Educational differences in associations of noticing anti-tobacco information with smoking-related attitudes and quit intentions: findings from the International Tobacco Control Europe Surveys.

This study examined educational differences in associations of noticing anti-tobacco information with smoking-related attitudes and quit intentions among adult smokers. Longitudinal data (N = 7571) from two waves of six countries of the International Tobacco Control (ITC) Europe Surveys were included. Generalized estimating equation analyses and multiple linear and logistic regression analyses were conducted. Higher educated smokers noticed anti-tobacco information slightly more often than lower educated smokers (F(2) = 25.78, P < 0.001). Noticing anti-tobacco information was associated with more negative smoking-related attitudes (ß = 0.05, P < 0.001) and more quit intentions (OR = 1.08, P < 0.001). Among smokers without a quit intention at baseline, a positive association was found for noticing anti-tobacco information at baseline with follow-up quit intention (OR = 1.14, P = 0.003). No other longitudinal associations were found. No educational differences were found in the association of noticing anti-tobacco information with smoking-related attitudes but associations with quit intentions were found only among low (OR = 1.12, P = 0.001) and high educated respondents (OR = 1.11, P < 0.001) and not among moderate educated respondents (OR = 1.02, P = 0.43). Noticing anti-tobacco information may positively influence quit intentions and possibly smoking-related attitudes. Lower educated smokers were as likely to be influenced by anti-tobacco information as higher educated smokers but noticed anti-tobacco information less often; increasing reach of anti-tobacco information may increase impact in this group.

Association of availability of tobacco products with socio-economic and racial/ethnic characteristics of neighbourhoods.

OBJECTIVE: To examine the association of neighbourhood median income and racial/ethnic composition with the availability of tobacco products in Omaha Metropolitan Area, Nebraska, USA. METHODS: A total of 94 census tracts were selected at random. The outcome measures were the percentage of stores that sold tobacco and the number of stores that sold tobacco per square mile in each census tract. RESULTS: Median household income was negatively associated (P<0.001), and percentage African American population (P<0.001) and percentage Hispanic population (P=0.049) were positively associated with the percentage of stores that sold tobacco. Median household income was negatively associated (P<0.001) and percentage Hispanic population (P=0.012) was positively associated with the number of stores that sold tobacco per square mile. CONCLUSION: Policies that reduce the number of tobacco outlets might reduce social disparities in tobacco use.

Racial/ethnic and socioeconomic variations in duration of smoking: results from 2003, 2006 and 2007 Tobacco Use Supplement of the Current Population Survey.

BACKGROUND: Little is known about racial/ethnic and socioeconomic variations in the duration of smoking. The goal of this research was to examine these variations. METHODS: Data came from the 2003, 2006 and 2007 Tobacco Use Supplement of the Current Population Survey. The analysis was limited to ever-smokers (n = 117,168). The outcome was number of years of daily smoking. Survival analysis was employed to predict smoking duration. RESULTS: American Indians with 32 years had the highest median duration of smoking, followed by Blacks and 'other' races with 30 years, Whites with 28 years and Hispanics with 24 years. The difference in the duration of smoking between Blacks and Whites disappeared after adjusting for poverty. Individuals in poverty had a median duration of smoking of 40 years, while those with a family income of at least three times that of the poverty threshold had a median duration of 22 years. Median duration of smoking was 40 years among individuals without a high-school diploma and 18 years among those with a bachelors or higher degree. CONCLUSION: This research revealed large variations in smoking duration between racial/ethnic and socioeconomic groups. Longer exposure to tobacco among groups that are already disadvantaged is likely to exacerbate existing health disparities.

The effect of smoke-free policies on revenue in bars in Tasmania, Australia.

