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

Drug and Alcohol Dependence 138 (2014) 7–16

Contents lists available at ScienceDirect

Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep

Review

Equity impact of population-level interventions and policies to reduce smoking in adults: A systematic review夽 Tamara Brown a , Stephen Platt b , Amanda Amos a,∗ a b

UK Centre for Tobacco Control Studies, Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9AG, UK Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9AG, UK

a r t i c l e

i n f o

Article history: Received 9 December 2013 Received in revised form 21 February 2014 Accepted 2 March 2014 Available online 13 March 2014 Keywords: Smoking Inequalities Disparities Policy Cessation Review

a b s t r a c t Background and aims: There is strong evidence about which tobacco control policies reduce smoking. However, their equity impact is uncertain. The aim was to assess the effectiveness of population-level interventions/policies to reduce socioeconomic inequalities in adult smoking. Methods: Systematic review of studies of population-level interventions/policies reporting smokingrelated outcomes in adults of lower compared to higher socioeconomic status (SES). References were screened and independently checked. Studies were quality assessed. Results are presented in a narrative synthesis. Equity impact was assessed as: positive (reduced inequality), neutral (no difference by SES), negative (increased inequality), mixed (equity impact varied) or unclear. Results: 117 studies of 130 interventions/policies were included: smokefree (44); price/tax (27); mass media campaigns (30); advertising controls (9); cessation support (9); settings-based interventions (7); multiple policies (4). The distribution of equity effects was: 33 positive, 36 neutral, 38 negative, 6 mixed, 17 unclear. Most neutral equity studies benefited all SES groups. Fourteen price/tax studies were equity positive. Voluntary, regional and partial smokefree policies were more likely to be equity negative than national, comprehensive smokefree policies. Mass media campaigns had inconsistent equity effects. Cigarette marketing controls were equity positive or neutral. Targeted national smoking cessation services can be equity positive by achieving higher reach among low SES, compensating for lower quit rates. Conclusions: Few studies have assessed the equity impact of tobacco control policy/interventions. Price/tax increases had the most consistent positive equity impact. More research is needed to strengthen the evidence-base for reducing smoking inequalities and to develop effective equity-orientated tobacco control strategies. © 2014 Published by Elsevier Ireland Ltd.

Contents 1. 2.

3.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2.1. Search strategy and study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.2. Eligibility criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.3. Data extraction and quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.4. Data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3.1. Methodological characteristics and quality of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 3.2. Price/tax increases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 3.3. Smokefree policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

夽 Supplementary material can be found by accessing the online version of this paper. Please see Appendix A for more information. ∗ Corresponding author. Tel.: +44 131 650 3236; fax: +44 131 650 6909. E-mail address: [email protected] (A. Amos). http://dx.doi.org/10.1016/j.drugalcdep.2014.03.001 0376-8716/© 2014 Published by Elsevier Ireland Ltd.

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T. Brown et al. / Drug and Alcohol Dependence 138 (2014) 7–16

Identification Screening

Smoking is both the single most important preventable cause of premature mortality and a major contributor to socioeconomic inequalities in health in North America and Europe (Lim et al., 2012; Mackenbach et al., 2008). Smoking prevalence rates differ substantially within countries according to educational level, occupational class and income (Kunst et al., 2004; Hiscock et al., 2012a,b). The patterning of smoking by socioeconomic status (SES) reflects the stage of the tobacco epidemic in that country. The US, Canada, Australia and most countries in the European Union are characterised as being in the fourth (last) stage of the epidemic (Lopez et al., 1994; Eriksen et al., 2012). In these countries, lower SES groups have higher smoking prevalence, higher levels of cigarette consumption and lower rates of quitting compared to higher SES groups (Hiscock et al., 2012a,b). There is good evidence on what is effective in reducing adult smoking. A review of international evidence by the World Bank (Joosens and Raw, 2006) identified six cost-effective policies which should be prioritised in tobacco control programmes: cigarette price increases, comprehensive smokefree public places, anti-tobacco mass media campaigns, bans on advertising, health warnings and cessation support. These priorities were endorsed by World Health Organisation (WHO, 2008) and form the basis of the Framework Convention on Tobacco Control (FCTC), the first international public health treaty (FCTC, 2003). While considerable progress has been made in tobacco control in many countries in recent years, there is considerable variation in the strength and comprehensiveness of tobacco control policies and their implementation (Joosens and Raw, 2006; Joosens and Raw, 2011). While smoking prevalence in stage 4 countries is declining, the social gradient in smoking is not. This is of increasing concern in many countries which have recognised that tackling inequalities in smoking is central to reducing health inequalities. Health equity is defined as the absence of avoidable and unfair inequalities in health (Whitehead, 1992). For example, both the English and Scottish national tobacco control strategies identify reducing inequalities and smoking as their key priority (Department of Health, 2011; Scottish Government, 2013). However, two previous systematic reviews which examined the equity effect of tobacco control interventions (Fayter et al., 2008; Amos et al., 2011) concluded that there was limited evidence to inform tobacco control interventions/policies aimed at reducing socioeconomic inequalities in smoking. This systematic review forms part of the European project (SILNE Consortium, 2012) ‘Tackling socioeconomic inequalities in smoking’ (SILNE). The review’s aim is to assess the effectiveness of population-level interventions/policies to reduce socioeconomic inequalities in smoking among adults by assessing primary studies of any intervention/policy that reported differential effects on a smoking-related outcome in at least two socioeconomic groups.

