Tobacco Control Activities Research Articles

The Marlboro Man Versus Uncle Sam: The First Amendment Constitutionality of Graphic Cigarette Warning Labels

According to the Surgeon General, tobacco use is the leading preventable cause of death in the United States. Smoking-related diseases kill 443,000 Americans each year, more than are killed by HIV, illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined. To address this public health threat, Congress enacted the Family Smoking Prevention and Tobacco Control Act (TCA) in 2009, which gave the federal government unprecedented power to regulate the tobacco industry. Among its provisions, the TCA requires the U.S. Food and Drug Administration to select images that depict smoking’s deleterious effects and compels tobacco companies to display the images, accompanied by a textual warning, on half of the front and rear panels of every cigarette package. This new graphic format — the first alteration of cigarette package warnings in over twenty-five years — represents a significant and aggressive change in the way that the government communicates the dangers of smoking to the public.To prevent the introduction of these new labels into the marketplace, the tobacco industry has filed suit alleging that the graphic warnings infringe on its First Amendment right to refrain from speaking. The two circuit courts that have considered this issue are divided sharply over the labels’ constitutionality and the appropriate framework for assessing them. This Note examines this legal fissure and argues that the warnings should be examined under the strict scrutiny standard of judicial review. Ultimately, this Note contends that the labels do not pass muster under this intense level of scrutiny and are thus unconstitutional compulsions of speech.

Developing Leaders in Priority Populations to Address Tobacco Disparities

Few published evaluations documenting the results of community health leadership programs exist. Furthermore, few leadership programs specifically address cross-cultural issues or priority populations, and none have focused on the area of tobacco control. The goal of the evaluation was to determine the effectiveness of the Leadership and Advocacy Institute to Advance Minnesota's Parity for Priority Populations Institute. Institute Fellows were recruited from 5 priority populations, including African/African American, American Indian, Asian American, Chicano Latino and Lesbian, Gay, Bisexual, and Transgender. The Institute's impact on the acquisition and application of particular leadership skills was assessed, along with its impact in building priority population capacity to engage in tobacco control activities. DESIGN AND MEASURE: Findings are based on mixed methods, including Fellows' completion of paper surveys prior, during, and post-Institute, and telephone interviews conducted post-Institute. Perceived skills increased in all areas assessed. Fellows reported applying specific skills acquired 16 months after the Institute. Furthermore, a high number of Fellows were more intensely involved in tobacco control work compared to baseline and reported involvement in cross-cultural collaborations or initiatives post-Institute. The Institute achieved both short-term and intermediate outcomes; skills were acquired during the Institute and sustained and applied in areas of tobacco control over 1 year later.

Health System Preparedness for Tobacco Control: Situational Analysis of Existing Health Programs in Andhra Pradesh, India

Andhra Pradesh (AP) is one of the largest tobacco producing states in India. About 29% of adults in AP currently use tobacco in some form. Almost 24% of males and 4% of females are smokers. The prevalence of tobacco use in the state is higher than the national average of 15% for male and 2% for female smokers. However, few attempts have been made to understand the current situation of tobacco control resources, activities and strategies in the context of such a high tobacco prevalence state. The present study aimed to identify the gaps in existing tobacco control program and areas where tobacco control efforts can be integrated. Data were collected using both quantitative and qualitative methods. Semi-structured interviews were undertaken with a total of 95 key officials of state health departments, program managers, and project directors in six districts to understand ongoing tobacco control efforts. To facilitate the interviews, semi-structured guides were developed. Simple descriptive statistical analysis was conducted on the quantitative data using SPSS version 17. The results of the situational analysis suggest that a sufficient health workforce and infrastructure with the potential to integrate tobacco control activities is available in the surveyed districts. However, lack of integration of the tobacco control program intothe tuberculosis control program and the National Rural Health Mission was observed. Information, education and communication activities were lacking at block level health facilities. Our findings indicate that lack of trained health professionals, paucity of dedicated funds, lack of information, education and communication materials and low priority given to tobacco control activities are some of the factors which impede integration of tobacco control into existing health and developmental programmes in the districts of Andhra Pradesh, India.