OBJECTIVE: To examine the impact of smoke-free policies on revenue in Tasmanian bars. METHOD: Monthly sales turnover from January 2002 to March 2007, provided by the Australian Bureau of Statistics was analysed. There were two OUTCOME MEASURES: (1) the ratio of monthly bar sales turnover in Tasmania to monthly bar sales turnover in four other Australian states, and (2) the ratio of monthly bar turnover to monthly retail turnover in Tasmania. Linear regression was used to assess the impact of the smoke-free policy on expenditure. RESULTS: The smoke-free policy had no effect on sales turnover. CONCLUSION: The smoke-free policy protects hospitality workers and patrons from exposure to secondhand smoke and has had no adverse effect on sales turnover.

Smoking and inadequate housing: results from an Australian national survey.

OBJECTIVES: To examine the effect of: (a) the smoking status of the household; and (b) the amount spent on smoking by the household on inadequate housing. STUDY DESIGN: This was a cross-sectional study using data from the first wave of the Household Income and Labour Dynamics in Australia survey. METHODS: A total of 7673 households were eligible for analysis. The outcome, inadequate housing, was derived from a questionnaire item asking respondents about the adequacy of their housing with respect to their housing needs in general. A house was defined as a smoking household if at least one member smoked. Amongst smoking households, the total amount spent on smoking per week was calculated. Other factors included in the analyses were education, occupation and age of the head of the household, household size, household disposable income and housing tenure. RESULTS: There was evidence for an unadjusted association between being a smoking household and having inadequate housing [odds ratio (OR) 1.64, 95% confidence interval (CI) 1.32-2.03, P<0.001]; however, after adjusting for indicators of socio-economic status and age, evidence for the association became much weaker (OR 1.15, 95% CI 0.90-1.47, P=0.262). For smoking households, there was little evidence for an association between inadequate housing and the amount spent on smoking by the household, either unadjusted or adjusted. CONCLUSIONS: It appears that antismoking policies will not enhance housing adequacy, which is predominantly affected by indicators of socio-economic status.

What happened to smokers' beliefs about light cigarettes when "light/mild" brand descriptors were banned in the UK? Findings from the International Tobacco Control (ITC) Four Country Survey.

AIM: This paper examines how beliefs of smokers in the UK were affected by the removal of "light" and "mild" brand descriptors, which came into effect on 30 September 2003 for Member States of the European Union (EU). PARTICIPANTS: The data come from the first four waves (2002-2005) of the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey, an annual cohort telephone survey of adult smokers in Canada, USA, UK and Australia (15 450 individual cases). DESIGN: The UK ban on misleading descriptors occurred around the second wave of data collection in the ITC survey, permitting us to compare beliefs about light cigarettes among adult smokers in the UK before and after the ban, with beliefs in the three other ITC countries unaffected by the ban. RESULTS: There was a substantial decline in reported beliefs about the benefits of light cigarettes in the UK following the policy change and an associated public information campaign, but by 2005 (ie, wave 4), these beliefs rebounded slightly and the change in beliefs was no greater than in the USA, where there was no policy change. CONCLUSIONS: The findings reveal that high levels of misperceptions about light cigarettes existed among smokers in all four countries before and after the EU ban took effect. We cannot conclude that the policy of removing some aspects of misleading labels has been effective in changing beliefs about light cigarettes. Efforts to correct decades of consumer misperceptions about light cigarettes must extend beyond simply removing "light" and "mild" brand descriptors.

Levels and correlates of awareness of tobacco promotional activities among adult smokers in Malaysia and Thailand: findings from the International Tobacco Control Southeast Asia (ITC-SEA) Survey.

AIM: To examine the impact of tobacco advertising policy on adult smokers' awareness of tobacco promotion in two developing countries--Malaysia and Thailand. METHODS: Data from 2004 Malaysian and 2000 Thai adult smokers who participated in the baseline wave of the International Tobacco Control Southeast Asia survey (ITC-SEA). Respondents were asked in a face-to-face interview conducted between January and March 2005 to indicate their levels of awareness of tobacco advertising and promotional activities in the last six months. RESULTS: Unprompted awareness of any tobacco marketing activities was very low in Thailand (20%) but significantly higher in Malaysia (53%; OR = 5.6, 95% CI: 3.5 to 8.9, p<0.001). When prompted about specific locations, Thai adult smokers reported very low recall of tobacco advertising where it was banned, being highest around point of sale, particularly street vendors (7.5%). In contrast, Malaysian adult smokers reported significantly higher levels of awareness of tobacco advertising in all locations (range = 17.7% noticing in disco lounges to 59.3% on posters) including where they are notionally banned (for example, billboards). CONCLUSIONS: These findings demonstrate that comprehensive tobacco advertising legislation when well implemented can lead to dramatic decline in awareness of tobacco promotion, thus supporting strong implementation of Article 13 of the Framework Convention on Tobacco Control.

