Centre for Population Health Sciences
University of Edinburgh
A systematic review of the effectiveness of policies and interventions to reduce socio-economic inequalities in smoking among adults.
Final Report May 2013
Amanda Amos
Tamara Brown
Stephen Platt
SILNE - Tackling socio-economic inequalities in smoking: learning from natural experiments by time trend analyses and cross-national comparisons
Project team
Amanda Amos, Professor of Health Promotion
Tamara Brown, Research Fellow
Stephen Platt, Professor of Health Policy Research
Centre for Population Health Sciences
School of Molecular, Genetic and Population Health Sciences
The University of Edinburgh
Medical School
Teviot Place
Edinburgh
Scotland
EH8 9AG
Phone: (+44)-(0)131-650-3237
Fax: (+44)-(0)131-650-6909
Acknowledgements
The project team would like to thank members of the SILNE project and members of the European Network for Smoking and Tobacco Prevention (ENSP) who helped in the search for grey literature. In particular we would like to thank Gera Nagelhout, researcher at STIVORO and Maastricht University (CAPHRI), the Netherlands for identifying four Dutch reports on mass media campaigns and kindly providing synopses in English.
Table of Contents
EXECUTIVE SUMMARY 5
1 Introduction 10
1.1 Background 10
1.2 Aims and objectives 12
2 Methods 12
2.1 Search strategy 12
2.2 Study selection 13
Study selection process 13
Inclusion criteria 14
Data extraction 16
Quality assessment 16
Data synthesis 16
3 Results 18
3.1 Introduction 18
3.2 Smoking restrictions in workplaces, enclosed public places, cars and homes. 21
3.2.1 Smoking restrictions in workplaces 24
3.2.2 Smoking restrictions in enclosed public places 33
3.2.3 Smoking restrictions in cars 54
3.3 Increases in price/tax of tobacco products 64
3.4 Controls on advertising, promotion and marketing of tobacco 85
3.5 Mass media campaigns 94
3.5.1 Mass media cessation campaigns 97
3.5.2 Mass media campaigns to promote calls to Quitlines and use of NRT 119
3.6 Multiple policies 131
3.7 Settings based interventions 136
3.7.1 Community 137
3.7.2 Workplace 141
3.7.3 Hospitals 143
3.8 Population-level cessation support interventions 146
3.8.1 National Quitlines 146
3.8.2 UK NHS Smoking Cessation Services 146
3.8.3 New Zealand General Practice Smoking Cessation Services 152
4 Discussion 154
4.1 Future research 165
5 Conclusions 166
6 References 168
7 APPENDICES 177
7.1 Appendix A Search strategies: electronic searches, handsearching and searching for grey literature 177
7.2 Appendix B WHO European countries and other stage 4 countries 189
7.3 Appendix C Inclusion/exclusion form 190
7.4 Appendix D Included studies 192
7.5 Appendix E Excluded studies 203
7.6 Appendix F Data extraction 207
7.7 Appendix G Quality assessment 426
7.8 Appendix H Equity Impact 433
7.9 Appendix I Summary of Equity Impact 480
EXECUTIVE SUMMARY
· Smoking is the single most important preventable cause of premature mortality in Europe and a major cause of inequalities in health. Adult smoking prevalence in the EU is declining but the social gradient in smoking is not. Reducing inequalities in smoking is therefore a key public health priority.
· Some progress has been made in tobacco control in many EU countries in recent years. However, there is considerable variation in the strength and comprehensiveness of tobacco control policies and their implementation.
· While there is good evidence on which tobacco control policies are effective in reducing adult smoking, little is known about what is effective in reducing inequalities in smoking.
· The aim of this report was to undertake a systematic review of the effectiveness of population-level policies and interventions to reduce socioeconomic inequalities in smoking in adults.
· The systematic review included primary studies involving adults (aged 18 years and older), published between January 1995 and January 2013, which assessed the impact of population-level policies and interventions by socioeconomic status (SES).
· The search strategy included searches of 10 electronic databases, papers ‘in press’ in four key journals, and contacting tobacco control experts for grey literature.
· Any type of tobacco control or other policy intervention, of any length of follow-up, with at least one smoking-related outcome was included, such as quit attempts, intentions to quit, exposure to second-hand smoke (SHS) and social norms/attitudes, was included.
