Smoking Cessation Support in Social and Community Service Organizations: Potential Activities, Barriers, and Facilitators.

INTRODUCTION: Social and Community Service Organizations (SCSOs) are a potential setting to reach and support people with a low socioeconomic position who smoke, yet smoking cessation is not widely supported by SCSO professionals. AIMS AND METHODS: This study aims to identify SCSO professionals' (1) potential activities to support smoking cessation and (2) barriers and facilitators in undertaking these activities. Between July and November 2022, semi-structured interviews were conducted with 21 professionals recruited through SCSOs in Amsterdam North, including participation workers, welfare workers, parent and child counselors, budget coach, debt counselor, welfare work, community sports, and community center coordinators. Data were analyzed using a thematic approach. RESULTS: Eight activities were identified that could support the client either directly (ie, recognizing smoking clients, discussing smoking and smoking cessation, referring clients, providing smoking cessation counseling, offering help around services) or indirectly (ie, collaboration with relevant network partners, implementing smoke-free environments, enhancing professional skills). Various barriers and facilitators were identified related to the (1) client and their environment (ie, clients' readiness and social environment), (2) interaction between professional and client (ie, topic sensitivity), (3) professional (ie, professional is non-smoker, knowledge, and self-efficacy), (4) professionals' work environment (ie, necessity, responsibility, priority, and time), and (5) smoking cessation services (ie, availability of appropriate services and referral process). CONCLUSIONS: There is potential for SCSO professionals to support smoking cessation, but several barriers hinder their efforts. To address these barriers, it is essential to take into account the factors that SCSO professionals believe facilitate the provision of smoking cessation support. IMPLICATIONS: This study provides insight into how the potential of SCSOs in Amsterdam North to support smoking cessation efforts among people with a low socioeconomic position can be harnessed. Barriers were found at multiple levels (client, professional, client-professional interaction, and organizational) and these findings imply that stakeholders across these levels will need to prioritize smoking cessation to facilitate and stimulate SCSO professionals in supporting smoking cessation. A concrete action would be to offer SCSO professionals additional training in conversational skills to discuss smoking. As a prerequisite, easily accessible and suitable smoking cessation services should be available in the neighborhood.

A Novel Methodological Approach to Measure Linear Trends in Health Inequalities: Proof of Concept With Adolescent Smoking in Europe.

We describe a new method for presenting and interpreting linear trends in health inequalities, and present a proof-of-concept analysis of inequalities in smoking among adolescents in Europe. We estimated the regression line of the assumed linear relationship between smoking prevalence in low- and high-socioeconomic status (SES) youth over time. Using simulation, we constructed a 95% confidence interval (CI) for the smoking prevalence in low-SES youth for when this would be 0% in high-SES youth, and we calculated the likelihood of eradicating smoking inequality (<5% for both low and high SES). This method was applied to data on adolescents aged 15-16 years (n = 250,326) from 23 European countries, derived from the 2003-2015 European Survey Project on Alcohol and Other Drugs. Smoking prevalence decreased more slowly among low- than among high-SES adolescents. The estimated smoking prevalence was 9.4% (95% CI: 6.1, 12.7) for boys and 5.4% (95% CI: 1.4, 9.2) for girls with low SES when 0% with high SES. The likelihood of eradicating smoking inequality was <1% for boys and 37% for girls. We conclude that this novel methodological approach to trends in health inequalities is feasible in practice. Applying it to trends in smoking inequalities among adolescents in Europe, we found that Europe is currently not on track to eradicate youth smoking across SES groups.

Ex ante evaluation of the impact of tobacco control policy measures aimed at the point of sale in the Netherlands.

