A Multilevel Study of Students in Vietnam: Drinking Motives and Drinking Context as Predictors of Alcohol Consumption.

BACKGROUND: This study used multi-level analysis to estimate which type of factor explains most of the variance in alcohol consumption of Vietnamese students. METHODS: Data were collected among 6011 students attending 12 universities/faculties in four provinces in Vietnam. The three most recent drinking occasions were investigated per student, resulting in 12,795 drinking occasions among 4265 drinkers. Students reported on 10 aspects of the drinking context per drinking occasion. A multi-level mixed-effects linear regression model was constructed in which aspects of drinking context composed the first level; the age of students and four drinking motives comprised the second level. The dependent variable was the number of drinks. RESULTS: Of the aspects of context, drinking duration had the strongest association with alcohol consumption while, at the individual level, coping motive had the strongest association. The drinking context characteristics explained more variance than the individual characteristics in alcohol intake per occasion. CONCLUSIONS: These findings suggest that, among students in Vietnam, the drinking context explains a larger proportion of the variance in alcohol consumption than the drinking motives. Therefore, measures that reduce the availability of alcohol in specific drinking situations are an essential part of an effective prevention policy.

Direct and indirect effects of alcohol expectancies through drinking motives on alcohol outcomes among students in Vietnam.

OBJECTIVE: To investigate whether the links between alcohol expectancies (tension reduction; global positive change; improved cognitive and motor abilities; and change in social behavior) and alcohol outcomes (drinking volume, 6+ drinks, alcohol problems, and symptoms of alcohol dependence) are mediated by drinking motives (social, enhancement, conformity, and coping). METHOD: A multi-stage sampling strategy was used in four Vietnamese provinces, resulting in a final sample of 4756 students (43.2% females) with mean age 20.6 (SD 1.8) years. Structural equation models, including indirect effects, were estimated for women and men separately. RESULTS: Overall, there were many cases of full mediation (indirect effects range from -0.006 to 0.083 and p-values from <0.05 to <0.001) and little indication of partial mediation (indirect effects range from -0.009 to 0.025 and p-values from <0.05 to <0.001). In both men and women, coping motives most frequently mediated the influence of expectancies on alcohol outcomes. Among men, enhancement motives and, to a lesser extent, social motives also played a role in mediating the effects of expectancies on alcohol outcomes. Among women, full mediation was found far less often and less consistently. CONCLUSION: By confirming that, in Vietnam, motives mediate the link between expectancies and drinking behavior, this study supports the cultural robustness of a key assumption of the motivational model (i.e. that drinking motives are more closely associated with alcohol use than expectancies). Enhancement, coping and social motives are most frequently found as mediators among male students whereas coping motive only is most frequently found as a mediator among female students. As most of the effects of expectancies were mediated by motives, drinking motives appear to be a promising factor for interventions.

Development and Psychometric Evaluation of an Instrument to Assess Cross-Cultural Competence of Healthcare Professionals (CCCHP).

BACKGROUND: Cultural competence of healthcare professionals (HCPs) is recognized as a strategy to reduce cultural disparities in healthcare. However, standardised, valid and reliable instruments to assess HCPs' cultural competence are notably lacking. The present study aims to 1) identify the core components of cultural competence from a healthcare perspective, 2) to develop a self-report instrument to assess cultural competence of HCPs and 3) to evaluate the psychometric properties of the new instrument. METHODS: The conceptual model and initial item pool, which were applied to the cross-cultural competence instrument for the healthcare profession (CCCHP), were derived from an expert survey (n = 23), interviews with HCPs (n = 12), and a broad narrative review on assessment instruments and conceptual models of cultural competence. The item pool was reduced systematically, which resulted in a 59-item instrument. A sample of 336 psychologists, in advanced psychotherapeutic training, and 409 medical students participated, in order to evaluate the construct validity and reliability of the CCCHP. RESULTS: Construct validity was supported by principal component analysis, which led to a 32-item six-component solution with 50% of the total variance explained. The different dimensions of HCPs' cultural competence are: Cross-Cultural Motivation/Curiosity, Cross-Cultural Attitudes, Cross-Cultural Skills, Cross-Cultural Knowledge/Awareness and Cross-Cultural Emotions/Empathy. For the total instrument, the internal consistency reliability was .87 and the dimension's Cronbach's α ranged from .54 to .84. The discriminating power of the CCCHP was indicated by statistically significant mean differences in CCCHP subscale scores between predefined groups. CONCLUSIONS: The 32-item CCCHP exhibits acceptable psychometric properties, particularly content and construct validity to examine HCPs' cultural competence. The CCCHP with its five dimensions offers a comprehensive assessment of HCPs' cultural competence, and has the ability to distinguish between groups that are expected to differ in cultural competence. This instrument can foster professional development through systematic self-assessment and thus contributes to improve the quality of patient care.

