Impact on Outcomes

Possible gaps in Evidence

Sources

Impact on short term and intermediate outcomes

There is review level evidence supporting:

• a range of interventions targeted at retailers being effective  e.g.:
• interventions with retailers leading to decreases in the number of outlets selling cigarettes to young people
• active enforcement and/or multi-component educational strategies with retailers leading to decreases in the number of outlets selling cigarettes to young people and being more effective in reducing illegal sales than simply providing retailers with information
• legislation alone not being sufficient to prevent tobacco sales to minors
• limiting sales of tobacco potentially having an effect on young people’s perceptions of ease of access to cigarettes and on smoking behaviour
• compliance checks including warnings and fines for retailers who illegally make sales to underage youth. [These have been shown to reduce the proportion of retailers who are willing to sell tobacco during compliance checks; however it has been difficult to demonstrate a clear effect on young smokers' perceptions of how easily they can buy cigarettes, or on their smoking behaviour.]
• access restriction interventions impacting effectiveness in terms of the number of sales to young people, young people’s ability to access cigarettes and store clerk compliance (but a lack of information on whether they impact behaviours, attitudes, beliefs, intentions or perceptions)
• active enforcement, comprehensive interventions, interventions produced by tobacco control bodies, requesting age/proof of ID, demographics of the vendor/store clerk, site/setting of the access intervention, and the demographics of the target audience as being factors that have been shown to influence number of sales, young people’s ability to access cigarettes and store clerk compliance.  Overall, the factors … work best when combined with requesting proof of age/ID, active enforcement … and other youth prevention strategies and when combined with broader tobacco control initiatives produced by tobacco control bodies.
• increasing compliance with new or existing laws to reduce access to tobacco products and/or increases in duty on tobacco potentially increasing demand for illicit sales of tobacco, although there is a lack of evidence on whether access restrictions shift the way tobacco is purchased to other sources (including illicit activities); the importance therefore of trying to tackle illicit sales although there is a lack of evidence on the factors that support implementation of interventions to reduce illegal tobacco sales
• mass-media and point-of-sales measures should be combined with other prevention activities as part of a comprehensive tobacco control strategy

[Note that a policy document cites evidence suggesting that cheaper smuggled tobacco products undermine the impact of pricing and sales controls and that smuggled tobacco is most likely to be sold in deprived areas and increasingly to target children, with smuggling potentially having a disproportionate impact on smoking behaviour by young people in these areas and be a factor in perpetuating health inequalities. The report also includes a commitment on the part of Scottish Government to continue collaborating with HM's Revenue & Customs to reduce the impact of illicit sales of tobacco products on Scottish communities with action linked to better enforcement of tobacco sales law. It follows that in addition to protection and control measures affecting supply, enforcing tobacco advertising legislation to reduce demand is also important.]

There is policy document support for:

• measures to protect young people from the impact of tobacco, through legislation and other forms of regulation/control as being a vital component of any smoking prevention strategy
• statutory controls contributing to shifting social norms by making smoking less socially acceptable within communities across Scotland
• vigorous enforcement of under-age sales legislation (good evidence that it reduces cigarette sales to minors and can have some impact on smoking rates among minors – more stringent underage sales policies being associated with lower youth smoking rates)
• active use of test purchasing and encouraging vendors to require proof of age before selling to young customers
• vigorous enforcement of the minimum legal purchase age combined with high compliance by retailers being more effective in reducing illegal sales than non-legislative measures (unenforced voluntary agreements or education of retailers)

Gaps in the evidence include:

• whether access interventions shift the way tobacco is purchased to other sources (including illicit activities)
• the factors that support implementation of interventions to reduce illegal tobacco use

There are both review and policy documents concluding that:

• tobacco taxation is a particularly effective way of reducing tobacco consumption among young people (strong evidence)
• increasing the price of cigarettes is effective for reducing tobacco use prevalence and consumption among both adolescents and young adults

Additionally, the ‘treatobacco.net’ site signposts to evidence that:

• higher cigarette prices are effective in reducing the initiation of regular smoking.
• smoking in lower socioeconomic groups is more responsive to price than smoking in higher economic groups

Other issues acknowledged by review level evidence and policy documents are the following:

• environmental, socio-demographic, behavioural and individual factors are all associated with the uptake of smoking and particularly having a parent or sibling who smokes which is strongly associated with uptake
• the synergistic effect of broad, multi-faceted approaches to prevent and reduce smoking in that it may have a positive effect on those outwith the target group, …and that carrying out a range of interventions in the most effective way is of prime importance
• the importance of contextual factors in influencing smoking behaviour (citing many factors contributing to encouraging young people to start and continue smoking including: parental attitudes and behaviour; friends who smoke; and the availability, cost and perceived attractiveness of cigarettes)
• early evidence that smoking bans in enclosed public places may reduce youth smoking (from a pre-UK smoke-free legislation policy document).  The smoke-free legislation has the potential to make a major contribution to smoking prevention by reducing SHS exposure and observation of smoking in leisure or work situations, reinforcing a negative image of smoking, and resulting in smoking cessation and prevention of deaths due to passive smoking

Source:
NICE (2008). Public Health Guidance 14 – Preventing the uptake of smoking by children and young people: mass-media and point-of-sales measures to prevent the uptake of smoking by children and young people. NICE, London.

An NHS Health Scotland Commentary on this piece of NICE Guidance is available at www.healthscotland.com/scotlands-health/evidence/NICE.aspx

Stead, L.F. and Lancaster, T. (2005). Interventions for preventing tobacco sales to minors. Cochrane Database of Systematic Reviews, 1, Art. No: CD001497; doi:10.1002/14651858.CD001497.pub2

Scottish Executive (2006). Towards A Future Without Tobacco.Scottish Executive, Edinburgh.

Scottish Government (2008). Scotland’s Future is Smoke Free: A Smoking Prevention Action Plan. Scottish Government, Edinburgh.

NICE (2010). Public Health Guidance 23 – School-based interventions to prevent the uptake of smoking among children. NICE, London.

Naidoo B et al. (2004) Smoking and public health: A review of reviews of interventions to increase smoking cessation, reduce smoking initiation, and prevent further uptake of smoking.   London: H.D.A.  

Treatobacco.net. Health Economics section, Key Findings, www.treatobacco.net/en/page_173.php.

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