INTRODUCTION: The Netherlands aims to implement stricter tobacco control policies targeting the retail environment. This paper is an ex ante policy evaluation of the potential impact of the current tobacco display and advertising ban as well as future tobacco sales bans on tobacco outlet visibility and availability. METHODS: Between September 2019 and June 2020, all potential tobacco retailers in four Dutch cities (Amsterdam, Eindhoven, Haarlem and Zwolle) were visited and mapped using Global Positioning System. For each retailer selling tobacco, we completed a checklist on the visibility of tobacco products and advertising. Expected reductions in tobacco outlet visibility and availability were calculated per policy measure in absolute numbers (percentage or percentage point decrease) as well as density and proximity. RESULTS: Out of 870 tobacco outlets, 690 were identified with visible tobacco products/advertising. The display ban in supermarkets and small outlets (respectively) is expected to decrease the number (-15; -42 percentage points), outlet density per 10 000 capita (-0.9; -2.6) and proximity in metres (+27 m; +400 m) of outlets with visible products/advertising. The upcoming bans on vending machines and sales in supermarkets are expected to decrease the number (-12%; -31%), density (-0.7; -1.9) and proximity (+12 m; +68 m) of tobacco outlets. Further changes in the number, density and proximity (respectively) of tobacco outlets may be achieved with future sales bans in petrol stations (-7%; -0.4; +60 m) and particularly with a ban on sales in small outlets (-43%; -2.7; +970 m). CONCLUSION: A display ban and a sales ban in small outlets will contribute most to reducing tobacco outlet visibility and availability, assuming that no market shift towards other tobacco outlets will take place.

Bans on tobacco display, advertising and vending machines in the Netherlands: impact on visibility of tobacco and compliance of retailers.

INTRODUCTION: Visibility of tobacco products at retail tobacco outlets is associated with smoking initiation. To address this, across 2020-2022 the Netherlands banned tobacco product displays, advertisements and vending machines in the retail environment. Tobacco/vape specialist shops were exempted. This study assessed the impact of these policies on tobacco visibility in the retail environment and retailer compliance. METHODS: We conducted observational audits of all tobacco outlets in four Dutch cities (Amsterdam, Haarlem, Eindhoven and Zwolle) between 2019 and 2022 (before and after policy implementation), assessing visibility of tobacco products and advertisements, compliance and remaining sources of tobacco visibility (after implementation). We described results by location and outlet type. RESULTS: The number of tobacco outlets with any tobacco advertising or product visibility declined from 530 to 267 (-50%). Among outlets not exempt from the ban, the number with visibility declined from 449 to 172 (-62%), with lower postban visibility in petrol stations (12%) and supermarkets (6%) than small shops (47%). Visibility among tobacco/vape shops increased by 17%. Tobacco product displays remained the main source of visibility. 93% of tobacco vending machines were removed. Maps showed that non-compliance is concentrated in Amsterdam's city centre and more evenly distributed in other cities. CONCLUSION: The bans on tobacco display and tobacco advertising halved the visibility of tobacco in the retail environment, and the vending machine ban practically eradicated vending machines. To further reduce tobacco visibility, violations in small shops should be addressed and tobacco visibility should be regulated in currently exempt tobacco specialist shops.

Socioeconomic differences in tobacco outlet presence, density, and proximity in four cities in the Netherlands.

BACKGROUND: Previous studies found that tobacco outlets were unevenly distributed by area socioeconomic status (SES). However, evidence from continental Europe is limited. This study aims to assess differences in tobacco outlet presence, density and proximity by area SES in the Netherlands. METHODS: All tobacco outlets in four Dutch cities (Amsterdam, and medium-sized cities Eindhoven, Haarlem, and Zwolle) were mapped between September 2019 and June 2020. We estimated associations between average property value of neighbourhoods (as an indicator of SES, grouped into quintiles) and (1) tobacco outlet presence in the neighbourhood (yes/no), (2) density (per km2), and (3) proximity to the closest outlet (in meters), using logistic and linear regression models. RESULTS: 46% of neighbourhoods contained at least one tobacco outlet. Tobacco outlets were mostly situated in city centres, but the distribution of tobacco outlets varied per city due to differences in urban structures and functions. In the medium-sized cities, each quintile higher neighbourhood-SES was associated with lower tobacco outlet presence (OR:0.71, 95%CI:0.59;0.85), lower density (B:-1.20 outlets/km2, 95%CI:-2.20;-0.20) and less proximity (B:40.2 m, 95%CI 36.58;43.83). Associations were the other way around for Amsterdam (OR:1.22, 95%CI:1.05;1.40, B:3.50, 95%CI:0.81;6.20, and B:-18.45, 95%CI:-20.41;-16.49, respectively). Results were similar for most types of tobacco outlets. CONCLUSION: In medium-sized cities in the Netherlands, tobacco outlets were more often located in low-SES neighbourhoods than high-SES. Amsterdam presented a reverse pattern, possibly due to its unique urban structure. We discuss how licensing might contribute to reducing tobacco outlets in low-SES neighbourhoods.