# of records identified through database searching N=29,047

Eligbility

1. Introduction

Included

4.

3.4. Mass media campaigns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5. Controls on advertising, promotion and marketing of tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6. Population-level cessation support interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.7. Settings-based interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.8. Multiple policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role of funding source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11 11 12 12 12 12 13 13 14 14 14 14

# of additional records identified through other sources N=23

# of records after duplicates removed N=15,111

# of records after 1995 screened N=13,937

# of full-text articles assessed for eligibility N=353

# of studies included in qualitative synthesis N=117 (from 120 papers)

# of studies included in quantitative synthesis (meta-analysis) N=0

# of records excluded N=13,584

# of full-text articles excluded N=233 Cessation review=20 Youth review=18 Did not meet inclusion criteria=195 of which 51 excluded from this review: Not an intervention/policy to reduce adult smoking=18; Does not report outcomes for high versus low socio-economic group=16; Did not report reach by SES (quitline) =1; Focus on cigar use=1; Does not link with specific intervention/policy=3; Not European/Stage 4=2; No baseline comparison=1; Focus on alcohol outcomes=1; Cessation survey=1; Composite outcome measure only (including smoking) =1; Does not report outcomes by intervention group=1; Focus on tobacco replacement products=1; Abstract only=2; Focus on BMI outcomes=1; Not population-level cessation support=1

Fig. 1. PRISMA flow diagram.

2. Methods The study protocol is available on request from the corresponding author (AA). The review was written following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-equity reporting guidelines: PRISMA-E 2012 (supplementary material1 ; Welch et al., 2012). The search strategy identified studies for both this review and two other reviews for the SILNE project which covered interventions targeting youth and adult individual cessation support interventions (Fig. 1).

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


2.1. Search strategy and study selection A comprehensive search strategy was implemented in 10 electronic databases: Biosis, Cinahl, Cochrane Library, Conference Proceedings Citation Index, Embase, Eric, Medline, Psycinfo, Science Citation Index Expanded, and Social Sciences Citation Index (January 2013). Terms for smoking, smoking policies and outcomes, and SES were combined using database specific terms and keywords (supplementary material2 ). No specific equity terms were incorporated into the search. Papers pending publication were identified through handsearching of four key journals: Addition, Nicotine and Tobacco Research, Social Science and Medicine, and Tobacco Control (February, 2013). Two key reviews were searched for relevant primary studies (Fayter et al., 2008; Amos et al., 2011). Reference lists of included studies were also searched. Members of SILNE and the European Network for Smoking and Tobacco Prevention (ENSP) were contacted to identify any additional studies. No limits were set on the type of intervention/policy. A database of references generated from the search was produced using Reference Manager 12. A sample of the initial 200 references was screened by title and abstract independently by two reviewers (AA and TB) to establish consistency of screening. One reviewer (TB) screened the remaining references which were independently checked by another (AA). Any disagreements between reviewers were resolved by discussion and, if necessary, a third reviewer (SP) was consulted. 2.2. Eligibility criteria Studies based in a country at stage 4 (Lopez et al., 1994; Richmond, 2013) of the tobacco epidemic or in the WHO European Region were eligible for inclusion. Studies from non-stage 4 countries were excluded as they have a different patterning of smoking by SES. Experimental designs are often not feasible or appropriate for evaluating certain types of tobacco control interventions/policies, such as smokefree legislation and national media campaigns. Therefore, all primary study designs were eligible, including randomised controlled trials, non-randomised trials, cohort studies (controlled and uncontrolled), cross-sectional and qualitative studies. The minimum age for study participants for this review was originally set at 18 years; this was later modified to include studies which measured children’s reports of parental smoking. We included population-level interventions/policies and cessation support which could be delivered at a population level. Population-level tobacco control interventions were defined as ‘those applied to populations, groups, areas, jurisdictions or institutions with the aim of changing the social, physical, economic or legislative environments to make them less conducive to smoking’ (Fayter et al., 2008). The UK is the only country to have established a comprehensive state-reimbursed stop smoking service (SSS) providing behavioural support and pharmacotherapy. Services are delivered at the individual level; however, because of their national coverage, they can also be regarded as a population-level intervention. Cessation support interventions had to report reach by SES to be included, so that impact at the population-level could be assessed. Any type of tobacco control intervention/policy or other type of policy (e.g., social, educational), of any follow-up length, with any type of smoking-related outcome was included. There were several smoking-related outcomes including: social norms/attitudes,


