thesis in smoking

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• Published: 21 January 2021

The effects of tobacco control policies on global smoking prevalence

• Luisa S. Flor   ORCID: orcid.org/0000-0002-6888-512X 1 ,
• Marissa B. Reitsma 1 ,
• Vinay Gupta 1 ,
• Marie Ng   ORCID: orcid.org/0000-0001-8243-4096 2 &
• Emmanuela Gakidou   ORCID: orcid.org/0000-0002-8992-591X 1  

Nature Medicine volume  27 ,  pages 239–243 ( 2021 ) Cite this article

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Substantial global effort has been devoted to curtailing the tobacco epidemic over the past two decades, especially after the adoption of the Framework Convention on Tobacco Control 1 by the World Health Organization in 2003. In 2015, in recognition of the burden resulting from tobacco use, strengthened tobacco control was included as a global development target in the 2030 Agenda for Sustainable Development 2 . Here we show that comprehensive tobacco control policies—including smoking bans, health warnings, advertising bans and tobacco taxes—are effective in reducing smoking prevalence; amplified positive effects are seen when these policies are implemented simultaneously within a given country. We find that if all 155 countries included in our counterfactual analysis had adopted smoking bans, health warnings and advertising bans at the strictest level and raised cigarette prices to at least 7.73 international dollars in 2009, there would have been about 100 million fewer smokers in the world in 2017. These findings highlight the urgent need for countries to move toward an accelerated implementation of a set of strong tobacco control practices, thus curbing the burden of smoking-attributable diseases and deaths.

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Decades after its ill effects on human health were first documented, tobacco smoking remains one of the major global drivers of premature death and disability. In 2017, smoking was responsible for 7.1 (95% uncertainty interval (UI), 6.8–7.4) million deaths worldwide and 7.3% (95% UI, 6.8%–7.8%) of total disability-adjusted life years 3 . In addition to the health impacts, economic harms resulting from lost productivity and increased healthcare expenditures are also well-documented negative effects of tobacco use 4 , 5 . These consequences highlight the importance of strengthening tobacco control, a critical and timely step as countries work toward the 2030 Sustainable Development Goals 2 .

In 2003, the World Health Organization (WHO) led the development of the Framework Convention on Tobacco Control (FCTC), the first global health treaty intended to bolster tobacco use curtailment efforts among signatory member states 1 . Later, in 2008, to assist the implementation of tobacco control policies by countries, the WHO introduced the MPOWER package, an acronym representing six evidence-based control measures (Table 1 ) (ref. 6 ). While accelerated adoption of some of these demand reduction policies was observed among FCTC parties in the past decade 7 , many challenges remain to further decrease population-level tobacco use. Given the differing stages of the tobacco epidemic and tobacco control across countries, consolidating the evidence base on the effectiveness of policies in reducing smoking is necessary as countries plan on how to do better. In this study, we evaluated the association between varying levels of tobacco control measures and age- and sex-specific smoking prevalence using data from 175 countries and highlighted missed opportunities to decrease smoking rates by predicting the global smoking prevalence under alternative unrealized policy scenarios.

Despite the enhanced global commitment to control tobacco use, the pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, sex and age 8 ; in 2017, there were still 1.1 billion smokers across the 195 countries and territories assessed by the Global Burden of Diseases, Injuries, and Risk Factors Study. Global smoking prevalence in 2017 among men and women aged 15 and older, 15–29 years, 30–49 years and 50 years and older are shown in Extended Data Figs. 1 , 2 , 3 and 4 , respectively. We found that, between 2009 and 2017, current smoking prevalence declined by 7.7% for men (36.3% (95% UI, 35.9–36.6%) to 33.5% (95% UI, 32.9–34.1%)) and by 15.2% for women globally (7.9% (95% UI, 7.8–8.1%) to 6.7% (95% UI, 6.5–6.9%)). The highest relative decreases were observed among men and women aged 15–29 years, at 10% and 20%, respectively. Conversely, prevalence decreased less intensively for those aged over 50, at 2% for men and 9.5% for women. While some countries have shown an important reduction in smoking prevalence between 2009 and 2017, such as Brazil, suggesting sustained progress in tobacco control, a handful of countries and territories have shown considerable increases in smoking rates among men (for example, Albania) and women (for example, Portugal) over this time period.

In an effort to counteract the harmful lifelong consequences of smoking, countries have, overall, implemented stronger demand reduction measures after the FCTC ratification. To assess national-level legislation quality, the WHO attributes a score to each of the MPOWER measures that ranges from 1 to 4 for the monitoring component (M) and 1–5 for the other components. A score of 1 represents no known data, while scores 2–5 characterize the overall strength of each measure, from the lowest level of achievement (weakest policy) to the highest level of achievement (strongest policy) 6 . Between 2008 and 2016, although very little progress was made in treatment provision (O) 7 , 9 , the share of the total population covered by best practice (score = 5) P, W and E measures increased (Fig. 1 ). Notably, however, a massive portion of the global population is still not covered by comprehensive laws. As an example, less than 15% of the global population is protected by strongly regulated tobacco advertising (E) and the number of people (2.1 billion) living in countries where none or very limited smoke-free policies (P) are in place (score = 2) is still nearly twice as high as the population (1.1 billion) living in locations with national bans on smoking in all public places (score = 5).

To assess national-level legislation quality, the WHO attributes a score to each MPOWER component that ranges from 1 to 5 for smoke-free (P), health warning (W) and advertising (E) policies. A score of 1 represents no known data or no recent data, while scores 2–5 characterize the overall strength of each policy, from 2 representing the lowest level of achievement (weakest policy), to 5 representing the highest level of achievement (strongest policy).

Source data

In terms of fiscal policies (R), the population-weighted average price, adjusted for inflation, of a pack of cigarettes across 175 countries with available data increased from I$3.10 (where I$ represents international dollars) in 2008 to I$5.38 in 2016. However, from an economic perspective, for prices to affect purchasing decisions, they need to be evaluated relative to income. The relative income price (RIP) of cigarettes is a measure of affordability that reflects, in this study, what proportion of the country-specific per capita gross domestic product (GDP) is needed to purchase half a pack of cigarettes a day for a year. Over time, cigarettes have become less affordable (RIP 2016 > RIP 2008) in about 75% of the analyzed countries, with relatively more affordable cigarettes concentrated across high-income countries.

Our adjusted analysis indicates that greater levels of achievement on key measures across the P, W and E policy categories and higher RIP values were significantly associated with reduced smoking prevalence from 2009 to 2017 (Table 2 ). Among men aged 15 and older, each 1-unit increment in achievement scores for smoking bans (P) was independently associated with a 1.1% (95% UI, −1.7 to −0.5, P  < 0.0001) decrease in smoking prevalence. Similarly, an increase of 1 point in W and E scores was associated with a decrease in prevalence of 2.1% (95% UI, −2.7 to −1.6, P  < 0.0001) and 1.9% (95% UI, −2.6 to −1.1, P  < 0.0001), respectively. Furthermore, a 10 percentage point increase in RIP was associated with a 9% (95% UI, −12.6 to −5.0, P  < 0.0001) decrease in overall smoking prevalence. Results were similar for men from other age ranges.

Among women, the magnitude of effect of different policy indicators varied across age groups. For those aged over 15, each 1-point increment in W and E scores was independently associated with an average reduction in prevalence of 3.6% (95% UI, −4.5 to −2.9, P  < 0.0001) and 1.9% (95% UI, −2.9 to −1.8, P  = 0.002), respectively, and these findings were similar across age groups. Smoking ban (P) scores were not associated with reduced prevalence among women aged 15–29 years or over 50 years. However, a 1-unit increase in P scores was associated with a 1.3% (95% UI, −2.3 to −0.2, P  = 0.016) decline in prevalence among women aged 30–49 years. Lastly, while a 10 percentage point increase in RIP lowered women smoking prevalence by 6% overall (95% UI, −10.0 to −2.0, P = 0.014), this finding was not statistically significant when examining reductions in prevalence among those aged 50 and older (Table 2 ).

If tobacco control had remained at the level it was in 2008 for all 155 countries (with non-missing policy indicators for both 2008 and 2016; Methods ) included in the counterfactual analysis, we estimate that smoking prevalence would have been even higher than the observed 2017 rates, with 23 million more male smokers and 8 million more female smokers (age ≥ 15) worldwide (Table 3 ). Out of the counterfactual scenarios explored, the greatest progress in reducing smoking prevalence would have been observed if a combination of higher prices—resulting in reduced affordability levels—and strictest P, W and E laws had been implemented by all countries, leading to lower smoking rates among men and women from all age groups and approximately 100 million fewer smokers across all countries (Table 3 ). Under this policy scenario, the greatest relative decrease in prevalence would have been seen among those aged 15–29 for both sexes, resulting in 26.6 and 6.5 million fewer young male and female smokers worldwide in 2017, respectively.

Our findings reaffirm that a wide spectrum of tobacco demand reduction policies has been effective in reducing smoking prevalence globally; however, it also indicates that even though much progress has been achieved, there is considerable room for improvement and efforts need to be strengthened and accelerated to achieve additional gains in global health. A growing body of research points to the effectiveness of tobacco control measures 10 , 11 , 12 ; however, this study covers the largest number of countries and years so far and reveals that the observed impact has varied by type of control policy and across sexes and age groups. In high-income countries, stronger tobacco control efforts are also associated with higher cessation ratios (that is, the ratio of former smokers divided by the number of ever-smokers (current and former smokers)) and decreases in cigarette consumption 13 , 14 .

Specifically, our results suggest that men are, in general, more responsive to tobacco control interventions compared to women. Notably, with prevalence rates for women being considerably low in many locations, variations over time are more difficult to detect; thus, attributing causes to changes in outcome can be challenging. Yet, there is already evidence that certain elements of tobacco control policies that play a role in reducing overall smoking can have limited impact among girls and women, particularly those of low socioeconomic status 15 . Possible explanations include the different value judgments attached to smoking among women with respect to maintaining social relationships, improving body image and hastening weight control 16 .

Tax and price increases are recognized as the most impactful tobacco control policy among the suite of options under the MPOWER framework 10 , 14 , 17 , particularly among adolescents and young adults 18 . Previous work has also demonstrated that women are less sensitive than men to cigarette tax increases in the USA 19 . Irrespective of these demographic differences, effective tax policy is underutilized and only six countries—Argentina, Chile, Cuba, Egypt, Palau and San Marino—had adopted cigarette taxes that corresponded to the WHO-prescribed level of 70% of the price of a full pack by 2017 (ref. 20 ). Cigarettes also remain highly affordable in many countries, particularly among high-income nations, an indication that affordability-based prescriptions to countries, instead of isolated taxes and prices reforms, are possibly more useful as a tobacco control target. In addition, banning sales of single cigarettes, restricting legal cross-border shopping and fighting illicit trade are required so that countries can fully experience the positive effect of strengthened fiscal policies.

Smoke-free policies, which restrict the opportunities to smoke and decrease the social acceptability of smoking 17 , also affect population groups differently. In general, women are less likely to smoke in public places, whereas men might be more frequently influenced by smoking bans in bars, restaurants, clubs and workplaces across the globe due to higher workforce participation rates 16 . In addition to leading to reduced overall smoking rates, as indicated in this study, implementing complete smoking bans (that is, all public places completely smoke-free) at a faster pace can also play an important role in minimizing the burden of smoking-attributable diseases and deaths among nonsmokers. In 2017 alone, 2.18% (95% UI, 1.8–2.7%) of all deaths were attributable to secondhand smoke globally, with the majority of the burden concentrated among women and children 21 .

Warning individuals about the harms of tobacco use increases knowledge about the health risks of smoking and promotes changes in smoking-related behaviors, while full advertising and promotion bans—implemented by less than 20% of countries in 2017 (ref. 20 )—are associated with decreased tobacco consumption and smoking initiation rates, particularly among youth 17 , 22 , 23 . Large and rotating pictorial graphic warnings are the most effective in attracting smokers’ attention but are lacking in countries with high numbers of smokers, such as China and the USA 20 . Adding best practice health warnings to unbranded packages seems to be an effective way of informing about the negative effects of smoking while also eliminating the tobacco industry’s marketing efforts of using cigarette packages to make these products more appealing, especially for women and young people who are now the prime targets of tobacco companies 24 , 25 .

While it is clear that strong implementation and enforcement are crucial to accelerating progress in reducing smoking and its burden globally, our heterogeneous results by type of policy and demographics highlight the challenges of a one-size-fits-all approach in terms of tobacco control. The differences identified illustrate the need to consider the stages 26 of the smoking epidemics among men and women and the state of tobacco control in each country to identify the most pressing needs and evaluate the way ahead. Smoking patterns are also influenced by economic, cultural and political determinants; thus, future efforts in assessing the effectiveness of tobacco control policies under these different circumstances are of value. As tobacco control measures have been more widely implemented, tobacco industry forces have expanded and threaten to delay or reverse global progress 27 . Therefore, closing loopholes through accelerated universal adoption of the comprehensive set of interventions included in MPOWER, guaranteeing that no one is left unprotected, is an urgent requirement as efforts toward achieving the Sustainable Development Goals by 2030 are intensified.

This was an ecological time series analysis that aimed to estimate the effect of four key demand reduction measures on smoking rates across 175 countries. Country-year-specific achievement scores for P, W and E measures and an affordability metric measured by RIP—to capture the impact of fiscal policy (R)—were included as predictors in the model. Although the WHO also calls for monitoring (M) and tobacco cessation (O) interventions, these were not evaluated. Monitoring tobacco use is not considered a demand reduction measure, while very little progress has been made in treatment provision over the last decade 7 , 9 . Further information on research design is available in the Life Sciences Reporting Summary linked to this paper.

Smoking outcome data

The dependent variable is represented by country-specific, age-standardized estimates of current tobacco smoking prevalence, defined as individuals who currently use any smoked tobacco product on a daily or occasional basis. Complete time series estimates of smoking prevalence from 2009 to 2017 for men and women aged 15–29, 30–49, 50 years and older and 15 years and older, were taken from the Global Burden of Disease (GBD) 2017 study.

The GBD is a scientific effort to quantify the comparative magnitude of health loss due to diseases, injuries and risk factors by age, sex and geography for specific points in time. While full details on the estimation process for smoking prevalence have been published elsewhere, we briefly describe the main analytical steps in this article 3 . First, 2,870 nationally representative surveys meeting the inclusion criteria were systematically identified and extracted. Since case definitions vary between surveys, for example, some surveys only ask about daily smoking as opposed to current smoking that includes both daily and occasional smokers, the extracted data were adjusted to the reference case definition using a linear regression fit on surveys reporting multiple case definitions. Next, for surveys with only tabulated data available, nonstandard age groups and data reported as both sexes combined were split using observed age and sex patterns. These preprocessing steps ensured that all data used in the modeling were comparable. Finally, spatiotemporal Gaussian process regression, a three-step modeling process used extensively in the GBD to estimate risk factor exposure, was used to estimate a complete time series for every country, age and sex. In the first step, estimates of tobacco consumption from supply-side data are incorporated to guide general levels and trends in prevalence estimates. In the second step, patterns observed in locations, age groups and years with smoking prevalence data are synthesized to improve the first-step estimates. This step is particularly important for countries and time periods with limited or no available prevalence data. The third step incorporates and quantifies uncertainty from sampling error, non-sampling error and the preprocessing data adjustments. For this analysis, the final age-specific estimates were age-standardized using the standard population based on GBD population estimates. Age standardization, while less important for the narrower age groups, ensured that the estimated effects of policies were not due to differences in population structure, either within or between countries.

Using GBD-modeled data is a strength of the study since nearly 3,000 surveys inform estimates and countries are not required to have complete survey coverage between 2009 and 2017 to be included in the analysis. Yet, it is important to note that these estimates have limitations. For example, in countries where a prevalence survey was not conducted after the enactment of a policy, modeled estimates may not reflect changes in prevalence resulting from that policy. Nonetheless, the prevalence estimates from the GBD used in this study are similar to those presented in the latest WHO report 28 , indicating the validity and consistency of said estimates.

MPOWER data

Summary indicators of country-specific achievements for each MPOWER measure are released by the WHO every two years and date back to 2007. Data from different iterations of the WHO Report on the Global Tobacco Epidemic (2008 6 , 2009 29 , 2011 30 , 2013 31 , 2015 32 and 2017 20 ) were downloaded from the WHO Tobacco Free Initiative website ( https://www.who.int/tobacco/about/en/ ). To assess the quality of national-level legislation, the WHO attributes a score to each MPOWER component that ranges from 1 to 4 for the monitoring (M) dimension and 1–5 for the other dimensions. A score of 1 represents no known data or no recent data, while scores 2–5 characterize the overall strength of each policy, from the lowest level of achievement (weakest policy) to the highest (strongest policy).

Specifically, smoke-free legislation (P) is assessed to determine whether smoke-free laws provide for a complete indoor smoke-free environment at all times in each of the respective places: healthcare facilities; educational facilities other than universities; universities; government facilities; indoor offices and workplaces not considered in any other category; restaurants or facilities that serve mostly food; cafes, pubs and bars or facilities that serve mostly beverages; and public transport. Achievement scores are then based on the number of places where indoor smoking is completely prohibited. Regarding health warning policies (W), the size of the warnings on both the front and back of the cigarette pack are averaged to calculate the percentage of the total pack surface area covered by the warning. This information is combined with seven best practice warning characteristics to construct policy scores for the W dimension. Finally, countries achievements in banning tobacco advertising, promotion and sponsorship (E) are assessed based on whether bans cover the following types of direct and indirect advertising: (1) direct: national television and radio; local magazines and newspapers; billboards and outdoor advertising; and point of sale (indoors); (2) indirect: free distribution of tobacco products in the mail or through other means; promotional discounts; nontobacco products identified with tobacco brand names; brand names of nontobacco products used or tobacco products; appearance of tobacco brands or products in television and/or films; and sponsorship.

