Periodic Report Summary – SILNE (Tackling socioeconomic inequalities in smoking: learning from natural experiments by time trend analyses and cross-national comparisons)

Project context and objectives:In all European countries, smoking is increasingly concentrated in lower socioeconomic status (SES) groups, especially in the youngest generations. Tackling inequalities in smoking is therefore vital to any strategy that is aimed at avoiding a further widening of socioeconomic inequalities in health.

Several effective interventions and programmes are now available to address smoking in Europe. These include bans on smoking in public places and cessation support services for those wanting to quit. In addition, several supply-side measures are potentially effective, including bans on advertisements, increased tax on tobacco, and restrictions on sales of tobacco products to young people.

A main challenge for research is to assess which of these tobacco control measures have the potential to reduce socioeconomic inequalities in smoking, beside their impact on general smoking prevalence. The evidence accumulated so far is encouraging but limited. Unfortunately, much of this current evidence is derived from evaluations of controlled experiments in selective populations.

There is therefore an urgent need for evaluations of policies, programmes and interventions that have already been implemented at national or local levels. Evaluations of real-world actions may help to estimate more directly what has been achieved, and what can further be achieved in the field of tobacco control. We therefore aim to assess effects of such real-world policies by analysing ‘natural policy experiments’.

The project takes advantage of the fact that Europe offers a large number of natural experiments in the field of tobacco control. Since the 1990s, many European countries have intensified tobacco control policies and introduced measures such as bans on smoking in public places, and further tax increases. Similarly, at any moment in time, large differences exist between European countries in the type and extent of tobacco control measures that have been adopted.

Both trends over time and variations between countries can be studied with the aim to obtain new evidence on the effectiveness of different types of tobacco control measures. We will aim to obtain such evidence both on smoking cessation by adult smokers, and on smoking initiation by young people.

The overall aim of the project is thus to analyse several ‘natural experiments’ available within Europe in order to generate new empirical evidence to inform strategies to reduce socioeconomic inequalities in smoking. The project has three specific objectives:

(1) to assess, using trend analysis for several European countries, whether changes in specific national tobacco control policies since 1990s were associated with changes in socioeconomic inequalities in smoking cessation and related factors;
(2) to assess, through comparisons between European countries, whether differences in specific tobacco control policies and in educational systems are associated with differences in socioeconomic inequalities in smoking initiation and related factors;
(3) to review the evidence of published intervention studies on their impact on socioeconomic inequalities in smoking, to integrate this with the evidence generated in the current project, and to disseminate the combined evidence across Europe.

Project results:

Work on smoking cessation

Work package (WP)2 utilised data of the international ITC survey on smoking cessation and related factors in six western European countries. We first examined the impact of a national reimbursement policy for smoking cessation aids in the Netherlands in 2011. The number of (successful) quit attempts increased. The income of respondents was unrelated to these trends. This implied that a national reimbursement policy does not decrease or increase inequalities in smoking. A next paper explored cross-border purchasing of cigarettes in six European countries. Cross-border cigarette purchasing was more common reported by smokers with higher education and income. A possible explanation is that this incurs travel costs, which smokers with lower education and income may not be able to pay up-front.

WP3 complemented WP2 by analyses of trends in smoking cessation in Southern and Eastern European countries. We first prepared an overview of trends in tobacco control policies in European countries. We also obtained micro data from national interview surveys held in Spain, Portugal, Italy, Baltic countries, Poland and Ukraine.

Currently, we are analysing these data with the aim to evaluate the impact of tobacco control policies. For example, for Lithuania we documented that tobacco control policies intensified in 2000 and 2007. We observed a positive relationship with tobacco control: the more tobacco control, the more ever-smokers had quit. This relationship was stronger among high educated than low educated people. A widening of inequalities occurred especially among men.

Work on youth smoking

WP4 utilised data of the international HBSC survey amongst adolescents of 11 – 15 years in 38 European countries. In a first paper, we investigated the association between national wealth and inequalities in adolescent smoking. We identified inequalities in early smoking initiation and maintenance of smoking at 15 years of age in the 38 countries. Remarkably, wealthier nations showed larger inequalities for all measures of adolescent smoking than less affluent nations.

In one additional paper, we include information on other characteristics of countries. We hypothesised that greater ‘educational differentiation’ to be related to larger inequalities in youth smoking. Preliminary results, however, do not seem to support this hypothesis.

In WP5, we have designed and implemented a new survey on smoking amongst 16-year-old school pupils in Finland, Germany, Belgium, Italy, Portugal and the Netherlands. The survey will facilitate social network analyses of smoking simultaneously in different countries. Within each country, we selected a city of medium size and median income level. In each city, 4 to 13 secondary schools were selected. We designed and piloted questionnaires to be administered to pupils of about 16 years. Per school, each class room pertaining to corresponding grades was included, and all students per classroom were invited to participate. For the 6 countries together, we obtained questionnaires for about 9300 pupils.

Literature review

WP6 reviewed the published evidence on the impact of policies on inequalities in smoking. Three reports were written, as narrative syntheses:

(a) on the effects of interventions on youth smoking;
(b) on the effects of interventions on adult smoking; and
(c) on the effects of individual-level smoking cessation support on adult smoking.

The youth report concluded that very few studies have assessed the equity impact of policies and interventions on smoking among youth. The adult report concludes that, though 116 studies were identified, it remains uncertain which interventions are likely to reduce inequalities in smoking. The most consistent evidence of a positive equity impact was for price / tax increases. The adult smoking cessation support review concluded that individual-level cessation services are likely to increase inequalities in smoking unless they are targeted at low SES smokers.

Potential impact:

The project will contribute evidence on the differential health effects of policy interventions, and the impact of alternative options for enhancing equity. Because of its focus on smoking, the project is able to provide new evidence on the differential effect of tobacco control policies, thereby offering direct input to an important field of public health action.

The project is designed to provide the strongest evidence that is possible on the equity impact of real-world policies as implemented within Europe. By applying innovative methods to mostly existing databases, it will be able to generate much new empirical evidence on how these policies affect inequalities in smoking. Furthermore, it will make a systematic effort to integrate this new evidence with the available scientific evidence as reviewed in WP6.

The consortium will disseminate the new results to the scientific community and related professionals through various channels (conferences, journals, training researchers). Additional channels will be used to disseminate the results of this project to policy makers, professionals as well as general public (media, link with organisation, conferences).

In the reporting period, several dissemination activities were developed. We developed and maintained a project website (see online). We set up a network of interested policy makers, professionals and other stakeholders. We organised an interim workshop with experts and stakeholders, to evaluate the approaches and the first results of the project, and to make recommendations for further work (Athens, June 2013). Finally, we ensured dissemination within the scientific community through presentations at scientific conferences and submission of articles to international journals.

This Periodic Report Summary is also available on the European Commission website.