The Food and Drug Administration's Regulation of Tobacco: The Center for Tobacco Products' Office of Science

The Family Smoking Prevention and Tobacco Control Act (TCA) was signed into law on June 22, 2009, and provided the Food and Drug Administration (FDA) broad regulatory authority with respect to the manufacture, marketing, and distribution of tobacco products. The three public health goals of the Center for Tobacco Products (CTP), FDA, are to prevent youth initiation of tobacco use, decrease harm and/or addictiveness of tobacco products, and encourage tobacco use cessation. The CTP has established an Office of Science to ensure that sound science exists with which to develop regulatory actions. Although there is a vast and sound science base with regard to numerous provisions within the TCA, new research will not only help assess the impact of FDA regulatory authority over tobacco products but will inform future regulatory activities. In order to meet the broad science demands within the TCA, the CTP developed seven research priority areas: 1understanding the diversity of tobacco products; 2reducing addiction to tobacco products; 3reducing toxicity and carcinogenicity of tobacco products and smoke; 4understanding adverse health consequences of tobacco use; 5understanding communications about tobacco products; 6understanding tobacco product marketing; and 7understanding economics and policies on tobacco use and perceptions.

Abstract PL04-01: The global tobacco epidemic in 2012.

Abstract This presentation addresses the global tobacco epidemic as it enters its second century. The epidemic began in the late 19th century with the monopolistic rise of American Tobacco, the first multinational tobacco company. In the United States and Europe, smoking rates rose, first in men around the time of World War I, and subsequently in women, around the time of World War II. In these countries, smoking rates peaked in the 1950s and 1960s and have since declined substantially because of evidence-based tobacco control. However, smoking rates are now high among men in a number of low- and middle-income countries and the tobacco industry is aggressively marketing in these countries as its developed-country markets shrink. The most recent data on smoking at the global level were obtained through the new Global Adult Tobacco Survey (GATS) for adults and through the ongoing Global Youth Tobacco Survey (GYTS). Using nationally representative household surveys with comparable methods to obtain relevant information from individuals aged 15 years or older in 14 low-income and middle-income countries (Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, and Vietnam), 48.6% (95% CI 47.6–49.6) of men and 11.3% (10.7–12.0) of women were current tobacco users. Early initiation of smoking in women and low quit ratios across many of the participating countries were also reported. The GYTS, a school-based survey of 13-15 year olds that has now been conducted in 140 countries and 11 territories worldwide for up to two rounds per country, has found that 9.5% (7.9-11.3) of children were regular smokers (12.1% of boys and 6.8% of girls). In 2012, tobacco control action by governments, non-governmental organizations (NGOs), academia and civil society as a whole, at international, national and sub-national levels, continues to be implemented with the impetus of the Framework Convention on Tobacco Control (FCTC). The evidence foundation for tobacco control globally has been summarized by the World Health Organization in its MPOWER package: M for monitoring or surveillance; P for protection of nonsmokers from exposure to secondhand smoke; O for offering effective cessation; W for warn through appropriate pack warnings; E for enforcement of tobacco control policies and regulations; and R for raise taxes to an appropriate level. The GATS and the GYTS provide an approach for tracking the impact of tobacco control at the global level.

Chapter 10: A Macro‐Model of Smoking and Lung Cancer: Examining Aggregate Trends in Lung Cancer Rates Using the CPS‐I and CPS‐II and Two‐Stage Clonal Expansion Models

Past studies have examined the relationship of lung cancer to smoking using longitudinal data for select samples. This study applies the two-stage clonal expansion (TSCE) model to U.S. +xsmoking data over a 25-year period. Smoking Base Case (SBC) data on actual smoking duration and intensity from the years 1975-2000 are applied by gender to separate TSCE models, which are then calibrated to historical trends in lung cancer death rates using regression analysis. The uncalibrated and calibrated TSCE models are also applied to SBC data for two scenarios: (1) no tobacco control and (2) complete tobacco control. The results are used to develop estimates of the number of lives saved as a result of tobacco control and how many lives would be saved if cigarette use had ceased in 1965. Predictions of lung cancer from the TSCE models with CPS-II and the CPS-I data for males and especially females are considerably below historical rates with the deviations from historical rates increasing over time. Residual trends unrelated to the smoking models were also found. Tobacco control activities saved approximately 625,000 lives between the years 1975 and 2000. An additional 2,110,000 lives would have been saved if all smoking was stopped in 1965. Tobacco control has successfully prevented lung cancer deaths, but many more lives could be saved with further reductions in smoking rates. Systematic biases were observed from TSCE models using CPS-I and CPS-II data to estimate smoking-related lung cancer deaths.