P, W and E achievement scores, ranging from 2 to 5, were included as predictors into the model. The goal was to not only capture the effect of adopting policies at its highest levels but also assess the reduction in prevalence that could be achieved if countries moved into the expected direction in terms of implementing stronger measures over time. Additionally, having P, W and E scores separately, and not combined into a composite score, enabled us to capture the independent effect of different types of policies.

Although compliance is a critical factor in understanding policy effectiveness, the achievement scores incorporated in our main analysis reflect the adoption of legislation rather than degree of enforcement, representing a limitation of these indicators.

Prices in I$ for a 20-cigarette pack of the most sold brand in each of the 175 countries were also sourced from the WHO Tobacco Free Initiative website for all available years (2008, 2010, 2012, 2014 and 2016). I$ standardize prices across countries and also adjust for inflation across time. This information was used to construct an affordability metric that captures the impact of cigarette prices on smoking prevalence, considering the income level of each country.

More specifically, the RIP, calculated as the percentage of per capita GDP required to purchase one half pack of cigarettes a day over the course of a year, was computed for each available country and year. Per capita GDP estimates were drawn from the Institute for Health Metrics and Evaluation; the estimation process is detailed elsewhere 33 .

Given that the price data used in the analysis refer to the most sold brand of cigarettes only, it does not reflect the full range of prices of different types of tobacco products available in each location. This might particularly affect our power in detecting a strong effect in countries where other forms of tobacco are more popular.

Statistical analysis

Sex- and age-specific logit-transformed prevalence estimates from 2009 to 2017 were matched to one-year lagged achievement scores and RIP values using country and year identifiers 34 . The final sample consisted of 175 countries and was constrained to locations and years with non-missing indicators. A multiple linear mixed effects model fitted by restricted maximum likelihood was used to assess the independent effect of P, W and E scores and RIP values on the rates of current smoking. Specifically, a country random intercept and a country random slope on RIP were included to account for geographical heterogeneity and within-country correlation. The regression model takes the following general form:

where y c,t is the prevalence of current smoking in each country ( c ) and year ( t ), β 0 is the intercept for the model and β p , β w , β e and β r are the fixed effects for each of the policy predictors. \(\mathrm{P}_{c,\,t - 1},\,\mathrm{W}_{c,\,t - 1},\,\mathrm{E}_{c,\,t - 1}\) are the P, W and E scores and R c , t −1 is the RIP value for country c in year t  − 1. Finally, α c is the random intercept for country ( c ), while δ c represent the random slope for the country ( c ) to which the RIP value (R t − 1 ) belongs. Variance inflation factor values were calculated for all the predictor parameters to check for multicollinearity; the values found were low (<2) 35 . Bivariate models were also run and are shown in Extended Data Fig. 5 . The one-year lag introduced into the model may have led to an underestimation of effect sizes, particularly as many MPOWER policies require a greater period of time to be implemented effectively. However, due to the limited time range of our data (spanning eight years in total), introducing a longer lag period would have resulted in the loss of additional data points, thus further limiting our statistical power in detecting relevant associations between policies and smoking prevalence.

In addition to a joint model for smokers from both sexes, separate regressions were fitted for men and women and the four age groups (15–29, 30–49, ≥50 and ≥15 years old). To assess the validity of the mixed effects analyses, likelihood ratio tests comparing the models with random effects to the null models with only fixed effects were performed. Linear mixed models were fitted by maximum likelihood and t -tests used Satterthwaite approximations to degrees of freedom. P values were considered statistically significant if <0.05. All analyses were executed with RStudio v.1.1.383 using the lmer function in the R package lme4 v.1.1-21 (ref. 36 ).

A series of additional models to examine the impact of tobacco control policies were developed as part of this study. In each model, cigarette affordability (RIP) and a different set of policy metrics was used to capture the implementation, quality and compliance of tobacco control legislation. In models 1 and 2, we replaced the achievements scores by the proportion of P, W and E measures adopted by each country out of all possible measures reported by the WHO. In model 3, we used P and E (direct and indirect measures separately) compliance scores provided by the WHO to represent actual legislation implementation. Finally, an interaction term for compliance and achievement to capture the combined effect of legislation quality and performance was added to model 4. Results for men and women by age group for each of the additional models are presented in the Supplemental Information (Supplementary Tables 1–4 ).

The main model described in this study was chosen because it includes a larger number of country-year observations ( n  = 823) when compared to models including compliance scores and because it is more directly interpretable.

Counterfactual analysis

To further explore and quantify the impact of tobacco control policies on current smoking prevalence, we simulated what smoking prevalence across all countries would have been achieved in 2017 under 4 alternative policy scenarios: (1) if achievement scores and RIP remained at the level they were at in 2008; (2) if all countries had implemented each of P, W and E component at the highest level (score = 5); (3) if the price of a cigarette pack was I$7.73 or higher, a price that represents the 90th percentile of observed prices across all countries and years; and (4) if countries had implemented the P, W and E components at the highest level and higher cigarette prices. To keep our results consistent across scenarios, we restricted our analysis to 155 countries with non-missing policy-related indicators for both 2008 and 2016.

Random effects were used in model fitting but not in this prediction. Simulated prevalence rates were calculated by multiplying the estimated marginal effect of each policy by the alternative values proposed in each of the counterfactual scenarios for each country-year. The global population-weighted average was computed for status quo and counterfactual scenarios using population data sourced from the Institute for Health Metrics and Evaluation. Using the predicted prevalence rates and population data, the additional reduction in the number of current smokers in 2017 was also computed. Since models were ran using age-standardized prevalence, the number of smokers was proportionally redistributed across age groups using the sex-specific numbers from the age group 15 and older as an envelope.

The UIs for predicted estimates were based on a computation of the results of each of the 1,000 draws (unbiased random samples) taken from the uncertainty distribution of each of the estimated coefficients; the lower bound of the 95% UI for the final quantity of interest is the 2.5 percentile of the distribution and the upper bound is the 97.5 percentile of the distribution.

Reporting Summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

The dataset generated and analyzed during the current study is publicly available at http://ghdx.healthdata.org/record/ihme-data/global-tobacco-control-and-smoking-prevalence-scenarios-2017 ( https://doi.org/10.6069/QAZ7-6505 ). The dataset contains all data necessary to interpret, replicate and build on the methods or findings reported in the article. Tobacco control policy data that support the findings of this study are released every two years as part of the WHO’s Global Report on Tobacco Control; these data are also directly accessible at https://www.who.int/tobacco/global_report/en/ . Source data are provided with this paper.

Code availability

All code used for these analyses is available at http://ghdx.healthdata.org/record/ihme-data/global-tobacco-control-and-smoking-prevalence-scenarios-2017 and https://github.com/ihmeuw/team/tree/effects_tobacco_policies .

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Acknowledgements

The study was funded by Bloomberg Philanthropies (grant 47386, Initiative to Reduce Tobacco Use). We thank the support of the Tobacco Metrics Team Advisory Group, which provided valuable comments and suggestions over several iterations of this manuscript. We also thank the Tobacco Free Initiative team at the WHO and the Campaign for Tobacco-Free Kids for making the tobacco control legislation data available and providing clarifications when necessary. We thank A. Tapp, E. Mullany and J. Whisnant for assisting in the management and execution of this study. We thank the team who worked in a previous iteration of this project, especially A. Reynolds, C. Margono, E. Dansereau, K. Bolt, M. Subart and X. Dai. Lastly, we thank all GBD 2017 Tobacco collaborators for their valuable work in providing feedback to our smoking prevalence estimates throughout the GBD 2017 cycle.

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Luisa S. Flor, Marissa B. Reitsma, Vinay Gupta & Emmanuela Gakidou

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L.S.F., M.N. and E.G. conceptualized the study and designed the analytical framework. M.B.R. and V.G. provided input on data, results and interpretation. L.S.F. and E.G. wrote the first draft of the manuscript. All authors read and approved the final version of the manuscript.

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Extended data

Extended data fig. 1 prevalence of current smoking for men (a) and women (b) aged 15 years and older (age-standardized) in 2017..

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 15 years and older for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 2 Prevalence of current smoking for men (a) and women (b) aged 15 to 29 years old (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 15–29 years old for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 3 Prevalence of current smoking for men (a) and women (b) aged 30 to 49 years old (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 30–49 years old for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 4 Prevalence of current smoking for men (a) and women (b) aged 50 years and older (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 50 years and older for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 5 Percentage changes in current smoking prevalence based on fixed effect coefficients from bivariate mixed effect linear regression models, by policy component, sex and age group.

Bivariate models examined the unadjusted association between smoke-free (P), health warnings (W), and advertising (E) achievement scores, and cigarette’s affordability (RIP) and current smoking prevalence, from 2009 to 2017, across 175 countries (n = 823 country-years). Linear mixed models were fit by maximum likelihood and t-tests used Satterthwaite approximations to degrees of freedom. P values were considered statistically significant if lower than 0.05.

Supplementary information

Supplementary information.

Supplementary Tables 1–4: additional models results.

Source Data Fig. 1

Input data for Fig. 1 replication.

Source Data Extended Data Fig. 1

Input data for Extended Data 1 replication.

Source Data Extended Data Fig. 2

Input data for Extended Data 2 replication.

Source Data Extended Data Fig. 3

Input data for Extended Data 3 replication.

Source Data Extended Data Fig. 4

Input data for Extended Data 4 replication.

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Flor, L.S., Reitsma, M.B., Gupta, V. et al. The effects of tobacco control policies on global smoking prevalence. Nat Med 27 , 239–243 (2021). https://doi.org/10.1038/s41591-020-01210-8

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• Published: 01 February 2017

College anti-smoking policies and student smoking behavior: a review of the literature

• Brooke L. Bennett 1 ,
• Melodi Deiner 1 &
• Pallav Pokhrel 1  

Tobacco Induced Diseases volume  15 , Article number:  11 ( 2017 ) Cite this article

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Currently, most college campuses across the U.S. in some way address on-campus cigarette smoking, mainly through policies that restrict smoking on campus premises. However, it is not well understood whether college-level anti-smoking policies help reduce cigarette smoking among students. In addition, little is known about policies that may have an impact on student smoking behavior. This study attempted to address these issues through a literature review.

A systematic literature review was performed. To identify relevant studies, the following online databases were searched using specific keywords: Ovid MEDLINE, PsycINFO, PubMed, and Google Scholar. Studies that met the exclusion and inclusion criteria were selected for review. Studies were not excluded based on the type of anti-smoking policy studied.

Total 11 studies were included in the review. The majority of the studies (54.5%) were cross-sectional in design, 18% were longitudinal, and the rest involved counting cigarette butts or smokers. Most studies represented more women than men and more Whites than individuals of other ethnic/racial groups. The majority (54.5%) of the studies evaluated 100% smoke-free or tobacco-free campus policies. Other types of policies studied included the use of partial smoking restriction and integration of preventive education and/or smoking cessation programs into college-level policies. As far as the role of campus smoking policies on reducing student smoking behavior is concerned, the results of the cross-sectional studies were mixed. However, the results of the two longitudinal studies reviewed were promising in that policies were found to significantly reduce smoking behavior and pro-smoking attitudes over time.

More longitudinal studies are needed to better understand the role of college anti-smoking policies on student smoking behavior. Current data indicate that stricter, more comprehensive policies, and policies that incorporate prevention and cessation programming, produce better results in terms of reducing smoking behavior.

Tobacco use, especially cigarette smoking, continues to remain a leading preventable cause of mortality in the United States (U.S.). Across different age-groups, young adults (18–29 year olds) tend to show the highest prevalence of cigarette smoking [ 1 ]. For example, past-30-day prevalence of cigarette smoking among 18–24 year olds is 17%, whereas the prevalence is approximately 9% among high school students [ 2 ]. Although most smokers initiate cigarette smoking in adolescence, young adulthood is the period during which experimenters transition into regular use and develop nicotine dependence [ 1 ]. Young adulthood is also the period that facilitates continued intermittent or occasional smoking [ 3 ], neither of which is safe. In addition to the possibility that intermittent smokers may show escalation in nicotine dependence, intermittent smoking exposes individuals to carcinogens and induces adverse physiological consequences [ 4 ].

Research [ 5 ] shows that smokers who quit smoking before the age of 30 almost eliminate the risk of mortality due to smoking-induced causes. Thus smoking prevention and cessation efforts that target young adults are of importance. Traditionally, tobacco-related primary prevention efforts have mostly focused on adolescents [ 6 ] and have utilized mass media as well as school and community settings [ 7 , 8 ]. This is only natural given that most smoking initiation occurs in adolescence. However, primary and secondary prevention efforts focusing on young adults have been less common. This is particularly of concern because tobacco industry is known to market tobacco products strategically to promote tobacco use among young adults by integrating tobacco use into activities and places that are relevant to young adults [ 9 ].

As more and more young adults attend college [ 10 ], college campuses provide a great setting for primary and secondary smoking prevention as well as smoking cessation efforts targeting young adults. According to the American College Health Association [ 11 ], approximately 29% U.S. college students report lifetime cigarette smoking and 12% report past-30-day smoking. Currently, most college campuses across the U.S. in some way address on-campus cigarette smoking, mainly through policies that restrict smoking [ 12 , 13 ]. One of the main reasons why such policies are considered important is the concern about students’ exposure to secondhand tobacco smoke [ 14 ]. Therefore, at their most rudimentary forms, such policies tend to be extensions of local- or state-level policies restricting smoking in public places [ 15 ]. However, some colleges may take a more comprehensive approach, by integrating, for example, smoke-free policies with anti-smoking campaigns and college-sponsored cessation services [ 16 ]. Further, some colleges may implement plans to enhance enforcement of and compliance to the smoke-free policies [ 17 – 19 ].

At present, there are a number of questions related to college-level anti-smoking policies that need to be examined carefully in order to scientifically inform how colleges can be better utilized to promote smoking prevention and cessation among young adults. Besides the degree of variation in anti-smoking policies, there are questions about students’ compliance with such policies and whether such policies have influence on students’ attitudes and behavior related to cigarette smoking. Past reviews of the studies on the effects of tobacco control policies in general (e.g., not specific to college populations) [ 20 – 22 ] emphasize the need for a review such as the current study. Wilson et al. [ 20 ] found that interventions involving smoke-free public places, mostly restaurants/bars and workplaces, showed a moderate to low effect in terms of reducing smoking prevalence and promoting smoking cessation. The review included three longitudinal studies, none of which showed that the policies had an effect on smoking cessation. Fichtenberg & Glanz [ 21 ] focused on smoke-free workplaces and found that the effects of such policies seemed to depend on their strength. That is, 100% smoke-free policies were found to reduce cigarette consumption and smoking prevalence twice as much as partial smoke-free policies that allowed smoking in certain areas. In a recent exhaustive review, Frazer et al. [ 22 ] found that although national restrictions on smoking in public places may improve cardiovascular health outcomes and reduce smoking-related mortality, their effects on smoking behavior appear inconsistent. There are reasons why college anti-smoking policies may be more effective than policies focused on restaurant/bars or even workplaces. For example, students tend to spend the majority of their time on campus premises. In fact, in the case of 4-year colleges, a large number of students live on or around campus premises. Strong anti-smoking policies may deter students from smoking by making, for example, smoking very inconvenient. However, the current state of research on college anti-smoking policies and student smoking behavior is not well documented.

The purpose of the current study is to systematically review quantitative studies that have investigated the impact of college-level anti-smoking policies on students’ attitudes towards tobacco smoking and smoking behavior. In the process, we intend to highlight the types of research designs used across studies, the types of college and student participants represented across studies, and the studies’ major findings. A point to note is that this review’s focus is on anti-smoking policies and cigarette smoking. Although the review does assess tobacco-free policies in general, our assumption at the outset has been that most studies in the area have had a focus on smoke-free policies and smoking behavior because of the emphasis on secondhand smoke exposure. Smoke-free and tobacco-free policies are different in that smoke-free policies have traditionally targeted smoking only whereas tobacco-free policies that have targeted tobacco use of any kind, including smokeless tobacco [ 23 ]. Both types of policy could be easily extended to incorporate new tobacco products such as the electronic nicotine delivery devices, commonly known as e-cigarettes. Given that e-cigarettes are a relatively new phenomenon in the process of being regulated, we assumed that the studies eligible for the current review might not have addressed e-cigarette use, although if addressed by the studies reviewed, we were open to addressing e-cigarettes and e-cigarette use or vaping in the current review.

