Matthew J. Spittal

Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence.

OBJECTIVES We sought to assess the impact of several tobacco control policies and televised antismoking advertising on adult smoking prevalence. METHODS We used a population survey in which smoking prevalence was measured each month from 1995 through 2006. Time-series analysis assessed the effect on smoking prevalence of televised antismoking advertising (with gross audience rating points [GRPs] per month), cigarette costliness, monthly sales of nicotine replacement therapy (NRT) and bupropion, and smoke-free restaurant laws. RESULTS Increases in cigarette costliness and exposure to tobacco control media campaigns significantly reduced smoking prevalence. We found a 0.3-percentage-point reduction in smoking prevalence by either exposing the population to televised antismoking ads an average of almost 4 times per month (390 GRPs) or by increasing the costliness of a pack of cigarettes by 0.03% of gross average weekly earnings. Monthly sales of NRT and bupropion, exposure to NRT advertising, and smoke-free restaurant laws had no detectable impact on smoking prevalence. CONCLUSIONS Increases in the real price of cigarettes and tobacco control mass media campaigns broadcast at sufficient exposure levels and at regular intervals are critical for reducing population smoking prevalence.

Weekend Sun Protection and Sunburn in Australia Trends (1987-2002) and Association with SunSmart Television Advertising

BACKGROUND The Australian state of Victoria has run a population-based skin cancer prevention program called SunSmart since 1988, incorporating substantial public education efforts and environmental change strategies. Trends over 15 years in behavioral risk factors for skin cancer were examined in a population exposed to the SunSmart program. Whether outcomes were associated with extent of SunSmart television advertising was then assessed. METHODS In nine cross-sectional surveys from 1987 to 2002, 11,589 adults were interviewed by telephone about their sun exposure and sun protection during outdoor activities on summer weekends. Analyses completed in 2007 adjusted for ambient temperature and ultraviolet radiation. RESULTS Sun protection and sunburn show substantial general improvement over time, but have stalled in recent years. Use of hats and sunscreens significantly increased over time and peaked during the mid to late 1990s, compared with the pre-SunSmart baseline. The mean proportion of unprotected skin was reduced and was lowest in the summer of 1997-1998. Summer sunburn incidence declined over time and was 9.1% in 2002, almost half baseline (OR=0.53; 95% CI=0.39-0.73). Higher exposure to SunSmart advertising in the 4 weeks before the interview increased: (1) preference for no tan, (2) hat and sunscreen use, and (3) proportion of body surface protected from the sun. CONCLUSIONS The general improvement in sun-protective behaviors over time highlight that a populations sun-protective behaviors are amenable to change. Population-based prevention programs incorporating substantial television advertising campaigns into the mix of strategies may be highly effective in improving a populations sun-protective behaviors.

Happiness and Life Satisfaction Prospectively Predict Self-Rated Health, Physical Health, and the Presence of Limiting, Long-Term Health Conditions:

Purpose. To examine the effect of happiness and life satisfaction on health. Design. Longitudinal data from waves 1 and 3, conducted in 2001 and 2004, respectively, of the Household Income and Labour Dynamics in Australia survey. Setting. Australia. Subjects. A total of 9981 respondents aged 18 years and older. Measures. Outcomes were self-reported health; the absence of long-term, limiting health conditions; and physical health. Happiness was assessed with the following question: “During the past 4 weeks, have you been a happy person”? Life satisfaction was determined with the following question: “All things considered, how satisfied are you with your life”? Analysis. We used multiple regression analysis to estimate odds ratios (ORs), beta coefficients (β), and 95% confidence intervals (CIs) for the associations between baseline happiness or life satisfaction and health at wave 3. Results. Baseline happiness and life satisfaction both were positively associated at wave 3 with excellent, very good, or good health (OR = 1.50, CI = 1.33–1.70, p < .0001; and OR= 1.62, CI = 1.27–2.08, p < .0001, respectively); with the absence of long-term, limiting health conditions (OR = 1.53, CI = 135–1.15, p < .0001; and OR = 1.51, CI = 1.25–1.82, p < .0001, respectively); and with higher physical health levels (β̂ = .99, CI = .60–1.39, p < .0001; and β̂ = .99, CI = .20–1.18, p < .0145, respectively). Conclusion. This study showed that happier people and those who were more satisfied with their lives at baseline reported better health (self-rated health; absence of limiting, long-term conditions; and physical health) at the 2-year follow-up when adjusted for baseline health and other relevant covariates.

Suicide by occupation: Systematic review and meta-analysis

BACKGROUND Previous research has shown that those employed in certain occupations, such as doctors and farmers, have an elevated risk of suicide, yet little research has sought to synthesise these findings across working-age populations. AIMS To summarise published research in this area through systematic review and meta-analysis. METHOD Random effects meta-analyses were used to calculate a pooled risk of suicide across occupational skill-level groups. RESULTS Thirty-four studies were included in the meta-analysis. Elementary professions (e.g. labourers and cleaners) were at elevated risk compared with the working-age population (rate ratio (RR) = 1.84, 95% CI 1.46-2.33), followed by machine operators and deck crew (RR = 1.78, 95% CI 1.22-2.60) and agricultural workers (RR = 1.64, 95% CI 1.19-2.28). Results suggested a stepwise gradient in risk, with the lowest skilled occupations being at greater risk of suicide than the highest skill-level group. CONCLUSIONS This is the first comprehensive meta-analytical review of suicide and occupation. There is a need for future studies to investigate explanations for the observed skill-level differences, particularly in people employed in lower skill-level groups.