A Sisyphean Task: How Electronic Cigarettes are Stymieing Efforts of Both Congress and the FDA to Protect Public Health

The adverse effects of smoking have fostered a natural market for smoking cessation and smoking reduction products. Smokers attempting to quit or reduce consumption have tried everything: "low" or "light" cigarettes; nicotine-infused chewing gum, lozenges, and lollipops; dermal patches; and even hypnosis. The latest craze in the quest to find a safer source of nicotine is the electronic cigarette. Electronic cigarettes (e-cigarettes) have swept the market, reaching a rapidly expanding international consumer base. Boasting nicotine delivery and the tactile feel of a traditional cigarette without the dozens of other chemical constituents that contribute to carcinogenicity, e-cigarettes are often portrayed as less risky, as a smoking reduction or even a complete smoking cessation product, and perhaps most troubling for its appeal to youth, as a flavorful, trendy, and convenient accessory. The sensationalism associated with e-cigarettes has spurred outcry from health and medical professional groups, as well as the Food and Drug Administration (FDA), because of the unknown effects on public health. Inhabiting a realm of products deemed "tobacco products" under recent 2009 legislation, e-cigarettes pose new challenges to FDA regulation because of their novel method of nicotine delivery, various mechanical and electrical parts, and nearly nonexistent safety data. Consumer use, marketing and promotional claims, and technological characteristics of e-cigarettes have also raised decades old questions of when the FDA can assert authority over products as drugs or medical devices. Recent case law restricting FDA enforcement efforts against e-cigarettes further confounds the distinction among drugs and medical devices, emerging e-cigarette products, and traditional tobacco products such as cigarettes, cigars, and smokeless tobacco. This Article investigates the e-cigarette phenomenon in the wake of the recently enacted Family Smoking Prevention and Tobacco Control Act of 2009 (TCA). It examines the tumultuous history of attempts at tobacco regulation by reflecting on the history of Congressional activity to regulate tobacco sales and promotion. Furthermore, this Article suggests a feasible approach to strengthening regulation of e-cigarettes under the existing statutory framework. This approach includes increased scrutiny of manufacturer and distributor claims that trigger drug and medical device provisions, utilization of new tobacco product and modified risk tobacco product provisions, and promulgation of new FDA regulations and guidance specifically directed at e-cigarettes.

Tobacco use and nicotine dependency in a cross-sectional representative sample of 18,018 individuals in Andaman and Nicobar Islands, India

BackgroundData on prevalence, pattern of tobacco use, proportion of population dependent on nicotine and their determinants are important for developing and implementing tobacco control strategies. The aim of the study was to estimate the prevalence and determinants of tobacco use and nicotine dependency.MethodsA cross-sectional survey among a representative sample of 18,018 individuals in the age group of >=14 years was conducted in the Union Territory of Andaman and Nicobar Islands during 2007–09. A structured questionnaire, a modified version of an instrument which was used successfully in several multi-country epidemiological studies of the World Health Organisation, was used to survey individual socio-demographic details, known co-morbid conditions, tobacco use and alcohol use. Fagerström Test for Nicotine Dependence (FTND) was used to estimate nicotine dependence.ResultsThe response rate of our survey was 97% (18,018/18,554). Females (n = 8,888) were significantly younger than males (34.3 + 14.6 Vs 36.2 + 15.4 years). The prevalence of current tobacco use in any form was 48.9% (95% CI: 48.2–49.6). Tobacco chewing alone was prevalent in 40.9% (95% CI: 40.1–41.6) of the population. While one tenth of males (9.7%, 95% CI: 9.1–10.4) were nicotine dependent, it was only 3% (95% CI: 2.7–3.4) in females. Three fourth of the tobacco users initiated use of tobacco before reaching 21 years of age. Age, current use of alcohol, poor educational status, marital status, social groups, and co-morbidities were the main determinants of tobacco use and nicotine dependence in the population.ConclusionThe high prevalence of tobacco use especially the chewing form of tobacco in the Union Territory of Andaman and Nicobar Islands and the differences in prevalence and pattern of tobacco use and nicotine dependency observed across subgroups warrants implementation of culturally specific tobacco control activities in this population.