Study selection

We searched Ovid MEDLINE (1990 to June, 2016), PubMed (1990 to June, 2016), PsycINFO (1990 to 2013), and Google Scholar databases to identify U.S.-based peer-reviewed studies that examined the effects of college anti-smoking policies on young adults’ smoking behavior. Searches were conducted by crossing keywords “college” and “university” separately with “policy/policies” and “smoking”, “tobacco”, “school tobacco”, “smoke-free” “smoking ban,” and “tobacco free.” Article relevance was first determined by scanning the titles and abstracts of the articles generated from the initial search. Every quantitative study that dealt with college smoking policy was selected for the next round of appraisal, during which, the first and the last authors independently read the full texts of the articles to vet them for selection. Studies were selected for inclusion in the review if they met the following criteria: studies 1) were conducted in the U.S. college campuses, including 2- and 4-year colleges and universities; 2) were focused on young adults (18–25 year olds); 3) focused on implementation of college-level smoking policies; 4) were quantitative in methodology (e.g., case studies and studies based on focus groups and interviews were excluded); and 5) directly (e.g., self-report) or indirectly (e.g., counting cigarette butts on premises) assessed the cigarette smoking behavior. References and bibliographies of the articles that met the inclusion criteria were also carefully examined to locate additional, potentially eligible studies.

Selected studies were reviewed independently by the first and the last authors in terms of study objectives, study design (i.e., cross-sectional or longitudinal), data collection methods, participant characteristics, U.S. region where the study was conducted, college type (e.g., 2- year vs. 4-year), policies examined and the main study findings. The review results independently compiled by the two authors were compared and aggregated after differences were sorted out and a consensus was reached.

Study characteristics

Figure  1 depicts the path to the final set of articles selected for review. Initial searches across databases resulted in total 71 titles and abstracts related to college smoking policies. Of these, 49 were deemed ineligible at the first phase of evaluation. The remaining 22 articles were evaluated further, of which, 11 were excluded eventually. Two studies [ 24 , 25 ] were excluded because these studies did not assess students’ tobacco use behavior. One study [ 26 ] was excluded because it was not quantitative. Five studies [ 17 – 19 , 27 , 28 ] were excluded because the studies focused on compliance to existing smoking policies and did not assess the impact of policies on behavior. One study [ 15 ] was excluded because although it studied college students, the smoking policies examined were county-wide rather than college-level. Two studies [ 29 , 30 ] were excluded because their samples consisted of college personnel rather than students. Thus, a total of 11 studies were included in the current review.

Chart depicting selection of the final set of articles reviewed

Table  1 summarizes the selected studies in terms of research purpose, study design, subjects, type of college, region, policies and findings. The majority of the studies were conducted in the Midwestern ( n  = 3; 27.3%) or Southeastern United States ( n  = 3; 27.3%). Other regions represented across studies were Southern ( n  = 2; 18.1%), Northwestern ( n  = 2; 18.1%), and Western United States ( n  = 1; 9.1%). Six studies (54.5%) included predominantly White participants (i.e., greater than 70%), and 2 studies (18%) included predominantly female participants. Nationally, women and Whites comprise 56% and 59% of the U.S. college student demographics, respectively [ 10 ]. Two studies (18.1%) assessed smoking behavior indirectly by counting cigarette butts on college premises, counting the number of individuals smoking cigarettes in campus smoking “hotspots,” or counting the number of smokers who utilized smoking cessation services. Across studies, the sample size ranged between N  = 36 and N  = 13,041. The mean and median sample sizes across studies were 3102 (SD = 4138) and 1309, respectively. Participants tended to range between 18 and 30 years in age. The majority of the studies ( n  = 6; 54.4%) were cross-sectional in design. Only 2 (18%) of the studies were longitudinal. The majority of the studies were conducted at 4-year colleges ( n  = 10; 90.9%). Only 1 study was conducted at a 2-year college ( n  = 1; 9.1%).

Three studies (27%) focused on tobacco-free policies and 3 studies (27%) on smoke-free policies. Three studies ( n  = 3; 27.3%) compared the associations of differing policies on smoking behavior. One study [ 31 ] examined the relative impacts of policies utilizing preventive education, smoking cessation programs, and designated smoking areas or partial smoking restriction. Another study [ 32 ] implemented an intervention to increase adherence to a partial smoking policy (i.e., smoking ban within 25 ft of buildings). The intervention involved increasing anti-tobacco signage, moving receptacles, marking the ground, and distributing reinforcements and reminder cards.

Anti-smoking policies and students’ smoking behavior

Table  1 lists the types of anti-smoking policies examined across studies and the corresponding findings. Major findings are as follows:

Partial smoking restriction

Borders et al. [ 31 ] compared colleges that utilized partial smoking restriction by providing “designated smoking areas” to curb smoking with college-level policies that incorporated preventive education and with those that provided smoking cessation courses only. Results indicated that the presence of preventive education was associated with lower odds of past-30-day smoking whereas the presence of designated smoking areas only or smoking cessation programs only was associated with higher odds of past-30-day smoking. Fallin et al. [ 16 ] found that college campuses with designated smoking areas tended to show higher prevalence of smoking, compared with campuses that enforced smoke-free and tobacco-free policies. Braverman et al.’s [ 33 ] findings indicate that enforcing smoke-free policies tends to reduce secondhand exposure close to college buildings but may increase smoking behavior on the campus periphery.

Smoke- and tobacco-free campuses

Fallin et al. [ 16 ] found that compared with policies that relied on partial smoking restriction, tobacco-free policies were associated with reduced self-reported exposure to secondhand smoke as well as students’ lower self-reported intentions to smoke cigarettes in the future. Studies [ 34 , 35 ] consistently observed fewer cigarette butts or smokers in campuses under smoke-free policies compared with campuses without smoke-free policies. Prevalence of cigarette butts was likely to be inversely related to policy strength [ 35 ]. A study that monitored smokers’ behavioral compliance to smoke-free policies [ 32 ] indicated that interventions to promote compliance, such as use of signage, are likely to be effective in improving compliance and reducing student smoking in areas were the policy is enforced.

Lechner et al. [ 36 ] conducted assessments at a single college campus before and after a tobacco-free policy went into implementation. The policy, which also involved making smoking cessation services available campus-wide, was found to reduce proportions of high- and low-frequency smokers, pro-smoking attitudes (i.e., weight loss expectancy), and exposure to second-hand tobacco smoke [ 36 ]. The study did not find an effect on smoking prevalence. Seo et al. [ 37 ] followed a similar design where a policy intervention was evaluated based on pretest and posttest surveys. However, this study [ 37 ] included a “control” campus where similar assessments as in the “treatment” campus were conducted but no intervention was implemented. The study found that compared with the control campus, the campus that implemented smoke-free policies showed an overall decrease in smoking prevalence.

Other policies

Borders et al. [ 31 ] did not find policies governing the sales and distribution of cigarettes on campus to be associated with smoking behavior. Hahn et al. [ 38 ] found that college smoking policies that integrate smoking cessation services may increase the use of such services as well as promote smoking cessation. This study kept track of students who utilized the smoking cessation service offered by a college after the policy offering such a service was enacted. Sixteen months after the policy was first implemented, smokers who utilized the service were surveyed. Based the results it was estimated that approximately 9% of them had quit smoking.

To our knowledge, this is the first study to systematically review studies examining the effects of anti-smoking policies on smoking behaviors among U.S. college students. We found that such studies are severely limited. Only 11 studies met the inclusion criteria in the present review, although the review appeared to encompass all policies aimed at smoking behavior on college campuses. Thus, this review stresses the need for increased smoking policy and smoking behavior research on college campuses.

Rigorous evaluation of existing college anti-tobacco policies are needed to refine and improve the policies so that national-level efforts to reduce tobacco use among young adults are realized. Key initiatives at the national level have recognized the importance of mobilizing college campuses in the fight against tobacco use. For example, in September 2012 several national leaders involved in tobacco control efforts, in collaboration with the ACHA, came together to launch the Tobacco-Free College Campus Initiative (TFCCI) [ 39 ]. The TFCCI aims to promote and support the use of college-level anti-tobacco policies as a means to change pro-tobacco social norms on campuses, discourage tobacco use, protect non-smokers from second-hand exposure to tobacco smoke and promote smoking cessation. The ACHA’s position statement [ 11 ] regarding college tobacco control recommends a no tobacco use policy aimed towards achieving a 100% indoor and outdoor campus-wide tobacco-free environment.

We found that the majority of studies on smoking policies were cross-sectional in nature. Researchers relied upon students to report their smoking behavior or their observations of other students’ smoking behavior after a smoke-free or tobacco-free policy had been implemented. It is difficult to draw conclusions about an anti-smoking policy’s ability to change smoking behavior without knowing the smoking behavior prior to policy implementation. This domain of research would benefit from additional longitudinal studies. Ideally, research studies should collect data before the policy is implemented, immediately after, and at follow-up time points.

We found inconsistencies in the measurement of smoking behavior across studies. Two studies [ 34 , 35 ] counted cigarette butts, one study [ 38 ] counted people seeking tobacco dependence treatment, one study [ 32 ] counted smokers violating policy, and seven studies [ 16 , 31 , 36 , 37 , 40 , 41 ] relied upon self-report of smoking behavior. Another study [ 33 ] used survey methods to obtain participants’ response on other students’ smoking behavior. Counting cigarette butts has been validated as an effective measure of smoking behavior [ 19 ], especially when validating compliance to an anti-smoking policy, and self-report measures are commonly used in public health research [ 42 ]. Despite the validity and feasibility of these measures, the lack of a consistent measurement tool makes comparing effectiveness of anti-smoking policies on smoking behaviors across campuses difficult. Research in this domain would benefit from a consistently used measurement of smoking behaviors.

Although the reviewed studies represented diverse U.S. regions, the majority of the research was set in the Southeastern and Midwestern United States; Northeastern and Southwestern regions were not represented. Only one of the reviewed studies reported a sample that contained less than 50% White participants. Across studies, the minority group most represented was Asian American; but only one of the reviewed studies [ 16 ] included 20% or more Asian Americans. Relatively few studies included or reported Hispanic participants, although Hispanics are the largest minority group in the United States [ 43 ]. None of the reviewed studies included 20% or more Black participants. Only three studies [ 33 , 36 , 37 ] included American Indian/Alaska Natives and in only one of those studies [ 32 ] was the proportion greater than one percent. Only two studies [ 33 , 37 ] included Pacific Islanders, and in both the proportion was less than one percent. Clearly, more research is needed on minority populations, specifically Black, Hispanic, Native Hawaiian/Pacific Islander, American Indian/Alaska Native students and the subgroups commonly subsumed under these ethnic/racial categories. The U.S. college student demography is ethnically/racially diverse [ 10 ], comprising 59% Whites. The remaining 44% include various minority groups. Thus, for research on U.S. college students across the nation, studies with more ethnically/racially diverse student samples are needed.

The review findings were helpful in elucidating the types of tobacco policies being implemented on college campuses and their effects on the smoking behavior of U.S. college students. Mainly, three types of smoking policies were studied: smoke-free policies, tobacco-free policies and policies that enforced partial smoking restriction, including prohibition of smoking within 20–25 ft of all buildings and providing designated smoking areas. Indeed, campus-wide indoor and outdoor tobacco-free policy is considered a gold-standard for college campus tobacco control policy [ 11 ]. But only one study [ 16 ] compared tobacco-free and smoke-free policies. Other policies such as governing the sale and distribution of tobacco products, preventive education programs, and smoking cessations programs were also studied, but to a lesser extent. In general, interventions regarding the implementation of smoking policies on college campuses were difficult to find in the existing literature.

The combined results of the studies reviewed suggest that stricter smoking policies are more successful in reducing the smoking behavior of students. Tobacco-free and smoke-free policies were linked with reduced smoking frequency [ 16 , 36 , 37 ], reduced exposure to second-hand smoke [ 16 , 36 ], and a reduction in pro-smoking attitudes [ 36 ]. Implementation of a campus-wide tobacco-free or smoke-free policy combined with access to smoking cessation services was also associated with increased quit attempts [ 38 , 40 ] and treatment seeking behaviors [ 38 ]. It appears that 100% smoke-free policies are not only successful in reducing smoking rates, but also have strong support from students and staff members alike [ 33 ]. These results remained consistent when compared to less comprehensive tobacco control policies, which was evidenced by student report and the number of cigarette butts found on campus [ 34 , 35 ].

There was one important consistent exception to the general success of anti-smoking policies: designated smoking areas. All three studies which included designated smoking areas [ 16 , 31 , 41 ] found that designated smoking areas were associated with higher rates of smoking compared with smoke-free or tobacco-free policies. Designated smoking areas were also associated with the highest rates of recent smoking [ 16 ]. Lochbihler, Miller, and Etcheverry [ 41 ] proposed that students using the designated areas were more likely to experience positive effects of social interaction while smoking. They found that social interaction while smoking on campus significantly increased the perceived rewards associated with smoking and the frequency of visits to designated smoking areas [ 41 ].

None of the studies included in this review addressed new and emerging tobacco products such as e-cigarettes. This is understandable given that the surge in e-cigarette use is relatively new and in general there have only been a few studies examining the effects of anti-smoking policies on student smoking behavior, which has been the focus of this review. However, going forward, it will be crucial for studies to examine how campus policies are going to handle e-cigarette use, including the enforcement of on-campus anti-smoking policies given the new challenges posed by e-cigarette use [ 44 ]. For example, e-cigarette use is highly visible, the smell of the e-cigarette vapor does not linger in the air for long and e-cigarette consumption does not result in something similar to cigarette butts. These characteristics are likely to make the monitoring of policy compliance more difficult. Moreover, because of the general perception among e-cigarette users that e-cigarette use is safer than cigarette smoking, compared with cigarette smokers smoking cigarettes, e-cigarette users might be more likely to use e-cigarettes in public places. The fact that the TFCCI strongly recommends the inclusion of e-cigarettes in college tobacco-free policies [ 39 ] bodes well for the future of college health.

The current study has certain limitations. It is possible that this review might have missed a very small number of eligible studies. We believe that the literature searches we completed were thorough. However, new studies are regularly being published and the possibility that a new, eligible study may have been published after we completed our searches cannot be ignored. In addition, we may not have tapped eligible studies that were in press during our searches. If indeed a few eligible studies were not included in our review, the non-inclusion may have biased our results somewhat, although it is difficult for us to speculate the nature of such a bias. Hence, we recommend that similar studies need to be conducted in the future to periodically review the literature. Second, non-peer-reviewed articles or book chapters were excluded from this review. Despite the potential relevance of non-peer-reviewed materials, the choice was made to limit the inclusion in order to maintain scientific rigor of the review. However, it is possible that some data pertinent to the review might have been overlooked because of this, thus increasing the possibility of introducing a bias to the current findings. Third, this study focused on anti-smoking policies. Although we used “tobacco free” as search terms, “smoking” dominated our search strategies. Thus our results are more pertinent to cigarette smoking than other tobacco products and may not generalize to the latter. Lastly, in order to be as inclusive as possible, we reviewed three studies [ 32 , 35 , 38 ] that focused on more on compliance to anti-smoking policy than on the effect of policy on student smoking behavior. The findings of these studies may not be comprehensive in regard to student smoking behavior, even though they are indicative of the success of the policies under examination.

Conclusions

Despite limitations, this study is significant for increasing the understanding of smoking policies on U.S. college campuses and their effects on the smoking behavior of college students. We found that research on smoking policies on U.S. college campuses is very limited and is an area in need of additional research contribution. Within existing research, the majority used samples that were primarily White females. More diverse samples are needed. Future research should also report the full racial/ethnic characteristics of their samples in order to identify where representation may be lacking. Future research would benefit from longitudinal and interventional studies of the implementation of smoking policies. The majority of current research is cross-sectional, which does not provide the needed data in order to make causal statements about anti-smoking policies. Lastly, existing research was primarily conducted at 4-year colleges or universities. Future research would benefit from broadening the target campuses to include community colleges and trade schools. Community colleges provide a rich and unique opportunity to collect data on a population that is often older and more racial diverse than a typical 4-year college sample [ 45 ]. Also, there is at present a need to understand through research how evidence-based implementation and compliance strategies can be utilized to ensure policy success. A strong policy on paper does not often translate into a strong policy in action. Thus, comparing policies on the strength of written documents alone is not enough; policies need to be compared on the extent to which they are enforced as well as the impact they have on student behavior.

This review may be of particular interest to college or universities in the process of making their own anti-smoking policies. The combined results of the existing studies on the impact of anti-smoking policies on smoking behaviors among U.S. college students can help colleges and universities make informed decisions. The existing research suggests that stricter policies produce better results for smoking behavior reduction and with smoking continuing to remain a leading preventable cause of mortality in the U.S. across age-groups [ 1 ], college and university policy makers should take note. Young adults (18–25 year olds) show the highest prevalence of cigarette smoking [ 1 ], which places colleges and universities in the unique position to potentially intervene through restrictive anti-smoking policies on campus.

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This research was supported by National Cancer Institute (NCI) grant 1R01CA202277-01.

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BB conducted the literature review, analyzed and interpreted results, and was a major contributor in writing the manuscript. MD assisted with the literature review. PP conceptualized the study, assisted with the literature review and manuscript preparation, and provided overall guidance. All authors read and approved the final manuscript.

