/-1.1) 1996; 52.2 (+/-1.0) 1999; 84% increaseService workers 35.5 (+/-1.1) 1993; 51.5 (+/-1.2) 1996; 57.5 (+/-1.2) 1999; 62% increase

Food service workers reportedsmoking prevalence rates that arealmost double those of white collarworkers and these rates did notchange over the 6-year time period,1993 to 1999. In contrast, smokingprevalence declined by 8.2% amongwhite collar workers and by nearly

Internal validityFew details of analysis of data.External validityLarge nationally representative dataset.Validity of author’s conclusionValid but doesn’t take into account smoking status of participants?

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places

10% among all workersTrends in Smoking prevalence among various occupational groups of indoor workers andPercent change in prevalence Between 1993 and 1999:Non-food service White collar workers 20.5 (+/-0.4) 1993; 19.5 (+/-0.4) 1996; 18.8 (+/-0.4) 1999; -8.2% Non-food service Blue collar workers 34.7 (+/-1.0) 1993; 32.7 (+/-0.8) 1996; 31.5 (+/-0.9) 1999; -9.2% Non-food service Service workers 32.9 (+/-1.2) 1993; 32.0 (+/-1.1) 1996; 30.4 (+/-1.0) 1999; -7.5% Author’s conclusion of SES impactProtection for workers is increasing, but those in food preparation and service occupations are significantly less protected than others.

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Smoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Sims 2012CountryEnglandDesign Repeat cross-sectionalObjectiveTo examine trends in and predictors of SHS exposure among non-smoking adults to determine whether exposure changed after the introduction of smokefree legislation and whether these changes varied by SES and by household smoking status.SES variablesSocial class householdsAnalysesMultivariate regression

Data sourcessalivary cotinine data from the Health Survey for England that were collectedin 7 of 11 annual surveys; Participant selectionData collection involves an interviewer visit, in which all adults ≥ 16 years of age and up to two children in each household are eligible to be interviewed, followed by a nurse visit.Participant characteristicsNon-smoking adultsIntervention 1 July 2007, smokefree legislation was implemented in England, which made virtually all enclosed public places and workplaces smokefree.Length of study11 years; 1998 to 2008OutcomesSHS exposure

General population Secondhand smoke exposure was higher among those exposed at home and among lower-SES groups. Exposure declined markedly from 1998 to 2008 (the proportion of participants with undetectable cotinine was 2.9 times higher in the last 6 months of 2008 compared with the first 6 months of 1998 and geometric mean cotinine declined by 80%). We observed a significant fall in exposure after legislation was introduced—the odds of having undetectable cotinine were 1.5 times higher [95% confidence interval (CI): 1.3, 1.8] and geometric mean cotinine fell by 27% (95% CI:17%, 36%) after adjusting for the prelegislative trend and potential confounders.SES Determinants of secondhand smoke exposurethe odds of having undetectable cotinine decreased with declining SES status with the lowest levels in social class IV and V [29% lower than social class I and II, 95% confidence interval (CI): 21, 35] and in adults with no qualifications (19% lower than those with a higher education qualification, 95% CI: 11, 26).Variation in the estimated impact of thesmokefree legislation by social classSignificant impacts were observed only among those from social classes I to III. The odds of having undetectable cotinine were 1.8 (95% CI:1.4, 2.3) times higher among those in social classes I and II and 1.5 (95% CI: 1.1, 1.9) times higher among those in social classes III after the legislation, whereas geometric mean cotinine levels fell by 37% (95% CI: 24%, 48%) and 23% (95% CI: 6%, 37%) respectively. By contrast, no significant impact was seen in social classes IV

Internal validityImpact adjusted for the prelegislative downward trend in exposure observed between 1998 and 2008 however no cotinine data from 2004 to 2006.External validitySurvey includes only individuals living in private households in England.lower levels of prelegislative exposure compared with ScotlandValidity of author’s conclusionValid – large representative sample using biomarker to validate.

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and V when measured using either the OR of undetectable cotinine [0.38 (95% CI: 0.12, 1.2) and 1.00 (95% CI: 0.64,1.6) respectively], or multiplicative change in geometric cotinine [1.5 (95% CI: 0.89, 2.5) and 1.0 (95% CI: 0.7, 1.4) respectively].Author’s conclusion of SES impactNon-smokers from lower social classes appear not to have benefitted significantly from the legislation.

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Details Method Results Comments

Smoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Skeer 2004CountryMassachusetts, USADesign Cross-sectionalObjectiveTo identify and quantify differences in sociodemographic characteristics of communities relative to the strength of local restaurant smoking regulationsSES variablesTown-level SESAnalysesMultinomial logistic regression

Data sourcesDatabase of restaurant smoking regulations by town maintained by Massachusetts Tobacco Control Progam (MTCP)Participant selectionn/aParticipant characteristics351 local restaurant smoking regulations in MassachusettsIntervention 3 measures of strength of ordinances: strong=smokefree, medium=separate ventilated areas for smoking, weak=designated smoking areas or no restrictionsLength of studyOne time-point; June 2002OutcomesTown-level policy coverage

General population Towns with board of health funding by the MTCP were nearly 5 times more likely to adopt strong regulations and more than 11 times more likely to adopt medium regulations.SES Bivariate: local smokefree restaurant regulations were significantly more likely to be adopted by towns with a higher proportion of college graduates, a higher per capita income. Strength of regulation was not significantly related to household income or poverty level.Multivariate: education and per capita income became insignificant (authors state may be explained by other significant measure which was agreeing with the 1992 ballot to create the MTCP which was highly correlated with both education (r=0.90) and per capita income (r=0.74).Author’s conclusion of SES impactEducation and income were significantly related to the strength of protection from ETS exposure in restaurants. Current policy of smokefree enactment is fostering disparities in health protection.

Internal validityeducation and per capita income became insignificant in multivariate analysisExternal validity‘Free standing bars’ not included as defined as separate establishments by the regulations. Town-level SES may not translate to individual-level SES.Validity of author’s conclusionStudy addresses a theoretical level of protection from SHS exposure provided by regulations rather than actual level of protection but presence of regulation should correlate with reduced exposure.

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Stamatakis 2002CountryUSADesign Cross-sectionalObjectiveTo assess differences in the likelihood of exposure to ETS at home and at work among an ethnically diverse sample of women age 40 and older in the United States.SES variableseducationAnalysesunadjusted OR and adjusted (aOR) for exposure to ETS at home and at work, where each risk factor was adjusted for all sociodemographic variables (race, age, education, location, and having children in the home) using logistic regression.

Data sourcesU.S. Women’s Determinants StudyParticipant selectionPhone numbers were selected from zip codes with more than 20% of one of the following groups: African American, American Indian/Alaska Native, Asian American/Pacific Islander, and Hispanic. Only women of these racial/ethnic backgrounds who lived in selected zip codes and met the criterion of being 40 years or older were surveyed. Proportional-to size sampling was conducted to ensure that the sample had a proportionality similar to that of the total population.White women of the same age group were surveyed using standard BRFSS random-digit dialing techniques.Participant characteristicsnon-smoking (defined as former and never smokers) women (n=2326). The analysis of ETS exposure and smoking restrictions at work was further restricted to include only employed women, resulting in a sample size of 1100.The proportion of women in the lowest education group, having achieved only an eighth grade or less education, was 13.2%, and nearly 40% of the respondents had an annual income of $20,000 or less. A majority of the respondents were married (58.7%), lived in nonrural areas (60.6%), and had no children living in the home (66.6%).Intervention Workplace smoking policy

General population Among employed women, 19.2% were exposed to ETS at work, and 22% were employed at worksites that allowed smoking in some or all work areas. Exposure to ETS at work substantially higher for women who worked where smoking was allowed in some (adjusted OR 15.1, 95% CI 10.2, 22.4) or all (adjusted OR 44.8, 95% CI 19.6, 102.4) work areas.SES Exposure to ETS at work was higher among women with some high school education (adjusted OR 2.8, 95% CI 1.5, 5.3) and high school graduates (adjusted OR 3.1, 95% CI 1.9, 5.1) and marginally so for those with some college (aOR 1.5, 95% CI 0.9, 2.5).An eighth grade or less education level was associated with about twice the risk of home ETS exposure (aOR 2.1, 95% CI 1.3, 3.6), as was having a high school education (aOR 2.2, 95% CI 1.4, 3.3) compared with college graduates.Author’s conclusion of SES impactAmong individual risk factors, lower education level was most strongly related to ETS exposure at work.

Internal validityAsian/Pacific Islanders were not included in the final sample because of a prohibitively low response rate in this group.Income was excluded from the final model due to the high proportion of missing cases (16.7%) and its collinearity with educational level.results of the test-retest study indicated that overall reliability was very good for exposure to ETS at work (kappa = 0.82)External validityExcluded women without a telephone at home – these women could have been more exposed to ETSValidity of author’s conclusion

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Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places

Length of study1996 to 1997Outcomesexposure to ETS

290

Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor, year Tang 2003 CountryCalifornia, USADesign Repeat cross-sectionalObjectiveTo examine patron responses to a California smoke-free bar lawSES variablesEducation, incomeAnalysesBivariate and multivariate logistic regression

Data sources3 cross-sectional telephone surveys. Survey 1: March 1998, 3 months post implementation of law; Survey 2: August 1998, 8 months post intervention; Survey 3: June 2000 2.5yrs post intervention.Participant selectionRandom-digit dialling, each household identified a respondent aged 21 or older. The first eligible respondent who had visited a bar at least once in the past year was asked for an interview.Participant characteristicsSample size: Survey 1 – 1001; 2: 1020; 3: 1000. Intervention On 1 January 1998 – law came into effect banning smoking in “practically all bars”. In 1998 California Tobacco Control program launched campaign to introduce new law, focused on changing social norms regarding tobacco use through media and other educational efforts.Length of study2.5 years; March 1998 to June 2000OutcomesApproval of the law Likelihood of visiting a bar compliance with the law

General population Approval of the law rose from 59.8% to 73.2% (odds ratio [0R] = 1.95; 95% confidence interval [Cl] = 1.58. 2.40). Self-reported noncompliance decreased from 24.6% to 14.0% (OR = 0.50; 95% Cl = 0.30, 0.85). Likelihood of visiting a bar or of not changing bar patronage after the law was implemented increased from 86% to 91% (OR = 1.76: 95% Cl = 1.29, 2.40).SES Approval of the lawAll results are reported as OR (95% CI); *p<0.05;**p<0.01; ***p<0.001;Respondents who approved of the law were more likely to be more highly educated.Educational level: ≥ college graduate 1.34 (1.11 to 1.62)** compared to ≤High school;Household income $: ≥60,001 1.22 (1.00 to 1.47)* compared to ≤20,000;More likely or no difference of bar visitingPatrons with higher income, educational attainment (data not reported) tended to report they were “more likely” to visit bars or to report “no change” in their patronage.Education – OR not reportedIncome: ≥$60,001 1.37 (1.04 to 1.81)* compared to ≤20,000;Perceived non-compliance with the lawPatrons with an income =/>60,000, or visiting restaurant/hotel bar were less likely to perceive non-compliance.Income: ≥$60,001 0.77 (0.63 to 0.95)* compared to ≤20,000;Author’s conclusion of SES impactNo conclusion reported by SES not

Internal validityResponse rates for each wave were 28% (March 1998), 32% (August 1998), and 30% (June 2000).Education level was the only statistically significant demographic variable across the different surveys. In the third survey (June 2000), the percentage of respondents reporting both lowest and highest education levels rose slightly, compared with the first and second surveys (25.7%, 22.5%, 22.4%, respectively, for lowest level; 41.9%, 39.2%. 39.5%, respectively, for highest level).External validityIn 1994 California legislature passed a Bill banning smoking in “virtually” all indoor workplaces. Because of their willingness to complete the survey, the respondents selected may be inclined to support the law.Validity of author’s conclusion

291

Details Method Results CommentsSmoking restrictions in cars, homes, workplaces and enclosed public places Details Method Result CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor , year Tong, 2009CountryCalifornia, USADesigncross-sectional ObjectiveTo compare how adoption and enforcement of smokefree policies differed for Asian-American women by educational statusSES variables EducationAnalysesMultivariate logistic regression

Data sourcesCalifornia Tobacco Use Surveys for Chinese and Korean Americans (CCATUS and KCATUS)Participant selection18+years, Chinese or Korean or Mixed ethnicity, matched and weighted to the 2000 census characteristics for Chinese and Korean populations.Response rates: 52% Chinese 48% Korean=879 for Chinese, 1023 Korean.Participant characteristicsLow education = 795, high 1082.High education mostly 25-44 year olds.Mostly low income – 59.4% less than $30k. InterventionLinguistically and culturally-adapted version of California’s smoke-free social norm campaign, established in 1988.Length of studyData from 2003 survey, analyses conducted in 2008Outcomes Smokefree policy adoption and enforcement.Self-report exposure (none, <=30mins, 30-120mins, >120mins per week)

General populationLower-educated and higher-educated women had similar proportions of smoke-free policies at home (58%) or indoor work (90%).SES Lower education women as likely as higher educated to report a smoke-free house, and to have equivalent knowledge about the health impacts of second hand smoke. However more likely to have been exposed at home, and not to be in control of home smoking regulations.Also more likely to be exposed at work. Lower-educated women were more likely than higher-educated women to report anyone ever smoking at home (OR=1.62, 95% CI=1.06, 2.48, p=0.03) and exposure during the past 2 weeks at an indoor workplace (OR=2.43, 95% CI= 1.30, 4.55, p=0.005), even after controlling for ethnicity, smoke-free policy, knowledge about the health consequences of secondhand smoke exposure, and acculturation. Author’s conclusion of SES impactDespite similar rates of knowledge and adoption low educated Asian-American women suffer higher exposure to secondhand smoke in the home. Similar rates of smokefree policies at work and at home but disparity in enforcement by educational status with lower educated Asian-American women reporting greater SHS exposure.

Internal validityHard to capture knowledge of SHS based on a Likert scale.Self-report exposure data.External validityCould be difficult to translate and adapt policy to different ethnic sub-groups and expensive in areas with less dense minority ethnic populations.Research was built upon a 15 year old policy, so effectiveness is difficult to isolate.Response rate lowValidity of author’s conclusionValid

292

Details Method Result CommentsSmoking restrictions in cars, homes, workplaces and enclosed public placesAuthor , year Verdonk-Kleinjan, 2009 CountryThe NetherlandsDesignRepeat cross-sectional ObjectiveTo examine whether a workplace smoking ban reduced exposure and inequalitiesSES variablesEducationAnalysesLogistic regression

Data sourcesContinuous Survey of Smoking Habits (CSSH) Dutch internet survey. Sample weighted to be nationally representative. 200 respondents selected randomly each week. Any positive response coded as exposed.Participant selection11,291 non-smoking, working (15+ hours/week) respondents between 16-65 years old.Participant characteristics56% male, mostly 30-49 years, 84% non-Government employees, 63.9% working 35+ hours per week. 39.2% middle education, 34.3% high.InterventionWorkplace smoking ban in the Netherlands 2004; full ban of smoking in workplaces except bars, cafes and restaurants, designated smoking rooms allowed.Length of studyJuly 2003 to July 2005Outcomes Exposure to ETS among non-smokers

General population ETS exposure decreased among all employees and subgroups that were at higher risk before the ban (male and low-educated). 52.2% still reported being exposed post-legislation.SES Lower-educated workers twice as likely to be exposed as those with higher level of education. % exposed, before + after.Low: 79.7% - 61.5%Mid: 71.0% - 53.6%High: 63.5% - 41.7%Sig diff @ p<0.001 both for differences between subgroups and the decrease since intervention.OR between low and middle, pre and post-legislation: 1.61 (1.23-2.10); 1.21 (1.16-1.47) OR Low v high educated: 2.29 (1.74-3.01; 2.17 (1.91-2.45)Author’s conclusion of SES impactBan has not abolished inequalities in exposure. Both before and after implementation of the ban, males and lower educated employees were about two times more likely to be exposed to ETS.

Internal validityDichotomising responses could be over-stating exposure (‘sometimes’ could be almost insignificant). Could be including exposure while entering/leaving the building as exposure.Brief period of data collection pre-ban, offered less seasonal variability.External validityEducation a difficult measure of SES to compare across generations and internationally, more so here as no definition is provided for ‘low, middle, high’.Internet sample may not be representativeValidity of author’s conclusionAccurate, least educated still significantly more exposed than middle or high educated groups.

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Details Method Results Comments

Increases in price/tax of tobacco productsAuthor, year Azagba & Sharaf 2011CountryCanadaDesign Longitudinal cohort data - econometricObjectiveTo examine the impact of cigarette taxes on smoking participationSES variablesHousehold income, educationAnalysesHistorical tax data are obtained from the respective provincial tax offices. The tax rates are matched with each respondent‘s province of residence and date of interview available in the NPHS. To obtain the real cigarette tax per carton, both the federal and provincial consumer price index obtained from CANSIM are used to deflate each of the nominal tax components .The sum of the deflated taxes is the real exercise tax in 2000 dollars.

Data sourcesCanadian National Population Health Survey and tax dataParticipant selectionNo detailsParticipant characteristicsAged 12 to 65 years, >50,000 for income and education subgroupsIntervention Cigarette tax increasesLength of study1998/9 to 2008/9 (cycles 3 to 8), follow-up every 2 yearsOutcomesSmoking prevalence, tax elasticity

General population The decreased proportion of Canadian smokers is larger for most of the selected groups between the years 2000 and 2002 and average real cigarette tax went up during this period.The tax elasticity estimate for the whole population is −0.227. This result implies that if there is a 10% increase in taxes then smoking participation will fall by about 2.3%. SES The higher and middle income groups are less likely to be smokers than the low income group. Individuals with post-secondary education are less likely to smoke than those with less than secondary education.While the participation tax elasticity of the high income group (−0.202) is larger than the low income group (−0.183), it is not statistically significant.The low education group are more tax sensitive than the high educated group. Tax elasticities by education level are: less secondary (−0.555), secondary (−0.218), some post-secondary (−0.018) and post-secondary (−0.042).Author’s conclusion of SES impactEvidence of a heterogeneous response to cigarette taxes among different groups of smokers. The differential response of low income/education smokers versus high income/education smokers raises the debate about the distributional impact of such taxes.

Internal validityDue to the small sample size of the low income group, income was grouped into two categories: low income category = low/middle income household and high income group = high income household.Education levels split in two categories and also into four categories.External validityThe survey excludes those living on Indian Reserves and Crown Lands, full-time members of the Canadian Forces Bases and some remote areas of Ontario and Quebec.Average real taxes varied by province but this is accounted for in the analyses.Graphic pictorial warning labels were introduced during period 2000 to 2002.Validity of author’s conclusionPictorial warning labels may have influenced smokers as well as increases in cigarette tax.

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Details Method Results Comments

Increases in price/tax of tobacco productsAuthor, year Biener 1998 CountryMassachusetts, USADesign Cross-sectional study ObjectiveTo examine smokers perceptions of the impact of new tobacco taxes.SES variableshousehold incomeAnalysesMultinomial logistic regression using bivariate and multivariate models

Data sourcesTelephone interviews (retrospective survey)Participant selectionrandom-digit-dialling on the basis of household enumeration; response rate=78%Participant characteristicsN=4733 adults, 1657 current adult smokers and 126 posttax quittersIntervention 1993 tobacco excise tax increase of 25 cents per cigarette pack (=15% increase) on January 1st 1993.Length of studyOctober 1993 to March 1994OutcomesSmoking behaviour; respondents were assigned to one of three mutually exclusive categories: (1) did not respond to taxes (2) cut costs by reducing number smoked or changed to cheaper brand (3) considered quitting

General population 35% considered quitting, 28% changed to cheaper brand, 17% reduced number smoked.8% of adult who had been smokers before tax increase reported quitting after price increase. On a 4-point rating scale, 56% of these quitters said that price increase had no effect at all on their decision to quit and 44% said it had at least some effect.SES Among adult smokers those with lower incomes were 3 times as likely as those with higher incomes to report cutting costs of smoking and twice as likely to consider quitting as opposed to having no response to the price increase (significant in both bivariate and multivariate models). Household income was not related to choice between cutting costs and considering quitting.The only individual predictor that reached significance was income in terms of impact on quitting; the lower the household income, the greater the impact of the price increase on the respondent’s decision to quit. Author’s conclusion of SES impactLower income smokers are significantly more likely than higher income smokers to respond to an increase in cigarette prices. Low income adults were more likely to cut costs or consider quitting rather than not react to a price increase.

Internal validity46% continuing smokers denied having any of the 3 potential reactions to the price increase.External validityNo further details of sample demographics compared to general population; limits generalisabilityValidity of author’s conclusionPossible that study failed to measure an important variable.

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Details Method Results Comments

Increases in price/tax of tobacco productsAuthor, year Bush 2012Country16 states including Alaska, Connecticut, Georgia, Hawaii, Indiana, Maine, Maryland, Missouri, North Carolina, Oklahoma, Oregon, South Carolina, Utah, Virginia, Washington and Wisconsin, USADesign Repeat cross-sectional (before and after) plus 7-month follow-up of random sampleObjectiveto (1) describe call volumes to 16 statequitlines before and after the tax increase; (2) examine the characteristics of tobacco users who enrolled with quitlines before and after the tax increase and (3) examine the outcomes (quit rates) of tobacco users who enrolled with state quitlines before and after the tax increase.SES variablesEducation levelAnalysesChi-square and t-test statistics to compare characteristics of callers during 2009 tax increase and for the same months in the prior year and included state as fixed variable to account for the variability in services provided across quitlines.For the four states with data from the seven-month follow-up, multivariate logistic regression analyses were used.

Data sourcesAdministrative data from the Free & Clear database for 16 of 17 state tobacco quitlines. Seven-month follow up from four state quitlines based on random samples of quitline participants. Participant selectionRandom sampleParticipant characteristicsN= 29,674 (before tax increase) and 50,254 after tax increase, mean age 41, 59% femaleIntervention April 1, 2009, federal cigarette excise tax increase from 39 cents to $1.01 per pack. Tobacco control varied between states but all quitlines provided mailed support materials, a single reactive (inbound) counselling call to all tobacco users, and three or four additional outbound calls to select groups. Some state quitlines refer insured tobacco users to cessation benefits offered through their health plan or employer. All but four states offered at least some free NRT depending on the state-approved eligibility criteria.Length of studyMarch-May 2008 and March-May 2009 OutcomesMonthly call volume,Daily call volume,Seven day point prevalence,30-day point prevalence

General population Overall, there was a 23.5% increase in total call volume when comparing December 2007–May 2008 (84,541 calls) to December 2008–May 2009 (104,452 calls). The tax effect on call volumes had returned to the before tax levels in May. Tobacco users who enrolled with the quitline before and after the announcement and implementation of the April 2009 federal tax increase: age of callers was slightly younger (41.9 versus 41.2), fewer callers were aged 18–24 years (11.5% after tax versus 13.6% before tax). Although fewer callers enrolled in the multicall program (4-5 counselling calls) after tax, they completed slightly more counselling sessions compared with those who enrolled for the multiple calls before tax (1.9 versus 2.2, respectively, P < 0.0001). Participant quit rates did not differ significantly before versus after the tax (controlled for age, gender, race, education, chronic condition, amount smoked, how heard about quitline, and state). Callers after the tax increase were more likely to report that friends and family told them about the quitline than those who called before the tax increase.SES More callers in 2009 (compared with the prior year) had less than a high school education: 58.6% vs 61.0%, p=0.007. Magnitude of the differences before and after tax was small.Author’s conclusion of SES impactCalls to the quitlines increased by 23.5% in 2009 and more smokers with less education called after (versus before) the tax.

Internal validitySeven-month response rate N = 645/1651 (39.1%)All participating states used same data collection methods and questionnaire to collect demographic and tobacco use data at intake and follow-up.External validitySmokers in participating states represented 24% of smokers inUS 2009.Other tobacco control policies occurred during study period that are not accounted for.Validity of author’s conclusionValid and reports that cannot estimate impact of federal tax increase separately from other excise tax increases and other changes in state and local level tobacco control policies.

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Outcomes were reported in two ways: first among those who completed the survey (respondent analysis) and second using the “intent-to-treat” (ITT) analysis whereby persons with missing outcomes data are assumed to be smoking.

297

Details Method Results CommentsIncreases in price/tax of tobacco productsAuthor, year Choi 2012CountryMinnesota, USADesign Longitudinal cohortObjectiveTo estimate the prevalence of the use of price-minimizing strategies in a cohort of current smokers immediately following the federal tobacco tax increase in 2009 and to examine the demographic and social characteristics of those who use price minimizing strategies.SES variablesEducation (categorized into less than high school, high school graduate, some college, and college graduate or above);Annual household income was categorized into less than $25,000, $25,000 – $ 50,000, $50,000 – $ 75,000, and more than $75,000.AnalysesMultivariate logistic regression

Data sourcesMinnesota Adult Tobacco Survey (MATS) Cohort StudyParticipant selectionThe sample was drawn from the 12,580 MATS 2007 participants randomly selected from the Minnesota adult population (n = 7,532) and Blue Cross Blue Shield members (n = 5,048). Of those eligible for MATS, 2,436 (77%) agreed to participate in MATS.Participant characteristics718 current smokers in 2009 (reported smoking at least 1 day in the previous 30 days) and 602 resurveyed in 2010 = 84% follow-up rateIntervention federal tobacco tax increase 2009Length of study2009 to 2010OutcomesSix cigarette price-minimizing strategies;(a) bought a cheaper brand of cigarettes, (b) rolled their own cigarettes, (c) used a form of tobacco other than cigarettes, (d) used coupons, rebates, or promotions (e.g., buy-one-get-one free, in-store discount), (e) purchased cartons instead of individual packs, and (f) found less expensive places to buy cigarettes.QuitQuit attemptsCigarette consumption?

General population Overall, 78% of participants used at least one price minimizing strategy in 2009 to save money on cigarettes. About 53% reported buying from less expensive places, 49% used coupons or promotions, 42% purchased by the carton, and 34% changed to a cheaper brand. Participants’ characteristics differed somewhat by strategy. Participants who reported buying by the carton were less likely to attempt to quit smoking and cut back on cigarette consumption subsequently; those who used more strategies were less likely to cut back on their cigarette consumption.SES The lowest income group was more likely than the highest income group to report buying cigarettes from cheaper places, buying a cheaper brand, and rolling their own cigarettes ( p < .05). The middle - income groups (i.e., those who reported annual household income between $25,000 and $75,000) were more likely than the highest income group to report buying cigarettes from cheaper places, using coupons or promotions, and buying cartons instead of packs ( p < .05).Having some college education, having an annual household income between $25,000 and $ 75,000 were associated with higher odds of using at least one price-minimizing strategy ( p < .05); having less than high school education, having annual household income less than $75,000, were associated with higher number of strategies used ( p < .05).Author’s conclusion of SES impactNo specific conclusions regarding SES impact.

Internal validityAdditional analysis showed that smokers who were lost to follow-up between 2009 and 2010 were more likely to be younger and have someone close to them who smokes or uses tobacco (p < .05).External validityState-specific sample, which limits the generalizability of findings to the adult smokers in the United States.Validity of author’s conclusionValid but small regional sample?

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Details Method Results CommentsEffects of increases in price/tax of tobacco productsAuthor, year CDC 1998CountryUSADesignRepeat cross-sectional - econometricObjectiveTo evaluate the responses to increases in cigarette prices by race/ethnicity, income and age groupsSES variables Family incomes; respondents with incomes equal to or below the median were compared with those above the median income ($33,106 in 1997 dollars).AnalysisA probit (limited dependent variable) model, an ordinary least squares model,

Data sourcesNational Health Interview Survey (NHIS) Participant selectionMultistage probability sample, response rate 80% to smoking history supplement. Participant characteristicsNoninstitutionalised civilian population 18 years+, the 14 cross-sections of the NHIS have 367,106 respondents; of these, 355,246 respondents had complete demographic and price data (approximately 24,000 respondents per year).Intervention Survey of smoking behaviour, Current smokers were persons who reported having smoked at least 100 cigarettes during their lifetimes and who currently smoked cigarettes. Length of study1976 to 1993Outcomes Prevalence price elasticityConsumption price elasticityTotal price elasticity

General population For all respondents, the models estimated a prevalence price elasticity of –0.15 and a consumption price elasticity of –0.10, yielding a total price elasticity estimate of –0.25. Therefore, a 50% price increase could cause a 12.5% reduction in the total U.S. cigarette consumption (i.e., 50% X –0.25=–12.5%)SES Lower-income populations were more likely to reduce or quit smoking than those with higher incomes. The total price elasticity was –0.29 for lower-income persons compared with –0.17 for higher income personsEditorial note: Smokers with family incomes equal to or below the study sample median were more likely to respond to price increases by quitting than smokers with family incomes above the median (e.g., 10% quitting compared with 3% quitting in response to a 50% price increase)Author’s conclusion of SES impactEditorial note: indicates that lower income smokers would be more likely than other smokers to be encouraged to quit in response to a price increase.

Internal validityNot all respondents for whom price data was available reported family incomeExternal validityAnalysis does not control fully for other factors unrelated to price (e.g., differences between states in social and policy environments) that could reduce demand and be confounded with the state’s excise tax level. This is a summary report.Validity of author’s conclusionValid

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Details Method Result CommentsIncrease in price/tax of tobacco productsAuthor , year Colman, 2008 CountryUSADesignRepeat cross-sectional - Econometric ObjectiveTo examine whether cigarette taxes are progressiveSES variables IncomeAnalysesEconometric

Data sourcesCurrent Population Survey’s Income Supplements and Tobacco Use Survey, Participant selectionExcluded those without matching data across surveys, under 18 years, those replying through proxies and those with missing values. Participant characteristicsN=294693. Smoking prevalence higher among the low income group at all time points. Low income more likely to be an ethnic minority, and not in the labour force. Low income group more likely to have high school education or lower, high income group more likely to have college or post-graduate qualification.Intervention Real cigarette price rose by over 70% during study period. Estimated the impact of a further $1 increase on 2003 prices.Length of studyCross-sectional data from 1993, 96, 99, 2001, 2002 and 2003.Outcomes Current smoking, either every day or some days.

General population N/ASES Higher income individuals are less price-sensitive; however the difference is less than the standard error between groups.A $1 rise in taxation would cause a decline of approximately 2.3 percentage points in the low-income group, 1.7 percentage points in the middle income group and 0.8 percentage points in the high income group. The tax rise would absorb 1.9% of the median income of low income smokers, and 0.7% and 0.3% for the mid and high income smokers. Disparity even wider once the above increase in cessation is accounted for.Author’s conclusion of SES impactHigher prevalence of smoking among low income groups means that the benefit of taxation is outweighed by the tax burden borne by non-quitters. Taxes may be progressive for a small section of smokers under some behavioural models.

Internal validity

External validityEnglish population would have more cessation support services available to them than were available in USA during the data collection period.

Validity of author’s conclusionIncreasing tobacco taxation had a small narrowing effect on socio-economic inequalities in smoking.

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Details Method Result CommentsIncrease in price/tax of tobacco productsAuthor, year De Cicca, 2008CountryUSADesignRepeat cross-sectional - econometricObjectiveTo investigate the responsiveness of older adult smokers to large cigarette tax risesSES variables Education (high school diploma or equivalent, or lower) and income (household income <$35,000).

Data sourcesBehaviour Risk Factor Surveillance Survey, an annual survey of US adults.Participant selectionIndividuals between the ages of 45-59 with state of residence data selected.Participant characteristicsNo discussed, but survey described as state-representative.Intervention Increases in state tax of at least 50c per pack of 20 cigarettes, introduced between 2000 and 2005. Price increases ranged from 50c to $1, with resulting taxes ranging from 70c to $2.46. 22 tax increases are included, from 18 states (Michigan, Montana, New Jersey and Washington introduced two tax increases during the study period).Length of study2000 to 2005Outcomes Smoking prevalence (self-reported smoking every day or some days).

General population Daily smokers fell from 19.6% to 17.9%, with almost all decrease coming after 2003 (2003: 19.4%, 2004: 17.9%), after the larger tax increases started. Some days smokers follow similar patterns.Estimate that a $1 increase in state cigarette tax reduces daily smoking by 1.4 percentage points (approx. 8% overall). Price participation elasticity (PPE) of -0.29 to -0.31.SES Greater impact among low-educated smokers. $1 increase would reduce the fraction of low-educated smokers by over 10%, and only 3% among those with more than a high school education. Price participation elasticities of -0.43 and -0.12 respectively. If low education is only those with less than a high school degree, the PPE is -0.9.A similar pattern is seen by income. Low-income individuals, defined as those living in households with annual incomes of less than $35,000, are found to quit at a much higher rate in response to higher taxes than their counterparts from higher income households. Price participation elasticities were -0.39 for low-income (<$35,000) and -0.12 for high income ($>35,000). A rise of $1 would reduce fraction of low-income smokers by about 10% and high income by 2%.Author’s conclusion of SES impactSmokers with low education and income showed greater reduction in smoking participation following large tax increases. Relative response would need to be far more significant for tax increases to be considered a progressive policy option.

Internal validityOther tobacco control initiatives are controlled for, but still not necessarily evidence that smokers are quitting in response to the tax increase.External validityStudied taxes arising from a relatively low starting point. Unclear whether further tax rises on top of high English prices would have the same impact. Validity of author’s conclusionAssociated with a large narrowing of the education and income-related smoking disparities.

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Details Method Result CommentsIncreases in price/tax of tobacco productsAuthor, year Dinno 2009CountryUSADesignSingle cross-sectionalObjectiveTo consider disparities in tobacco control both by evaluating possible differences in the effects of clean indoor air laws and cigarette prices by different social circumstances, and by establishing whether vulnerabilities exist for smoking participation and consumption and, if so, whether these vulnerabilities covary with tobacco control policies.SES variables Education, household incomeAnalysesNon-linear gression models

Data sourcesFebruary 2002 panel of the Tobacco Use Supplement of the Current Population Survey (54,024 individuals representing the US population aged 15–80). Data on strong clean indoor air laws in effect at time of interview were obtained from the American Lung Association’s State of Tobacco Control 2002 and local ordinances from the American Nonsmokers’ Rights Foundation Local Tobacco Control Ordinance database; price from the average state cigarette prices per pack from The Tax Burden on TobaccoParticipant selectionNon-institutionalized civilian individuals in 266 counties in 50 states plus the District of Columbia. Participant characteristics54,024 self-respondents aged 15 to 18 yearsIntervention Strong clean indoor air laws and cigarette prices.Strong clean indoor air laws include 100% prohibition without exception of smoking in public and private workplaces (including non-hospitality work sites like manufacturing and office sites among others), restaurants (with and without attached bars), and bars and taverns.Length of studyFebruary 2002Outcomes Smoker statusConsumptionSmoking elasticities

General population Clean indoor air laws and cigarette prices are independently associated with reductions in smoking.Independent associations of strong clean indoor air laws were found for current smoker status (OR 0.66, 95% CI 0.60, 0.73), and consumption among current smokers (-2.36 cigarettes/day, 95% CI -2.43, -2.29).Cigarette price was found to have independent associations with both smoking and consumption, an effect that saturated at higher prices. The odds ratio for smoking for the highest versus lowest price over the range where there was a price effect, was 0.83. Average consumption declined (-1.16 cigarettes/day) over the range of effect of price on consumption.The effect of clean indoor air laws on smoking status (OR 0.66) was larger than the effect of cigarette prices over the range of prices at which we found smokers to be price sensitive (OR 0.83 for $2.91 to $3.28).SES Established patterns of education, income, and race/ethnic disparity in smoking are largely unaffected by either clean indoor air laws or price in terms of both mean effects and variance.Author’s conclusion of SES impactClean indoor air laws and price increases appear to benefit all SES groups equally in terms of reducing smoking participation and consumption and are generally neutral with regard to health disparities.

Internal validityThe household response rate for the February 2002 CPS was 93%.External validityOne of few studies to look at separate impact of smokefree legislation and priceValidity of author’s conclusionvalid

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Details Method Results CommentsIncreases in price/tax of tobacco productsAuthor, year Dunlop 2011CountryNew South Wales, AustraliaDesign Repeat cross-sectional ObjectiveTo track smokers responses to the increasing price of cigarettes after a tax increase and assess socio-demographic differences in responsesSES variablesIncome, education and Socio-Economic Indices for Areas (SEIFA)AnalysesMultinomial logistic regressions

Data sourcesThe Cancer Institute NSW’s Tobacco Tracking Survey (CITTS) is a continuous tracking telephone survey. 50 interviews per week are conducted across most weeks of the year. Participant selectionHouseholds are recruited to the telephone survey using random digit dialling and participants are recruited using a random selection procedure. An overall response rate of 30% was achieved, with a cooperation rate of 67% among eligible respondents.Participant characteristics834 smokers and 163 recent quitters (quit in last 12 months)Intervention Smokers were asked what effect, if any, the increasing price of cigarettes had on them when: (a) they tried to quit; (b) cut down; (c) thought about quitting; (d) changed to lower-priced cigarette brands; (e) started using ‘roll your own’ or other loose tobacco, such as ‘chop chop’; or (f) bought in bulk. Multiple responses were allowed.Length of studyMay to September 2010OutcomesSmoking related and product related changes to cigarette price increases

General population 47.5% of smokers made smoking-related changes and 11.4% made product-related changes without making smoking-related changes. The proportion of smokers making only product-related changes decreased with time, while smoking-related changes increased. Recent quitters who quit after the tax increase (versus before) were more likely to report that price influenced them.SES Low- or moderate-income smokers (versus high-income) were more likely to make smoking-related changes compared to no changes.Smokers with less than high school education were more likely to have cut down, thought about quitting or started using loose tobacco than those with a tertiary education, and those with a high school or technical college education were also more likely to have started using loose tobacco than those with tertiary education.Smokers with lower incomes (<$40 000) were more likely to have cut down, changed to a lower price brand or started to use loose tobacco than those with higher incomes, and those with a moderate income were more likely to have changed to a lower priced brand. A greater proportion of smokers from low SES neighbourhoods switched to lower-priced brands than those from moderate–high SES neighbourhoods.Author’s conclusion of SES impactThe effect of increasing cigarette prices on smoking does not appear to be mitigated by using cheaper cigarette products or sources.

Internal validity

External validityPrior to the tax increase, cigarette prices had been increasing incrementally from approximately AU$11.00 per pack in 2005 to AU$14.00 in April 2010.Study did not relate the price increase questions directly to the 30 April tax increase..Validity of author’s conclusion

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Details Method Results CommentsIncreases in price/tax of tobacco productsAuthor, year Farrelly 2001 CountryUSADesign Repeat cross-sectional - econometricObjectiveTo evaluate the effect of cigarette price increases by gender, income, age and race or ethnicity with a nationally representative sample of more than 350,000 adultsSES variablesFamily incomeAnalysesEconometric. Two-part model of demand: firstly a probit model of the decision to smoke (participation); followed by linear regression (ordinary least squares) of the amount smoked by smokers.

Data sourcesNational Health Interview Survey; multistage probability sample of the civilian, noninstitutionalized U.S. population age 18 and olderParticipant selectionN=367,106 (all respondents); 354,228 (those with complete sociodemographic and price data)Participant characteristics53% female; mean (SD) age 44 (17.7); 10% African-American/non-Hispanic; 6% Hispanic; 26% high school dropout; 38% high school graduate; 18% some college; 10% college graduate; 7% postgraduate; mean (SD) family income $25,784 ($18,670)Intervention Cigarette price increasesLength of study14 years (1976-1980, 1983, 1985, and 1987-1993)OutcomesPrice elasticities

General population Elasticity [* p<0.10]-0.13 (participation)-0.15 (amount smoked)-0.28 (total).SES Adults with a lower income are moreprice-responsive than those with ahigh income.Elasticity [* p<0.10]Stratified resultsElasticity [* p<0.10]Family income less or equal to median(median value was not reported)-0.21* (participation)-0.22* (amount smoked)-0.43 (total)Family income above median0.01 (participation)-0.11 (amount smoked)-0.10 (total, not significant)Author’s conclusion of SES impactAdults with income at or below the median are more than four times as price-responsive as those with income above the median

Internal validitycontrolled for within-state variation in the modelsExternal validityMedian income not reportedValidity of author’s conclusionValid but comparisons with other econometric studies unclear because did not report median income

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Details Method Results CommentsIncreases in price/tax of tobacco productsAuthor, year Farrelly 2012 CountryUSADesign Repeat cross-sectional and comparison groupObjectiveTo analyse differences in smoking prevalence and consumption overall and by three income levels nationally and in the state with the highest cigarette excise tax ($4.35), New York.SES variablesAnnual household income, less than $30,000; $30,000 to $59,999; and $60,000 or more.AnalysesAdjusted Wald tests, logistic regression, linear regression, imputed missing income

Data sourcesNew York Adult Tobacco Survey (NY ATS) and a National Adult Tobacco Survey (NATS)Participant selectionNot reportedParticipant characteristics7,536 adults and 1,294 smokers from New York and 3,777 adults and 748 smokers nationally.Intervention New York state had the highest cigarette excise tax ($4.35) compared with the national average of $1.46 per pack. The average price per pack was $7.95 in New York compared with $5.21 nationally.Length of study2010 to 2011, amount spent by smokers on cigarettes annually as a share of household income for 2003–2004 and 2010–2011 (adjusted for underreporting).OutcomesSmoking prevalence,Daily cigarette consumption,Share of annual income spent on cigarettes,

General population Overall, smoking prevalence is lower in New York (16.1%) than nationally (22.2%) and is strongly associated with income in New York and nationally (P<.001). 6.8 cigarettes per smoker per day are purchased outside of NewYork’s tax jurisdiction.SES Smoking prevalence ranges from 12.2% to 33.7% nationally and from 10.1% to 24.3% from the highest to lowest income group. In 2010–2011, the lowest income group spent 23.6% of annual household income on cigarettes in New York (up from 11.6% in 2003–2004) and 14.2% nationally. The middle-income group spent 5.4% of their income on cigarettes in New York and 4.3% nationally. Smokers in the highest income group spent 2.2% of their income on cigarettes in New York and 2.0% nationally. The relationship between the percentage of income spent on cigarettes and income level differs significantly between New York and the United States (P<.05).Percentage of income spent on cigarettes increased in New York over time for smokers overall, from 6.4% in 2003–2004 to 12.0% in 2010–2011 p<0.001, as the state cigarette excise tax increased from $1.50 to $4.35. Percentage of income spent on cigarettes more than doubled for the lowest income category, increasing from 11.6% to 23.6% (P<0.01). This percentage also increased for the middle income group from 4.0% to 5.4% (P<0.01), but not for the highest income group.Daily cigarette consumption is not related to income either nationally or in New York.