FDA's Tobacco Products Research Program likely to play role in cancer prevention

Editor's note: This is Part 2 of a 2-part series on cancer prevention research. Part 1 was published in the June 1 issue of “CancerScope.” When the Family Smoking Prevention and Tobacco Control Act (TCA) became law in 2009, giving the US Food and Drug Administration (FDA) the power to regulate tobacco products, the FDA created the Center for Tobacco Products. The center's principal mission is to regulate the manufacture, marketing, and distribution of tobacco products. According to David Ashley, PhD, director of the center's Office of Science, scientific research is necessary to inform the FDA's regulations, which involve reducing initiation, promoting cessation, and reducing harms for those who use tobacco products. Understanding the diversity of tobacco products; Reducing addiction to tobacco products; Reducing the toxicity and carcinogenicity of tobacco products and smoke; Understanding the adverse health consequences of tobacco use; Understanding communications about tobacco products; Understanding tobacco product marketing; and Understanding how economics and policies affect tobacco product use. Center representatives add that scientists also can submit basic research proposals if they can inform regulatory issues. Within this framework, the FDA recently announced 56 questions they would like to see answered through research. (For the full list of questions, visit the Center for Tobacco Products' summary of its meeting on research priorities at www.fda.gov/TobaccoProducts and click on “News & Events.”) “They're growing a regulatory and research arm from scratch, in a paradigm that's totally foreign to the FDA,” says Peter Shields, MD, president of the American Society of Preventive Oncology and deputy director at the Lombardi Comprehensive Cancer Center at Georgetown University Medical Center. “If they applied any of the rules they use for drugs or food to tobacco, they would get rid of it, but the law prohibits them from banning it.” Because Congress will never ban tobacco, the FDA is trying to limit as much as possible the harm of tobacco products, he says. “Tobacco research has been underfunded for 20 years, and now the FDA needs data that doesn't exist,” says Dr. Shields. “There are fundamental, basic questions that need to be answered.” National Study Will Assess Regulation Impact The first large-scale FDA/National Institutes of Health (NIH) study to be announced since the FDA gained authority to regulate tobacco products is a national study of tobacco users to monitor and assess the behavioral and health impacts of new government tobacco regulations. The effort is a collaboration between the NIH's National Institute on Drug Abuse and the Center for Tobacco Products. What makes people susceptible to tobacco use; Use patterns and resulting health problems; Patterns of tobacco cessation and relapse in the era of tobacco regulation; The effects of regulatory changes on risk perceptions and other tobacco-related attitudes; and Differences in attitudes, behaviors, and key health outcomes in racial/ethnic, gender, and age subgroups. Tobacco research has been underfunded for 20 years, and now the FDA needs data that doesn't exist. There are fundamental, basic questions that need to be answered.—Peter Shields, MD Knowledge gleaned from this study will help the FDA target the most effective actions to decrease the toll of tobacco use on the nation's health, said Margaret Hamburg, FDA commissioner, when the study was announced last fall. More specifically, the results will help the FDA assess the impact of the TCA and understand how best to use its regulatory authority regarding product marketing and standards and communicating the risks of tobacco use. Additional Efforts Similar to the Department of Defense funding breast cancer research, the FDA is contracting with the NIH to award additional grants. Among the questions to be answered is whether the FDA should regulate levels of nicotine. In addition, researchers need to test the blood and urine of people using the new tobacco products to understand their impact. Tobacco companies claim these products reduce carcinogens, but scientists currently do not have those tests. As a result, the best options now are testing individuals for certain biomarkers and developing and validating specific modeling that will determine how regulators can best impact public health, Dr. Shields says. Researchers also need to understand how people use the new products and what they think of them. Clinical trials are difficult to conduct because the typical tobacco user does not want to participate in a trial, Dr. Shields adds. “Tobacco is a complex problem that's been around a long time, and it won't be solved overnight,” he says.