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Bennett, B.L., Deiner, M. & Pokhrel, P. College anti-smoking policies and student smoking behavior: a review of the literature. Tob. Induced Dis. 15 , 11 (2017). https://doi.org/10.1186/s12971-017-0117-z

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The forgotten smoker: a qualitative study of attitudes towards smoking, quitting, and tobacco control policies among continuing smokers

• Navneet Uppal 1 ,
• Lion Shahab 2 ,
• John Britton 1 &
• Elena Ratschen 1  

BMC Public Health volume  13 , Article number:  432 ( 2013 ) Cite this article

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Although research suggests that the majority of smokers want to quit smoking, the uptake of Stop Smoking Services, designed to assist smokers with quitting, remains low. Little is known about continuing smokers who do not access these services, and opportunities to influence their motivation and encourage quit attempts through the uptake of services. Using PRIME theory, this study explored differences between continuing smokers who had varying levels of motivation to quit, in terms of their plans to quit, evaluative beliefs about smoking, cigarette dependence, and attitudes towards tobacco control policies and services.

Twenty-two current smokers, recruited from the community, were classified by motivation level to quit using a self-report questionnaire (two groups: high/low). Four focus groups (n=13) and individual interviews (n=9) were conducted with both groups using an interview guide incorporating aspects of PRIME theory. Discussion areas included motives for smoking, attitudes towards smoking and quitting, perceptions of dependence, motives for quitting, barriers to quitting, and attitudes towards existing and impending tobacco control policies and services. Verbatim transcripts were analysed using thematic framework analysis.

All participants expressed low motivation to quit during discussions, despite some initially self-classifying as having high explicit levels of motivation to quit. Both groups reported similar attitudes towards smoking and quitting, including a perceived psychological addiction to smoking, positive evaluations about smoking which inhibited plans to quit, and similar suggested methods to increase motivation (simply wanting to, save money, improve health). Most felt that they ‘ought’ to quit as opposed to ‘wanted’ to. Little influence was ascribed towards tobacco control policies such as plain packaging and hidden sales displays, and participants felt that price increases of tobacco products needed to be considerable in order to influence motivation. Highly motivated smokers expressed more willingness to visit Stop Smoking Services, although none had done so.

Continuing smokers’ attitudes towards smoking and quitting suggests that research and policy need to focus on increasing smokers’ implicit motivation to quit smoking, even for those who classified themselves as having high motivation to quit. Targeted information and further education about Stop Smoking Services is required to increase uptake.

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As in other developed countries, smoking remains the single largest cause of preventable deaths in England, with over 86,000 deaths per year caused by this harmful addictive behaviour [ 1 ], and an enormous financial burden of £5bn placed on the NHS [ 2 ]. Reducing smoking prevalence and preventing smoking uptake have therefore been identified as important public health targets [ 3 ], with increasingly comprehensive measures of tobacco control policy (including smokefree legislation, increased taxation and advertising restrictions [ 4 ]) and standards for clinical practice [ 5 ] aimed at achieving this goal. Although smoking prevalence has been decreasing steadily over the last decades, the decrease appears to have stagnated in recent years, with 21% of the population currently still smoking [ 6 ]. Evidence suggests that the majority of current smokers (70%) are motivated to quit [ 7 ]; however, it is only a small minority of smokers (4% each year) who access the NHS Stop Smoking Services (SSS) [ 8 ] to assist them, which provide evidence-based behavioural and pharmacological support [ 9 ]. Although some research has shown that successful quit attempts may be unplanned [ 10 ] or made without any form of pharmacological and/or behavioural support [ 11 , 12 ], other research has demonstrated the benefits of an assisted approach in encouraging quit attempts [ 13 , 14 ]. However, NHS SSS are known to attract smokers with a relatively high level of motivation to quit, as these smokers take the initiative to access services for assistance in quitting [ 15 ], whereas the population of smokers who report general motivation to give up, but do not access services, remain underserved in both research and practice; these smokers may be coined ‘forgotten smokers’.

In order to understand the potential of supporting behavioural change in continuing smokers who are not engaged in current quit attempts, the exploration of views and attitudes towards smoking, quitting, and measures of tobacco control is important. Theories of behaviour change espouse the central importance of an individual’s motivation for processes by which an addicted person may quit an addiction. For example, PRIME ( P lans, R esponses, I mpulses, M otives, E valuations) theory [ 16 ] of motivation, which has been applied specifically to smoking, states that the decision to quit smoking is based on a smoker’s evaluative beliefs about smoking (either positive or negative), which influence motives to either continue or quit. This motivation then interacts with internal tensions (impulses and urges to smoke) and external triggers (e.g. cues in the environment) to determine subsequent behaviour. Policy measures such as hidden sales displays and smokefree legislation may reduce the environmental cues to smoke, and other measures such as graphic warning imagery may enhance the cues to refrain from smoking. All of this is embedded in a smoker’s overall plan about smoking or quitting (i.e. their overall intentions or rules). While PRIME theory [ 16 ] has been applied to smokers in attempting to explain how quit attempts are made, little is known about the spectrum of continuing smokers, and about internal and external factors that may contribute to changes in motivational levels across this spectrum of different ‘types’ of smokers.

Using the conceptual framework of PRIME theory [ 16 ], this study aimed to explore aspects related to continuing smokers’ motivation to quit, with a focus on individuals’ overall plans to continue/quit smoking, evaluative beliefs about smoking and quitting, cigarette dependence, attitudes towards various measures of existing and impeding tobacco control (including packaging of cigarettes and hidden sales displays), and attitudes towards NHS SSS. Aiming ultimately at the development of a typology of smokers to match a range of targeted clinical and policy interventions in support of quitting smoking, a qualitative design was adopted to explore smokers’ beliefs in more detail in a smaller community sample, and to identify the key similarities and differences between continuing smokers with varying levels of motivation to quit.

Study design

Qualitative focus groups and semi-structured face-to-face interviews were conducted with continuing smokers.

Study participants and recruitment

A purposive approach was used to recruit a community sample of smokers aged over 18 who were not currently engaged in quit attempts, but had varying levels of motivation to quit in the future. Participants were recruited from a variety of residential areas across Nottingham and included a range of demographic factors (Aspley, Wollaton, Dunkirk, and Lenton). Recruitment was aimed to continue until theoretical saturation [ 17 ] was reached, i.e. no new meaningful data were being obtained. Advertising posters inviting smokers to discuss their opinions about smoking, with wording aiming to recruit both ‘happy’ smokers and those ‘wanting to quit’, were placed in community centres, public houses, libraries, supermarkets, and post offices. A snowballing approach was also used to support recruitment. The study was approved by the ethics board within the Medical School at the University of Nottingham. Participants received £10 as reimbursement for their efforts.

Study instruments

Participants were initially screened to determine motivation level to quit smoking using the validated Readiness to Quit Ladder [ 18 ]; a scale of items 1-10 (‘I have quit smoking’ to ‘I have decided not to quit smoking for my lifetime, I have no interest in quitting’). It was decided a priori by the researchers to classify those with a score of below 6 as having low motivation to quit, and those with a score of 6 and above as having high motivation to quit; previous research has found an average mean value ranging between 5.33 and 5.57 [ 19 ]. Participants also completed a short baseline questionnaire designed to gather quantitative data on demographic factors and details of previous quit attempts. Cigarette dependence was assessed using the Fagerstrom Test for Cigarette Dependence (FTCD) [ 20 ]. An interview guide was developed to explore a variety of factors to assist in identifying the characteristics and attitudes of both smokers with high and low motivation to quit, and included concepts from PRIME theory [ 16 ], such as details of plans to continue/quit smoking and evaluative beliefs about smoking, and several other factors designed to understand why smokers continue to smoke, and methods which may encourage motivation to quit and uptake of NHS SSS (e.g. discussion of the influence of policy measures such as taxation of cigarettes and the impact of this on motivation to quit). Areas for discussion included: motives for smoking, attitudes towards smoking and quitting, motives for quitting, barriers to quitting, and attitudes towards existing and impending policies (e.g. hidden sales displays, plain packaging) and services (e.g. local NHS SSS).

An initial meeting was set up with each participant, prior to arranging a date and time for the focus group, to complete the baseline questionnaire and to screen according to their motivation score [ 18 ] (categorised into either low motivation smokers or high motivation smokers). Throughout the course of the focus groups, the researcher felt that group dynamics may have inhibited some responses by participants, as anecdotal evidence from post-focus group discussions with individual participants revealed further details about smoking, which could have been usefully discussed within the focus group itself. This may have been due to a variety of factors related to focus group dynamics and individuals’ confidence in speaking in front of a group of unfamiliar individuals; hence, the study design was adapted to include semi-structured face-to-face interviews with both groups of smokers, to allow for participants to speak freely about their experiences in a more confidential manner. It was felt that both formats, focus groups and individual interviews, were useful to address the research question. Both focus groups and interviews took place at publically accessible locations for participants including community centres. During focus groups and interviews, and throughout data analysis, the researcher critically reflected on her own role in the communicative process, aiming to reduce social desirability effects by creating an environment in which participants felt free to express their own thoughts and beliefs without a sense of judgement.

Focus group lasted for approximately 45 minutes, and interviews for approximately 20-30 minutes, and were recorded using a dictaphone. The researcher followed the interview schedule to cover pre-defined themes for discussion, and allowed for novel themes to emerge freely in both focus groups and interviews.

Data analysis

Both focus group and interview data were analysed in accordance with thematic Framework Analysis [ 21 , 22 ] to allow for themes to emerge from the data, alongside analysing pre-existing concepts inferred by the researcher (such as differences in motivation level). Separate analysis of focus groups and interviews was considered; however, in view of the identical research question and predefined themes explored, this appeared to yield little more than formal value. Whilst maintaining awareness of this context, data were thus analysed together, using an overarching framework. Analysis involved transcribing each interview verbatim , and familiarisation with the data through multiple readings of the transcripts. A priori defined themes and emerging key points were developed into a thematic framework table, where each main point was divided into sub-points which were then coded in the transcripts. Analysis was undertaken manually, and in order to identify within which group of participants each point occurred, the transcript data were then synthesised and charted into the table so that each key point contained details of each participants’ response to it. Interpretative analysis [ 21 ] involved grouping together similar key points to identify recurrent themes which revealed attitudes towards smoking and quitting in both groups, and any differences which occurred between the two groups.

A total of 22 participants (12 classified as low motivation smokers and 10 as high motivation smokers) were recruited until saturation was reached. 13 smokers participated in focus groups (4 groups held in total) and 9 performed individual interviews.

Although not significantly so, cigarette dependence scores were lower in low motivation smokers compared with high motivation smokers. Participants did not differ on other demographic or smoking-related characteristics as a function of their motivation level (Table  1 ).

Although low motivation smokers had scored a mean motivation score [ 18 ] of 4.5 and high motivation smokers of 6.7 during initial screening, this difference was not reflected during focus groups or interviews. On further exploration by the facilitator, members of both groups were revealed to have low motivation to quit smoking in the immediate context, but had some thoughts about quitting ‘one day’ in the future:

“Oh, yeah, certainly. One day… it’s easier said than done isn’t it?” (High motivation smoker, Male, Age 57, Interview ).

“ Part of the reason I don ’ t think about quitting that much is that I ’ ve always kind of considered that it will be something that I ’ ll do in the natural course of things .” ( High motivation smoker , Male , Age 22 , Interview ).

“ I ’ m just biding my time . Don ’ t know when , could be ten years , or three years , or 15 years .” ( Low motivation smoker , Male , Age 40 , Focus Group ).

As the data revealed no differences between the two predefined groups in terms of their motivation to quit smoking (indicating a potential lack of reliability of the screening instrument in this group of smokers), the three main themes identified through the thematic analysis process - plans to quit smoking; evaluative beliefs about smoking; and perceived effectiveness of tobacco control policies and services on individual smoking behaviour - are presented with illustrative quotes for both groups, with differentiation between groups highlighted only where dictated by findings.

P lans to continue/quit smoking (PRIME theory)

Barriers undermining motivation to quit.

In accordance with PRIME theory [ 16 ], several barriers to quitting were apparent which may have reduced motivation to quit, and enhanced motivation to continue to smoke as part of smokers’ overall plans. The main reasons given as to why smokers did not want to quit immediately were that they felt no detrimental health effects, they enjoyed smoking a lot, and that they would eventually quit in the future. Low motivation smokers also noted that they simply did not want to quit enough to actually do it:

“ Health reasons will be the main reason I give it up , but right now I don ’ t even think about it … I ’ m quite happy smoking , I like smoking ” ( High motivation smoker , Female , Age 23 , Focus group ).

“ I ’ ve not had any real reason to I suppose . No driving reason to stop doing something I enjoy ” ( Low motivation smoker , Male , Age 25 , Interview ).

“ I ’ ve been thinking about it , but I don ’ t want to stop . That ’ s the point .” ( Low motivation smoker , Male , Age 33 , Focus Group ).

Probing deeper into motivation for quitting, many stated that any desire to quit was based more on what they ‘ought’ to do, rather than what they actually ‘wanted’ to do; as PRIME theory [ 16 ] states, ‘wanting’ to change behaviour is a fundamental factor required to elicit behaviour change:

[ Do you want to stop ?] “ Erm … I ’ m not sure . Maybe . I think I should stop , but I don ’ t think I will .” ( Low motivation smoker , Female , Age 24 , Interview ).

“ No , I don ’ t want to stop . But I know I have to stop .” ( High motivation smoker , Female , Age 23 , Focus Group ).

Factors likely to increase motivation to quit

The main methods believed by participants of both groups to increase motivation to quit in the future were: ‘wanting’ to quit enough, emergence of detrimental health effects, financial concerns, pregnancy/starting a family, and social disapproval.

“ It ’ s just wanting to do it and having the willpower to do it . ( High motivation smoker Female , Age 24 , Interview ).

“ I don ’ t want to be one of those people who are in their 60s who have an artificial voice box , it ’ s not good .” ( Low motivation smoker , Male , Age 22 , Interview ).

“ It ’ s like burning money away . Three and half , four and a half grand a year if I smoke 10 to 20 fags a day .” ( Low motivation smoker , Male , Age 25 , Focus Group ).

During discussions, smokers were very quick in identifying these factors, and appeared confident that they would quit ‘one day’ due to any one of the reasons they identified.

E valuative beliefs about smoking

As PRIME theory [ 16 ] states, evaluative beliefs about smoking can impact upon a smoker’s motives and desires to continue/quit smoking. As such, the following sub-themes represent smokers’ evaluative beliefs about smoking:

Reasons for smoking

The most common reasons for smoking mentioned were enjoyment of smoking, boredom, force of habit, dependency, stress, seeing others smoke, and association with alcohol. In discussions, smokers were very keen to openly discuss why they liked smoking. Additionally, low motivation smokers noted more practical reasons than high motivation smokers for smoking, such as having more breaks at work and something to do with their hands:

“ If you ’ re at work and smoke , you tend to get a lot more breaks at work . I work in a job where I don ’ t get many breaks anyway , apart from smoking .” ( Low motivation smoker , Male , Age 25 , Focus Group ).

All smokers stated they were addicted to smoking in some manner; however, the perceived nature of this addiction differed. Although many noted the biological addiction to nicotine, most thought themselves to be more psychologically addicted to the habit of smoking. During discussions, smokers disagreed about the nature of their addiction, and were willing to discuss this freely with other group members:

“ It might be a psychological addiction where I have a pint in my hand and think ‘ I ’ ll have a fag ’. Whereas if I have a bottle of beer at home , I won ’ t take a cigarette .” ( Low motivation smoker , Male , Age 40 , Focus Group ).

“ I ’ d always say mine is habitual rather than dependence . It ’ s a routine that I do every day .” ( High motivation smoker , Female , Age 23 , Focus Group ).

Perceptions of being a smoker

Many smokers, in particular low motivation smokers, had positive evaluations about being a smoker and stated that they enjoyed being a smoker. In some focus groups, smokers encouraged each other to recall stories of smoking experiences, and to further highlight the benefits of being a smoker and things they would miss if they quit. Perceived benefits of being a smoker across both groups were that it was sociable, provided an opportunity to escape, and there was a clear in-group favouritism towards other smokers:

“ I ’ m very suspicious of non - smokers … you go to a pub and like the non - smokers are always a bit square , and a bit boring , and the smokers are always having a good time .” ( Low motivation smoker , Female , Age 35 , Focus Group ).

“ I ’ d probably miss the social aspect of it . There ’ s something about being a smoker in a social situation because you ’ re in that group and there ’ s kind of a nice side to it .” ( High motivation smoker , Male , Age 29 , Interview ).

By contrast, some participants illustrated their dislike of being a smoker, in one case in the context of expressing disapproval of a relapse following a successful quit attempt:

“ I don ’ t like being a smoker myself , especially as I ’ d quit , and then ended up smoking again .” ( High motivation smoker , Female , Age 28 , Focus Group ).

Smokers stated that if they were to quit, they would miss the physical action of smoking and the social aspect associated with smoking; thus reinforcing their positive evaluations of being a smoker:

“ I just like the action of smoking , especially when I ’ m drinking .” ( Low motivation smoker , Male , Age 25 , Interview ).

Cognitive dissonance of attitudes towards smoking

Cognitive dissonance, whereby smokers held beliefs about smoking which conflicted with their behavioural actions and led to rationalisation of their behaviour, was apparent in many smokers. Although most smokers enjoyed smoking, some negative attributes of smoking were noted, mainly with high motivation smokers regarding moral norms:

“ I would never smoke around children . Never . And I don ’ t like smoking around people who don ’ t smoke .” ( High motivation smoker , Female , Age 23 , Focus Group ).

