Challenges and successes in the sustainment of Dutch community-level smoking cessation interventions for residents with a low socioeconomic position.

BACKGROUND: When health promotion interventions are implemented, the gains are often short-lived, as interventions are seldom successfully sustained. The current study explores how and under what conditions community-level smoking cessation interventions for people with a lower socioeconomic position can be sustained, drawing upon interventions delivered in Dutch neighbourhoods with a predominantly low socioeconomic position. METHODS: We conducted 15 semi-structured interviews with key stakeholders from three Dutch community-level smoking cessation interventions implemented at least three years prior. The topic guide was developed based on the Determinants of Innovation framework and transcripts were analysed thematically. RESULTS: We identified several factors that promote the sustainment of smoking cessation community-level interventions: 1) structural, long-term funding through the commitment of health insurers and policy makers; 2) continued stakeholder enthusiasm and involvement; 3) training and time for professionals to discuss smoking cessation, thereby also increasing the visibility of the intervention for professionals and residents; 4) integrating the intervention with existing initiatives and adapting it to be compatible with current working practices of executive staff; and 5) planning for sustainment as a team from the outset. CONCLUSIONS: The current study highlights challenges and successes in intervention sustainment for people with a lower socioeconomic position. Lack of structural funding was one of the most challenging aspects for intervention sustainment in which health insurers and policy makers can play an important role. Planning for sustainment from the outset would enable intervention coordinators to consider the abovementioned factors early on. This need not be done alone but can best be discussed within a team of stakeholders.

Trends in Individualized Affordability of Factory-Made Cigarettes: Findings of the 2008-2020 International Tobacco Control Netherlands Surveys.

INTRODUCTION: Cigarette affordability, the price of tobacco relative to consumer income, is a key determinant of tobacco consumption. AIMS AND METHODS: This study examined trends over 12 years in individualized factory-made cigarette affordability in the Netherlands, and whether these trends differed by sex, age, and education. Data from 10 waves (2008-2020) of the International Tobacco Control Netherlands Surveys were used to estimate individualized affordability, measured as the percentage of income required to buy 100 cigarette packs (Relative Income Price [RIP]), using self-reported prices and income. The higher the RIP, the less affordable cigarettes are. Generalized estimating equation regression models assessed trends in individualized affordability over time and by sex, age, and education. RESULTS: Affordability decreased significantly between 2008 and 2020, with RIP increasing from 1.89% (2008) to 2.64% (2020) (p ≤ .001), except for 2008-2010, no significant year-on-year changes in affordability were found. Lower affordability was found among subgroups who have a lower income level: Females (vs. males), 18-24 and 25-39-year-olds (vs. 55 years and over) and low or moderate-educated individuals (vs. highly educated). Interactions between wave and education (p = .007) were found, but not with sex (p = .653) or age (p = .295). A decreasing linear trend in affordability was found for moderately (p = .041) and high-educated (p = .025), but not for low-educated individuals (p = .149). CONCLUSIONS: Cigarettes in the Netherlands have become less affordable between 2008 and 2020, yet this was mostly because of the decrease in affordability between 2008 and 2010. There is a need for more significant increases in tax to further decrease affordability. IMPLICATIONS: Our findings suggest that cigarettes have become less affordable in the Netherlands between 2008 and 2020. But, this appears to be the result of a steep decrease in affordability between 2008 and 2010. Affordability was lower among groups who have on average lower incomes (females, young adults, and low- and moderate-educated individuals), and differences in trends across education levels could be explained by per capita income changes. Our individualized measure indicated lower affordability than published aggregate affordability estimations. Future tax increases should be large enough to result in a lower affordability.

Price minimizing behaviours by smokers in Europe (2006-20): evidence from the International Tobacco Control Project.