Secondhand effects of alcohol use among students in Vietnam.

BACKGROUND: In many countries worldwide, heavy drinking can cause harm not only to drinkers but also to those around them. OBJECTIVE: To examine the prevalence and predictors of secondhand effects of alcohol use among students in Vietnam. DESIGN: In this cross-sectional study, a multistage sampling strategy was used to select 6,011 students (from the first to final study year) of 12 universities/faculties in four provinces in Vietnam. During class, students filled in a questionnaire asking for demographic information, and about alcohol-related problems and details of secondhand effects of alcohol during the past year. Exploratory factor analysis of the secondhand effects indicated two factors: non-bodily harm and bodily harm. A logistic regression model was used to explore the association between predictors and non-bodily harm and bodily harm. RESULTS: The prevalence of secondhand effects of alcohol is high among students in Vietnam: 77.5% had non-bodily effects and 34.2% had bodily effects. More than 37% of the population reported three to four non-bodily effects and more than 12% reported two to three bodily harms due to the drinking of others. However, most respondents who reported secondhand effects experienced these less than once per month. Factors most strongly associated with the yearly non-bodily harm were the weekly drinking habits of the people the respondents live with, and living in a smaller city; the factor most strongly associated with the yearly bodily harm was the respondent's own alcohol-related problems. Moreover, weekly drinking habits of the people the respondents live with, and respondent's own alcohol-related problems are strongly associated with the frequent experience of non-bodily and bodily effects of alcohol. CONCLUSIONS: In addition to dealing with alcohol-related harm of drinkers themselves, preventing secondhand effects should also be a major focus of prevention policy.

Alcohol consumption and its related harms in The Netherlands since 1960: relationships with planned and unplanned factors.

AIM: to establish which unplanned (social developments) and planned (alcohol policy measures) factors are related to per capita consumption and alcohol-related harms in the Netherlands. METHODS: linear regression was used to establish which of the planned and unplanned factors were most strongly connected with alcohol consumption and harms. Artificial Neural Analysis (ANN) was used to inspect the interconnections between all variables. RESULTS: mothers age at birth was most strongly associated with increase in consumption. The ban on selling alcoholic beverages at petrol station was associated with a decrease in consumption. The linear regression of harms did not show any relation between alcohol policy measures and harms. The ANN-analyses indicate a very high interconnectedness between all variables allowing no causal inferences. Exceptions are the relation between price of beer and wine and the consumption of these beverages and the relation between a decrease in transport mortality and the increased use of breathalyzers tests and a restriction of paracommercial selling. CONCLUSIONS: unplanned factors are most strongly associated with per capita consumption and harms. ANN-analysis indicates that price of alcoholic beverages, breath testing, and restriction of sales may have had some influence. The study's limitations are noted.

Preventing adolescent alcohol use: effects of a two-year quasi-experimental community intervention intensifying formal and informal control.

PURPOSE: To determine the effect on adolescent alcohol use of a community intervention combining intensified formal control (restricting retail supply) and informal control (restricting social supply). Intervention effects on intermediate intervention goals were investigated. Analyses for different age groups were performed. METHODS: A longitudinal quasi-experimental design (baseline at 2008, plus two yearly post-measurements) was used, including one intervention and one matched-comparison community in The Netherlands. We assessed outcomes by observing 1,368 Dutch adolescents aged 13-15 years at baseline. Main dependent variables were weekly drinking status and progression into drunkenness among weekly drinkers. Additional dependent variables were formal control intermediate intervention goals (frequency of alcohol purchases and perceived ease of purchasing alcohol) and informal control intermediate intervention goals (frequency of alcohol-specific rules and parental alcohol supply). RESULTS: Survival analyses showed no significant reduction in the risk of drinking weekly for adolescents in the intervention region; however, the risk of progressing into drunkenness was reduced by 15% (p = .04) for adolescents drinking weekly. No intervention effects on the intermediate intervention goals were found among 14- and 15-year-olds. The intervention had a positive effect on two of four intermediate intervention goals (i.e., parental alcohol supply and alcohol-specific rules) among 13-year-olds. CONCLUSIONS: A combined formal and informal community intervention package is associated with a reduced risk of progressing into drunkenness among drinking adolescents. Interventions focusing on discouraging drinking below a certain age might cause a greater increase in the frequency of purchasing alcohol once reaching this age.