Although some negative attributes were noted, these were not sufficiently compelling to encourage a quit attempt in the immediate future. Furthermore, all smokers stated reasons why they ought to quit smoking, most commonly for their health, and to save money:

“ Logically we should all quit because it ’ s stupid killing yourself ” ( Low motivation smoker , Male , Age 40 , Focus Group ).

However, these reasons were often counteracted with statements to justify their smoking habit, and positive appraisals of their behaviour related to positive reasons for smoking; thus reinforcing smokers’ continuation of smoking behaviour and inhibiting the opportunity for making a quit attempt:

“ Even if you don ’ t do anything you ’ re going to die aren ’ t you ? It ’ s the old joke isn ’ t it ? If you give up drinking , smoking , relationships , will you live longer ? No , it ’ ll just seem like it ” ( Low motivation smoker , Male , Age 48 , Focus Group ).

“ I would feel that I definitely ought not to smoke , but that just makes it more attractive .” ( High motivation smoker , Male , Age 22 , Focus Group ).

“ If I took away the element of it being carcinogenic and all the detrimental impacts it has on your life , I ’ d say I enjoy it .” ( High motivation smoker , Male , Age 22 , Interview ).

Perceived effectiveness of policies and services

Attitudes towards tobacco control policies.

As PRIME theory [ 16 ] states, environmental cues can influence the decision to smoke by triggering impulses. However, point of sale displays and packaging of cigarettes were perceived to have little effect on smokers’ purchasing behaviour, as price, taste, and brand familiarity were said to influence purchases the most. Additionally, proposed tobacco control policies were believed to be ineffective in affecting purchases for most smokers. Plain packaging of cigarettes was predicted to have no effect on the brand or quantity of cigarettes bought, neither were hidden sales displays, but these policies were noted to have some potential in deterring younger smokers or preventing impulse purchases:

“ If people think the same way as I think , you ’ re going to buy cigarettes whether they ’ re hidden under the counter or there in front of them .” ( High motivation smoker , Female , Age 28 , Focus Group ).

“ It [ hidden sales displays in Canada ] really inhibited you from buying something spur of the moment . You really needed to know exactly what you wanted .” ( High motivation smoker , Male , Age 22 , Interview ).

“ It will work from the point of view of some kids who are drawn to shiny things … but I don ’ t think it ’ s going to make much difference to established smokers .” ( Low motivation smoker , Male , Age 40 , Focus Group ).

Many smokers stated that price increases of cigarettes needed to be more drastic in order to effectively reduce the number of purchases made:

“ The incremental rises are pathetic , it doesn ’ t deter anyone ”. ( Low motivation smoker , Male , Age 40 , Focus Group ).

“ If it gets to £ 4 a pint , I won ’ t drink alcohol . And then it gets to four and you ’ re like ‘ if it gets to £ 5 , that will be the final straw ’. And it ’ s the same with cigarettes … you find a way ”. ( Low motivation smoker , Male , Age 48 , Focus Group ).

[ Would you keep paying it ?] “ Yeah , I think I probably would . Because the inclinations are so small really . It ’ s not going to go from £ 4 to £ 10 , it ’ s slow , incremental .” ( High motivation smoker , Female , Age 23 , Focus Group ).

Attitudes towards NHS SSS

Differences between groups were apparent in attitudes towards NHS SSS. Low motivation smokers were more dismissive towards these stating that quitting was ‘a personal thing’, and were less willing to use such services, whereas high motivation smokers appeared generally more appreciative of the assistance on offer, and although none had actually used NHS SSS, they stated they would use it if they felt the need to (e.g. to combat the nicotine addiction using harm reduction methods or if an unassisted quit attempt had failed). However, during discussions, it was apparent that there was a clear lack of knowledge regarding what NHS SSS were, and how to access them. Only after the facilitator had explained what they offered, was there some appreciation and willingness to use a service if required:

“ I think if I seriously wanted to quit , and I thought that I wouldn ’ t be able to do it myself , I would be very willing to go and use that kind of service .” ( High motivation smoker , Female , Age 23 , Interview ).

“ If I was going to try and stop the nicotine addiction , then it would be a good idea to go to somebody who knows what they ’ re doing .” ( High motivation smoker , Male , Age 29 , Interview ).

When asked about the potential quit methods smokers would most likely use, the majority across groups stated that they would prefer to ‘go cold turkey’:

“ I ’ d be quite happy going cold turkey and seeing what happens .” ( Low motivation smoker , Male , Age 25 , Interview ).

“ I think I ’ d probably wake up and think ‘ right , last packet of cigarettes ’ and then no more .” ( High motivation smoker , Female , Age 24 , Interview ).

However, some high motivation smokers also suggested being offered a sympathetic and supportive approach by health professionals would help them to quit, suggesting that these smokers might benefit the most from increased encouragement to access NHS SSS:

“ You can go to your doctor or your chemist and there ’ s a lot more encouragement and advice to help you pack in . That wasn ’ t true say five years ago … That ’ s a far more sympathetic approach than trying to put the cost up .” ( High motivation smoker , Male , Age 52 , Interview ).

Attitudes towards NRT

Smokers displayed differing opinions regarding NRT; some believed they were an effective cessation tool whereas others did not:

“ I whacked one on in the morning and was like ‘ yeah , shall we just have a fag ?’ So we took them off and had a fag ” ( Low motivation smoker , Female , Age 35 , Focus Group ).

“ You honestly do not feel the need , that craving , to smoke . It ’ s really difficult to want to smoke while having that patch .” ( High motivation smoker , Male , Age 22 , Interview ).

Many smokers had negative views towards NRT stating that they were concerned about the side effects (including taste and irritability), and also that it simply didn’t work as it was believed to only treat the nicotine addiction and not the habitual aspects of smoking, whereas others liked the relief and confidence it provided; highlighting the individual preferences for quit support that need to be considered by health professionals:

“ The plastic thing that makes you feel sick . The sweets are disgusting .” ( High motivation smoker , Female , Age 24 , Interview ).

“ I ’ d probably use other means , because it just seems a bit clinical . Because I don ’ t smoke for the nicotine , I smoke for everything else with it .” ( High motivation smoker , Male , Age 22 , Focus Group ).

“ It does give you the idea that stopping smoking is possible , from a position where you think it ’ s going to be really hard .” ( High motivation smoker , Male , Age 29 , Interview ).

In this study, attitudes towards smoking and quitting were similar for both low motivation and high motivation smokers, despite participants demonstrating explicit differences in motivational scores to quit smoking during the screening process. This suggests that more sensitive measures of current levels of motivation to quit need to be developed in further research. The discrepancy between high motivation smokers’ questionnaire-based and interview-based motivation levels may be explained theoretically by explicit and implicit motivations, as research has shown that explicit and implicit attitudes are distinct concepts [ 23 ] that may not necessarily be related [ 24 ]. Hence, high motivation smokers may appear to be motivated to quit, but their implicit attitudes revealed a liking for smoking and a lower motivation to quit. Furthermore, this may suggest that the estimated figure of 70% of smokers who report motivation to quit [ 7 ] may be misleading, as many smokers may lack the implicit motivation needed to quit, which may explain the low uptake of NHS SSS [ 7 ].

With regards to the first main theme ‘ P lans to continue/quit smoking’, according to PRIME theory [ 16 ], a strong motive (‘want’), as opposed to a rational thought (‘ought’) to quit is required to inhibit internal impulses to smoke. Smokers are thought to be in a state of motivational tension and if only a rational thought, but no strong motive to quit is present, the impulse to smoke triumphs. Previous research has also found that smokers feel they ‘ought’ to quit, rather than ‘want’ to quit [ 25 ]. Generally, smokers’ overall plans were to continue to smoke, with only some thoughts given to quitting in the future. This finding may have practical implications for treatment, as it may be effective for primary care providers to offer brief cessation advice to all patients who smoke during consultations [ 26 ]. In this manner, moving away from the traditional Transtheoretical model [ 27 ] of only providing support to smokers who are motivated to quit, it may be possible to trigger a quit attempt and referral to NHS SSS through changing a smoker’s overall P lan about smoking during a period of motivational tension [ 28 ].

In terms of the second main theme of ‘ E valuative beliefs about smoking’ which can influence smokers’ motives and overall plans, smokers knew the health risks of smoking yet some continued to justify their smoking behaviour through positive appraisals. Research has shown that cognitive dissonance is common in smokers, whereby smokers know the health risks of smoking but rationalise their smoking behaviour to accommodate this [ 29 ]. Further research [ 30 ] has also shown that self-exempting beliefs are constructed by smokers who do not intend to quit, in order to justify their smoking behaviour (for example, smoking is ‘worth it’). However, in the present study, these beliefs were found in both low motivation and high motivation smokers, suggesting that even smokers who explicitly state having higher levels of motivation to quit, may implicitly hold some self-exempting beliefs which obstruct plans to quit.

Within the third main theme of ‘perceived effectiveness of policies and services’, consistent with other qualitative research [ 31 ], participants had unfavourable attitudes towards tobacco control measures and highlighted the perceived ineffectiveness of policies such as plain packaging of cigarettes and hidden sales displays. However, high motivation smokers did note that these policies may deter younger smokers and inhibit impulse purchases. This is consistent with research that has found that only high motivation smokers view plain packaging as an effective strategy to support cessation [ 32 ] and that point of sale displays do influence purchases in younger smokers [ 33 ] and encourage more smoking in established smokers [ 34 ]. Participants noted that any tobacco product price increases need to be substantial in order to have a real impact on motivations, despite research demonstrating the effectiveness of this policy as it currently stands [ 35 ]. This finding is consistent with other qualitative research [ 31 ], although some research has shown that price increases may lead to an increase in contraband tobacco use in smokers who feel highly addicted [ 36 ].

None of the participants had used NHS SSS, but high motivation smokers were more willing to do so, whereas low motivation smokers were more dismissive of this support. Consistent with this study, other qualitative research has also found that smokers have little knowledge of NHS SSS and perceive them to be ineffective [ 37 ]. Attitudes towards NRT itself varied greatly with different perceptions of the effectiveness of this cessation tool, with some negative views stating the side effects of NRT and that it is too clinical a treatment. Previous qualitative research has also shown that smokers are wary of the side effects of NRT and have misconceptions regarding the cost of such treatments [ 31 , 38 ]; however, cost was not found to be an inhibiting factor in this study. Although many smokers stated that their preferred quit method was ‘cold turkey’, which, as previously noted [ 12 ], may be a successful quit method for some smokers, other research has suggested that further education to increase knowledge of the effectiveness and accessibility of available cessation tools may be beneficial to smokers who need support [ 38 ] and thus, might potentially increase the uptake of NHS SSS and assist more smokers in quitting.

Further research of the association between the characteristics of continuing smokers who have not accessed NHS SSS, and their susceptibility towards different interventions and policy measures by quantitative means is required to assist in the development of a typology to target measures to increase motivation to quit across the spectrum of continuing smokers, and to support the further decrease of smoking prevalence rates in the future.

Study limitations

There were high levels of non-attendance at some focus groups, and inhibited responses by some participants within focus groups which may have restricted discussions; however, individual interviews were conducted to compensate for the loss in recruitment and to provide an opportunity for more in-depth open discussion with individuals who may otherwise have felt restricted speaking in a group. A small sample of smokers were recruited which limits generalizability; however, this was the first exploratory step towards informing the development of a typology of smokers, and it is recommended to recruit a larger sample and conduct a quantitative study in order to replicate and further generalise these results.

This study found that despite some smokers self-classifying as having high motivation to quit, during discussions, they were revealed to have low motivation to quit in the immediate future. As such, the discrepancy between explicit and implicit motivations needs to be further researched. Smokers felt they ‘ought’ to quit smoking rather than ‘wanted’ to, thus highlighting the need to identify personally relevant levers to increase motivation to quit. Smokers felt that price increases of tobacco products needed to be more drastic in order to influence motivation and reduce the number of purchases. Increased knowledge of NHS SSS is required to increase uptake in smokers who may require support, but are unaware of the pharmacological and behavioural support that is available within these services to combat both the physical and psychological aspects of smoking.

Author’s contributions

NU conducted the interviews, analysis, and drafted the manuscript under supervision from ER, LS, and JB who supported the interview guide development, reviewed the analysis and results, and revised the manuscript draft. All authors read and approved the final manuscript.

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The study was undertaken within the UK Centre for Tobacco Control Studies, with funding from the ESRC in the context of a PhD in Epidemiology and Public Health.

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Uppal, N., Shahab, L., Britton, J. et al. The forgotten smoker: a qualitative study of attitudes towards smoking, quitting, and tobacco control policies among continuing smokers. BMC Public Health 13 , 432 (2013). https://doi.org/10.1186/1471-2458-13-432

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National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2012.

Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General.

1 introduction, summary, and conclusions.

• Introduction

Tobacco use is a global epidemic among young people. As with adults, it poses a serious health threat to youth and young adults in the United States and has significant implications for this nation’s public and economic health in the future ( Perry et al. 1994 ; Kessler 1995 ). The impact of cigarette smoking and other tobacco use on chronic disease, which accounts for 75% of American spending on health care ( Anderson 2010 ), is well-documented and undeniable. Although progress has been made since the first Surgeon General’s report on smoking and health in 1964 ( U.S. Department of Health, Education, and Welfare [USDHEW] 1964 ), nearly one in four high school seniors is a current smoker. Most young smokers become adult smokers. One-half of adult smokers die prematurely from tobacco-related diseases ( Fagerström 2002 ; Doll et al. 2004 ). Despite thousands of programs to reduce youth smoking and hundreds of thousands of media stories on the dangers of tobacco use, generation after generation continues to use these deadly products, and family after family continues to suffer the devastating consequences. Yet a robust science base exists on social, biological, and environmental factors that influence young people to use tobacco, the physiology of progression from experimentation to addiction, other health effects of tobacco use, the epidemiology of youth and young adult tobacco use, and evidence-based interventions that have proven effective at reducing both initiation and prevalence of tobacco use among young people. Those are precisely the issues examined in this report, which aims to support the application of this robust science base.

Nearly all tobacco use begins in childhood and adolescence ( U.S. Department of Health and Human Services [USDHHS] 1994 ). In all, 88% of adult smokers who smoke daily report that they started smoking by the age of 18 years (see Chapter 3 , “The Epidemiology of Tobacco Use Among Young People in the United States and Worldwide”). This is a time in life of great vulnerability to social influences ( Steinberg 2004 ), such as those offered through the marketing of tobacco products and the modeling of smoking by attractive role models, as in movies ( Dalton et al. 2009 ), which have especially strong effects on the young. This is also a time in life of heightened sensitivity to normative influences: as tobacco use is less tolerated in public areas and there are fewer social or regular users of tobacco, use decreases among youth ( Alesci et al. 2003 ). And so, as we adults quit, we help protect our children.

Cigarettes are the only legal consumer products in the world that cause one-half of their long-term users to die prematurely ( Fagerström 2002 ; Doll et al. 2004 ). As this epidemic continues to take its toll in the United States, it is also increasing in low- and middle-income countries that are least able to afford the resulting health and economic consequences ( Peto and Lopez 2001 ; Reddy et al. 2006 ). It is past time to end this epidemic. To do so, primary prevention is required, for which our focus must be on youth and young adults. As noted in this report, we now have a set of proven tools and policies that can drastically lower youth initiation and use of tobacco products. Fully committing to using these tools and executing these policies consistently and aggressively is the most straight forward and effective to making future generations tobacco-free.

The 1994 Surgeon General’s Report

This Surgeon General’s report on tobacco is the second to focus solely on young people since these reports began in 1964. Its main purpose is to update the science of smoking among youth since the first comprehensive Surgeon General’s report on tobacco use by youth, Preventing Tobacco Use Among Young People , was published in 1994 ( USDHHS 1994 ). That report concluded that if young people can remain free of tobacco until 18 years of age, most will never start to smoke. The report documented the addiction process for young people and how the symptoms of addiction in youth are similar to those in adults. Tobacco was also presented as a gateway drug among young people, because its use generally precedes and increases the risk of using illicit drugs. Cigarette advertising and promotional activities were seen as a potent way to increase the risk of cigarette smoking among young people, while community-wide efforts were shown to have been successful in reducing tobacco use among youth. All of these conclusions remain important, relevant, and accurate, as documented in the current report, but there has been considerable research since 1994 that greatly expands our knowledge about tobacco use among youth, its prevention, and the dynamics of cessation among young people. Thus, there is a compelling need for the current report.

Tobacco Control Developments

Since 1994, multiple legal and scientific developments have altered the tobacco control environment and thus have affected smoking among youth. The states and the U.S. Department of Justice brought lawsuits against cigarette companies, with the result that many internal documents of the tobacco industry have been made public and have been analyzed and introduced into the science of tobacco control. Also, the 1998 Master Settlement Agreement with the tobacco companies resulted in the elimination of billboard and transit advertising as well as print advertising that directly targeted underage youth and limitations on the use of brand sponsorships ( National Association of Attorneys General [NAAG] 1998 ). This settlement also created the American Legacy Foundation, which implemented a nationwide antismoking campaign targeting youth. In 2009, the U.S. Congress passed a law that gave the U.S. Food and Drug Administration authority to regulate tobacco products in order to promote the public’s health ( Family Smoking Prevention and Tobacco Control Act 2009 ). Certain tobacco companies are now subject to regulations limiting their ability to market to young people. In addition, they have had to reimburse state governments (through agreements made with some states and the Master Settlement Agreement) for some health care costs. Due in part to these changes, there was a decrease in tobacco use among adults and among youth following the Master Settlement Agreement, which is documented in this current report.