Internal validitySelf-reported cigarette price and household income could be misreported and this could vary by income level and bias results.External validityResults specific to New York State.Validity of author’s conclusionValid.

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Details Method Results CommentsIncreases in price/tax of tobacco products

Author’s conclusion of SES impactHigh cigarette taxes reduce cigarette smoking but impose a significant financial burden on low-income smokers in New York State. Lower income smokers in New York State have not had a greater response to higher taxes than smokers with higher incomes.

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Details Method Result CommentsIncreases in price/tax of tobacco productsAuthor , year Franks, 2007CountryUSADesignRepeat cross-sectional - econometric ObjectiveTo examine the relationship between cigarette pack price and smoking participation to inform future tobacco control policy aimed at lessening income-based disparities in smokingSES variables Income group (<25th percentile vs >25th percentile)AnalysesFixed effects logistic regression

Data sourcesBehavioural Risk Factor Surveillance System (BRFSS), telephone survey, The Tax Burden on Tobacco,'' an annual compendium that includes cigarette tax and price dataParticipant selectionMultistage cluster design based on random-digit dialling across all states. Non-institutionalised adults (18+), 13.6% missing outcome data were excluded. State participation in the BRFSS increased from 15 states in 1984 to all states in 1995; the total sample included more than 2.6 million respondents. The data sets included weights to adjust for nonresponse (which varied by state and year) and selection criteria to enable nationally representative estimates of parameters of interestParticipant characteristicsNationally representative sample of adultsInterventionCigarette price increases adjusted for inflation to 2004 levels.Length of study1984 to 2004Outcomes Smoking prevalence, price elasticity

General population Pack price increased throughout the study period, and smoking decreased overallSES Increased real cigarette-pack price overtime was associated with a marked decline in smoking among higher-income but not among lower-income persons. Lowest income group have stayed fairly constant (~30% to 28%), whereas middle groups have shown a downward trend (both 30% to 25+22%). Highest income saw substantial decline between 1990-1993, stable since (c.24% to 16%). – derived from figure in paper1984 to 1996: The association between price and smoking is significant for both income groups, with a larger elasticity in the lower-income group (-0.45 vs -0.22 for the higher-income group).In the later time period, the relationshipbetween price and smoking was not statistically significant in the lower income group or in the higher-income groupAuthor’s conclusion of SES impactNo significant contribution to reducing smoking disparities. Income related smoking disparities have increased, and may impose a disproportionate burden on poor smokers. Further price rises likely to exacerbate inequalities due to the burden of tax placed on low income groups.

Internal validityOnly reports lowest income against all other, although figure of smoking prevalence reports data for four income categories.. External validityBRFSS only included all states from 1995 onwards (after the large fall in high income smoking). Excludes people without telephones.Validity of author’s conclusionAppears that high income group have responded to prices reaching a threshold (c.$2.50) and have no further price responsiveness. So despite the widening of inequality the absolute gap of smoking probability narrows as price increases (between lowest and others). – derived from figure in paper.

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Details Method Results CommentsIncreases in price/tax of tobacco productsAuthor, year Frieden 2005CountryNew York City, USADesign Repeat cross-sectionalObjectiveto determine the Impact of comprehensive tobacco control measures in New York CitySES variableseducationAnalysesUnivariate and multivariate

Data sourcesAnnual New York State Behavioral Risk Factor Surveillance System (BRFSS), New York City Department of Health and Mental Hygiene (DOHMH) conducted a population-based, random-digit dialed telephone community health surveyParticipant selectionrandomly selectedParticipant characteristicsadult New York City resident Intervention 5. April and July 2002 state and city tax

increases raised the cost of a pack of cigarettes by approximately 32%, to a retail price of approximately $6.85

6. 2002 Smoke-Free Air Act (SFAA) became effective in March 2003 eliminated existing exemptions to make virtually all indoor workplaces, including restaurants and bars, smokefree.

7. April 2003 nicotine-patch distribution program began providing free 6-week courses (coupled with brief telephone counseling) to 34 000 of the city's heavy smokers

8. Expansion of educational efforts such as publications and advertisements in broadcast and print media, emphasized the health risks of environmental tobacco smoke and the benefits of quitting. There was also extensive media coverage of the debate regarding smoke-free workplace legislation.

Length of study

General population During the 10 years preceding the 2002 program, smoking prevalence did not decline in New York City; within a year of implementation of the new policies, a large, statistically significant decrease occurred. From 2002 to 2003, smoking prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%, (P=.0002) approximately 140000 fewer smokers).Increased taxation appeared to account for the largest proportion of the decrease; however, between 2002 and 2003 the proportion of cigarettes purchased outside New York City doubled, reducing the effective price increase by a third.SES Smoking declined among all education levels. The decrease was more pronounced among low-income women (an 18.1% decrease, from 21.6% to 17.8%; P=.OO9). Significant decreases in smoking were found among people with more than a high school education (a 12.4% decrease, from 19.3% to 16.9%; P=.O1). Declines were also large among people with annual family incomes of less than $25000 (a 12.6% decrease) or $75000 or more (a 13.4% decrease).In 2003, former smokers who had quit within the past year were more likely to have low incomes compared with former smokers who had quit more than 1 year previously (43.6% vs 32.0%, p=.0001).Residents with low incomes (<$25000 per year) or with less than a high school education were more likely than those with high incomes (>$75 000 per year) and those with a high school education or higher to report that the tax increase reduced the number of cigarettes they

Internal validityResponse rates per wave among contacted households were 64%, 59%, and 64% respectively for three waves of data collection 2002 to 2003.ORs significantly reduced for smoking, only for people in income <$25,000 and ‘some college’ education.External validityAnalyses of education level were restricted to adults aged 25 years and olderValidity of author’s conclusionValid, but respondents' attribution of the impact of various control measures on their smoking behaviour may not be accurate.

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Details Method Results CommentsIncreases in price/tax of tobacco products

May 2002 to November 2003; The 2002 community health survey was considered to be the preintervention sample, and the 2 surveys conducted in 2003 were combined and treated as the postintervention sample.OutcomesSmoking prevalenceOR for smokingResponse to tax increaseResponse to workplace smoking ban

smoked (income: 26% [low] vs 13.0% [high], P=.0002; educational attainment: 27.5% [lower] vs 19.3% [higher], P=.OO9).High-income people were more likely than low-income people to report that the SFAA reducedtheir exposure to ETS (53.3% vs 41.9%, P<.0001).Author’s conclusion of SES impactGroups that experienced the largest declines in smoking prevalence included people in the lowest and highest income brackets and people with higher educational levels.Our data suggest that people with lower incomes may have been more heavily affectedby the increase in taxation, whereas people with higher incomes may have been more affected by greater awareness of the dangers of environmental tobacco smoke and expansion of smoke-free workplace legislation.

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Details Method Results Comments

Increases in price/tax of tobacco productsAuthor, year Gospodinov & Irvine 2009CountryCanadaDesign Repeat cross-sectional - EconometricObjectiveTo investigate the overall magnitude of the demand response to price and also the difference in response by socioeconomic levelSES variablesEducationAnalysesEconometric - estimates price elasticities for different socioeconomic groups using recent Canadian survey data for a period during which prices rose to a level of about $7 per pack.

Data sourcesStatistics Canada/Health Canada Canadian Tobacco Use Monitoring survey (CTUMS) for years 2000 through 2005. The dollar price series is constructed for tobacco products from the monthly tobacco-price index for each province from Canadian Socioeconomic Information Management system (CANSIM) and dollar prices for cigarettes for November 2001 from the Department of FinanceParticipant selectionn/aParticipant characteristics90,850 individuals aged 20+ years, of whom 69,215 (76.2%) are non-smokersIntervention Cigarette price increasesLength of study5 years – 2000 to 2005OutcomesSmoking prevalenceWeekly consumption per personPrice elasticityType of cigarette smoked

General population Prevalence and number of cigarettes smoked per person each declined by about one third. Smokers tend to mitigate the impact of tobacco taxes by switching towards brands that have higher nicotine levels. That is, they move along the ultralight—regular spectrum, in an effort to get more nicotine for their dollar.Aggregate price elasticity lies in the range −0.28 to −0.3 depending on whether it is estimated at the median or mean SES Those with less than a completed high school education level experienced declines that were just slightly above the average, those with completed high school and college level experienced declines considerably below the average, and those with university level experienced declines in excess of the average. For this last group participation declined by 30% while quantity declined by more than 40%. The elasticities for high school and college graduates are approximately −0.3, while smokers with less than high school appear to be less responsive to price movements with a median elasticity of −0.22. None of these estimates is in the region of unity, and there is no evidence of either a declining elasticity value as we move from a low to high education group or a higher elasticity value for the lower group.Cumulative frequency distributions for all smokers for each year in our data show a downward shift in these distributions over time indicating that continuing smokers are progressively smoking stronger cigarettes while the higher education group has seen little change in its choice of cigarette, the lowest

Internal validityDue to the low participation rate and the large proportion of occasional smokers (with 5 or less cigarettes per week) for the group with university degree, its effective sample size becomes very small and this education group was excluded from the subsequent analysis.External validityDoes not account for illegal products and cross-border sales.Estimates are based on data where prices are closer to what might reasonably considered an ‘optimal’ range.Validity of author’s conclusionStudy looks at data on pack choice but not the intensity with which high and low socioeconomic groups smoke their cigarettes, nor how such intensity patterns may have changed in response to the major tax increases of the period 2002 and 2003.

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income group has. This distributional shift on the part of the lowest income group may reflect the tendency of quitters to be ‘light/mild’ smokers and for non-quitters to be ‘regular’ smokers.Author’s conclusion of SES impactLittle hope that such tax increases may really benefit low socioeconomic groups, or disadvantage them to a lesser degree than high socioeconomic groups

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Details Method Results Comments

Increases in price/tax of tobacco productsAuthor, year Gruber 2003CountryCanadaDesign Repeat cross-sectional - econometricObjectiveTo provide a framework for estimating elasticities in the context of widespreadSmuggling and to explore the price sensitivity of smoking by income groupSES variablesAfter-tax income quartiles and expenditure quartilesAnalysesestimate demand models for Canada that attempt to correct for the smuggling problem in two different ways:

1. use legal sales data, and exclude the regions and years where the smuggling problem was the worst

2. use household level expenditure data on smoking.

Data sourcesCigarette prices ffrom Statistics Canada, legal sales from National Clearinghouse on Tobacco and Health Program, household cigarette expenditure from Canadian Survey of Family Expenditure (FAMEX), renamed the Survey of Household Spending after 1996.Participant selectionn/aParticipant characteristicsThe resulting FAMEX data set consists of 81,479 observations across eight survey years.Intervention Econometric estimation ofsensitivity of smoking to priceLength of studyn/aOutcomeselasticity

General population Elasticity not accounting for smuggling is -0.72. Excluding smuggling provinces elasticity is -0.47.Using expenditure data elasticity is -0.45. thereis only a small and insignificant effect of prices on the presence of any tobacco expenditure in the family. But there is a large elasticity of conditional expenditures of −0.41. Thus, it appears that almost all of the response of consumption to price changes occurs through reductions in consumption and not quitting smoking. Excluding smuggling provinces and using expenditure data suggests bias from using legal prices instead of illegal prices paid through smuggling is quite modest because elasticities are similar.SES Lower income groups spend a much larger share of their incomes on cigarettes than do higher income groups. there is a pattern of much higher elasticities for the lowest income groups than for the highest income groups showing that the lowest income group is much more price sensitive than higher income groups.After-tax income quartiles: there is a much larger price elasticity of demand among the lowest income smokers. In the bottom income quartile, there is no effect of higher taxes on cigarette spending, with an estimated elasticity of demand close to −1. This elasticity falls to −0.45 in the second quartile, and then to −0.31 in the third quartile before rising again to −0.36 in the top quartile. The drop between the lowest income quartile and the other three quartiles is a statistically significant one, whereas the

Internal validity

External validityWidespread smuggling is only relevant to certain countriesValidity of author’s conclusionThis paper accounts for smuggling (which biases the response legal cigarette sales to price) and by doing so might produce a more ‘true’ price elasticity estimate.

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differences in elasticities within the top three quartiles are not statistically significant. Expenditure quartiles: elasticity pattern is similar, except that the big drop-off is between the second and third quartiles (this drop is statistically significant), while the difference in elasticities between the first and second quartiles and the third and fourth quartiles are not statistically significant.Author’s conclusion of SES impactcigarette taxes may not be as regressive as previously suggested

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Details Method Result CommentsIncreases in price/tax of tobacco productsAuthor, year Hawkins 2012CountryUSADesignRepeat cross-sectionalObjectiveTo examine the impact of cigarette excise taxes and smoke-free legislation on tobacco use among households with school-age children and adolescents as well as disparities in children’s secondhand smoke exposure.SES variables Total combined family income during the past calendar year before taxes. A household’s percentage of the federal poverty level was calculated from household size and income. Highest level of education in the household wasconstructed by comparing education of the mother and father: less than/high school graduate or more than high school graduateAnalysescompared the results from models using causal inference techniques (differences in differences) to those from cross-sectional models using ordinal least squares regressions models

Data sourcesNational Survey of Children’s Health, state-level cigarette excise taxes, smoke-free legislation total score (0 [none]–32 [very strong]) in 2001 and 2005 (National Cancer Institute’s State Cancer Legislative Database).Participant selectionNot stated Participant characteristicsfamilies of 6–17-year-olds from the 2003 (N = 67,607) and 2007 (N = 62,768)Intervention Cigarette excise taxes and smoke-free legislation.From 2003 to 2007 40 states raised cigarette excise taxes with a mean increase of 54.5 cents (SE 6.4; range 7–175). In 2005, the mean tax was 84.7 cents (SE 7.9; range 5–246). From 2001–2005, 18 states strengthened smoke-free legislation with a mean increase of 13.3 (SE 1.8; range 1–28). In 2005, the mean smoke-free legislation total score was 12.0 (SE 1.3; range 0–32).Length of studyJanuary 2003 – July 2004 and repeated separate sample April 2007 – July 2008.Outcomes Household tobacco use

General populationIn adjusted causal inference models every $1.00 increase in cigarette excise tax between 2001 and 2005 was associated with a 4 percentage point decrease in household tobacco use between 2003 and 2007 (p = 0.008); however, there was no effect of smoke-free legislation on household tobacco use.In adjusted cross-sectional models, a higher smoke-free legislation total score was associated with a lower prevalence of household tobacco use.SES Cigarette tax increases but not smokefree legislation total score, were associated with reductions in household tobacco use for lower income households (100–399 % of the federal poverty level) using casual inference techniques.Cigarette tax increases and smokefree were associated with reductions in household tobacco use for lower income households.Author’s conclusion of SES impactStronger tobacco control policies decreased tobacco use among households with school-age children and adolescents; however, which policy reduced parental smoking depended on the modelling approach used. In causal inference models we found that stronger cigarette excise taxes decreased household tobacco use, particularly for families with children from lower income groups, but smoke-free legislation did not change tobacco use. In cross-sectional models we showed that a higher smoke-

Internal validityHousehold tobacco use as a proxy for children’s secondhand smoke exposure. Two year lag between tax and smokefree policies and outcomes.External validityNational survey data used which should be generalisable to US parentsValidity of author’s conclusionThis is a comparison of methods study in which authors focus on causal inference model results. Aim of increasing cigarette tax is to reduce prevalence of smoking and aim of smokefree legislation is to protect from SHS exposure.

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free legislation total score, indicating stronger policies or a greater coverage of policies, was associated with a lower prevalence of household tobacco use. Results suggest that increasing cigarette excise taxes may help reduce disparities by influencing parental smoking behaviours for the most at-risk children.

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Details Method Result CommentsIncreases in price/tax of tobacco productsAuthor, year Levy, 2006 CountryUSADesignRepeat cross-sectionalObjectiveTo examine association between smoking and tobacco control policies among women of low SES.SES variables Not completed high school or no high school degree or GEDAnalysesmultivariate logistic models,

Data sourcesTobacco Use Supplement, four waves between 1992 and 2002. Sample nationally representative of non-institutionalised civilian population over the age of 15. Participant selectionFemales grouped by education level (less than high school, high school or higher, bachelor’s degree). Low education males included as a reference population. Sample varies between 176,452 and 228,552.Participant characteristicsMajority white, with increasing Hispanic proportion in later surveys. Majority 25 year olds or over. Over 40% from the South, approx. 20% each from the Midwest, Northeast and West.Low educated female constitutes between 21.6 and 26.6% of each survey, mid-educated 19.3-22.4%, high educated are 7.3 to 9.2% Intervention cigarette prices, clean air regulations, and tobacco control media campaigns, Clean air laws were represented by an index of state level clean air regulations. States with ‘‘no smoking allowed (100% smoke free)’’ were counted as 100% of the effect, with ‘‘no smoking allowed or designated smoking areas allowed if separately ventilated’’ as a 50% effect, and with ‘‘designated smoking areas required or allowed’’ as a 25% effect. We used separate indices by type of law, and settled on an aggregate weighted index, with worksite laws weighted by 50%, restaurant laws by 30%, and laws for other public places by 20%. Media campaign exposure measured at the state level rather than individual, and youth campaigns coded as half a media campaign.

General population impactSmoking prevalence declining across all categories.SES Price:As price increased the OR of low-education female smoking fell, but influence varies over survey waves. Only lower than 1 in 1992-3 and 2001-02. Med-higher educated groups less responsive. Media:In a state with a media campaign low education women’s OR=0.86, medium education = 0.89, high = 0.93 (non sig). Low education men also significantly less likely to smoke (0.92) Generally, the association of the media variable and smoking prevalence declines in the more recent survey waves.Smokefree legislationMarginal effect on current smoking. Over the period 1992–2002, current smoking among low education women is inversely related to the index of clean air laws with an odds ratio of 0.91 (0.80, 1.03), but is significant only in the medium education female subpopulation, with an odds ratio of 0.88 (0.83, 0.94). However, only in the 2001/02 model do clean air laws seem to play a part for the medium education female sample, although the confidence intervals around the estimates for each survey wave overlap for this group.Author’s conclusion of SES impactLow education women particularly responsive to media and price increases especially in comparison with high education women. Tax increases can play an important role. Tax increases and media messages may reduce prevalence among

Internal validityNo before and after, simply tracks the association between policy and prevalence. Fail to adjust for confounding individual characteristics.Small sample sizes at some state levels.External validityMost of the developments in clean air regulations at the state level occurred after 2001.A number of tobacco control policies were introduced during this period as well as changing social norms and increasing awareness, all of which may have influenced the results. Data is now one, in some cases nearly two, decades out of date. Covers a substantial Hispanic population that wouldn’t exist in the UK.No description of the types of media campaigns involved, and which were the most effective (either the mode of intervention or locations) in order to replicate the study.Validity of author’s conclusionNo examination of individual level exposure, or whether media campaigns were actively influencing people to change their smoking behaviour. Outcome may simply be the consequence of changing social norms in these populations.

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Length of study1992 to 2002Outcomes Individual use, attitudes towards smoking and clean air laws, and smoking bans at home or work.

women with low education. Health-SES relationship not irreversible.

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Details Method Result CommentsIncreases in price/tax of tobacco productsAuthor, year Madden, 2007 CountryIrelandDesignSingle cross-sectional survey containing retrospective cohort data - econometricObjectiveTo investigate the role of tobacco taxes in starting and quitting smoking and explores how tax effect differs by educationSES variables Education (primary, junior (age 16), secondary (age 18), University)AnalysesDuration analyses – various parametric duration models

Data sourcesRetrospective data from a survey on women’s knowledge, understanding and awareness of lifetime health needs (Saffron Survey, 1998).Participant selectionAll survey respondents who were born after 1950 (so that sample’s exposure matches price data). Participant characteristicsN=703. Average age 34, ex-smokers slightly older. 10% primary education, 27% junior education, 40% secondary, 21% university. Ever-smokers and current smokers more likely to have lower levels of education. 55% employment rate, 47.5% among current smokers.Intervention Tobacco taxation from 1960 onwards.Length of study1960 to 1998Outcomes Ever smoked, age of initiation, and cessation.

General populationHigher tax levels are associated with later initiation and earlier cessation.SES Taxation has a stronger effect to prevent or delay initiation among those with intermediate education, and weakest among those with the lowest education.Taxation has the strongest effect on cessation among those with the lowest education, an equal impact on those with other levels of education.Author’s conclusion of SES impactResults are extremely tentative, but it appears that the greater impact is among those with intermediate education. Greatest effect on quitting for the lowest levels of education.

Internal validityPotential for recall bias, going back up to 40 years in some cases. Doesn’t capture failed attempts to quit.External validityRevenue Commissioners does not breakdown the tax component into excise and VAT for the period up to 1973. Thus, authors have taken the total tax component of the retail price and deflated it by the personal consumption deflator to arrive at a real tax on tobacco.Tax was relatively low through the study period, unclear whether the relationship would continue with further increases from current levels of taxation.Potential quitters had less cessation support available.Only covers Irish females.Covers a period of increasing awareness of the impact of smoking, unclear whether cessation was linked to taxation or increased awareness.Validity of author’s conclusionResults are extremely tentative

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Details Method Results CommentsIncreases in price/tax of tobacco productsAuthor, year Metzger 2005CountryNew York City, USADesign Prospective longitudinal cohort of pharmacies with repeat cross-sectional dataObjectiveTo assess the impact of an increase in cigarette excise tax and a smokefree workplace law on smoking cessationSES variablesTertiles based on income for pharmacy locationAnalysesrepeated-measures analysis with Poisson generalized estimating equations

Data sourcesData on over-the-counter pharmacy sales are collected daily from more than 200 store locations in New York City, representing approximately 30% of all pharmacies in New York CityParticipant selection166/200 pharmaciesParticipant characteristicsn/aIntervention State tax increase (implemented April 3, 2002), the city tax increase (implemented July 2, 2002), and the Smoke-Free Air Act (SFAA. the New York City smoke-free workplace law, enacted March 30, 2003). New York City's free patch program (April 2, 2003, to May 14. 2003), during which almost 35000 free courses of the nicotine patch were distributed to heavy smokers, defined as those who smoked more than 10 cigarettes per day living in New York City.Length of study2 years; 2002 to 2004OutcomesPharmacy specific weekly over-the-counter sales of 12 brand-name and generic nicotine patch and nicotine gum products

General population We found a 27% increase in nicotine patch sales during the week of the state tax increase and a 50% increase during the week of the city tax increase. These percentages gradually declined over the ensuing weeks. Sales of nicotine gum increased by 7% and 10% following the rise in state and city cigarette taxes, respectively, but these increases generally did not persist for a period as long as the increases in nicotine patch sales.The week of the implementation of the SHAA was associated with a 31% increase in nicotine patch sales and an 8% increase in nicotine gum sales, even though the free patch program began the same week. Sales of the patch, but not the gum declined during the subsequent weeks, corresponding with the duration of the 6 week free patch program. Gum sales increased by 11% during the fourth week after the SFAA was enacted, coinciding with the beginning of the act's enforcement.SES Pharmacies in low income areas generally had larger and more persistent increases in response to tax increases than those in higher-income areas.Author’s conclusion of SES impactCigarette tax increases and smoke-free workplace regulations were associated with increased smoking cessation attempts in New York City, particularly in low-income areas.

Internal validity166/200 pharmacies provided data at follow-up.The model controlled for temporal and seasonal patterns, included major holidays, the World Trade Center attack (September 11, 2001), and the Northeast blackout (August 14, 2003).Study conducted an analysis of over-the-counter sales of analgesic products to act as a control.External validityPharmacy sales of NRT are a proxy measure for smoking cessation attempts.Validity of author’s conclusionValid but only a proxy measure.

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Details Method Results Comments

Increases in price/tax of tobacco productsAuthor, year Mostashari 2005CountryNew York City, USADesign Cross-sectional at one time-pointObjectiveTo inform New York City’s (NYC’s) tobacco control program SES variablesEducation and incomeAnalysesBivariate and multivariate

Data sourcesNYC Department of Health andMental Hygiene (DOHMH) random digit-dialed telephone surveyParticipant selectionRandomly selected; To provide neighbourhood estimates, a quota of 300 interviews was set for each of 33 neighbourhood strata defined by zip code aggregation.Participant characteristics9,674 New York City adultsIntervention New York City’s April 2002 increase in the state cigarette excise tax. Response to the April 2002 increase in the state cigarette excise tax was recorded by asking individuals “How has the increase in cigarette prices (since April 3) affected your smoking?”Length of studyMay to July 2002OutcomesPrevalence of smokingExposure to SHSResponse of smokers to state tax increaseCessation practices

General population Even after controlling for sociodemographic factors (age, race/ethnicity, income, education, marital status, employment status, and foreign-born status) smoking rates were highest in Central Harlem and in the South Bronx.Sixteen percent of nonsmokers reported frequent exposure to second-hand smoke at home or in a workplace. More than one fifth of smokers reported reducing the number of cigarettes they smoked in response to the state tax increase. Of current smokers who tried to quit, 65% used no cessation aid.Purchases from sales channels outside of NYC included 4.6% who reported buying cigarettes elsewhere within New York State, 7.3% in other states, and 1.9% on the Internet. Response to the 13% price increase; nearly one in four smokers reported reducing their cigarette consumption shortly after the tax increase, whereas 2.8% of smokers reported quitting smoking. In addition, 5.6% of all recent smokers indicated that they had thought about quitting, 4.0% tried to quit, and 2.8% quit smoking in response to the 39-cent price increase.SES Lower household income was independently predictive of current smoking. US born college graduates were less likely to smoke than other New Yorkers.among nonsmokers lower education was a significant predictor of exposures to SHSInternet purchases were more common among those with a college education or higher compared with those with a high school education or less (4.1% VS. 1.1%, P=.003).21.9% of individuals who had smoked cigarettes

Internal validityFinal sample represented 64% of the eligible households contacted.External validityThe survey represents only noninstitutionalized NYC adults with working residential telephones.Validity of author’s conclusionData only collected at one time-point shortly after increase in state cigarette excise tax

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in the past 3 months reported that they had reduced the number of cigarettes they smoked in response to price increase. This response varied by income level, from 27.2% of those with low incomes (<$25,000) to 11.0% of those with high incomes (>$50,000) (P < .0001).Quit attempts were associated with lower income.Author’s conclusion of SES impactTax evasion through cross-border and Internet cigarette purchases could blunt the effectiveness of local tax increases and argue for a national cigarette tax increase.

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Details Method Results Comments

Increases in price/tax of tobacco productsAuthor , year Nagelhout 2013CountryThe NetherlandsDesignCohortObjectiveTo examine age and educational inequalities in smoking cessation due to the implementation of a tobacco tax increase, smoke-free legislation and a cessation campaign.SES variables Education, low (primary education and lower pre-vocational secondary education), moderate (middle pre-vocational secondary education and secondary vocational education) and high [senior general secondary education, (pre-) university education and higher professional education].AnalysesUnivariate and multivariate logistic regression. All analyses were weighted by age and gender to be representative of the adult smoker population in the Netherlands.

Data sourcesThree survey waves of the International Tobacco Control (ITC) Netherlands Survey, 2008 (before) and 2009 and 2010 (after)Participant selectionRecruited from a probability-based web databaseParticipant characteristicsN=1820/2331 (78.1%) in first survey, 1447 in second survey and 1275 in third survey. Analyses restricted to respondents who participated in all three survey waves (n=1176). And excluded 128 who had quit during 2008 and 2009 surveys, n=1048 and then answered all questions, n=962.Dutch smokers (having smoked at least 100 cigarettes in their lifetime and currently smoking at least once per month) aged 15 years and olderIntervention Tobacco tax increase, smoke-free hospitality industry legislation and mass media cessation campaign (all at national level) implemented during the same time period in the Netherlands in 2008. The Dutch cessation campaign focused on smokers with low to moderate educational levels.Length of study2008 – 2010

General populationCessation: 281 out of 962 respondents (29.3%) had tried to quit smoking between the 2009 and 2010 surveys. At the 2010 survey, 86 out of 962 respondents (8.9%) had successfully quit smoking. There were no significant age inequalities in successful smoking cessation. Smokers aged 15–39 years were more likely to attempt to quit smoking.Exposure:In total, 82.4% reported having paid more for their cigarettes in the 2009 survey than in the 2008 survey, 65.6% reported having visited a drinking establishment that had some form of smoking restriction and 83.1% reported having experienced one or more parts of the campaign. Smokers aged 15–24 years were more exposed to the smoke-free legislation, whereas smokers aged 25–39 years were more exposed to the cessation campaign.Exposure to the smoke-free legislation and to the cessation campaign had a significant positive association with attempting to quit smoking in the univariate analyses, but not with successful smoking cessation. In the multivariate analyses, only the association between exposure to the smoke-free legislation with attempting to quit smoking remained significant [odds ratio (OR)=1.11, 95% confidence interval (95% CI)=1.01–1.22, P=0.029]. Exposure to the price

Internal validity70% follow-up rateExternal validityPrices increased by only 8%. Smokefree legislation was weak, not well implemented and issues with compliance.Study authors report that almost half of the sample was either lost to follow-up or did not answer all questions. These respondents were younger, less addicted and had more intention to quit smoking. Therefore, our results may not be fully generalizable to the broader population of Dutch smokers.Validity of author’s conclusionSmokefree, price, mass media campaigns were not associated with reduction in prevalence of smoking.

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Outcomes Exposure,Quit attempts,7-day point prevalence (successful quitters)

increase only predicted successful smoking cessation among young respondents.SES Exposure: Higher educated smokers were more exposed to the price increase and the smoke-free legislation.Smokers from different educational levels were reached equally by the mass media campaign.Cessation: There were no significant educational inequalities in successful smoking cessation.Author’s conclusion of SES impactThere were no overall ages or educational differences in successful smoking cessation after the implementation of the three interventions.

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Details Method Result Comments

Increases in price/tax of tobacco products

Author , year Peretti-Watel, 2009 CountryFranceDesignmixed-methods, included both national repeat cross-sectional data and in-depth interviews ObjectiveTo study the social differentiation of smoking between 2000 and 2008, and why low-income smokers are less sensitive to price increases.SES variables Subjective social statusLow-income, subjective: Wealthy, satisfying, on short side = Other. Hard to make ends meet OR we had to get into debt = ‘poor’. Consistency checked using neighbourhood socio-demographic profile and respondent’s education and occupational status Occupation: executive managers and professional occupations, manual workers, unemployed (for prevalence trend)

Data sources6 telephone surveys conducted by the National Institute for Prevention and Health Education (INPES) between 2000 and 2008 (N varied from 2000 to 30,000)Participant selection‘Next birthday’ method. Motivation studied through data extracted from the 2008 survey (poor n=115, other =506, response rate 71%). in-depth interviews with 31 ‘poor’ smokers

Participant characteristicsPoor smokers more likely to be female, manual worker/clerk, less than HS education, single parent compared to ‘other smokers’.31 qualitative interviews: The 31 participants were 13 women and 18 men, seven aged 30 or less, 12 aged 30 to 50, 12 aged 51 to 60. All participants reported financial and/or housing problems, and 25 were currently unemployed.Intervention Tobacco price increase between 2000 and 2008. Increase from €3.20, €3.35, €3.60, €4.60, €5(3y) to €5.30(2y) Length of study2000 to 2008 for prevalence data, 2008 only for motivation dataOutcomesApproaches to smoking

General populationN/ASES Difference in prevalence by occupational class has widened (from 36% EM&P v 44&45% to 29% v 43&50%). Smoking prevalence among executive managers and professionals fell after the cigarette prices had begun to increase, whereas manual groups showed a smaller, later, and temporary decline (prevalence increased again soon after).Reasons for smokingWere aware of addiction and of its financial cost. All spoke of stress-relief, several spoke of ‘little moment of happiness’, and it filled voids with nothing else to do, compensate for loneliness or emotional problems. Many felt it was the only joy they had left.Quantitative data – Concerning reactions to the cigarette price increase, about one third of poor smokers and other smokers reduced their cigarette consumption, but poor smokers were more likely to turn to cheaper or hand-rolled cigarettes (50% did so, versus 33% for other smokers).Significantly more likely to smoke automatically, less likely to smoke for social reasons, more likely to relieve stress and take mind of worries, less to aid concentration.Author’s conclusion of SES impactSmokers in low occupational groups and of low-income are less likely to respond to tobacco control measures due to the harsh living environment acts to sustain their attachment to smoking, despite understanding the costs. Acknowledging the functional aspects of smoking helps understand why price is unlikely to deter many poor smokers.

Internal validitySubjective measure of wealth, influenced by peers’ as much as personal wealth? Use two different measures of poverty between quantitative and qualitative data analyses.Validity of these findings is weakened by the relatively small sample of the manual group in most of the survey years. Size of occupational groups is not provided, but lower groups are only 30% and 10% respectively for the one year that they’re mentioned.

External validityQualitative interviews with 31 smokers who were based in South-Eastern France – may be region specific

Validity of author’s conclusionTentative, based on small sample sizes

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Variations in self-reported smoking status (smoking, non-smoker, never smoker)

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Details Method Results Comments

Increases in price/tax of tobacco productsAuthor, year Peretti-Watel 2009CountryFranceDesign Longitudinal cohort studyObjectiveto investigate how HIV-infected smokers reacted to a sharp increase in cigarette priceSES variablesEducation, income supportAnalysesUnivariate and multivariate analyses, generalised estimating equations

Data sourcesFrench cohort study APROCO-COPILOTE investigated biomedical and sociobehavioural characteristics of HIV-1 positive individuals who started an antiretroviral therapy including protease inhibitors. Monthly data on cigarette prices were provided by the French Monitoring Centre for Drugs and Drug Addiction). They corresponded to the price of a pack of cigarette of the bestselling brand in France.Participant selectionSubjects were enrolled between May 1997 and June 1999 in 47 French hospital departments delivering specialized care for HIV/AIDS patients. Participant characteristics1,146 HIV-infected smokers; socio-demographic background of seropositive patients varied greatly across the transmission groups. Patients infected through IDU had a lower SES, especially when compared to those infected through homosexual intercourse: only 6% had graduated from university (versus 15% and 31% in the heterosexual and homosexual groups respectively), 44% were clerks or manual workers (versus 34% and 21% respectively), and 63% were unemployed or on income support at baseline, month 28 or month 52 (versus 34% and 29% respectively).Intervention In France, the price of cigarettes doubled between 1997 and 2007 (from US$4 to US$8 approximately).Length of study

General population n/a – grouped by transmission group (infection through intravenous drug use (IDU), homosexual intercourse, heterosexual intercourse or otherSES We found striking differences across transmission groups regarding socio-demographic background and smoking prevalence. The IDU group was characterised by a lower socioeconomic status, a higher smoking prevalence and a smaller decrease in this prevalence over the period 1997-2007. The homosexual group had a higher socioeconomic status, an intermediate smoking prevalence in 1997, and the highest rate of smoking decrease. In the dynamic multivariate analysis, smoking remained correlated with indicators of socioeconomic disadvantage and with infection through IDU. Aging and cigarette price increase had a negative impact on smoking among the homosexual group, but not for the IDU group. In both univariate and multivariate analyses, smoking remained much more prevalent among the IDU group and, to a lesser extent among patients with a lower educational level as well as those who were unemployed or on income support during follow-up. In multivariate analysis only, smoking was significantly more prevalent among patients who never worked, as well as among those with an intermediate level of occupation.Author’s conclusion of SES impactAmong seropositive people, just as for the general population, poor smokers are poor quitters.

Internal validityattrition rate: 69% after 9 years but attrition not correlated with smoking statusExternal validityIn this study, the smoking prevalence observed among HIV-infected patients between 1997 and 2007 was higher than that measured in the French general population during the same period. Study results are generalisable to HIV infected smokers only having antiretroviral therapy.Validity of author’s conclusionBetween 1997 and 2007, increasing the excise taxes on tobacco products was the main instrument of French tobacco control policy (the ban on smoking in public places was only introduced in 2008), so conclusions valid.

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10 years (1997 to 2007) Data regarding respondents’ smoking status was collected every 8 months over the first 5 years, and every 12 months thereafter.Outcomesprevalence

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Details Method Result Comments

Increases in price/tax of tobacco productsAuthor , year Peretti-Watel, 2012 CountryFranceDesignSingle, cross-sectionalObjective(1) To build a typology of persistent smokers’ reactions to increasing cigarette prices (persistent smokers were defined as smokers who did not quit because of such increases) and (2) to investigate which factors were correlated with their reactions (no reaction, trying to quit or smoking less, reducing the cost of smoking).SES variables Educational level: <below high-school graduation; high-school completed; University degreeFinancial resources of the household: <1500D/month, ≥1500D/monthStudy analysesLogistic regressions

Data sourcesNational telephone survey conducted by the French Institute for Health Promotion and Health Education (INPES)Participant selectionRandom digit dialling methods were used to obtain listed and unlisted telephone numbers (including mobile phone numbers). The corresponding households were notified about the survey by mail. A professional interviewer selected one person age 18–75 in each household at random to be interviewed. Overall, 71% of the households contacted agreed to participate, giving a sample of 2000 respondents.Participant characteristicsCurrent smokers, n=621, 54% male, mean age 37.7%.<below high-school graduation (N = 351) 57%high-school completed (N = 121) 19%University degree (N = 149) 24%Financial resources of the household<1500D/month (N = 122) 20%≥1500D/month (N = 499) 80%Intervention Cigarette price increase. Questions about smokers’ reactions to increasing cigarette prices, as well

General population24% of persistent smokers did not change their smoking habits at all, 31% only reduced the cost of smoking (they neither reduced their consumption nor tried to quit) and 45% tried to give up smoking or reduced their consumption (they also frequently reduced the cost of smoking). Quit attempt = 29%.SES The more highly educated smokers more frequently reduce only the cost of smoking rather than quit attempt or smoke less (OR = 1.8 among those who had completed a university degree) and were much more likely to have shown no reaction (OR=3.0)Wealthier smokers more frequently reported no reaction at all to price increase rather than quit attempt or smoke less (OR=2.4 among those earning at least 1500 euros/monthAuthor’s conclusion of SES impactMore educated smokers and wealthier smokers more frequently reported no reaction at all to price increase.

Internal validityRefusal rate = 29%. Retrospective self-report. Weighted data so that sample representative of all French adults in terms of age, gender, education, geographical area and size of town of residence.External validityfocused mainly on the responses of smokers whodid not quitValidity of author’s conclusionValid but only tentative conclusions due to study design weaknesses – difficult to assess equity impact as focuses on smokers who did not quit

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as questions about their socio-demographic background, personal time perspective, smoking behaviour and reasons for smoking.Length of studyJune-July 2008, retrospective to 2003OutcomesQuit attempt/smoking less,Reduced smoking cost only,No change in smoking behaviour

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Details Method Results CommentsIncreases in price/tax of tobacco productsAuthor, year Ringel (2001)CountryUSAStudy designRepeat cross-sectional -econometric ObjectiveTo estimate how changes in statecigarette taxes affect the smokingbehaviour of pregnant womenSES variableseducation (none, less than highschool, high school, some college, college)Analysesprobit model, using a within-group estimator to account for state-specific effects and factors that vary over time

Data sourcesNatality Detail File, an annual census of births in the US (1989 to 1995), self-reported data for if mothers smoked during pregnancy and the amount smoked. Monthly state excise tax data from “The Tax Burden on Tobacco” adjusted to real 1997 values by the Consumer Price Index.Participant selectionParticipant characteristicsN=20,025,000. 16.5% of mothers reported smoking in pregnancy. 17.5% black, 67.1% white, 11% Hispanic; 39.7% aged 24 or less; 21.1% less than high school education, 36.6%high school, 40.2% college.Intervention Increase in cigarette taxLength of study1989 to 1995Outcomes smoking participation during pregnancy

General populationpregnant women onlyPrice elasticityFull sample: -0.70SESPrice elasticityEducationLess than high school:: -0.30High school: -0.49Some college: -0.86College: -3.39Author’s conclusion of SES impactSmoking participation rates varied widely across demographic and socioeconomic groups implying that responsiveness to price changes would vary in a similar way. The results indicate that highly educated women are most responsive to changes in cigarette taxes. All subgroups of pregnant women had higher price elasticities than the general population. This is not surprising because as many pregnant women try to quit smoking interventions such as tax increases may be more effective during pregnancy.