Alcohol-related harm among university students in Hanoi, Vietnam.

INTRODUCTION AND AIM: This study examines the prevalence of and risk factors for alcohol-related harm and types of harm among medical students from Hanoi Medical University (Vietnam). Risk factors include aspects of drinking patterns and relevant socio-demographic variables. STUDY DESIGN AND METHODS: A cross-sectional study involving 1st to 6th year students (N=1216; response rate 96.5%). Of these, 210 students from each academic year were randomly selected from a sampling frame covering all students from each academic year. Data were collected using a questionnaire distributed in class by researchers. Drinkers completed 23 questions on alcohol-related harm categorized into: 1) 'negative influence on daily activities'; 2) 'social conflict'; 3) 'loss of control, acute consequences, and withdrawal'; 4) 'mental health conditions'; and 5) 'physical and medical health problems'. Logistic and Poisson regression models were used to identify the predictors of alcohol-related harm and the amount of harm, respectively. RESULTS: The prevalence of alcohol use associated with at least one or more of the five types of harm was higher in men (81.8%) than in women (60.4%). In female and male students, the most common harm category was 'loss of control, acute consequences, and withdrawal' (51.8 and 75.6%, respectively), followed by 'negative influence on daily activities' (29.4 and 55.8%, respectively). Age, living away from home, and average number of standard drinks per occasion among male drinkers, and age and frequency of drinking per week among female drinkers were associated with alcohol-related harm. CONCLUSIONS: These data suggest that alcohol-related harm represents a serious public health problem among young educated individuals in Vietnam. The risk factors indicate that prevention should be aimed at aspects of drinking patterns and specific subpopulations defined by gender, age, and (for men only) type of living situation.

Are the effects of early pubertal timing on the initiation of weekly alcohol use mediated by peers and/or parents? A longitudinal study.

We investigated whether the link between early pubertal timing and initiation of weekly alcohol use is mediated by changes in perceived parental alcohol-specific rule setting and changes in perceived proportion of drinkers in the peer group. Longitudinal data including 3 annual waves were used to estimate the hazard for adolescents to initiate drinking alcohol using Cox proportional hazard structural equation models in 1,286 Dutch adolescents (50.2% boys) 13-14 years old at baseline in 2008. Early pubertal timing increased the risk to initiate weekly alcohol use. However, this risk was entirely mediated by a large increase in the perceived proportion of drinkers in the peer group and a large decrease in the frequency of perceived alcohol-specific rules for early pubertal timers within a period of 1 year. There is no direct risk for early pubertal timers to initiate weekly drinking per se but an indirect one via changes in their social environments, that is, a large increase in the perceived proportion of drinkers in their peer group and parents becoming more lenient in their alcohol-specific rule setting. It is important to motivate parents not to relax their alcohol-specific rule setting over time, particularly parents of early pubertal timers.

Compliance with the workplace-smoking ban in the Netherlands.

INTRODUCTION: In 2004 the Dutch government instituted a workplace-smoking ban. This study focuses on differences in compliance over time and between occupational sectors, and describes the background variables. METHODS: Telephone interviews were conducted with company employees across industry, public and service sectors in 2004 (n=705), 2006 (n=2201) and 2008 (n=2034). The questions concerned smoking policy, aspects of awareness and motivation to implement this ban. RESULTS: Compliance rates increased between 2006 (83%) and 2008 (96%) after an initial stagnation in the rate of compliance between 2004 and 2006. The increase in compliance was accompanied by a less negative attitude and an increase in confidence in one's ability to comply (self-efficacy). Differences in compliance between sectors with the highest compliance (public sector) and the lowest compliance (industry) decreased from about 20% to nearly 4%. Simultaneously, in the industry there was a stronger increase for risk perception of enforcement, social influence and self-efficacy. DISCUSSION: The initial stagnation in increase of compliance might be due to the lack of a (new) coherent package of policy measures to discourage smoking. Over the entire period there was a stronger increase in compliance in the industry sector, probably due to the intensification of enforcement activities and additional policy like legislation, which might increase awareness and social support.