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exposure to secondhand smoke (SHS), policy reach, use of quitting services, quit attempts, smoking prevalence and morbidity. This broad range of outcomes was included to reflect the diversity of ways in which tobacco control policies can influence smokingrelated outcomes. Studies were included whether or not they had an equity focus. Only studies which reported differential smoking-related outcomes for at least two socioeconomic groups were included. Socioeconomic variables included income, education, occupation and area-level socioeconomic deprivation. Studies published since 1995 in full-text and in English were included. A measure of SES had to be reported in the abstract of the electronic references to be included. Evidence identified through handsearching, searching of key reviews, or contacting experts, could be included if a measure of SES was reported in the main text even if the abstract did not report on SES. Reports not written in English were included if an English synopsis was provided. 2.3. Data extraction and quality assessment Data from each study were extracted by one reviewer (TB) and checked by another (AA) using a piloted data extraction form. Data relating to study design, population characteristics, intervention details, and outcomes by SES were extracted. Details of SES variables were extracted including how each study measured SES and data sources. All smoking-related outcomes by SES were extracted, including relative and absolute differences. All studies were quality assessed by one reviewer (TB) and checked by another (SP). The exceptions were reports where reference to quality was reported in the review text. Quality was assessed by adapting the method used in a previous review by the Centre for Reviews and Dissemination (CRD; Fayter et al., 2008). Each study was assessed using the Six Item Checklist Of Quality Of Execution adapted from criteria developed for the Effective Public Health Practice Project in Hamilton, Ontario (Thomas, 2003), including representativeness of study samples; randomisation; comparability of baseline groups; credibility of data collection tools; attrition rate; and attributability to the intervention. An additional criterion of ‘generalisability’ assessed whether findings were likely to be transferable at a regional or national level. A typology of study designs was used to compare study methodologies. While some sources of potential bias were not applicable to all study designs, attrition and confounding issues were always considered within the quality assessment form. Particular attention was paid to internal and external validity; important quality and validity issues are discussed alongside study results. 2.4. Data analysis Given the variation in study designs, intervention types and outcome measures, it was not possible to conduct a meta-analysis. Results are presented as a narrative synthesis according to intervention type. Logic models were used to group outcomes for smokefree (Haw et al., 2006) and mass media (Niederdeppe et al., 2008a,b) interventions/policies. The equity effect of each intervention/policy was summarised by adapting a model used in the CRD (Fayter et al., 2008; Fig. 2). 3. Results The electronic search produced 29,047 references and 23 outputs were identified through hand-searching, searching grey literature and key reviews, and contacting experts. After removing duplicate references and outputs published before 1995, 13,937 titles and abstracts were screened. Three hundred and fifty-three full-text outputs were assessed; 120 outputs were included and

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Positive equity impact -evidence that lower SES groups were relatively more responsive to the intervention/policy. Neutral equity impact-no social gradient in the effectiveness of the intervention by level of SES i.e. same impact on high and low SES groups. Negative equity impact -evidence that higher SES groups were relatively more responsive to the intervention/policy. Mixed equity impact-effect of intervention/policy varied by SES measure and/or other variables such as gender, setting, country and/or outcome measure. Unclear equity impact-not possible to assess the equity impact e.g. no statistical analysis by SES group.

Fig. 2. Definitions of equity impact of each intervention/policy.