Internal validitylarge dataset from an annual census of allbirthsExternal validityUnderreporting of smoking status may be more of a problem for data from pregnant women compared with the general population. Generalisable to all pregnant women in USA.Validity of author’s conclusionValid

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Details Method Result CommentsIncreases in price/tax of tobacco productsAuthor, year Schaap, 2008 Country18 European countries; Finland, Sweden, Denmark, England, Ireland, Netherlands, Belgium, Germany, France, Italy, Spain, Portugal, Slovakia, Hungary, Czech Rep., Lithuania, Latvia, EstoniaDesignCross-sectionalObjectiveTo examine the extent to which tobacco control policies are correlated with smoking cessation, especially among lower education groupsSES variables Education; relative index of inequality (RII). The RII assesses the association between quit ratios and the relative position of each educational group, can be interpreted as the risk of being a former smoker at the very top of the educational hierarchy compared to the very lowest end of the educational hierarchyAnalysesLog-linear regression analyses to explore the correlation between national quit ratios and the national score on the Tobacco Control Scale (TCS).

Data sourcesNational health surveys. 100,893 respondents over 18 countries.Participant selectionSelection process varies. Non-response rate between 13.4 and 49% depending on country. Participant characteristicsIreland has most developed tobacco control policy, Latvia least. Intervention Joosens and Raw’s tobacco control scale used as a proxy, with some analysis by individual policies including:Price, advertising bans, public place bans, campaign spending, health warningsLength of studyYear 2000, except Germany and Portugal = year 1998-9.Outcomes Quit ratios

General population Large variations in quit rate and RII between countries.Quit rates positively associated with tobacco control scale score. Policies related to cigarette price showed the strongest association with quit ratios. A comprehensive advertising ban showed the next strongest associations with quit ratios in most subgroups. Health warnings negatively associated with quit rates. Regression coefficient 2.08 (-0.36 to 8.48) for men and 2.07 (-1.09 to 8.66) for women for price.Regression coefficient 1.33 (1.11 to 8.02) for men and 1.59 (1.39 to 8.67) for women for advertising bans.Regression coefficient 0.94 (-2.43 to 5.89) for men and 0.41 (-3.84 to 5.26) for women for public place bans.Regression coefficient 0.54 (-3.05 to 6.17) for men and 0.54 (-3.52 to 6.41) for women for campaign spending.Regression coefficient -0.40 (-7.32 to 2.31) for men and -0.42 (-9.51 to 3.43) for women for health warnings.A ‘stripped’ analysis focusing on price, health warnings and treatment (excluding recent policy developments) supported the main findings.SES Quit rates positively associated with tobacco control scale score. More educated smokers more likely to have quit than lower educated, for men and women. Larger absolute difference between high and low educated for 25-39 year olds. However no consistent differences were found between quit

Internal validityNon-response percentages ranged from about 15% in Italy and Spain up to 49% in Slovakia, while percentages in most other countries were between 20% and 35%.Survey conducted before tobacco control scale devised, and before some policies enacted so may underestimate the impact of recent policies.Difficult to draw conclusions about causality as study only examines the association between ex-smokers and presence of policies, rather than changes in prevalence post-implementation.Occasional smokers excluded from all analyses.External validityIncluded data from Eastern Europe and Baltic countries. Limited analyses to the adult population aged 25–59 years.Difficulty in drawing conclusions from multiple nations with varying average standards of education, definition of ‘highly educated’ likely to vary for some nations. Validity of author’s conclusionConclusion is consistent with the data presented; however it’s difficult to draw strong conclusions about the impact of any one intervention given the methodological limitations discussed above.

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ratios in high and low educated groups and tobacco control scale score.Policies related to cigarette price showed the strongest association with quit ratios. Significant positive association between quit ratio and price for high SES aged 40-59 years.A comprehensive advertising ban showed the next strongest associations with quit ratios in most subgroups (not low SES aged 40-59 or low SES women aged 25-39 years. Health warnings negatively associated with quit rates. Author’s conclusion of SES impactHigh and low educated groups seem to benefit equally from nationwide tobacco control policies. More developed tobacco control policies are associated with higher quit rates.

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Details Method Result CommentsIncreases in price/tax of tobacco productsAuthor , year Siahpush, 2009 Countryfive largest cities of Australia; Sydney, Melbourne, Brisbane, Perth, and AdelaideDesignRepeat cross-sectional - EconometricObjectiveTo examine the effect of price on cigarette smoking prevalence across three income groupsSES variables Income level of households highest earner; <$18,000 (low); $18,000–$49,000 (medium); >/=$49,000 (high).AnalysesPoisson regression modelling

Data sourcesRoy Morgan Single Source; weekly omnibus survey, face-to-face interviews by Roy Morgan Research, an Australian market research company. Cigarette price data were acquired from the retail trade magazine Australian Retail Tobacconist, which gave the recommended retail price for packs of all brands in each state and territory throughout the period of the study. Price was adjusted for inflation to reflect 2006 dollars. The adjusted price is often referred to as “real price.”Participant selection18+ years. random sample of Australian residents in the five largest cities of AustraliaParticipant characteristicsn=515866; 48% male, 21% 18-19 years, 41% 30-49 years. Approximately18% and 58% of the sample had low and medium levels of education, respectively. Approximately 23% and 45% had low and medium incomes, respectively.Intervention Change in adjusted (‘real’) cost of packet of cigarettes based on two leading brands; two top selling Australian brands, Peter Jackson 30s and Winfield 25s,

General population Between January 1991 and December 2006. Prevalence decreased from 28.2% to 19.7%, and price increased from $3.39 to $11.60. In the beginning of the period, the age-adjusted prevalences in the low-, medium-, and high-income groups were 36.5%, 28%, and 21.5%, respectively. At the end of the study period, the prevalences had decreased to 28.4%, 21.8%, and 16.6%, respectively.real price and prevalence were negatively associated (p<0.001)SESPrice elasticity in lowest income groups (<AU $18,000) of -0.32, but only -0.04 and -0.02 in medium and high income groups.One Australian dollar increase in price was associated with a decline of 2.6%, 0.3%, and 0.2% in the prevalence of smoking among low-, medium-, and high-income groups, respectively.There was a clear gradient in the effect of income on prevalence that diminished at higher levels of price.Author’s conclusion of SES impactLowest income group are most responsive to price increases.

Internal validityNo data on survey refusal rates.Included controls for several other policies enacted during the survey period; televised antismoking advertising, the availability of nicotine patches by prescription, the availability of nicotine replacement therapy by over-the-counter sale, the availability of buproprion by prescription, the introduction of six bold rotating health warnings on cigarette packs, the ban of most forms of tobacco sponsorship, and addiction (both myopic and rational).External validitySurvey covers 61% of adult population, but only in metropolitan areas. Generalisability to rural areas unknown.Over the 4-year period during which prices were monitored, the average actual price of cigarettes sold across all outlets was significantly lower than the recommended prices, but the extent to which it was lower remained constant over the course of the study. Study focuses on only 2 brands – 38% of the market in 2003 – is this sufficient to capture valid results?Validity of author’s conclusion

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Length of study1991 to 2006Outcomes Smoking prevalence, measured by whether respondents currently smoked manufactured cigarettes or had smoked roll your own tobacco in the previous month

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Details Method Results Comments

Controls on advertising, promotion and marketing of tobaccoAuthor , year Cantrell 2013CountryUSADesignRCT (random numbers generator)ObjectiveTo evaluate the potential impact of pictorial warning labels compared with text-only labels among U.S. adult smokers from diverse racial/ethnic and socioeconomic subgroups.SES variables income (<150% federal povertylevel [FPL]/150–300% FPL/300%+ FPL);education (high school or less/some college/college or more)Analysesregression analyses adjusted for race/ethnicity, education, and income

Data sourcesweb-based experimental studyParticipant selectionRecruited from two online research panels (GfK Group [formerly Knowledge Networks] KnowledgePanel® and Research Now – both had purposive recruitingParticipant characteristicsN = 3,371, adult smokers, 1,665 subjects were randomized to the text-only condition and 1,706 subjects were randomized to the pictorial HWL condition.<150% FPL:26.3%150–300% FPL:28.1%300%+ FPL:45.6%Education HS or less:29.1%Some college:41.6%College+:29.3%

Intervention Warning label policy. U.S. Family Smoking Prevention and Tobacco Control Act of 2009 requires updating of the existing text only health warning labels on tobacco packaging with nine new warning statements accompanied by pictorial images.Participants viewed either the new FDA approved pictorial warnings or text-only warnings.

General populationSignificantly stronger reactions for the pictorial condition for each outcome: salience (b = 0.62, p<.001); perceived impact (b = 0.44, p<.001); credibility (OR = 1.41, 95% CI = 1.22-1.62), and intention to quit (OR = 1.30, 95% CI = 1.10-1.53). SES Individuals with a high school education or less compared with higher educated individuals had stronger responses for perceived impact and salience. There were no significant differences in reactions across income categories.No significant results were found for interactions between condition and race/ethnicity, education, or income. Which suggest that the greater impact of the pictorial HWLs compared to the text-only HWL was consistent across these study subpopulations. The only exception concerned the intention to quit outcome, where the condition-by-education interaction was nearly significant (p = 0.057). Stronger effect for the pictorial condition versus the text-only condition among individuals with moderate education compared with higher educated groups.Author’s conclusion of SES impactFindings suggest that the greater impact of the pictorial warning label compared to the text-only warning is consistent across diverse racial/ethnic and socioeconomic populations. suggest that the FDA-

Internal validityThis paper reports wave 1 (of 3) of data analyses. Study adequately powered. For the KnowledgePanel®, the panel recruitment rate was 14.3% and the survey completion rate 50.4%; for the opt-in panel (Research Now), the survey completion rate for the opt-in panel was 18.0%.Compared to participants in the experimental condition, those in the control group included slightly more individuals with college education (i.e., 27.8% versus 30.9%,), fewer individuals with some college education (i.e., 39.5% versus 43.6%) and fewer individuals who were ready to quit (21% versus 24.2%). However, these differences were relatively small and only marginally statistically significant.Race/ethnicity, education and income differed across the two panels by design, due to purposive recruiting of specific subgroups of smokers available in each panel. Smoking behaviors also varied between the two panels, with most markers of addiction

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2x9 factorial with two conditions (text-only and text+ pictorial images) and 9 HWL messages (e.g., ‘‘Cigarettes cause cancer’’).Participants assigned to the control condition were exposed to one of nine text-only HWLs, and participants in the experimental condition were exposed to one of 9 pictorial HWL with the same text messages as in the control condition. The HWL stimuli included the 9 distinct textual messages and the pictorial imagery designed to accompany them. The stimuli consisted of the front of a plain package of cigarettes, which was approximately 2 inches wide by 2.75 inches high on the computer screen with the HWL text or HWL text+pictorial covering the front and top 50% of the package. The size, color and font of the text were equivalent in both the text only and text+pictorial images.Length of studySeptember 2011Outcomes Salience,Perceived impact,Credibility, Intention to quit

approved pictorial HWLs can achieve their desired effect without exacerbating inequalities

being somewhat higher among the KnowledgePanel® respondents: for example, KnowledgePanelH subjects smoked significantly more cigarettes per day and had lower readiness to quit compared with the opt-in panel.Table 3 does not report data for highest SES groups (income and education)External validityThe text-only warnings in this study are not equivalent in placement, size or font to the current text-only warnings in the U.S., which are on the sides of packs, in smaller font and in colours that blend in with the colour scheme of the pack.Study does not replicate real life.Validity of author’s conclusionValid, authors hypothesised that pictorial labels would be more effective than text-only labels amongst lower SES

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Details Method Results Comments

Controls on advertising, promotion and marketing of tobaccoAuthor , year Frick 2012CountryColumbus, Ohio, USADesignSingle cross-sectionalObjectiveTo assess retailer compliance with Food and Drug Administration (FDA) regulations on tobacco sales and advertising practices, including point-of-sale advertisements, in two distinct Columbus, Ohio neighbourhood groups by income.SES variables High and low income neighbourhoods, defined as proportion of families in poverty with those above median designated as low income and those below median as high incomeAnalysesDescriptive, t tests and Chi square

Data sourcesField observationsParticipant selectionRandom sampleParticipant characteristics129 licensed tobacco retailersIntervention Tobacco Control Act and FDA regulations on tobacco sales and advertising practices, including point-of-sale advertisements. Practices considered out of compliance with FDA regulation were: sales of loose cigarettes, offering free items with cigarette or smokeless tobacco (ST) purchase, and self-service access to cigarette or ST products.Length of studyOctober to December 2010Outcomes Compliance with exterior and interior marketing and sales practices

General populationNo outlets were out of compliance by selling loose cigarettes or offering free items with cigarette purchase.SES Less than 10% of sampled outlets were out of compliance by offering self-service access to cigarettes, which did not differ by neighbourhood income (P<0.05).There were no significant differences in compliance by income, but the mean number of advertisements on the building and self-service access to cigars was significantly different by neighbourhood income (TCA does not apply to cigar self-service).Author’s conclusion of SES impactHighly prevalent advertising and marketing and also high degree of compliance with regulations. Some significant difference between high and low income neighbourhoods.

Internal validityAll tobacco retailers required state licence and only 3 retailers currently in business were not surveyed.Single observer.External validitySpecific to this urban region and regions with similar distributions of families in poverty.Validity of author’s conclusionValid. Study doesn’t inform on how advertising and sales practice influence smoking behaviour.

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Details Method Results CommentsControls on advertising, promotion and marketing of tobaccoAuthor, year Hammond 2013

CountryUS

Study design Quasi-randomised trial

ObjectiveTo evaluate the efficacy of the 36 proposed FDA warnings for each of the nine “statements” or health effects specified in the Act.

SES variablesAnnual net household income (Low <$30,000,Medium $30,000 – 59,999, High ≥ $60,000)Education level (Low = high school or less, Medium = technical/trade/community college or some university, and High = university degree or higher). Study analysisLinear mixed effects models were used to test all pairwise differences between individual warnings within each of the nine health effect sets (separately for the adult and youth samples), adjusting for multiple comparisons using the Tukey correction.

Data sourcesWeb-based survey of US respondents Participants were compensated with points from the survey firm (equivalent to ~ $3 USD).

Participant selectionRecruited via email from a consumer panel through Global Market Insite, Inc.

Participant characteristicsAdult smokers (n=783, aged 19 years or older, mean age 47, and smoked at least one cigarette in the last month) and youth (n=510, aged 16 – 18, including both smokers and non-smokers).Adults: 25% low education, 45% medium education and 30% high education. 24% low income, 39% medium income, 35% high income and 2% refused.

InterventionWeb-based survey to view and rate two sets of 6-7 health warnings, each set corresponding to one of nine health effect statements required under the Tobacco Control Act

Length of studyDecember 2010

Outcomes Respondents rated each warning while the image appeared on screen, one at a time then ranked the warnings within a set

General population impactComparisons on specific elements indicated that warnings were perceived as more effective if they were: full color (vs. black and white), featured real people (vs. comic book style), contained graphic images (vs. nongraphic), and included a telephone “quitline” number or personal information. Among adults, younger respondents gave higher effectiveness ratings.Impact by SES variableAssociation between index ratings scores and both education and income were not significant. Author’s conclusion of SES impactThe most effective ratings performed equally well across SES groups.

Internal validityDue to a technical flaw in the program, the second set of warnings assigned to respondents was not assigned at random from the remaining eight sets. For example, for a respondent randomly assigned to see Set 3 first (all sets received an arbitrary number for the purposes of programing), the second set of warnings was randomly assigned from sets 4 through 9 only, rather than Sets 1, 2, and 4 – 9. Therefore, the number of participants who viewed each set of warnings not balanced.Internal consistency of the four outcome measures was tested on a subset of responses (the first warning labels viewed by participants) and was demonstrated to be very high (Cronbach’s α = .93). Therefore, a single index of warning label effectiveness was created by calculating the mean rating of the four measures.External validityStudy sample likely to be more educated and have a higher socioeconomic profile than the general population. The study setting in which participants rated a series of warnings after viewing the warnings for a brief amount of time does not replicate the repeated exposures of health warnings in “real life.”

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on overall effectiveness. Youth not assessed by SES.Validity of author’s conclusionNot representative study sample and results by SES only described in text.

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Details Method Results CommentsControls on advertising, promotion and marketing of tobaccoAuthor , year Hitchman 2012CountryFrance, Germany, the Netherlands, UKDesignCross-sectional ObjectiveTo examine the effectiveness of the text health warnings among daily cigarette smokers in France, Germany, the Netherlands, UKSES variables Education, net household incomeAnalysesLinear and logistic regressions

Data sourcesInternational Tobacco Control Policy Evaluation Project.Computer-assisted telephone interviewing (CATI). In the Netherlands, two different sampling and survey modes were used: (i) a CATI sample a computer-assisted web interviewing (CAWI) sample Participant selectionrandom digit dialling, CAWI sample drawn from internet panel TNS NIPObaseParticipant characteristicsDaily smokers (>/=18 years of age) from France (n = 1,532), Germany (n = 1,305), the Netherlands (n = 1,788) and the UK (n = 1,788).Intervention The European Commission requires tobacco products sold in the European Union to display standardized text health warningsLength of studySingle survey wave in each of the 4 countries between 2007 and 2008Outcomes (i) smokers’ ratings of the health warnings on warning salience, thoughts of harm and quitting and forgoing of cigarettes; (ii) impact of the warnings using a Labels Impact Index (LII), with higher scores signifying greater impact;

General populationScores on the LII differed significantly across countries. Scores were highest in France, lower in the UK, and lowest in Germany and the Netherlands. Impact tended to be highest in countries with more comprehensive tobacco control programmes.SES Across all countries, scores were significantly higher among low-income smokers (i.e. rated warnings more effective) F3,6142 = 5.44, P = 0.001, with no significant interaction between country and income. There was a main effect of education, F2, 6142 = 5.46, P = 0.004, as well as a country x education interaction, F6,6142 = 4.62, P < 0.001. Although scores on the LII tended to be higher among smokers with low to moderate education in France, Germany and the Netherlands, the opposite trend was observed in the UK.Author’s conclusion of SES impactThe impact of the health warnings was highest among smokers with lower incomes and smokers with low to moderate education (except the UK in the case of education) suggests that health warnings could be more effective among low SES groups.

Internal validitySurvey cooperation rates were: France (75.3%), Germany (94.9%), the Netherlands CATI (78.1%), the Netherlands CAWI (78.1%) and the UK (87.3%). Stratified geographically except France and analyses weighted on sex and age.External validityComparison of data across 4 European countries.Validity of author’s conclusionValid although UK and France now have pictorial warnings

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(iii) differences on the LII by demographic characteristics and smoking behaviour.

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Details Method Results Comments

Controls on advertising, promotion and marketing of tobaccoAuthor, year Kasza 2011CountryUnited Kingdom, Canada, Australia, and the United StatesDesign prospective cohort surveyObjectiveTo examine the effectiveness of advertising restrictions enacted in different countries on exposure to different forms of product marketing, and differences in exposure across different SES groups.SES variablesannual household income and level of education were combined to create a three-category indicator of SES using the following criteria: if both income and education were low, then SES was defined as low, if either income or education was low, then SES was defined as moderate, and if neither income nor education were low, then SES was defined as high.Analysesgeneralized estimating equations multivariate regression analyses adjusted for age, gender, minority group, and the heaviness of smoking index

Data sourcesInternational Tobacco Control Four Country Survey (ITC-4)Participant selectionRandom digit dialling was initially used to recruit current smokers within strata defined by geographic region and community size.Participant characteristics21,615 adult smokers (5251 in the UK, 5265 in Canada, 4806 in Australia, and 6293 in the US).Intervention 35-minute telephone survey to evaluate the psychosocial and behavioural impact of various national-level tobacco control policies on marketing regulations.Length of study6 years; waves 1 to 7 collected between 2002 to 2008OutcomesAwareness of tobacco marketing through 15 different channels.

General population Since 2002, various tobacco marketing regulations have been enacted in the United Kingdom (UK), Canada, Australia and the United States.Tobacco marketing regulations, once implemented, were associated with significant reductions in smokers’ reported awareness of pro-smoking cues, and the observed reductions were greatest immediately following the enactment of regulations. While tobacco marketing regulations have been effective in reducing exposure to certain types of product marketing there still remain gaps, especially with regard to in-store marketing and price promotions.SES Changes in reported awareness were generally the same across different SES groups, although some exceptions were noted: awareness of billboard advertising and arts sponsorships in the UK were reduced more sharply among those in the high SES group relative to those in the low SES group immediately following enactment of Tobacco Advertising and Promotion Act 2002.In each of the four countries, the high SES groups experienced greater reductions in the total number of channels through which they reported being aware of tobacco marketing compared to the low SES groups. However, at baseline, the high SES groups in each country were exposed to more marketing channels than were the low SES groups, leaving the high groups more room to experience reduction across the study period.Author’s conclusion of SES impacttobacco marketing regulations are associated

Internal validityRespondents lost to attrition were replenished at each wave. All respondents who participated in at least one of the seven survey waves were included in the present study.External validityFindings from each of the four countries can be compared as same survey used. Validity of author’s conclusionIn the UK, national legislation prohibiting smoking in worksites, bars, and restaurants was implemented during this time might have influenced awareness of tobacco marketing.

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with reduced exposure to pro-smoking cues among all SES groups, evidence indicates that certain channels are still being used by tobacco companies to reach significant percentages of smokers in each country.

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Details Method Result CommentsControls on advertising, promotion and marketing of tobaccoAuthor, year Schaap, 2008 Country18 European countries; Finland, Sweden, Denmark, England, Ireland, Netherlands, Belgium, Germany, France, Italy, Spain, Portugal, Slovakia, Hungary, Czech Rep., Lithuania, Latvia, EstoniaDesignCross-sectionalObjectiveTo examine the extent to which tobacco control policies are correlated with smoking cessation, especially among lower education groupsSES variables Education; relative index of inequality (RII). The RII assesses the association between quit ratios and the relative position of each educational group, can be interpreted as the risk of being a former smoker at the very top of the educational hierarchy compared to the very lowest end of the educational hierarchyAnalysesLog-linear regression analyses to explore the correlation between national quit ratios and the national score on the Tobacco Control Scale (TCS).

Data sourcesNational health surveys. 100,893 respondents over 18 countries.Participant selectionSelection process varies. Non-response rate between 13.4 and 49% depending on country. Participant characteristicsIreland has most developed tobacco control policy, Latvia least. Intervention Joosens and Raw’s tobacco control scale used as a proxy, with some analysis by individual policies including:Price, advertising bans, public place bans, campaign spending, health warningsLength of studyYear 2000, except Germany and Portugal = year 1998-9.Outcomes Quit ratios

General population Large variations in quit rate and RII between countries.Quit rates positively associated with tobacco control scale score. Policies related to cigarette price showed the strongest association with quit ratios. A comprehensive advertising ban showed the next strongest associations with quit ratios in most subgroups. Health warnings negatively associated with quit rates. Regression coefficient 2.08 (-0.36 to 8.48) for men and 2.07 (-1.09 to 8.66) for women for price.Regression coefficient 1.33 (1.11 to 8.02) for men and 1.59 (1.39 to 8.67) for women for advertising bans.Regression coefficient 0.94 (-2.43 to 5.89) for men and 0.41 (-3.84 to 5.26) for women for public place bans.Regression coefficient 0.54 (-3.05 to 6.17) for men and 0.54 (-3.52 to 6.41) for women for campaign spending.Regression coefficient -0.40 (-7.32 to 2.31) for men and -0.42 (-9.51 to 3.43) for women for health warnings.A ‘stripped’ analysis focusing on price, health warnings and treatment (excluding recent policy developments) supported the main findings.SES Quit rates positively associated with tobacco control scale score. More educated smokers more likely to have quit than lower educated, for men and women. Larger absolute difference between high and low educated for 25-39 year olds. However no consistent

Internal validityNon-response percentages ranged from about 15% in Italy and Spain up to 49% in Slovakia, while percentages in most other countries were between 20% and 35%.Survey conducted before tobacco control scale devised, and before some policies enacted so may underestimate the impact of recent policies.Difficult to draw conclusions about causality as study only examines the association between ex-smokers and presence of policies, rather than changes in prevalence post-implementation.Occasional smokers excluded from all analyses.External validityIncluded data from Eastern Europe and Baltic countries. Limited analyses to the adult population aged 25–59 years.Difficulty in drawing conclusions from multiple nations with varying average standards of education, definition of ‘highly educated’ likely to vary for some nations. Validity of author’s conclusionConclusion is consistent with the data presented; however it’s difficult to draw strong conclusions about the impact of any one intervention given the methodological limitations discussed above.

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differences were found between quit ratios in high and low educated groups and tobacco control scale score.Policies related to cigarette price showed the strongest association with quit ratios. Significant positive association between quit ratio and price for high SES aged 40-59 years.A comprehensive advertising ban showed the next strongest associations with quit ratios in most subgroups (not low SES aged 40-59 or low SES women aged 25-39 years. Health warnings negatively associated with quit rates. Author’s conclusion of SES impactHigh and low educated groups seem to benefit equally from nationwide tobacco control policies. More developed tobacco control policies are associated with higher quit rates.

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Details Method Results Comments

Controls on advertising, promotion and marketing of tobaccoAuthor, year Willemsen 2005CountryThe NetherlandsDesign Cross-sectionalObjectiveTo examine the self-reported effect of thehealth warnings on cigarette packets on the attractiveness of cigarettes, on smokers' motivation to quit and on smoking behaviour, and to determinewhether these effects differed for subgroups of smokers.SES variableseducationAnalysesUnivariate and multivariate logistic regression

Data sourcesContinuous Survey of Smoking Habits(CSSH) carried out by TNS NIPO.Participant selectionInternet survey in which each week 800 households are randomly selected from a database of .50 000 households.Participant characteristics12,654 aged 15 years+, in original sample; 3,937 of original sample were smokers (31%), 3318 (84.3%) had noticed change to health warnings and were asked further questionsIntervention EU Directive as of 30 Sept 2002, the front of cigarette packets in EU countries were required to have one of two health warnings, covering 30% of surface. The back of the packet must contain one of 14 different health warnings, covering 40% of the surface. On 1 May 2002 the new health warning labels came into effect in The Netherlands.Length of studyJune 2002 to June 2003Outcomesnoticing changes to warningssmoking behaviourmotivation to quitPreference for buying pack with / withoutnew warning inclination to buy cigarette packwith new warning

General population Across the survey period, 3318 (84.3%) said they had noticed changes to the health warnings. This percentage was higher in the 3 months directly after the introduction (90%) compared with the months April to June of 2003 (81% p<0.001). Of all smokers, 14% indicated they were less inclined to purchase cigarettes as a result of the new warnings; 31.8% said they prefer to buy packets without the new warnings; and 10.3% said they smoked less because of the new warnings. A strong dose-response relationship was observed, e.g. the higher the intention the greater the impact of the warnings. 17.9% reported that warnings made them more motivated to quit; Multivariate analysis showed that those intending to quit smoking within 1 month had higher change of reporting that they smoke less because of new warnings (OR 7.89) independent of other variables.SES Self-reported change in smoking behaviourThere were no significant differences in level of education for respondents in reported change in smoking behaviour.Self-reported change in motivation to quitMore respondents with medium level of education (19.4%) reported being more motivated to quit than those of high (18.3%) or low levels (15.8%) (p<0.001)Preference for buying pack with/without new warningMore respondents with a higher level of education (35.5%) reported a preference for buying packs without the new warning compared to those of low (28%%) or medium

Internal validityExcluded proxy interviews and excluded interviews in April and May 2003 as smokers unable to purchase packets containing new warnings.External validityUnclear whether internet survey is representativeValidity of author’s conclusionOnly surveys smoker participants who had noticed the new health warning labels who might be more motivated to change smoking behaviour

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levels 31%.Change in inclination to buy cigarette pack with new warningThere was no significant difference between education levels in inclination to buy the new packs.Author’s conclusion of SES impactResults by SES not discussed outwith tables

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Details Method Results CommentsControls on advertising, promotion and marketing of tobaccoAuthor, year Wilson 2010aCountryNew ZealandDesign Prospective cohortObjectiveTo examine how recognition of a nationalquitline number changed after new health warnings were required on tobacco packagingSES variablessmall area deprivation, individualdeprivation, and financial stressAnalysesPaired matched odds ratio

Data sourcesInternational Tobacco ControlPolicy Evaluation Survey (ITC Project) New Zealand armParticipant selectionThe NZ arm of the ITC Project survey differs somewhat from other ITC samples as the smokers involved are New Zealand Health Survey (NZHS) participants. NZHS respondents were selected by a complex sample design, which included systematic boosted sampling of the Māori, Pacific, and Asian populations. Invited at end of NZHS to participate in this study.Participant characteristics923/1376Intervention Wave 1 respondents were exposed to text-based warnings with a quitline number but no wording to indicate that it was the “Quitline” number. Wave 2 respondents were exposed to pictorial health warnings (PHWs) that included the word “Quitline” beside the number as well as a cessation message featuring the Quitline number and repeating the word “Quitline.” Length of study12 months (wave 1 between March 2007 and February 2008 and wave 2 between March 2008 and February 2009.OutcomesQuitline number recognition

General population The introduction of the new PHWs was associated with a 24 absolute percentage point between-wave increase in Quitline number recognition (from 37% to 61%, p < .001). Matched odds ratio of 3.31, 95% CI = 2.63 to 4.21.SES A majority of all five quintiles of socioeconomic deprivation using a small area measure (range 58.0%–65.5%) recognized the Quitline number in Wave 2. The increase between the waves was lowest in the most deprived quintile (p < .001), though this group had the highest level of recognition at baseline. For individual deprivation, the increase was highest in the second to least deprived grouping and lowest in the most deprived. For both types of deprivation, the most deprived had the highest level of recognition in Wave 1 and the lowest level of recognition at Wave 2 (though in the latter, the differences were not significantly different).Recognition increased from a minority of respondents to a majority for all deprivation levels (using small area and individual measures), and financial stress (two measures). Author’s conclusion of SES impactThis study provides some evidence for the value of clearly identifying quitline numbers on tobacco packaging as part of PHWs and appeared to benefit all sociodemographic groups. It may also help equalize differences that previously existed, for both measures of deprivation.

Internal validityBetween-wave attrition of 32.9% occurred. External validityThe overall response rate for this study was 32.6%. Weighting process may not have fully adjusted for nonresponse bias.Validity of author’s conclusionMay not be generalisable to whole of New Zealand due to sampling.

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Details Method Results CommentsControls on advertising, promotion and marketing of tobaccoAuthor , year Zacher 2012CountryMelbourne, AustraliaDesignCohort of stores (before and after) ObjectiveTo evaluate compliance with legislation which restricted cigarette displays in retail outlets, and to assess prevalence of pro- and anti-tobacco elements in stores pre- and post-legislation.SES variables Neighbourhood SES: Australian Bureau of Statistics’ Socio-Economic Indexes for Areas (SEIFA) index of disadvantage. Low-SES includes postcodes in the first two quintiles of the index, mid-SES includes postcodes in the third and fourth quintiles, and high-SES contains postcodes in the upper quintile.Analysesmixed model repeated measures

Data sources3 observational audits Participant selectionStores randomly selected using electronic white and/or yellow pagesParticipant characteristics302 stores (milk bars, convenience stores, newsagents, petrol station, supermarket)Intervention Point of Sale cigarette display ban. Legislation which restricted cigarette displays in retail outlets.Experienced fieldworkers attended stores and observed tobacco displays, behaving like regular customers. Length of studyOctober 2010 and December 2011Outcomes Anti-Tobacco Signage Index;Pro-Tobacco Index

General populationOf 290 stores, 94.1% observed the full ban on cigarette package visibility, while new restrictions on price board size and new requirements for graphic health warnings were followed in 85.9% and 67.2% of stores, respectively. In Audit 3, 89.7% of the remaining 281 stores complied with price board restrictions, and 82.2% of stores followed requirements for graphic health warnings.SES Overall, the prevalence of anti-tobacco signage increased and pro-tobacco features decreased between audits for every store type and neighbourhood SES.Mid-SES stores had consistently lower scores than low- and high-SES stores for non-mandated signage (i.e. removed graphic health warning indicator) but not mandated signage.Author’s conclusion of SES impactAnti-tobacco signage was observed more frequently over time in all store types and for all neighbourhood SES groups. The large variation in the extent of pro-tobacco features in different store types prior to the legislation diminished substantially after the legislation was introduced, leaving stores of all types (and from all SES areas) with very few pro-tobacco features.

Internal validitySpecialist tobacconists were excluded, as they were exempt from the legislation.290/302 still sold tobacco at second audit and 281/302 still sold tobacco at third audit.External validitysample of stores located in the Melbourne, Victoria, metropolitan area, results may not be generalizable to all tobacco retailers in the state of Victoria, though Melbourne accounts for 74% of Victoria’s populationValidity of author’s conclusionValid

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Details Method Results CommentsMass media - Quit & Win campaignAuthor, year Alekseeva 2007CountryNovobirsk, RussiaDesign Repeat yearly cohortsObjectiveTo study participants of the campaignSES variableseducationAnalysesRegistration card at baseline and follow-up questionnaire at one year follow-up

Data sourcesNovosibirsk Quit & Win Campaign 1998 to 2004Participant selectionn/aParticipant characteristics18 years and older, smoked at least one cigarette a day during one year and wants to quitIntervention Interviewed registered participants of international quit & win campaign one year after each campaign. Conducted at same time in each country, all participants to abstain from 1st May to 29th

May and end on International non-smoking day 31st May. Participants who did not smoke may take part in drawing of the prize, abstinence biochemically confirmed. International prize (10,000 US$) and 6 regional prizes (2,500 US$) are raffled between winners from participating countries.Length of study6 years; 1998 to 2004Outcomes1 month abstinence (cotinine)1 year abstinence (cotinine)Uptake of campaign by education level

General population did not smoke during month of campaign:1994=69.8% (n=1261)1996=92% (n=455)1998=88% (n=1358)2000=82% (n=1228)2002=90% (n=742)did not smoke in following year:1994=36.5% (n=1261)1996=37.5% (n=455)1998=40% (n=1358)2000=40% (n=1228)2002=40.6% (n=742)90% did not smoke during month of campaign and 40% did not smoke in following year. Number of people willing to stop smoking completely increased from year to year. Participants intentions before the campaign:Intention to quit completely:1996=77%1998=79%2000=82%2002=87%Intention to quit for one month:1996=11%1998=10%2000=8%2002=2%Intention to decrease smoking:1996=12%1998=11%2000=10%2002=11%

Internal validityOnly analyses uptake by education level and not abstinenceExternal validitythere is no comparison with the SES of smokers in the general populationValidity of author’s conclusionCannot tell if there is an equity effect.

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Details Method Results CommentsMass media - Quit & Win campaign

35% in 1998 and 92% in 2004.SES Higher education; 32% in 1998, 43% in 2000, 30% in 2002; Secondary professional education; 28% in 1998, 27% in 2000, 27% in 2002;Secondary school education; 15% in 1998, 16% in 2000, 13% in 2002Primary education; 10% in each campaignAuthor’s conclusion of SES impactMass antismoking campaigns are effective.

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Details Method Results CommentsMass media - Quit & Win campaignAuthor, year Bains 2000Country4 counties, Eastern Ontario, CanadaDesign Cohort with comparison cohort groupObjectiveTo evaluate the impact of an intervention that was developed to help daily smokers to quit smoking completely.SES variableseducationAnalysesBivariate and multiple logistic regression

Data sourcesTelephone surveyParticipant selectionComparison group selected by random telephone survey from larger 4-county areaParticipant characteristics231 Quit & Win Challenge participants from two of the four Eastern Ontario counties (Frontenac, Lennox & Addington). 1) Residents of Eastern Ontario; 2) aged 18 or older; 3) daily smokers, consuming a minimum average of 10 cigarettes per day; and 4) entered the Quit and Win contest in January 1995.Smokers selected by random telephone survey (n = 385) came from these regions as well as two neighbouring counties (Hastings, Prince Edward). 1) Residents of Eastern Ontario; 2) aged 18 or older; and 3) daily smokers, consuming a minimum average of 10 cigarettes per day.4 counties in Eastern Ontario = combined population of approximately 306,000. About two thirds of the population resided in an urban area, and the first language of 92% of residents was English. The

General population After one year, 19.5% of Quit & Win participants reported that they were smoke-free, whereas less than 1% of the random comparison group had achieved cessation. Participation rate of 0.83% combined with the cessation rate means impact rate was 0.17% (extrapolates to 1 in 8 smokers led to quit due to Quit & Win contest).SES Compared with the random survey group, Quit and Win participants tended to be more educated at baseline. Intervention vs control:Less than high school 1.8% vs 11.2% Some high school 13.2% vs 22.9%Completed high school 29.8% vs 34.0%Some college/university 16.7% vs 14.0%Completed college 38.6% vs 18.2%P=0.001Author’s conclusion of SES impactNo association between level of education or occupation level and cessation at one year. The intervention did not well represent smokers with lower SES.

Internal validityResponse rates = 97.7% for intervention group and 92.8% for control groupFollow-up rate = 86.5%, n=200) in intervention group and 84.4% (n=325) in control groupExternal validitySpecific to region of Eastern Ontario.87% Quit & Win participants were actively trying to quit at baseline (and were more likely to successfully quit) so only relevant to highly motivated population. person's motivation to quit, as indicated by categorization according to the Stages of Change model, showed a strong (albeit not statistically significant) association with one-year cessation.Validity of author’s conclusionValid – less SES could be due to differences in motivation between SES groups or differences in exposure to advertising/methods of

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Details Method Results CommentsMass media - Quit & Win campaign

median household income in 1991 was about $44,000, and the overall rate of unemployment was 8.6%.Intervention Quit & Win challenge, incentive-based intervention plus Quit Kit. The intervention was developed to help daily smokers to quit smoking completely.Enrolled adult smokers who pledged to quit smoking for a designated period of time. In exchange, they were entered into a lottery with a cash prize of $1,000 and secondary prizes of lesser values. The initiative was promoted through the local print and radio media, as well as through the distribution of leaflets. A contest winner, who was required to be smoke-free in the month leading up to the prize ceremony, was selected by random draw approximately three months after the contest was initiated. As described in the contest rules, the winner was asked to provide the name of a "buddy" to be contacted to verify his or her smoke-free status. Those who enrolled in the contest were also given the educational Quit Kit, which contained a letter of encouragement,

advertising by SES groups.

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Details Method Results CommentsMass media - Quit & Win campaign

information on cessation methods, a list of local cessation programs, helpful tips on maintaining a smoke-free status and a refrigerator magnet with the telephone number of a health unit information line.Length of study1995 to 1996OutcomesSelf-reported 6 months continuous abstinence

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Details Method Results CommentsMass mediaAuthor, year CDC 2007CountryNew York City, USADesign Before and after study (different participants)ObjectiveTo assess the effect of two mass media campaigns on smoking prevalenceSES variableseducationAnalysesregression

Data sources2006 New York City Department of Health and Mental Hygiene (DOHMH) annual health surveys Participant selectionrandom-digit–dialed health surveys of approximately Participant characteristics10,000 adult New York City residents Intervention Extensive, television-based anti-tobacco media campaign using graphic imagery of the health effects of smoking; focused on increasing smokers’ motivation to quit. Advertisements included testimonials from sick and dying smokers and graphic images of the effects of smoking on the lungs, arteries, and brains of smokers.Advertisements included diverse messages in both English and Spanish. The television campaign broadcast for 23 of 40 weeks during January–October 2006, with 100–600 gross ratings points (GRPs) per week, for a total of approximately 6,500 GRPs.New York State Department of Health also aired a separate, simultaneous statewide television-based anti-tobacco media campaign that included New York City. The campaign included advertisements featuring graphic images of the effects of smoking and emphasizing the effects of secondhand smoke on children. The broadcasts equated to approximately 4,400 GRPs in New York City from January through December 2006. Thus, in total, New York

General population The smoking prevalence among New York City residents decreased significantly from 21.5% in 2002 to 18.4% in 2004 (p<0.001). From 2004 to 2005, smoking prevalence did not change significantly among New York City residents overall. in 2006, the year during which television advertisements were aired, smoking prevalence did not change significantly among New York City residents overall (17.5% in 2006 compared with 18.9% in 2005, p=0.055). The total decrease associated with New York City’s comprehensive program from 2002 to 2006 was 19%, an average annual decrease of 5%.SES From 2002 to 2004 decreases were demonstrated in all education subgroups. % change in smoking prevalence from 2002 to 2006 among those with less than a college education was higher than among those with more education (p<0.001). From 2004 to 2005, no significant changes occurred within education subgroups. Author’s conclusion of SES impactIntensive, broad-based media campaign has reduced smoking prevalence among certain subgroups.