BACKGROUND: Effectiveness of tobacco taxation can be undermined through smokers applying price-minimizing behaviours rather than quitting or reducing consumption. Common price-minimizing strategies are buying cheaper tobacco [discount brands or roll-your-own (RYO) tobacco], bulk buying and cross-border purchasing. This study analyses trends in and factors associated with such behaviours in four European countries from 2006 to 2020. METHODS: Data came from adult smokers participating in the International Tobacco Control (ITC) Surveys conducted between 2006 and 2020 in England (9 waves, n = 768-4149), France (4 waves, n = 1415-1735), Germany (5 waves, n = 513-1515) and the Netherlands (10 waves, n = 1191-2177). Country-specific generalized estimating equation regression models were fit to assess trends in smoking RYO tobacco, discount brands, bulk buying and cross-border purchasing within the European Union. RESULTS: Buying discount brands or RYO tobacco was the most common strategy in all countries, except France. Except for buying discount brands, estimates of price-minimizing behaviours were highest in France (2019: RYO = 27.2%, discount brands = 17.3%, bulk buying = 34.1%, cross-border purchasing = 34.2%), and lowest in Germany (2018: RYO = 18.6%, discount brands = 43.7%, bulk buying = 8.0%, cross-border purchasing = 9.8%). Direction and magnitude of trends differed by country, and behaviour. Young smokers were less likely to buy in bulk. Low-income and low-education smokers were more likely to purchase RYO tobacco or discount brands. The association with discount brands was not found for French low-income smokers. CONCLUSIONS: Smoking cheaper tobacco is the most prevalent price-minimizing strategy in three countries (England, Germany and Netherlands), and more prevalent among low-income individuals. Harmonizing prices across products and countries would reduce switching to cheaper tobacco.

Demand for Factory-Made Cigarettes and Roll-Your-Own Tobacco and Differences Between Age and Socioeconomic Groups: Findings From the International Tobacco Control Netherlands Survey.

INTRODUCTION: Macroeconomic studies have shown that young individuals who smoke, and have a low socioeconomic status respond more strongly to price increases. Most of this evidence stems from research on factory-made (FM) cigarettes. With the rising popularity of roll-your-own (RYO) tobacco, there is a need for studies on cigarette demand that distinguish between both. AIMS AND METHODS: This study examined whether individual demand differed for FM and RYO tobacco, and across age, and socioeconomic (income and education) groups. Purchase tasks for FM and RYO cigarettes were included in the 2020 International Tobacco Control (ITC) Netherlands Survey. Adults who smoke daily (n = 1620) stated how many cigarettes they would smoke in 24 hours across eight prices. Four demand indices were derived: intensity (consumption at zero costs), alpha (rate of change in elasticity), Pmax (turning point elasticity), and breakpoint (lowest price where consumption equals zero). The indices were tested for subgroup differences. RESULTS: Individuals who smoke RYO tobacco indicated higher intensity, and greater alpha than individuals who smoke FM cigarettes. Participants aged 25-39 had lower Pmax, and 18-24 year olds displayed higher breakpoints. Participants with low income displayed higher intensity, and lower Pmax than other income groups. No associations were found with education. CONCLUSIONS: Individuals who smoke RYO tobacco indicated higher price sensitivity than those smoking FM cigarettes, supporting the need to harmonize tobacco taxation. Taxation may be especially beneficial to reducing consumption among individuals with a low income or smoke RYO tobacco. Substantially higher prices are needed in the Netherlands to achieve the desired results. IMPLICATIONS: Individuals who smoke daily were willing to pay substantially higher prices than the current market prices, indicating the room and need for much higher taxation levels. Demand for RYO tobacco was more sensitive to price changes than demand for FM cigarettes. Taxation should be raised at equivalent rates for FM and RYO cigarettes. Taxation appears to be especially effective in reducing consumption among people who smoke RYO tobacco and low-income individuals. It remains important to combine increased taxation with other tobacco control measures.

How Financial Incentives Increase Smoking Cessation: A Two-Level Path Analysis.

INTRODUCTION: Financial incentives effectively increase smoking cessation rates, but it is unclear via which psychological mechanisms incentives influence quit behavior. The current study examines how receiving financial incentives for smoking cessation leads to quitting smoking and investigates several mediators and moderators of that relationship. AIMS AND METHODS: The study sample consisted of 604 tobacco-smoking employees from 61 companies in the Netherlands who completed a baseline and follow-up questionnaire. The current study is a secondary analysis from a cluster randomized trial where employees received smoking cessation group counseling at the workplace. Participants in the intervention group additionally received financial incentives of €350 in total for 12-month continuous smoking abstinence. We used a two-level path analysis to test a model that assesses the effects of financial incentives through smoking cessation program evaluation, medication use, nicotine replacement use, attitudes, self-efficacy, and social influences on quit success. We additionally tested whether an individual's reward responsiveness moderated the influence of incentives on quit success. RESULTS: The effect of financial incentives on quit success was mediated by a higher self-efficacy. Financial incentives were also associated with a higher use of cessation medication. A more positive program evaluation was related to higher self-efficacy, more social influence to quit, and more positive attitudes about quitting. The results did not differ significantly by individual reward responsiveness. CONCLUSIONS: The results of the current study suggest that financial incentives may be used to increase medication use and self-efficacy for quitting smoking, which offers an indirect way to increase successful smoking cessation. IMPLICATIONS: (1) This is the first study investigating via which psychological pathways financial incentives for quitting smoking can lead to long-term quit success. (2) The results showed a path between financial incentives and a higher likelihood of medication use. Incentives may encourage smokers to use medication in order to increase their chance of quitting smoking and receive the reward. (3) There was a path from financial incentives to quit success via a higher self-efficacy. (4) The effects of financial incentives did not depend on individual reward responsiveness.

