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. This study aims to identify SCSO professionals' 1) potential activities to support smoking cessation and 2) barriers and facilitators in undertaking these activities. METHODS: 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 (i.e., recognizing smoking clients, discussing smoking and smoking cessation, referring clients, providing smoking cessation counseling, offering help around services) or indirectly (i.e., 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 (i.e., clients' readiness and social environment), 2) interaction between professional and client (i.e., topic sensitivity), 3) professional (i.e., professionals is non-smoker, knowledge and self-efficacy), 4) professionals' work environment (i.e., necessity, responsibility, priority and time), and 5) smoking cessation services (i.e., 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 conversational skills to discuss smoking. As a prerequisite, easily accessible and suitable smoking cessation services should be available in the neighborhood.

Socioeconomic Inequalities in Type 2 Diabetes: Mediation Through Status Anxiety?

Objectives: While status anxiety has received attention as a potential mechanism generating health inequalities, empirical evidence is still limited. Studies have been ecological and have largely focused on mental and not physical health outcomes. Methods: We conducted individual-level analyses to assess status anxiety (feelings of inferiority resulting from social comparisons) and resources (financial difficulties) as mediators of the relationship between socioeconomic status (SES) (education/occupation/employment status) and type 2 diabetes (T2D). We used cross-sectional data of 21,150 participants (aged 18-70 years) from the Amsterdam-based HELIUS study. We estimated associations using logistic regression models and estimated mediated proportions using natural effect modelling. Results: Odds of status anxiety were higher among participants with a low SES [e.g., OR = 2.66 (95% CI: 2.06-3.45) for elementary versus academic occupation]. Odds of T2D were 1.49 (95% CI: 1.12-1.97) times higher among participants experiencing status anxiety. Proportion of the SES-T2D relationship mediated was 3.2% (95% CI: 1.5%-7.0%) through status anxiety and 10.9% (95% CI: 6.6%-18.0%) through financial difficulties. Conclusion: Status anxiety and financial difficulties played small but consistent mediating roles. These individual-level analyses underline status anxiety's importance and imply that status anxiety requires attention in efforts to reduce health inequalities.

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.

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.

Intervention Activities Associated with the Implementation of a Comprehensive School Tobacco Policy at Danish Vocational Schools: A Repeated Cross-Sectional Study.

School tobacco policies are often poorly implemented, which may explain their limited effectiveness. Further, constructs to measure implementation outcomes of school tobacco policies are missing. The Smoke-Free Vocational Schools intervention was designed to stimulate the implementation of a comprehensive school tobacco policy into routine practice. This study (1) developed implementation fidelity outcomes measures for the school tobacco policy and (2) examined associations between intervention activities and implementation fidelity at two time points. We applied a repeated cross-sectional survey study design across seven schools: the first time point was >5 months after the policy was established and the second time point > 14 months after policy establishment. The dependent/outcome variables were four binary fidelity domains as well as a total score across domains. A total of six intervention activities were measured among either students (e.g., new school-break facilities) or staff/managers (e.g., a joint workshop before policy implementation). Associations were analyzed separately for students and staff/managers using generalized linear mixed models, adjusted for confounders. A total of n = 2674 students and n = 871 staff/managers participated. The total implementation fidelity scores increased over time among both students and staff/managers. Three intervention activities were consistently associated with the total implementation fidelity score, including: new school-break facilities (BT1 = 0.08, 95% CI = 0.03; 0.12; BT2 = 0.07, 95% CI = 0.04-0.50), the joint workshop before policy implementation (BT1 = 0.13, 95% CI = 0.02; 0.25; BT2 = 0.13, 95% CI = 0.004; 0.24), and internalization of fixed procedures for enforcement (BT1 = 0.19, 95% CI = 0.13-0.26; BT2 = 0.16, 95% CI = 0.13-0.26). These findings can be applied by schools and other actors in practice. The developed implementation fidelity outcomes measures can be applied in future research on school tobacco policies.

Educational inequalities in exposure to tobacco promotion at the point of sale among adolescents in four Dutch cities.

This study aimed to assess educational differences in adolescents' exposure to tobacco outlets. Data were collected among 312 13-17-year-old non-smoking secondary school students in four Dutch cities. In a smartphone app, exposure (≤10 m from outlet) was measured using GPS and participants reported their educational track (pre-vocational vs. pre-university). Associations were estimated in negative binomial regression models. Mean exposure to tobacco outlet was 16.6 times in 14 days. Pre-vocational education was associated with higher exposure compared to pre-university education (IRR:1.46, 95%CI:1.08-1.98), especially around school (IRR:2.61,95%CI:1.50-4.55). These differences may contribute to socioeconomic inequalities in smoking.

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.

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).

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.

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 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.

Dutch youth's smoking behaviour during a partial Covid-19 lockdown.

Previous research found that adult smokers increased their smoking in response to the Covid-19 lockdown in spring 2020. This study explored changes in youth's smoking during, compared to before, the partial lockdown in the Netherlands in a cross-sectional sample of 287 adolescents. Smoking prevalence increased from 4.5% to 5.2%. Cigarette consumption remained the same on school days and increased with +1.9 cigarettes per weekend day. The largest increase in cigarette consumption on weekend days was observed for adolescents who 1) did not consider smoking a risk factor for contracting Covid-19 (+4.5), 2) had smoking siblings (+4.1), and 3) had smoking friends (+2.4). Youth without smoking friends (-0.8) and who considered smoking a risk factor for Covid-19 (-0.2) decreased their cigarette consumption.