Internal validitytelephone survey excluded certain populations (e.g., military personnel residing on bases, institutionalized populations, and persons without landline telephonesExternal validityThis decrease in prevalence occurred more quickly than those documented by BRFSS in California (3%–4% annually during 1998–2005), Massachusetts (2% annually during 1995–2005), or the United States as a whole (2% annually during 1965–2004 and 3% annually during 2002–2006) in any period since data were first collected in 1965.Validity of author’s conclusionEditor’s note: the New York City data suggest that large-scale, intensive anti-tobacco media campaigns, when implemented in the context of existing comprehensive tobacco-control components such as taxation and smoke-free workplace legislation, can have a contributoryeffect on reducing smoking prevalence among certain subpopulations

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Details Method Results CommentsMass media

City adult smokers were exposed to nearly 11,000 GRPs during this 1-year period, equating to the average viewer in NYC seeing an advertisement approximately 110 times over the year.Length of study4 years, 2002 to 2006 OutcomesSmoking prevalence

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Details Method Results CommentsMass media Author, year Civljak 2005CountryCroatiaDesign Cross-sectional ObjectiveTo evaluate the impact on smokers behaviour of ‘smoke out day’ depending on gender age and education levelSES variableseducationAnalyses

Data sourcesAnonymous survey in homesParticipant selectionSelected from the database of 1.124,711 individual radio and TV subscribers in the Republic of Croatia. The selection was geographically stratified, with a variable fraction according to the density of the population.Participant characteristics2,143 (1,026 men and 1,117 women) TV viewers and radio listeners aged 15 and older. The selected group of subjects consisted of 700 individual radio and TV subscribers and all members of their households who were 15 years or older.Intervention First national ‘smoke out day’ media campaign on first day of Lent as part of the ‘Say yes to no smoking’ campaign. The activity was connected with an event of cultural and religious significance for the majority of the Croatian people (88% of the population are Roman Catholic) and was also supported by other religious communities, governmental, and non-governmental associations. Various strategies were used (intense media campaign, round tables, stands, public events at main town squares, activities in nurseries, schools, and work places). Theaim of these simultaneous activities was to reach the target population, ie smokers, in the phase of contemplation about quitting smoking regardless of age, gender, or duration of smoking.Length of study

General population In the total analysed sample 1,822 (85.0%) heard of the activity and 1,608 (75.0%) knew the exact date of the “Smoke out day.” Among smokers, 27% had given up smoking on that day and 16% declared they would not smoke during Lent.SES Among smokers, 141 (15%) subjects had primary school education, 579 (64.1%) secondary school education, 71 (7.9%) had university education, and 112 (12.4%) were students. The analysis of abstainers according to the level of education showed that the lowest response to “Smokeout day” was among smokers with university education. 20.4% primary school educated abstained for one day, compared with 59.1% secondary school educated, 16.8% university educated (3.7% were students).Author’s conclusion of SES impactAntismoking mass media activity can influence smokers’ behavior especially if it is connected to cultural and religious aspects. In the future, efforts should be made to make activities and messages more attractive to different subgroups of smokers and evoke a better response.

Internal validityOf 2,310 selected listeners and viewers, 2,143 (92.7%) responded and were interviewed.External validitymembers of the household who were currently in institutions or in other town were excluded from the study. The study is only generalisable to Croatia and possibly other countries with majority Roman Catholics.Small numbers in group of abstainers limits generalisability.Validity of author’s conclusionAbstaining for one day may not lead to long-term abstinence.

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Details Method Results CommentsMass media

One week (began the day after ‘smoke out day’ 2003OutcomesSmoking behaviour Attitudes to smoking

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Details Method Results Comments

Mass mediaAuthor , year Dunlop 2012CountryNewSouth Wales, AustraliaDesignRepeat cross-sectionalObjectiveTo identify modifiable factors that increase the efficiency of an advertisement reaching the target audience and of their recalling that advertisement.SES variables The income and education variables were combined into dummy variables indicating low, middle or high SES. Postcodes were used with the Socio-Economic Indices for Areas to indicate neighbourhood SES (quintiles 4–5=low SES, quintiles 1–3=moderate–high SES).AnalysesMultivariable logistic regression

Data sourcesThe Cancer Institute NSW’s Tobacco Tracking Survey (CITTS) telephone survey with weekly interviews of adult smokers and recent quittersParticipant selectionHouseholds are recruited using random digit dialling of landline telephone numbers and a random selection procedure is used to select participants (selecting the nth oldest eligible adult in the household).Participant characteristicsAdutl smoekrs and recent quitters, N=13,301, 42% low SES, 25% moderate SES, 33% high SESIntervention Antismoking advertising, low emotion; high emotion with graphic imagery; high emotion with narrative formatLength of studyApril 2005 and December 2010Outcomes Unprompted recall,Prompted recognition

General populationGRPs and broadcasting recency were positively associated with advertisement recall, such that advertisements broadcast more at higher levels or in more recent weeks were more likely to be recalled.Advertisements were more likely to be recalled in their launch phase than in following periods. Controlling for broadcasting parameters, advertisements higher in emotional intensity were more likely to be recalled than those low in emotion; and emotionally intense advertisements required fewer GRPs to achieve high levels of recall than lower emotion advertisements. There was some evidence for a diminishing effect of increased GRPs on recall.SES Unprompted recall:Univariate associations: moderate and high SES had increased OR for recall compared to low SES. Neighbourhood SES not significant.Multivariate association: high SES but not moderate SES had increased OR for recall compared to low SES (OR 1.11, 95%CI:1.04 to 1.19)p=0.001.Multivariate with interactions (between advertisement type and broadcasting parameters): high SES but not moderate SES had increased OR for recall compared to low SES.Prompted recognition:

Internal validityTracked recall and recognition while advertisements were currently or recently on air. External validityOverall response rate of 40% limits generalisability.Validity of author’s conclusionAuthors do not discuss SES data in text, only reported in tables.Individual composite measure of SES (income and education) but not neighbourhood measure of SES showed significant associations with recall and recognition. Association was different between two outcome measures: high SES had increased recall, moderate and high SES had decreased recognition in comparison with low SES.

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Univariate associations: moderate and high SES had decreased OR for recognition compared to low SES. Neighbourhood SES not significant.Multivariate association: high SES and moderate SES had decreased OR for recall compared to low SES (OR 0.91, 95%CI: 0.85 to 0.97, p=0.004; and OR 0.89 95% CI: 0.83 to 0.96, p=0.002 respectively.Multivariate with interactions (between advertisement type and broadcasting parameters): high SES and moderate SES had decreased OR for recall compared to low SES.Author’s conclusion of SES impactNot reported

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Details Method Results CommentsMass media Author, year Durkin, 2009 CountryMassachusetts, USADesignCohortObjectiveTo assess which types of mass media messages might reduce disparities in smoking prevalence among disadvantaged population subgroupsSES variables Cumulative measure. High school education or lower and household income of $50,000 or less = low SES. More than $50,000 household income and at least college education = high SES. All others medium.AnalysesMultivariate logistic regression. Exposure measured by Gross Rating Points (GRP, estimated). 1 unit increase in GRP equates to 10 exposures to an advert over the study period.

Data sourcesFirst 2 waves of UMass Tobacco Study, a longitudinal survey of Massachusetts adults designed to investigate responses to the Massachusetts Tobacco Control Program.Participant selectionProbability sample of 6739, over-sampling 18-30 year olds and recent quitters. Response rate 46%, follow up rate 56%. Excluded those not smoking at baseline and not from Massachusetts’s three main media markets. Participant characteristicsAverage age 40, 55% women, 41% ear under $50,000, 46% high school education or lower. 87% live in Boston. 83.9% non-Hispanic white.InterventionTelevision adverts of varying intensity aired in the two years prior to data collection. 20.2% were highly evocative personal testimonials, 13.4% emotional but not testimonials, 11.2% testimonials but not highly emotional, and 53.7% not highly emotional or testimonials.Length of study24 months (baseline was January 2001 to June 2002, follow-up was January 2003 to July 2004)Outcomes Smoking status (quit=one month

General population On average, smokers were exposed to more than 200 antismoking ads during the 2-year period, as estimated by televised gross ratings points (GRPs). The odds of having quit at follow-up increased by 11% with each 10 additional potential ad exposures (per 1000 points, OR=1.11; 95% CI=1.00, 1.23; P<.05). Greater exposure to ads that contained highly emotional elements or personal stories drove this effect (OR=1.14; 95% CI 1.02, 1.29; P<.05), which was greater among respondents with low and mid socioeconomic status than among high–socioeconomic status groups. Comparison ads show no significant effect (OR=0.93)SES Television-watching frequency varied, low SES more likely to watch TV 0-3 days a week or 7 days a week (no indication of length of time viewing).But reports no significant variation in exposure: Low 440.5 GRP, Mid 439.9, and High 434.8.Likelihood of quitting for each 10 additional potential exposures to an emotionally evocative or personal testimonial ad, adjusting for all co-variates:Increased for respondents in the low-SES group (approx. 13%), the mid-SES group (highest increase, approx. 47%), and the undetermined-SES group. By contrast, smokers in the high-SES group showed a decreased likelihood of quitting with each

Internal validityOne branch of adverts not included in analysis due to lack of data on exposure.Unusual interpretation of socio-economic status.218 (14.6%) undetermined socio-economic status due to lack of data.Tracking quit rates against exposure pre-baseline. Miss those who quit smoking during the initial two year period, and the effect of other interventions during the subsequent two years.External validityPopulation appear to have similar characteristics as the UK population. Unclear whether English audiences would react as strongly to emotive adverts.Validity of author’s conclusionDisagree about overall impact of the advert exposure - raw data shows middle and high SES groups had a higher quit rate than low SES despite lower overall exposure. But they report no significant interaction between total exposure and SES.Greater impact on mid-SES

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abstinence) 10 additional potential exposures to these types of ads.Quit status at follow-up: 12.9% of low SES ex-smokers at follow up, 18.2% of mid and 19.2% of high SES. Middle and high SES groups had a higher quit rate than low SES despite no significant variation in exposure between SES groups.Effects of Potential Exposureto 2 Types of Ads on Odds of QuittingSmoking: Mid SES significantly more likely to quit than low SES (OR=1.70, 1.02-2.83, p<0.05) High SES slightly less significant (OR=1.70, 0.95-3.03, p<0.1). Undetermined SES most likely to quit (OR=2.11, 10.7-4.14, p<0.05).Greater impact on mid-SES groups than low.Author’s conclusion of SES impactConsidered together, all adverts had an equal effect on SES. Exposure to harder hitting adverts (highly emotional and/or personal testimonial) had a greater impact on low and mid-SES groups. Likely to be more effective among high-risk (low SES), and high-proportions of smokers (mid-SES).

groups than low. No relationship between television watching and SES, suggests that adverts could be better targeted to have a greater impact on SES.Role of undetermined SES group may be undermining the significance of intervention’s impact.

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Details Method Results CommentsMass media Author , year Farrelly 2012CountryNew York State, USADesignRepeat cross-sectionalObjectiveTo assess the impact of emotional and/or graphic antismoking TV advertisements on quit attempts in the past 12 months among adult smokers in New York State.SES variables Education (high-school degree or less education and at least some college education),Household income (<$30,000 and >/=$30,000)AnalysesRegression

Data sourcesNew York Adult Tobacco Surveys (NY-ATS)Participant selectionrandom-digit-dial telephone surveyParticipant characteristics8780 current adult smokers (at least 100 lifetime cigarettes and smoking every or some days at time of interview) for GRP models and 5936 for confirmed recall modelsIntervention Mass media – antismoking advertisements, emotional and/or graphic. Smokers saw an average of three emotional and/or graphic (defined as such by interrater agreement 0.81 to 1.00) and three comparison advertisements (defined as not emotional and/or graphic) per month across the study period. Of the 142 study advertisements, 98 (69%) were comparison and 44 (31%) were emotional and/or graphic.Length of studyQuarterly data from 2003 to 2010Outcomes Exposure (self-reported confirmed and market level gross rating points = annual number of GRPs for each of the ten media markets in the state. Past-year GRP variables were divided by 5000 such that an OR

General populationOverall exposureBoth measures of exposure to antismoking advertisements (all types) are positively associated with increased odds of making a quit attempt among all smokers. Current smokers who recall recently seeing at least one advertisement have an increased odds of making a quit attempt in the past year of 31% (p<0.01). For every increase of 5000 GRPs annually, the odds of making a quit attempt increase by 21% (p<0.01).Education is not a predictor of quit attempts by all types of exposure measured by confirmed recall and past-year GRP models. Income is marginally signifıcant in the confırmed recall model.Exposure by typeExposure to emotional and/or graphic advertisements is positively associated with making quit attempts among smokers overall. Exposure to advertisements without strong negative emotions or graphic images had no effect. Recalling at least one emotional or graphic advertisement recently is associated with a 29% increase in the odds of making a quit attempt (p<0.05), whereas each additional 5000 GRPs of exposure to emotional and/or graphic advertisements in the past year is associated with a 38% increase in the odds of making a quit attempt (p<0.01). Education is not a predictor of quit attempts, income is marginally signifıcant in

Internal validityData were weighted to reflect the state population of adults, adjusting for different probabilities of selection and survey nonresponse.Controlled for market-level cigarette prices and an annual secular trend variable.External validitySpecific to New York Ste adults.Validity of author’s conclusionAs well as exposure by SES measured through both recall and GRP, this study provides quit attempts by SES. Results show equally effective for all SES when measured by GRP but most effective for high SES for all types of adverts and for low SES for emotional and/or graphic adverts when measured by recall.

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represents the change in odds for an increase of 5000 GRPs).Past year quit attempts

the confırmed recall model.SES GRP measureExposure to all types of advertisements and to emotional and/or graphic advertisements is positively associated with making quit attempts by income, and education. Recall measureSmokers with incomes of >/=$30,000, and smokers with some college education or beyond were more likely to make a quit attempt if they reported recall of advertisements (all types).Recall of emotional and/or graphic advertisements was associated with making a quit attempt for smokers with incomes <$30,000 and those with a high-school degree or less (p<0.05). Exposure to the comparison advertisements, as measured by past year GRPs and confırmed recall, was not associated with quitting for any group of smokers.Author’s conclusion of SES impactThe emotional and/or graphic advertisements were effective with low-income and low education smokers.

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Details Method Results CommentsMass media Author , year Graham, 2008 CountryMinnesota and New Jersey, USADesignCohortObjectiveTo examine the feasibility of online advertising to increase demand for cessation services.SES variables EducationAnalysesUnivariate

Data sourcesHealthways QuitNet database Participant selectionRegistered with QuitNet either through traditional (n=23293) or online advertising (n=8536, total=9655 but 1119 registered for phone only and data not available).Participant characteristicsPredominantly female (59%), white (84%), age 25-44 (57.3%), preparing or contemplating quitting (86.1%)Intervention Online ads placed on national and local websites and search engines between Dec 1 2004 and October 31 2006 to promote QuitNet’s web-based cessation program and state run telephone quitlines (Minnesota and New Jersey). Invite user to click to receive more information (3 diff ways to quit). Comparison: Billboards, tv and radio ads, outdoor ads (eg bus shelters), direct mail and physician referrals.Length of studyDecember 1, 2004 and October 31, 2006Outcomes Number of’ clicks’, demographic, smoking and treatment use characteristics of those recruited, and cost.

General population106291 clicked on online advert, but only 9.1% registered for Intervention (6.8% for a web-only intervention).Online ads recruited more males, non-whites, and 18-24 years, with high school degree or less.Significant, but relatively small, difference in engagement with the intervention between smokers recruited traditionally and via the online ads.SES Online ads recruited more people with a high school degree or less than traditional media (24.6% v 23.2%, p<0.02). Humorous online ads were significantly more likely to recruit than traditional media (26.8%, p<0.01).Banner adverts, rather than actively searching for cessation assistance, was a source of significantly more smokers with high or lower school education. Engagement not analysed by SES.Author’s conclusion of SES impactMore effective at recruiting smokers from certain minority groups. Results suggest that online advertising is promising. Enrolment rate of 9.1% exceeds most studies of traditional recruitment approaches.

Internal validityBig drop off between those who click on the ads and those who register External validityOnly likely to attract, and keep engaged those who are fairly regular internet users. Study was a partnership between Healthways Quitnet, ClearWay Minnesota and New Jersey Dept. of Health.Validity of author’s conclusionWould fail to reach parts of the population who are not internet users, or infrequent users so potential equity impact for the lowest groups is limited.Doesn’t entirely compare like with like – humorous ads may be more effective than traditional media as a whole but may not be as effective as a humorous traditional advert. May still be inequitable as doesn’t compare to SES and smoking in the population

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Details Method Results CommentsMass media Author, year Hawk 2006CountryErie and Niagara counties, Western New York region, USADesign3 intervention groups with regional control groupObjectiveTo compare baseline characteristics and determine abstinence and predictors of abstinence.SES variablesEducation; AnalysesMultivariate logistic regression

Data sourcesTelephone survey of the Quit & Win and NRT giveaway, compared with Erie-Niagara Tobacco Use Survey (ENTUS)Participant selectionRandom sample of 341 Quit & Win participants (40%) and 314 (46%) NRT voucher and 230 (100%) combination group. Follow-up rates were 60-64%, n=204, 179, 143 for Quit & Win, NRT, combination groups respectively.Participant characteristicsQuit & Win participants younger than those signed up for NRT voucher.N=849 Quit & Win only;N=690 NRT only;N=230 combination group;Intervention Concurrent Quit & Win contest and nicotine replacement therapy (NRT) voucher giveaway. Smokers could enrol in both or either programme (combined group).Daily smokers (at least 10 cigarettes per day) offered opportunity to win prizes including $1000 if they stopped smoking for the month of January 2003 with quit date of 1st January. NRT voucher redeemable at

General populationAt follow-up the self-reported quit rates were similar across 3 intervention groups: 25 to 30%. Higher quit rate in younger smokers in the combination group.SES ‘more than high school education’Quit & Win: 62% NRT: 57%Combined: 60%Erie-Niagara Tobacco Use Survey: 51%Compared with smokers in region – those enrolled in the 3 interventions had more years of formal education p<0.05.Adjusted OR for 7-day point prevalence = 1.11 (95% CI: 0.72 vs 1.70) for ‘high school or less’ vs ‘some college’Author’s conclusion of SES impactThe results for recruitment of low educated smokers were not positive.

Internal validityCompleters were older than noncompleters (41 years vs 38 years). Quit & Win participants had follow-up that was 2 weeks earlier than other 2 groups.External validityWe don’t know how representative the regional cohort of smokers was in the ENTUS survey, authors’ state ‘relatively representative’.Smokers in all 3 intervention groups were heavier smokers than in general population (20-21 vs 17 cigarettes per day).Validity of author’s conclusiondon’t know how representative the regional cohort of smokers was in the ENTUS survey which was used to measure reach

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pharmacies for a 2-week supply of nicotine gum or patch.Media coverage included press conference, newspaper and television coverage. $35,000 spent on radio advertisments aired on 6 local radio stations. Focus mainly on Quit & Win contest – when phoned Ney York State (NYS) quitline people were informed of free NRT giveaway.$22,500 newspaper advertising of Quit & Win and NRT then $22,500 only on Quit & Win. Marketed to minority populations (A frican American and Latino) using newspaper, churches and community sites.Length of study4 to 7 months from 1st January 2003, median 5.5 months follow-upOutcomesReach,7-day point prevalence

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Details Method Result CommentsMass mediaAuthor, year Levy, 2006 CountryUSADesignRepeat cross-sectionalObjectiveTo examine association between smoking and tobacco control policies among women of low SES.SES variables Not completed high school or no high school degree or GEDAnalysesmultivariate logistic models,

Data sourcesTobacco Use Supplement, four waves between 1992 and 2002. Sample nationally representative of non-institutionalised civilian population over the age of 15. Participant selectionFemales grouped by education level (less than high school, high school or higher, bachelor’s degree). Low education males included as a reference population. Sample varies between 176,452 and 228,552.Participant characteristicsMajority white, with increasing Hispanic proportion in later surveys. Majority 25 year olds or over. Over 40% from the South, approx. 20% each from the Midwest, Northeast and West.Low educated female constitutes between 21.6 and 26.6% of each survey, mid-educated 19.3-22.4%, high educated are 7.3 to 9.2% Intervention cigarette prices, clean air regulations, and tobacco control media campaigns, Clean air laws were represented by an index of state level clean air regulations. States with ‘‘no smoking allowed (100% smoke free)’’ were counted as 100% of the effect, with ‘‘no smoking allowed or designated smoking areas allowed if separately ventilated’’ as a 50% effect, and with ‘‘designated smoking areas required or allowed’’ as a 25% effect. We used separate indices by type of law, and settled on an aggregate weighted index, with worksite laws weighted by 50%, restaurant laws by 30%, and laws for other public places by 20%. Media campaign exposure measured at the state level rather than individual, and youth campaigns coded as half a media campaign.

General population impactSmoking prevalence declining across all categories.SES Price:As price increased the OR of low-education female smoking fell, but influence varies over survey waves. Only lower than 1 in 1992-3 and 2001-02. Med-higher educated groups less responsive. Media:In a state with a media campaign low education women’s OR=0.86, medium education = 0.89, high = 0.93 (non sig). Low education men also significantly less likely to smoke (0.92) Generally, the association of the media variable and smoking prevalence declines in the more recent survey waves.Smokefree legislationMarginal effect on current smoking. Over the period 1992–2002, current smoking among low education women is inversely related to the index of clean air laws with an odds ratio of 0.91 (0.80, 1.03), but is significant only in the medium education female subpopulation, with an odds ratio of 0.88 (0.83, 0.94). However, only in the 2001/02 model do clean air laws seem to play a part for the medium education female sample, although the confidence intervals around the estimates for each survey wave overlap for this group.Author’s conclusion of SES impactLow education women particularly responsive to media and price increases especially in comparison with high education women. Tax increases can play an important role. Tax increases and media messages may reduce prevalence among

Internal validityNo before and after, simply tracks the association between policy and prevalence. Fail to adjust for confounding individual characteristics.Small sample sizes at some state levels.External validityMost of the developments in clean air regulations at the state level occurred after 2001.A number of tobacco control policies were introduced during this period as well as changing social norms and increasing awareness, all of which may have influenced the results. Data is now one, in some cases nearly two, decades out of date. Covers a substantial Hispanic population that wouldn’t exist in the UK.No description of the types of media campaigns involved, and which were the most effective (either the mode of intervention or locations) in order to replicate the study.Validity of author’s conclusionNo examination of individual level exposure, or whether media campaigns were actively influencing people to change their smoking behaviour. Outcome may simply be the consequence of changing social norms in these populations.

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Length of study1992 to 2002Outcomes Individual use, attitudes towards smoking and clean air laws, and smoking bans at home or work.

women with low education. Health-SES relationship not irreversible.

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Details Method Results CommentsMass MediaAuthor , year Nagelhout 2013CountryThe NetherlandsDesignCohortObjectiveTo examine age and educational inequalities in smoking cessation due to the implementation of a tobacco tax increase, smoke-free legislation and a cessation campaign.SES variables Education, low (primary education and lower pre-vocational secondary education), moderate (middle pre-vocational secondary education and secondary vocational education) and high [senior general secondary education, (pre-) university education and higher professional education].AnalysesUnivariate and multivariate logistic regression. All analyses were weighted by age and gender to be representative of the adult smoker population in the Netherlands.

Data sourcesThree survey waves of the International Tobacco Control (ITC) Netherlands Survey, 2008 (before) and 2009 and 2010 (after)Participant selectionRecruited from a probability-based web databaseParticipant characteristicsN=1820/2331 (78.1%) in first survey, 1447 in second survey and 1275 in third survey. Analyses restricted to respondents who participated in all three survey waves (n=1176). And excluded 128 who had quit during 2008 and 2009 surveys, n=1048 and then answered all questions, n=962.Dutch smokers (having smoked at least 100 cigarettes in their lifetime and currently smoking at least once per month) aged 15 years and olderIntervention Tobacco tax increase, smoke-free hospitality industry legislation and mass media cessation campaign (all at national level) implemented during the same time period in the Netherlands in 2008. The Dutch cessation campaign focused on smokers with low to moderate educational levels.Length of study2008 – 2010

General populationCessation: 281 out of 962 respondents (29.3%) had tried to quit smoking between the 2009 and 2010 surveys. At the 2010 survey, 86 out of 962 respondents (8.9%) had successfully quit smoking. There were no significant age inequalities in successful smoking cessation. Smokers aged 15–39 years were more likely to attempt to quit smoking.Exposure:In total, 82.4% reported having paid more for their cigarettes in the 2009 survey than in the 2008 survey, 65.6% reported having visited a drinking establishment that had some form of smoking restriction and 83.1% reported having experienced one or more parts of the campaign. Smokers aged 15–24 years were more exposed to the smoke-free legislation, whereas smokers aged 25–39 years were more exposed to the cessation campaign.Exposure to the smoke-free legislation and to the cessation campaign had a significant positive association with attempting to quit smoking in the univariate analyses, but not with successful smoking cessation. In the multivariate analyses, only the association between exposure to the smoke-free legislation with attempting to quit smoking remained significant [odds ratio (OR)=1.11, 95% confidence interval (95% CI)=1.01–1.22, P=0.029]. Exposure to the price

Internal validity70% follow-up rateExternal validityPrices increased by only 8%. Smokefree legislation was weak, not well implemented and issues with compliance.Study authors report that almost half of the sample was either lost to follow-up or did not answer all questions. These respondents were younger, less addicted and had more intention to quit smoking. Therefore, our results may not be fully generalizable to the broader population of Dutch smokers.Validity of author’s conclusionSmokefree, price, mass media campaigns were not associated with reduction in prevalence of smoking.

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Outcomes Exposure,Quit attempts,7-day point prevalence (successful quitters)

increase only predicted successful smoking cessation among young respondents.SES Exposure: Higher educated smokers were more exposed to the price increase and the smoke-free legislation.Smokers from different educational levels were reached equally by the mass media campaign.Cessation: There were no significant educational inequalities in successful smoking cessation.Author’s conclusion of SES impactThere were no overall ages or educational differences in successful smoking cessation after the implementation of the three interventions.

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Details Method Results CommentsMass media Author , year Niederdeppe, 2008 CountryWisconsin, USADesignBefore and after (same participants)ObjectiveTo examine whether impact of televised smoking cessation ads differed by education or income. SES variables Education, incomeAnalysesMultivariate logistic regression

Data sourcesWisconsin Tobacco Survey 2003 (baseline, random digit dialling). Wisconsin Behavioral Health Survey 2004 (follow up).Participant selectionParticipants in both health surveys above. Smoked over 100 cigs in lifetime and currently smoked some/every day.Participant characteristicsEducation: 47% high school degree or less, 33% some college, 20% college degree.Annual household income: <25k (31%) 25-50k (36%) 50k+ (29%) Unreported (4%)Intervention Televised smoking cessation ads in Wisconsin Tobacco Control and Prevention Programme. TV ads aired most weeks between May 2002 and Dec 03. Highlighted dangers of SHS or keep trying to quit messages (KTQ), and aimed to promote Quitline calls.SHS ads included personal testimonials, KTQ didn’t. Subset of both ads targeted at low SES groups.Length of study2003 to 2004Outcomes Quit attempts, abstinence, ad recall

General population 42% had made a quit attempt, 13% abstinent at one year.SES KTQ ads had higher recall among higher educated groups (p<.05). Positive relation between KTQ ad recall and quit attempts for higher educated, but negative relationship for lower educated. No relationship between KTQ recall and income. KTQ ad recall showed some, non-significant, association with education (high school or lower v college educated OR=0.47, 0.16-1.33). SHS ads showed no differential recall. Low educated group who recalled SHS ad were less likely to agree that SHS concerns were over-stated.SHS ads were also associated with low income respondents being more likely to believe that SHS is harmful.Author’s conclusion of SES impactMedia messages may have a greater impact on quit attempts among more-educated populations, though there is no indication of directionality (quit because they saw the advert, or recall advert because they were trying to quit?). SHS ads may have lower chance of widening health disparities.

Internal validityResponse rate = 51%, follow-up rate = 29%Less loss to follow up among older, women, non-Hispanic, more educated, more nicotine dependent, more quit attempts, and advised by Doctor to quit.Combined with small initial sample size to give low overall ability to detect influence of adverts.External validityDoesn’t mention which form of television the adverts were run on. Funding considerably lower than CDC recommended level.Validity of author’s conclusionSHS ads only have lower chance of widening health disparities because they appear to have little impact on behaviour.

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Details Method Results CommentsMass media Author , year Niederdeppe 2011CountryNew York, USADesignRepeat cross-sectionalObjectiveTo (1) examine SES variation in response to different types of cessation ads and (2) apply predictions derived from studies using the Stages of Change Model in an attempt to understand why SES differences may occurSES variables Education, (high school diploma, some college, college degree, graduate school)IncomeAnalysesLogistic and ordinary least squares regressions

Data sourcesNew York Media Tracking Survey Online a self-administered web-based surveyParticipant selectionAdult smokers who currently participate in the Harris Poll Online and reside in either New York or media markets within New Jersey where the New York Tobacco Control Program purchased advertising time.Participant characteristicsThe Recall dataset consisted of 5004 unique adult smokers (62.1% female; 82.6% white, 5.3% African American, 6.0% Hispanic, 6.1% other/not specified; mean age = 45.0, SD = 12.7). The Effectiveness dataset consisted of 7060 unique adult smokers (64.5% female; 83.3% white, 5.3% African American, 5.6% Hispanic, 5.7% other/not specified; mean age = 45.1, SD = 12.7).Intervention Mass media antismoking advertising. Exposed each participant to videos of a random selection of specific ads via online multimedia within the survey. The exact number of ads viewed by each respondent ranged from four to six.All ads were 30 seconds long and the order in which ads were presented to any single participant was

General populationParticipants recalled Why-Testimonial ads at higher rates than ads using the other three themes. Participants perceived Why-Graphic ads as more effective than all three other ad themes.SES Recall:Significant interaction between How ads (vs. Why-Testimonial) and income.Significant interactions between both Why-Graphic and How ads (vs. Why-Testimonial) and education.The interactions between How ads and income/education were not robust to the inclusion of both interaction terms.Stage of change did not interact with ad theme: did not change the size or significance of the coefficients for the interaction between Why-Graphic ads or How ads (vs. Why-Testimonial) and education on aided ad recall.Why-Testimonial ads had the highest and How ads had the lowest ad recall across all levels of education. This difference was greatest at low levels of education. For example, among those with 10 years of education, the model predicts 71% recall of Why-Testimonial ads vs. 33% recall of How ads, a difference of 38 percentage points. Among those with 20 years of education, the model predicts 67% recall of Why-Testimonial ads vs. 40% recall of How ads,

Internal validityA subset of participants (n = 834 in the Recall dataset; n = 1170 in Effectiveness dataset) completed more than one wave of the survey.Two coders independently categorized each ad (Cohen’s k = 0.77). Analyses using education variable was restricted to smokers aged 25 years and higher.External validityThe New York survey sample is not representative of the broader population of smokers in New York, New Jersey or elsewhere). The internet-based sample was skewed toward White, affluent and educated smokers.Validity of author’s conclusionValid, thematic differences in recall and response were more pronounced among smokers with the lowest levels of education.

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randomized. participants showed a number of ads from five main categories: (1) Why-Graphic (n = 10 ads), (2) Why-Testimonial (n = 15 ads), (3) How (n = 7 ads, only one of which used a personal testimonial), (4) Anti-Industry (n = 4 ads), and (5) Secondhand Smoke (n = 9 ads).SHS ads excluded from analyses.Length of studyFive waves over two years: spring2007, summer 2007, spring 2008, summer 2008, and spring 2009.Outcomes Aided ad recall,Perceived ad effectiveness

a difference of 27 percentage points.Effectiveness:Significant interactions between How ads (vs. Why-Graphic ads) and income, and How ads (vs. Why-Graphic ads) and education, respectively.How ads (vs. Why-Graphic) and income was not robust to the inclusion of interactions with education. Significant interaction between How ads and the contemplation stage, although in the opposite direction of what would be expected based on the theory. The inclusion of interactions between ad theme and stage of change did not substantially alter the size or significance of the interaction between How ads and education.Why-Graphic ads had the highest level of perceived effectiveness. This value was higher than How ads across all levels of education. Once again, however, the difference was most pronounced at low levels of education.Author’s conclusion of SES impactSmokers (particularly those with low education) recalled ads focused on How less often, and perceived them as less effective, than ads using graphic imagery or personal testimonials to convey why to quit. Differences in readiness to quit between higher and lower educated populations did not explain why thematic differences in recall and response were

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more pronounced among smokers with the lowest levels of education.

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Details Method Results CommentsMass media – EX campaignAuthor, year Richardson 2011CountryUSADesign Longitudinal cohortObjectiveTo examine whether changes in cessation-related cognitions mediate the relationship between awareness of a national mass-media smoking cessation campaign, the EX campaign, and quit attemptsSES variablesEducation (less than high school, high school, some college, and college graduate or beyond).Analysesstructural equation modeling

Data sourcescohort of 3,571 current smokers drawn from eight U.S. Designated Market AreasParticipant selectionRandomly selected, among baseline respondents, 4,067 successfully completed the follow-up survey, resulting in a follow-up response rate of 73% and an overall response rate of 48% among known eligible households.Participant characteristics3,571 current smokers; 88.6% were current daily smokers and 11.5% were current nondaily smokers. The mean number of cigarettes smoked per day was 17.6 among current daily smokers and 6.4 among current nondaily smokers at baseline. A majority of respondents were seriously thinking of quitting at baseline, with 15.6% expressing an intention to quit within 30 days and 51.6% within six months.The majority was non-Hispanic White (79.9%), followed by non-Hispanic Black (12.5%), and Hispanic (7.6%; Table 1). The sample consisted of slightly more females (55.3%) and tended to fall in the target demographic of 25–49 years of age (84.5%). Almost half of the sample reported earning either a high-school

General population At the six-month follow-up, 46.5% had con-firmed awareness of the EX campaign (EX awareness). The mean value of the cessation-related cognitions index at baseline was 21.3 and stayed constant at 21.2 at follow-up. The percentage of current smokers making a quit attempt was 44.6% at baseline and 42.2% at follow-up. The greatest predictor of quit attempts at follow-up was baseline quit attempts. This estimate was 0.320 (SE = 0.02), indicating that reporting a quit attempt at baseline increased the likelihood of reporting a quit attempt at follow-up by approximately 32%. Lower levels of nicotine dependence at baseline (i.e., longer time to first cigarette in the morning) was also positively and significantly related to quit attempts at follow-up, with an effect estimate of 0.044 (SE = 0.01).The direct effect of EX awareness on quit attempts was 0.031 (SE = 0.01), which indicates that EX awareness increases the probability of reporting a quit attempt at follow-up by approximately 3%. Although small, the effect is statistically significant. The indirect effect of EX awareness on quit attempts (0.010, SE = 0.004) was calculated by multiplying the estimate from the independent effect of EX awareness on cessation-related cognitions at follow-up with the estimate from the independent effect of cessation-related cognitions on

Internal validityOther behavioural outcomes, such as cigarette consumption and utilization of smoking cessation resources, were considered but not analysed due to lack of a statistically significant association with EX awareness.A cessation-related cognitions index measured at the follow-up survey was used as a mediating variable in the model. The index had a Cronbach’s alpha of .79.The sample for this analysis excluded an additional 6.7% of follow-up respondents who quit successfully between baseline and follow-up. Uses structural equation modeling to formally test a mechanism by which confirmed awareness of a nationally televised smoking cessation mass-media campaign affects quit behaviour.External validityMay only be generalisable to adults considering quitting and aged 25 to 49 years.Validity of author’s conclusion

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Details Method Results CommentsMass media – EX campaign

diploma or GED. (43.6%), while approximately one fifth reported having less than a high-school education (19.7%).Intervention EX national media campaignLength of studyFebruary 2008 to October 2008.OutcomesConfirmed awareness of campaignQuit attempts

quit attempts at follow-up (0.408 × 0.025 = 0.010). The indirect effect of EX awareness on quit attempts at follow-up, although statistically significant, was smaller than the direct effect. Altogether, the model explained approximately 18% of the variance in quit attempts at follow-up. Data suggest that there are both a direct effect of confirmed awareness of EX on quit attempts as well as an indirect effect mediated by positive changes in cessation-related cognitions.SES only respondents with less than a high-school education showed a statistically significant effect of EX awareness on quit attempts, and this effect was both direct (0.082, SE = 0.04) and indirect (0.017, SE = 0.01). Author’s conclusion of SES impactAwareness of EX is significantly associated with positive changes in cessation-related cognitions and quit attempts in those with less than a high-school education.

Authors hypothesis was that EX awareness manifested in changes in quit behaviour through initial modification of cessation-related cognitions. The data, however, do not fully support this hypothesis. While there was a statistically significant effect of EX awareness on quit attempts mediated through cessation-related cognitions, the larger effect of EX awareness on quit behaviour was not mediated through cessation related cognitions. Furthermore, the mechanism underlying how EX awareness promotes quit attempts differs across education subgroups.

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Details Method Results CommentsMass Media – EX campaignAuthor, year Vallone 2011CountryUnited StatesDesign Before and after study (same participants)ObjectiveTo assess effectiveness of large-scale national smoking cessation media campaign – EX – across racial/ethnic and educational subgroupsSES variableseducationAnalysesMultiple logistic and linear regression analyses

Data sourcesLongitudinal panel data setParticipant selectionRandom digit-dial from 8 designated markets areasParticipant characteristics4067/5616 current smokers, 18 to 49 years, mean age 37 yearsIntervention Branded national smoking cessation media campaign designed to promote cessation among lower income and blue collar smokers of diverse race/ethnicity, ages 25 to 49, who are interested in quitting, based on behaviour change theory. This study focuses on impact of campaign television advertising onlyLength of study6 months, August to October 2008OutcomesCessation-related cognitions index score and quit attempts

General population n/a – only presented by race/ethnicitySES EX campaign awareness differed significantly by education, with higher awareness observed among those with higher educational attainment (41.0% weighted estimate for college degree vs. 30.2% for less than high school diploma, summary p value = .002). EX was significantly related to a higher cognitions index score at 6-month follow-up only among respondents who had achieved less than a high school education (OR = 2.6, p = .037). Baseline cognition index score was consistently predictive of follow-up cognition index score for all educational strata at the p < .000 level. a statistically significant relationship between confirmed awareness of EX and having made a quit attempt at follow-up was observed among those with less than high school education (OR = 2.1, p = .016).Among smokers with less than a high school education, confirmed awareness of the EX campaign more than doubled their odds of having more favourable cognitions about quitting smoking at 6-month follow-up, and doubled their odds of having made a quit attempt during the study period.Author’s conclusion of SES impactEX campaign may be effective in promoting cessation-related cognitions and

Internal validity73% follow-up rate and overall response rate of 48% among known eligible households.External validityResults are limited to impact of television advertising only and may only be generalisable to these 8 media markets. Relatively low level of media delivery—47% of the Centers for Disease Control and Prevention's media delivery recommendation—its effect may not have been detectable at the national level.Validity of author’s conclusionvalid

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Details Method Results CommentsMass Media – EX campaign

behaviours among minority and disadvantaged smokers

380

Details Method Result CommentsMass MediaAuthor , year Van Osch, 2009CountryThe NetherlandsDesignCohort with controlObjectiveTo explore determinants of successful quitting through a Quit and Win contest.SES variables Education: low level of education = primary or basic vocational school, medium level education = secondary vocational school or high school, high level of education = higher vocational school or university.AnalysesLogistic regression

Data sourcesBaseline questionnaires and follow ups at 1 month and 1 year.Participant selectionFour inclusion criteria: (i) a minimum age of 18, (ii) living in The Netherlands, (iii) having smoked for at least 1 year and (iv) daily smoking.Entrants who provided a valid email address were contacted (2887 of 3694), 1551 (54%) consented to participate in study. Random sample of 7500 Dutch smokers approached by email to act as control group, 1147 agreed, 244 met selection criteria. 39% Quit & Win and 25% Control lost to follow up at one month, 56% Quit & Win and 49% Control at one year.Participant characteristicsMean age 36.9, 60% females, 96% Dutch, 29.7% less than high school education, 44.5% high school, 25% higher. Controls older and less educated. Intervention The Dutch Quit and Win contest took place in May 2005 and was organized and coordinated by the Dutch Cancer Society. The main objective was to encourage

General populationAbstinence rates at 1 and 12 months:Control: 15.3% and 5.6%Quit & Win: 57.7% and 27.1%OR=7.83 and 3.03 (p<0.001 for both)Abstinence rates at 1 and 12 months including non-respondents as still smoking:Control: 10.9% and 2.9%Quit & Win: 35.4% and 11.9%OR=4.70 and 2.46, (p<0.001 for both) One-month abstinence was significantly predicted by use of buddy support and Quit and Win e-mail messages. Quit and Win e-mail messages remained significant predictor for continuous abstinence at 12 months.52.3% recruited by radio, 26.2% by friends.SES Participants with a higher educationwere more likely to maintain their quit attempt for the entire contest month.Higher education was a slightly significant predictor of cessation at one month (OR = 1.199 (95%CI 1.032-1.393) p<0.05), but did not predict continuous abstinence at 12 months (OR=1.109 (0.895-1.374).