Tobacco Retailers' Support for Point-of-Sale Tobacco Control Policies in England: Association Study of Retailers' Perceived Importance of Tobacco Sales, Contact with the Tobacco Industry, and the Perceived Impact of the Policy.

INTRODUCTION: Political acceptability and successful implementation of tobacco control policies at the point of sale may depend on, among other factors, tobacco retailers' level of support for these policies. This study quantified the level of support among small tobacco retailers for four point-of-sale tobacco control policies and its association with three predictors. METHODS: We used cross-sectional telephone survey data (August 2019) of 508 small tobacco retailers in England. Weighted logistic regression analyses examined associations between support for the product display ban, price display ban, minimum pack size, and standardized packaging, and self-reported importance of tobacco sales for a business, contact with the tobacco industry, and the perceived impact of the policy on their overall business. RESULTS: A majority of retailers support minimum pack size (66%), product display ban (65%), price display ban (54%), and standardized packaging (55%). The importance of tobacco sales was not associated with support for the policies. More frequent contact with the tobacco industry was associated with higher odds of support for minimum pack size (OR: 2.01, 95%CI:1.25-3.21), but not with the other three policies. The negative perceived impact of the policies, compared with neutral, was associated with 1.5 to three times lower odds of support for all four policies. CONCLUSION: In England, small retailers' support for the four point-of-sale tobacco control policies varied between 54% and 66%. Support seems unrelated to the perceived importance of tobacco sales, and contact with the tobacco industry, but seems strongly related to the perceived impact of tobacco control policies on their business. IMPLICATIONS: This study shows that small independent retailers' support for point-of-sale (PoS) tobacco control policies is fairly high and that the lack of support voiced by retail trade organizations is not representative of the views of retailers in England. Support rates may be further improved by addressing retailers' perceptions of the impact of policies on their business. Support was not related to retailers' perceived importance of tobacco sales for their business and their contact with the tobacco industry. The industry rhetoric is not supported by our findings, as the majority of small independent retailers in England support tobacco control regulations.

Association Between Smoke-Free Legislation in Hospitality Venues and Smoking Behavior of Young People: A Systematic Review.

INTRODUCTION: While evaluations of indoor smoke-free legislation have demonstrated major public health benefits among adults, their impact on the smoking behavior of young people remains unclear. Therefore, we performed a systematic review of the association between smoke-free legislation in hospitality venues and smoking behavior of young people. AIMS AND METHODS: A systematic search was conducted in PubMed, Scopus, and Embase in June 2020. We searched for studies that assessed the association of any form of smoke-free legislation in any hospitality venue (eg, bar and restaurant) with a smoking behavior outcome (eg, initiation and current smoking) among young people (aged 10-24 years). . RESULTS: Our search yielded 572 articles of which 31 were screened based on full-text and 9 were included in the analysis. All studies were published between 2005 and 2016. The majority of studies used a quasi-experimental design. Four studies evaluated smoke-free legislation in hospitality venues specifically. Two studies reported that comprehensive, but not weaker, smoke-free legislation decreases progression to established smoking. Two other studies provided mixed results on which level of comprehensiveness of legislation would be effective, and which smoking outcomes would be affected. Five studies evaluated legislation that also included other workplaces. Out of these five studies, three studies found significant decreases in current smoking, smoking frequency, and/or smoking quantity, whereas two other studies did not. CONCLUSIONS: Most of the studies found that smoke-free legislation in hospitality venues is associated with a decrease in smoking behavior among young people. Their results indicate the need for comprehensive smoke-free legislation without exemptions. IMPLICATIONS: This is the first systematic review to provide insight into the relationship between smoke-free legislation in hospitality venues and smoking behavior of young people. Our findings show that there is a need for comprehensive smoke-free legislation without exemptions (such as designated smoking areas).

Self-reported exposure of Indonesian adolescents to online and offline tobacco advertising, promotion and sponsorship (TAPS).