The effect of smoke-free policies on electronic gaming machine expenditure in Victoria, Australia.

OBJECTIVE: To examine the impact of smoke-free policies in Victorian gambling venues on electronic gaming machine (EGM) expenditure. METHOD: Monthly EGM expenditure from July 1998 to December 2005, provided by the Victorian Commission for Gambling Regulation and the Office of the Liquor and Gambling Commissioner in South Australia, was analysed. The outcome measure was the ratio of monthly expenditure for Victoria to monthly expenditure in South Australia. Intervention analysis and autoregressive integrated moving average modelling were used to assess the impact of the smoke-free policy on expenditure. RESULTS: The smoke-free policy resulted in an abrupt, long-term decrease in the level of EGM expenditure. The mean level of monthly expenditure decreased by approximately 14%. CONCLUSION: The smoke-free policy not only protects hospitality workers and patrons from exposure to secondhand smoke but has also had an impact on slowing gambling losses.

Risk factors for overweight and obesity: results from the 2001 National Health Survey.

OBJECTIVES: A significant rise in the proportion of overweight and obese adults has produced a serious health epidemic in Australia and worldwide. The current research aimed to identify sociodemographic and behavioural predictors of overweight and obesity among a large representative sample of Australian adults. STUDY DESIGN: We used the National Health Survey conducted by the Australian Bureau of Statistics in 2001. The survey involved a stratified multistage area sample of private dwellings and face-to-face interviews. METHODS: We analysed data from 8643 females and 7600 males who responded to the 2001 National Health Survey. Multinomial logistic regression examined the association of being overweight or obese versus a healthy weight with a range of sociodemographic and behavioural variables. RESULTS: Fewer females than males were overweight while similar proportions were obese. For females and males, overweight and obesity were significantly associated with older age, being born in Australia, not being in a marriage-like relationship, low education, physical inactivity, and being a non/ex-smoker. High household incomes are protective from obesity but not from being overweight. Additionally, females with high levels of area social disadvantage and males in professional or white-collar occupations were more likely to be overweight or obese than a healthy weight. CONCLUSIONS: Reductions in mortality and morbidity associated with overweight and obesity may be achieved by targeting health promotion strategies to high-risk groups such as those who are older, single, Australian born, socioeconomically disadvantaged, physically inactive, and non-smokers.

Methods of the International Tobacco Control (ITC) Four Country Survey.

This paper outlines the design features, data collection methods and analytic strategies of the International Tobacco Control (ITC) Four Country Survey, a prospective study of more than 2000 longitudinal respondents per country with yearly replenishments. This survey possesses unique features that sets it apart among surveys on tobacco use and cessation. One of these features is the use of theory-driven conceptual models. In this paper, however, the focus is on the two key statistical features of the survey: longitudinal and "quasi-experimental" designs. Although it is often possible to address the same scientific questions with a cross-sectional or a longitudinal study, the latter has the major advantage of being able to distinguish changes over time within individuals from differences among people at baseline (that is, differences between age and cohort effects). Furthermore, quasi-experiments, where countries not implementing a given new tobacco control policy act as the control group to which the country implementing such a policy will be compared, provide much stronger evidence than observational studies on the effects of national-level tobacco control policies. In summary, application of rigorous research methods enables this survey to be a rich data resource, not only to evaluate policies, but also to gain new insights into the natural history of smoking cessation, through longitudinal analyses of smoker behaviour.