Internal validityLow participation rate.High rate of loss to follow up, higher in the experimental group than the control.Self-report measure of cessation likely to over-estimate the impact of the contest.Differences in baseline characteristics between intervention and control sample; control sample were older and less educated (all analyses corrected for baseline differences).External validityNot a representative study sample.Validity of author’s conclusionQuit & Win contestants more educated than random control group. Higher SES Quit & Win contestants more likely to maintain abstinence at one month but not at 12 months. No analyses of various types of cessation support by SES.

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Details Method Result Commentsrespondents to abstain from smoking for at least 1 month. Recruitment of participants was promoted on a national as well as regional level. Regionally, several municipal health centres suspended campaign posters and distributed brochures to the public and placed advertisements in regional newspapers. On a national level, several radio stations and newspapers drew attention to the contest. In total, five supportive e-mail messages were sent to the participants. Participants were offered the opportunity to receive computer-tailored cessation advice, support from a telephonic coach, and they could enrol in an e-mail counselling programme, all of which were provided by the Dutch Foundation on Smoking and Health (STIVORO).Participants were also asked to name a buddy, whom they could call upon for support during their cessation attempt. Other cessation support included NRT and bupropion. After 1 month, prize winners were randomly selected from a pool of successful quitters. Winners of prizes (first prize: €1.000 and 11 regional prizes

No analysis of recruitment method, use of buddy system or other aids by SES.Author’s conclusion of SES impactNot discussed.

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Details Method Result Commentsof €450) were obliged to undergo a urine cotinine test to verify their abstinence from smoking.Length of studyOne yearOutcomes Abstinence at 1 and 12 months

383

Details Method Result CommentsMass media - QuitlinesAuthor, year Burns, 2010 CountryColorado, USADesignQuasi-experimental (2-group pre-post design)ObjectiveTo examine the effect of a Spanish-language media campaign on the reach and outcomes of a state-sponsored Quitline among Latino smokers.SES variables Education, insurance statusAnalysesLogistic regression

Data sourcesService utilisation data from the Quitline database during pre and post-campaign periods (Apr-Aug and Sep-Nov 2007). Random selection of users from pre and post groups was followed up at 7 months.Participant selectionAll smokers calling the Quitline were eligible if they provided data on ethnicity.Participant characteristicsSee results column.Intervention Spanish-language advertising to promote a state Quitline to Latino smokers in Colorado, a population historically under-represented among users of the service. Adverts were aired between Sep-Nov 2007 on predominantly Spanish-language television and radio channels and in movie theatres attended by Latino populations.Ads designed to deliver positive, supportive, family-oriented messages about cessation.Quitline offered free NRT and 5 proactive coaching sessions. First 40% of participants and heavy smokers referencing the campaign received 8 weeks of NRT, others received 4 weeks.Length of study7 months; April to November 2007Outcomes

General population Estimated 79.8% of households exposed to campaign messages an average of 12 times each. Call volume increased from 390 per month to 614 per month during the intervention period. Service use was higher and more sustained during the campaign. QuitLine calls increased among Latinos during the campaign by 57.6% (1169 vs 1842 in 3-month periods). Compared with pre-campaign Latino study respondents, Latino respondents during the campaign were significantly younger (younger than 45 years), more often Spanish speaking, uninsured, and less educated. Among Latino enrolees, program completion and nicotine replacement therapy use were similar before and during the campaign.Six-month abstinence among Latinos increased significantly during the campaign, (18.8% vs 9.6%; P<.05) and 7 day abstinence increased marginally (41.0% vs 29.6%; P=.06). However abstinence rates at both time periods were significantly lower for non-Latinos during the campaign. Suggest that this may be a consequence of NRT protocol change that occurred partway through the study that limited NRT to a 4-week supply instead of an 8-week supply.Impact by SES variableLatino Respondents during the campaign period were significantly more likely to be less educated and uninsured. 42.5% of callers during the intervention had less than high school education, compared to 22.2% pre-intervention. 56.0% uninsured,

Internal validityPotential for advertising campaign to have influenced the cessation outcomes among pre-intervention callers. Post-campaign group was actual ‘during’ campaign, may have missed the influence of final weeks of the campaign.No direct measure of campaign exposure.Response rates 44.1% and 50.4% among pre and post-campaign Latinos, and 54.3% and 52.7% among pre and post-intervention non-Latinos. Individuals lost to follow up typically younger and uninsured, less likely to have completed the program, and less likely to have requested a second NRT shipment. Used complete case outcomes, rather than including non-response at follow up as a failed cessation attempt which appears more likely given the characteristics of non-respondents presented.External validityTarget ethnic group is not as substantial in England, unclear if a similarly targeted intervention would be as effective among other minority ethnic groups. Validity of author’s conclusionSES variations in quit rates are not discussed, but is assumed that the rise in low SES callers has led to a rise in low SES service utilisation and quit rates.

384

Characteristics of Quitline callers, service utilisation, abstinence.

compared to 40.5% pre-intervention.Author’s conclusion of SES impactIncreased reach among low SES Latinos, while sustaining or improving service use among the group. Negative impact among non-Latino ethnic groups.

Appears that the media intervention is having a positive impact on inequalities in smoking behaviours, but the changes in Quitline NRT-provision have had a negative impact on overall quit rates, potentially more significantly among low SES service users.

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Details Method Results CommentsMass media - NRTAuthor , year Czarnecki, 2010aCountryNew York City, USADesignCross-sectional ObjectiveTo improve understanding of: (1) awareness of the 2006 Nicotine Patch Program (NPP) among New York City (NYC) smokers; (2) differences in sociodemographic characteristics among those who reported a desire to participate compared to those who did not; (3) perceived barriers and reasons for not wanting to participate; and (4) suggested outreach methods for future giveaways and media campaigns.SES variables Income, educationAnalysesDifferences between groups were assessed using t-tests.

Data sourcesRandom telephone survey of adult smokers in NYC (n=1000) conducted in 2006. Survey conducted in English or Spanish only. Responses weighted Participant selectionCurrent smokers (10 cigarettes or more) or those who had quit since beginning of NPP (14% screening response rate). 56% of eligible smokers completed the survey (n=602).Participant characteristicsHard to assess due to the use of ‘population estimates’. Appears sample was dominated by Hispanics, males, and mid-low income groups.High school graduates the largest group, followed by college educated, then some college and <high school. No indication of the representativeness of the sample.Intervention Media campaign to promote an NRT giveaway. Nicotine patch giveaway between May 3rd and June 6th 2006. Smokers could enrol via free non-emergency Government information line. Callers received 4 weeks of patches.Advertised via multimedia campaign (TV/radio/print in English & Spanish)

General population 35,000 registered for the program. Program awareness high (60% overall), with most awareness coming from TV advertising (62%) followed by word-of mouth(19%) and radio advertisements (14%).Interest among those who hadn’t heard of the program fairly high (54%).The most common reason for not calling was not being ready to quit smoking (25%). Most ‘barriers’ were a lack of interest in quitting/aids.SESPopulations with lower levels of income and education expressed more interest in the program compared to groups with higher levels of income and education.Compared to 37% of respondents with an annual income of $75,000 or more, 56% of respondents each earning less than $25,000 (p=0.04) and $25,000 to less than $50,000 (p=0.03) reported program interest. Sixty-three percent of those with less than a high school education (p=0.04) and 67% of high school graduates (p<0.001) reported program interest, compared to 43% of college graduates.No SES evaluation of the other research questions (3) perceived barriers and reasons for not wanting to participate; and (4) suggested outreach methods for future giveaways and media campaigns.% reported awareness significantly lower

Internal validityResponse and co-operation rates were low. Extrapolated from a very small population to make assertions about a huge, diverse city. No assessment of the representativeness of the sample of either smokers or NYC as a whole.Likely to over-estimate the number of people aware of the programme, and also potential users given the hypothetical question on interest (those reporting interest would significantly outweigh the number of actual users).Doesn’t mention the type of TV used: free-to-air, potential demographics.External validityLikely to be less cost-effective in less dense populations.Unlikely to be representative of most urban populations.Program awareness estimates may also be overestimates, as the NPP was tied to a larger social marketing campaign around quitting smoking.Validity of author’s conclusionDifficult to make serious

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Details Method Results CommentsMass media - NRT

from January to October 2006, including testimonials from dying/sick smokers, and graphic images of smoking’s impact.Length of studyJanuary to October 2006Outcomes Program awareness, untapped interest in programme, perceived barriers (not by SES), future outreach methods (not by SES)

for highest income group ($75,000 or more) and for highest education (college graduate) group.% reported awareness (95%CI) N=602:Income ($)<$25,000 = 58.7 (49.2, 67.6) P=0.138$25,000–<$50,000 (ref)=67.5 (60.1, 74.1) $50,000–<$75,000=59.9(49.5,69.5) P=0.2287>/=$75,000=51.2 (43.4, 59.0) P=0.0025*EducationLess than high school grad=57.3 (47.2, 66.8) P=0.2789High school grad=61.5 (54.5, 68.0) P=0.612Some college (ref)=64.0 (56.7, 70.7) College grad =51.6 (45.0, 58.1) P=0.0120*Untapped interest: respondents who would have participated in 2006 Nicotine Patch Program (n=199)Income ($)<$75,000 = 56.1 (41.2, 70.0) P=0.0400*$25,000–<$50,000=55.5(42.5,67.7) P=0.0310* $50,000–<$75,000=50.1(34.4,65.9) P=0.1792>/=$75,000=36.5 (25.9, 48.6) refEducationLess than high school grad=62.7 (45.3, 77.3) P=0.0413*High school grad=67.3 (56.2, 76.8)

judgements given the concerns over validity.

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Details Method Results CommentsMass media - NRT

P=0.0007*Some college =47.4 (35.4, 59.8)p=0.5635 College grad =42.8 (33.6, 52.6) refAuthor’s conclusion of SES impactHighest untapped interest in the lower SES groups. Mass media effective for informing smokers.

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Details Method Results CommentsMass media - NRTAuthor, year Czarnecki 2010bCountryNew York City, USADesignCross-sectional ObjectiveTo use geographic information system (GIS) analyses to monitor large-scale distribution of nicotine replacement therapy (NRT) in New York City (NYC).SES variablesEducation, Neighborhood income is measured as percent of residents that are below 200% of the Federal Poverty Level (FPL); Low income=43–90% of residents are below 200% FPL; Middle income=30–42% of residents are below 200% FPL; High income=12–30% of residents are below 200% FPL.AnalysesThe intake data were analysed in two ways, as the percent of NYC current smokers enrolled (through intake reporting) and the geographic density of enrolment (through mapping).

Data sources2008 Nicotine Patch and Gum Program (NPGP), Population estimates for current smokers are based on the Community Health SurveyParticipant selectionParticipant characteristics18 years and over, resident in NYCIntervention 2008 Nicotine Patch and Gum Program, 16 days April to May 2008 conducted in collaboration with 3-1-1 NYC’s non-emergency information line. Large-scale distribution of NRT in NYC. All campaign messages directed interested smokers to call 3-1-1 during the publicized dates. Applicants were notified of program eligibility via mail; eligible callers received the appropriate NRT package (determined by the number of cigarettes smoked per day), while ineligible callers received a letter with a referral to other cessation services. Recruitment was by TV and radio commercials and recruitment letters. Two days before the end of the NPGP, the NYC Department Of Health and Mental Hygiene issued a press release announcing that there

General populationIn 2006 the adult smoking prevalence in NYC was 17.5%, representing 1,065,000 smokers. More than 32,000 smokers applied for the 2008 NPGP and almost 30,000 (92.1%) were found eligible. Almost all of the applicants and enrollees (99.6%) had geocodable addresses. The primary sources of referral reported by all NPGP enrollees were TV commercials (66.5%), followed by recruitment letters (11.2%), word of mouth (9.5%), and radio commercials (5.2%).3% NYC smokers enrolled in the programme.SES Low income adults had high enrolment percentages of 3.3% (% of NYC current smokers enrolled) compared to 2.5% middle income neighbourhood and 2.6% high income neighbourhood.Adults with less than a high school education had high enrolment (3.6%) compared to 2.7% for high school graduate; 2.7% for ‘some college’ and 1.2% for college graduate. Neighbourhoods varied in percentage of smokers enrolled, ranging from 1.2 to 5.1%, with the low and medium income neighbourhoods having more enrollees compared to high income neighbourhoods

Internal validitySingle cross-sectional studyExternal validityResults are specific to NYC neighbourhoods. GIS provided near real-time assessment of participation patterns and impact of media and outreach strategies.Validity of author’s conclusionValid. One of few studies to assess reach of NRT programme.

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Details Method Results CommentsMass media - NRT

was only 48 hours left to call for NRT.The complete intake data were electronically passed from 3-1-1 to the NYC DOHMH daily for analysis, reporting, and mapping. Length of study16 days in 2008OutcomesReach - % of NYC current

smokers enrolled

(data not shown).Among neighbourhoods with high smoking prevalence, lower income neighbourhoods had higher enrolment compared to higher income neighbourhoods.Author’s conclusion of SES impactNPGP data were collected at a finer resolution than a ZIP code (a geocoded address), differences were identified that otherwise might not be apparent when viewing data aggregated to the neighbourhood level.

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Details Method Results CommentsMass media - quitline & NRTAuthor, year Deprey 2009CountryOregon, USADesign Before and after study – different participants. ObjectiveTo determine whether an offer of free NRT in the form of nicotine patches could generate and sustain incoming call volumes more efficiently than paid media advertising.SES variablesInsurance status, educationAnalysesA sample 6 months prior to the launch was utilized as the comparison group

Data sourcesOregon Tobacco Quit LineParticipant selectionThe sample size consisted of 22 health plans and included health maintenance organizations (both Medicaid and non-Medicaid), preferred provider organizations, and indemnity-based plans. Of the health plans contacted as potential collaborators, 12 agreed to promote the Free Patch Initiative (FPI).Participant characteristics920 before intervention and 6491 after launchIntervention Oregon Free Patch Initiative (FPI): for 2.5 months the Oregon Tobacco Quit Line offered a free 2-week starter kit of nicotine patches to all callers and one counselling call with a tobacco quit coach. Supplemented with NRT that participants would obtain on their own (either via their health plan or by purchasing).The promotional plan, utilizing Roger’s Diffusion of Innovation theory, targeted health plans, local policy makers, media sources, and referral sources, such as healthcare

General population In 3 months, the FPI achieved free news media coverage, generated a 12-fold increase in calls to the ORQL, sustained a two-fold increase in calls for 5 months after the FPI, and reached 1.3 percent of all Oregon smokers in 3 months.Between October and December 2004, the top two specific sources of hearing about the ORQL identified were TV news (17.1%) and family or friends (16.2%). In the preinitiative sample, the two top sources of hearing about the ORQL identified at registration were TV/commercial (19.3%) and a Medicaid letter (17.9%). In the first week of the initiative launch, the number of registrations with the ORQL increased from 224 to 2 614. In all of October 2004, 4 810 callers registered for services (In November 2004, 1 423 tobacco users registered and in December 1 018 tobacco users registered with the ORQL. Overall, the high volume of registrations with the ORQL continued well after the free patch offer was discontinued. Utilizing the 2004 smoking rate of 19.9 percent in Oregon adults the ORQL reached 1.3 percent of the adult smokers in Oregon during the FPI (3 months). If these volumes were sustained, the annualized reach would be

Internal validityA comparison sample used during the same time period 12 months prior would have controlled for seasonal call volume differences that are seen from October to December due to the Great American Smoke Out and other quitline promotions leading up to New Year’s Day. However, the ORQL was not active from October to December 2003 due to a decision to close services temporarily.Another limitation to the study results is that more than 10 percent of the data were missing for certain variables in the prelaunch sample: ethnicity, cigarettes smoked per day, time to first cigarette, and previous quit attempts. With this high percentage of missing data, the generalizability of the results is reduced and limited.External validityResults mainly relate to

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Details Method Results CommentsMass media - quitline & NRT

providers. Word-of-mouth advertising was also encouraged using a free patch card, which could be handed out to tobacco users. Six weeks prior to the public launch, information about the initiative was disseminated by e-mailing and sending letters to public and private sector partners. The ORQL paid for media (TV commercials) during the preinitiative period, but not during the initiative.Length of study6 months - March through May 2004 (preinitiative) and October through December 2004 (postlaunch). Free Patch Initiative launched October 2004 until December 2004OutcomesCalls to quitline

5.2 percent.SES The ratio of insured to uninsured callers dramatically increased in October. In the 9 months preceding the FPI, the ratio of insured to uninsured callers ranged from 1:6 (January and February) to 1:4 in all other months. In October, the ratio increased to 1:2. Of the tobacco users reporting insurance status, 30.5 percent of the FPI participants reported being uninsured compared with 21.5 percent of the preinitiative group. At the time of the FPI, the rate of uninsured was 17 percent in Oregon. 56.2% ‘high school or less education’ vs 54.2% after launch; 36% ‘some college’ before and 35.3% after; ‘college graduate or more’ 7.8% before and 10.5% after;Author’s conclusion of SES impacthealth plans’ and insurers’ promotional activities of the initiative may have increased the calls from insured smokers to the quitline

insurance status which is specific to USA and may not generalise to other countriesValidity of author’s conclusionTwo plans waived the copay for telephone counselling, and two sent a voucher for 6 additional weeks of NRT. One plan waived a required doctor’s office visit for additional NRT. Within 6 months of the FPI, 2 of the 22 health plans decided to add tobacco cessation phone counselling as a member benefit. These Health Plan system changes that occurred during the initiative may have influenced call rates.

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Details Methods Results CommentsMass media - Quitlines Author, year Durkin 2011CountryVictoria, AustraliaDesign Cross-sectionalObjectiveTo examine the efficacy of different types of mass media advertisements in driving lower SES smokers to utilise quitlinesSES variablessocioeconomic index for areas (ranks postcodes)Analysesnegative binomial regressions examined relationship between exposure to ads and calls to quitline adjusting for covariates

Data sources33,719 calls to Victorian quitline Participant selectionN/AParticipant characteristicstarget group=18 to 39 year old smokersIntervention 13 advertisements designed to motivate smokers to quit, all advertisements ended with quitline number displayedLength of study2yrs (Dec 2006 to Dec 2008)OutcomesCalls to quitline

General population 8839 anti-smoking ad TARPS, or each person within target population exposed 88.39 times, rates of exposure similar across ad types. After all significant covariates were included, increases in anti-smoking advertising TARPs were significantly associated with the number of quitline calls (Rate Ratio = 1.070, 95% CI 1.020 to 1.122, P = 0.005). Higher emotion narrative ad exposure had the strongest association with quitline calls, increasing call rates by 13% for every additional ad exposure per week (per 100 points, rate ratio = 1.132, P = 0.001).SES Victorian quitline received 6275 calls from low SES (18.61% of total calls), 5458 calls from mid-low SES (16.19% of total calls), 9619 calls from mid-high SES (28.53% of total calls) and 12 367 calls from high SES callers (36.68% of total calls). Victorian quitline received a significantly higher rate of calls from high SES (RR = 4.177, P < 0.001) and mid-high SES (RR = 1.804, P < 0.001) smokers compared with those from the low SES group, but call rates from mid low SES smokers (RR = 0.869, P < 0.001) were significantly lower than those from the low SES smokers, there was no interaction between TARPs and SES group P = 0.223).Substantially, greater increases in calls to quitline from lower SES groups were observed when higher emotion narrative ads were on air compared with when other ad types were on air, and this advantage was not as strong among higher SES groups.Author’s conclusion of SES impactalthough there was an over-representation of Quitline calls from the high SES group over the study period, when the ads were on air, Quitline calls increased by the same degree across each SES group. This suggests that the overall effect of the advertising aired over this period neither increased nor reduced SES disparities in quitline calls. Airing higher emotion narrative anti-smoking ads may contribute to reducing, but not eliminating, socio-economic disparities in calls to the quitline through maximizing the responses of the lower SES smokers.

Internal validity

External validityintroduction of smokefree pubs and clubs legislation was significant covariate which was adjusted for in modelValidity of author’s conclusion

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Details Method Results CommentsMass media – NRTAuthor, year Hawk 2006CountryErie and Niagara counties, Western New York region, USADesign3 intervention groups with regional control groupObjectiveTo compare baseline characteristics and determine abstinence and predictors of abstinence.SES variablesEducation; AnalysesMultivariate logistic regression

Data sourcesTelephone survey of the Quit & Win and NRT giveaway, compared with Erie-Niagara Tobacco Use Survey (ENTUS)Participant selectionRandom sample of 341 Quit & Win participants (40%) and 314 (46%) NRT voucher and 230 (100%) combination group. Follow-up rates were 60-64%, n=204, 179, 143 for Quit & Win, NRT, combination groups respectively.Participant characteristicsQuit & Win participants younger than those signed up for NRT voucher.N=849 Quit & Win only;N=690 NRT only;N=230 combination group;Intervention Concurrent Quit & Win contest and nicotine replacement therapy (NRT) voucher giveaway. Smokers could enrol in both or either programme (combined group).Daily smokers (at least 10 cigarettes per day) offered opportunity to win prizes including $1000 if they stopped smoking for the month of January 2003 with quit date of 1st January. NRT voucher redeemable at

General populationAt follow-up the self-reported quit rates were similar across 3 intervention groups: 25 to 30%. Higher quit rate in younger smokers in the combination group.SES ‘more than high school education’Quit & Win: 62% NRT: 57%Combined: 60%Erie-Niagara Tobacco Use Survey: 51%Compared with smokers in region – those enrolled in the 3 interventions had more years of formal education p<0.05.Adjusted OR for 7-day point prevalence = 1.11 (95% CI: 0.72 vs 1.70) for ‘high school or less’ vs ‘some college’Author’s conclusion of SES impactThe results for recruitment of low educated smokers were not positive.

Internal validityCompleters were older than noncompleters (41 years vs 38 years). Quit & Win participants had follow-up that was 2 weeks earlier than other 2 groups.External validityWe don’t know how representative the regional cohort of smokers was in the ENTUS survey, authors’ state ‘relatively representative’.Smokers in all 3 intervention groups were heavier smokers than in general population (20-21 vs 17 cigarettes per day).Validity of author’s conclusiondon’t know how representative the regional cohort of smokers was in the ENTUS survey which was used to measure reach

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Details Method Results CommentsMass media – NRT

pharmacies for a 2-week supply of nicotine gum or patch.Media coverage included press conference, newspaper and television coverage. $35,000 spent on radio advertisments aired on 6 local radio stations. Focus mainly on Quit & Win contest – when phoned Ney York State (NYS) quitline people were informed of free NRT giveaway.$22,500 newspaper advertising of Quit & Win and NRT then $22,500 only on Quit & Win. Marketed to minority populations (A frican American and Latino) using newspaper, churches and community sites.Length of study4 to 7 months from 1st January 2003, median 5.5 months follow-upOutcomesReach,7-day point prevalence

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Details Method Results CommentsMass media – NRTDetails Method Results CommentsMass media - NRTAuthor, year Miller 2005CountryNew York, USADesign Quasi-experimentalAt 6 months after treatment, we assessed smoking status of 1305 randomly sampled NRT recipients and a non-randomly selected comparison group of eligible smokers who, because of mailing errors, did not receive the treatment. NRT recipients were compared with local survey-derived data for heavy smokers in New York CityObjectiveTo assess the effectiveness of a programme of free NRT to improve smoking cessationSES variablesArea-level deprivation - Zip code of residence at the time of enrolment was used to assign NRT recipients to specific neighbourhoods,16 which were grouped into three categories (<30%, 30–44%, >/=45%) on the basis of the percentage of people living in households with an income less than 200% of the federal poverty level.AnalysesLogistic regression

Data sourcesIn 2003, the New York City Department of Health and Mental Hygiene (NYC DOHMH), in collaboration with the New York State Department of Health and the Roswell Park Cancer Institute, undertook a large-scale distribution programme of free NRT. Comparison group from Community Health Survey (cluster survey design).Participant selectionFrom April 2, to May 14, 2003, more than 38 000 callers were screened for eligibility to receive free NRT patches. To qualify for free treatment, smokers had to be at least 18 years of age, a resident of New York City, have no medical contraindications to NRT patch use, not be using other NRT or bupropion, agree to attempt to quit in the week after the screening call, have smoked ten or more cigarettes per day for at least a year, and agree to be contacted for follow-up.Participant characteristics34 090 individualsIntervention large-scale programme that used existing telephone helplines to screen smokers for NRT eligibility and to post a full course of free NRT patches directly to those who were eligible.On April 2, 2003, the NYC DOHMH announced the availability of free 6-week

General population An estimated 5% of all adults in New York City who smoked ten cigarettes or more daily received NRT; most (64%) recipients were non-white, foreign-born, or resided in a low-income neighbourhood. Of individuals contacted at 6 months, more NRT recipients than comparison group members successfully quit smoking (33% vs 6%, p<0·0001), and this difference remained significant after adjustment for demographic factors and amount smoked (odds ratio 8·8, 95% CI 4·4–17·8).NRT recipients who received counselling calls were more likely to stop (246 [38%] vs 189 [29%], adjusted odds ratio 1·5; 95% CI, 1·1–1·9) than those who did not.SES Similar proportions of NYC heavy smokers and NRT recipients resided in low-income neighbourhoods. Neighbourhood income level and educational attainment were not associated with quit success.Author’s conclusion of SES impactEasy access to cessation medication for diverse populations could help many more smokers to stop.

Internal validityRandom sample but exclusions. Of the people in the random sample, about 60% of NRT recipients participated in the 6-month follow-up survey. 31% response rate for non-random comparison group (eligible callers who did not receive NRT).Comparison group more likely to be living in low-income neighbourhoods than NRT intervention group.External validityAn estimated 5% of all NYC heavy smokers (ten cigarettes per day or more) and 15% of those smoking more than one pack of 20 cigarettes per day received free NRT throughout this programme.New York City implemented this programme at a time when new smoke-free workplace legislationand increased taxation on cigarettes focused public attention on cessation.Validity of author’s conclusionValid

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Details Method Results CommentsMass media – NRT

courses of NRT patches to the first 35 000 eligible smokers to call the New York State Smokers’ Quitline. All major metropolitan newspapers and television and radio stations reported the programme launch. Neighbourhood-specific media and promotional efforts were used to reach populations with the highest prevalence of heavy smokers.Kits contained a 2-week supply each of generic 21 mg, 14 mg, and 7 mg patches; instruction sheets in English and Spanish; patient information from the manufacturer; a self-help stop-smoking guide; and a list of local services for smoking cessation. Counselling calls, averaging 3 min, were attempted to all NRT recipients at 3 weeks and again at about 14 weeks after the intake call. Counselling included advice on patch usage, management of adverse reactions, and encouragement to start or continue a quit attempt. Telemarketing staff, trained by NYC DOHMH, made the calls using a computer-assisted script. Of the NRT recipients, 15 212 (45%) received at least one counselling call, and 5128 (15%) received two calls.Length of study6 monthsOutcomesquit attempts, successful quits

397

Details Method Results CommentsMass media - QuitlinesAuthor, year Owen 2000CountryEnglandDesign CohortObjectiveTo evaluate the impact of a telephone helpline (Quitline) with additional support (written information) on callers who use the service during the HEA 3-month TV and radio advertising campaign.SES variablesSocial classes ABC1 include professional, managerial, clerical, and administrative grades; C2DEs include skilled manual and unskilled manual and those on state benefits.AnalysesAnalysis of caller profiles from log sheets completed by Quitline counsellors. The second and third stages involved a series of telephone recall interviews with a sample of callers conducted two months and one year after their initial call to the helpline. The recall interviews were carried out by Consumer Focus, an independent research company.

Data sourcesrecall surveys of callers to the helpline carried out two months and one year after their initial callParticipant selection3019 of 18,873 log sheets were randomly selected in proportion to total number of calls each day between 26 December and 31 March 1998. 905 of 6038 (participants who had left telephone numbers to be contacted) were randomly selected for 2-month recall survey. Only 473 (of 905) recontact interviews were achieved at 11 months post-baseline. Fresh sample (n = 951) was randomly drawn from the 5133 baseline log sheets with telephone numbers that had not been used for the two month recall study. This provided an additional 257 respondents. Thus a total of 730 respondents were interviewed one year after their initial call to Quitline; 521 were current smokers at baseline. Participant characteristicsCompared with all smokers in general population in England, callers were more likely to be women, to be in the age groups 25-34 or 35-44 years, to come from households with children under the age of 16 years, and to be heavy smokers (smoke 20 or more cigarettes a day). Intervention The helpline is staffed by trained counsellors who offer one-to-one telephone information, advice, and counselling. Callers can also receive an

General population Currently Quitline receives around half a million calls in the course of one year, 93% of whom are phoning for themselves. This represents 4.2% of the total population of adult smokers in England. At one year the social class profile of callers to the helpline reflected the social class profile of all adult smokers; 63% of the sample were of manual occupations or unemployed compared with 61% of the adult smoker population.Among smokers at baseline, 24% of those who received the two month recall reported not smoking at one year compared with 18% who had not received the two month recall (X2 = 3.123, narrowly missed significance at p < 0.05).At one year 22% (95% CI; 18.4% to 25.6%) of smokers reported that they had stopped smoking. Assuming that those who refuse to take part in the one year follow up are continuing smokers and a further 20% of reported successes fail biochemical validation, this yields an adjusted quit rate of 15.6% (95% CI 12.7% to 18.9%) at one year. Among ex-smokers, 41% (95% CI 34.3% to 47.7%) reported that they were still not smoking at one year. The adjusted figure for ex-smokers at one year is 29% (95% CI 23.3% to 34.8%). Of those who resumed smoking 28% were smoking less than they had been initially. SES Social classes ABC1 were associated with not smoking at one year among ex-smokers.25% (17.05 to 32.95) social classes ABC1 stopped smoking at one year.21% (13.52 to 28.48) social class C2DE stopped smoking at one year.

Internal validity730 of 6038 were followed-up at one year = 12%. Compared with callers at baseline, women, those aged 35 and over, and those with moderate consumption levels (10-19 cigarettes a day) were overrepresented in the one year recall sample. The one year recall sample also included more long term smokers.Information on social class was not available at baseline and so it is not possible to assess any bias attributable to this factor. External validitySmall sample sizeValidity of author’s conclusionValid but small sample size

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Details Method Results CommentsMass media - Quitlines

information pack through the post containing information on a variety of smoking related topics such as the risks of smoking and advice on how to quit.The advertising campaign comprised television and radio advertisements and was supported by advertorials (adverts that look like editorial) in women's magazines. The television advertisements were targeted at young smokers (aged 16-24 years) and aimed to challenge their reasons for smoking and provide them with reasons to quit. In contrast to previous campaigns, the TV adverts adopted a hard hitting testimonial approach. The radio and magazine adverts were aimed at a slightly wider audience and were intended to provide support and encouragement to those who want to quit. All adverts included the Freephone Quitline number.Length of studyDecember 1997 to February 1999OutcomesCalls to helpline, smoking status at one year

Author’s conclusion of SES impactThe social class distribution of callers to the Quitline reflected the social class distribution of smoking in the population, with nearly two thirds of callers being in manual occupations or unemployed. One fifth of the smokers who called Quitline who were in manual occupations or unemployed reported having stopped at one year, it seems likely that such a service can make a major contribution to achieving smoking reductions among these priority groups.

399

Details Method Result CommentsMass media - quitlinesAuthor, year Siahpush, 2007CountryVictoria, AustraliaDesignCross-sectional ObjectiveTo assess the socioeconomic variations in call rates to the Quitline (Victoria, Australia) and in the impact of anti-tobacco television advertising on call rates.SES variables Index of Socioeconomic DisadvantageAnalysesNegative binomial regression

Data sourcesQuitline, VictoriaParticipant selectionCallers requesting Quit Packs Participant characteristicsTelevision viewers in Victoria who responded to anti-smoking and NRT adverts.InterventionPredominantly featured hard-hitting advertisements on the health risks of smoking, and promotion of a telephone Quitline. Adverts shown irregularly over 169 week period (88weeks = no ads, 42weeks=medium volume, 39weeks= high volume).Attempts made to tailor adverts to low SES groups, including placement and content. Message mostly focused on health impacts of smoking, one looked at tobacco industry tactics.Length of studyQuitline calls tracked between January 2001 and March 2004Outcomes Number of calls to Victoria Quitline, and the number of calls per 100,000 smokers in the quintile

General population Higher weekly TARPs correspond closely with a larger overall volume of calls. Antismoking and NRT TARPs were positively associated with call rates. Week had a rate ratio smaller than unity, indicating a decreasing trend over time in rates of calls to the Quitline. Likelihood ratio tests for the interaction of antismoking TARPs (p=0.934), NRT TARPs (p=0.995) revealed no evidence of an interaction. SES Exposure to TV adverts led to higher Quitline call-rates across all 5 SES quintiles. Call rates increased almost universally by 2.5-2.7 times in all five quintiles.SES and call rates were positively associated. SES and call rates were inversely associated. Adjusted call rate was 57% (95% CI 45% to 69%) higher in the highest than the lowest SES quintile. The call rates gradient appears to be very similar across SES groups.The trend in calls appears to be very similar across SES categories, indicating no interaction between TARPs and SES in their effect on the volume of calls. No evidence of an interaction if time with SES (p=0.336), suggesting that SES differentials in call rates were stable in the study period.

Internal validityNo indication of how they know SES of Quit Pack requesters represented the SES of all callers, as area was the SES indicator used.Only those who own a TV set eligible for recruitment.Definitions of low-med-high exposure used to generate equal groups, not by any genuine perception of ‘high’ exposure.Doesn’t mention which channels are used, i.e. Free-to-airExternal validityPossible influence of indigenous Australians’ engagement with the campaign? Not explored as a confounder. Applicability outside of urban settings?Validity of author’s conclusionValid - the exposure/call relationship shows no variation.

400

Author’s conclusion of SES impactSES groups had similar levels of responsiveness to television adverts

401

Details Method Results CommentsMass media - QuitlinesAuthor, year Sood 2008CountryUSADesign Cross-sectional with control comparisonObjectiveTo describe the characteristics of current smokers calling a national reactive telephone helplineSES variablesEducational status, annual household incomeAnalysescharacteristic in the studypopulation were compared withthe theoretic control population ofadult current smokers in the UnitedStates.

Data sourcesHelpline callers plus 2002 NationalBehavioral Risk Factor SurveillanceStudy (BRFSS) and the 1999-2001National Health Interview Study(NHIS) Participant selectionConvenience sample, 890 of 899 eligible adult smokers participated (98.9%) mostly from the Midwestern and Southern states Participant characteristics890 adult current smokers, new and voluntary callers onlyIntervention Mass media advertising campaigns using health consequences messages directed homogeneously across all population segments were used to boost helpline usage.Helpline provides assistance to callers across the United States via a toll-free number. The helpline offers live counselling that is standardized and based upon transtheoretic model of behavioural change as applied to smoking cessation, supplemented by the principles of social cognitive theory, a patient-centred counselling strategy, and the latest recommendations by clinical experts; all new callers are mailed a free package of self-help educational materials.Length of studyJanuary 2003 to October 2005Outcomes

General population Based upon an independent survey report of 432 callers, billboards were noted to be the most common method (49.6%) for the users to learn about the helpline, followed by radio (12.5%), television (10.6%), and word of mouth (7.6%).SES There was significant overrepresentation of poorer and less educated smokers. Smokers who used this national reactive telephone helpline, when compared with the general adult population of smokers across the United States, were significantly more likely to be women, at least 45 years of age, black, non-Hispanic, educated up to high school level, and urban residents, and to earn an annual household income of less than $35,000, more likely to be heavy smokers (i.e., smoking >25 cigarettes daily).Author’s conclusion of SES impactReactive telephone helplines may be preferentially used by disadvantaged smokers who are in greatest need of assistance

Internal validityThe helpline callers were not sampled by a stratified design across the entire United States. Further, all comparisons between the two populations were based on crude or unadjusted prevalence rates. Does not take into account the secular trends in smoking behaviour during the period 1999 to 2005.External validityParticipants were mostly from the Midwestern and Southern states so results may not be generalisable across US. Helpline callers were more likely to represent the contemplation stage of behavioural change than the general population of smokers.Validity of author’s conclusionGiven all the validity concerns the equity impact of the campaign and the helpline are unknown.

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Details Method Results CommentsMass media - Quitlines

Helpline callers

403

Details Method Results CommentsMass media - quitlinesAuthor, year Wilson 2010aCountryNew ZealandDesign Prospective cohortObjectiveTo examine how recognition of a nationalquitline number changed after new health warnings were required on tobacco packagingSES variablessmall area deprivation, individualdeprivation, and financial stressAnalysesPaired matched odds ratio

Data sourcesInternational Tobacco ControlPolicy Evaluation Survey (ITC Project) New Zealand armParticipant selectionThe NZ arm of the ITC Project survey differs somewhat from other ITC samples as the smokers involved are New Zealand Health Survey (NZHS) participants. NZHS respondents were selected by a complex sample design, which included systematic boosted sampling of the Māori, Pacific, and Asian populations. Invited at end of NZHS to participate in this study.Participant characteristics923/1376Intervention Wave 1 respondents were exposed to text-based warnings with a quitline number but no wording to indicate that it was the “Quitline” number. Wave 2 respondents were exposed to pictorial health warnings (PHWs) that included the word “Quitline” beside the number as well as a cessation message featuring the Quitline number and repeating the word “Quitline.” Length of study12 months (wave 1 between March 2007 and February 2008 and wave 2 between March 2008 and February 2009.OutcomesQuitline number recognition

General population The introduction of the new PHWs was associated with a 24 absolute percentage point between-wave increase in Quitline number recognition (from 37% to 61%, p < .001). Matched odds ratio of 3.31, 95% CI = 2.63 to 4.21.SES A majority of all five quintiles of socioeconomic deprivation using a small area measure (range 58.0%–65.5%) recognized the Quitline number in Wave 2. The increase between the waves was lowest in the most deprived quintile (p < .001), though this group had the highest level of recognition at baseline. For individual deprivation, the increase was highest in the second to least deprived grouping and lowest in the most deprived. For both types of deprivation, the most deprived had the highest level of recognition in Wave 1 and the lowest level of recognition at Wave 2 (though in the latter, the differences were not significantly different).Recognition increased from a minority of respondents to a majority for all deprivation levels (using small area and individual measures), and financial stress (two measures). Author’s conclusion of SES impactThis study provides some evidence for the value of clearly identifying quitline numbers on tobacco packaging as part of PHWs and appeared to benefit all sociodemographic groups. It may also help equalize differences that previously existed, for both measures of deprivation.

Internal validityBetween-wave attrition of 32.9% occurred. External validityThe overall response rate for this study was 32.6%. Weighting process may not have fully adjusted for nonresponse bias.Validity of author’s conclusionMay not be generalisable to whole of New Zealand due to sampling.

404

Details Method Results CommentsMass media – NRTAuthor, year Zawertailo 2012CountryOntario, CanadaDesign2 intervention cohorts with control cohortObjectiveTo determine the effectiveness of free nicotine replacement therapy (NRT), brief advice and self-help materials on quit attempts and 6-month quit rates in motivated smokers.SES variablesEducation, incomeAnalysesRegression analyses using log-binomial regression model. In these analyses, the OTS cohort making up the comparator arm was restricted to smokers matching STOP inclusion criteria and was re-weighted by age and sex to match the STOP intervention arm.

Data sourcesSTOP(Smoking Treatment for Ontario Patients) Study and population-based estimates of smoker characteristics in the Ontario Tobacco Survey (OTS) studyParticipant selection6261 consented to follow-up from 13143 eligible participants = 48%;Sub cohort of OTS used as comparator which matched STOP participants, n=780Participant characteristicsOntario residents 18 years ofage and older who smoked at least 10 cigarettes perday and were willing to make a quit attempt within30 days.nicotinepatch (n=10 000) or nicotine gum (n=4000)Intervention Provision of free NRT by mail following a brief telephone intervention.5 weeks of NRT (patches or gum) plus self-help and community resource materials, to the first 14 000 eligible smokers to call a toll-free

General populationpercentage reporting abstinence after6 months in the treatment cohort was 21.4%, relative to 11.6% in the no-intervention cohort (rate ratio of 1.84;95% CI 1.79 to 1.89), with the 30-day point prevalence of 17.8% and 9.8% for the intervention and nointervention cohorts, respectively (rate ratio 1.81; CI 1.75 to 1.87).SES Compared with all adult Ontario smokers (OTS cohort not restricted to STOP eligibility criteria), STOP participants were more likely to have less than high school education.Lowest income group associated with lower percentage of self-reported quit at time of interview (bivariate analyses). In multivariate analyses neither education or income was significantly related to self-reported at least one serious quit attempt within 6 months; being quit at the time of interview; 30-day quit point prevalence;Author’s conclusion of SES impactinitial brief intervention plus 5 weeks of free NRT to motivated smokers in Ontario with completer follow-up data significantly increased self-reported 6-month abstinence rates compared with our no intervention control arm who did not receive any free

Internal validityCompleter analyses only: 42% had complete follow-up data.Two methods were used to address the possible impact of loss to follow-up as a source of bias in comparing cessation rates between STOP and OTS.Completers were older than noncompleters. Completers had lower incomes than noncompleters but differences were small.External validityMotivated smokers, heavier smokers than in general population. large population-wide smoking cessation intervention provided across urban, rural and remoteareasValidity of author’s conclusionValid, comparator cohort conducted concurrently and recruited subjects from the same general population of Ontario smokers.