OBJECTIVES: To quantify tobacco advertising, promotion and sponsorship (TAPS), self-reported exposure from online and offline platforms among adolescents in Indonesia. METHODS: A cross-sectional school-based survey was conducted in 2017. In total, 2820 students aged 13-18 years were recruited from 22 schools in seven cities. Respondents reported TAPS exposure on online (online news, YouTube, Facebook, Twitter and Instagram), and offline platforms (broadcast media, tobacco industry sponsored events and outdoor advertising). For outdoor advertisements, respondents reported the locations where they were exposed. We used multilevel analysis to assess TAPS exposure by age, gender, smoking status and city. RESULTS: Online TAPS exposure was high on Instagram (29.6%), and relatively low on Twitter (7.3%). Offline TAPS exposure was high via television (74.0%), billboards (54.4%) and live music events (46.2%), but low on radio (6.9%). In all cities, outdoor advertising was seen particularly on the streets and in minimarkets. Overall, TAPS exposure was higher among older than younger adolescents, boys than girls, and smokers than non-smokers. CONCLUSIONS: Overall TAPS exposure was high on both online and offline platforms. Banning online tobacco advertising, in addition to complete bans on outdoor and television advertising, is essential to adequately protect Indonesian adolescents from tobacco advertising.

Tobacco retail licencing systems in Europe.

Tobacco retailer licencing has been recommended as an effective tobacco control strategy. In most European countries, however, retailers do not need a licence to sell tobacco products. We aimed to stimulate a discussion on the potential for tobacco retail licencing in Europe by describing (1) potential public health benefits, (2) licencing methods and (3) barriers and success factors in adoption of licencing systems. There is limited scientific evidence, but tobacco retail licencing may reduce smoking in three ways: (1) improved enforcement of and compliance to existing point-of-sale tobacco control policies (eg, minimum age of sale), (2) a reduction in the number and/or density of tobacco retail outlets and (3) denormalisation of tobacco. Licencing systems may take diverse forms. Systems may make licences expensive, and set criteria for purchasing a licence and retaining the licence after first purchase. In Europe, licencing systems have been implemented in Finland, Hungary, France, Italy and Spain. Licencing in Finland and Hungary was adopted for public health reasons; in Finland, with strong public support. In France, Italy and Spain, tobacco sales were state-monopolised, driven by economic motives. The cases of Norway and Scotland show that adoption of retail licencing may fail when political support is insufficient and tobacco retailers organise opposition with support from the tobacco industry. In conclusion, tobacco retailer licencing is a promising method to contribute to tobacco control efforts. Placing tobacco retailer licencing in a child protection framework may help generate the strong political and public support needed to effectively adopt licencing systems.

The role of health literacy in the association between academic performance and substance use.

BACKGROUND: To address social inequalities in adolescent substance use and consequent disparities in health, it is important to identify the mechanisms of the association between substance use and academic performance. We study the role of health literacy (HL) in the association between academic performance and weekly smoking, monthly alcohol use and cannabis ever-use among adolescents in Europe. METHODS: SILNE-R school survey data, which was collected in 2016-17 with paper-and-pencil-method from Hanover (GE), Amersfoort (NL) and Tampere (FI), were used (N = 5088, age 13-19). Health Literacy for School-aged Children instrument was used to assess students' HL. Logistic regression analyzed the association of substance use with academic performance and HL, separately and in the same model. Linear and multinomial logistic regression analyzed the association between academic performance and HL. RESULTS: Poor academic performance compared with high was associated with smoking [odds ratio (OR) 3.94, 95% confidence interval (CI) 2.83-5.49], alcohol use (OR: 2.94, 95% CI: 2.34-3.68) and cannabis use (OR: 2.56, 95% CI: 1.89-3.48). Poor HL was also associated with each substance use (with ORs of 2.32, 1.85 and 1.29). HL was positively associated with academic performance (ß = 1.04, 95% CI: 0.89-1.20). The associations between academic performance and substance use were only slightly attenuated after controlling for HL. CONCLUSIONS: Academic performance and HL were both determinants of substance use, confirming their role in tackling the disparities in substance use. However, HL did not demonstrably mediate the association between academic performance and substance use. A wider set of factors needs to be tackled to address emerging social inequalities in adolescent substance use.

The Association Between Tobacco Outlet Density and Smoking Among Young People: A Systematic Methodological Review.