A Dutch panel study on the relation between structure of everyday life, daily hassles, and alcohol consumption.

BACKGROUND: A widely held assumption within the general public is that one way in which people cope with their daily hassles is by drinking alcohol. Although the idea of drinking to compensate for daily hassles is intuit, empirical evidence is actually rather scarce. This study aimed to test whether structure of everyday life results in more daily hassles and has a protective effect regarding alcohol consumption (as predicted by classic role theory) or - in case the relation between daily hassles and alcohol consumption is positive (as predicted by tension reduction theories) - daily hassles would decrease the protective effect of having a more structured everyday life. METHODS: A general population panel study (N = 2,440; 47% women; age: M = 52 years, SD = 17), measuring structure of everyday life and daily hassles (T1; 90% response rate) as well as alcohol consumption (T2; 85% response rate). RESULTS: In line with classic role theory - structure of everyday life was positively associated with daily hassles and had a negative effect on alcohol consumption. Daily hassles was not associated with alcohol consumption. CONCLUSIONS: Daily hassles did not mediate the relationship between structure of everyday life and alcohol consumption.

Effects of a natural community intervention intensifying alcohol law enforcement combined with a restrictive alcohol policy on adolescent alcohol use.

PURPOSE: Determining whether intensified inspections on alcohol retailers, combined with a policy withdrawing liquor licenses if retailers are fined twice per annum, is effective in reducing adolescents' odds to initiate weekly drinking and drunkenness. Causal pathways by which the intervention was assumed to work were tested. METHODS: A longitudinal (2008, 2009, and 2010) quasi-experimental comparison group design including two Dutch communities, one intervention and one comparison, was used. Outcomes were assessed by following a cohort of 1,327 adolescents (aged 13-15 years at baseline). RESULTS: The intervention resulted in increased retail inspections but only seven sanctions and no repeated sanctions in 1 year. The intervention did not reduce adolescents' odds to initiate weekly drinking. Weekly drinking adolescents in the intervention community were at reduced risk to initiate drunkenness. This effect was not mediated by smaller increases in the frequency of adolescents' alcohol purchases or their perceived ease of purchasing alcohol. CONCLUSIONS: Intensified enforcement was effective in preventing adolescent drunkenness. No mediating causal pathways were detected. Effectiveness of enforcement could be increased by adopting enforcement methods with a high likelihood of apprehension, increasing social support for restrictive measures, and mobilizing the community to be more outspoken against adolescent (heavy) drinking.

Concern about passive smoking and tobacco control policies in European countries: an ecological study.

BACKGROUND: Because of the magnitude of the global tobacco epidemic, the World Health Organisation developed the Framework Convention on Tobacco Control (FCTC), an international legally binding treaty to control tobacco use. Adoption and implementation of specific tobacco control measures within FCTC is an outcome of a political process, where social norms and public opinion play important roles. The objective of our study was to examine how a country's level of tobacco control is associated with smoking prevalence, two markers of denormalisation of smoking (social disapproval of smoking and concern about passive smoking), and societal support for tobacco control. METHODS: An ecological study was conducted, using data from two sources. The first source was the Tobacco Control Scale (TCS) from 2011, which quantifies the implementation of tobacco control policies in European Union (EU) countries. Data on smoking prevalence, societal disapproval of smoking, concern about passive smoking, and societal support for policy measures were taken from the Eurobarometer survey of 2009. Data from Eurobarometer surveys were aggregated to country level. Data from the 27 European Union member states were used. RESULTS: Smoking prevalence rates in 2009 were negatively associated with a country's TCS 2011 score, although not statistically significant (r = -.25; p = .21). Experience of societal disapproval was positively associated with higher TCS scores, though not significantly (r = .14; p = .48). The same was true for societal support for tobacco control (r = .27; p = .18). The TCS score in 2011 was significantly correlated with concern about passive smoking (r = .42; p =.03). Support for tobacco control measures was also strongly correlated with concern about passive smoking (r = .52, p = .006). CONCLUSIONS: Smokers in countries with a higher TCS score were more concerned about whether their smoke harms others. Further, support for tobacco control measures is higher in countries that have more of these concerned smokers. Concerns about passive smoking seem central in the implementation of tobacco control measures, stressing the importance of continuing to educate the public about the harm from passive smoking.

Agreement between self-reports and on-site inspections of compliance with a workplace smoking ban.