233 were excluded. These 120 outputs covered 117 separate studies which evaluated 130 interventions/policies (Fig. 1). 3.1. Methodological characteristics and quality of included studies One hundred studies were population-based observational studies: 25 single cross-sectional studies, 43 repeat cross-sectional studies, 20 uncontrolled cohort studies and 12 econometric studies. Six studies were intervention-based observational studies: four before and after studies with the same participants and two studies comparing different types of interventions. Six studies were intervention-based experimental studies: three RCTs, two nonrandomised controlled trials, and one quasi-experimental trial. Five studies were qualitative. 112 studies were assessed for quality (supplementary material3 ). Three Dutch mass media studies (van den Putte et al., 2005; Wiebing et al., 2010; Willems et al., 2012) and one NHS SSS report (Galbraith, 2012) were not formally quality assessed. Observational studies, which accounted for the bulk of the evidence, have a number of methodological limitations, including selection and measurement bias and confounding. Only 41 studies had representative study samples, of which 28 were generalisable on a national scale and 13 on a regional scale. None of the six experimental trials met criteria for baseline comparability between groups; only one RCT (Cantrell et al., 2013) reported results for all randomised groups. 108 studies used valid and reliable data collection tools. 22 studies had unacceptably high attrition rates (30+%). In 58 studies it was not possible to be confident that the observed effects were attributable to the intervention, largely because of study design limitations or other concurrently implemented tobacco control legislation. The literature was international, with 53 studies (46%) from the USA. 21 studies were conducted in the UK (mainly smokefree and NHS SSS) and 11 in the Netherlands. Other study countries included Australia, Belgium, Canada, Croatia, France, Germany, Italy, New Zealand, Russia and Sweden. 5 studies included data from several countries and 6 studies included data from multiple countries within the UK. Participants included smokers and non-smokers in the general population, workers, tobacco retailers, bar/restaurant customers, patients, pregnant women, parents, households with children, school children (included as proxies for outcomes), and car drivers. Participants were generally healthy but some studies included HIV-positive patients, adults at risk of cardiovascular events, and patients with alcohol addiction. Participant numbers ranged from 40 to over 6 million. The data collection period ranged from a single time point to 20 years. Different indicators were used


to measure SES, including income (household, family, personal, poverty level, financial stress), occupation (status), education, area of residence (income level, deprivation score) and composite scores (education and income). The types of interventions/policies included were: smoking restrictions in cars, homes, workplaces and other public places (44); mass media campaigns including promoting the use of quitlines and NRT (30); increases in the price/tax of tobacco products (27); controls on advertising, promotion and marketing of tobacco including warning labels (9); cessation support interventions (9); settings-based interventions (community, workplace, hospital) (7); multiple policy interventions (4). Eight studies examined more than one type of policy and reported results for each policy. Only one study assessed a non-tobacco control intervention/policy: the New Deal for Communities (NDC; Stafford et al., 2008) targeted health, unemployment, education, crime and the physical environment in deprived areas in England. Types of outcomes included: smoking status, consumption, prevalence and cessation; quitting intentions, attempts, rates and ratios; smoking-related morbidity and mortality; smokefree policy adoption, coverage and compliance; SHS exposure; home/car smoking bans; awareness and recall of mass media campaigns; use of smoking cessation services including calls to quitlines and sales of nicotine replacement products (NRT); perceived impact of cigarette warning labels; uptake and reach of Quit and Win campaigns, quitlines and NRT promotion. The findings of the equity impact of each type of intervention/policy are summarised in Table 1. (For summary equity of each study see supplementary file 44 .) 3.2. Price/tax increases Twenty-seven studies examined the equity impact of cigarette price/tax increases (Azagba and Sharaf, 2011; Biener et al., 1998; Bush et al., 2012; CDC, 1998; Choi et al., 2012; Colman, 2008; DeCicca and McLeod, 2008; Dinno and Glantz, 2009; Dunlop et al., 2011; Farrelly et al., 2001, 2012a,b; Franks et al., 2007; Frieden et al., 2005; Gospodinov and Irvine, 2009; Gruber et al., 2003; Hawkins et al., 2012; Levy et al., 2006; Madden, 2007; Metzger et al., 2005; Mostashari et al., 2005; Nagelhout et al., 2013a,b; Peretti-Watel et al., 2012, 2009; Peretti-Watel and Constance, 2009; Ringel and Evans, 2001; Schaap et al., 2008; Siahpush et al., 2009). These were associated with larger reductions in smoking prevalence and/or consumption in lower compared with higher SES groups. Fourteen studies demonstrated a positive equity impact, six studies were neutral, one mixed and two unclear. Four studies showed a negative equity impact (including studies of HIV-positive adults (Peretti-Watel et al., 2009) and pregnant women (Ringel and Evans, 2001). 3.3. Smokefree policies Studies on the equity effect of smokefree polices were divided into two groups: those that assessed policies that were voluntary, regional or partial and those assessing comprehensive national smokefree legislation. Twenty-five studies (Arheart et al., 2008; Delnevo et al., 2004; Deverell et al., 2006; Ellis et al., 2009; Farrelly et al., 1999; Ferketich et al., 2010; Frieden et al., 2005; Guse et al., 2004; Guzman et al., 2012; Hawkins et al., 2012; Hemsing et al., 2012; Levy et al., 2006; Moussa et al., 2004; Nabi-Burza et al., 2012; Parry and Platt, 2000; Patel et al., 2013; Plescia et al., 2005; Razavi et al., 1997; Shavers



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Table 1 Summary equity impact of included studies and policies.