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Details Method Results CommentsMass media – NRT

quitline. STOP launched in January 2006. Region-specific media promotion was used to increase the reach in more remote regions of the province with a high prevalence of smoking.Length of study5 weeksOutcomesself-reported at least one seriousquit attempt within 6 months;being quit at the time of interview;30-day quit point prevalence;

NRT, materials or advice to quit.Type of smokers reached through this programme tended to be older, female, less-educated heavier smokers with high prevalence of psychiatric co-morbidities.

406

Details Method Results CommentsMultiple policiesAuthor, year Frieden 2005CountryNew York City, USADesign Repeat cross-sectionalObjectiveto determine the Impact of comprehensive tobacco control measures in New York CitySES variableseducationAnalysesUnivariate and multivariate

Data sourcesAnnual New York State Behavioral Risk Factor Surveillance System (BRFSS), New York City Department of Health and Mental Hygiene (DOHMH) conducted a population-based, random-digit dialed telephone community health surveyParticipant selectionrandomly selectedParticipant characteristicsadult New York City resident Intervention

9. April and July 2002 state and city tax increases raised the cost of a pack of cigarettes by approximately 32%, to a retail price of approximately $6.85

10. 2002 Smoke-Free Air Act (SFAA) became effective in March 2003 eliminated existing exemptions to make virtually all indoor workplaces, including restaurants and bars, smokefree.

11. April 2003 nicotine-patch distribution program began providing free 6-week

General population During the 10 years preceding the 2002 program, smoking prevalence did not decline in New York City; within a year of implementation of the new policies, a large, statistically significant decrease occurred. From 2002 to 2003, smoking prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%, (P=.0002) approximately 140000 fewer smokers).Increased taxation appeared to account for the largest proportion of the decrease; however, between 2002 and 2003 the proportion of cigarettes purchased outside New York City doubled, reducing the effective price increase by a third.SES Smoking declined among all education levels. The decrease was more pronounced among low-income women (an 18.1% decrease, from 21.6% to 17.8%; P=.OO9). Significant decreases in smoking were found among people with more than a high school education (a 12.4% decrease, from 19.3% to 16.9%; P=.O1). Declines were also large among people with annual family incomes of less than $25000 (a 12.6% decrease) or $75000 or more (a 13.4% decrease).

Internal validityResponse rates per wave among contacted households were 64%, 59%, and 64% respectively for three waves of data collection 2002 to 2003.ORs significantly reduced for smoking, only for people in income <$25,000 and ‘some college’ education.External validityAnalyses of education level were restricted to adults aged 25 years and olderValidity of author’s conclusionValid, but respondents' attribution of the impact of various control measures on their smoking behaviour may not be accurate.

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Details Method Results CommentsMultiple policies

courses (coupled with brief telephone counseling) to 34 000 of the city's heavy smokers

12. Expansion of educational efforts such as publications and advertisements in broadcast and print media, emphasized the health risks of environmental tobacco smoke and the benefits of quitting. There was also extensive media coverage of the debate regarding smoke-free workplace legislation.

Length of studyMay 2002 to November 2003; The 2002 community health survey was considered to be the preintervention sample, and the 2 surveys conducted in 2003 were combined and treated as the postintervention sample.OutcomesSmoking prevalenceOR for smokingResponse to tax increaseResponse to workplace smoking ban

In 2003, former smokers who had quit within the past year were more likely to have low incomes compared with former smokers who had quit more than 1 year previously (43.6% vs 32.0%, p=.0001).Residents with low incomes (<$25000 per year) or with less than a high school education were more likely than those with high incomes (>$75 000 per year) and those with a high school education or higher to report that the tax increase reduced the number of cigarettes they smoked (income: 26% [low] vs 13.0% [high], P=.0002; educational attainment: 27.5% [lower] vs 19.3% [higher], P=.OO9).High-income people were more likely than low-income people to report that the SFAA reducedtheir exposure to ETS (53.3% vs 41.9%, P<.0001).Author’s conclusion of SES impactGroups that experienced the largest declines in smoking prevalence included people in the lowest and highest income brackets and people with higher educational levels.Our data suggest that people with lower incomes may have been more heavily affectedby the increase in taxation, whereas

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Details Method Results CommentsMultiple policies

people with higher incomes may have been more affected by greater awareness of the dangers of environmental tobacco smoke and expansion of smoke-free workplace legislation.

409

Details Method Results CommentsMultiple policiesAuthor, year Nagelhout 2012CountryThe NetherlandsDesign Repeat cross-sectionalObjectiveTo examine trends in socioeconomic inequalities in smoking prevalence, consumption, initiation, and cessation between 2001 and 2008 in the Netherlands.SES variablesEducation; low (primary education and lower prevocational secondary education), moderate (middle prevocational secondary education and secondary vocational education) and high (senior general secondary education, (pre-)university education and higher professional education). Gross yearly household income level was also categorized into three equal sized groups: low (less than 28,500 Euro=< 25,600 GBP), moderate (between 28,500 and 45,000 Euro= 25,600 - 40,430 GBP), and high (more than 45,000 Euro =>40,430 GBP).AnalysesLogistic regression analyses

Data sourcesDutch Continuous Survey of Smoking Habits (DCSSH). The DCSSH is conducted by market research company TNS NIPO for the Dutch expert centre on tobacco control (STIVORO). Respondents for the DCSSH were selected from TNS NIPObase, a database containing more than 140,000 potential respondents who participate in internet-based research on a regular basis.Participant selectionStratified random sampleParticipant characteristicsApproximately 18,000 respondents 15years+ participated in the survey each year, totaling 144,733 respondents in the period 2001 to 2008.Intervention several tobacco control policies were implemented; 2002 text warning labels for cigarette packages 2002 tobacco advertising ban 2003 youth access law 2004 smoke-free workplace legislation which was extended in 2008 so as to include the hospitality industry. Tax increases were implemented in 2001, 2004, and 2008. Intensive national mass media smoking cessation campaigns ran in 2003, 2004, and 2008.Length of study2001 to 2008

General population Not reportedSES Lower educated respondents were significantly more likely to be smokers, smoked more cigarettes per day, had higher initiation ratios, and had lower quit ratios than higher educated respondents. Income inequalities were smaller than educational inequalities and were not all significant, but were in the same direction as educational inequalities. Among women, educational inequalities widened significantly between 2001 and 2008 for smoking prevalence, smoking initiation, and smoking cessation. Among low educated women, smoking prevalence remained stable between 2001 and 2008 because both the initiation and quit ratio increased significantly. Among moderate and high educated women, smoking prevalence decreased significantly because initiation ratios remained constant, while quit ratios increased significantly. Among men, educational inequalities widened significantly between 2001 and 2008 for smoking consumption only.Author’s conclusion of SES impactWhile inequalities in smoking prevalence were stable among Dutch men, they increased among women, due to widening inequalities in both smoking cessation and initiation.

Internal validityThere were no significant differences in education level, gender, and age group between years. However, income level differed significantly between years (χ2 (14) = 669.19, p<0.001), which was due to an increase in respondents with higher incomes over time.External validityPossible lack of representativeness of the Internet sampling frame used.Validity of author’s conclusionvalid

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Details Method Results CommentsMultiple policies

OutcomesSmoking prevalenceSmoking consumptionInitiation ratios = current + former smokers/all respondentsQuit ratios = (former smokers/current + former smokers)

411

Details Method Result CommentsMultiple policiesAuthor, year Schaap, 2008 Country18 European countries; Finland, Sweden, Denmark, England, Ireland, Netherlands, Belgium, Germany, France, Italy, Spain, Portugal, Slovakia, Hungary, Czech Rep., Lithuania, Latvia, EstoniaDesignCross-sectionalObjectiveTo examine the extent to which tobacco control policies are correlated with smoking cessation, especially among lower education groupsSES variables Education; relative index of inequality (RII). The RII assesses the association between quit ratios and the relative position of each educational group, can be interpreted as the risk of being a former smoker at the very top of the educational hierarchy compared to the very lowest end of the educational hierarchyAnalysesLog-linear regression analyses to explore the correlation between national quit ratios and the national score on the Tobacco Control Scale (TCS).

Data sourcesNational health surveys. 100,893 respondents over 18 countries.Participant selectionSelection process varies. Non-response rate between 13.4 and 49% depending on country. Participant characteristicsIreland has most developed tobacco control policy, Latvia least. Intervention Joosens and Raw’s tobacco control scale used as a proxy, with some analysis by individual policies including:Price, advertising bans, public place bans, campaign spending, health warningsLength of studyYear 2000, except Germany and Portugal = year 1998-9.Outcomes Quit ratios

General population Large variations in quit rate and RII between countries.Quit rates positively associated with tobacco control scale score. Policies related to cigarette price showed the strongest association with quit ratios. A comprehensive advertising ban showed the next strongest associations with quit ratios in most subgroups. Health warnings negatively associated with quit rates. Regression coefficient 2.08 (-0.36 to 8.48) for men and 2.07 (-1.09 to 8.66) for women for price.Regression coefficient 1.33 (1.11 to 8.02) for men and 1.59 (1.39 to 8.67) for women for advertising bans.Regression coefficient 0.94 (-2.43 to 5.89) for men and 0.41 (-3.84 to 5.26) for women for public place bans.Regression coefficient 0.54 (-3.05 to 6.17) for men and 0.54 (-3.52 to 6.41) for women for campaign spending.Regression coefficient -0.40 (-7.32 to 2.31) for men and -0.42 (-9.51 to 3.43) for women for health warnings.A ‘stripped’ analysis focusing on price, health warnings and treatment (excluding recent policy developments) supported the main findings.SES Quit rates positively associated with tobacco control scale score. More educated smokers more likely to have quit than lower educated, for men and women. Larger absolute difference between high and low educated for 25-39 year olds. However no consistent

Internal validityNon-response percentages ranged from about 15% in Italy and Spain up to 49% in Slovakia, while percentages in most other countries were between 20% and 35%.Survey conducted before tobacco control scale devised, and before some policies enacted so may underestimate the impact of recent policies.Difficult to draw conclusions about causality as study only examines the association between ex-smokers and presence of policies, rather than changes in prevalence post-implementation.Occasional smokers excluded from all analyses.External validityIncluded data from Eastern Europe and Baltic countries. Limited analyses to the adult population aged 25–59 years.Difficulty in drawing conclusions from multiple nations with varying average standards of education, definition of ‘highly educated’ likely to vary for some nations. Validity of author’s conclusionConclusion is consistent with the data presented; however it’s difficult to draw strong conclusions about the impact of any one intervention given the methodological limitations discussed above.

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Details Method Result Commentsdifferences were found between quit ratios in high and low educated groups and tobacco control scale score.Policies related to cigarette price showed the strongest association with quit ratios. Significant positive association between quit ratio and price for high SES aged 40-59 years.A comprehensive advertising ban showed the next strongest associations with quit ratios in most subgroups (not low SES aged 40-59 or low SES women aged 25-39 years. Health warnings negatively associated with quit rates. Author’s conclusion of SES impactHigh and low educated groups seem to benefit equally from nationwide tobacco control policies. More developed tobacco control policies are associated with higher quit rates.

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Details Method Result CommentsDetails Method Results CommentsMultiple policiesAuthor, year Verdonk-Kleinjan 2011CountryThe NetherlandsDesign Repeat cross-sectionalObjectiveTo explore how the combination of a workplace smoking ban and two tax increases influences the smoking behaviour of the general population.SES variableseducationAnalyseslinear and logistic regression

Data sourcesDutch Continuous Survey of Smoking Habits; each week, 200 respondents are randomly selected from a database of more than 200,000 respondents’ representative for the Dutch population aged 15 years and older. Sample is weighted for region, urbanization, gender, age, household composition, and level of education. The subjects were approached by Internet to fill in a questionnaire.Participant selectionSelected all 32,014 respondents aged 16–65 years in 2003, 2004 and 2005. With paid work (n = 27,150) and without (n = 4,864) paid work.Participant characteristics32,014 respondents (27,150 with paid work and 4,864 without paid work) aged 16–65 years.There were significant (p < .001) differences in gender, age, and level of education when we compared the group of the respondents with paid work with that without paid work.Intervention Respondents with paid work were exposed to the following interventions:the workplace-smoking ban from January 1, 2004 to February 1, 2004 (n = 601), the workplace-smoking ban and the first tax increase from February 1, 2004 to January 1, 2005 (n = 8,427), and the workplace-smoking ban and the first and

General population When controlling for the covariates (period after New Year, number of working hours, and age) the effects of the interventions on quit attempts were not significant among those with or without paid work. For respondents with paid work, the combination of a smoking ban and 2 tax increases led to a decrease in the number of cigarettes per day and in the prevalence of daily smoking. For respondents without paid work, there was no significant effect on any of the outcome parameters.For paid workers, there was no significant change (OR: 0.87) in the likelihood of daily smoking among the respondents interviewed in the one month (January 2004) in which the ban without additional tax increases was in force, although the OR was similar to the other interventions. The effects of the first (OR: 0.86) and second tax increase (OR: 0.85) after the ban on daily smoking were significant and in the expected direction.Among those without paid work, the tax increases had no significant effect on the likelihood of daily smoking. However, in terms of effect size, there was little difference between those with and without paid work in the effect of the first (OR: 0.86 vs. OR: 0.87) and second (OR: 0.85 vs. OR: 0.94) tax increase.SES In both paid and unpaid groups, there was no evidence that the effect of the measures on smoking was moderated by the respondent’s level of education.The likelihood of daily smoking was lower among the higher educated group compared

Internal validitythe lack of significance for the workplace-smoking ban may be due to too low statistical powerExternal validityPossible lack of representativeness of the Internet sampling frame used. In the Netherlands, the proportion of people with access to Internet in 2005 is relatively high (83%). Among those without work, Internet access is lower (66%) than among those with paid work (90%).Validity of author’s conclusionThe influence of the workplace-smoking ban is likely to be incorporated in the effects found for the first and second tax increase because ban only in force without tax increase for one month.

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Details Method Result Commentssecond tax increase from January 1, 2005 to December 31, 2005 (n = 8,908).Those without paid work were not exposed to an intervention until February 2004 (n = 1,825); they were exposed to the first tax increase from February 1, 2004 to January 1, 2005 (n = 1,521) and to the first and second tax increases fromJanuary 1, 2005 to December 31, 2005 (n = 1,518).Length of study3 years; 2003 to 2005OutcomesIntensity of smokingQuit attemptsSmoking prevalence

with the lower educated group (OR:0.59) with paid work. Higher educated respondents were less likely to be daily smokers (OR: 0.54) without paid work.Author’s conclusion of SES impactThere was no evidence that the effect of the measures on smoking was moderated by the respondent’s level of education.

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Details Method Results CommentsSettings based interventionsAuthor, year Darity 2006CountryUSADesign Quasi-experimental, 2-group pre-post design, with repeat cross-sectional samples and follow-up of longitudinal cohortObjectiveto determine the most effective educational interventions to reduce smoking among African-American smokersSES variableslow income vs moderate income areasAnalyses18-month analyses, cohort retrospective analyses, sequential cross-sectional analyses, process variable analysis

Data sourcessurveyParticipant selectionrandomly selectedParticipant characteristics2,644 black smoking households in four sites in the north-eastern and south-eastern parts of the United States; A sample of 520 smokers was randomly drawn from the baseline cohort for the six-month follow-up. For the twelve-month follow-up a random sample of 490 smokers were selected from the original cohort after excluding those individuals who had participated in the six-month follow-up. At the time of the eighteen-month follow-up survey, there were 2096 remaining members of the original cohort left with known addresses who could be followed up.Intervention Community-based intervention centred on the health belief and diffusion of innovation models. The active intervention areas were the subject of special area-based intervention activities, while the community as a whole (both the active and the passive areas) were exposed to a mass media campaign designed to promote readiness to quit smoking.Length of study18 months; 1989 to 1990Outcomespoint prevalence of non-smokingPeriod prevalence of quit attempts in the prior six months; Number of smoke-free days in theprior six months;

General population 18-month: among the 1344 baseline smokers re-interviewed at eighteen months, in the active intervention groups combined, the point prevalence of non-smoking was 16.7 percent while it was 11.8 percent in the passive groups combined, for an absolute difference of 4.9 percent. In other words, there was a 41.5 percent greater point prevalence rate of non-smoking in the active versus the passive intervention areas among the smokers interviewed, a difference which was statistically significant at p = 0.012.In this same survey, the period prevalence of attempting to quit at least once in the prior six months was 33.8 percent for the active intervention groups combined and 26.2 percent for the passive intervention groups combined. This absolute difference of 7.6 percent was statistically significantly at p = 0.003.There was a statistically significant difference in smoke-free days (p = 0.001) between the active group with a mean of 28.1 and the passive group with a mean of 19.4 for a difference of 8.7 percent. The number of smoke-free days was 31 percent higher in the active intervention group.Finally, there was a statistically significant difference (p = 0.004), between the active and passive intervention areas in the reduction in numbers of cigarettes smoked at eighteen months versus at baseline. There was a mean decrease of 2.0 and 0.4 fewer cigarettes smoked daily, respectively, in the active and passive groups when non-smokers were omitted, for an absolute difference of 1.6. This represents a 400 percent greater reduction in cigarettes smoked in the active intervention group.

Internal validityThe initial research design strategy was to select four Black neighborhoods in each of the selected cities: two middle-income areas and two lower-income areas. One middle-income and one lower-income area in each city were designated as passive intervention sites while the remaining middle- and low-income areas were the active intervention sites. Subsequent to the baseline survey the four areas of Springfield were combined into a single active intervention site while the four areas of Hartford were designed a single passive site.The cross-sectional studies contained different individuals (in the case of the 6- and 12-month surveys), and only some of the individuals in the eighteen-month group overlapped with those from the six- and twelve-month surveys. Such a difference in population make-up can be a source of selection bias which can result in spurious differences in outcome variables between surveys.There are no specific outcomes by income area and income areas are not defined in any more detail.External validityGeneralisable to black smokers in North-eastern and south-eastern parts of USValidity of author’s conclusionIt is difficult to tell from the paper

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Number of cigarettes smoked daily at the time of interview.

SES 18-month analyses: The moderate income areas tended to show a smaller percentage change in smoking outcomes in the intervened versus non-intervened groups than did the lower income areas, although the differences were not significant. The exception to this is the greater percentage reduction in the number of cigarettes smoked. There was only a small non-significant increase in personal smoking behavior in moderate income groups as opposed to low income groups.Education was not significantly related to outcome variablesAuthor’s conclusion of SES impactThe moderate income areas tended to show a smaller percentage change in smoking outcomes in the intervened versus non-intervened groups than did the lower income areas, although the differences were not significant. The exception to this is the greater percentage reduction in the number of cigarettes smoked.An analysis of process variables strongly suggests that, within this African-American Community, “hands on” or “face to face” approaches along with mass media, mailings, and other less personal approaches were more effective in reducing personal smoking behavior than media, mailings, and other impersonal approaches alone addressed to large audiences.

what the impact was by area SES.

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Details Method Results CommentsSettings based interventionsAuthor, year Donath 2009CountryGermanyDesign Multi-centre field study with pre–post design as well as a parallel cross-sectional assessment of tobacco control policy at participating centres. Data are part of an RCT before the intervention in the experimental group started.ObjectiveTo explore the influence of tobacco control policies in German in-patient substance abuse treatment centres on smoking status of alcohol-addicted patients at discharge.SES variableseducationAnalysesmultiple regression

Data sources40 in-patient treatment centres. The tobacco control policy questionnaire was anonymous and answered by the director of each treatment centre.Participant selection30 smaller centres self-recruited and 11 of 31 centres with at least 50 beds were recruited by invitation. (92.5%) were included in follow-up; 774 patients out of 1178 at baseline (65.7%). Patients recruited consecutively in 6-month period starting June 2005.Participant characteristics774 alcohol addicted patients mean number of beds =112 (SD=65), mean number of employees =62 (SD=35). The mean duration of treatment was 12.9 weeks (SD=4.1). The majority of the centres were located in the western part of Germany. One fourth of the recruited patients were female, the mean age of the patients was 42 years. The majority of the patients were not employed and had an education of less than 12 years. The mean smoking prevalence of patients at admission was 84% varying between 65% and 100%.Intervention Institutional tobacco control policy, 7 elements included Restrictions, Enforcement, Assessment of smokers, Smoking cessation offers, Non-smoker protection, Activities, Training of Employees,Length of studyJune 2005 to March 2006

General population The strength of tobacco control policy lie in the areas of assessment of smokers, enforcement of smoking restrictions and restrictiveness of smoking policy. There was a small but significant effect of centres’ tobacco control policy on patients’ smoking cessation. A total of 39 patients being smokers at admission (N=774) were non-smokers (7-day prevalence) at discharge. This equals an abstinence rate of 3.3% (Intent-to-treat-analysis) respectively 5.0% (exclusion of drop outs). Abstinence rates vary between centres within the range of 0.0% to 23.0%.Lower tobacco dependency predicted non-smoking status at discharge (OR=0.84, 95% CI= 0.71 to 0.99).Comprehensiveness of smoking restrictions (OR=1.03, 95% CI=1.00 to 1.07) and intensity of smoking related training of the employees (OR=1.02, 95%CI=1.00 to 1.03)are significant predictors for the variance in quit rates between the institutions.SES Significant individual predictors for quitting include educational status (OR=1.86, 95%CI=1.25 to 2.75).Author’s conclusion of SES impactHigher education predicted non-smoking status at discharge. There were two predictive areas of tobacco control policy (restrictions and employee training) while an overall effectiveness of the developed concept could not be proven.

Internal validityThe questionnaire consisted of scores up to an optimal 100, for seven policy areas and was developed using published material and piloted. Retest reliability was acceptable in 5 of 7 areas (r=0.61 to r=0.81) and in 2 areas the retest reliability was ≤0.5.The tobacco control policy was measured by ratings of a single person.External validityVery specific population of smokers whose quit rates are relatively low and effects of tobacco control policy are small. Compared with the general German population the education of the sample was lower and the unemployment higher. The mean smoking prevalence of patients at admission was 84% varying between 65% and 100%. May be some selection bias as sample was only one-fifth of all German in-patient substance abuse treatment centres.Validity of author’s conclusionOnly some of the policy areas were predictive of smoking status and not the whole policy.

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Outcomes7-day point prevalence tobacco consumption

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Details Method Results CommentsSettings based interventionsAuthor, year Secker-Walker 2000CountryTwo counties in Vermont and 2 in NewHampshire, USADesign 2 pairs of demographically matched counties assessed preintervention and postintervention.ObjectiveTo reduce the prevalence of cigarette smoking among women with special emphasis on lower-income women of childbearing age, among whom smoking was most prevalent.SES variablesHousehold incomeAnalysesPreintervention and post-intervention random digit-dialed telephone surveys in the intervention counties and the 2 matched comparison counties

Data sourcesrandom-digit-dialed telephone surveys of ‘Breathe Easy’ studyParticipant selectionOne county in each state was adjacent to the other. These were designated the intervention counties, giving geographic separation of mass media markets between conditions.Participant characteristicsIn 1990, the total population of the intervention counties, Windham County, Vt, and Cheshire County, NH, was 111 709 (41 588 and 70 121), of whom 35382 (12904 and 22478) were women aged 18 to 64 years. The total population of the comparison counties, Rutland County, Vt, and Belknap County, NH, was 111 357 (62 141 and 49216), of whom 34480 (19473 and 15007) were women aged 18 to 64 years.The overall sample sizes were 6379 and 6436, baseline and follow-up.Intervention Social cognitive theory, the transtheoretical model of behaviour change, diffusion of innovation theory, and communications theory guided the intervention. Community organization approaches to create coalitions and task forces to develop and implement a multicomponent intervention in 2 counties in Vermont and New Hampshire, with a special focus on providing support to help women quit smoking. community coordinator formed a local planning group, and the program was named

General population In the intervention counties, compared with the comparison counties, the odds of a woman being a smoker after 4 years of program activities were 0.88 (95% confidence interval = 0.78, 1.00)(P=0.02, 1-tailed); women smokers' perceptions of community norms about women smoking were significantly more negative (P=0.002, 1-tailed); and the quit rate in the past 5 years was significantly greater (25,4% vs 21,4%; P=,02,1-tailed).SES Quit rates were significantly higher in the intervention counties among women with household annual incomes of $25 000 or less (14.6±2.0) compared with control counties (22.6±2.3), p<0.01. No significant difference in 5 year quit rates between intervention and control with household income >$25,000.Author’s conclusion of SES impactHigher quit rates were seen among those specially targeted by the interventions—younger women and those with lower incomes.

Internal validityResponse rates of 79,1% for thebaseline survey and 89,9% for the year 5 survey of eligible householdsExternal validityMass media campaign used in the context of a comprehensive community programme including telephone counselling, support groups, primary care interventions, cessation classes, workplace initiatives, health fairs and public events – mass media was relatively minor component of the programme.Validity of author’s conclusiondifficult to tease out independent effects of any separate component

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Details Method Results CommentsSettings based interventions

"Breathe Easy." Each county's planning group formed a coalition, and each coalition recruited volunteers to serve on 5 working groups: support systems, health professionals, educators, worksites, and mass media.Length of study1989 to 1994OutcomesQuit ratesPerceptions of norm

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Details Method Results CommentsSettings based interventionsAuthor, year Sorensen 1998CountryEastern and central Massachusetts, USADesign RCT one worksite in each matched pair was randomly assigned to intervention and the other to controlObjectiveTo evaluate the effects of the intervention on dietary habits and smoking and whether intervention effects differed by job category or exposure to occupational hazards.SES variables3 occupation groups; ‘skilled and unskilled’ ‘office work’ and ‘professional, managerial and administrative work’AnalysesWorksite was unit of analysis, repeat measures linear modelling.

Data sourcesWellWorks study; self-administered surveysParticipant selectionRecruited worksites in Massachusetts based on number of workers (250 to 2500), less than 20% turnover rate, less than 20% non-English speaking employees and use of known or suspected carcinogens in work processes. Random sample of workers selected at each work site at baseline and follow-up to complete surveys. 61% completed surveys at baseline, range by worksite was 36 to 99%.Participant characteristics2386 workers in 24 predominantly manufacturing worksites.Intervention Worksite cancer prevention initiative for blue-collar workers targeting behavioural risk factors and exposure to job-related hazards. Three key intervention elements targeted health behaviour change: (1) joint worker management participation in programme planning and implementation (2) consultation with management on work-site environmental change (3) health education programmes.Length of study1989 to 1994Outcomes6-month self-reported abstinence

General population No significant effects were observed for smoking cessation. Six-month smoking abstinence rates were 15% in the intervention worksites and 9% in control worksites controlling for worksites (p=0.123). When work site removed from the model, the OR for the intervention effect was 1.83 (p=0.04).SES Only job category was significantly associated with smoking. Intervention by job category was not significant; 6-month abstinence rate for skilled and unskilled workers was 17.9% in the intervention sites and 9.0% in the control sites. For office workers abstinence was 5.1% in control sites vs 2.5% in intervention sites, for professionals and managers abstinence was 18.6% in control and 14.2% in intervention sites (abstinence rates higher in control).Author’s conclusion of SES impactAlthough the differences by job category were not significant; smoking abstinence rates among blue-collar workers were comparable to those among professional and managerial workers.

Internal validity62% completed survey at follow-up (range=43 to 92%).Compared with those responding only at baseline; the cohort had higher percentage of skilled and unskilled labourers (49 vs 43%) and lower smoking prevalence (23% vs 26%). Members of the cohort were less likely to have college degrees (26% vs 30%) but more likely to have some college (37% vs 32%).External validityLimited sample size for baseline smokers-number assessed not reported.Validity of author’s conclusion

422

Details Method Results CommentsSettings based interventionsAuthor, year Sorensen 2003CountryMassachusetts, USADesign RCT- Cross-sectional sample before and after intervention and ‘embedded cohort’ObjectiveTo examine whether, in comparison to a standard health promotion intervention, an intervention integrating health promotion plus occupational health and safety would result in significant and meaningful increases in smoking cessation and consumption of fruits and vegetables, both in all workers and among blue-collar workersSES variablesBlue collar workers measured as ‘hourly wage earners’. White collar workers classified as ‘paid on salary’AnalysesLinear logistic regression for cross-sectional data and repeated-measures analysis of change for ‘embedded cohort’ data

Data sourcesWellWorks-2 studyParticipant selectionEligibility criteria for worksites recruited to the study included the following: (i) employ between 4oo and 2ooo workers, (2) probable use of chemical hazards, and (3) turnover rate less than 20%. Workers were eligible to participate in the surveys if they were non-contractual workers employed on a permanent basis for 15 hours per week or more, and worked onsite Participant characteristicsWorksites ranged in size from 424 workers to 1585 workers (mean: 741 per site). Types of manufacturing conducted at the recruited worksites included adhesives, food, technology, jewellery, motor controls, paper products, newspaper, abrasives, automobile parts, and metal fabrication.5156 subjects responded to both the baseline and final survey. Embedded cohort of smokers at baseline who responded to final survey: n = 880.Intervention Worksite cancer prevention intervention,Worksite health promotion only (HP Group; eight worksites); and (2) Worksite health promotion integrated with an occupational health and safety intervention (HP/OHS Group; seven worksites).Included interventions at the individual,

General population For all smokers the quit rates were somewhat higher in the HP/OHS condition compared to the HP group, but the difference was not statistically significant; 11.3% vs 7.5% respectively, p=0.17.SES Smoking quit rates among hourly workers in the HP/OHS condition more than doubled relative to those in the HP condition (11.8% VS 5.9%; p=0.04), No differences in quit rates between groups for salaried workers. Smoking quit rates among salaried workers in the HP/OHS condition was 9.9% vs 12.7% in the HP condition p=0.63.Author’s conclusion of SES impactA programme integrating health promotion and occupational health and safety efforts can significantly improve smoking quit rates among blue-collar workers compared to health promotion alone.Resulted in a quit rate among blue-collar workers that was over double that observed among blue-collar workers in the health promotion only group.

Internal validityThe unit of randomization and intervention was the worksite, while the unit of measurement was the employee. Of 41 eligible worksites, 15 agreed to participate = 37% response rate. Response rate to the baseline cross-sectional survey was favorable at 8o%, the response rate to the final survey was 65%.Unclear how many smokers at baseline in the embedded cohort did not respond to follow-up survey – although this study was an RCT, quit rates not assessed in all smokers randomised to each intervention.Unclear which differences in baseline characteristics between groups were adjusted for in analyses.External validityParticipating worksites may not be representative of general population of worksites of this size and type of business. Measure of blue and white collar workers may not transfer over to other types of business.Validity of author’s conclusion

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Details Method Results CommentsSettings based interventions

organizational, and environmental levels of influence.Length of study2 years from 1997 to 1999OutcomesSelf-reported abstinence for six months prior to the survey. Current smokers defined as smoked at least 100 cigarettes in their lives and defined themselves as current smokers

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Details Method Results CommentsSettings based interventionsAuthor, year Stafford 2008CountryEnglandDesign Cohort with comparison groupObjectiveTo assess health improvement and differential changes in health across various sociodemographic groups in neighbourhood renewal areasSES variablesIndex of multiple deprivation for NDC, education for individualAnalysesMultilevel regression

Data sourcesIn 2002, MORI/NOP undertook a survey of 500 residents aged 16 years and over in each of the 39 NDC areas.Participant selectionNo detailsParticipant characteristics10,390 residents in New Deal for Communities (NDC) areas and 977 residents in comparator areas in England.Intervention New Deal for Communities (NDC) area-based initiative that aims to improve conditions in some of the most deprived neighbourhoods in England and reduce the gap between them and the rest of the country. There are 39 NDC areas, each with a budget of approximately £50 million with which to address five specific outcome areas (health, unemployment, education, crime and the physical environment) over 10 years.Length of study2 years from 2002 to 2004OutcomesQuitting smoking

General population Small overall improvements were seen on all domains in NDC areas but similar improvements were also seen in comparator areas. More than 10% of residents quit smokingSES At baseline there were large differences by education for smoking and these differences widened over the two-year follow-up. In NDC areas, higher educational groups were more likely to stop smoking.Author’s conclusion of SES impactEvidence from two-year follow-up does not support an NDC effect, either overall or for particular population groups. Residents with lower education experienced the least favourable health profiles at baseline and the smallest improvements. Investigation of the reasons for the differential improvement by educational group was beyond the scope of this study. It is possible that lower educational groups are simply slower to take up new services and resources and that, over time, the socioeconomic differences will diminish.

Internal validity73% attrition rate. The comparator areas had a slightly lower proportion of residents with no educational qualifications (33% versus 39%), however, which may indicate that the areas were slightly less deprived than their NDC counterparts.External validityThere was considerable overlap of area-based initiatives in NDC areas and it is likely that interventions were underway in some of the similarly deprived comparator areas.Validity of author’s conclusionvalid

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Details Method Result CommentsSettings based interventionsAuthor, year Wendell-Vos 2009 CountryMaastricht (in the south Netherlands) and Doetinchem (in the middle of the Netherlands on the east)DesignCohort with comparison groupObjectiveTo investigate the effect of a CVD prevention program 5 years onSES variables Education (less than intermediate school, intermediate or higher secondary, higher vocational education or university)Analysescompared mean within-person change in lifestyle factors between the intervention group and the control group using linear regression analyses, assuming a normal distribution for the variables under study

Data sourcesBaseline questionnaires and physical examination, and follow-up questionnaire 5 years on. Participant selectionPopulations taken from previous monitoring studies. Gender and age stratified sample used from Maastricht (experiment) and Doetinchem (control) 2356 participants in experimental area, 758 in control. Follow-up rate >80%Participant characteristicsAged 31-70, 24% male smokers, 27% female. 25% and 22% in control region.45% males and 61% females of Low education, 43% and 61% for control.InterventionThe Hartslag Limburg Intervention, 5 year community lifestyle intervention program, encouraging people to reduce their fat intake, be physically active, and stop smoking.Umbrella project with two strategies, one at population level and the other targeted at deprived communities. 790 interventions were implemented (9 anti-smoking). Almost 50% took place in deprived areas.Examples of these major interventions are nutrition parties; debt assistance (people with debts are taught to cook a healthy meal on a small budget); printed guides showing walking and cycling routes; a daily TV guided aerobics program, including information about the health advantages of exercising; and antismoking campaigns using billboards, posters, and leaflets.Length of studyJanuary 1998 to January 2003Outcomes

General population 6.5% of men in the intervention group quit smoking after 5 years, compared to 5.8% in the control group. 5.8% and 5.9% respectively for women. Initiation was 3.2% and 2.3% for men, and 3.3% and 3.2% for women.All changes were significant at p<0.05.There were no significant differences between intervention and control groups.SESSmoking quit rates by education:Low (Control) , med/high (control)6.2% (5.8%) and 6.1% (5.9%). Smoking initiation by education: Low (Control), med/high (control) 2.2% (2.0%), 4.3% (3.7%).There were no significant between intervention and control by educational level.Author’s conclusion of SES impactPrevented negative change in a number of behavioural traits [but not smoking], particularly among women and those of low SES.

Internal validityLow rate of drop-out. >80% of the subjects completed both the baseline and the follow-up measurement.External validityPopulation involved in previous health monitoring study, and so likely more health-conscious than the general population.Validity of author’s conclusionNo apparent impact of the intervention over the five year period, either overall or by education.

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Smoking status and frequency (smoker defined as anyone who currently smokers, regardless of quantity)

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Details Method Results CommentsPopulation-level cessation support interventions - UK Smoking Cessation ServicesAuthor , year Bauld 2003Country76 Health Authorities, EnglandDesignCross-sectionalObjectiveTo determine the extent to which UK NHS SSS’s in England reach smokers and support them to quit at four weeksSES variables Index of Multiple Deprivation (IMD),Health Action Zone (HAZ)AnalysesOrdinary least squares regression

Data sourcesNHS SSS quarterly monitoring forms for 2000-2001 and co-ordinator postal survey 2001Participant selectionNoneParticipant characteristicsSmokers attending NHS SSS’s and setting a quit date in 76 Health Authorities in EnglandIntervention NHS SSSLength of studyOne year – April 2000 to March 2001Outcomes Reach,Self-report quits at 4-weeks,Cessation rate (number of smokers who reported quitting at four weeks as a percentage of those setting a quit date).

General populationN/aSESCessation services based in HAZ reached 140% more smokers compared to other more affluent areas, and the number of people who reported quitting at four weeks was 90% greater in HAZ areas. When the service was operating at full capacity, reach was diminished and the number of people reporting quitting at four weeks was larger. However, there was an inverse relationship between reach and cessation rates (the number of smokers who reported quitting at four weeks as a percentage of those setting a quit date). Cessation rates were lower in deprived areas compared with more advantaged areas. Services operating in deprived areas were more likely to lose clients between setting a quit date and reporting outcomes at four weeks.Author’s conclusion of SES impactThe strong inverse relation between reach and cessation rate suggests that when more effort went into attracting a large number of smokers to the service, this tended to be at the expense of cessation rates. However, the overall pattern of results suggests that high reach is desirable if the primary objective is to maximise the actual number of people who stop smoking.

Internal validityLimited by self-report data and short-term (4 weeks).External validityGeneralisable across UK but unique to the UK. Study was done when NHS SSS’s were relatively new.Validity of author’s conclusionValid

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Details Method Results CommentsPopulation-level cessation support interventions - UK Smoking Cessation ServicesAuthor , year Bauld 2007CountrySpearhead areas, EnglandDesignRepeat cross-sectionalObjectiveTo assess whether NHS Stop Smoking Services (SSS) are reducing inequalities in smoking prevalenceSES variables Index of Multiple Deprivation (IMD) 2004 Local Authority Summary average scoreAnalysesThe statistical significance of differences between areas is shown using Pearson's 2 test. Simple measures of health inequality are calculated in terms of absolute rate gaps and relative rate ratios (with 95% confidence intervals) between the Spearhead Group on the one hand and non-Spearhead areas and England as a whole.

Data sourcesOffice for National Statistics and DoH annual statistical reports of NHS SSS for EnglandParticipant selectionParticipant characteristicsIntervention Length of study2003-4 to 2005-6Outcomes Self-report quits at 4-weeks;Estimated one-year quit rates (assuming an average relapse rate of 75% for both Spearhead and non-Spearhead areas);

General populationIn total, almost 1.5 million smokers were treated in England during the period as a whole. Fifty-five per cent (832 678) of smokers accessing treatment services and setting a quit date self-reported that they had quit at short-term follow-up. SESCessation rate was lower (52.6% overall) in the Spearhead Group areas than elsewhere (57.9%) (p<0.001). On the other hand, the proportion of all smokers treated was higher (16.7%) in the more disadvantaged areas than in the remainder of England (13.4%) (p<0.001 ). Overall, the proportion of all smokers who were estimated to have quit at four-week and 52-week follow up was higher in the Spearhead areas (8.8% and 2.2%) than elsewhere (7.8% and 1.9%) (p<0.001). Assuming 75% of 4-week quitters will relapse (across all areas) the absolute rate gap between Spearhead and non-Spearhead areas was reduced from 5.2 to 5.0 %, and the relative rate ratio from 1.215 (CIs: 1.216 to 1.213) to 1.212 (CIs: 1.213 to 1.210), between 2003 and 2006.Author’s conclusion of SES impactAlthough disadvantaged groups had proportionately lower success rates than their more affluent neighbours, services were treating many more clients in disadvantaged communities. Overall, therefore, the net effect of service intervention was to achieve a greater

Internal validityAssumes that each smoker treated is a unique individual, but some people will have been treated more than once and so overestimates impact of the service.Assumes 75% of short-term quitters will relapse within less than one year. External validityGeneralisable across UK but unique to the UKValidity of author’s conclusionValid, although quit rates are lower among more disadvantaged groups (lower SES) this is offset by substantial positive discrimination towards such groups in the delivery of services. The net effect of new services is to achieve a modest reduction in inequalities.

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Details Method Results CommentsPopulation-level cessation support interventions - UK Smoking Cessation Services

proportion of quitters among smokers living in the most disadvantaged areas.