Does Level of Tobacco Control Relate to Smoking Prevalence in Canada: A National Survey of Public Health Organizations

To describe levels of tobacco control “effort” in public health organizations across provinces, and to test the hypothesis that “effort” is associated with the prevalence of daily smoking. Data were drawn from a national survey (Oct 2004-Apr 2005) of all public health organizations engaged in chronic disease prevention in Canada in 2004. We investigated the association between “effort” and decline in smoking prevalence (CTUMS, 1 999-2009) across provinces in an écologie study design. “Effort” was assessed using two indicators: percent of public health organizations engaged in tobacco control, and mean level of involvement in engaged organizations. Of 216 organizations, 88% had undertaken tobacco control activities in the three years prior to data collection and were categorized as “engaged". Level of involvement in tobacco control was highest in community-at-large settings; and it was generally higher for population- than for individual-level strategies. Nova Scotia reported higher levels of involvement than other provinces. There was substantial variability in “effort” across provinces. High-"effort” provinces (BC, NS, ON, QC) experienced, on average, improvement in the “change in smoking prevalence” score (1999 to 2009). The findings provide evidence that provincial tobacco control “effort” relates to declines in smoking prevalence. Given that smoking remains a critical public health issue, the kinds of data reported herein are needed to inform the debate on how best to invest in tobacco control infrastructure to combat the most important public health threat of our times.

Does level of tobacco control relate to smoking prevalence in Canada: a national survey of public health organizations.

To describe levels of tobacco control "effort" in public health organizations across provinces, and to test the hypothesis that "effort" is associated with the prevalence of daily smoking. Data were drawn from a national survey (Oct 2004-Apr 2005) of all public health organizations engaged in chronic disease prevention in Canada in 2004. We investigated the association between "effort" and decline in smoking prevalence (CTUMS, 1999-2009) across provinces in an ecologic study design. "Effort" was assessed using two indicators: percent of public health organizations engaged in tobacco control, and mean level of involvement in engaged organizations. Of 216 organizations, 88% had undertaken tobacco control activities in the three years prior to data collection and were categorized as "engaged". Level of involvement in tobacco control was highest in community-at-large settings; and it was generally higher for population- than for individual-level strategies. Nova Scotia reported higher levels of involvement than other provinces. There was substantial variability in "effort" across provinces. High-"effort" provinces (BC, NS, ON, QC) experienced, on average, improvement in the "change in smoking prevalence" score (1999 to 2009). The findings provide evidence that provincial tobacco control "effort" relates to declines in smoking prevalence. Given that smoking remains a critical public health issue, the kinds of data reported herein are needed to inform the debate on how best to invest in tobacco control infrastructure to combat the most important public health threat of our times.

Smokers and Marriage: Attitude of Youth in the United Arab Emirates

In order to control the tobacco scourge, an array of measures is required. Among them is focusing on adolescent relationships as it has been shown that being in a close relationship with a smoker or a non smoker will in the long run be a major factor in deciding whether the individual adopts smoking for initial non-smokers or ceases the habit for initial smokers. To assess the attitude of youth towards other smokers and towards marrying a smoker. A cross-sectional study was carried out among 415 students from five universities in the United Arab Emirates (UAE). Self-administered structured questionnaires were used for data collection. The Chi square test was used to detect significant differences between frequencies. Of the 415 participants who provided their gender information, 99 (24%) were males and 314 (76%) were females. Of all the participants, 83.5% were not willing to marry smokers, while 16.5% were willing. Of those whose parents smoked (106) 68% did not like it when their parents smoked, 13.6% had no opinion, 17.5% did not mind, while the other 1% had other thoughts. Of those whose close friends smoked, 43.4% did not like it, 16.2% did not have any opinion, 36.9% did not mind while 3.5% had other thoughts. Most participants, both males and females are not willing to marry smokers and prefer to have non-smokers as spouses. Also, smokers are seen as less attractive by both genders in contrast to what appears as popular beliefs amongst youngsters and what is depicted in tobacco advertisements. Tobacco control activities can be undertaken in the community and colleges by incorporating students as facilitators.

Does Intolerance of Smoking at School or in Restaurants or Corner Stores Decrease Cigarette Use Initiation in Adolescents?

In addition to individual-level characteristics, the social and physical environment may influence the initiation of cigarette smoking in adolescents. The objective of this paper is to describe the association between smoking intolerance in schools, and in restaurants and corner stores located near schools, and initiation of cigarette smoking among adolescents. Data on cigarette smoking were collected in self-report questionnaires every 3 months from 1999 to 2005 in a sample of 1,293 Grade 7 students in 10 secondary schools in Montreal, Canada. Baseline never-smokers (n = 868) were retained for analysis. School administrators completed questionnaires on tobacco control policies and activities within schools. Data on access to tobacco products and smoking restrictions in restaurants and corner stores located in school neighborhoods were collected through direct observation. Schools, restaurants, and corner stores were classified as smoking tolerant or intolerant. Time to initiation of cigarette smoking was modeled as a function of smoking intolerance in schools, restaurants, and corner stores in survival analyses (Cox proportional hazards modeling). Students in smoking-intolerant schools were less likely to initiate smoking than students in smoking-tolerant schools (hazard ratio [HR; 95% CI] = 0.83 [0.68, 1.01]). Students attending schools located in neighborhoods with smoking-intolerant restaurants were less likely to initiate smoking (HR [95% CI] = 0.85 [0.68, 1.07]). There was no association between corner store smoking intolerance and initiation. Smoking intolerance in schools and restaurants may protect against initiation of cigarette smoking and could be useful targets for more intense tobacco control efforts.

