Public policy and health behaviour: An investigation of tobacco control policy and smoking in Ireland
Aim: This thesis documents four interrelated studies, which seek to understand the impact tobacco control policies have had on patterns of smoking in Ireland.
Methods: Study 1 critically compares four tobacco use surveys in Ireland: SLAN, OTC, EURO, and FAST, and examines trends in smoking prevalence and social inequalities in smoking between 1990 and 2011. Study 2 re-contacts young adult respondents to SLAN 2007 (age 20-39 years, n = 1039; 83% response rate) to complete structured telephone interviews three years later. This study examines factors associated with continuity and change in smoking, and cessation related outcomes (quit intentions, quit attempts and nicotine dependence). Study 3 uses the same young adult follow-up data to examine responses to a recent large tax increase and estimates factors associated with compensatory behaviour. Lastly, Study 4 employed IrelandSS - an adapted version of the SimSmoke simulation model, to examine the effect of past policies and the potential effect of stronger policies on smoking prevalence and smoking-attributable deaths.
Main findings: Triangulation of data suggests a significant downward trend in overall smoking prevalence among adults (18+ years) between 1990 and 2011; however, rates among the young and most socioeconomically disadvantaged are high (over 32%) and have not declined significantly. Social inequalities in smoking prevalence, initiation and cessation are increasing in both relative and absolute terms. The social differential in smoking prevalence is largely driven by widening inequalities in smoking among women and a widening differential in quit ratios between the highest and lowest socioeconomic groups.
Longitudinal analysis of young adults suggests overall prevalence declined from 33.3% to 32.2% between 2007 and 2009, with one in five making some transition in smoking behaviour; 5.8% (n=60) increased through initiation (n=32, 3.1%), relapse (n=28, 2.7%) or escalation from occasional to daily smoking (n=19,1.8%), while 8.7% (n=90) decreased reducing from daily to occasional smoking (n=22, 2.1%) or quitting altogether (n=68, 6.6%). Older age, lower education and lower perceived behavioural control were associated with higher odds of nicotine dependence at follow-up. Risky drinking predicted an upward smoking trajectory, while higher education predicted a downward trajectory. Smokers with higher perceived control and social norms favourable to smoking cessation were more likely to intend to quit. A past attempt and higher perceived control increased the odds of a current quit attempt. Young adult smokers of hand-rolled tobacco (HRT) (n=57,17%) and low- or untaxed tobacco (n=48, 15.3%) were more likely to be of lower socioeconomic position and significantly more likely to be men. Younger smokers with lower socioeconomic status were more likely to report responding to the tax increase.
IrelandSS simulations suggest that tobacco control policies implemented between 1998 and 2010 contributed to a 22% relative reduction in smoking prevalence by 2010. Stronger policies could reduce prevalence by 13.1% in the first year and 27.7% by 2040 relative to the status quo scenario, with greater reductions among young adults, and could avert 24,768 smoking-attributable deaths between 2011 and 2040.
This thesis concludes that tobacco control policies implemented in Ireland have contributed significantly to overall reductions in smoking prevalence; however, there is further scope for improvement. A number of implications for future research and policy are documented.