AIM: Evidence on the association between tobacco outlet density and proximity and smoking behavior among youth is inconsistent, which may be due to methodological problems in some studies. We assessed the association of outlet density or proximity with smoking behavior among young people while taking into account the methodological quality of studies. METHODS: MEDLINE, EMBASE, and Google Scholar were systematically searched for studies on the relationship between outlet density or proximity and smoking behavior among 12- to 25-year-olds, published between 1997 and 2017. Methodological quality of the included studies was evaluated independently by two reviewers. RESULTS: Twenty studies were included in the review. The quality assessment identified five primary sources of potential bias: overadjustment for mediators (problems identified in 14 studies), underadjustment for confounders (six studies), poor statistical model fit (four studies), selection bias (three studies), and misclassification of exposure measurements (eight studies). Four studies were of high methodological quality. In studies with relatively high quality, 10 associations were reported, of which seven were nonsignificant, two positive, and one negative. Similarly, the complete body of evidence demonstrated mostly nonsignificant associations, but a larger proportion of positive associations than negative. CONCLUSION: Although there is some support for a positive direction, current literature does not provide consistent evidence for a positive association between outlet density and smoking among youth. This is not necessarily due to bias in specific studies, but more to fundamental challenges in study design and exposure measurements. These issues need to be addressed in future studies using more rigorous methods. IMPLICATIONS: Our findings suggest that, although there is some evidence for a positive association, current scientific literature does not provide consistent support to claim an effect of tobacco outlet density or proximity on youth smoking. This underlines the need for more research with improved methodology. There is a need for quasiexperimental studies, in which the outlet density changes substantially, studies measuring the actual exposure of youth to tobacco outlets, and qualitative research on the mechanisms underlying any association.

School tobacco policies and adolescent smoking in six European cities in 2013 and 2016: A school-level longitudinal study.

Assessment of the effectiveness of school tobacco policies (STPs) in reducing adolescent smoking remains inconclusive. Previous studies took insufficient account of different dimensions of STPs, the different views of students and staff, and policy changes over time. This study assessed how a multidimensional STP, as perceived by students and staff, was associated with adolescent smoking over time in six European cities. The SILNE and SILNE-R surveys were conducted among students (n = 18,502) and staff (n = 438) in 38 schools in 2013 and 2016. Three dimensions (comprehensiveness, enforcement, and communication) were assessed and we calculated total STP scores. Multilevel logistic regressions estimated associations of STPs with adolescent smoking on and just outside school premises and with weekly smoking. Further analyses estimated associations between 2013 and 2016 STP changes and smoking outcomes in 2016, controlling for STP and smoking prevalence in 2013. On average, there were few increases in STP scores over time. Greater STP enforcement, as perceived by students, was associated with lower odds of weekly smoking (OR:0.93, 95%CI:0.89-0.97) and of smoking on school premises (OR:0.80, 95%CI:0.72-0.90). Higher total STP scores were associated with lower odds of smoking on school premises (OR:0.76, 95%CI:0.67-0.86), but not of smoking just outside premises or smoking weekly. Greater increases in STP scores over time were associated with lower odds of smoking on school premises in 2016 (OR:0.65, 95%CI:0.47-0.89). Well-enforced STPs may help reduce adolescent smoking at school. Schools should be supported in adopting comprehensive policies that also extend to the surroundings of their premises.

Impact of the "Stoptober" Smoking Cessation Campaign in England From 2012 to 2017: A Quasiexperimental Repeat Cross-Sectional Study.

INTRODUCTION: Since 2012, England has an annual "Stoptober" campaign for collective smoking cessation. Our aim was to assess (1) overall impact of the Stoptober campaign on quit attempts over its first 6 years, (2) consistency of impact over the campaign years, and (3) the role of the campaign budget. METHODS: We used data of 51 399 adult smokers and ex-smokers in 132 repeat cross-sectional monthly surveys in England, 2007-2017. In a quasiexperimental design, adjusted logistic regression analyses compared past-month quit attempt rate between (1) October and other months in the year, between 2007-2011 and 2012-2017; (2) October and other months, across years 2012-2017; and (3) October and other months, between high-budget (2012-2015) and low-budget Stoptober campaigns (2016-2017). Bayes factors (BF) differentiated insensitive data and absence of an effect. RESULTS: (1) In 2012-2017, quit attempts were more prevalent in October versus other months (odds ratio [OR]: 1.24, 95% confidence interval [CI]: 1.00 to 1.53), whereas similar in 2007-2011 (OR: 0.95, 95% CI: 0.76 to 1.18; BF = 0.2); data were somewhat insensitive but supported this difference (OR: 1.30, 95% CI: 0.97 to 1.75; BF = 2.1). (2) In 2012-2017, quit attempt prevalence ranged from 3.1% to 8.5% in October and 5.0% to 7.3% in other months. The difference between October and other months was large in 2012 (absolute unadjusted difference of 3.3%; OR: 1.92, 95% CI: 1.23 to 2.98) and 2015 (3.1%; OR: 1.84, 95% CI: 1.14 to 2.95), but small in 2013-2014 and 2016-2017 (0.36 < BF < 1.02). (3) Data were somewhat insensitive but supported interaction with campaign budget (OR: 1.50, 95% CI: 0.92 to 2.44; BF = 2.2). DISCUSSION: In 2012-2017, there appears to have been an increase in past-month quit attempts during October in England. The increase was inconsistent across Stoptober campaigns and appears to have been greater when the campaign budget was higher. IMPLICATIONS: Over the first 6 years of Stoptober campaigns, there appears to have been an overall increase in past-month quit attempts during October in England, and the data imply that a sufficiently high budget contributes to greater impact of the Stoptober campaign. These findings encourage the further spread of the Stoptober campaign to other countries. Future research should clarify how increased quit attempts as a consequence of Stoptober translate into quit success and which of Stoptober's ingredients were most important in increasing quit attempts, especially among vulnerable groups.