INTRODUCTION: This study compares self-reports on compliance with a workplace smoking ban with on-site inspections of the same workplace, in the Netherlands, to assess the validity of self-reported compliance by employees. METHODS: A total of 360 companies had participated in the telephone survey (in October and November 2006) and were also visited by inspectors directly after the survey to establish compliance. The sampling frame included companies with 5 or more employees, stratified according to the number of employees and type of economic activity. We calculated the agreement, the under- or overestimation and the predictive values, and explored nonresponse research. RESULTS: The percent agreement on compliance between the two measures was 77.5%, the McNemar test was not significant, and the agreement coefficient with first order correction was .68, indicating moderately strong agreement. Furthermore, the results indicate a slight overestimation of compliance. Concerning the predictive values, we found most variance among the self-reported noncompliance: 55.2% of those reporting noncompliance did in fact comply. CONCLUSIONS: This study allows to conclude that self-reports on compliance with a workplace smoking ban are largely valid and that social desirability is negligible. For agencies enforcing the workplace smoking ban, these results indicate that a strategy to identify noncompliance among responding companies might be useful. Moreover, such a strategy reduces the burden of inspecting among complying companies.

Parents' alcohol use: gender differences in the impact of household and family chores.

BACKGROUND: Social roles influence alcohol use. Nevertheless, little is known about how specific aspects of a given role, here parenthood, may influence alcohol use. The research questions for this study were the following: (i) are family-related indicators (FRI) linked to the alcohol use of mothers and fathers? and (ii) does the level of employment, i.e. full-time, part-time employment or unemployment, moderate the relationship between FRI and parental alcohol use? METHODS: Survey data of 3217 parents aged 25-50 living in Switzerland. Mean comparisons and multiple regression models of annual frequency of drinking and risky single occasion drinking, quantity per day on FRI (age of the youngest child, number of children in the household, majority of child-care/household duties). RESULTS: Protective relationships between FRI and alcohol use were observed among mothers. In contrast, among fathers, detrimental associations between FRI and alcohol use were observed. Whereas maternal responsibilities in general had a protective effect on alcohol use, the number of children had a detrimental impact on the quantity of alcohol consumed per day when mothers were in paid employment. Among fathers, the correlations between age of the youngest child, number of children and frequency of drinking was moderated by the level of paid employment. CONCLUSION: The study showed that in Switzerland, a systematic negative relationship was more often found between FRI and women's drinking than men's. Evidence was found that maternal responsibilities per se may protect from alcohol use but can turn into a detrimental triangle if mothers are additionally in paid employment.

Dynamics of friendship networks and alcohol use in early and mid-adolescence.

OBJECTIVE: Similarity in alcohol consumption among adolescent friends could be caused by the influence of friends or by the selection of friends who consume similar levels of alcohol. This article aims to disentangle influence and selection processes while specifically examining changes over time in these processes and possible differences between reciprocal and nonreciprocal friendships. METHOD: The design was longitudinal with four observations (Time 1-Time 4 [T1-T4]). Data consisted of a longitudinal sample of 1,204 Finnish adolescents in 10 junior high schools. The main measurements were adolescents' friendship networks and alcohol consumption. For three successive periods, T1-T2, T2-T3, and T3-T4, actor-based models for the co-evolution of networks and behavior were analyzed (Mage: T1 = 13.6 years, T2 = 14.6 years, T3 = 15.6 years, T4 = 16.1 years). RESULTS: Selection, as well as influence processes, played an important role in adolescent alcohol consumption. Influence was found during the first period (T1-T2), whereas support for selection was found during the last two periods (T2-T3 and T3-T4). The strength of influence and selection processes did not differ for reciprocal and nonreciprocal friendships. CONCLUSIONS: The impact of selection and influence processes changed over time such that influence was only present during early adolescence, whereas selection was present during mid-adolescence. During early adolescence, youngsters would benefit from learning to resist social influence. Alcohol-consumption prevention programs targeting mid-adolescence should consider peer selection processes. These findings stress the importance of considering changes over time in future practice and research.

Contextual determinants of alcohol consumption changes and preventive alcohol policies: a 12-country European study in progress.