Cost-effectiveness and cost-utility analysis of a work-place smoking cessation intervention with and without financial incentives.

AIMS: To perform an economic evaluation of a work-place smoking cessation group training programme with incentives compared with a training programme without incentives. DESIGN: A trial-based cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) from a societal perspective and an employer's perspective. SETTING: Sixty-one companies in the Netherlands. PARTICIPANTS: A total of 604 tobacco-smoking employees. INTERVENTION AND COMPARATOR: A 7-week work-place smoking cessation group training programme. The intervention group earned gift vouchers of €350 for 12 months' continuous abstinence. The comparator group received no incentives. MEASUREMENTS: Online questionnaires were administered to assess quality of life (EQ-5D-5 L) and resource use during the 14-month follow-up period (2-month training period plus 12-month abstinence period). For the CEA the primary outcome measure was carbon monoxide (CO)-validated continuous abstinence; for the CUA the primary outcome was quality-adjusted life years (QALY). Bootstrapping and sensitivity analyses were performed to account for uncertainty. Incremental cost-effectiveness ratio (ICER) tables were used to determine cost-effectiveness from a life-time perspective. FINDINGS: Of the participants in the intervention group, 41.1% had quit smoking compared with 26.4% in the control group. From a societal perspective with a 14-month follow-up period, the ICER per quitter for an intervention with financial incentives compared with no incentives was €11 546. From an employer's perspective, the ICER was €5686. There was no significant difference in QALYs between the intervention and control group within the 14-month follow-up period. The intervention was dominated by the comparator in the primary analysis at a threshold of €20 000 per QALY. In the sensitivity analysis, these results were uncertain. A life-time perspective showed an ICER of €1249 (95% confidence interval = €850-2387) per QALY. CONCLUSIONS: Financial incentives may be cost-effective in increasing quitting smoking, particularly from a life-time perspective.

Implementation of Financial Incentives for Successful Smoking Cessation in Real-Life Company Settings: A Qualitative Needs Assessment among Employers.

Randomized studies have shown that financial incentives can significantly increase the effect of smoking cessation treatment in company settings. Evidence of effectiveness alone is, however, not enough to ensure that companies will offer this intervention. Knowledge about the barriers and facilitators for implementation in the workplace is needed, in order to develop an implementation strategy. We performed a qualitative needs assessment among 18 employers working in companies with relatively many employees with a low educational level, and our study revealed priority actions that aim to improve the implementation process in these types of workplaces. First, employers need training and support in how to reach their employees and convince them to take part in the group training. Second, employers need to be convinced that their non-smoking employees will not consider the incentives unfair, or they should be enabled to offer alternative incentives that are considered less unfair. Third, the cost-effectiveness of smoking cessation group trainings including financial incentives should be explained to employers. Finally, smoking cessation should become a standard part of workplace-based health policies.

Does free or lower cost smoking cessation medication stimulate quitting? Findings from the International Tobacco Control (ITC) Netherlands and UK Surveys.

OBJECTIVE: To investigate whether mentioning free or lower cost smoking cessation medication as a trigger for thinking about quitting is related to higher medication use, more quit attempts and quit success, and whether these associations are modified by education and income. METHODS: Data were derived from the 2013 and 2014 surveys of the International Tobacco Control Netherlands (n=1164) and UK (n=768) cohort. Logistic regression analyses were used to assess associations between mentioning in 2013 that free/lower cost smoking cessation medication was a trigger for thinking about quitting smoking and the use of medication, quit attempts and smoking cessation in 2014. RESULTS: 37.0% of smokers in the UK and 24.9% of smokers in the Netherlands mentioned free/lower cost medication as a trigger for thinking about quitting. Smokers who mentioned this trigger were more likely to have used cessation medication during a quit attempt both in the UK (OR=4.19, p<0.001) and in the Netherlands (OR=2.14, p=0.033). The association between mentioning free/lower cost medication as a trigger for thinking about quitting and actual quit attempts was significant in the UK (OR=1.45, p=0.030), but not in the Netherlands (OR=1.10, p=0.587). There was no significant association with quit success. Associations did not differ across income and education groups. CONCLUSION: Free/lower cost smoking cessation medication may increase the use of cessation medication and stimulate quit attempts among smokers with low, moderate and high education and income.