Smokeless Tobacco Marketing and Sales Practices in Appalachian Ohio Following Federal Regulations

Smokeless tobacco (ST) use is increasingly prevalent among poor and vulnerable groups, especially rural males. Access to tobacco products, as well as marketing messages, is associated with tobacco usage. In June 2010, the Tobacco Control Act (TCA) marked the beginning of federal regulation of the sale and marketing of tobacco products--including ST. The goal of this study was to describe marketing practices over time and to provide early assessment of the federal regulation in rural tobacco-licensed retail outlets. Observational data were collected from a sample of retail outlets within three Ohio Appalachian counties. From an estimated 300 retail establishments, a stratified random sample was drawn (n = 86). Trained observers surveyed the sales and marketing of tobacco products. Baseline surveys were conducted between November 2009 and May 2010 before the TCA; follow-up surveys were repeated in August 2010. Follow-up surveys were completed for 79 tobacco-licensed retail outlets. The majority of retail outlets were gas stations or convenience stores. Compared with baseline, there was a significant reduction in the frequency of exterior and interior advertisements observed after the TCA (p < .01). Despite the lack of change in the proportion of stores advertising ST, the number of ST brands being advertised doubled between baseline and follow-up. Initial compliance with certain elements of the federal restrictions appears to be high in Appalachian Ohio. The significant increase in ST brands advertised suggests that advertising remains a clear presence in retail outlets in Appalachian Ohio.

The impact of changes in tobacco control funding on healthcare expenditures in California, 2012–2016

ObjectiveThis study presents estimates of the impact of changes in California tobacco control funding on healthcare expenditures for 2012–2016 under four funding scenarios.MethodsSmoking prevalence is projected using a cointegrated time...

National trends in Aboriginal and Torres Strait Islander smoking and quitting, 1994–2008

To describe the trends in the prevalence of smoking, quitting and initiation among Aboriginal and Torres Strait Islander men and women aged 18 years and over. Analysis of responses to smoking questions in national Indigenous surveys in 1994, 2002, 2004 and 2008. Male Indigenous smoking prevalence fell significantly from 58.5% in 1994 to 52.6% in 2008, an absolute decrease of 0.4 (CI 0.1-0.7)% per year, with the same decline in remote and non-remote areas. Female smoking fell from 51.0% to 47.4%, with markedly different changes in remote and non-remote areas. In non-remote areas, there was an absolute decrease in female smoking of 0.5 (CI 0.2-0.9)% per year, but in remote areas, female smoking increased by 0.4 (CI 0.0-0.8)% per year. From 2002 to 2008, the percentage of ever-smokers who had quit (quit ratio) increased absolutely by 1% per year in both men and women, remote and non-remote areas. Results about trends in initiation were inconclusive. Health Minister Roxon has committed to halving the Indigenous smoking prevalence by 2018, and has dramatically increased Indigenous-specific funding and activity in tobacco control. The reported historical trends in this paper are encouraging as they occurred at a time when there was little such tobacco control activity focused on Aboriginal and Torres Strait Islander people. However, to meet the Minister's goal, Indigenous smoking prevalence will need to fall more than six times as quickly as occurred from 1994 to 2008.

Can social and community service organisations embrace tobacco control for their disadvantaged clients?