The Mediating Role of Parental Factors in the Social Patterning of Smoking among Adolescents in Urban Indonesia.

INTRODUCTION: Parental factors may explain part of the social patterning of smoking among adolescents. This study aims at assessing the association between adolescent smoking and family characteristics (parental education, family wealth, and religion) and the mediating role of parental factors (smoking, control, and permissiveness towards smoking). METHODS: In 2017, a cross-sectional survey was conducted in eight Indonesian cities among 2,393 students aged 13-18 years. Multilevel logistic regression analysis estimated the associations between family characteristics and adolescent smoking. Generalized Structural Equation Models (GSEM) quantified mediation of these associations by parental factors. Analyses were stratified by gender. RESULTS: Smoking prevalence was 35.8% among boys and 2.6% among girls. Odds of smoking were higher among those with lower parental education among boys (low vs. high: OR:1.57, 95%CI:1.01-2.43), but not girls (OR:0.91, 95%CI:0.24-3.43). The association among boys was partially mediated by father's smoking status, parental control, and parental permissiveness towards smoking. High family wealth was associated with higher odds of smoking among girls (poorer vs. wealthier: OR:0.39, 95%CI:0.15-0.99), but not boys (OR:0.76, 95%CI:0.52-1.10). This association among girls was not clearly mediated by parental factors. Religion was not associated with smoking among boys or girls. CONCLUSIONS: In Indonesia's urban settings, inequalities in boys' smoking by educational background may be addressed by measures aimed at supporting lower educated parents to improve parental control and to reduce permissiveness towards smoking.

Smoking cessation among adolescents in Europe: The role of school policy and programmes.

INTRODUCTION: European estimates of adolescent smoking cessation are lacking and studies on the role of schools in quit behaviour are scarce. We aimed to describe smoking cessation attempts and success among adolescents in Europe and explored the association with school policy and programmes. METHODS: We used cross-sectional data from the 2013 and 2016-2017 surveys of the European SILNE and SILNE-R projects. We included 4,509 12-19-year-old current or ex-smokers in 67 secondary schools in seven countries (Belgium, Germany, Finland, Ireland, Italy, the Netherlands, and Portugal). School staff reported strength of smoke-free school policies (SFSPs), proportion of grades in which anti-tobacco education was offered, and whether the school offered any form of cessation support programme. Multilevel logistic regression analysis determined school-level variation and the association of school-level and individual-level variables with self-reported and self-defined quit attempts and quit success. RESULTS: Over three quarters (77.3%) of students reported a quit attempt and half of them (50.1%) reported quit success. Prevalence rates of quit success and quit attempts, showed relatively small variations between schools within countries. Associations of smoke-free school policy, tobacco educational programmes and cessation programmes with quit attempts and quit success could not be demonstrated with statistical significance. Quit attempts and quit success were inversely associated with alcohol use, parental smoking, and friend smoking. CONCLUSION: This study demonstrates that adolescence is an important time to encourage quitting and to support quit attempts. We did not find evidence for a contribution of school policies and programmes to quit behaviour of adolescent smokers.

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.

The impact of local smoke-free policies on smoking behaviour among adults in Indonesia: a quasi-experimental national study.

AIMS: To investigate to what extent the adoption of local smoke-free policies (SFPs) in Indonesia in 2007-13 was associated with changes in adult smoking behaviour. DESIGN: A quasi-experimental study. SETTING: Indonesia, 2007 and 2013. PARTICIPANTS: A total of 1 052 611 > 25-year-old adults. Data were derived from the 2007 and 2013 Indonesian national health survey. MEASUREMENTS: For both years, provincial and district SFPs were identified from government documents in 497 districts in 33 provinces. Multi-level logistic regression analysis assessed the association of adoption of provincial and district SFPs between 2007 and 2013 with smoking continuation (among ever-smokers), current smoking and high smoking intensity (among current smokers). We controlled for survey year, SFP in 2007, socio-demographics and district characteristics. FINDINGS: Provincial SFP exposure was associated with lower odds of smoking continuation [strong SFP versus no SFP: odds ratio (OR) = 0.71, 95% confidence interval (CI) = 0.66-0.76] and smoking intensity (strong SFP: OR= 0.91, 95% CI = 0.86-0.97), but also with higher odds of current smoking (strong SFP versus no SFP: OR = 1.08; 95% CI = 1.04-1.12). District SFP exposure was associated with higher odds of smoking continuation (strong SFP versus no SFP: OR = 1.07, 95% CI = 1.01-1.14) and current smoking (strong SFP versus no SFP: OR = 1.09, 95% CI = 1.05-1.14), but with lower odds of smoking intensity (moderately strong SFP versus no SFP: OR = 0.95, 95% CI = 0.91-0.99). CONCLUSIONS: There may be an association between the adoption of local smoke-free policies in Indonesia and decreased adult smoking intensity. However, the evidence is inconsistent, which may reflect problems with policy implementation and enforcement.

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.