Effect of a workplace-based group training programme combined with financial incentives on smoking cessation: a cluster-randomised controlled trial.

BACKGROUND: Financial incentives are potentially useful tools to aid smoking cessation, but robust evidence to support their efficacy, particularly in combination with other interventions (eg, group counselling), has not been reported. We aimed to investigate whether financial incentives combined with a smoking cessation group training programme (compared with a training programme with no incentives) organised at the workplace would increase 12-month abstinence rates in tobacco-smoking employees with different education and income levels. METHODS: This cluster-randomised controlled trial was done in the Netherlands with companies that offer a smoking cessation group training programme to all of their smoking employees. Eligible participants were tobacco-smoking employees and spouses of employees who were at least 18 years of age. Participants in the control group received a weekly 90-min session of smoking cessation group training for 7 weeks at the workplace; in addition to the group training, participants in the intervention group received vouchers for being abstinent (€50 at the end of the training programme, €50 3 months after completion of the programme, €50 after 6 months, and €200 after 12 months). Companies were randomly assigned by an independent research assistant to the intervention group or the control group with a digital randomisation programme, using a biased urn method. The primary outcome was carbon monoxide-validated continuous abstinence at 12 months. All randomised participants were included in the modified intention-to-treat analyses, with the exception of unavoidable loss (participants who had died or moved to an untraceable address (according to the Russell Standard), and in the sensitivity analyses, except the complete case analysis, which included only participants for whom all variables included in the model were not missing. This study is registered with the Dutch Trial Register, number NTR5657. FINDINGS: Between March 1, 2016, and March 1, 2017, 61 companies with 604 participating smokers were enrolled. 31 companies (319 smokers) were randomly assigned to the intervention group and 30 companies (285 smokers) to the control group. 12 months after finishing the smoking cessation programme, the proportion of individuals abstaining from smoking in the intervention group was significantly higher than that in the control group (131 [41%] of 319 vs 75 [26%] of 284; adjusted odds ratio 1·93, 95% CI 1·31-2·85, p=0·0009; adjusted for education level, income level, and Fagerström score). INTERPRETATION: Financial incentives in addition to a smoking cessation group training programme can significantly increase long-term smoking abstinence. The results of the current study could motivate employers to facilitate a workplace smoking cessation programme with financial incentives to help employees to quit smoking. FUNDING: Dutch Cancer Society.

Over-Time Impacts of Pictorial Health Warning Labels and their Differences across Smoker Subgroups: Results from Adult Smokers in Canada and Australia.

Introduction: This study examines patterns of change in different smoker subgroups' responses to new pictorial health warning labels (HWLs) over the initial, two year post-implementation period in Canada, where HWLs include package inserts with cessation messages, and Australia, where "plain" packaging (i.e., prohibition of brand imagery) was also implemented. Methods: Data were collected from online consumer panels in Canada (nsmokers = 3153; nobservations = 5826) and Australia (nsmokers = 2699; nobservations = 5818) from September 2012 to September 2014, with approximately 1000 adult smokers surveyed in each country every four months, using replenishment to maintain sample size. Data were analyzed using generalized estimating equation models where main effects and interactions among time, country, and socio-demographic factors on HWL responses (i.e., attention to HWLs; cognitive and behavioral responses to HWLs) were examined. Results: Over time, attention to HWLs declined but cognitive and forgoing responses to HWLs increased, in both Canada and Australia. In both countries, compared to smokers with low income and/or education, smokers with high income and/or education showed an increase over time in attention and cognitive responses to HWLs (p < .05). In Australia only, compared to older smokers, younger smokers showed less decline over time in attention and greater increase in cognitive and forgoing responses to HWLs (p < .001). Conclusions: Novel HWL policies in Canada and Australia appear effective in staving off "wear out" over the first 2 years after implementation, particularly amongst smokers who are from higher SES groups and, in Australia, who are younger. Implications: Previous research shows that the effects of health warning label (HWL) on smokers decline over time, but no studies to date have evaluated whether trends differ across socio-demographic groups. This study suggests that innovative policy configurations that combine prominent pictorial HWLs with inserts (Canada) and with "plain" packaging (Australia) may delay wear out over the first 2 years after implementation. While this study found evidence for wear out in attention to HWLs, other HWL responses (cognitive responses, forgoing cigarettes) actually increased over time, with greater increases amongst smokers with higher income and/or education.