Support for and reported compliance with smoke-free restaurants and bars by smokers in four countries: findings from the International Tobacco Control (ITC) Four Country Survey.

OBJECTIVE: To explore determinants of support for and reported compliance with smoke-free policies in restaurants and bars across the four countries of the International Tobacco Control (ITC) Four Country Survey. DESIGN: Separate telephone cross-sectional surveys conducted between October and December 2002 with broadly representative samples of over 2000 adult (>or=18 years) cigarette smokers in each of the following four countries: the United States, Canada, the United Kingdom, and Australia. OUTCOME MEASURES: Support for smoke-free policies in restaurants and pubs/bars and reported compliance with existing policies. RESULTS: Reported total bans on indoor smoking in restaurants varied from 62% in Australia to 5% in the UK. Smoking bans in bars were less common, with California in the USA being the only major part of any country with documented bans. Support for bans in both restaurants and bars was related to the existence of bans, beliefs about passive smoking being harmful, lower average cigarette consumption, and older age. Self-reported compliance with a smoking ban was generally high and was associated with greater support for the ban. CONCLUSIONS: Among current cigarette smokers, support for smoking bans was associated with living in a place where the law prohibits smoking. Smokers adjust and both accept and comply with smoke-free laws. Associates of support and compliance are remarkably similar across countries given the notably different levels of smoke-free policies.

Socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: results from the 2002 International Tobacco Control (ITC) Four Country Survey.

BACKGROUND: Socioeconomic status is strongly associated with smoking prevalence and social class differences contribute substantially to social inequalities in mortality. This research investigated socioeconomic and country variations in smokers' knowledge that smoking causes heart disease, stroke, impotence and lung cancer, that smoke contains cyanide, mercury, arsenic and carbon monoxide, and whether nicotine causes most of the cancer. METHODS: Data were from the International Tobacco Control (ITC) Four Country Survey, a cohort survey of over 9000 adult smokers from four countries: the United States, Canada, the United Kingdom, and Australia. Data were collected via telephone interviews in 2002. RESULTS: Higher education and income were associated with higher awareness. For example, the odds of knowing that smoking causes heart disease, stroke and lung cancer were respectively 71%, 34% and 83% larger for respondents with high versus low income. The odds of knowing that smoke contains cyanide, mercury, arsenic and carbon monoxide were respectively 66%, 26%, 44% and 108% larger for respondents with a university degree than those with a high school diploma or lower level of education. Results also revealed that awareness of harms of smoking was generally the highest in Canada and the lowest in the UK. CONCLUSIONS: Lower socioeconomic status was associated with lower awareness of the harms of smoking and misunderstanding around nicotine. There is a need to improve knowledge of the dangers of smoking among the disadvantaged segments of the population.

Socioeconomic variations in nicotine dependence, self-efficacy, and intention to quit across four countries: findings from the International Tobacco Control (ITC) Four Country Survey.

OBJECTIVE: To examine the effect of socioeconomic status (SES) on nicotine dependence, self-efficacy, and intention to quit. DESIGN SETTING AND PARTICIPANTS: Data were from the first wave (2002) of the International Tobacco Control (ITC) Four Country Survey (ITC-4), a panel study of over 2000 adult smokers from each of four countries: the United States, Canada, the United Kingdom, and Australia. Data were collected via telephone interviews. MAIN OUTCOME MEASURES: Nicotine dependence, intention to quit, and self-efficacy to quit smoking were the main outcome measures used in this study. RESULTS: Lower levels of education were associated with higher nicotine dependence. The effect of lower income on higher heaviness of smoking index (HIS) scores was significant in Canada, the UK, and Australia. Respondents with low education had 35% larger odds of low self-efficacy than those with high education. Respondents with low education had 40% larger odds of having no intention to quit than those with high education. Respondents with low income had 23% larger odds of having no intention to quit than those with high income. Country was not a moderator of the association of SES with self-efficacy and intention to quit. CONCLUSION: To the extent that lower SES smokers are more addicted, they are likely to need more intensive support if they are to be successful in their attempts to quit. Given their lower incomes, this places a special responsibility on government to provide or subsidise such services. This should include access to the widest possible range of effective pharmacotherapies complemented with evidence based counselling and support.