· All primary studies based in a WHO Europe country or non-European countries at stage 4 of the tobacco epidemic were eligible. SES variables included education, income and occupation.
· A quality assessment tool was adapted to enable appraisal of the diverse range of intervention types and study designs encompassed in the included studies. The results are presented in the form of a narrative synthesis and according to intervention type.
· The equity impact(s) of each intervention/policy on smoking-related outcomes was assessed as either being: positive (reduced inequality), neutral (no difference by SES), negative (increased inequality), mixed (equity impact varied by SES measure and/or gender, setting, country and/or outcome measure) or unclear (not possible to assess the equity impact).
· One hundred and sixteen studies were included which evaluated 129 interventions/policies. Electronic searches produced 93 studies and 23 studies were identified through hand-searching, grey literature, key reviews and contacting experts.
· There was considerable variation in study design and quality. More than half the studies were carried out in the USA. Eighteen studies were carried out in the UK, mostly assessing the impact of smokefree legislation and NHS smoking cessation services, and eight in the Netherlands. This limited geographical coverage raises concerns about the generalisability and potential transferability to, or relevance for, countries in Europe with different social and cultural contexts and/or levels of tobacco control.
· The types of interventions/policies included were: smoking restrictions in cars, homes, workplaces and other public places (44 studies); increases in the price/tax of tobacco products (27); controls on advertising, promotion and marketing of tobacco (9); mass media campaigns including promoting the use of quitlines and NRT (30); multiple policy interventions (4); settings-based interventions including community, workplace and hospital (7); and population-level cessation support interventions (8). Eight studies included more than one type of policy/intervention.
· Only one relevant study of non-tobacco control interventions and polices (e.g. education, employment, social policy) was identified.
· The equity impacts of the 129 included interventions/policies were: 33 positive, 35 neutral, 38 negative, 6 mixed and 17 unclear.
· Twenty-six of the 29 neutral equity impact studies showed similar beneficial impacts across SES groups. Three studies, all community-based, found no significant intervention effect for any SES group.
· Some trends in equity effect by type of intervention/policy emerged. Over half of the studies of increases in the price/tax of cigarettes were associated with a positive equity impact. More than half the smokefree policy/legislation studies (these included voluntary and partial smokefree policies) were associated with a negative equity impact, making up the bulk of the negative studies. There were no negative studies for controls on advertising, marketing and promotion of tobacco products. Four of the six studies of UK NHS cessation services had a positive equity impact. There was no clear trend for the equity impact of mass media campaign studies.
· Smokefree policies and legislation (44 studies) - The evidence suggests that partial, voluntary or regional adoption of smokefree policies can increase socioeconomic inequalities in protection from secondhand smoke (SHS) exposure. The recent increase in smokefree policies in bars, restaurants and workplaces in Australia, Canada, UK and USA has had a positive equity impact, reducing inequalities in policy coverage by SES, with low SES worksites and public places catching up in adopting total smokefree policies.
National comprehensive smokefree legislation reduces SHS exposure, increases quit attempts and has positive population health effects. By definition such policies have a positive equity impact in removing inequalities in policy coverage. However, only two of the 22 studies that evaluated national smokefree legislation demonstrated an overall positive equity impact using other outcome measures. The national smokefree legislation in Scotland, Wales and Northern Ireland did not displace smoking into the home. Although smoking restrictions in the car and home increased following this legislation, there was no change in smoking-related inequality. SES differences remained, with a greater proportion of lower SES adults smoking in the car/home.
· Price and tax increases (27 studies) - The majority of studies on price/tax increases on cigarettes were associated with a positive equity impact and had the most consistent of all the policy results. Overall, lower SES adults appear more responsive to price/tax increases in terms of larger price elasticities compared with higher SES adults in respect of reducing prevalence and/or consumption. Most of the econometric studies did not measure longer-term effects on quitting, cross-border sales or smokers’ price reducing strategies which may differ by SES.
· Controls on advertising, marketing and promotion (9 studies) - Most of the studies were on health warnings and found that they had neutral (3) or positive (2) equity effects. Only three studies looked at restrictions on marketing and were associated with neutral equity impacts.