Healthcare financing systems for increasing the use of tobacco dependence treatment.

BACKGROUND: Tobacco smoking is the leading preventable cause of death worldwide, which makes it essential to stimulate smoking cessation. The financial cost of smoking cessation treatment can act as a barrier to those seeking support. We hypothesised that provision of financial assistance for people trying to quit smoking, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts. This is an update of the original 2005 review. OBJECTIVES: The primary objective of this review was to assess the impact of reducing the costs for tobacco smokers or healthcare providers for using or providing smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use or prescription of smoking cessation treatment, or both, and on the number of smokers making a quit attempt (quitting smoking for at least 24 hours). We also assessed the cost effectiveness of different financial interventions, and analysed the costs per additional quitter, or per quality-adjusted life year (QALY) gained. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialised Register in September 2016. SELECTION CRITERIA: We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers, or both. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed the quality of the included studies. We calculated risk ratios (RR) for individual studies on an intention-to-treat basis and performed meta-analysis using a random-effects model. MAIN RESULTS: In the current update, we have added six new relevant studies, resulting in a total of 17 studies included in this review involving financial interventions directed at smokers or healthcare providers, or both.Full financial interventions directed at smokers had a favourable effect on abstinence at six months or longer when compared to no intervention (RR 1.77, 95% CI 1.37 to 2.28, I² = 33%, 9333 participants). There was no evidence that full coverage interventions increased smoking abstinence compared to partial coverage interventions (RR 1.02, 95% CI 0.71 to 1.48, I² = 64%, 5914 participants), but partial coverage interventions were more effective in increasing abstinence than no intervention (RR 1.27 95% CI 1.02 to 1.59, I² = 21%, 7108 participants). The economic evaluation showed costs per additional quitter ranging from USD 97 to USD 7646 for the comparison of full coverage with partial or no coverage.There was no clear evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%, 2311 participants).Full financial interventions increased the number of participants making a quit attempt when compared to no interventions (RR 1.11, 95% CI 1.04 to 1.17, I² = 15%, 9065 participants). There was insufficient evidence to show whether partial financial interventions increased quit attempts compared to no interventions (RR 1.13, 95% CI 0.98 to 1.31, I² = 88%, 6944 participants).Full financial interventions increased the use of smoking cessation treatment compared to no interventions with regard to various pharmacological and behavioural treatments: nicotine replacement therapy (NRT): RR 1.79, 95% CI 1.54 to 2.09, I² = 35%, 9455 participants; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%, 6321 participants; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65, I² = 75%, 9215 participants.There was evidence that partial coverage compared to no coverage reported a small positive effect on the use of bupropion (RR 1.15, 95% CI 1.03 to 1.29, I² = 0%, 6765 participants). Interventions directed at healthcare providers increased the use of behavioural therapy (RR 1.69, 95% CI 1.01 to 2.86, I² = 85%, 25820 participants), but not the use of NRT and/or bupropion (RR 0.94, 95% CI 0.76 to 1.18, I² = 6%, 2311 participants).We assessed the quality of the evidence for the main outcome, abstinence from smoking, as moderate. In most studies participants were not blinded to the different study arms and researchers were not blinded to the allocated interventions. Furthermore, there was not always sufficient information on attrition rates. We detected some imprecision but we judged this to be of minor consequence on the outcomes of this study. AUTHORS' CONCLUSIONS: Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting. There was no clear and consistent evidence of an effect on smoking cessation from financial incentives directed at healthcare providers. We are only moderately confident in the effect estimate because there was some risk of bias due to a lack of blinding in participants and researchers, and insufficient information on attrition rates.

How economic recessions and unemployment affect illegal drug use: A systematic realist literature review.