Recent Surgeon General Reports Addressing Youth Issues

Other reports of the Surgeon General since 1994 have also included major conclusions that relate to tobacco use among youth ( Office of the Surgeon General 2010 ). In 1998, the report focused on tobacco use among U.S. racial/ethnic minority groups ( USDHHS 1998 ) and noted that cigarette smoking among Black and Hispanic youth increased in the 1990s following declines among all racial/ethnic groups in the 1980s; this was particularly notable among Black youth, and culturally appropriate interventions were suggested. In 2000, the report focused on reducing tobacco use ( USDHHS 2000b ). A major conclusion of that report was that school-based interventions, when implemented with community- and media-based activities, could reduce or postpone the onset of smoking among adolescents by 20–40%. That report also noted that effective regulation of tobacco advertising and promotional activities directed at young people would very likely reduce the prevalence and onset of smoking. In 2001, the Surgeon General’s report focused on women and smoking ( USDHHS 2001 ). Besides reinforcing much of what was discussed in earlier reports, this report documented that girls were more affected than boys by the desire to smoke for the purpose of weight control. Given the ongoing obesity epidemic ( Bonnie et al. 2007 ), the current report includes a more extensive review of research in this area.

The 2004 Surgeon General’s report on the health consequences of smoking ( USDHHS 2004 ) concluded that there is sufficient evidence to infer that a causal relationship exists between active smoking and (a) impaired lung growth during childhood and adolescence; (b) early onset of decline in lung function during late adolescence and early adulthood; (c) respiratory signs and symptoms in children and adolescents, including coughing, phlegm, wheezing, and dyspnea; and (d) asthma-related symptoms (e.g., wheezing) in childhood and adolescence. The 2004 Surgeon General’s report further provided evidence that cigarette smoking in young people is associated with the development of atherosclerosis.

The 2010 Surgeon General’s report on the biology of tobacco focused on the understanding of biological and behavioral mechanisms that might underlie the pathogenicity of tobacco smoke ( USDHHS 2010 ). Although there are no specific conclusions in that report regarding adolescent addiction, it does describe evidence indicating that adolescents can become dependent at even low levels of consumption. Two studies ( Adriani et al. 2003 ; Schochet et al. 2005 ) referenced in that report suggest that because the adolescent brain is still developing, it may be more susceptible and receptive to nicotine than the adult brain.

Scientific Reviews

Since 1994, several scientific reviews related to one or more aspects of tobacco use among youth have been undertaken that also serve as a foundation for the current report. The Institute of Medicine (IOM) ( Lynch and Bonnie 1994 ) released Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths, a report that provided policy recommendations based on research to that date. In 1998, IOM provided a white paper, Taking Action to Reduce Tobacco Use, on strategies to reduce the increasing prevalence (at that time) of smoking among young people and adults. More recently, IOM ( Bonnie et al. 2007 ) released a comprehensive report entitled Ending the Tobacco Problem: A Blueprint for the Nation . Although that report covered multiple potential approaches to tobacco control, not just those focused on youth, it characterized the overarching goal of reducing smoking as involving three distinct steps: “reducing the rate of initiation of smoking among youth (IOM [ Lynch and Bonnie] 1994 ), reducing involuntary tobacco smoke exposure ( National Research Council 1986 ), and helping people quit smoking” (p. 3). Thus, reducing onset was seen as one of the primary goals of tobacco control.

As part of USDHHS continuing efforts to assess the health of the nation, prevent disease, and promote health, the department released, in 2000, Healthy People 2010 and, in 2010, Healthy People 2020 ( USDHHS 2000a , 2011 ). Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. For 3 decades, Healthy People has established benchmarks and monitored progress over time in order to encourage collaborations across sectors, guide individuals toward making informed health decisions, and measure the impact of prevention activities. Each iteration of Healthy People serves as the nation’s disease prevention and health promotion roadmap for the decade. Both Healthy People 2010 and Healthy People 2020 highlight “Tobacco Use” as one of the nation’s “Leading Health Indicators,” feature “Tobacco Use” as one of its topic areas, and identify specific measurable tobacco-related objectives and targets for the nation to strive for. Healthy People 2010 and Healthy People 2020 provide tobacco objectives based on the most current science and detailed population-based data to drive action, assess tobacco use among young people, and identify racial and ethnic disparities. Additionally, many of the Healthy People 2010 and 2020 tobacco objectives address reductions of tobacco use among youth and target decreases in tobacco advertising in venues most often influencing young people. A complete list of the healthy people 2020 objectives can be found on their Web site ( USDHHS 2011 ).

In addition, the National Cancer Institute (NCI) of the National Institutes of Health has published monographs pertinent to the topic of tobacco use among youth. In 2001, NCI published Monograph 14, Changing Adolescent Smoking Prevalence , which reviewed data on smoking among youth in the 1990s, highlighted important statewide intervention programs, presented data on the influence of marketing by the tobacco industry and the pricing of cigarettes, and examined differences in smoking by racial/ethnic subgroup ( NCI 2001 ). In 2008, NCI published Monograph 19, The Role of the Media in Promoting and Reducing Tobacco Use ( NCI 2008 ). Although young people were not the sole focus of this Monograph, the causal relationship between tobacco advertising and promotion and increased tobacco use, the impact on youth of depictions of smoking in movies, and the success of media campaigns in reducing youth tobacco use were highlighted as major conclusions of the report.

The Community Preventive Services Task Force (2011) provides evidence-based recommendations about community preventive services, programs, and policies on a range of topics including tobacco use prevention and cessation ( Task Force on Community Preventive Services 2001 , 2005 ). Evidence reviews addressing interventions to reduce tobacco use initiation and restricting minors’ access to tobacco products were cited and used to inform the reviews in the current report. The Cochrane Collaboration (2010) has also substantially contributed to the review literature on youth and tobacco use by producing relevant systematic assessments of health-related programs and interventions. Relevant to this Surgeon General’s report are Cochrane reviews on interventions using mass media ( Sowden 1998 ), community interventions to prevent smoking ( Sowden and Stead 2003 ), the effects of advertising and promotional activities on smoking among youth ( Lovato et al. 2003 , 2011 ), preventing tobacco sales to minors ( Stead and Lancaster 2005 ), school-based programs ( Thomas and Perara 2006 ), programs for young people to quit using tobacco ( Grimshaw and Stanton 2006 ), and family programs for preventing smoking by youth ( Thomas et al. 2007 ). These reviews have been cited throughout the current report when appropriate.

In summary, substantial new research has added to our knowledge and understanding of tobacco use and control as it relates to youth since the 1994 Surgeon General’s report, including updates and new data in subsequent Surgeon General’s reports, in IOM reports, in NCI Monographs, and in Cochrane Collaboration reviews, in addition to hundreds of peer-reviewed publications, book chapters, policy reports, and systematic reviews. Although this report is a follow-up to the 1994 report, other important reviews have been undertaken in the past 18 years and have served to fill the gap during an especially active and important time in research on tobacco control among youth.

• Focus of the Report

Young People

This report focuses on “young people.” In general, work was reviewed on the health consequences, epidemiology, etiology, reduction, and prevention of tobacco use for those in the young adolescent (11–14 years of age), adolescent (15–17 years of age), and young adult (18–25 years of age) age groups. When possible, an effort was made to be specific about the age group to which a particular analysis, study, or conclusion applies. Because hundreds of articles, books, and reports were reviewed, however, there are, unavoidably, inconsistencies in the terminology used. “Adolescents,” “children,” and “youth” are used mostly interchangeably throughout this report. In general, this group encompasses those 11–17 years of age, although “children” is a more general term that will include those younger than 11 years of age. Generally, those who are 18–25 years old are considered young adults (even though, developmentally, the period between 18–20 years of age is often labeled late adolescence), and those 26 years of age or older are considered adults.

In addition, it is important to note that the report is concerned with active smoking or use of smokeless tobacco on the part of the young person. The report does not consider young people’s exposure to secondhand smoke, also referred to as involuntary or passive smoking, which was discussed in the 2006 report of the Surgeon General ( USDHHS 2006 ). Additionally, the report does not discuss research on children younger than 11 years old; there is very little evidence of tobacco use in the United States by children younger than 11 years of age, and although there may be some predictors of later tobacco use in those younger years, the research on active tobacco use among youth has been focused on those 11 years of age and older.

Tobacco Use

Although cigarette smoking is the most common form of tobacco use in the United States, this report focuses on other forms as well, such as using smokeless tobacco (including chew and snuff) and smoking a product other than a cigarette, such as a pipe, cigar, or bidi (tobacco wrapped in tendu leaves). Because for young people the use of one form of tobacco has been associated with use of other tobacco products, it is particularly important to monitor all forms of tobacco use in this age group. The term “tobacco use” in this report indicates use of any tobacco product. When the word “smoking” is used alone, it refers to cigarette smoking.

• Organization of the Report

This chapter begins by providing a short synopsis of other reports that have addressed smoking among youth and, after listing the major conclusions of this report, will end by presenting conclusions specific to each chapter. Chapter 2 of this report (“The Health Consequences of Tobacco Use Among Young People”) focuses on the diseases caused by early tobacco use, the addiction process, the relation of body weight to smoking, respiratory and pulmonary problems associated with tobacco use, and cardiovascular effects. Chapter 3 (“The Epidemiology of Tobacco Use Among Young People in the United States and Worldwide”) provides recent and long-term cross-sectional and longitudinal data on cigarette smoking, use of smokeless tobacco, and the use of other tobacco products by young people, by racial/ethnic group and gender, primarily in the United States, but including some worldwide data as well. Chapter 4 (“Social, Environmental, Cognitive, and Genetic Influences on the Use of Tobacco Among Youth”) identifies the primary risk factors associated with tobacco use among youth at four levels, including the larger social and physical environments, smaller social groups, cognitive factors, and genetics and neurobiology. Chapter 5 (“The Tobacco Industry’s Influences on the Use of Tobacco Among Youth”) includes data on marketing expenditures for the tobacco industry over time and by category, the effects of cigarette advertising and promotional activities on young people’s smoking, the effects of price and packaging on use, the use of the Internet and movies to market tobacco products, and an evaluation of efforts by the tobacco industry to prevent tobacco use among young people. Chapter 6 (“Efforts to Prevent and Reduce Tobacco Use Among Young People”) provides evidence on the effectiveness of family-based, clinic-based, and school-based programs, mass media campaigns, regulatory and legislative approaches, increased cigarette prices, and community and statewide efforts in the fight against tobacco use among youth. Chapter 7 (“A Vision for Ending the Tobacco Epidemic”) points to next steps in preventing and reducing tobacco use among young people.

• Preparation of the Report

This report of the Surgeon General was prepared by the Office on Smoking and Health (OSH), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), USDHHS. In 2008, 18 external independent scientists reviewed the 1994 report and suggested areas to be added and updated. These scientists also suggested chapter editors and a senior scientific editor, who were contacted by OSH. Each chapter editor named external scientists who could contribute, and 33 content experts prepared draft sections. The draft sections were consolidated into chapters by the chapter editors and then reviewed by the senior scientific editor, with technical editing performed by CDC. The chapters were sent individually to 34 peer reviewers who are experts in the areas covered and who reviewed the chapters for scientific accuracy and comprehensiveness. The entire manuscript was then sent to more than 25 external senior scientists who reviewed the science of the entire document. After each review cycle, the drafts were revised by the chapter and senior scientific editor on the basis of the experts’ comments. Subsequently, the report was reviewed by various agencies within USDHHS. Publication lags prevent up-to-the-minute inclusion of all recently published articles and data, and so some more recent publications may not be cited in this report.

• Evaluation of the Evidence

Since the first Surgeon General’s report in 1964 on smoking and health ( USDHEW 1964 ), major conclusions concerning the conditions and diseases caused by cigarette smoking and the use of smokeless tobacco have been based on explicit criteria for causal inference ( USDHHS 2004 ). Although a number of different criteria have been proposed for causal inference since the 1960s, this report focuses on the five commonly accepted criteria that were used in the original 1964 report and that are discussed in greater detail in the 2004 report on the health consequences of smoking ( USDHHS 2004 ). The five criteria refer to the examination of the association between two variables, such as a risk factor (e.g., smoking) and an outcome (e.g., lung cancer). Causal inference between these variables is based on (1) the consistency of the association across multiple studies; this is the persistent finding of an association in different persons, places, circumstances, and times; (2) the degree of the strength of association, that is, the magnitude and statistical significance of the association in multiple studies; (3) the specificity of the association to clearly demonstrate that tobacco use is robustly associated with the condition, even if tobacco use has multiple effects and multiple causes exist for the condition; (4) the temporal relationship of the association so that tobacco use precedes disease onset; and (5) the coherence of the association, that is, the argument that the association makes scientific sense, given data from other sources and understanding of biological and psychosocial mechanisms ( USDHHS 2004 ). Since the 2004 Surgeon General’s report, The Health Consequences of Smoking , a four-level hierarchy ( Table 1.1 ) has been used to assess the research data on associations discussed in these reports ( USDHHS 2004 ). In general, this assessment was done by the chapter editors and then reviewed as appropriate by peer reviewers, senior scientists, and the scientific editors. For a relationship to be considered sufficient to be characterized as causal, multiple studies over time provided evidence in support of each criteria.

Four-level hierarchy for classifying the strength of causal inferences based on available evidence.

When a causal association is presented in the chapter conclusions in this report, these four levels are used to describe the strength of the evidence of the association, from causal (1) to not causal (4). Within the report, other terms are used to discuss the evidence to date (i.e., mixed, limited, and equivocal evidence), which generally represent an inadequacy of data to inform a conclusion.

However, an assessment of a casual relationship is not utilized in presenting all of the report’s conclusions. The major conclusions are written to be important summary statements that are easily understood by those reading the report. Some conclusions, particularly those found in Chapter 3 (epidemiology), provide observations and data related to tobacco use among young people, and are generally not examinations of causal relationships. For those conclusions that are written using the hierarchy above, a careful and extensive review of the literature has been undertaken for this report, based on the accepted causal criteria ( USDHHS 2004 ). Evidence that was characterized as Level 1 or Level 2 was prioritized for inclusion as chapter conclusions.

In additional to causal inferences, statistical estimation and hypothesis testing of associations are presented. For example, confidence intervals have been added to the tables in the chapter on the epidemiology of youth tobacco use (see Chapter 3 ), and statistical testing has been conducted for that chapter when appropriate. The chapter on efforts to prevent tobacco use discusses the relative improvement in tobacco use rates when implementing one type of program (or policy) versus a control program. Statistical methods, including meta-analytic methods and longitudinal trajectory analyses, are also presented to ensure that the methods of evaluating data are up to date with the current cutting-edge research that has been reviewed. Regardless of the methods used to assess significance, the five causal criteria discussed above were applied in developing the conclusions of each chapter and the report.

• Major Conclusions
• Cigarette smoking by youth and young adults has immediate adverse health consequences, including addiction, and accelerates the development of chronic diseases across the full life course.
• Prevention efforts must focus on both adolescents and young adults because among adults who become daily smokers, nearly all first use of cigarettes occurs by 18 years of age (88%), with 99% of first use by 26 years of age.
• Advertising and promotional activities by tobacco companies have been shown to cause the onset and continuation of smoking among adolescents and young adults.
• After years of steady progress, declines in the use of tobacco by youth and young adults have slowed for cigarette smoking and stalled for smokeless tobacco use.
• Coordinated, multicomponent interventions that combine mass media campaigns, price increases including those that result from tax increases, school-based policies and programs, and statewide or community-wide changes in smoke-free policies and norms are effective in reducing the initiation, prevalence, and intensity of smoking among youth and young adults.
• Chapter Conclusions

The following are the conclusions presented in the substantive chapters of this report.

Chapter 2. The Health Consequences of Tobacco Use Among Young People

• The evidence is sufficient to conclude that there is a causal relationship between smoking and addiction to nicotine, beginning in adolescence and young adulthood.
• The evidence is suggestive but not sufficient to conclude that smoking contributes to future use of marijuana and other illicit drugs.
• The evidence is suggestive but not sufficient to conclude that smoking by adolescents and young adults is not associated with significant weight loss, contrary to young people’s beliefs.
• The evidence is sufficient to conclude that there is a causal relationship between active smoking and both reduced lung function and impaired lung growth during childhood and adolescence.
• The evidence is sufficient to conclude that there is a causal relationship between active smoking and wheezing severe enough to be diagnosed as asthma in susceptible child and adolescent populations.
• The evidence is sufficient to conclude that there is a causal relationship between smoking in adolescence and young adulthood and early abdominal aortic atherosclerosis in young adults.
• The evidence is suggestive but not sufficient to conclude that there is a causal relationship between smoking in adolescence and young adulthood and coronary artery atherosclerosis in adulthood.