Increases in price/tax of tobacco products Smokefree – voluntary, regional, partial Smokefree – compulsory, national, comprehensive Mass media campaigns Mass media campaigns – quitlines and NRT Controls on advertising, promotion and marketing of tobacco Population-level cessation support interventions Settings based interventions (community, workplace, hospital) Multiple policies Total policies Total studies

Positive

Neutral

Negative

Mixed

14 1 2 3 5 2 4 2 0 33 31b

6 1 9 2 3 7 2 4 2 36 30

4 19 6 5 3 0 0 1 0 38 37

1 0 1 2 0 0 1 0 1 6 6

Unclear 2 4 4 6 1 2 0 1 17 14b

Total 27 25 19 18 12 9 9 7 4 130a 117

a Eight studies assessed more than one type of policy: Dinno 200935 = Smokefree, Price/Tax; Frieden 200549 = Smokefree, Price/Tax, Multiple policies; Hawk 200699 = Mass Media, Mass Media – quitlines and NRT; Hawkins 201253 = Smokefree, Price/Tax. b Levy 200641 = Smokefree, Price/Tax, Mass Media; Nagelhout 201354 = Smokefree, Price/Tax, Mass Media; Schaap 200847 = Smokefree, Price/Tax, Controls on advertising, promotion and marketing of tobacco, Multiple policies; Wilson 2010a115 = Controls on advertising, promotion and marketing of tobacco, Mass media – quitlines and NRT.

et al., 2006; Shopland et al., 2004; Skeer et al., 2004; Stamatakis et al., 2002; Tang et al., 2003; Tong et al., 2009; Verdonk-Kleinjan et al., 2009) evaluated voluntary, regional or partial smokefree policies: local adoption of smokefree policies exclusively in the workplace (12) or in public places (3), regional impacts of smokefree policy (6), partial national workplace smoking bans (2), and voluntary smoking bans in cars (2). The equity impact of these studies was: one positive, one neutral, 19 negative and four unclear. This pattern of findings demonstrates the potential of such policies to increase socioeconomic inequalities in terms of protection from SHS exposure. The only worksite study which showed positive equity effects for reducing SHS exposure included workers who were both non-smokers and not exposed to SHS at home; the study findings are therefore probably not generalisable to all workers (Arheart et al., 2008). The overall equity impact of 19 comprehensive national smokefree policies (Barnett et al., 2009; Cesaroni et al., 2008; Dinno and Glantz, 2009; Eadie et al., 2008; Federico et al., 2012; Fowkes et al., 2008; Hackshaw et al., 2010; Hawkins et al., 2011; King et al., 2011; MacCalman et al., 2012; Moore et al., 2012, 2011; Nagelhout et al., 2011a,b, 2013a,b; Ritchie et al., 2010a,b; Schaap et al., 2008; Semple et al., 2010; Sims et al., 2012) was: two positive, nine neutral, six negative, one mixed and one unclear. National comprehensive smokefree legislation is equity positive as it removes inequalities in protection from SHS produced by voluntary policies. However, in terms of equity impact on other smoking-related outcomes, only two studies demonstrated an overall positive equity impact. One showed that the recent proliferation of smokefree policies across Australia, Canada, UK and USA reduced inequalities in policy coverage by SES (King et al., 2011). The other study in England, Wales and Scotland (Semple et al., 2010) showed that bars in deprived areas experienced a greater percentage reduction in SHS levels up to 12 months post-implementation of national smokefree legislation. No studies evaluated the equity impact of smokefree vehicle laws. Two studies (Moore et al., 2011, 2012) evaluated the impact of comprehensive national smokefree legislation on smoking in the home and car. One showed a neutral (Moore et al., 2012) and the other a negative (Moore et al., 2011) equity impact. 3.4. Mass media campaigns Studies on the equity effect of mass media campaigns were divided into two groups: those aimed at increasing quit motivations and/or attempts, and those aimed at increasing calls to quitlines or uptake of free NRT. Eighteen studies examined the equity impact of mass media campaigns focussed on quitting (Alekseeva et al., 2007; Bains et al., 2000; CDC, 2007; Civljak et al., 2005; Dunlop et al., 2012; Durkin