BACKGROUND: Economic recessions may influence illegal drug use via different mechanisms, for example increased use due to more psychological distress or decreased use due to lower incomes and purchasing power. This paper reviews the literature on how economic recessions and unemployment affect the use of illegal drugs among adults. METHODS: We conducted a systematic realist literature review, which is an explanatory method that aims to understand underlying mechanisms that connect an event to an outcome in a specific context. A systematic search was performed in EconLit, Embase, Medline, PsycINFO, SocIndex, and Web of Science for studies examining mechanisms explaining how recessions or unemployment affect illegal drug use. RESULTS: We synthesized 28 studies published between 1990 and 2015. Most evidence (17 studies) was found for the counter-cyclical mechanism that recessions and unemployment increase psychological distress, which increases drug use. Mainly supportive evidence for this mechanism was found in several high quality studies, in different contexts, and in a diverse number of countries and samples. In contrast, decreased income did not seem to decrease drug use (10 studies). Little evidence was available on the non-working time mechanism (4 studies) and the social exclusion mechanism (5 studies). Most of the studies that did examine these latter mechanisms confirmed the hypothesized counter-cyclical associations. CONCLUSION: The current evidence is in line with the hypothesis that drug use increases in times of recession because unemployment increases psychological distress which increases drug use. During times of recession, psychological support for those who lost their job and are vulnerable to drug use (relapse) is likely to be important.

Inequalities in the Impact of National Reimbursement of Smoking Cessation Pharmacotherapy and the Influence of Injunctive Norms: An Explorative Study.

In 2011, the Dutch government reimbursed smoking cessation pharmacotherapy with behavioral therapy for quitting smokers. We investigate whether inequalities in the use of pharmacotherapy change and, if not, whether this is due to a relatively positive injunctive norm in lower socioeconomic status (SES) groups. A total of 75,415 participants aged ≥15 years from the Dutch Continuous Survey of Smoking Habits, 2009-2012, were considered with the following measures: SES (education/income), injunctive norm (mostly acceptable/neutral/mostly unacceptable), period (2011/all other years), and pharmacotherapy use (yes/no). The proportion of low SES smokers compared with high SES smokers making quit attempts with pharmacotherapy did not differ significantly. The injunctive norm of low SES smokers differed significantly from high SES smokers and nonsmokers of all SES levels. Low income smokers with mostly acceptable injunctive norms were significantly less likely to make quit attempts using pharmacotherapy than those with a neutral or less accepting injunctive norm. The significantly lower use of pharmacotherapy in quit attempts in low income smokers with a positive injunctive norm toward smoking may partly underlie the lack of uptake of reimbursed pharmacotherapy in low SES smokers.

Attrition analysed in five waves of a longitudinal yearly survey of smokers: findings from the ITC Netherlands survey.

BACKGROUND: Attrition bias can affect the external validity of findings. This article analyses attrition bias and assesses the effectiveness of replenishment samples on demographic and smoking-related characteristics for the International Tobacco Control Netherlands Survey, a longitudinal survey among smokers. METHODS: Attrition analyses were conducted for the first five survey waves (2008-12). We assessed, including and excluding replenishment samples, whether the demographic composition of the samples changed between the first and fifth waves. Replenishment samples were tailored to ensure the sample remained representative of the smoking population. We also constructed a multivariable survival model of attrition that included all five waves with replenishment samples. RESULTS: Of the original 1820 respondents recruited in 2008, 46% participated again in 2012. Demographic differences between waves due to attrition were generally small and replenishment samples tended to minimize them further. The multivariable survival analysis revealed that only two of the 10 variables analysed were significant predictors of attrition: a weak effect for gender (men dropped out more often) and weak to moderate effects for age (respondents aged 15-24 years dropped out more than aged 25-39 years, who dropped out more than those aged 40+ years). CONCLUSIONS: Weak to moderate attrition effects were found for men and younger age groups. This information could be used to minimize respondent attrition. Our findings suggest that sampling weights and tailored replenishment samples can effectively compensate for attrition effects. This is already being done for the International Tobacco Control Netherlands Survey, including the categories that significantly predicted attrition in this study.

Educational differences in the impact of pictorial cigarette warning labels on smokers: findings from the International Tobacco Control (ITC) Europe surveys.