High smoking rates among the disadvantaged lead to inequalities in health, quality-of-life and financial well-being. Non-government social and community service organisations (SCSO) are a promising setting for tobacco control interventions targeting disadvantaged smokers. Financial grants were provided to twenty SCSO in New South Wales to support multi-level changes in service culture, smoking related policies and cessation support between 2007 and 2009. Evaluation was conducted using a mixed-methods approach that included key informant interviews, document analysis and staff survey data. SCSO working with disadvantaged clients can feasibly implement tobacco control activities, including smoking-related policy changes and cessation support. Tobacco control activities were generally acceptable to staff and clients, and staff pessimism regarding their clients' ability to quit reduced, as did the acceptability of staff smoking with their clients. Improvements in levels of organisational support for cessation training and resources, smoking policies and provision of free nicotine replacement therapy (NRT) were reported. Within mental health SCSO there was a positive response from staff to cessation support, financial benefits of quitting and the role of NRT. The evaluation pointed to the acceptability and feasibility of engaging disadvantaged smokers by SCSO, and that tobacco policy and attitude changes can be achieved by small investments, such as grant programs.

A Decade of Tobacco Control Efforts in New Zealand (1996-2006): Impacts on Inequalities in Census-Derived Smoking Prevalence

Smoking prevalence in New Zealand is highly related to socioeconomic disadvantage and ethnicity, with particularly high smoking prevalence among the Māori population. In the 10-year period from 1996 to 2006, a range of tobacco control activities were implemented in New Zealand. Uniquely in New Zealand, the national census has regularly included questions on smoking status. The purpose of this paper is to inform policy by examining the relationships between smoking prevalence and age, sex, socioeconomic position, and ethnicity, comparing data from the 1996 and 2006 national censuses. Socioeconomic deprivation was measured using the year-specific NZDep index of socioeconomic deprivation for small areas, based on 9 variables from the relevant census. Ethnicity (Māori, Pacific, and European & Other) was assessed using self-definition. Smoking information from each census is stratified by age group, sex, NZDep, and ethnicity. The strong relationship between small-area socioeconomic deprivation and smoking prevalence remained unchanged in New Zealand over the decade 1996-2006. Smoking prevalence continued to be associated with Māori ethnicity independently of small-area socioeconomic deprivation. Smoking prevalence reduced modestly between 1996 and 2006 but increased in some age/sex/ethnic/deprivation groups. The findings of this analysis provide information to support the design and implementation of tobacco control policies in New Zealand over the next 10 years and suggest that current tobacco control policies need to be strengthened and additional, more carefully targeted, measures implemented.

A Smoke-Free Paso del Norte: impact over 10 years on smoking prevalence using the Behavioral Risk Factor Surveillance System.

We assessed the impact of a tobacco control initiative over 10 years on cessation and prevention. We examined 2000-2009 Behavioral Risk Factor Surveillance System cases of a metropolitan statistical area (MSA) with systematic tobacco control efforts throughout the decade (El Paso, TX) and 2 comparison MSAs similar in size and population with less coordinated tobacco control efforts (Austin-Round Rock, TX and San Antonio, TX). Yearly, El Paso exhibited a 6% increase in the prevalence of former smokers, a 6% decrease in prevalence of daily smokers, and a 7% decrease in the prevalence of established smoking (≥ 100 cigarettes per lifetime and currently smoking); we did not observe similar trends in the comparison MSAs. There was no change in the prevalence of nondaily smokers in any of the MSAs. The coordinated tobacco control activities in El Paso are related to cessation among daily smokers and prevention of established smoking at the population level but have not stimulated cessation among nondaily smokers. Comprehensive tobacco control should focus more on not only daily smokers but also nondaily smokers.

Tobacco smoking in China: Prevalence, disease burden, challenges and future strategies

About one-third of the world's tobacco is produced and consumed in China. Despite existing tobacco control policies and activities, the prevalence of smoking in China remains high with 350 million smokers and 740 million passive smokers. Furthermore, smoking rates in the young population and in females are increasing. The number of deaths attributed to tobacco use has reached 1.2 million per year, whereas the death toll is expected to rise to 2 million annually by 2025. Sociocultural factors favouring smoking initiation, lack of awareness among the public about the hazards of smoking, weak support from the government and strong resistance from the tobacco industry are major reasons for the lack of effectiveness of current tobacco control measures. Effective intervention efforts are urgently required. Commitments from the government are crucial in tobacco control. Firm action should be taken on tobacco control issues at multiple levels including a reduction in tobacco supply, increased tobacco taxation, increased education, tobacco advertising limitations, decreased second-hand smoke exposure and smoking cessation support. The health-care community should also play a leading role in anti-tobacco campaigns and take a more active role in smoking cessation programmes.