Chapter 3. The Epidemiology of Tobacco Use Among Young People in the United States and Worldwide

• Among adults who become daily smokers, nearly all first use of cigarettes occurs by 18 years of age (88%), with 99% of first use by 26 years of age.
• Almost one in four high school seniors is a current (in the past 30 days) cigarette smoker, compared with one in three young adults and one in five adults. About 1 in 10 high school senior males is a current smokeless tobacco user, and about 1 in 5 high school senior males is a current cigar smoker.
• Among adolescents and young adults, cigarette smoking declined from the late 1990s, particularly after the Master Settlement Agreement in 1998. This decline has slowed in recent years, however.
• Significant disparities in tobacco use remain among young people nationwide. The prevalence of cigarette smoking is highest among American Indians and Alaska Natives, followed by Whites and Hispanics, and then Asians and Blacks. The prevalence of cigarette smoking is also highest among lower socioeconomic status youth.
• Use of smokeless tobacco and cigars declined in the late 1990s, but the declines appear to have stalled in the last 5 years. The latest data show the use of smokeless tobacco is increasing among White high school males, and cigar smoking may be increasing among Black high school females.
• Concurrent use of multiple tobacco products is prevalent among youth. Among those who use tobacco, nearly one-third of high school females and more than one-half of high school males report using more than one tobacco product in the last 30 days.
• Rates of tobacco use remain low among girls relative to boys in many developing countries, however, the gender gap between adolescent females and males is narrow in many countries around the globe.

Chapter 4. Social, Environmental, Cognitive, and Genetic Influences on the Use of Tobacco Among Youth

• Given their developmental stage, adolescents and young adults are uniquely susceptible to social and environmental influences to use tobacco.
• Socioeconomic factors and educational attainment influence the development of youth smoking behavior. The adolescents most likely to begin to use tobacco and progress to regular use are those who have lower academic achievement.
• The evidence is sufficient to conclude that there is a causal relationship between peer group social influences and the initiation and maintenance of smoking behaviors during adolescence.
• Affective processes play an important role in youth smoking behavior, with a strong association between youth smoking and negative affect.
• The evidence is suggestive that tobacco use is a heritable trait, more so for regular use than for onset. The expression of genetic risk for smoking among young people may be moderated by small-group and larger social-environmental factors.

Chapter 5. The Tobacco Industry’s Influences on the Use of Tobacco Among Youth

• In 2008, tobacco companies spent $9.94 billion on the marketing of cigarettes and $547 million on the marketing of smokeless tobacco. Spending on cigarette marketing is 48% higher than in 1998, the year of the Master Settlement Agreement. Expenditures for marketing smokeless tobacco are 277% higher than in 1998.
• Tobacco company expenditures have become increasingly concentrated on marketing efforts that reduce the prices of targeted tobacco products. Such expenditures accounted for approximately 84% of cigarette marketing and more than 77% of the marketing of smokeless tobacco products in 2008.
• The evidence is sufficient to conclude that there is a causal relationship between advertising and promotional efforts of the tobacco companies and the initiation and progression of tobacco use among young people.
• The evidence is suggestive but not sufficient to conclude that tobacco companies have changed the packaging and design of their products in ways that have increased these products’ appeal to adolescents and young adults.
• The tobacco companies’ activities and programs for the prevention of youth smoking have not demonstrated an impact on the initiation or prevalence of smoking among young people.
• The evidence is sufficient to conclude that there is a causal relationship between depictions of smoking in the movies and the initiation of smoking among young people.

Chapter 6. Efforts to Prevent and Reduce Tobacco Use Among Young People

• The evidence is sufficient to conclude that mass media campaigns, comprehensive community programs, and comprehensive statewide tobacco control programs can prevent the initiation of tobacco use and reduce its prevalence among youth.
• The evidence is sufficient to conclude that increases in cigarette prices reduce the initiation, prevalence, and intensity of smoking among youth and young adults.
• The evidence is sufficient to conclude that school-based programs with evidence of effectiveness, containing specific components, can produce at least short-term effects and reduce the prevalence of tobacco use among school-aged youth.
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• Cite this Page National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2012. 1, Introduction, Summary, and Conclusions.
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Ubc theses and dissertations, cigarette smoking by adolescents : exploring a hypothesis of social marginalization dovell, ronald a. --> -->.

This study investigates the use of tobacco by young people. It compares the personal characteristics of adolescent smokers and non-smokers as well as their social context. The principal hypothesis is that young smokers tend to be marginalized from their home or school environments. Such psycho-social alienation creates conditions where attempts toward social bonding, particularly among peers, can include behaviour such as using tobacco. While the investigation is focused on smoking, it also considers other behaviour known to compromise health. The study quantifies the relative strength of the relationships among health-compromising behaviour and determines social variables associated with such behaviour. The hypothesis of a relationship among health-compromising behaviour is supported by Problem Behaviour Theory as developed by Jessor and Jessor, 1977. Additional theories and empirical evidence are used to place smoking and other risk behaviour within a broad social framework. The framework is intended to clarify important factors that exist when young people start to smoke. It is used to test the hypothesis that the uptake of smoking is associated with adolescents who provide indications of being socially marginalized. The project exploits a large database sponsored by the World Health Organization. The database, "Health Behaviours of School-Aged Children," contains information from adolescents of several countries, including Canada. The Canadian portion provides results from three national cross-sectional surveys conducted at three times during the past decade: 1989-90, 1993-94 and 1997- 98. Several questions used in the latter two surveys are nearly identical. The similarity makes them useful for temporal comparisons as well as merging into one database for modeling and testing hypotheses. The expanded dataset facilitates socio-demographic comparisons such as age, gender and socio-economic status. The analysis proceeds with the development of a marginalization model. The model is based on a synthesis of the literature including reports of the U.S. Surgeon General, Social Bonding Theory and Problem Behaviour Theory. The model delineates demographic variables as well as areas of marginalization that are important to adolescents. The important dimensions of adolescent lives include the home environment, school environment, peer groups and personal factors. Indicators for these dimensions were selected from the Health Behaviour surveys and subjected to a variety of statistical procedures. We assessed relationships between the demographic variables, dimensions of marginalization and behaviour. Due to the public health significance of smoking, the behaviour received a central focus during our analysis. We were unable to develop a composite indicator of socioeconomic status that would logically explain smoking status. The analysis of smoking status by age group found large increases in the proportion of smokers from the age of 11 to 15 years. The distribution of smoking status by age group was comparable to other national surveys. This project makes several contributions to public health, including: 1) Quantitative modeling to clarify the conditions that prevail during the uptake of smoking in Canada. 2) Testing of a hypothesis that adolescent smoking is associated with marginalization from formal social networks. 3) Insight into associations between smoking by young people and other risk behaviour that can compromise health. We have found that smoking is related to other behaviours that can compromise health. Smoking is associated with the use of illicit drugs, consumption of alcohol and failure to take safety precautions. Exercising and taking care of teeth were minimally associated with smoking. Relationships between the indicators of marginalization and smoking status were highly consistent. Relatively uniform increases in the proportion of smokers occurred as levels of Likert scales indicated greater marginalization. Each of the summary constructs of our marginalization model was able to differentiate current smokers and never smokers. A slight paramountcy of the home environment became evident from summary statistics using binary logistic regression and standardized scores of marginalization. Examination of the individual indicators illuminated the need for programs to assist interpersonal relations of adolescents. For example, to reduce the difficulties of marginalization programs need to assist with communication skills, building mutual trust and developing realistic expectations that are relevant to youth. The fact that marginalization differentiates smoking status in every domain that we identified as important to the lives of adolescents, tells us that theories and programs to prevent smoking must be comprehensive. The programs need to guide and support adolescents across these important domains in order to lower the burden of difficulties created by marginalization. Our research implies that benefits can accrue beyond the prevention of smoking. Additional research is required to investigate the full potential for enhancing population health by reducing marginalization and helping youth meet the challenges of marginalization.

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Psychological Health and Smoking in Young Adulthood: Smoking Trajectories and Responsiveness to State Cigarette Excise Taxes

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• March 19, 2019
• Affiliation: Gillings School of Global Public Health, Department of Health Behavior
• While smoking rates have significantly decreased among the general population in the past several decades, they have not significantly decreased among those with poorer psychological health. As posited by theories such as the Transactional Model of Stress and Coping, smoking may represent an important coping mechanism for individuals who experience stress or unpleasant feelings related to poorer psychological health. If poorer psychological health is experienced during young adulthood, a critical time for tobacco use experimentation and uptake, individuals may be particularly likely to become dependent on nicotine and develop longer term smoking habits. In addition, tobacco control policies that have reduced tobacco use in the general population, like raising the price of cigarettes, may be less effective among people with poorer psychological health. Using two indicators of psychological health, a continuum of psychological distress and ever diagnosis of a mental illness, this dissertation explored first, how psychological health accounts for variability within and between individuals in trajectories of smoking (status and amount) across the ages of 18 to 30, and second, whether psychological health moderates the effectiveness of cigarette excise taxes in preventing and reducing smoking. Using a longitudinal national sample across years 2007 to 2013, between-individual effects were found such that individuals with poorer psychological health were more likely to be smokers and to smoke greater numbers of cigarettes over young adulthood than those with better psychological health (Aim 1 and Aim 2). Additionally, the positive effect of having a diagnosed mental illness on smoking amount increased with age, suggesting older young adults may be important targets for intervention (Aim 1). While the effect of cigarette excise taxes encouragingly was not shown to differ by psychological health, cigarette excise taxes showed little effect on smoking at all, perhaps suggesting taxes need to be raised higher than they have been to meaningfully impact smoking (Aim 2). Interventions should aim to target high-risk young adults with poorer psychological health to treat unpleasant psychological symptoms simultaneously with smoking prevention and cessation programs. Overall, this work helps us understand the relationships between psychological health, smoking, and tobacco control policy, with implications for interventions.
• psychological distress
• mental health
• Health sciences
• Mental health
• tobacco control
• public health
• young adults
• https://doi.org/10.17615/ef4w-5738
• Dissertation
• In Copyright
• Ribisl, Kurt
• Ennett, Susan
• Gottfredson, Nisha
• Golden, Shelley
• Aiello, Allison
• Doctor of Philosophy
• University of North Carolina at Chapel Hill Graduate School

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235 Smoking Essay Topics & Examples

Looking for smoking essay topics? Being one of the most serious psychological and social issues, smoking is definitely worth writing about.

🏆 Best Smoking Essay Examples & Topic Ideas

🥇 good titles for smoking essay, 👍 best titles for research paper about smoking, ⭐ simple & easy health essay titles, 💡 interesting topics to write about health, ❓ essay questions about smoking.

In your essay about smoking, you might want to focus on its causes and effects or discuss why smoking is a dangerous habit. Other options are to talk about smoking prevention or to concentrate on the reasons why it is so difficult to stop smoking. Here we’ve gathered a range of catchy titles for research papers about smoking together with smoking essay examples. Get inspired with us!

Smoking is a well-known source of harm yet popular regardless, and so smoking essays should cover various aspects of the topic to identify the reasons behind the trend.

You will want to discuss the causes and effects of smoking and how they contributed to the persistent refusal of large parts of the population to abandon the habit, even if they are aware of the dangers of cigarettes. You should provide examples of how one may become addicted to tobacco and give the rationales for smokers.

You should also discuss the various consequences of cigarette use, such as lung cancer, and identify their relationship with the habit. By discussing both sides of the issue, you will be able to write an excellent essay.

Reasons why one may begin smoking, are among the most prominent smoking essay topics. It is not easy to begin to enjoy the habit, as the act of smoke inhalation can be difficult to control due to a lack of experience and unfamiliarity with the concept.

As such, people have to be convinced that the habit deserves consideration by various ideas or influences. The notion that “smoking is cool” among teenagers can contribute to the adoption of the trait, as can peer pressure.

If you can find polls and statistics on the primary factors that lead people to tweet, they will be helpful to your point. Factual data will identify the importance of each cause clearly, although you should be careful about bias.

The harmful effects of tobacco have been researched considerably more, with a large body of medical studies investigating the issue available to anyone.

Lung cancer is the foremost issue in the public mind because of the general worry associated with the condition and its often incurable nature, but smoking can lead to other severe illnesses.

Heart conditions remain a prominent consideration due to their lethal effects, and strokes or asthma deserve significant consideration, as well. Overall, smoking has few to no beneficial health effects but puts the user at risk of a variety of concerns.

As such, people should eventually quit once their health declines, but their refusal to do so deserves a separate investigation and can provide many interesting smoking essay titles.

One of the most prominent reasons why a person would continue smoking despite all the evidence of its dangers and the informational campaigns carried out to inform consumers is nicotine addiction.

The substance is capable of causing dependency, a trait that has led to numerous discussions of the lawfulness of the current state of cigarettes.

It is also among the most dangerous aspects of smoking, a fact you should mention.

Lastly, you can discuss the topics of alternatives to smoking in your smoking essay bodies, such as e-cigarettes, hookahs, and vapes, all of which still contain nicotine and can, therefore, lead to considerable harm. You may also want to discuss safe cigarette avoidance options and their issues.

Here are some additional tips for your essay:

• Dependency is not the sole factor in cigarette consumption, and many make the choice that you should respect consciously.
• Cite the latest medical research titles, as some past claims have been debunked and are no longer valid.
• Mortality is not the sole indicator of the issues associated with smoking, and you should take chronic conditions into consideration.

Find smoking essay samples and other useful paper samples on IvyPanda, where we have a collection of professionally written materials!