OBJECTIVE: To examine (1) the impact of pictorial cigarette warning labels on changes in self-reported warning label responses: warning salience, cognitive responses, forgoing cigarettes and avoiding warnings, and (2) whether these changes differed by smokers' educational level. METHODS: Longitudinal data of smokers from two survey waves of the International Tobacco Control (ITC) Europe Surveys were used. In France and the UK, pictorial warning labels were implemented on the back of cigarette packages between the two survey waves. In Germany and the Netherlands, the text warning labels did not change. FINDINGS: Warning salience decreased between the surveys in France (OR=0.81, p=0.046) and showed a non-significant increase in the UK (OR=1.30, p=0.058), cognitive responses increased in the UK (OR=1.34, p<0.001) and decreased in France (OR=0.70, p=0.002), forgoing cigarettes increased in the UK (OR=1.65, p<0.001) and decreased in France (OR=0.83, p=0.047), and avoiding warnings increased in France (OR=2.93, p<0.001) and the UK (OR=2.19, p<0.001). Warning salience and cognitive responses decreased in Germany and the Netherlands, forgoing did not change in these countries and avoidance increased in Germany. In general, these changes in warning label responses did not differ by education. However, in the UK, avoidance increased especially among low (OR=2.25, p=0.001) and moderate educated smokers (OR=3.21, p<0.001). CONCLUSIONS: The warning labels implemented in France in 2010 and in the UK in 2008 with pictures on one side of the cigarette package did not succeed in increasing warning salience, but did increase avoidance. The labels did not increase educational inequalities among continuing smokers.

Trends and socioeconomic differences in policy triggers for thinking about quitting smoking: Findings from the International Tobacco Control (ITC) Europe Surveys.

INTRODUCTION: The aim of the current study is to investigate trends and socioeconomic differences in policy triggers for thinking about quitting in six European countries. METHODS: Data were derived from all available survey waves of the International Tobacco Control (ITC) Europe Surveys (2003-2013). France conducted three survey waves (n=1420-1735), Germany three waves (n=515-1515), The Netherlands seven waves (n=1420-1668), Ireland three waves (n=582-1071), Scotland two waves (n=461-507), and the rest of the United Kingdom conducted seven survey waves (n=861-1737). Smokers were asked whether four different policies (cigarette price, smoking restrictions in public places, free or lower cost medication, and warning labels on cigarette packs) influenced them to think about quitting. Generalized Estimating Equation (GEE) models were estimated for each country. RESULTS: Cigarette price was mentioned most often in all countries and across all waves as trigger for thinking about quitting. Mentioning cigarette price and warning labels increased after the implementation of price increases and warning labels in some countries, while mentioning smoking restrictions decreased after their implementation in four countries. All studied policy triggers were mentioned more often by smokers with low and/or moderate education and income than smokers with high education and income. The education and income differences did not change significantly over time for most policies and in most countries. CONCLUSIONS: Tobacco control policies work as a trigger to increase thoughts about quitting, particularly in smokers with low education and low income and therefore have the potential to reduce health inequalities in smoking.

Trends and socioeconomic differences in roll-your-own tobacco use: findings from the ITC Europe Surveys.

OBJECTIVES: To examine if exclusive Roll-Your-Own (RYO) tobacco use relative to factory-made (FM) cigarette use has been rising over time, to determine the extent to which economic motives and perceptions that RYO cigarettes are less harmful act as primary motivations for use, and to examine the association of income and education with the level of RYO tobacco use among smokers in four European countries. METHODS: Data were obtained from the International Tobacco Control (ITC) Europe Surveys, and a cohort sample of 7070 smokers from the Netherlands, Germany, France and UK were interviewed between June 2006 and December 2012. Generalised estimating equations (GEE) were used to assess trends in RYO use, and whether RYO consumption varied by socioeconomic variables. RESULTS: Exclusive RYO use over the study period has increased significantly in the UK from 26.4% in 2007 to 32.7% in 2010 (p<0.001); France from 12.2% in 2006 to 19.1% in 2012 (p<0.001); and Germany from 12.7% in 2007 to 18.6% in 2011 (p=0.031), with increased borderline significantly in the Netherlands (31.7% to 34.3%, p=0.052), from 2008 to 2010. Over three-quarters of users in each of the study countries indicated that lower price was a reason why they smoked RYO. Just over a fourth of smokers in the UK, less than a fifth in France, and around a tenth in Germany and the Netherlands believed that RYO is healthier. Compared with exclusive FM users, exclusive RYO users were more likely to have lower incomes and lower education. CONCLUSIONS: Effective tobacco tax regulation is needed in the European Union and elsewhere to eliminate or reduce the price advantage of RYO tobacco. Additional health messages are also required to correct the misperception that RYO tobacco is healthier than FM cigarettes.

Was the media campaign that supported Australia's new pictorial cigarette warning labels and plain packaging policy associated with more attention to and talking about warning labels?