Beginning with France in the 1950s, alcohol consumption has decreased in Southern European countries with few or no preventive alcohol policy measures being implemented, while alcohol consumption has been increasing in Northern European countries where historically more restrictive alcohol control policies were in place, even though more recently they were loosened. At the same time, Central and Eastern Europe have shown an intermediate behavior. We propose that country-specific changes in alcohol consumption between 1960 and 2008 are explained by a combination of a number of factors: (1) preventive alcohol policies and (2) social, cultural, economic, and demographic determinants. This article describes the methodology of a research study designed to understand the complex interactions that have occurred throughout Europe over the past five decades. These include changes in alcohol consumption, drinking patterns and alcohol-related harm, and the actual determinants of such changes.

Housewife or working mum--each to her own? The relevance of societal factors in the association between social roles and alcohol use among mothers in 16 industrialized countries.

AIMS: To investigate whether differences in gender-income equity at country level explain national differences in the links between alcohol use, and the combination of motherhood and paid labour. DESIGN: Cross-sectional data in 16 established market economies participating in the Gender, Alcohol and Culture: An International Study (GenACIS) study. SETTING: Population surveys. PARTICIPANTS: A total of 12,454 mothers (aged 25-49 years). MEASUREMENTS: Alcohol use was assessed as the quantity per drinking day. Paid labour, having a partner, gender-income ratio at country level and the interaction between individual and country characteristics were regressed on alcohol consumed per drinking day using multi-level modelling. FINDINGS: Mothers with a partner who were in paid labour reported consuming more alcohol on drinking days than partnered housewives. In countries with high gender-income equity, mothers with a partner who were in paid labour drank less alcohol per occasion, while alcohol use was higher among working partnered mothers living in countries with lower income equity. CONCLUSION: In countries which facilitate working mothers, daily alcohol use decreases as female social roles increase; in contrast, in countries where there are fewer incentives for mothers to remain in work, the protective effect of being a working mother (with partner) on alcohol use is weaker. These data suggest that a country's investment in measures to improve the compatibility of motherhood and paid labour may reduce women's alcohol use.

Associations between drinking motives and changes in adolescents' alcohol consumption: a full cross-lagged panel study.

AIMS: Longitudinal full cross-lagged models are essential to test causal relationships. This study used such a model to test the predictive value of internal (enhancement and coping) and external (conformity and social) drinking motives for changes in alcohol use over time, and tested possible reversed causality (i.e. alcohol use explains later drinking motives). DESIGN: Longitudinal data consisting of two waves (separated by 1 year) were used to estimate cross-lagged structural equation models. SETTING: Three comparable (regarding urbanization and social stratification) Dutch communities. PARTICIPANTS: A total of 454 alcohol-using adolescents aged 13-16 years (mean = 14.8 years, SD = 0.78) at wave 1. MEASUREMENTS: Standardized questionnaires including the Drinking Motive Questionnaire-revised, and items on total weekly consumption and frequency of heavy episodic drinking. FINDINGS: In adolescence, drinking motive preferences are already relatively stable over time. Also, only social motives significantly predicted increases in total weekly consumption and frequency of heavy episodic drinking. No feedback mechanisms by which alcohol consumption explains later drinking motives scores were found. CONCLUSIONS: Among drinking adolescents in a wet drinking culture, such as the Dutch drinking culture, social drinking motives, rather than enhancement or coping motives for drinking, appear to predict overall consumption and frequency of heavy episodic use a year later. Parents and other important social actors have an active role in reducing alcohol availability and monitoring adolescents' drinking.

Effects of a workplace-smoking ban in combination with tax increases on smoking in the Dutch population.

INTRODUCTION: In the Netherlands, between 2003 and 2005, 3 tobacco control measures were implemented: a workplace-smoking ban and 2 tax increases on tobacco products. This study explores how the combination of measures influences the smoking behavior of the general population divided into subpopulations with and without paid work (all aged 16-65 years). METHODS: Data from the Dutch Continuous Survey of Smoking Habits were used. The total sample consisted of 32,014 respondents (27,150 with paid work and 4,864 without paid work) aged 16-65 years. Analyses were done by linear and logistic regression, controlling for relevant factors. RESULTS: 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. In both groups, there was no evidence that the effect of the measures on smoking was moderated by the respondent's gender, age, or level of education. CONCLUSIONS: The combination of policy measures has influenced the smoking behavior of respondents with paid work in a positive way. Compared with most other studies, the effect of the workplace-smoking ban alone is smaller. However, the effect of the combined interventions is higher than the that of tax increases in other studies. Among respondents without paid work who were exposed to tax increases only, no significant effects were found.