et al., 2009; Farrelly et al., 2012a,b; Graham et al., 2008; Hawk et al., 2006; Levy et al., 2006; Nagelhout et al., 2009, 2013a,b; Niederdeppe et al., 2008a,b, 2011; Richardson et al., 2011; Vallone et al., 2011; Wiebing et al., 2010; Willems et al., 2012; van den Putte et al., 2005; van Osch et al., 2009). Three studies showed a positive equity impact, two were neutral, five negative (including four Quit & Win competitions), two mixed and six unclear. A Dutch multimedia campaign (Willems et al., 2012), targeted at lower educated smokers with quitting intentions, was associated with a positive equity impact for campaign awareness. A US media campaign (Levy et al., 2006) was associated with a more rapid decline in smoking prevalence among low SES women. The television element of the EX mass media campaign (Vallone et al., 2011; Richardson et al., 2011) increased cessation-related cognitions and increased quit attempts only among low SES smokers. Evidence from two mixed equity studies showed that highly emotive and personal testimony advertisements were more effective with low SES groups Durkin et al., 2009) and emotive or graphic advertisements were more effective with low SES smokers (Farrelly et al., 2012a,b). Twelve studies examined the equity impact of mass media campaigns promoting the use of quitlines and/or NRT (Burns and Levinson, 2010; Czarnecki et al., 2010a,b; Deprey et al., 2009; Durkin et al., 2011; Miller et al., 2005; Owen, 2000; Siahpush et al., 2007; Sood et al., 2008; Wilson et al., 2012; Zawertailo et al., 2013). Five studies were positive, three neutral, three negative, and one unclear for equity impact. The equity impact was inconsistent, although three of the five positive equity impact studies promoted free NRT. A US Spanish-language campaign promoting a state quitline increased reach, service use and abstinence among low SES Latino smokers (Burns and Levinson, 2010). The addition of the Quitline number with new pictorial health warning labels in New Zealand increased Quitline number recognition across all SES groups, and the gap in quitline number recognition between the least and most deprived groups narrowed (Wilson et al., 2012). A Canadian campaign that supplied free NRT by mail following a brief telephone intervention had higher reach among lower SES smokers and increased quits compared to a regional control group (Zawertailo et al., 2013). Two campaigns in New York City promoting NRT showed positive equity impact for awareness and uptake (Czarnecki et al., 2010a,b). Higher emotion narrative anti-smoking advertisements may potentially reduce socioeconomic inequalities in calls to quitlines through maximising the responses of low SES smokers (Durkin et al., 2011). 3.5. Controls on advertising, promotion and marketing of tobacco Nine studies examined the socioeconomic impact of controls on tobacco advertising, promotion and marketing, including five

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studies of health warning labels (Cantrell et al., 2013; Frick et al., 2012; Hammond et al., 2013; Hitchman et al., 2012; Kasza et al., 2011; Schaap et al., 2008; Willemsen, 2005; Wilson et al., 2012; Zacher et al., 2013). Seven studies had a neutral equity impact. Two demonstrated a positive equity impact; EU text-only health warnings (Hitchman et al., 2012) and the addition of a quitline number to new pictorial health warnings (Wilson et al., 2012). 3.6. Population-level cessation support interventions Nine studies were included (Bauld et al., 2007, 2003; Chesterman et al., 2005; Galbraith, 2012; Hiscock et al., 2009; Low et al., 2007; Simpson et al., 2010; Taggar et al., 2012; Wilson et al., 2010). Four studies had a positive equity impact, two had a neutral equity impact, one was mixed and two were unclear. Six studies (five in the UK and one in New Zealand) examined the population-level impact of combined behavioural and pharmacological cessation support interventions. Four studies showed NHS SSSs were successful in recruiting relatively more low SES smokers. One early study of NHS SSSs (Bauld et al., 2003) showed a higher reach and lower quit rates for low SES smokers compared with higher SES smokers. However, the study did not link reach with quit rates; consequently, the overall equity impact was unclear. Three other studies (Bauld et al., 2007; Chesterman et al., 2005; Galbraith, 2012) (including the national monitoring of Scottish SSSs) demonstrated that NHS SSSs reached proportionately more lower SES than high SES smokers, which more than compensated for the lower quit rates among low SES smokers. Thus, the overall equity effect on quitting was positive. Two studies evaluated the impact of cessation support interventions on smoking prevalence rates and showed neutral equity impact. One UK study (Low et al., 2007) found that SSSs in one PCT (Derwentshire) had a neutral equity impact on area smoking prevalence. The PEGS programme (Hiscock et al., 2009) in New Zealand (delivered by general practitioners and targeted at deprived areas) reduced smoking prevalence. However, there was no evidence of a significant impact on area smoking prevalence inequalities. Two studies (Simpson et al., 2010; Taggar et al., 2012) evaluated the impact of financial incentives to UK General Practices for providing smoking cessation advice and referral to NHS SSSs. One study had a positive equity impact: low SES patients were more likely to have both a record of smoking status and cessation advice (Taggar et al., 2012). One study had a mixed equity impact: proportionately more lower SES smokers were referred to SSSs, and the proportion had increased over time. However, the absolute gap between low and high SES smoking prevalence increased, while the relative gap decreased (similar proportions of low and high SES smokers were provided with smoking cessation advice) (Simpson et al., 2010). A New Zealand study evaluated a national quitline targeted at disadvantaged smokers (Wilson et al., 2010). The equity impact was unclear because of inconsistency between SES measures of quitline usage and a potentially biased study sample. In addition, the concurrent introduction of other tobacco control policies might have accounted for the increased quitline usage. 3.7. Settings-based interventions Seven studies examined the equity impact of settings-based interventions (four community, two workplace and one hospital), which varied considerably in scope and approach (Darity et al., 2006; Donath et al., 2009; Secker-Walker et al., 2000; Sorensen et al., 1998, 2003; Stafford et al., 2008; Wendel-Vos et al., 2009). Both workplace studies included smoking cessation as part of cancer prevention initiatives (Sorensen et al., 1998, 2003), the community Hartslag Limburg intervention (Wendel-Vos et al., 2009)