An Increase in the Tobacco Age-of-Sale to 21: For Debate in Europe.

A debate on the adoption of a tobacco age-of-sale of 21 in Europe has not occurred, with the recent exception of the United Kingdom. The current legally set age of 18 years is proving to be inadequate as adolescents continue to access cigarettes. Tobacco 21 laws have the potential to further limit access to cigarettes by minors. We believe that soon the time will be ripe for this discussion to spread throughout Europe, specifically among countries that have adopted a smoke-free generation movement.

Trends in Attempts to Quit Smoking in England Since 2007: A Time Series Analysis of a Range of Population-Level Influences.

AIM: To quantify population-level associations between quit attempts and factors that have varied across 2007-2017 in England. METHODS: Data from 51 867 past-year smokers participating in the Smoking Toolkit Study (a monthly cross-sectional survey of individuals aged 16+) were aggregated over an 11-year period. Time series analysis was undertaken using ARIMAX modeling. The input series were: (1) prevalence of smoking reduction using (a) e-cigarettes and (b) nicotine replacement therapy; (2) prevalence of roll-your-own tobacco use; (3) prevalence of (a) smoking and (b) non-daily smoking; (4) mass media expenditure; (5) average expenditure on smoking; (6) characteristics in the form of (a) prevalence of high motivation to quit, (b) average age, (c) proportion from lower social grades, and (d) average number of cigarettes smoked; and (7) implementation of tobacco control policies. RESULTS: There was a decline in the prevalence of quit attempts from 44.6% to 33.8% over the study period. The partial point-of-sale ban was associated with a temporary increase in quit attempt prevalence (Badjusted = 0.224%; 95% confidence interval [CI] 0.061 to 0.388). Quit attempts were positively associated with the prevalence of high motivation to quit (Badjusted = 0.165%;95% CI 0.048 to 0.282) and negatively associated with the mean age of smokers (Badjusted = -1.351%; 95% CI -2.168 to -0.534). All other associations were nonsignificant. CONCLUSION: Increases in the prevalence of high motivation to quit was associated with higher prevalence of attempts to quit smoking, while an increase in the mean age of smokers was associated with lower prevalence. The introduction of the partial point-of-sale ban appeared to have a temporary positive impact. IMPLICATIONS: This study provides insight into how monthly changes in a wide range of population-level factors are associated with changes in quit attempts over an extended time period in a country with a strong tobacco control climate. The findings suggest a need for intervention or policy to stimulate quit attempts in older smokers. Otherwise, increases in the mean age of a smokers appears likely to undermine wider efforts to promote quit attempts in a population.

Youth Access to Cigarettes Across Seven European Countries: A Mixed-Methods Study.