Lower levels of occupation, income and education are strongly associated with a longer smoking duration: multivariate results from the 2001 Australian National Drug Strategy Survey.

OBJECTIVE: Our aim was to investigate the association of socio-economic status (SES) with duration of smoking among ever smokers. STUDY DESIGN: We used a subsample of ever smokers (n = 9973) aged 18+ years from the 2001 National Drug Strategy Household Survey (conducted by the Australian Institute of Health and Welfare), which involved a multistage area sample and mainly self-administered questionnaires. METHODS: The outcome was smoking duration from onset to cessation. We used survival analysis to predict smoking duration. RESULTS: Results showed that smoking duration from onset to cessation was 14% longer for blue-collar workers than for professionals. Respondents who earned under 300 US dollars/week smoked for 38% longer than those earning 800 US dollars+/week. Individuals with less than 10 years of education smoked for 13% longer than those with 12+ years of education. CONCLUSIONS: Smokers from lower social strata smoke for much longer durations. This finding and the fact that smoking increases the likelihood of financial stress suggest that lower SES smokers who experience financial stress are more likely to suffer a longer period of compromised living standards than their counterparts in the higher strata. The financial and health burdens of smoking coupled with social inequalities in smoking behaviour suggest that smoking may exacerbate social class differences in health and standards of living. Thus, targeting smoking among disadvantaged groups would not only represent a public health policy but also a social policy to reduce social inequalities.

Is household smoking status associated with expenditure on food at restaurants, alcohol, gambling and insurance? Results from the 1998-99 Household Expenditure Survey, Australia.

AIM: To examine how household expenditure on food at restaurants, alcohol, gambling and insurance vary between smoking and non-smoking households. DESIGN: Cross sectional survey of households from private dwellings, conducted by the Australian Bureau of Statistics (ABS), using a stratified multistage area sample design. SETTING: Australia, 1998-99. PARTICIPANTS: Nationally representative sample of households (n = 6892). MAIN OUTCOME MEASURES: Expenditure on meals at restaurants, alcohol, alcoholic beverages at licensed premises, gambling, and insurance. RESULTS: The odds of reporting expenditure on restaurant food and health insurance were 20% and 40% smaller for smoking than non-smoking households, respectively. The odds of reporting expenditure on alcohol (not including expenditure at licensed premises), drinking at licensed premises, and gambling were 100%, 50%, and 40% greater for smoking than for non-smoking households, respectively. CONCLUSIONS: The study suggests that smokers are more likely to engage in risky behaviour. Implementing smoking bans in licensed premises and gambling venues can provide an opportunity to reduce smoking prevalence. Quitting or cutting down smoking can provide opportunities for expenditure on other products or services, and enhance standards of living.

Socioeconomic status and tobacco expenditure among Australian households: results from the 1998-99 Household Expenditure Survey.

OBJECTIVE: To investigate the relation between socioeconomic status (SES) and tobacco expenditure among Australian households. DESIGN AND SETTING: Cross sectional study (The Household Expenditure Survey 1998-99) by the Australian Bureau of Statistics, based on a multi-stage national sample of 9682 households. PARTICIPANTS: From selected households, all members aged 15 and over were interviewed. MAIN RESULTS: Lower SES was associated with higher odds of reporting tobacco expenditure. Among smoking households, those from lower SES spent more of their funds on tobacco. For example, households headed by a person with no educational qualification spent 34% more on tobacco than those headed by a person with a university degree. Blue collar households spent 23% more than professional households. Percentage of total household expenditure on tobacco in the first income quintile was 62% more than that of households in the fifth quintile. CONCLUSION: Antismoking interventions and policies that are specifically aimed at lower SES groups can potentially improve social equality. They can also ameliorate social inequalities in health, given that much of the SES differentials in morbidity and mortality are attributed to the pronounced SES gradient in smoking.