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Details Method Results CommentsPopulation-level cessation support interventions - UK Smoking Cessation ServicesAuthor , year Bauld 2012CountryLiverpool, Knowsley, UKDesignCohortObjectiveTo assess longer-term outcomes of a drop-in rolling-group model of behavioural support for smoking cessation and the factors that influence cessation outcomes.SES variables National Statistics Socio-Economic Classification (NSSEC), entitlement to free prescriptions, education assessed through school-leaving age (16 years or under compared with over 16 years), housing tenure (owner, other or unknown and renter) and neighbourhood deprivation, as measured by the English Index of Multiple Deprivation (IMD) 2007.Preliminary analysis showed that the sample distribution was skewed towards the most disadvantaged decile (68% of the sample resided in the most deprived decile), so IMD deciles were recalculated for Liverpool postcode areas only and the five more affluent deciles were compared to the five more deprived deciles.Home ownership; managerial,

Data sourcesObservational study of Roy Castle Lung Cancer Foundation (RCLCF) Fag Ends NHS Stop Smoking Service in Liverpool and Knowsley, UK.Participant selectionDrop-inParticipant characteristics2585 clients, aged 16 or over, setting a quit dateIntervention State-reimbursed clinical stop-smoking service providing behavioural support and medication. ‘Fag Ends’ is an alternative intervention type with support centred on drop-in rolling groups. Quit date is different for attendees and can be determined by the client; no waiting lists, no appointments; no requirement to be referred by a third party, although referral systems are in place. Weekly sessions run continuously. Clients can attend as many sessions as they wish and can continue to attend even if they relapse. Advisers are trained in providing behavioural support to smokers and providing information about stop smoking medication. Although there is a developed service protocol, the approach taken by the service staff can be dependent

General populationAt 1 year, 8.2% self-reported quit. The CO-validated prolonged abstinence rate at 52 weeks for smokers attending the groups was 5.6%, compared with 30.7% at 4 weeks (a relapse rate of 78.2%).SES ReachThe sample was particularly disadvantaged: 68% resided in the most deprived decile of the English Index of Multiple Deprivation. Fag Ends clients are drawn from particularly disadvantaged groups when compared to the general population: only 20% finished their education after age 16, whereas in England 49% have qualifications obtained after age 16 in 2009; nearly two-thirds were eligible for free prescriptions, whereas 50% of the general population are eligible; and a third were long-term unemployed, whereas the General Lifestyle Survey 2008 estimate for UK over-16s was 4.2%.QuittingSchool leaving age was the only socio-economic indicator that was not related significantly to quitting.In general, more affluent clients were more likely to be quitters at 12 months. Nevertheless, the relationship between SES and quitting was not straightforward: groups with the highest affluence (those living in the most affluent decile of neighbourhoods and those with managerial

Internal validityThose clients self-reporting abstinence were asked for biochemical (CO) verification either at a service location or at home, and were offered a £30 shopping voucher to cover their time and travel costs. 147 of 211 self-report quitters at 52 weeks attended for CO validation so only able to validate biochemically the quit status of approximatelytwo-thirds of clientsExternal validityLiverpool and Knowsley region has high economic and social disadvantage. Liverpool is most disadvantaged local authority in England.Long-term success rates were lower than are found typically in clinical trials.In 2009–10 in England a total of 33 296 clients, 4% of those who set a quit date, attended drop-in rolling groups compared with 79% who received one-to-one structured support, 11% who attended drop-in clinics and 2% who attended closed groups, and these percentages remained virtually unchanged in

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Details Method Results CommentsPopulation-level cessation support interventions - UK Smoking Cessation Servicesprofessional or intermediate occupation and resident in the most affluent half of Liverpool postcode area neighbourhoods were significant predictors of quitting in the preliminary bivariate analysis and were assessed in multivariate analysis as composite indicatorAnalysesMultivariate logistic regression

on the numbers of clients who attend or the adviser’s own particular approach or experience in addressing their needs. One-to-one support in a less open forum is also available.Length of study26 January and 8 April 2009Outcomes Self-report quits (smoked five or fewer cigarettes between quit date and 52-week follow-up);Carbon monoxide (CO)-validated quit at 52-week follow-up (less than 10 parts per million)

and professional occupations) had lower quit rates than slightly less advantaged groups. This could be the result of a selected group of the most affluent enrolling, as only 4.7% of clients had managerial and professional occupations, whereas General Lifestyle Survey 2008 data suggest that about a third of the UK population can be classified as managerial or professional. Economically inactive groups had high rates of quitting.CO-validated quitters were more likely to be more affluent [1.33 (1.07–1.65) for each extra indicator of high socio-economic statusAuthor’s conclusion of SES impactHigher socio-economic status within the sample was a predictor of quitting. Group interventions can go some way towards equalizing outcomes, and thus have more potential to reduce inequalities than one-to-one support.

2010/2011.Validity of author’s conclusionValid. Highest SES group may not use this type of drop-in rolling group service.

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Details Method Result CommentsPopulation-level cessation support interventionsAuthor , year Hiscock 2009CountryChristchurch, New ZealandDesignRepeat cross-sectionalObjectiveTo identify the impact of a smoking cessation programme on area-based tobacco-use inequalities, “PreparationEducation Giving up and Staying smoke free’’ (PEGS) programme SES variables Neighbourhood deprivation, Census meshblocks were classified by area-level deprivation in 2001 measured using the New Zealand Deprivation Index (NZDep) and dividing allneighbourhoods into quintiles.AnalysesAdapted a methodology devised for NHS SSS’s

Data sourcesPEGS enrolment between 2001 and 2006, routine data collection geo-coded by neighbourhood.Pre-intervention city-wide smoking rate estimated from 1996 and 2006 census data.Participant selectionN=11325, f/u=7778 (69%)Participant characteristicsChristchurch residents at the time of PEGS implementation.Intervention PEGS is delivered by GPs. educational smoking cessation intervention with different types of counselling and literature based on patients level of readiness to quit. Most ready participants are also offered NRT and to nominate a quit date. The delivery of the programme is not consistent across practices butface-to-face support tends to be given when the patient collects the NRT from the practice every one or two weeks. The NRT is heavily subsidised by the Ministry of Health for up to three months. Enrolees are followed up by their GP 6 months after their enrolment.Length of studySix yearsOutcomes Enrolment, Self-reported cessation at 6 month follow up (assumed those lost to

General population Enrolment falling year on year.SESLittle difference in utilisation between highest and lowest deprivation areas as proportion of the city’s smoking population (22.0% for least deprived quintile and 20.7% for most deprived quintile)Quit rate for least deprived neighbourhoods was 36.1% v 25.6% for most deprived (25.2 v 17.5 assuming non-followed up failed to quit)Estimated actual gap between most and least affluent neighbourhoods was reduced by 0.2 percentage points (15.6% to 15.4%), but relative gap widened from 2.81 to 2.84 OR.Author’s conclusion of SES impactEffect was small and non-significant, coverage in deprived areas could be further improved. Effective at reducing smoking prevalence, but no evidence of impact on area inequalities. Confidence intervals overlap so we can conclude thatPEGS neither increased nor decreased deprivation-related inequalities in the smoking rate.

Internal validity31% loss to follow upGeographic areas not perfect measures of SES.External validityNo indication of the intervention’s likely impact in rural areas. Assumes a further 37.5% relapse over one year and excludes latent quitters from estimation of PEGs impact on population smoking ratesValidity of author’s conclusionLikely to over-estimate impact on deprived communities due to emphasis on ‘readiness’ for referral to the programme?Reach favoured more affluent neighbourhoods, quit rate higher in more affluent areas. Smoking rates in the most deprived neighbourhoods were nearly three times higher than in the most affluent areas and the PEGS cessation programme did not change this.

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follow-up were smokers),Absolute and relative smoking rate differences

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Details Method Results CommentsPopulation-level cessation support interventions - UK Smoking Cessation ServicesAuthor, year Simpson 2010CountryUKDesign Cross-sectionalObjectiveTo confirm the recent acceleration in smoking reduction found using survey data, and also describe the recording of smoking status, provision of smoking advice, and referral to specialist stop-smoking services in patients registered in primary care in the UK. It also aimed to investigate whether these trends differed between sex, age, and deprivation groups.SES variablesDeprivation – Townsend score (UK 2001 census)Analyses

Data sourcesAnonymised aggregated health data from 2.7 million patients from 525 general practices contributing to the QRESEARCH databaseParticipant selectionGeneral practices are self-selected Participant characteristicsPatients were included if they were registered in primary care on 1 April each year and were registered for the preceding 12 months and aged 16 years or over.Intervention April 2004, a quality-based General Medical Services contract was introduced into UK primary care – included financial incentives to record smoking status and provide smoking cessation supportLength of study6 years – 2001 to 2007OutcomesProvision of smoking cessation adviceReferral to stop smoking service

General population The proportion of people with smoking status recorded increased by 32.9% (2001/2002: 46.6% to 2006/2007: 79.5%). A large overall increase in the provision of smoking cessation advice (2001/2002: 43.6% to 2006/2007: 84.0%) and referral to stop-smoking services (2001/2002: 1.0% to 2006/2007: 6.6%) was also observed. The proportion of people who smoked (with a recorded smoking status) reduced by 6.0% (2001/2002: 28.4% to 2006/2007: 22.4%). SES The decrease in the proportion of people who smoked was greatest among patients in the most deprived areas (7.2%) and the youngest patients (16–25 years: 7.1%). In 2006/2007, more than twice as many patients in deprived areas smoked as those in affluent areas (most deprived: 33.8%; most affluent: 14.1%).In 2001/2002, patients in deprived areas (who had been recorded as smokers in the last 12 months) received the most smoking cessation advice (P<0.001). However, in 2006/2007, similar proportions from the most affluent and most deprived groups, were provided with smoking cessation advice. In 2001/2002, patients in deprived areas were more likely to be referred to a specialist stop smoking service (P<0.001). In 2006/2007, those living in the most deprived areas were most likely to be referred. Large increases in the number of patients referred to a specialist stop-smoking service were also found (P<0.001), most particularly among those in the most deprived areasAuthor’s conclusion of SES impactA significant and important reduction in the

Internal validityThere were a larger number of non-smokers being recorded over time which could overestimate decreases in proportion of people found to smoke.External validityDuring time period of study there were a range of smoking cessation initiatives introduced which could have influenced the results. Multifaceted government policies included publicity campaign; increase in cigarette tax; reduction in tobacco smuggling; NHS smoking cessation service; Tobacco Advertising and Promotion Act 2002Validity of author’s conclusionStudy authors do not attribute any specific intervention to observed effects.

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Details Method Results CommentsPopulation-level cessation support interventions - UK Smoking Cessation Services

number of UK smokers occurred between April 2001 and April 2007. However, although this is an improvement, comparatively high rates of smoking remain among younger adults and those who are the most socioeconomically deprived.

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Details Method Results CommentsPopulation-level cessation support interventions - UK Smoking Cessation ServicesAuthor , year Taggar 2012CountryUKDesignRepeat cross-sectional (before and after QOF)ObjectiveTo investigate the association between smoking-related QOF targets and recording of smoking status and delivery of cessation advice in patients’ medical records, factors which influence these clinical activitiesSES variables Townsend quintiles (quintile I representing the least deprived and quintile V the most deprived) AnalysesMultivariate logistic regression

Data sourcesThe Health Improvement Network (THIN) databaseParticipant selectionTHIN database includes over six million patients’ records from 446 practices throughout the UKParticipant characteristicsAged 15+, 1,998,631 participants 2002, 2,053,840 and 2,149,026 participants in 2004 and 2008, respectively. The mean (SD) age of patients in all analyses was 47.9 (19.0) years for patients with a record of smoking status and 44.6 (SD 16.1) years for patients with a record of advice against smoking.Intervention Quality and Outcomes Framework (QOF) incentivises the recording of smoking status and delivery of cessation advice in patients’ medical recordsLength of study2000 to 2008, April 2002 (before QOF), April 2004 (at introduction of QOF) and April 2008 (after QOF). Outcomes Record of smoking status within the last 27 months; Cessation advice within the last 15 months

General populationOverall, a greater proportion of patients had a record of smoking status and cessation advice in 2008 as compared to 2004, and in 2004 compared to 2002. A substantial acceleration in recording of both smoking status and cessation advice was observed between 2003 and 2005, although rates of increase plateaued after 2006. Similar trends were observed for patients with at least one QOF-defined chronic condition, although the compliance to QOF targets was greater at every time point compared to non-morbid patients.In 2008, 70.4% of women and 58.6% of men had their smoking status recorded and 57.1% of female and 44.6% of male smokers had a record of cessation advice.SES There was a greater recording of smoking status and cessation advice with advancing Townsend score (greater deprivation); this was most apparent in 2008, when 67.8% and 53.0% of patients had smoking status and cessation advice recorded in the most deprived quintile, respectively. Multivariate analyses for 2008 showed that patients with greater deprivation were 35% more likely to have smoking status recorded (OR 1.35, 95% CI 1.21-1.49, p<0.001) and 20% more likely to have cessation advice recorded (OR 1.20, 95% CI 1.10-1.30, p<0.001), than those least deprived.Author’s conclusion of SES impactAdults with greater social deprivation were independently more likely to have both a

Internal validityLarge sample size.External validitySmokefree legislation introducd around sme time which may have confounded study results.Validity of author’s conclusionValid but outcomes are only intermediate – do not inform how intervention impacts on smoking prevalence. Lower SES smokers less likely to besuccessful when they attempt to quit smoking, even afteraccessing support from a smoking cessation service

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Details Method Results CommentsPopulation-level cessation support interventions - UK Smoking Cessation Services

record of smoking status and cessation advice.

438

Details Method Results CommentsPopulation-level cessation support interventions - QuitlinesAuthor, year Wilson 2010bCountryNew ZealandDesign Repeat cross-sectional surveyObjectiveTo describe use of a national quitline service and the variation in its use by smoker characteristics.SES variablesNZ-specific deprivation index for small areas (quintiles, NZDep2006) and also an individual measure of deprivation (scores, NZiDep)Analysesmultivariate logistic regression

Data sourcesNew Zealand Health Survey (NZHS) as part of The International Tobacco Control Policy Evaluation Survey (ITC Project).Participant selectionComplex sample design, which included systematic boosted sampling of the Māori, Pacific, and Asian populations.Participant characteristics2,438 participants aged18 years and over. Between-wave attrition of 32.9% occurred, resulting in 923 respondents in Wave 2.Intervention national quitline service Length of study2007 to 2009Outcomes

General populationQuitline use in the last 12 months rose from 8.1% (95% CI = 6.3%–9.8%) in Wave 1 to 11.2% (95% CI = 8.4% to 14.0%) at Wave 2. SES There was higher usage with increasing small area deprivation (p = .04 for trend) and for higher ratings in one of the two measures of financial stress. Deprivation by two measures was not associated with Quitline usage, but smokers with financial stress were more likely to use the Quitline with this being statistically significant for the measure around “not spending on household essentials” in one model (i.e., for Model 2: AOR =1.71, 95% CI = 1.00–2.92).Author’s conclusion of SES impactNational Quitline service is successfully stimulating disproportionately more calls by those with some measures of disadvantage. It may therefore be contributing to reducing health inequalities.

Internal validityOverall response rate was 32.6%. Results were weighted to adjust for complex design and nonresponse.External validitySample could have become less representative of the national population of smokers(via nonresponse at various stages). The weighting process may not have fully adjusted for nonresponse bias, potentially affecting the generalizability of the findings to all NZ smokers.New pictorial health warningsand a more clearly identifiable Quitline number on packs andrelated mass media campaigns.Validity of author’s conclusionValid but not representative.

439

7.7 Appendix G Quality assessment

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Study study design+

Quality of execution

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Smoking restrictions in workplaces, enclosed public places, cars and homesArheart 2008 1.2 n/a n/a yes yes yesBarnett 2009 1.2 n/a n/a yes yesCesaroni 2008 1.2 n/a n/a yes yesDelnevo 2004 1.1 n/a n/a n/aDeverell 2006 1.2 yes n/a n/a yes yes regionalDinno 2009 1.4 yes n/a n/a yes n/a nationalEadie 2008 4.2 n/a yes yes yesEllis 2009 1.1 n/a n/a yes n/a yesFarrelly 1999 1.2 yes n/a n/a yes yes nationalFederico 2012 1.2 yes n/a n/a yes yes nationalFerketich 2010 1.1 n/a n/a yes n/aFowkes 2008 1.3 n/a n/a yesFrieden 2005 1.2 n/a n/a yes yes yesGuse 2004 1.2 yes n/a n/a yes yes regionalGuzman 2012 1.2 n/a n/a yes yes yesHackshaw 2010 1.2 n/a n/a yes yesHawkins 2011 1.3 n/a n/a yesHawkins 2012 1.2 yes n/a n/a yes yes nationalHemsing 2012 4.1 n/a n/a yes n/a yesKing 2011 1.3 yes n/a n/a yes yes nationalLevy 2006 1.2 yes n/a n/a yes yes nationalMacCalman 2012 1.3 n/a n/a yes yesMoore 2011 1.2 yes n/a n/a yes yes yes national

Moore 2012 1.2 yes n/a n/a yes yes yes national

Moussa 2004 1.1 n/a n/a n/aNabi-Burza 2012 1.1 n/a n/a yes n/aNagelhout 2011a 2.1 yes n/a n/a yes yes yes nationalNagelhout 2011b 1.2 yes n/a n/a yes yes nationalNagelhout 2013 1.3 n/a n/a yes yesParry 2000 4.1 n/a n/a n/a yesPatel 2011 1.1 n/a n/a yes n/a

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Plescia 2005 1.2 yes n/a n/a yes yes regionalRazavi 1997 1.2 n/a n/a n/aRitchie 2010a, Ritchie 2010b

4.3 n/a n/a yes yes yes

Schaap 2008 1.1 n/a n/a yes n/a yesSemple 2010 1.2 n/a n/a yes yes yesShavers 2006 1.2 yes n/a n/a yes yes nationalShopland 2004 1.2 yes n/a n/a yes yes yes nationalSims 2012 1.2 yes n/a n/a yes yes yes nationalSkeer 2004 1.1 n/a n/a yes n/aStamatakis 2002 1.1 n/a n/a yes n/aTang 2003 1.2 n/a n/a yes yes yesTong 2009 1.1 n/a n/a yes n/aVerdonk-Klienjan 2009 1.2 n/a n/a yesIncreases in price/tax of tobacco productsAzagba & Sharaf 2011 1.4 n/a n/a yes yesBiener 1998 1.1 yes n/a n/a n/a regionalBush 2012 1.2 n/a n/a yes yes regionalChoi 2012 1.3 yes n/a n/a yes yes regionalCDC 1998 1.4 yes n/a n/a yes yes nationalColman 2008 1.4 yes n/a n/a yes yes nationalDeCicca 2008 1.4 yes n/a n/a yes yes nationalDinno 2009 1.4 yes n/a n/a yes n/a nationalDunlop 2011 1.2 n/a n/a yes yesFarrelly 2001 1.4 yes n/a n/a yes yes nationalFarrelly 2012 1.2 yes n/a n/a yes yes regionalFranks 2007 1.4 yes n/a n/a yes yes nationalFrieden 2005 1.2 n/a n/a yes yes yesGospodinov & Irvine 2009 1.4 yes n/a n/a yes yes nationalGruber 2003 1.4 n/a n/a yes yesHawkins 2012 1.2 yes n/a n/a yes yes nationalLevy 2006 1.2 yes n/a n/a yes yes nationalMadden 2007 1.4 n/a n/a yes

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Metzger 2005 1.3? n/a n/a yes yesMostashari 2005 1.1 n/a n/a n/aNagelhout 2013 1.3 n/a n/a yes yesPeretti-Watel 2009 4.2 n/a n/a yes yesPeretti-Watel 2009 1.3 n/a n/a yesPeretti-Watel 2012 1.1 n/a n/a yes n/aRingel 2001 1.4 yes n/a n/a yes yes nationalSchaap 2008 1.1 n/a n/a yes n/a yesSiahpush 2009 1.4 n/a n/a yes yesControls on advertising, promotion and marketing of tobacco Cantrell 2013 3.1 yes yes yes yesFrick 2012 1.1 yes n/a n/a yes n/a yes regionalHammond 2013 3.2 yes n/a yesHitchman 2012 1.1 yes n/a n/a yes n/a yes nationalKasza 2011 1.3 yes n/a n/a yes nationalSchaap 2008 1.1 n/a n/a yes n/aWillemsen 2005 1.2 n/a n/a yes yesWilson 2010a 1.3 n/a n/a yes yes

Zacher 2012 1.3 yes n/a n/a yes yes yes regional

Mass media campaignsAlekseeva 2007 1.3 n/a n/a yes yes

Bains 2000 1.3 n/a n/a yes yes yes

CDC 2007 1.2 yes n/a n/a yes yes regional

Civljak 2005 1.1 yes n/a n/a n/a yes national

Dunlop 2012 1.2 n/a n/a yes yes yes

Durkin 2009 1.3 n/a n/a yesFarrelly 2012 1.2 yes n/a n/a yes yes yes regional

Graham 2008 1.3 n/a n/a yes yes

Hawk 2006 2.3 n/a n/a yes yesLevy 2006 1.2 yes n/a n/a yes yes nationalNagelhout 2013 1.3 n/a n/a yes yesNiederdeppe 2008 1.3 n/a n/a yes yes

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Niederdeppe 2011 1.2 n/a n/a yes yes yes

Richardson 2011, Vallone 2011

1.3 n/a n/a yes yes

Van Osch 2009 1.3 n/a n/a yes yes

Mass media campaigns - Quitlines, NRTBurns 2010 3.2 n/a n/a yes yesCzarnecki 2010a 1.1 n/a n/a yes n/aCzarnecki 2010b 1.1 yes n/a n/a yes n/a yes regionalDeprey 2009 1.2 n/a n/a yes yes yesDurkin 2011 1.1 n/a n/a yes n/a yesHawk 2006 2.3? n/a n/a yes yesMiller 2005 3.2 yes yes n/a yes regionOwen 2000 1.3 n/a n/a yes yesSiahpush 2007 1.1 n/a n/a yes n/a yesSood 2008 1.1 n/a n/a yes n/aWilson 2010a 1.3 n/a n/a yes yes

Zawertailo 2012 2.3 n/a n/a yes yes

Multiple policiesFrieden 2005 1.2 n/a n/a yes yes yesNagelhout 2012 1.2 n/a n/a yes yes yesSchaap 2008 1.1 n/a n/a yes n/a yesVerdonk-Kleinjan 2011 1.2 n/a n/a yes yes yesSettings based interventionsDarity 2006 3.2 yes yesDonath 2009 1.3 n/a n/a yesSecker-Walker 2000 1.2 yes n/a yes yes yes yes regionalSorensen 1998 3.1 yes yes yesSorensen 2003 3.1 yes yes yesStafford 2008 1.3 n/a Yes yesWendell-Vos 1.3 yes yes yes yesPopulation-level cessation support interventions Bauld 2003 1.1 Yes n/a n/a yes n/a yes nationalBauld 2007 1.2 yes n/a n/a yes yes yes national

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Bauld 2012 1.3 n/a n/a yes yesHiscock 2009 1.2 n/a n/a yes yesSimpson 2010 1.2 yes n/a n/a yes yes nationalTaggar 2012 1.2 yes n/a n/a yes yes national Wilson 2010b 1.2 n/a n/a yes yes

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# Typology of study designs

Code Study design

1.0 Population-based observational1.1 Cross-sectional 1.2 Repeat cross-sectional1.3 Cohort longitudinal 1.4 Econometric analyses (cross-sectional data)2.0 Intervention-based observational2.1 Single intervention (before and after, same participants)2.2 Single intervention with internal comparison2.3 Comparison between different types of intervention3.0 Intervention-based experimental3.1 Randomised controlled trial (individual or cluster)3.2 Non-randomised controlled trial3.3 Quasi-experimental trial4.0 Qualitative4.1 Cross-sectional4.2 Repeat cross-sectional4.3 Longitudinal

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## Quality of execution

*Representativeness: Were the study samples randomly recruited from the study population with a

response rate of at least 60% or were they otherwise shown to be representative of the study

population?

**Randomisation: Were participants, groups or areas randomly allocated to receive the intervention

or control condition?

***Comparability: Were the baseline characteristics of the comparison groups comparable or if there

were important differences in potential confounders were these appropriately adjusted for in the

analysis? If there is no comparison group this criterion cannot be met.

†Credibility of data collection instruments: Were data collection tools shown to be credible, e.g.

shown to be valid and reliable in published research or in a pilot study, or taken from a published

national survey, or recognized as an acceptable measure (such as biochemical measures of smoking).

††Attrition Rate: Were outcomes studied in a panel of respondents with an attrition rate of less than

30% or were results based on a cross-sectional design with at least 200 participants included in

analysis in each wave?

†††Attributability to intervention: Is it reasonably likely that the observed effects were attributable to

the intervention under investigation? This criterion cannot be met if there is evidence of

contamination of a control group in a controlled study. Equally, in all types of study, if there is

evidence of a concurrent intervention that could also have explained the observed effects and was not

adjusted for in analysis, this criterion cannot be met.

+ Generalisability: Is the study generalisable at National, State/Regional, or Local level? A study

cannot be generalisable if not representative or representativeness is unclear.

Randomisation is not applicable (N/A) for all study designs except trials coded 3.1. Attrition rate is

N/A to cross-sectional studies coded 1.1.

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7.8 Appendix H Equity Impact

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Smoking restrictions in workplaces, enclosed public places, cars and homes Arheart 2008

1.2 USA Occupation Smokefree workplace policies

SHS exposure (cotinine levels) in non-smokers not exposed to SHS at home

Disparities in SHS workforce exposure are diminishing with increased adoption of clean indoor laws. All worker groups had declining serum cotinine levels. Most dramatic reductions occurred in subgroups with the highest cotinine levels before smokefree policies. Large differences in cotinine levels in worker subgroups persist; including those employed in the construction sector, and blue-collar workers who continue to have the highest cotinine levels.

Positive

Barnett 2009

1.2 Christchurch Public Hospital, New Zealand

Neighbourhood social deprivation

National smokefree legislation

Acute Myocardial Infarction hospital admissions

Overall association of AMI admissions with smoking status and with deprivation was not consistently significant.Only among the 55 to 74 year age group does the RR analysis give a hint that admissions may be falling in less deprived areas with quintile 2 being statistically significant (RR 0.76; CI 0.59–0.97).

Neutral

Cesaroni 2008

1.2 Rome, Italy Small-area index of deprivation

National smokefree legislation

Acute coronary events

People aged 35 to 64 years living in low socioeconomic census blocks appeared to have the greatest reduction in acute coronary events after the smoking ban with significantly reduced

Neutral

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Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

ORs for SEP 3,4 and 5 but not 1 and 2 however there was no evidence of a statistically significant interaction between SEP and smokefree legislation.

Delnevo 2004

1.1 USA Education, income

Smokefree workplace policy

Policy coverage

The likelihood of being protected by a smoke-free workplace policy was significantly lower among workers who earned less than $50,000 annually, or had a high school education or less.

Negative

Deverell 2006

1.2 Massachusetts, USA

Education,Poverty level

Transition from no 100% smokefree restaurant regulations to statewide ban

Local adoption of smokefree regulations

The proportion of college graduates in Massachusetts protected from SHS in restaurants in their own town was consistently between 2 and 7 percentage points greater than the proportion of nongraduates who were protected. Just prior to the statewide smoking ban 40% of college graduates were protected compared to 33% of nongraduates. There was also substantial disparity in protection from SHS by individual’s poverty status (protection higher for those living above poverty line).

Negative

Dinno 2009

1.4 USA Education, household income

Strong (100% ban) indoor smokefree policies

Smoking participation, consumption

Indoor smokefree policies appeared to benefit all SES groups equally in terms of reducing smoking participation and consumption. Established patterns of education and income disparity in smoking were largely unaffected by smokefree policies in terms of both mean effects and variance.

Neutral

449

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Eadie 2008

4.2 Scotland Social grade National smokefree legislation

Compliance in community bars

Bars in deprived study communities tended to show lower compliance and less support for the legislation compared with the relatively affluent community, but there were exceptions to this. Social norms were related to social disadvantage and this partially explained variance in compliance between bars.

Negative

Ellis 2009 1.1 USA Education, income

New York City comprehensive smokefree workplace legislation

Prevalence, SHS exposure (cotinine levels) in non-smokers

Smoking prevalence in NYC was lower than that found nationally (23.3% vs. 29.7%, p < .05). Smoking prevalence in NYC (and nationally) was higher in those earning less than $20,000 per year. In NYC the effect of education on prevalence did not reach significance (but was significant nationally). A higher proportion of NYC non-smokers had an elevated cotinine level compared with non-smokers nationally (56.7% vs.44.9%, p < .01). In NYC those with less than high school education were 64% more likely than those with a high school education to have elevated cotinine level.

Negative

Farrelly 1999

1.2 USA Education Various types of workplace smoking policies

Prevalence, consumption in indoor workers

The percentage point declines in the prevalence of smoking in response to a smokefree environment were fairly uniform across educational groups. As a percentage of current rate of smoking, the largest effects (percentage

Unclear

450

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

decline) were for workers with a college degree (28.4% decline) and the least for high school dropouts (13.7% decline). However, the opposite was true for the effects of the smoking ban on average daily consumption.

Federico 2012

1.2 Italy Education National smokefree legislation

Prevalence,Quit ratios

Among highly educated females, trends in smoking prevalence and cessation were not altered by the ban. The immediate effect of the policy was more favourable among low-educated females than among the higher educated, with a 4.5% increase in quit ratios among low-educated females, p < 0.001. Long-term trends clearly favoured the higher educated and educational differences in quit ratios widened over time.Among both low and high educated males, prevalence and cessation were reduced in the short-term but not in the long-term. The absolute difference in smoking prevalence between high and low-educated males widened slightly over the whole time-period.

Negative

Ferketich 2010

1.1 Appalachia, USA

Education Adoption of clean air ordinances

Policy coverage (workplaces, restaurants and bars)

A positive relationship was shown between education and the presence of workplace and restaurant clean air policies in Appalachian communities outside West Virginia. Adjusting for state and county, a 1% increase in high

Negative

451

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

school completion rate was associated with a 10% increase in both the odds of a workplace policy and the odds of at least 1 policy (workplace or restaurant). There was a significant negative relationship between median income and presence of a restaurant policy. Communities with a higher education level were more likely to have a strong ordinance.

Fowkes 2008

1.3 Scotland Scottish Index of Multiple Deprivation (SMID) score

National smokefree legislation,clinical trial of aspirin in people at moderately increased risk of cardiovascular events

Quit No association between area of residence or SIMD with the probability of attempting to quit, or feeling influenced to quit. Smokers from more affluent areas more likely to have a positive perception of the legislation.

Neutral

Frieden 2005

1.2 USA Education,Family income

New York City smokefree legislation

Prevalence, SHS exposure

Smoking declined among all education levels. Groups that experienced the largest declines in smoking prevalence included residents in the lowest and highest income brackets and residents with higher educational levels.In 2003, former smokers who had quit within the past year were more likely to have low incomes compared with former smokers who had quit more than 1 year previously (43.6% vs 32.0%, p=.0001). High-income residents were

Unclear

452

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

more likely than low-income residents to report that the smokefree legislation reduced their exposure to ETS (53.3% vs 41.9%, P<.0001).

Guse 2004 1.2 USA Education, Income, Occupation

Statewide smokefree policies

Policy coverage,Prevalence

Residents with less than a high school education or with a high school diploma as well as residents making less than $15,000 were much more likely to work in an environment where smoking was permitted or unregulated. Smoking prevalence was generally higher among people in occupations with a lower percentage of workers covered by smokefree workplace policy.

Negative

Guzman 2012

1.2 USA Education, Family income

Statewide smokefree legislation

SHS exposure (home, outside home, workplace),Home smoking ban,Prevalence

Participant exposure to tobacco smoke outside the home improved among both education groups, and all income groups but it was decreased further in the highest income group (family income >$60,000 per year). Participants being exposed to smoke at work significantly reduced only for middle income group. Participants being exposed to smoke at home were significantly reduced only for the highest income group and the higher education group. Participants having a strict ban in the home were significantly increased only for the highest income group and the higher

Negative

453

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

education group.Smokefree legislation not associated with change in smoking prevalence but analyses weakened by small sample size.

Hackshaw 2010

1.2 England Occupational class

National smokefree legislation

Quit attempts No significant difference in quit attempts by social grade.

Neutral

Hawkins 2011

1.3 England and Scotland

Occupational class, household income, education

National smokefree legislation in Scotland (but not in comparison country which was England)

Quit rates, smoking uptake, home smoking among parents of children aged 0 to 5 years

Higher rate of smoking cessation between baseline and follow-up among mothers in England who had higher household income, higher occupational class, or left school at an older age. No significant relationship for these factors in Scotland. Lower SES associated with higher rates of maternal smoking uptake and smoking in the home in both countries. Socio-economic gradient in quitting smoking in Scotland has flattened slightly following the smokefree legislation.

Mixed

Negative for uptake and home smoking.Negative for quitting in England. Positive for quitting in Scotland

Hawkins 2012

1.2 USA Household income,Household education

Smokefree legislation

Household tobacco use in households with children aged 6 to 17 years

In adjusted causal inference models there was no effect of smokefree legislation on household tobacco use. In adjusted cross-sectional models, a higher smokefree legislation total score was associated with a lower prevalence of household tobacco use. The interaction between smokefree legislation and household income was only significant for households at the

Unclear

454

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

100–199 % Federal poverty level but not at 0–99 % Federal poverty level or above 199% federal poverty level.

Hemsing 2012

4.1 Canada Family income Smokefree legislation

Disparities in the effect of policies, management of SHS

Women and men living on a low income were more likely to live in more crowded areas, with more smokers and less safe, open spaces. These physical constraints limited opportunities to avoid SHS exposure in spite of increasing restrictions. Smoking in low-income areas may be normalized, smoking restrictions less enforced, and individuals experiencing the many stresses associated with living on a low income may find it difficult to quit.The physical, social, and economic barriers low income women and men encounter to reducing smoking and smoke exposure may reinforce or intensify health-related disparities.

Negative

King 2011 1.3 Australia, Canada, UK, US

Education, household income (composite)

Smokefree policies (worksites, bars, restaurants

Policy coverage

No consistent association was observed between SES and the presence or introduction of bans in worksites. Current smokers with higher SES were more likely to have a total smoking ban in the workplace; however, the rate of smokefree policy adoption in the workplace was comparable by SES group. Although smokefree workplaces have previously been more common in high SES occupations, this disparity

Positive

455

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

appears to have disappeared. The impact of recent efforts to expand the proliferation of smokefree policies in bars and restaurants in these four countries has been seemingly uniform across those serving different socioeconomic groups. On balance, the evidence indicates that smoke-free policies in public places are not being implemented differentially by the socioeconomic status of smokers.

Levy 2006 1.2 USA Education Smokefree legislation

Smoking status in women

Smokefree legislation was associated with a marginal effect on current smoking. Over the period 1992–2002, current smoking among low education women was inversely related to the index of clean air laws, with an odds ratio of 0.91 (0.80, 1.03), but was significant only in the medium education female subpopulation, with an odds ratio of 0.88 (0.83, 0.94).

Unclear

MacCalman

1.3 England, Scotland

Education National smokefree legislation

Attitude, Respiratory symptoms,Sensory symptoms in bar workers

For the majority of the questions bar workers who were educated to degree level and higher were significantly more positive towards the legislation than those who did not continue with education after school. Education did not significantly effect change in symptoms reported. All bar workers of all SES likely to benefit from SFL in terms of perceived health.

Neutral

456

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Moore 2011

1.2 Primary schools, Wales

FAS National smokefree legislation

Parental smoking in the home and car

The smokefree legislation in Wales benefitted only high-SES parents and was potentially associated with increased socioeconomic disparity in terms of parental smoking in the home and in the car. In terms of parental smoking in cars this conclusion is tentative because the number of children reporting car-based exposure at both timepoints was relatively low, with changes in percentage exposure based on small changes.

Negative

Moore 2012

1.2 Primary schools, Scotland, Northern Ireland, Wales

FAS National smokefree legislation

Smoking restrictions in the home and car

Following the smokefree legislation in the UK, smoking restrictions in the home and in the car increased. Post-legislation changes were not patterned by SES. No change in inequality following legislation for home and car-based smoking restrictions (socioeconomic patterning remained stable). The smokefree legislation in Scotland, Wales and Northern Ireland did not appear to displace smoking into the home or the car.

Neutral

Moussa 2004

1.1 Sweden Occupation Smokefree workplace policies

SHS exposure SHS exposure at work was highest among men in skilled manual work and women in unskilled manual work adjusting for age, country of origin, and smoking patterns.

Negative

Nabi- 1.1 Paediatric Parental Voluntary Smoking Parental education level was not Negative

457

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Burza 2012

practices, USA

education smokefree car policy

behaviour in cars and home

significantly associated with strictly enforced smokefree car policy on its own, only significant in interaction with child age and amount smoked. College educated parents of children aged less than one year old were more likely to have strict smoke-free car policies.

Nagelhout 2011a

2.1 Ireland, France, Germany, Netherlands

Education National smokefree legislation (partial and comprehensive)

Predictors of smoking in bars

Smokers with a low educational level were more likely than smokers with a high educational level to smoke in bars post-ban. Societal approval of smoking was a stronger predictor of smoking in bars among highly educated smokers.

Negative

Nagelhout 2011b

1.2 Netherlands Education National smokefree legislation – workplace then extended to hospitality industry

Prevalence, quit attempts,successful quit attempts

Workplace ban led to more successful quit attempts among higher educated smokers than medium or lower educated smokers.Hospitality industry ban had a larger effect on quit attempts among frequent bar visitors than on non-bar visitors - more frequent bar visitors more likely to be higher educated.

Negative

Nagelhout 2013

1.3 Netherlands Education National smokefree legislation

Quit attempts,7-day point prevalence (successful quits)

Higher educated smokers were more exposed to the smokefree legislation.There were no significant educational inequalities in successful smoking cessation.

Neutral

Parry 2000 4.1 Scotland Occupation Workplace smoking ban

Quit rates, change in

Significant differences were found in quit rates between academic and related

Negative

458

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

with some exceptions

smoking behaviour

staff and manual staff (16.0% vs. 4.2%) and in increase in smoking between academic and related staff and manual staff (2.8% vs. 8.9%). Workplace smoking restrictions were more beneficial for staff in higher occupational grades and the ban contributed to and sustained social inequalities among staff.

Patel 2011 1.1 New Zealand

Area-level deprivation

Voluntary smokefree car policy

Observed point prevalence of smoking in vehicles

Adults and children from high deprivation areas were much more likely to be exposed to SHS smoke. Although prevalence of smoking within vehicles appeared to have decreased over time and this reduction over time was relatively greater in lower SES areas than higher SES areas; absolute smoking prevalence and thus exposure to SHS within vehicles remained higher in more deprived areas and suggests the gap may be widening.

Negative

Plescia 2005

1.2 USA Occupation Regional smokefree workplace policies

Policy coverage

Significant disparities existed in policy coverage; blue collar and service workers were significantly less likely to report a smokefree worksite compared to white-collar workers

Negative

Razavi 1997

1.2 Belgium Occupation National decree to regulate smoking in the workplace

Implementation

Companies with a high blue/white collar ratio were less likely to have implemented health policy recommendations.The difference regarding a more strict

Negative

459

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

smoking policy between companies employing mostly blue collar (12% total non-smoking policy) and companies employing mostly white collar (2% total non-smoking policy) which was significant in 1990 had disappeared in 1993.

Ritchie 2010a, 2010b

4.3 Scotland area SEP National smokefree legislation

Changes in smoking behaviour, changes in physical spaces

Smokers’ narratives in the disadvantaged localities described more decreases in consumption and successful quitting than those in the affluent localities. Smokers in advantaged areas said that they smoked less, or quicker, because going outside interrupted social activity, and because of concerns over the stigma of being seen smoking. There appears to have been a more substantial change in deprived areas, because the advantaged areas already had reasonably comfortable accommodation for smokers outside. But is a small non-representaive sample.

Unclear

Schaap 2008

1.2 18 European countries

Education; relative index of inequality

Smokefree legislation

Quit ratios National score on the tobacco control scale was positively associated with quit ratios in all age-sex groups.No consistent differences were observed between higher and lower educated smokers regarding the

Neutral

460

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

association of quit ratios with score on the TCS. The regression coefficient for the association between national quit ratios and sub score for public place bans, on TCS was 0.94 (-2.43 to 5.89) for men and 0.41 (-3.84 to 5.26) for women.

Semple 2010

1.2 England, Scotland, Wales

Area-level deprivation

National smokefree legislation

Particulate matter levels in bars

Bars located in more deprived postcodes had higher PM2.5 levels prior to the legislation. Linear trend in the change in PM2.5 by deprivation category, which suggests more deprived areas experienced greater percentage reduction in PM2.5 levels up to 12 months post-implementation when compared to more affluent areas.

Positive

Shavers 2006

1.2 USA Poverty level Workplace and home smoking restrictions

Policy coverage, Home smoking restrictions,Quit attempts, in women only

Employed women further from the poverty line were more likely to be covered by restrictions on smoking in the workplace and home. Home smoking policies were more consistently associated with a lower prevalence of current smoking irrespective of poverty status than workplace policies.Lower adjusted odds ratio for quit attempts among those who permitted smoking in the home for all poverty level categories except for women who were 125%–149% of the poverty level. In contrast, workplace smoking policies

Negative

461

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

were not associated with a quit attempt in the past year for any of the poverty level categories.