addressed lifestyle risk factors and the New Deal for Communities (Stafford et al., 2008) addressed wider determinants of inequality. Two studies demonstrated positive equity impacts, four neutral and one negative. A workplace intervention integrating health promotion with occupational health and safety significantly improved quit rates among US blue-collar manufacturing workers compared to health promotion alone (Sorensen et al., 2003). The ‘Breathe Easy’ community intervention (Secker-Walker et al., 2000), which targeted lower-income women, produced higher quit rates amongst these women after 4 years. The evidence for any specific setting was insufficient to be able to draw firm conclusions. 3.8. Multiple policies Four studies examined the equity impact of multiple policies: two had a neutral equity impact, one mixed and one unclear (Frieden et al., 2005; Nagelhout et al., 2012; Schaap et al., 2008; Verdonk-Kleinjan, 2011). A study of 18 European countries (Schaap et al., 2008) found that countries with more developed tobacco control policies, as measured by their tobacco control scale score (TCS), were had higher quit rates but no consistent differences were found between high and low educated groups and the TCS (neutral equity impact). 4. Discussion The review identified 117 studies, which evaluated the equity impact of 130 interventions/policies. Overall equity effects for all types of interventions/policies were: 33 positive, 36 neutral, 38 negative, 6 mixed and 17 unclear. It is important to emphasise that 33 of the 36 neutral equity interventions/policies had a positive benefit across all SES groups. An expert panel which assessed the effectiveness of price/tax policies in 2010 (Chaloupka et al., 2011) concluded that there was ‘strong but not sufficient’ evidence that lower income populations in high income countries are more responsive to price/tax increases than higher income groups. As has been found in previous systematic reviews on the equity impact of tobacco control interventions (Amos et al., 2011; Fayter et al., 2008) this review found that the clearest and most consistent evidence of positive equity impact was for increasing the purchase price of cigarettes. Fourteen price/tax studies were associated with a positive equity effect. Low SES smokers appeared more responsive to price/tax increases in terms of larger price elasticities compared with high SES smokers. However, larger price elasticities among lower SES adults might be capturing short-term effects which do not translate into sustained quitting. In addition, cross-border sales or smuggling were not accounted for in most econometric studies. This omission might have biased the results: lower SES adults might be more likely to mitigate the effects of price/tax increases by switching to cheaper brands or buying illicit tobacco. However, a recent European study (Nagelhout et al., 2013a,b) showed that cross-border cigarette purchasing was more often reported by high SES smokers. Smokefree policies, when voluntary, regional or partial, increase socioeconomic inequalities in terms of protection from SHS: 19 out of 25 studies were associated with a negative equity effect. In contrast, only 6/19 studies of national comprehensive legislation showed a negative equity effect. The implementation of total smoking bans in some countries is reducing this inequality. A previous review carried out in 2010 (Amos et al., 2011) concluded that comprehensive legislated smokefree environments, along with price increases, had the greatest potential to reduce inequalities in smoking. By definition, such legislation removes inequalities in protection from SHS. Studies published since 2010, included in this review, show equal beneficial health effects