How has the prevalence of cigarette smoking changed among Australian adults? Trends in smoking prevalence between 1980 and 2001.

OBJECTIVE: To examine trends in the prevalence of cigarette smoking between 1980 and 2001 among several different sociodemographic groups within the Australian population. METHOD: National cross sectional surveys conducted by face to face interview every 3 years from 1980. Respondents were classified into five age groups and the occupation of respondents in the workforce were classified into one of upper or lower white collar or upper or lower blue collar. MAIN OUTCOME MEASURE: Prevalence of smoking at least weekly. RESULTS: The prevalence of smoking in 2001 was lower than that found in 1980 and this was true for all sociodemographic groups. Among adults smoking prevalence decreased from 35% in 1980 to 23% in 2001. The differential in smoking prevalence between men and women decreased between 1980 and 2001. Although smoking was more common among younger Australians (<24 years) than older Australians throughout the study, the differential between age groups reduced. For all years except 1980, the proportion of smokers among upper white collar workers was significantly lower than in all other occupation groups. CONCLUSION: There had been a continual decline in the prevalence of smoking among the Australian population since 1980. This decline had occurred across both sexes and in all age and occupation groups. Much of the decline in smoking prevalence between 1998 and 2001 was among blue collar worker group.

Smoking and financial stress.

AIM: Stress relief is commonly provided as a reason for smoking. However, it is plausible that the cost of smoking may create financial stress, particularly among the poor. The aim of the study was to examine the relationship between smoking and financial stress. DESIGN: Cross sectional survey of households from private dwellings conducted by the Australian Bureau of Statistics (ABS), using a stratified multistage area sample design. SETTING: Australia, 1998-99. PARTICIPANTS: Nationally representative sample of households (n = 6892). MAIN OUTCOME MEASURES: The outcome measures of objective financial stress were two dichotomous variables indicating whether the household had experienced any financial stress or severe financial stress in the past 12 months. RESULTS: The odds of experiencing any financial stress were 1.5 (95% confidence interval (CI) 1.3 to 1.7) times greater, and the odds of severe financial stress were twice (95% CI 1.6 to 2.5) as large for smoking households than non-smoking households. The effect of smoking on financial stress did not vary significantly across categories of income. Among smoking households, higher percentage of total household expenditure on tobacco was significantly related to financial stress. CONCLUSIONS: Given data were cross sectional, firm conclusions cannot be drawn about the causal relationship between smoking and financial stress. It is likely that they both affect each other. Undoubtedly, expenditure on tobacco will reduce available funds that could otherwise be used to ameliorate financial stress.

Socio-demographic variations in smoking status among Australians aged > or = 18: multivariate results from the 1995 National Health Survey.

OBJECTIVE: To determine the association between socio-demographic variables and smoking status in a national sample of Australians aged > or = 18. METHOD: The data came from the 1995 National Health Survey (NHS), which was conducted by the Australian Bureau of Statistics (ABS). Information was collected from 20,165 females and 18,948 males using face-to-face interviews. The dependent variable was smoking status distinguishing regular smokers from occasional, ex-smokers and never-smokers. Multiple logistic regression was used to examine the association of smoking status with gender, age, marital status, region of residence, country of birth and three socio-economic measures. RESULTS: Analyses showed that gender, age, marital status, country of birth and socio-economic position were significantly related to smoking status. The odds of being a smoker were largest for respondents who were 20-34 years old, were not married, had a low socio-economic standing, and were born in the Middle East, southern and western Europe for men, and the United Kingdom/Ireland and western Europe for women. The results also revealed that the geographic measure of socio-economic status had a stronger association with smoking likelihood than the individual level indicators (education and income), suggesting the importance of the social environment. CONCLUSION: There is substantial socio-demographic variability in smoking status. IMPLICATION: Of groups identified as having higher smoking rates, the socio-economically disadvantaged groups have the highest priority for targeted campaigns.