Shopland 2004

1.2 USA Occupation Smokefree workplace policies

Policy coverage

Blue collar and service workers showed the largest percentage gains in smokefree policy coverage 1993 - 1999 but continued to lag significantly behind their white collar counterparts with barely a majority reporting a smokefree workplace policy in 1999 compared with more than three-quarters of white collar workers.

Neutral

Sims 2012 1.2 England Household social class

National smokefree legislation

SHS exposure (salivary cotinine)

Significant beneficial impacts were observed only among those from social classes I to III. No significant beneficial impact was seen in social classes IV and V.

Negative

Skeer 2004

1.1 USA Population with college degree,Per capita income,Household income,Families living below poverty level

Local restaurant smoking regulations

Policy coverage

Local smokefree restaurant regulations were significantly more likely to be adopted by towns with a higher proportion of college graduates and a higher per capita income in bivariate but not in multivariate models. Strength of regulation was not significantly related to household income or poverty level. However ‘agreeing to create the Massachusetts Tobacco Control Program’ was significant in multivariate model and this measure was highly correlated with both education and per capita income.

Negative

462

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Stamatakis 2002

1.1 USA Education Smokefree workplace policies

SHS exposure at home and at work in non-smoking employed women

Exposure to SHS at work was higher among women with some high school education (adjusted OR 2.8, 95% CI 1.5, 5.3) and high school graduates (adjusted OR 3.1, 95% CI 1.9, 5.1) and marginally so for those with some college (adjusted OR 1.5, 95% CI 0.9, 2.5).

Negative

Tang 2003 1.2 USA Education, income

California smokefree bar law

Bar patrons responses

Respondents who approved of the law were more likely to be more highly educated or have household income ≥$60,001. Patrons with higher income, or educational attainment tended to report they were “more likely” to visit bars or to report “no change” in their patronage. Patrons with an income ≥$60,000 were less likely to perceive non-compliance.

Negative

Tong 2009 1.1 USA Education Smokefree indoor work policies, home smoking restrictions

Policy adoption and enforcement in Asian-American women

Similar rates of smokefree policies at work and at home but disparity in enforcement by educational status with lower educated Asian-American women reporting greater SHS exposure both at work and at home.

Negative

Verdonk-Klienjan 2009

1.2 The Netherlands

Education National workplace partial smoking ban (excluded hospitality industry)

SHS exposure in non-smoking workers

Both before and after implementation of the ban, lower-educated non-smoking workers were twice as likely to be exposed as those with higher level of education. Significant difference both for differences between educational subgroups and the decrease

Negative

463

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

since ban; so ban has not abolished inequalities in exposure.

Increases in price/tax of tobacco productsAzagba & Sharaf 2011

1.4 Canada Household income, education

Cigarette tax increase

Tax elasticity There was a differential response by income and education. While the participation tax elasticity of the high income group (−0.202) was larger than the low income group (−0.183), it was not statistically significant. However, the low educated group was more tax sensitive than the high educated group; less secondary (−0.555), secondary (−0.218), some post-secondary (−0.018) and post-secondary (−0.042).

Mixed,

Neutral for income, Positive for education

Biener 1998

1.1 USA Household income

Tobacco tax increase

Smoking behaviour

46% who continued to smoke denied having had any of the 3 reactions to price increase. Low income adults were 3 times more likely to cut costs and twice as likely to consider quitting rather than not react to a price increase. Household income was not related to choice between cutting costs and quitting. The lower the household income the greater the impact of price on the decision to quit.

Positive

Bush 2012 1.2 USA Education Federal cigarette excise tax increase

Calls to quitline

Calls to quitlines increased by 23.5% in 2009 and more smokers with less education called after (versus before) the tax. Quit rates at seven months did not differ from before tax increase, however this was not reported by SES.

Positive

464

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Choi 2012 1.3 USA Household income, education

Federal tobacco tax increase

Quit, quit attempts, smoking behaviour

Overall 42% purchased cartons rather than cigarette packs. The middle-income groups (annual household income between $25,000 and $75,000) were more likely than the highest income group to report buying cigarettes from cheaper places, using coupons or promotions, and buying cartons instead of packs. Participants who reported buying cartons instead of packs to save money were less likely to attempt to quit smoking in the following year.Having some college education, having an annual household income between $25,000 and $75,000 were associated with higher odds of using at least one price-minimizing strategy; having less than high school education, having annual household income less than $75,000, were associated with higher number of strategies used.

Negative

CDC 1998 1.4 USA Family income Cigarette price increase

Price elasticity Total price elasticity was –0.29 for lower-income persons compared with –0.17 for higher income persons

Positive

Colman 2008

1.4 USA Income Cigarette tax increase

Price elasticity, smoking prevalence

Total price elasticities were -0.37 for low-income, -0.35 for middle-income, and -0.20 for high-income groups. Increasing tobacco taxation had a small narrowing effect on socio-economic inequalities in smoking. It was

Positive

465

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

estimated that a $1 rise in the price of a packet of cigarettes would lead to a 2.3 percentage point (pp) decrease in smoking prevalence in low-income smokers, compared to 1.7pp and 0.8pp in the middle and high income groups, respectively.

DeCicca 2008

1.4 USA Income, education

22 cigarette tax increases

Price elasticity, smoking prevalence

Price participation elasticities of -0.43 (low education) and -0.12 (higher education). Price participation elasticities of -0.39 (low income) and -0.09 (higher income).There was a greater impact on lower SES smokers aged 45-59 years, whether measured by education or income. A $1 increase in tax reduced the prevalence of smoking among low-income (<$35,000) groups by 10%, while reducing smoking among those with higher incomes by only 2% (or by 10% and 3%, respectively, when analysing the impact by education).

Positive

Dinno 2009

1.4 USA Education, household income

Cigarette price increase

Smoking participation, consumption, price elasticity

Cigarette price increases appeared to benefit all SES groups equally in terms of reducing smoking participation and consumption. Established patterns of education and income disparity in smoking were largely unaffected by cigarette price in terms of both mean effects and variance.

Neutral

Dunlop 1.2 Australia Income, Cigarette Smoking and Overall, 47.5% of smokers made Positive

466

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

2011 education, Socio-Economic Indices for Areas

price/tax increase product related changes

smoking-related changes and 11.4% made product-related changes without making smoking-related changes. The proportion of smokers making only product-related changes decreased with time, while smoking-related changes increased with time. Smokers with lower incomes, less education or from lower SES neighbourhoods were more likely to report the price minimizing product or purchasing changes. However, these low-income, less-education smokers were no more likely to engage in these practices without also reporting some positive changes in their smoking-related behaviours. Smokers with less education or less income were more likely to have tried to quit, cut down or thought about quitting than those who were more educated or wealthier.

Farrelly 2001

1.4 USA Family income Cigarette price increases

Price elasticity Adults with income at or below the median were more than four times as price-responsive as those with income above the median

Positive

Farrelly 2012

1.2 USA Household income

New York State cigarette excise tax increase

Smoking prevalence,Daily cigarette consumption,Share of annual income

Percentage of income spent on cigarettes did not significantly increase over time for high income smokers but did for low income smokers. Lower income smokers in New York State have not had a greater response to

Neutral

467

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

spent on cigarettes

higher taxes than smokers with higher incomes.

Franks 2007

1.4 USA Income Cigarette tax increases

Price elasticity, smoking prevalence

Although the pre-Master Settlement Agreement (MSA) association between cigarette pack price and smoking revealed a larger elasticity in the lower- versus higher-income persons (-0.45 vs -0.22), the post-MSA association was not statistically significant for either income group.No evidence that increased cigarette prices reduced disparities in smoking prevalence, with some indication of increasing difference in prevalence between the low income and high income groups. It appeared that the high income group responded to prices reaching a threshold (c.$2.50) and had no further price responsiveness. So despite the widening of inequality the absolute gap of smoking probability narrowed as price increased (between lowest income and other income).

Neutral

Frieden 2005

1.2 USA Education Cigarette tax increase

Smoking prevalence,consumption

Smoking declined among all education levels. Groups that experienced the largest declines in smoking prevalence included people in the lowest and highest income brackets and people with higher educational levels.Residents with low incomes (<$25000

Unclear

468

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

per year) or with less than a high school education were more likely than those with high incomes (>$75 000 per year) and those with a high school education or higher to report that the tax increase reduced the number of cigarettes they smoked.

Gospodinov and Irvine 2009

1.4 Canada Education Cigarette price increases

Price elasticity, smoking prevalence, cigarette pack choice

There was no evidence of either a declining elasticity value moving from a low to high education group or a higher elasticity value for the lower education group. Education had a strictly declining impact on smoking. Whilst the higher education group has seen little change in its choice of cigarette, the lowest income group has; continuing smokers are progressively smoking stronger cigarettes.

Neutral

Gruber 2003

1.4 Canada After-tax income quartiles and expenditure quartiles

Cigarette price increases

Price elasticity Almost all of the response of consumption to price changes occurred through reductions in consumption and not quitting smoking. The lowest income group was much more price sensitive than higher income groups.

Positive

Hawkins 2012

1.2 USA Household income,Household education

Cigarette excise tax increase

Household tobacco use

An increase in excise tax was associated with an overall reduction in household tobacco use, but this reduction was not consistent across all income levels.  There was no significant reduction in consumption in

Unclear

469

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

the poorest households or in the least poor households.

Levy 2006 1.2 USA Education Cigarette price increases

Smoking prevalence in women

Declining trends in smoking over the period 1992–2002 appeared in all education subgroups, but greater relative declines occurred for low education populations. Moreover, evidence showed that compared with better educated women, low education women responded with greater positive effect to certain policy measures, particularly price.

Positive

Madden 2007

1.4 Ireland Education Cigarette tax changes

Smoking cessation in women

Taxation was associated with earlier cessation among those with a primary education, but had no differential impact among those with other levels of education.

Positive

Metzger 2005

1.3 USA Income (area) State and city tax increases

Over the counter sales of generic nicotine patch and gum products

Pharmacies in low income areas generally had larger and more persistent increases in sales of nicotine patch and gum products in response to tax increases than those in higher-income areas.

Positive

Mostashari 2005

1.1 USA Income Cigarette excise tax increase

Cigarette consumption

Response to the state tax increase varied by income level; 27.2% of those with low incomes (<$25,000) and 11.0% of those with high incomes (>$50,000) (P < .0001) reduced the number of cigarettes they smoked.

Positive

Nagelhout 2013

1.3 Netherlands Education Cigarette price increase

Exposure,Quit attempts,

Higher educated smokers were more exposed to the price increase. Exposure

Neutral

470

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

7-day point prevalence (successful quits)

to the price increase was not associated with significant increased odds of quit attempts or successful smoking cessation in any SES group.

Peretti-Watel 2009

1.3 France Education, income support, occupation

Cigarette price increases

Smoking prevalence among HIV-infected smokers having antiretroviral therapy

Striking differences across HIV transmission groups regarding socio-demographic background and smoking prevalence. The Intravenous Drug Use (IDU) group was characterised by a lower SES, a higher smoking prevalence and a smaller decrease in this prevalence over the period 1997-2007. The homosexual group had a higher SES, an intermediate smoking prevalence in 1997, and the highest rate of smoking decrease. In the dynamic multivariate analysis, smoking remained correlated with indicators of socioeconomic disadvantage.Smoking remained much more prevalent among patients with a lower educational level as well as those who were unemployed or on income support during follow-up. In multivariate analysis only, smoking was significantly more prevalent among patients who never worked, as well as among those with an intermediate level of occupation.

Negative

Peretti- 4.2 France Occupation, Cigarette price Smoking Smokers in low occupational groups Negative

471

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Watel 2009

subjective social status

increases prevalence, reasons for smoking

and of low-income were less likely to respond to cigarette price increases

Peretti-Watel 2012

1.1 France Education, Household income

Cigarette price increase

Changes in smoking behaviour: Quit attempts, consumption,smoking costs

Of smokers who did not quit: more educated smokers and wealthier smokers more frequently reported no reaction at all to price increase.

Positive

Ringel 2001

1.4 USA Education Cigarette tax increases

Price elasticity, smoking prevalence in pregnant women

Pregnant women at lower education levels (high school or less) had higher than average smoking rates but lower-than-average responsiveness to tax changes. In nearly all cases, pregnant women were found to be more responsive to higher cigarette taxes than the general adult population.Implied price elasticity = ‘less than high school’ -0.30, ‘high school’ -0.49, ‘some college’ -0.96, ‘college’ -3.39.Change in smoking percentage with $0.55 tax hike = ‘less than high school’ -2.6, ‘high school’ -3.1, ‘some college’ -3.1, ‘college’ -3.8.

Negative

Schaap 2008

1.1 18 European Countries

Education (relative index of inequality)

Cigarette price increases

Quit ratios National score on the tobacco control scale (TCS) was positively associated with quit ratios in all age-sex groups.No consistent differences were observed between higher and lower educated smokers regarding the

Neutral

472

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

association of quit ratios with score on TCS.Of all tobacco control policies of which the TCS is constructed, price policies showed the strongest association with quit ratios in both educational levels.

Siahpush 2009

1.4 Australia Income Cigarette price increases

Price elasticity, smoking prevalence

Rising inflation-adjusted cigarette price had the greatest impact on those in the lowest income category (<AU $18,000), with a price elasticity of -0.32 compared to -0.04 and -0.02 in the mid and higher income groups, respectively.There was a clear gradient in the effect of income on prevalence that diminished at higher levels of price.

Positive

Controls on advertising, promotion and marketing of tobaccoCantrell 2013

3.1 USA Education, income

Pictorial health warning labels on cigarette packs

Salience,perceived impact,credibility, intention to quit

Greater impact of the pictorial health warning labels compared to the text-only warning was consistent across SES groups.

Neutral

Frick 2012 1.1 USA Household income

FDA regulations on sales and advertising practice including point-of-sale advertisements

Compliance There were no significant differences in compliance by income, but there were significantly fewer advertisements on the buildings in high income areas.

Neutral

Hammond 2013

3.2 USA Education, annual net

Pictorial health warnings labels

Rated and ranked

The most effective ratings performed equally well across SES groups.

Neutral

473

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

household income

on cigarette packs

warnings Association between index ratings scores and both education and income were not significant.

Hitchman 2012

1.1 France, Germany, the Netherlands, UK

Education and annual net household income

EU text-only health warning labels on cigarette packs

Impact of the warnings using a Labels Impact Index

The impact of the health warnings was highest among smokers with lower incomes and smokers with low to moderate education (except the UK in the case of education).

Positive

Kasza 2011

1.3 Australia, Canada, UK, USA

annual household income and level of education were combined

Tobacco marketing regulations

Awareness Overall, in general, tobacco marketing regulations were associated with reduced awareness of pro-smoking cues among all SES groups.

Neutral

Schaap 2008

1.2 18 European countries

Education; relative index of inequality

Advertising bans, Health warnings,Tobacco control campaign spending

Quit ratios National score on the tobacco control scale (TCS) was positively associated with quit ratios in all age-sex groups.No consistent differences were observed between higher and lower educated smokers regarding the association of quit ratios with score on the TCS. A comprehensive advertising ban showed the next strongest associations with quit ratios (after price) in most subgroups (not low SES aged 40-59 or low SES women aged 25-39 years). No significant association between campaign spending or health warnings sub scores and national quit ratios.

Neutral

Willemsen 1.2 The Education EU text-only Smoking There were no significant differences in Neutral

474

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

2005 Netherlands health warning labels on cigarette packs

behaviour,motivation to quit,preference for buying pack with/withoutnew warning, inclination to buy cigarette pack with new warning

level of education for respondents in reported change in smoking behaviour nor inclination to buy the new packs.

Wilson 2010a

1.3 New Zealand

Small-area deprivation, individual-level deprivation, financial stress

Pictorial health warning labels including quitline number

Recognition of quitline number

Quitline number recognition included with new pictorial health warnings, increased across all SES groups, and the gap in quitline number recognition between the least and most deprived groups narrowed.

Positive

Zacher 2012

1.3 Australia Socio-Economic Indexes for Areas (SEIFA) index of disadvantage

Legislation which restricted cigarette displays in retail outlets including point-of-sale cigarette display ban

Compliance Overall, the prevalence of anti-tobacco signage increased and pro-tobacco features decreased between audits for every store type and neighbourhood SES.

Neutral

Mass media- cessation campaignsAlekseeva 2007

1.3 Russia Education Quit & Win Campaign

Uptake Only reports uptake by SES, which appears stable across time, the higher the education level the higher the participation. Study did not report abstinence by educational level nor make any comparisons with the SES of

Negative

475

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

smokers in the general population.Bains 2000

1.3 Canada Education,Occupation

Quit & Win Campaign plus ‘Quit Kit’

Reach,cessation

Lower SES adult daily smokers not as well represented as randomly selected control cohort. However SES was not significantly associated with cessation at 1 year.

Negative

CDC 2007 1.2 USA Education Television-based anti-tobacco media campaign (graphic imagery)

Prevalence Percentage change in smoking prevalence from 2005 to 2006 did not differ by educational subgroup. In 2006, smoking prevalence among those with less than a college education was higher than among those with more education.

Neutral

Civljak 2005

1.1 Croatia Education First national ‘smoke out day’ multi-media campaign on first day of Lent as part of ‘Say yes to no smoking’ campaign

Uptake, one day abstinence

Largest group of abstainers (one day) had secondary school education and smallest group of abstainers were those with university education. No analysis of quit rate by SES group.

Unclear

Dunlop 2012

1.2 Australia Composite measure of education and income,Neighbourhood SES

Antismoking television advertisements: low emotion; high emotion with graphic imagery; high emotion with narrative format

Unprompted recall, prompted recognition

Individual composite measure of SES (income and education) but not neighbourhood measure of SES showed significant associations with recall and recognition. Association was different between two outcome measures: high SES had increased recall of TV anti-smoking advertisements, moderate and high SES had decreased recognition of

Unclear

476

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

TV anti-smoking advertisements in comparison with low SES.

Durkin 2009

1.3 USA Cumulative measure of education and income

Television-based anti-tobacco media campaign (emotional and/or testimonials)

Quit rates (abstinence for one month), quit rates by type of advertisement

Middle and high SES groups had a higher quit rate at follow-up than low SES despite no significant variation in exposure between SES groups. The highly emotional or personal testimonial advertisements were more effective with the low, mid and undetermined SES groups compared to the high SES groups for increasing the likelihood of quitting smoking.

Mixed

Farrelly 2012

1.2 USA Education, income

Emotional and/or graphic antismoking television advertisements

Exposure (recall and GRP),quit attempts

Association between quit attempts and exposure to all types of antismoking media and to emotional and/or graphic media was equally effective for all SES groups when measured by GRP.When measured by recall, association between quit attempts and exposure to all type of antismoking adverts was most effective for high SES, and exposure to emotional and/or graphic adverts was most effective for low SES.

Mixed

Graham 2008

1.3 USA Education Online advertising of QuitNet’s web-based cessation program and state run telephone quitlines

Uptake (by clicking on advert), recruitment, engagement

Online ads recruited more people with a high school degree or less than traditional media (24.6% v 23.2%, p<0.02), mostly through passive banner ads rather than using active searching methods. Although engagement was slightly lower among online users.

Unclear

477

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Hawk 2006

2.3 USA Education Quit & Win contest and/or free 2-week NRT promotion. Media coverage included a press conference, newspaper and TV coverage.

Reach,7-day point prevalence

Compared with smokers in region – those enrolled in the 3 interventions (Quit & Win, NRT, combination) had more years of formal education p<0.05.Adjusted OR for 7-day point prevalence by level of education was not significant.

Negative overall

Negative for reach, Neutral for prevalence

Levy 2006 1.2 USA Education Tobacco control paid media campaign

Smoking prevalence among women

Smoking prevalence declined more rapidly among low-education compared to medium and high education women. Moreover, evidence showed that compared with higher educated women, low education women responded with greater positive effect to mass media. Generally, the association of the media variable and smoking prevalence declined in the more recent survey waves.

Positive

Nagelhout 2013

1.3 Netherlands Education Mass media smoking cessation campaign - ‘There is a quitter in every smoker’ ran on television, radio, print and internet.

Exposure,quit attempts,7-day point prevalence (successful quits)

Smokers from different educational levels were reached equally by the mass media campaign.There were no significant educational inequalities in successful smoking cessation.

Neutral

Niederdep 1.3 USA Education, Television-based Recall, Overall, neither Keep-trying-to-quit Unclear

478

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

pe 2008 income cessation adverts as part of Wisconsin Tobacco Control and Prevention Programme.

quit attempts, abstinence at one year

(KTQ) nor secondhand smoke ad recall was associated with quit attempts or smoking abstinence at one year. KTQ ads were significantly more effective in promoting quit attempts among higher- versus lower-educated populations. No relationship between KTQ recall and income. No differences were observed for SHS ads by the smokers' education or income levels.

Niederdeppe 2011

1.2 USA Education,income

Mass media antismoking television advertisements

Recall,Perceived effectiveness

Why-Testimonial ads had the highest and How ads had the lowest ad recall across all levels of education. This difference was greatest at low levels of education.Why-Graphic ads had the highest level of perceived effectiveness. This value was higher than How ads across all levels of education. Once again, however, the difference was most pronounced at low levels of education.Differences in readiness to quit between higher and lower educated populations did not explain why thematic differences in recall and response were more pronounced among smokers with the lowest levels of education.

Unclear

Richardson 2011, Vallone 2011

1.3 USA Education EX – Branded national smoking cessation multi media campaign.

Confirmed awareness, quit attempts, cessation-

Awareness of EX was significantly associated with positive changes in cessation-related cognitions and quit attempts in those with less than a high-

Positive

479

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Included focus on television advertising.

related cognitions index score

school education. While there was a statistically significant effect of EX awareness on quit attempts mediated through cessation-related cognitions, the larger effect of EX awareness on quit behaviour was not mediated through cessation related cognitions. Furthermore, the mechanism underlying how EX awareness promotes quit attempts differed across education subgroups.TV only: Among smokers with less than a high school education, confirmed awareness of the EX campaign more than doubled their odds of having more favourable cognitions about quitting smoking at 6-month follow-up, and doubled their odds of having made a quit attempt during the study period.

Van den Putte 2005

1.2 The Netherlands

Education Mass media campaign on television, radio, and the internet; entitled ‘Nederland start met stoppen/Nederland gaat door met stoppen’ ‘The Netherlands starts quitting/The

Psychosocial determinants, quit attempts, successful quit

There was no differential effect of the campaign on several psychosocial determinants of smoking cessation between lower and higher educated smokers. There were positive effects of the campaign for quit intention, attitude towards smoking cessation, social norms, and interpersonal communication about smoking cessation. The study examined both

Unclear

480

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Netherlands continues with quitting’

quit attempts and successful quitting, but positive effects of the campaign were only found for successful quitting. Successful quitting was self-reported and it was not specified how long people should be quit. Adults with lower education were less likely to successfully quit.

Van Osch 2009

1.3 The Netherlands

Education Quit & Win campaign

Abstinence at 1 and 12 months

Quit & Win contestants more educated than random control group. Higher SES Quit & Win contestants more likely to maintain abstinence at one month but not at 12 months.

Negative

Wiebing 2010

1.1 The Netherlands

Education Mass media campaign called ‘Rokers verdienen ‘n beloning’, de 24-uur-niet-rokenactie (‘Smokers deserve an award’, the 24-hour-no-smoking intervention). The intervention was announced on posters, flyers, local newspapers, banners on websites, with

Campaign awareness, willingness to quit

The 24 hour no-smoking intervention had greater reach in the higher SES groups which was measured using awareness of the campaign. The middle SES group had the highest rate of registration for participation in the 24-hour no-smoking day. Effects on smoking cessation were not studied, only on willingness to quit. There was no significant difference between the low and high SES groups on willingness to stop smoking by awareness of the campaign and by participation.

Negative

481

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

press releases, and radio spots. Smokers were encouraged to stop smoking for 24 hours and to register for participation.

Willems 2012

1.2 The Netherlands

Education Mass media campaign called ‘Echt stoppen met roken kan met de juiste hulp’ (‘Really quitting smoking can be done with the right help’) targeted at smokers with an intention to quit smoking in the future, with a focus on lower educated smokers. There was a television and radio commercial, banners, social media, posters and flyers, and

Campaign awareness

Lower educated smokers reported more often that they had heard from the campaign than higher educated smokers.

Positive

482

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

messages in newspapers and magazines.

Mass media campaigns – Quitlines, NRTBurns 2010

2.1 USA Education Spanish-language advertising (TV/radio/cinema) to promote a state Quitline to Latino smokers in Colorado

Characteristics of Quitline callers, service utilisation, abstinence

Increased reach, service use and abstinence of low SES Latino smokers. Six-month abstinence among Latinos increased significantly during the campaign, (18.8% vs 9.6%; P<.05) and 7 day abstinence increased marginally (41.0% vs 29.6%; P=.06). However abstinence rates at both time periods were significantly lower for non-Latinos during the campaign.

Positive

Czarnecki 2010a

1.1 USA Education, income

Multi Media campaign to promote a nicotine patch giveaway

Programme awareness, untapped interest in programme

Reported awareness was significantly lower for highest income and education groups. Highest untapped interest in the lower SES groups but this is hypothetical question on interest.

Positive

Czarnecki 2010b

1.1 USA Education, neighbourhood income (neighbourhood poverty level)

Large-scale NRT promotion

Reach Low income and low education smokers had higher participation rates. Among neighbourhoods with high smoking prevalence, lower income neighbourhoods had higher enrolment compared to higher income neighbourhoods.

Positive

Deprey 2009

1.2 USA Education Oregon Free Patch Initiative (earned media rather than using paid media) to

Characteristics of Quitline callers

The pre- and post-launch cohorts differed by educational level; 56.2% ‘high school or less education’ vs 54.2% after launch; 36% ‘some college’ before and 35.3% after;

Negative

483

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

generate call to quitline

‘college graduate or more’ 7.8% before and 10.5% after.

Durkin 2011

1.1 Australia Socioeconomic index for areas

13 different types of television advertisements aimed at driving lower SES smokers to utilise Victorian quitline

Characteristics of Quitline callers

There was an over-representation of Quitline calls from the high SES group. Quitline calls increased by the same degree across each SES group. Higher emotion narrative anti-smoking ads might potentially contribute to reducing socio-economic disparities in calls to the quitline through maximizing the responses of the lower SES smokers.

Neutral

Hawk 2006

2.3 USA Education Quit & Win contest and/or free 2-week NRT giveaway promotion. Media coverage included a press conference, newspaper and television coverage.

Reach,7-day point prevalence

Compared with smokers in region – those enrolled in the 3 interventions (Quit & Win, NRT, combination) had more years of formal education p<0.05.Adjusted OR for 7-day point prevalence by level of education was not significant.

Negative overall

Negative for reach, Neutral for prevalence

Miller 2005

3.2 USA Area-level deprivation

Newspaper, radio and TV campaign to promote 2-weeks free NRT

Quit rates More NRT recipients than comparison group members successfully quit smoking at six months. Neighbourhood income level and educational attainment were not associated with quit success.

Neutral

Owen 2000

1.3 England Occupational social class

3-month hard-hitting

Characteristics of helpline

The social class distribution of callers to the helpline reflected the social class

Negative

484

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

testimonial type TV and advertising (radio/magazine) campaign targeted at young smokers (aged 16-24 years) encouraging calls to freephone Quitline number and included additional support (written information)

callers, smoking status at one year

distribution of smoking in the population, with nearly two thirds of callers being in manual occupations or unemployed. However, 25% social classes ABC1 stopped smoking at one year, compared to 21% social class C2DE. Lower SES more likely to relapse.

Siahpush 2007

1.1 Australia Area – Index of Socioeconomic Deprivation

Hard-hitting television advertisements on the health risks of smoking, and promotion of a telephone Quitline

SES of Quitline callers

The pattern of increase in call rates associated with antismoking ad exposure was equal across SES groups. However the adjusted call rate was 57% (95% CI 45% to 69%) higher in the highest than the lowest SES quintile.

Neutral

Sood 2008 1.1 USA Education, income

Mass media advertising campaigns using health consequences messages

Characteristics of helpline callers

Convenience sample showed a significant overrepresentation of poorer and less educated smokers who used this national reactive telephone helpline, when compared with the general adult population of smokers

Unclear

485

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

directed homogeneously across all population segments were used to boost helpline usage

across the United States. The study did not directly measure TV advertising exposure amongst callers to the helpline.

Wilson 2010a

1.3 New Zealand

Small-area deprivation, individual-level deprivation, financial stress

Pictorial health warning labels including quitline number

Recognition of quitline number

Quitline number recognition included with new pictorial health warnings, increased across all SES groups, and the gap in quitline number recognition between the least and most deprived groups narrowed.

Positive

Zawertailo 2012

2.3 Canada Education, income

Mass media campaign and provision of free NRT by mail following a brief telephone intervention

Self-reported at least one seriousquit attempt within 6 months,being quit at the time of interview,30-day quit point prevalence

Compared with all adult Ontario smokers STOP participants were more likely to have less than high school education.The intervention significantly increased quit at time of interview and 30-day point prevalence compared to regional concurrent comparator cohort. In multivariate analyses neither education nor income was significantly related to 3 quit outcomes.

Positive overall

Positive for reach, neutral for quit rates

Multiple policiesFrieden 2005

1.2 USA Education Smokefree legislation,cigarette tax increase,tobacco control

Smoking prevalence,OR for smoking,Response to

Smoking declined among all education levels. Groups that experienced the largest declines in smoking prevalence included people in the lowest and highest income brackets and people with

Unclear

486

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

media campaign,free NRT

tax increase,Response to smokefree ban

higher educational levels.Authors state that data suggests people with lower incomes were more affected by the cigarette tax increase, whereas people with higher incomes may have been more affected by greater awareness of the dangers of SHS and smokefree legislation.

Nagelhout 2012

1.2 Netherlands Education,Household income

Smokefree workplace legislation,cigarette tax increases,cigarette text warning labels, tobacco advertising ban, mass media campaign,youth access law

Smoking prevalence,consumption,initiation ratios, quit ratios

While inequalities in smoking prevalence were stable among Dutch men, they increased among women, due to widening inequalities in both smoking cessation and initiation. Among men, educational inequalities widened significantly between 2001 and 2008 for smoking consumption only.Among moderate and high educated women, smoking prevalence decreased significantly because initiation ratios remained constant, while quit ratios increased significantly. Among low educated women, smoking prevalence remained stable between 2001 and 2008 because both the initiation and quit ratio increased significantly.

Mixed,

Negative for women, Neutral for men

Schaap 2008

1.2 18 European countries

Education; relative index of inequality (RII)

Smokefree legislation,cigarette price increase,advertising bans,health warnings,

Quit ratios National score on the tobacco control scale was positively associated with quit ratios in all age-sex groups.More developed tobacco control policies were associated with higher quit rates. High and low educated groups seem to

Neutral

487

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

tobacco control campaign spending

benefit equally from nationwide tobacco control policies. No consistent differences were observed between higher and lower educated smokers regarding the association of quit ratios with score on the TCS.Policies related to cigarette price showed the strongest association with quit ratios. Significant associations with price were found for high education males and females aged 40-59 years.A comprehensive advertising ban showed the next strongest associations with quit ratios; in most age/sex groups, the association was stronger in the higher educated group compared to the lower educated group. Health warnings were negatively associated with quit rates but not significant. Campaign spending was not significant.

Verdonk-Kleinjan 2011

1.2 Netherlands Education Smokefree workplace legislation, cigarette tax increases

Smoking prevalence, quit attempts,smoking intensity

For respondents with paid work, the combination of a smoking ban and 2 tax increases led to a decrease in the number of cigarettes/day and in prevalence of daily smoking. For respondents without paid work, there was no significant effect on any of the outcome parameters. In both groups, there was no evidence that the effect of the measures on smoking was moderated by the

Neutral

488

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

respondent’s level of education.Settings based interventionsDarity 2006

3.2 USA Low-income and moderate-income areas,Education

Community-based interventionto reduce smoking among Black African-American smokers

Point-prevalence of non-smoking,quit attempts number of smokefree days, consumption

Education was not significantly related to outcome variables. The moderate income areas tended to show a smaller percentage change in smoking outcomes in the intervened versus non-intervened groups than did the lower income areas, although the differences were not significant. The exception to this is the greater percentage reduction in the number of cigarettes smoked.

Neutral

Donath 2009

1.3 Germany Education Tobacco Control Policy score

7-day point prevalence tobacco consumption

Comprehensiveness of smoking restrictions and intensity of smoking related training of the employees were significant predictors for the variance in quit rates between the institutions. Significant individual predictors for quitting included gender, tobacco dependency and educational status. Higher education predicted non-smoking status at discharge.

Negative

Secker-Walker 2000

1.2 USA Household income

Community-based intervention ‘Breathe Easy’to reduce prevalence of smoking among women, particularly

Quit rates Quit rates in past 5 years were significantly higher in the intervention counties among women with household annual incomes of $25000 or less (14.6±2.0) compared with control counties (22.6±2.3), p<0.01. No significant difference in 5 year quit rates between intervention and control with household income >$25,000.

Positive

489

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

lower-income women of childbearing age

Sorensen 1998

3.1 USA Occupation Worksite cancer prevention initiative ‘WellWorks’ study

Abstinence Job category was significantly associated with smoking. No significant effects of the intervention for smoking cessation. Intervention by job category interaction was not significant.

Neutral

Sorensen 2003

3.1 USA Occupation Worksite cancer prevention initiative ‘WellWorks-2’ study

Abstinence A programme integrating health promotion and occupational health and safety efforts (HP/OHS) significantly improved smoking quit rates among blue-collar workers compared to health promotion alone (HP). No differences in quit rates between groups for salaried (white collar) workers.

Positive

Stafford 2008

1.3 England Index of Multiple Deprivation,Education

New Deal for Communities (NDC) initiative to improve conditions in some of most deprived neighbourhoods, by addressing 5 specific outcome areas; health, unemployment, education, crime and physical environment

Quit rates Evidence from two-year follow-up does not support an NDC effect, either overall or for particular population groups. Residents with lower education experienced the least favourable health profiles at baseline and the smallest improvements. The differences by education for smoking, widened over the two-year follow-up. In NDC areas, higher educational groups were more likely to stop smoking. No significant difference in quit rates between NDC and comparator areas.

Neutral

490

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

491

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Wendell-Vos 2009

1.3 Netherlands Education Hartslag Limburg Intervention, 5 year community lifestyle intervention programme, encouraging people to reduce their fat intake, be physically active, and stop smoking.

Quit rates,initiation rates

No apparent impact of the intervention over 5 years, either overall or by education.

Neutral

Population-level cessation support interventions

492

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

Bauld 2003

1.1 England Health action zones (HAZ)Index of Multiple deprivation

NHS Smoking Cessation Services

Reach, Number quit at 4 weeks,Cessation rate,Loss to follow-up

Cessation services based in health action zones (HAZ, areas of high deprivation) reached 140% more smokers compared to other more affluent areas, and the number of people who reported quitting at four weeks was 90% greater in HAZ areas. However, there was an inverse relationship between reach and cessation rates (the number of smokers who reported quitting at four weeks as a percentage of those setting a quit date). Cessation rates were lower in deprived areas compared with more advantaged areas. Typically the cessation rate in an area with an upper quartile deprivation score was 6% lower than that in an area in the lower quartile. Services operating in deprived areas were more likely to lose clients between setting a quit date and reporting outcomes at four weeks. The study did not assess the overall equity impact of the services (ie whether the higher reach in deprived areas compensated for lower quit rates).

Unclear

Bauld 2007

1.2 England Index of Multiple Deprivation

NHS Smoking Cessation Services

Quit rates (self-reported at 4 weeks and estimated at one year)

Although quit rates were lower among lower SES this was offset by substantial positive discrimination towards lower SES in the delivery of services. The net effect of NHS Smoking Cessation Services was to achieve a modest reduction in inequalities.

Positive

Bauld 2012

1.3 England Home ownership;

NHS Smoking Cessation

52 week validated quit

The services reached the most disadvantaged. Higher SES was a

Mixed

493

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

managerial, professional or intermediate occupation and resident in the most affluent half of Liverpool postcode area neighbourhoods= composite indicator

Services – drop-in rolling group service ‘Fag Ends’

rate predictor of quitting using a composite measure of SES. Group interventions might help to equalize outcomes, and thus have more potential to reduce inequalities than one-to-one support.

Positive impact on reach.Negative impact on quit rates.

Galbraith 2012

1.1 Scotland Scottish Index of Multiple Deprivation

NHS SSS’s Scotland

Reach,self-report 4-week quit

Those living in the most deprived communities (equivalent to SIMD 1-2) accounted for an estimated 31% of adult smokers in Scotland and for 37% of quit attempts made in NHS SSSs in 2011. One month quit outcomes by SIMD revealed that the lowest quit rates were in the most deprived areas (1-2) and the highest quit rates in the least deprived areas (9-10). However, in terms of overall numbers of quitters the most deprived areas (1-2) still accounted for the largest numbers of quitters of all the deprivation deciles. Combining reach with quit rates at one month, showed that the percentage of successful quitters was greater in the most deprived SIMD area 1 (4.2%) compared with least deprived SIMD

Positive

494

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

area 10 (3.4%).Hiscock 2009

1.2 New Zealand

Area deprivation General practice based behavioural and pharmacotherapy programme

Enrolment, self-report quit rate at 6 months, Absolute and relative smoking rate differences

Little difference in utilisation between highest and lowest deprivation areas as proportion of the city’s smoking population (22.0% for least deprived quintile and 20.7% for most deprived quintile)Quit rate for least deprived neighbourhoods was 36.1% v 25.6% for most deprived (25.2 v 17.5 assuming non-followed up failed to quit)Estimated actual gap between most and least affluent neighbourhoods was reduced by 0.2 percentage points (15.6% to 15.4%), but relative gap widened from 2.81 to 2.84 OR. Population-level effect was small and non-significant. PEGS effective at reducing smoking prevalence, but no evidence of impact on area inequalities.

Neutral

Simpson 2010

1.2 UK Area deprivation NHS Smoking Cessation Services

Smoking prevalence,provision of advice,referral to stop smoking services

In 2001/2002, patients in deprived areas (who had been recorded as smokers in the last 12 months) received the most smoking cessation advice (P<0.001). However, in 2006/2007, similar proportions from the most affluent and most deprived groups were provided with smoking cessation advice. In 2001/2002,

Positive

495

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

patients in deprived areas were more likely to be referred to SSSs (P<0.001). In 2006/2007, those living in the most deprived areas were most likely to be referred. Large increases in the number of patients referred to SSSs were also found (P<0.001), most particularly among those in the most deprived areas.In summary, a greater proportion of lower SES smokers were more likely to be referred to a SSS and this has increased over time. The absolute gap between low and high SES in terms of smoking prevalence appeared to be increasing whilst the relative gap was getting smaller.

Taggar 2012

1.2 UK Townsend deprivation quintiles

Quality and OutcomesFramework (QOF)

Record of smoking status within the last 27 months; Cessation advice within the last 15 months

Adults with greater social deprivation were independently more likely to have both a record of smoking status and cessation advice.

Positive

Wilson 2010b

1.2 New Zealand

Small-area deprivation, individual-level deprivation, financial stress

National quitline Quitline calls Overall, SES was not significantly associated with Quitline usage. There was higher usage with increasing small area deprivation (p = .04 for trend) and for higher ratings in one of the two

Unclear

496

Author, year

Study design

Country SES variable PolicyIntervention

Outcome Equity impact Summary (negative, neutral, positive, unclear, mixed)

measures of financial stress “not spending on household essentials”.

497

7.9 Appendix I Summary of Equity Impact

Positive Neutral Negative Mixed Unclear TotalSmoking restrictions in workplaces, enclosed public places, cars and homes

3 10 25 1 5 44

Increases in price/tax of tobacco products

14 6 4 1 2 27

Controls on advertising, promotion and marketing of tobacco

2 7 0 0 9

Mass media campaigns -cessation

3 2 5 2 6 18

Mass media campaigns - quitlines and NRT

5 3 3 0 1 12

Multiple policies 0 2 0 1 1 4Settings based interventions (community, workplace, hospitals)

2 4 1 0 0 7

Population-level cessation support interventions

4 1 0 1 2 8

Total policies 33 35 38 6 17 129*Total studies 31** 29 37 6 14** 116

* Eight studies assessed more than one type of policy

Dinno 200940 – Smokefree, Price/Tax = neutral

Frieden 200554 – Smokefree, Price/Tax, Multiple policies = unclear

Hawkins 201257 – Smokefree, Price/Tax = unclear

**Levy 200655 – Smokefree = unclear, Price/Tax, Mass Media cessation = positive

Nagelhout 201358 – Smokefree, Price/Tax, Mass Media cessation = neutral

Schaap 200856 – Smokefree, Price/Tax, Ad Controls, Multiple policies = neutral

Hawk 200693 – Mass Media cessation, Mass Media - quitlines and NRT = negative

Wilson 2010a91 – controls, Mass media for quitlines and NRT = positive

498