BACKGROUND: Population-level interventions can possibly enhance each other's effects when they are implemented simultaneously. When the plain packaging policy was implemented in Australia, pictorial health warning labels (HWLs) on cigarette packages were also updated and a national mass media campaign was aired. This study examined whether smokers who recalled the media campaign reported more attention to and talking about HWLs. METHODS: Longitudinal survey data was obtained among Australian adult smokers, aged 18 years and older, from an online consumer panel. One survey wave was conducted before (September 2012) and two waves were conducted after (January 2013 and May 2013) the interventions. The sample was replenished to maintain a sample size of 1000 participants at each wave. Generalized Estimating Equations analyses were performed. RESULTS: Compared to wave 1, attention to HWLs increased at wave 2 (b=0.32, SE=0.06, p<0.001), but not at wave 3 (b=0.10, SE=0.08, p=0.198). Talking about HWLs increased over time (IRR=1.82, 95% CI=1.58-2.09 and IRR=1.25, 95% CI=1.05-1.47, at wave 2 and wave 3 respectively). Campaign recall was significantly associated with more attention to HWLs (b=0.29, SE=0.05, p<0.001) and with more talking about HWLs (IRR=1.17, 95% CI=1.06-1.29) with similar effects across waves 2 and 3. CONCLUSIONS: Recall of the campaign was associated with more attention to and talking about HWLs. When adjusting for campaign recall, there was still an increasing trend in attention and talking. This suggests that the media campaign and the new packaging and labeling policies had independent and positive effects on attention to and talking about HWLs.

Socioeconomic inequalities in adolescent smoking across 35 countries: a multilevel analysis of the role of family, school and peers.

BACKGROUND: Tobacco-related heath inequalities are a major public health concern, with smoking being more prevalent among lower socioeconomic groups. The aim of this study is to investigate the mechanisms leading to socioeconomic inequalities in smoking among 15-year-old adolescents by examining the mediating role of psychosocial factors in the peer group, family and school environment. METHODS: Data were derived from the international WHO-collaborative 'Health Behaviour in School-aged Children (HBSC)' study 2005/2006, including 52 907 15-year-old students from 35 European and North American countries. Socioeconomic position was measured by the Family Affluence Scale. Multilevel logistic regression models were conducted to examine the contribution of family, school and peer factors in explaining the association between family affluence and weekly smoking. RESULTS: Across countries, adolescents from low affluent families had an increased risk of weekly smoking (OR(boys) 1.14, confidence interval (CI) 1.05-1.23; OR(girls) 1.36, CI 1.26-1.46) compared with adolescents from high affluent families. Family and school factors mediated the association between family affluence and smoking to a high extent up to 100% (boys) and 81% (girls) in joint analyses. The most important single factors were family structure, relationships with parents, academic achievement and school satisfaction. Peer factors did not mediate the association between family affluence and adolescent smoking. CONCLUSION: The association between socioeconomic status and adolescent weekly smoking can largely be explained by an unequal distribution of family- and school-related factors. Focusing on the parent-adolescent relationship and adolescent school achievement can help to better understand inequalities in adolescent smoking behaviour.

The Association Between Tobacco Control Policy and Educational Inequalities in Smoking Cessation in the Netherlands from 1988 Through 2011.

INTRODUCTION: Tobacco control policies seemed to have failed to reduce socioeconomic inequalities in smoking in the past. It has been argued that a comprehensive mix of policies is needed. Our aim was to assess whether tobacco control policy development in the Netherlands between 1988 and 2011 was associated with educational inequalities in smoking cessation and cigarette consumption. METHODS: Data were derived from the cross-sectional Dutch Continuous Survey of Smoking Habits, with a study sample of 259,140 respondents from 1988 through 2011. Outcomes were the quit ratio and mean number of cigarettes smoked per day. The determinant was the Tobacco Control Scale (TCS). We used multilevel logistic regression modeling, with years, quarters, and individuals as levels, and controlled for sex, age, and time. RESULTS: A significant association between the TCS and smoking cessation was found in 2001-2011, but not in 1988-2000. Associations for low- and high-education groups were similar (OR = 1.23; 95% CI = 1.12-1.34 and OR = 1.17; 95% CI = 1.03-1.32 respectively). The TCS was not significantly associated with the number of cigarettes smoked per day for either the low- or high-education groups (B = -0.09; 95% CI = -0.46-0.27 and B = -0.59; 95% CI = -1.24-0.06 respectively). CONCLUSIONS: Strong tobacco control policies introduced in the Netherlands after 2000 were positively associated with national trends in smoking cessation, whereas weaker policies introduced gradually before 2000 were not. However, these measures do not seem to have either widened or narrowed educational inequalities in smoking cessation rates-both groups benefitted about equally.