Review
Equity impact of population-level interventions and policies to reduce smoking in adults: A systematic review

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Abstract

Background and aims

There is strong evidence about which tobacco control policies reduce smoking. However, their equity impact is uncertain. The aim was to assess the effectiveness of population-level interventions/policies to reduce socioeconomic inequalities in adult smoking.

Methods

Systematic review of studies of population-level interventions/policies reporting smoking-related outcomes in adults of lower compared to higher socioeconomic status (SES). References were screened and independently checked. Studies were quality assessed. Results are presented in a narrative synthesis. Equity impact was assessed as: positive (reduced inequality), neutral (no difference by SES), negative (increased inequality), mixed (equity impact varied) or unclear.

Results

117 studies of 130 interventions/policies were included: smokefree (44); price/tax (27); mass media campaigns (30); advertising controls (9); cessation support (9); settings-based interventions (7); multiple policies (4). The distribution of equity effects was: 33 positive, 36 neutral, 38 negative, 6 mixed, 17 unclear. Most neutral equity studies benefited all SES groups. Fourteen price/tax studies were equity positive. Voluntary, regional and partial smokefree policies were more likely to be equity negative than national, comprehensive smokefree policies. Mass media campaigns had inconsistent equity effects. Cigarette marketing controls were equity positive or neutral. Targeted national smoking cessation services can be equity positive by achieving higher reach among low SES, compensating for lower quit rates.

Conclusions

Few studies have assessed the equity impact of tobacco control policy/interventions. Price/tax increases had the most consistent positive equity impact. More research is needed to strengthen the evidence-base for reducing smoking inequalities and to develop effective equity-orientated tobacco control strategies.

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.

References (153)

  • G.E. Nagelhout et al.

    Prevalence and predictors of smoking in “smoke-free” bars, Findings from the International Tobacco Control (ITC) Europe Surveys

    Soc. Sci. Med.

    (2011)
  • J. Niederdeppe et al.

    Socioeconomic variation in recall and perceived effectiveness of campaign advertisements to promote smoking cessation

    Soc. Sci. Med.

    (2011)
  • J. Niederdeppe et al.

    Media campaigns to promote smoking cessation among socioeconomically disadvantaged populations: what do we know, what do we need to learn, and what should we do now?

    Soc. Sci. Med.

    (2008)
  • N.V. Alekseeva et al.

    Some psychosocial aspects of smoking: 10-year experience in “Quit & Win” campaigns in Novosibirsk

    Alaska Med.

    (2007)
  • A. Amos et al.

    Tobacco Control, Inequalities in Health and Action at the Local Level in England

    (2011)
  • A. Amos et al.

    Women and tobacco: a call for including gender in tobacco control research, policy and practice

    Tob. Control

    (2012)
  • K.L. Arheart et al.

    Declining trends in serum cotinine levels in US worker groups: the power of policy

    J. Occup. Environ. Med.

    (2008)
  • S. Azagba et al.

    Cigarette taxes and smoking participation: evidence from recent tax increases in Canada

    Intl. J. Environ. Res. Public Health

    (2011)
  • N. Bains et al.

    Predictors of smoking cessation in an incentive-based community intervention

    Chronic Dis. Can.

    (2000)
  • L. Bauld et al.

    Impact of UK National Health Service smoking cessation services: variations in outcomes in England

    Tob. Control

    (2003)
  • L. Bauld et al.

    Assessing the impact of smoking cessation services on reducing health inequalities in England: observational study

    Tob. Control

    (2007)
  • L. Biener et al.

    Reactions of adult and teenaged smokers to the Massachusetts tobacco tax

    Am. J. Public Health

    (1998)
  • E.K. Burns et al.

    Reaching Spanish-speaking smokers: state-level evidence of untapped potential for QuitLine utilization

    Am. J. Public Health Suppl.

    (2010)
  • T. Bush et al.

    The 2009 US federal cigarette tax increase and quitline utilization in 16 states

    J. Environ. Public Health

    (2012)
  • J. Cantrell et al.