BACKGROUND: Despite widespread age-of-sale restrictions on tobacco, adolescents continue to obtain cigarettes and experiment with smoking. This mixed-methods study aimed to understand how European adolescents access cigarettes and how the policy context may influence this process, using a realist evaluation approach. This is the first study to assess access to cigarettes across various European contexts. METHODS: A survey of 4104 students was combined with qualitative data from focus groups among 319 adolescents aged 14-19 across seven European countries. Data were synthesized to explore mechanisms via which young people obtain cigarettes despite age-of-sale restrictions. RESULTS: While purchasing cigarettes from supermarkets was widely regarded as difficult, many participants purchased cigarettes from noncompliant retailers (often in smaller shops or cafes). Other contra-mechanisms included circumventing age checks, proxy purchases, and/or social sources. Dominant forms of access differed across the seven contexts, with direct purchases more common where perceived enforcement was low (eg, Belgium) and proxy purchases more important where perceived enforcement of age-of-sale laws was high (eg, Finland). The effectiveness of age-of-sale restrictions in reducing youth access appears to be influenced by a range of contextual factors including retailer compliance, the availability of vending machines, and the specific minimum age-of-sale. CONCLUSIONS: Our findings illustrate the relevance of programme theory in understanding the contra-mechanisms that undermine the effectiveness of age-of-sale laws in discouraging youth smoking. Young people's access to cigarettes could be further limited by addressing these contra-mechanisms, including an increase in the legal sales age (particularly in Belgium), banning vending machines, and strengthening enforcement. IMPLICATIONS: Despite widespread implementation of age-of-sale laws, a substantial proportion of minors continue to access cigarettes. Young people use a number of contra-mechanisms to circumvent age-of-sale restrictions. These include accessing cigarettes via social sources, proxy sales or by circumventing age checks. Our findings show that in contexts where perceived enforcement of age-of-sale restrictions is high, young people are more reliant on irregular forms of access such as proxy sales. Young people's access to cigarettes may be further reduced by policy interventions that address these contra-mechanisms-for example, banning vending machines, strengthening enforcement of age-of-sale laws, and increasing the minimum age-of-sale.

The Association Between Smoke-Free School Policies and Adolescents' Perceived Antismoking Norms: Moderation by School Connectedness.

INTRODUCTION: Many European schools implement smoke-free school policies (SFSPs). SFSPs may decrease adolescent smoking by causing adolescents to perceive stronger antismoking norms, yet there exists no quantitative evidence that indicates for which norms and for whom such effects may occur. This study therefore assessed to what extent adolescents' perceived antismoking norms among best friends, teachers, and society at large were associated with SFSPs, and whether these associations were moderated by adolescents' level of school connectedness. AIMS AND METHODS: Survey data were collected in 2016/2017 on 10,653 adolescents aged 14-16 years old and 315 staff members in 55 schools from seven European cities. Associations of adolescent-perceived SFSPs and staff-reported SFSPs with best friend, teacher, and societal antismoking norms were estimated in multilevel logistic regression models, adjusted for demographics and school-level smoking prevalence. We tested for interaction between school connectedness and SFSPs. RESULTS: Adolescent-perceived SFSPs were positively associated with antismoking norms by teachers (odds ratio [OR]: 1.46, 95% confidence interval [CI]: 1.15-1.85), were negatively associated with antismoking norms by best friends (OR: 0.81, 95% CI: 0.67-0.99), but were not significantly associated with antismoking norms by society at large (OR: 0.87, 95% CI: 0.74-1.02). All interaction tests between adolescent-perceived SFSPs and school connectedness were nonsignificant. Staff-reported SFSPs were not associated with any norm and showed no significant interaction with school connectedness. CONCLUSIONS: We found that SFSPs are associated with adolescents' perception of more antismoking norms by teachers, but less antismoking norms by best friends, irrespective of adolescents' level of school connectedness. IMPLICATIONS: Smoke-free school policies, just as many other tobacco control policies, are assumed to foster adolescents' perception of antismoking norms. Still, current evidence does not demonstrate which antismoking norms may be influenced by SFSPs and whether this influence is equal for adolescents with different levels of school connectedness. This study suggests that SFSPs foster adolescents' perception of antismoking norms by teachers, but may concurrently lead to the perception of less antismoking norms by best friends, irrespective of adolescents' school connectedness. SFSPs may therefore need to be complemented with interventions that target antismoking norms in adolescent peer groups.

Impact of a ban on the open display of tobacco products in retail outlets on never smoking youth in the UK: findings from a repeat cross-sectional survey before, during and after implementation.