across SES groups, including reducing myocardial infarctions and coronary events. However, only two of the 19 studies of comprehensive national smokefree legislation demonstrated a positive overall equity impact for other smoking-related outcomes, including smoking prevalence. This may reflect variation in time lags between policy implementation and impact on smoking behaviour (e.g., through changing social norms) by SES, and the higher levels of smoking and SHS exposure in low SES groups prior to the legislation in public places and homes. The equity effect of mass media campaigns was inconsistent. This is perhaps not surprising given the diversity of messages, media formats and levels of exposure. There was some evidence that certain types of messages are more effective with low SES smokers (Durkin et al., 2009; Farrelly et al., 2012a,b). There was some evidence that promoting free NRT can have a positive equity impact in jurisdictions where NRT is not state-reimbursed. The type of outcomes measured in the mass media campaigns varied, but were mainly short-term or intermediate. The evidence in this review supports the conclusion of a previous review on antismoking mass media campaigns (Niederdeppe et al., 2008a,b) that the outcomes related to the type of media message, media format and mechanisms of engagement can vary by SES. Controls on advertising, marketing and promotion of cigarettes, including warning labels, had mostly neutral equity effects (7/9 studies). A previous review (Amos et al., 2011) found consistent evidence that smoking cessation support, however provided, has a negative equity effect due to higher quit rates in high SES smokers. The current review, which included studies that measured both reach of services and quit rates by SES, found evidence that the UK comprehensive smoking cessation services, which are targeted at low SES smokers, can have a positive equity effect, since higher reach among low SES smokers compensates for lower quit rates. Studies on settings-based approaches were too few and diverse to draw any conclusions about their potential contribution to reducing inequalities in smoking. It was disappointing to find only one relevant study of non-tobacco control policies. Marmot and others have highlighted the importance of addressing the wider social determinants of health inequalities in reducing inequalities in smoking (Amos et al., 2012; Graham, 2009, 2012; Marmot, 2011). For example, there is evidence that policies which increase household incomes may increase smoking cessation rates (YoungHoon, 2012). The English New Deal for Communities (Stafford et al., 2008) was the only intervention to address wider social determinants of inequality and showed no increase in quitting rates, overall or in low SES communities, compared to control communities. While tobacco control strategies usually comprise a range of policies, few studies addressed interactions between multiple policies and possible synergistic effects. Different elements of these policies may impact differentially by SES. For example, low SES smokers might be more sensitive to cigarette price increases, but be less exposed to smokefree policies in public places and less engaged by mass media messages that are not salient to their beliefs and experiences. This review has strengths and limitations. The review synthesises a large amount of evidence on tobacco control interventions/policies reporting smoking-related outcomes by SES, which is relevant to countries at stage 4 of the tobacco epidemic. However, it is possible that studies which undertook analyses by SES but did not report this in their abstract were missed. This review goes beyond previous reviews (Amos et al., 2011; Fayter et al., 2008) in searching for non-tobacco control interventions/policies. Most of the primary study designs included in this review would not meet the criteria used by other systematic reviews, highlighting that very few experimental studies have been carried out in tobacco control. The vast majority of evidence was derived from studies using research

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designs which fail to deal with typical threats to internal validity, especially the problem of causal attribution. Nearly half the studies described interventions in the USA, raising concerns about the generalisability, transferability and relevance of findings for other stage 4 countries with different socio-cultural contexts and/or levels of tobacco control. The focus on stage 4 countries also means that the findings may not be applicable to countries at an earlier stage of the tobacco epidemic. The review excluded studies targeted at low SES adults that did not report smoking-related outcomes by SES. Although these studies provide evidence about impact in specific low SES groups, they cannot provide evidence of equity effect. This review goes beyond previous reviews by including population-level cessation support interventions. This review highlights the difficulties in assessing the equity impact of tobacco policies and the importance of measuring and reporting both absolute and relative differences in smoking-related outcomes between low and high SES groups. Assessing the overall equity impact of different types of interventions/policies was complicated by the fact that some studies had multiple outcomes or multiple measures of SES which varied in equity impact. In other cases the same SES measure or outcome varied by gender, setting or country. Scanlan (Scanlan, 2012) clarifies how different measures of assessing equity (relative and absolute differences) and the type of outcome (favourable or adverse) are systematically affected by changes in prevalence of an outcome and can produce conflicting equity results. Further research is required to improve methods for measuring and interpreting equity to inform future equity-oriented policies. Despite identifying 117 relevant studies, this review can only draw limited conclusions about which types of tobacco control interventions/policies are likely to reduce inequalities in smoking. The clearest and most consistent evidence of a positive equity impact is increasing the purchase price of cigarettes. As smoking prevalence continues to decline in stage 4 countries (Lopez et al., 1994) the tobacco control field has become more focused on how to achieve the ‘end game’ which is to reduce smoking prevalence to negligible levels (Warner, 2013). Indeed, several countries, including Scotland (Scottish Government, 2013), New Zealand (new Zealand Government, 2011) and Finland (Finnish Government, 2010), have set targets to achieve such a goal. The Scottish Government aims to create a ‘tobacco-free generation’ by 2034. A major challenge in achieving this end game is to reduce smoking more rapidly amongst low SES groups. There is therefore an urgent need to develop the evidence-base for effective equityorientated tobacco control strategies. Role of funding source This study is part of the project ‘Tackling socio-economic inequalities in smoking (SILNE)’, which is funded by the European Commission, Directorate-General for Research and Innovation, under the FP7-Health-2011 programme, with grant agreement number 278273. The European Commission had no further role in the study design; in the collection, analysis and interpretation of the data; in the writing of the report; or in the decision to submit the paper for publication. Contributors TB, SP and AA developed the initial strategy for the review; TB undertook the literature search with support from AA and SP; TB, SP and AA reviewed individual articles; TB wrote the first draft of this paper; AA and SP contributed to the writing of the manuscript and agree with its results and conclusions.

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