    Impact of tobacco-related health warning labels across socioeconomic, race and ethnic groups: results from a randomized web-based experiment

    PLoS ONE

    (2013)
  • Centers for Disease Control and Prevention

    Decline in smoking prevalence New York City, 2002–2006

    MMWR

    (2007)
  • Centers for Disease Control and Prevention

    Response to increases in cigarette prices by race/ethnicity, income, and age groups – United States, 1976–1993

    MMWR

    (1998)
  • G. Cesaroni et al.

    Effect of the Italian smoking ban on population rates of acute coronary events

    Circulation

    (2008)
  • F.J. Chaloupka et al.

    Effectiveness of tax and price policies in tobacco control

    Tob. Control

    (2011)
  • J. Chesterman et al.

    How effective are the English smoking treatment services in reaching disadvantaged smokers?

    Addiction

    (2005)
  • K. Choi et al.

    Use of price-minimizing strategies by smokers and their effects on subsequent smoking behaviors

    Nicotine Tob. Res.

    (2012)
  • M. Civljak et al.

    Why choose lent for a “smoke out day?.” Changing smoking behavior in Croatia

    Croat. Med. J.

    (2005)
  • G. Colman

    Vertical equity consequences of very high cigarette tax increases: if the poor are the ones smoking, how could cigarette tax increases be progressive?

    J. Policy Anal. Manage.

    (2008)
  • Conference of the Parties to the WHO FCTC

    WHO Framework Convention on Tobacco Control

    (2003)
  • K.D. Czarnecki et al.

    Media campaign effectiveness in promoting a smoking-cessation program

    Am. J. Prev. Med.

    (2010)
  • W.A. Darity et al.

    A multi-city community based smoking research intervention project in the African-American population

    Int. Q. Community Health Educ.

    (2006)
  • C.D. Delnevo et al.

    Predictors of smoke-free workplaces by employee characteristics: who is left unprotected?

    Am. J. Ind. Med.

    (2004)
  • Department of Health

    Healthy Lives, Healthy People: A Tobacco Control Plan for England

    (2011)
  • M. Deprey et al.

    Using free patches to improve reach of the Oregon Quit Line

    J. Public Health Manag. Pract.

    (2009)
  • M. Deverell et al.

    Diffusion of local restaurant smoking regulations in Massachusetts: identifying disparities in health protection for population subgroups

    J. Public Health Manag. Pract.

    (2006)
  • C. Donath et al.

    Prediction of alcohol addicted patients’ smoking status through hospital tobacco control policy: a multi-level-analysis

    Drugs Educ. Prev. Policy

    (2009)
  • S.M. Dunlop et al.

    Australian smokers’ and recent quitters’ responses to the increasing price of cigarettes in the context of a tobacco tax increase

    Addiction

    (2011)
  • S. Dunlop et al.

    The natural history of antismoking advertising recall: the influence of broadcasting parameters, emotional intensity and executional features

    Tob. Control

    (2012)
  • S.J. Durkin et al.

    Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups

    Am. J. Public Health

    (2009)
  • S.J. Durkin et al.

    Which types of televised anti-tobacco campaigns prompt more quitline calls from disadvantaged groups?

    Health Educ. Res.

    (2011)
  • D. Eadie et al.

    A qualitative analysis of compliance with smoke-free legislation in community bars in Scotland: implications for public health

    Addiction

    (2008)
  • J.A. Ellis et al.

    Secondhand smoke exposure among nonsmokers nationally and in New York City

    Nicotine Tob. Res.

    (2009)
  • M. Eriksen et al.

    The Tobacco Atlas

    (2012)
  • M.C. Farrelly et al.

    Response by adults to increases in cigarette prices by sociodemographic characteristics

    South. Econ. J.

    (2001)
  • M.C. Farrelly et al.

    The impact of workplace smoking bans: results from a national survey

    Tob. Control

    (1999)
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    Supplementary material can be found by accessing the online version of this paper. Please see Appendix A for more information.

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