ReviewEquity impact of population-level interventions and policies to reduce smoking in adults: A systematic review☆
Introduction
Smoking is both the single most important preventable cause of premature mortality and a major contributor to socioeconomic inequalities in health in North America and Europe (Lim et al., 2012, Mackenbach et al., 2008). Smoking prevalence rates differ substantially within countries according to educational level, occupational class and income (Kunst et al., 2004, Hiscock et al., 2012a, Hiscock et al., 2012b). The patterning of smoking by socioeconomic status (SES) reflects the stage of the tobacco epidemic in that country. The US, Canada, Australia and most countries in the European Union are characterised as being in the fourth (last) stage of the epidemic (Lopez et al., 1994, Eriksen et al., 2012). In these countries, lower SES groups have higher smoking prevalence, higher levels of cigarette consumption and lower rates of quitting compared to higher SES groups (Hiscock et al., 2012a, Hiscock et al., 2012b).
There is good evidence on what is effective in reducing adult smoking. A review of international evidence by the World Bank (Joosens and Raw, 2006) identified six cost-effective policies which should be prioritised in tobacco control programmes: cigarette price increases, comprehensive smokefree public places, anti-tobacco mass media campaigns, bans on advertising, health warnings and cessation support. These priorities were endorsed by World Health Organisation (WHO, 2008) and form the basis of the Framework Convention on Tobacco Control (FCTC), the first international public health treaty (FCTC, 2003). While considerable progress has been made in tobacco control in many countries in recent years, there is considerable variation in the strength and comprehensiveness of tobacco control policies and their implementation (Joosens and Raw, 2006, Joosens and Raw, 2011).
While smoking prevalence in stage 4 countries is declining, the social gradient in smoking is not. This is of increasing concern in many countries which have recognised that tackling inequalities in smoking is central to reducing health inequalities. Health equity is defined as the absence of avoidable and unfair inequalities in health (Whitehead, 1992). For example, both the English and Scottish national tobacco control strategies identify reducing inequalities and smoking as their key priority (Department of Health, 2011, Scottish Government, 2013). However, two previous systematic reviews which examined the equity effect of tobacco control interventions (Fayter et al., 2008, Amos et al., 2011) concluded that there was limited evidence to inform tobacco control interventions/policies aimed at reducing socioeconomic inequalities in smoking.
This systematic review forms part of the European project (SILNE Consortium, 2012) ‘Tackling socioeconomic inequalities in smoking’ (SILNE). The review's aim is to assess the effectiveness of population-level interventions/policies to reduce socioeconomic inequalities in smoking among adults by assessing primary studies of any intervention/policy that reported differential effects on a smoking-related outcome in at least two socioeconomic groups.
Section snippets
Methods
The study protocol is available on request from the corresponding author (AA). The review was written following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-equity reporting guidelines: PRISMA-E 2012 (supplementary material1; Welch et al., 2012). The search strategy identified studies for both this review and two other reviews for the SILNE
Results
The electronic search produced 29,047 references and 23 outputs were identified through hand-searching, searching grey literature and key reviews, and contacting experts. After removing duplicate references and outputs published before 1995, 13,937 titles and abstracts were screened. Three hundred and fifty-three full-text outputs were assessed; 120 outputs were included and 233 were excluded. These 120 outputs covered 117 separate studies which evaluated 130 interventions/policies (Fig. 1).
Discussion
The review identified 117 studies, which evaluated the equity impact of 130 interventions/policies. Overall equity effects for all types of interventions/policies were: 33 positive, 36 neutral, 38 negative, 6 mixed and 17 unclear. It is important to emphasise that 33 of the 36 neutral equity interventions/policies had a positive benefit across all SES groups.
An expert panel which assessed the effectiveness of price/tax policies in 2010 (Chaloupka et al., 2011) concluded that there was ‘strong
Role of funding source
This study is part of the project ‘Tackling socio-economic inequalities in smoking (SILNE)’, which is funded by the European Commission, Directorate-General for Research and Innovation, under the FP7-Health-2011 programme, with grant agreement number 278273. The European Commission had no further role in the study design; in the collection, analysis and interpretation of the data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
TB, SP and AA developed the initial strategy for the review; TB undertook the literature search with support from AA and SP; TB, SP and AA reviewed individual articles; TB wrote the first draft of this paper; AA and SP contributed to the writing of the manuscript and agree with its results and conclusions.
Conflict of interest
No conflict declared.
Acknowledgements
We would like to thank Thomas Tjelta for his help in acquiring some of the papers, Anton Kunst for his helpful comments on the review and ENSP for contacting members about relevant grey literature.
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Supplementary material can be found by accessing the online version of this paper. Please see Appendix A for more information.