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• Peer Pressure and Smoking Influence on Teenagers The study results indicate that teenagers understand the health and social implications of smoking, but peer pressure contributes to the activity’s uptake.
• Smoking: Benefits or Harms? Hundreds of smokers every day are looking for a way to get rid of the noose, which is a yoke around the neck, a cigarette.
• The Culture of Smoking Changed in Poland In the 1980-90s, Poland faced the challenge of being a country with the highest rates of smoking, associated lung cancer, and premature mortality in the world.
• The Stop Smoking Movement Analysis The paper discusses the ideology, objective, characteristics, context, special techniques, organization culture, target audience, media strategies, audience reaction, counter-propaganda and the effectiveness of the “Stop Smoking” Movement.”The Stop Smoking” campaign is a prevalent example of […]
• Health Promotion Plan: Smokers in Mississippi The main strategies of the training session are to reduce the number of smokers in Mississippi, conduct a training program on the dangers of smoking and work with tobacco producers.
• Smoking Health Problem Assessment The effects of smoking correlate starkly with the symptoms and diseases in the nursing practice, working as evidence of the smoking’s impact on human health.
• Integration of Smoking Cessation Into Daily Nursing Practice Generally, smoking cessation refers to a process structured to help a person to discontinue inhaling smoked substances. It can also be referred to as quitting smoking.
• E-Cigarettes and Smoking Cessation Many people argue that e-cigarettes do not produce secondhand smoke. They believe that the e-fluids contained in such cigarettes produce vapor and not smoke.
• Introducing Smoking Cessation Program: 5 A’s Intervention Plan The second problem arises in an attempt to solve the issue of the lack of counseling in the unit by referring patients to the outpatient counseling center post-hospital discharge to continue the cessation program.
• Outdoor Smoking Ban in Public Areas of the Community These statistics have contributed to the widespread efforts to educate the public regarding the need to quit smoking. However, most of the chronic smokers ignore the ramifications of the habit despite the deterioration of their […]
• Nicotine Replacement Therapy for Adult Smokers With a Psychiatric Disorder The qualitative research methodology underlines the issue of the lack of relevant findings in the field of nicotine replacement therapy in people and the necessity of treatment, especially in the early stages of implementation.
• Smoking and Drinking: Age Factor in the US As smoking and drinking behavior were both strongly related to age, it could be the case that the observed relationship is due to the fact that older pupils were more likely to smoke and drink […]
• Smoking Cessation Clinic Analysis The main aim of this project is to establish a smoking cessation clinic that will guide smoker through the process of quitting smoking.
• Cigarette Smoking Among Teenagers in the Baltimore Community, Maryland The paper uses the Baltimore community in Maryland as the area to focus the event of creating awareness of cigarette smoking among the teens of this community.
• Advocating for Smoking Cessation: Health Professional Role Health professionals can contribute significantly to tobacco control in Australia and the health of the community by providing opportunities for smoking patients to quit smoking.
• Lifestyle Management While Quitting Smoking Realistically, not all of the set goals can be achieved; this is due to laxity in implementing them and the associated difficulty in letting go of the past lifestyle.
• Smoking in the Actuality The current use of aggressive marketing and advertising strategies has continued to support the smoking of e-cigarettes. The study has also indicated that “the use of such e-cigarettes may contribute to the normalization of smoking”.
• Analysis of the Family Smoking Prevention and Tobacco Control Act The law ensures that the FDA has the power to tackle issues of interest to the public such as the use of tobacco by minors.
• “50-Year Trends in Smoking-Related Mortality in the United States” by Thun et al. Thun is affiliated with the American Cancer Society, but his research interests cover several areas. Carter is affiliated with the American Cancer Society, Epidemiology Research Program.
• Pulmonology: Emphysema Caused by Smoking The further development of emphysema in CH can lead to such complications caused by described pathological processes as pneumothorax that is associated with the air surrounding the lungs.
• Smoking and Lung Cancer Among African Americans Primarily, the research paper provides insight on the significance of the issue to the African Americans and the community health nurses.
• Health Promotion and Smoking Cessation I will also complete a wide range of activities in an attempt to support the agency’s goals. As well, new studies will be conducted in order to support the proposed programs.
• Maternal Mental Health and Prenatal Smoking It was important to determine the variables that may lead to postpartum relapse or a relapse during the period of pregnancy. It is important to note that the findings are also consistent with the popular […]
• Nursing Interventions for Smoking Cessation For instance, the authors are able to recognize the need to classify the level of intensity in respect to the intervention that is employed by nurses towards smoking cessation.
• Smoking and Cancer in the United States In this research study, data on tobacco smoking and cancer prevalence in the United States was used to determine whether cancer in the United States is related to tobacco smoking tobacco.
• Marketing Plan: Creating a Smoking Cessation Program for Newton Healthcare Center The fourth objective is to integrate a smoking cessation program that covers the diagnosis of smoking, counseling of smokers, and patient care system to help the smokers quit their smoking habits. The comprehensive healthcare needs […]
• Risks of Smoking Cigarettes Among Preteens Despite the good news that the number of preteen smokers has been significantly reducing since the 1990s, there is still much to be done as the effects of smoking are increasingly building an unhealthy population […]
• Public Health Education: Anti-smoking Project The workshop initiative aimed to achieve the following objectives: To assess the issues related to smoking and tobacco use. To enhance the health advantages of clean air spaces.
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• Health Campaign: Smoking in the USA and How to Reduce It That is why, the government is oriented to complete such objectives associated with the tobacco use within the nation as the reduction of tobacco use by adults and adolescents, reduction of initiation of tobacco use […]
• Smoking Differentials Across Social Classes The author inferred her affirmations from the participant’s words and therefore came to the right conclusion; that low income workers had the least justification for smoking and therefore took on a passive approach to their […]
• Cigarette Smoking Side Effects Nicotine is a highly venomous and addictive substance absorbed through the mucous membrane in the mouth as well as alveoli in the lungs.
• Long-Term Effects of Smoking The difference between passive smoking and active smoking lies in the fact that, the former involves the exposure of people to environmental tobacco smoke while the latter involves people who smoke directly.
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• Preterm Birth and Maternal Smoking in Pregnancy The major finding of the discussed research is that both preterm birth and maternal smoking during pregnancy contribute, although independently, to the aortic narrowing of adolescents.
• Enforcement of Michigan’s Non-Smoking Law This paper is aimed at identifying a plan and strategy for the enforcement of the Michigan non-smoking law that has recently been signed by the governor of this state.
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• Legalizing Electronic Vaping as the Means of Curbing the Rates of Smoking However, due to significantly less harmful effects that vaping produces on health and physical development, I can be considered a legitimate solution to reducing the levels of smoking, which is why it needs to be […]
• Inequality and Discrimination: Impact on LGBTQ+ High School Students Consequently, the inequality and discrimination against LGBTQ + students in high school harm their mental, emotional, and physical health due to the high level of stress and abuse of various substances that it causes.
• Self-Efficacy and Smoking Urges in Homeless Individuals Pinsker et al.point out that the levels of self-efficacy and the severity of smoking urges change significantly during the smoking cessation treatment.
• “Cigarette Smoking: An Overview” by Ellen Bailey and Nancy Sprague The authors of the article mentioned above have presented a fair argument about the effects of cigarette smoking and debate on banning the production and use of tobacco in America.
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• Dangers of Smoking While Pregnant In this respect, T-test results show that mean birthweight of baby of the non-smoking mother is 3647 grams, while the birthweight of smoking mother is 3373 grams. Results show that gestation value and smoking habit […]
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• Environmental Health: Tabaco Smoking and an Increased Concentration of Carbon Monoxide The small size of the town, which is around 225000 people, is one of the reasons for high statistics in diseases of heart rate.
• Advanced Pharmacology: Birth Control for Smokers The rationale for IUD is the possibility to control birth without the partner’s participation and the necessity to visit a doctor just once for the device to be implanted.
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• Clinical Effects of Cigarette Smoking Smoking is a practice that should be avoided or controlled rigorously since it is a risk factor for diseases such as cancer, affects the health outcomes of direct and passive cigarette users, children, and pregnant […]
• Public Health and Smoking Prevention Smoking among adults over 18 years old is a public health issue that requires intervention due to statistical evidence of its effects over the past decades.
• Smoking Should Be Banned Internationally The questions refer to the knowledge concerning the consequences of smoking and the opinions on smoking bans. 80 % of respondents agree that smoking is among the leading causes of death and 63, 3 % […]
• Microeconomics: Cigarette Taxes and Public Smoking Ban The problem of passive smoking will be minimized when the number of smokers decreases. It is agreeable that the meager incomes of such families will be used to purchase cigarettes.
• Tobacco Debates in “Thank You for Smoking” The advantage of Nick’s strategy is that it offers the consumer a role model to follow: if smoking is considered to be ‘cool’, more people, especially young ones, will try to become ‘cool’ using cigarettes.
• Alcohol and Smoking Impact on Cancer Risk The research question is to determine the quantity of the impact that different levels of alcohol ingestion combined with smoking behavioral patterns make on men and women in terms of the risks of cancer.
• Indoor Smoking Restriction Effects at the Workplace Regrettably, they have neglected research on the effect of the legislation on the employees and employers. In this research, the target population will be the employees and employers of various companies.
• Hypnotherapy Session for Smoking Cessation When I reached the age of sixty, I realized that I no longer wanted to be a smoker who was unable to take control of one’s lifestyle.
• Smoking Experience and Hidden Dangers When my best college friend Jane started smoking, my eyes opened on the complex nature of the problem and on the multiple negative effects of smoking both on the smoker and on the surrounding society.
• South Illinois University’s Smoking Ban Benefits The purpose of this letter is to assess the possible benefits of the plan and provide an analysis of the costs and consequences of the smoking ban introduction.
• Smoking Cessation in Patients With COPD The strategy of assessing these papers to determine their usefulness in EBP should include these characteristics, the overall quality of the findings, and their applicability in a particular situation. The following article is a study […]
• Smoking Bans: Preventive Measures There have been several public smoking bans that have proved to be promising since the issue of smoking prohibits smoking in all public places. This means it is a way of reducing the exposure to […]
• Ban Smoking Near the Child: Issues of Morality The decision to ban smoking near the child on father’s request is one of the demonstrative examples. The father’s appeal to the Supreme Court of California with the requirement to prohibit his ex-wife from smoking […]
• The Smoking Ban: Arguments Comparison The first argument against banning smoking employs the idea that smoking in specially designated areas cannot do harm to the health of non-smokers as the latter are supposed to avoid these areas.
• Smoking Cessation and Patient Education in Nursing Pack-years are the concept that is used to determine the health risks of a smoking patient. The most important step in the management plan is to determine a date when the man should quit smoking.
• Philip Morris Company’s Smoking Prevention Activity Philip Morris admits the existence of scientific proof that smoking leads to lung cancer in addition to other severe illnesses even after years of disputing such findings from health professionals.
• Virginia Slims’ Impact on Female Smokers’ Number Considering this, through the investigation of Philip Morris’ mission which it pursued during the launch of the Virginia Slims campaign in 1968-1970 and the main regulatory actions undertaken by the Congress during this period, the […]
• Cigarette Smoking and Parkinson’s Disease Risk Therefore, given the knowledge that cigarette smoking protects against the disease, it is necessary to determine the validity of these observations by finding the precise relationship between nicotine and PD.
• Tuberculosis Statistics Among Cigarette Smokers The proposal outlines the statistical applications of one-way ANOVA, the study participants, the variables, study methods, expected results and biases, and the practical significance of the expected results.
• Smoking Habit, Its Causes and Effects Smoking is one of the factors that are considered the leading causes of several health problems in the current society. Smoking is a habit that may be easy to start, but getting out of this […]
• Smoking Ban and UK’s Beer Industry However, there is an intricate type of relationship between the UK beer sector, the smoking ban, and the authorities that one can only understand by going through the study in detail The history of smoking […]
• Status of Smoking around the World Economic factors and level of education have contributed a lot to the shift of balance in the status of smoking in the world.
• Redwood Associates Company’s Smoking Ethical Issues Although employees are expected to know what morally they are supposed to undertake at their work place, it is the responsibility of the management and generally the Redwood’s hiring authority to give direction to its […]
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From a 100-year front fence ban to rules for circus animals, Canberra has a long history of obscure laws

This year marks a century since a social experiment based around the use of front-yard fences launched in the suburbs of Australia's new federal capital.

The fledgling city of Canberra was developing and its creators were still shaping the laws that would govern its design.

Expatriate British planner-architect Sir John Sulman is largely to thank — or blame — for the decision to ban front fences.

His appointment in 1921, as chairman of the Federal Capital Advisory Committee (FCAC), meant taking over planning control of Canberra from Walter Burley Griffin who designed the original plan for the city.

He was an advocate of the Garden City principles, which blended the economic advantage of urban environments with the health and wellbeing benefits of country life, and promoted civic design as a tool for social reform.

Sulman believed tenements and terrace housing led to overcrowding, poor sanitation and slums.

Unhealthy conditions could be avoided, he theorised, with open-plan neighbourhoods of single-storey cottages.

Enforcement may be rare, but front fences still aren't allowed

Similarly, Walter Burley Griffin was confident that detached, fenceless homes could help suburban society self-regulate because occupants, effectively under community supervision, would "feel pride or shame in [their] individual standards".

The FCAC's recommendations for residential development in the new federal capital included "a 'soft' enclosure and demarcation of properties with hedges", which was interpreted as the formal prohibition in 1924's Canberra Building Regulations.

"The concern was if you allowed front fences, you couldn't find out what people were doing behind them," Professor Nicholas Brown, a historian at the Australian National University, told the ABC in 2016.

"People might make the distinction between the beautiful city that they were supposed to be part of and their own little patch of ground in which they would go wild."

A century on, little has changed.

Fences facing the street in residential areas are "generally" not allowed in Canberra, though hedges are.

Closely spaced shrubs were initially provided and maintained by the government, according to Professor Brown, and "trimmed quite low" so people couldn't hide behind them.

Side or rear boundary fences — up to 2.3 metres above ground level — are also permitted, along with a fence as a boundary at the front of a corner block.

Apartments and townhouses are exempt.

There is no right to privacy that prevents your neighbour from looking over the fence or listening to conversations, according to Legal Aid ACT.

Neighbours must discuss replacements or repairs first, and evenly split all costs.

The policy can claim some success in shaming Canberrans to behave, at least as far as their garden upkeep is concerned.

The FCAC's final report in 1926 noted application of the "garden treatment" in the city's first four suburbs — Ainslie, Kingston, Forrest, and Yarralumla — had delivered improved landscaping and "stimulus for the cottage occupants" to maintain it.

This month, an ACT government spokesperson confirmed that "enforcement actions, like issuing fines, for these types of matters are rare".

Canberra's rules for circus animals, noisy dogs and public transport

But this is not the only obscure and quirky rule that is unique to Canberra.

According to one law introduced in 1992, circus troupes cannot use bears, elephants, giraffes, primates, and felines "other than a domestic cat''.

Meanwhile, ponies, dogs, goats, and camels are legally used in circus acts in parts of New South Wales, including Queanbeyan.

On the subject of animals, lodging a complaint about a neighbour's barking dog requires a 10-day animal noise diary.

Last month, Domestic Animal Services received 11 noise-related animal nuisance complaints — 10 about barking dogs and one about a rooster.

Legal recognition of animals as sentient beings means electric shock collars for dogs and animal fighting are banned, and a Good Samaritan can rescue a distressed animal from a locked vehicle without penalty.

Some other unique ACT rules include:

Putting your feet up while onboard public transport: $183 fine for an adult, $75 for a child. Using your phone to pay for a drive-through order, unless the vehicle is out of gear and handbrake applied: $598 fine and four demerit points. Beeping at another road user for cutting you off, tooting your horn "goodbye" and waving outside a car window: $252 for using the horn unnecessarily, $205 for having body parts outside the vehicle. Moving 3 metres or more away from your vehicle without turning off the engine (if no one left inside or only any children aged under 16: 20 penalty units; without taking the key with you: 20 penalty units.

Tennis was once outlawed

Until the mid-1980s, the ACT had hundreds of archaic laws on its books.

They forbid everything from playing tennis or lawn bowls in the Unlawful Games Act 1541, to anti-social behaviour in a churchyard — for which an offender would be sentenced to the loss of an ear under the Affrays in Churchyards Act 1551.

Of course, "archaic laws inherited from NSW, and in turn from Britain, at the beginning of the 20th century wouldn't have been regarded as much of a problem," Gary Humphries, a former ACT chief minister, said.

Mr Humphries is working on a PhD thesis on the history of ACT self-government.

"Many considered Australia still to be a little outpost of mother England, and a generous overlap with her laws was considered quite appropriate and natural," he said.

"In some cases, there would even have been resistance to the idea of departing from laws that applied elsewhere in the British empire."

Mr Humphries experienced this firsthand, during his time as ACT attorney-general.

"I discovered that some provisions of Magna Carta still applied in the ACT," he explained.

"My department wanted to repeal them, but I felt that this was unwise and said, 'no'.

"Having out-of-date laws on the statute books wasn't considered a day-to-day problem because they simply weren't applied, although in isolated cases — where they provided defences to crimes, for example — their existence did prove a problem," Mr Humphries said.

"As time went by, however, it became increasingly difficult to read statute books without knowing which laws were actually enforced and which ones weren't.

"It also made something of a mockery of the maxim that ignorance of the law is no excuse."

The ACT Law Reform Commission launched a legislative clean-up in 1971.

It took two years to identify statutes to be amended or repealed, and hand down reports, but almost all the recommendations sat idle for more than a decade.

"Clearing out old laws is a fairly labour-intensive exercise for the parliamentary draughtsmen, so it always had a low priority," Mr Humphries explained.

Finally, in late 1985, the wheels of legislative change began to turn.

A Tudor-era Piracy Act, which applied over Lake Burley Griffin, was repealed and, in 1988, the Fraud in the Manufacture of Clocks Act of 1754.

The Statute of Praemunire of 1392, which penalised ACT citizens for appealing to the Pope against a decision of the courts, also ended up on the scrap heap.

Others to be tossed included the Brawling Act of 1553; the Witchcraft Act of 1735; The Reeling False or Short Yarn Act of 1774; and the Coal Lumpers' Baskets Act of 1900, which mandated a maximum weight of 2cwt — or about 102kg.

In 1991, two years into self-government, the ACT Legislative Assembly repealed the right of husbands to sue for compensation for "loss of consortium", if his wife was injured and could not fulfil marital — ie sexual — and domestic "duties".

Mr Humphries said by 1995: "The principle that one should stop adding to the overall weight of the statute books had some popular support, and we promised never to add a new law without taking out an old one at the same time."

Today, only 19 laws of the NSW parliament and 16 of the British parliament remain in force in the ACT.

"While repealing obsolete statutes has some merit, it doesn't magically make the laws of our territory easy to understand when it happens," Mr Humphries said.

"Our laws will always be somewhat opaque … because the statute books never fully explain the law.

"The common law, made by courts and tribunals, adds to the full legal picture and that is never easy to discern without careful research."

The dress standards of Parliament House

Inside the Canberra bubble, the rules and conventions controlling Parliament House have delivered plenty of headline-making moments over the years.

When it comes to the Capital Hill dress code, discretion lies with the speaker but formal business attire is de rigueur.

ABC presenter Patricia Karvelas fell foul of this standard in 2018, when an official in the House of Representatives ruled her cap-sleeve top too risqué .

"I was kicked out of [Question Time] because you can allegedly see too much skin", Karvelas tweeted at the time.

Speaker Tony Smith later admitted Karvelas "should, in hindsight, not have been asked to leave".

Greens MP Max Chandler-Mather's decision to forgo wearing a tie in 2022 sparked an outcry from one member, who feared tradition was being "ignored" and could lead to MPs wearing "board shorts and thongs … maybe a onesie in winter."

Another law to be amended relatively recently applied to breastfeeding politicians, who were given a proxy vote until 2016.

Until then, infants in the care of members were classified as "strangers" and prohibited from the floor of the upper and lower houses.

In 2017, Greens senator Larissa Waters became the first politician to take advantage of the "family-friendly" reform.

There are numerous rules applicable to the hill that remain.

Visitors and press club members must be silent in the galleries and "applause is not permitted during proceedings".

Journalists cannot conduct impromptu or vox pop-style interviews with visitors.

Knitting and 'risqué' trousers

If we go further back, there are a whole host of laws applicable to Parliament House that were outlawed decades ago but are notable for their specificity.

In Provisional (Old) Parliament House, knitting was banned in the public galleries in 1932.

A year later, women were banned from wearing trousers, with media reports at the time suggesting Dorothy Henderson-Smart — who was visiting from South Africa — was a "daring young person" to arrive clad in slacks.

"Women [can] not be permitted to imperil the dignity of parliament by appearing in frivolous costume," the then-Senate president ruled.

Parliamentary staff were told "no woman in risqué attire is to be admitted".

A year after that, a law prohibiting demonstrations outside Parliament House was introduced.

The policy was in response to recent "organised marches of unemployed" and explicitly outlawed any "unlawful assembly" of more than 20 people where "grievances are made known, public matters are discussed, or any move is made for the repeal or enactment of any law".

Anyone caught taking part risked a 100-pound fine or six months' jail.

In 1942, eight thieves who stole roses from the gardens outside Parliament House faced court, after they were separately caught red-handed during November and December.

They were each charged with "cutting parts of plants, with intent to steal".

Court reporting shows one offender tried to make off with a suitcase full of blooms, while another told a police officer:

"You're keeping an eye on the roses, eh? Well, I've just got a few for the vase — just my usual few."

All eight were fined ten shillings.

And in good news for MPs, a law banning them from using on-site recreational facilities on Sundays was overturned in 1943.

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