BACKGROUND: In the UK, a ban on the open display of tobacco products at the point of sale (POS) was phased in between 2012 and 2015. We explored any impact of the ban on youth before, during and after implementation. METHODS: A repeat cross-sectional in-home survey with young people aged 11-16 years old in the UK was conducted preban (2011, n=1373), mid-ban (2014, n=1205) and postban (2016, n=1213). The analysis focuses on the never-smokers in the sample (n=2953 in total). Preban, we quantified the associations of noticing cigarettes displayed at POS and cigarette brand awareness with smoking susceptibility. We measured any change in noticing cigarettes displayed at POS, cigarette brand awareness and smoking susceptibility between preban, mid-ban and postban. Postban, we assessed support for a display ban, perceived appeal of cigarettes and perceived acceptability of smoking as a result of closed displays. RESULTS: Preban, noticing cigarettes displayed at POS (adjusted OR [AOR]=1.97, 95% CI 1.30 to 2.98) and higher brand awareness (AOR=1.15, 95% CI 1.03 to 1.29) were positively associated with smoking susceptibility. The mean number of brands recalled declined from 0.97 preban to 0.69 postban (p<0.001). Smoking susceptibility decreased from 28% preban to 23% mid-ban and 18% postban (p for trend <0.001). Postban, 90% of never-smokers supported the display ban and indicated that it made cigarettes seem unappealing (77%) and made smoking seem unacceptable (87%). CONCLUSIONS: Both partial and full implementation of a display ban were followed by a reduction in smoking susceptibility among adolescents, which may be driven by decreases in brand awareness.

The Use of the Alcohol Use Disorders Identification Test - Consumption as an Indicator of Hazardous Alcohol Use among University Students.

BACKGROUND: Hazardous drinking among students in higher education is a growing concern. The alcohol use disorders identification test (AUDIT) is the gold standard screening instrument for hazardous drinking in the adult population, for which an abbreviated version has been developed: the -AUDIT-Consumption (AUDIT-C). Currently, there's no gold standard for identifying hazardous drinking among students in higher education and little evidence regarding the concurrent validity of the AUDIT-C as a screening instrument for this group. This study investigated the concurrent validity of the AUDIT-C in a sample of university students and suggests the most appropriate cutoff points. METHODS: Cross-sectional data of health surveys from 5,401 university and university of applied sciences in the Netherlands were used. Receiver operating characteristic (ROC) curves, sensitivity, specificity, and positive and negative predictive values for different cutoff scores of AUDIT-C were calculated for the total sample and for subgroups stratified by age, gender, and educational level. AUDIT-score ≥11 was used as the criterion of hazardous and harmful drinking. RESULTS: Twenty percent of students were hazardous and harmful drinkers. The area under the ROC curve was 0.922 (95% CI 0.914-0.930). At an AUDIT-C cutoff score of ≥7, sensitivity and specificity were both >80%, while other cutoffs showed less balanced results. A cutoff of ≥8 performed better among males, but for other subgroups ≥7 was most suitable. CONCLUSION: AUDIT-C seems valid in identifying hazardous and harmful drinking students, with suggested optimal cutoffs 7 (females) or 8 (males). However, considerations regarding avoiding false-positives versus false-negatives, in relation to the type of intervention following screening, could lead to selecting different cutoffs.

Impact of removing point-of-sale tobacco displays on smoking behaviour among adolescents in Europe: a quasi-experimental study.

BACKGROUND: An increasing number of European countries implemented a point-of-sale (PoS) display ban on tobacco products. This study assessed the association between PoS display bans in Europe and adolescent smoking and perceived accessibility of tobacco, 2-6 years after PoS display ban implementation. METHODS: In a quasi-experimental design, we compared individuals in countries that did and countries that did not implement a PoS display ban, before and after implementation. We used repeated cross-sectional data of 174 878 15-year-old and 16-year-old adolescents from 25 countries from the 2007, 2011 and 2015 European Survey Project on Alcohol and Other Drugs surveys. Multilevel logistic regression models examined smoking behaviour (regular smoking vs other) and perceived access (easy vs difficult) as a function of display ban implementation and controlled for survey year, gender, parental education and implementation of other tobacco control policies. Interaction with gender was tested. RESULTS: The implementation of a PoS display ban was associated with a 15% larger drop in the odds of regular smoking (OR 0.85, 95% CI 0.79 to 0.91), but was not significantly associated with perceived accessibility of tobacco (OR 0.97, 95% CI 0.892 to 1.03). Associations were similar in males and females (cross-level interactions of gender with display ban were not statistically significant for either outcome). CONCLUSION: The implementation of PoS display bans in Europe was associated with a stronger decrease in regular smoking among adolescents. This decrease does not appear to be driven by a decreasing accessibility of tobacco, but might be caused by further de-normalisation of tobacco as a result of PoS display bans.