· Mass media cessation campaigns (18 studies) - There was no consistent equity impact for these studies, but only three studies had an overall positive equity impact. A Dutch multimedia campaign targeted at smokers with an intention to quit smoking and with a focus on lower educated smokers, was associated with a positive equity impact for campaign awareness. A tobacco control paid media campaign in the US was associated with a more rapid decline in smoking prevalence among low SES women. The EX mass media campaign (TV element) increased cessation-related cognitions only among those with less than a high-school education and increased quit attempts only among those with less than a high-school education.
Different types of media messages appeared to have differential impacts by SES, with some limited evidence that emotionally evocative, testimonial and graphic messages were more likely to be equity positive. The media format of the campaign and the mechanisms of engagement also varied by SES.
· Mass media quitline and NRT campaigns (12 studies) - all the studies found increases in calls to quitlines. However, the equity impact was inconsistent, though three of the five positive equity impact studies promoted free NRT.
· Multiple policies (4 studies) - The evidence suggests that different elements of multiple policies may impact differentially by SES. For example, people with lower incomes were more affected by cigarette tax increases, whereas people with higher incomes may have been more affected by voluntary smokefree policies. The evidence also suggests that, within and across different SES groups, the impact of multiple tobacco control policies can vary by age, gender and the type of smoking-related outcome.
· Settings-based interventions (7 studies) - the types of interventions included were very variable in approach and had inconsistent equity impacts. The only intervention in the review to address wider social determinants of inequality (community approach) had no impact on quitting rates.
· Comprehensive smoking cessation services (8 studies) – Four of the six UK NHS smoking cessation services studies had a positive equity impact. These studies found that the relatively higher reach of services among low SES smokers more than compensated for the relatively lower quit rates in low SES smokers. The UK smoking cessation service is unique in Europe in the extent of its population coverage. However, these findings may be relevant to increasing the positive equity impact of cessation support in other European countries. A study of a General Practitioner delivered smoking cessation service in New Zealand was effective in reducing smoking prevalence, but there was no evidence of a significant impact on area-based inequalities (neutral equity impact). The only quitline study produced an unclear equity impact.
· While 116 studies were identified, only limited conclusions can be drawn about which types of tobacco control interventions are likely to reduce inequalities in smoking. The clearest and most consistent evidence of a positive equity impact was for price/tax increases.
1 Introduction
1.1 Background
Smoking prevalence rates differ substantially within European countries according to people’s educational level, occupational class and income level; and smoking is a major cause of socioeconomic inequalities in mortality in the European Union (EU). The patterning of smoking by socioeconomic status (SES) within a country reflects the stage of the tobacco epidemic in that country. In general smoking is initially taken up by higher SES groups, followed by lower SES groups. Higher SES groups are then the first to show declines in smoking, followed by lower SES groups.1 The tobacco epidemic is also gendered in that men first take up smoking, followed by women.2 Most countries in the EU are characterised as being in the fourth (last) stage of the epidemic. In these countries lower SES groups have higher rates of smoking prevalence, higher levels of cigarette consumption and lower rates of quitting.3;4 Some EU countries are at a slightly earlier stage. This is reflected in the differential patterning of smoking by SES and gender, where the clear relationship between low SES and smoking found in men is only starting to emerge in women.
Since the 1990s, many European countries have intensified tobacco control policies and introduced measures such as legislation on smokefree public places, bans on tobacco promotion and tax increases. There is good evidence on what is effective in reducing adult smoking amongst the general population. A review of the international evidence by the World Bank in 20035 identified six cost-effective policies which they concluded should be prioritised in comprehensive tobacco control programmes:
· price increases through higher taxes on cigarettes and other tobacco products including measures to combat smuggling
· comprehensive smokefree public and work places
· better consumer information including mass media campaigns
· comprehensive bans on the advertising and promotion of all tobacco products, logos and brand names
· large, direct health warnings on cigarette packs and other tobacco products
· treatment to help dependent smokers stop, including increased access to medications
These priorities have been endorsed by World Health Organisation (WHO)6 and form the basis of the Framework Convention on Tobacco Control (FCTC), the first international public health treaty.7