Effects of mass media campaign exposure intensity and durability on quit attempts in a population-based cohort study

OBJECTIVE To assess the extent to which intensity and timing of televised anti-smoking advertising emphasizing the serious harms of smoking influences quit attempts. METHODS Using advertising gross rating points (GRPs), we estimated exposure to tobacco control and nicotine replacement therapy (NRT) advertising in the 3, 4-6, 7-9 and 10-12 months prior to follow-up of a replenished cohort of 3037 Australian smokers during 2002-08. Using generalized estimating equations, we related the intensity and timing of advertising exposure from each source to the likelihood of making a quit attempt in the 3 months prior to follow-up. RESULTS Tobacco control advertising in the 3-month period prior to follow-up, but not in more distant past periods, was related to a higher likelihood of making a quit attempt. Each 1000 GRP increase per quarter was associated with an 11% increase in making a quit attempt [odds ratio (OR) = 1.11, 95% confidence interval (CI) 1.03-1.19, P = 0.009)]. NRT advertising was unrelated to quit attempts. CONCLUSIONS Tobacco control advertising emphasizing the serious harms of smoking is associated with short-term increases in the likelihood of smokers making a quit attempt. Repeated cycles of higher intensity tobacco control media campaigns are needed to sustain high levels of quit attempts.

Taxation reduces social disparities in adult smoking prevalence.

BACKGROUND The CDC, the WHO, and the World Bank promote increases in the price of cigarettes as an effective and important tobacco-control strategy. This study was designed to assess the extent to which the association between the price of cigarettes and smoking prevalence, as measured monthly, varies by income group. METHODS Australian population survey data collected monthly from January 1991 to December 2006 were used to estimate Poisson regression models to assess the impact of the price of cigarettes on smoking prevalence across three income groups. Analyses were conducted in 2008. RESULTS There was strong evidence that real price and prevalence were negatively associated (p<0.001) and that the association was stronger in lower-income groups (p<0.001). One Australian dollar increase in price was associated with a decline of 2.6%, 0.3%, and 0.2% in the prevalence of smoking among low-, medium-, and high-income groups, respectively. CONCLUSIONS Increasing the price of cigarettes not only is an effective tobacco-control strategy to lower smoking prevalence in the general population, but also may provide a means of reducing social disparities in smoking.

Letters, green cards, telephone calls and postcards: systematic and meta-analytic review of brief contact interventions for reducing self-harm, suicide attempts and suicide

BACKGROUND There is growing interest in brief contact interventions for self-harm and suicide attempt. AIMS To synthesise the evidence regarding the effectiveness of brief contact interventions for reducing self-harm, suicide attempt and suicide. METHOD A systematic review and random-effects meta-analyses were conducted of randomised controlled trials using brief contact interventions (telephone contacts; emergency or crisis cards; and postcard or letter contacts). Several sensitivity analyses were conducted to examine study quality and subgroup effects. RESULTS We found 14 eligible studies overall, of which 12 were amenable to meta-analyses. For any subsequent episode of self-harm or suicide attempt, there was a non-significant reduction in the overall pooled odds ratio (OR) of 0.87 (95% CI 0.74-1.04, P = 0119) for intervention compared with control. The number of repetitions per person was significantly reduced in intervention v. control (incidence rate ratio IRR = 066, 95% CI 0.54-0.80, P<0001). There was no significant reduction in the odds of suicide in intervention compared with control (OR = 0.58, 95% CI 0.24-1.38). CONCLUSIONS A non-significant positive effect on repeated self-harm, suicide attempt and suicide and a significant effect on the number of episodes of repeated self-harm or suicide attempts per person (based on only three studies) means that brief contact interventions cannot yet be recommended for widespread clinical implementation. We recommend further assessment of possible benefits in well-designed trials in clinical populations.

Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia

Objectives (1) To determine the distribution of formal patient complaints across Australias medical workforce and (2) to identify characteristics of doctors at high risk of incurring recurrent complaints. Methods We assembled a national sample of all 18 907 formal patient complaints filed against doctors with health service ombudsmen (‘Commissions’) in Australia over an 11-year period. We analysed the distribution of complaints among practicing doctors. We then used recurrent-event survival analysis to identify characteristics of doctors at high risk of recurrent complaints, and to estimate each individual doctors risk of incurring future complaints. Results The distribution of complaints among doctors was highly skewed: 3% of Australias medical workforce accounted for 49% of complaints and 1% accounted for a quarter of complaints. Short-term risks of recurrence varied significantly among doctors: there was a strong dose-response relationship with number of previous complaints and significant differences by doctor specialty and sex. At the practitioner level, risks varied widely, from doctors with <10% risk of further complaints within 2 years to doctors with >80% risk. Conclusions A small group of doctors accounts for half of all patient complaints lodged with Australian Commissions. It is feasible to predict which doctors are at high risk of incurring more complaints in the near future. Widespread use of this approach to identify high-risk doctors and target quality improvement efforts coupled with effective interventions, could help reduce adverse events and patient dissatisfaction in health systems.

Association of Smoking Cessation With Financial Stress and Material Well-Being: Results From a Prospective Study of a Population-Based National Survey

OBJECTIVES We used 4 waves of prospective data to examine the association of smoking cessation with financial stress and material well-being. METHODS Data (n = 5699 at baseline) came from 4 consecutive waves (2001-2005) of the Household Income and Labour Dynamics in Australia survey. We used mixed models to examine the participant-specific association of smoking cessation with financial stress and material well-being. RESULTS On average, a smoker who quits is expected to have a 25% reduction (P<.001; odds ratio [OR]=0.75; 95% confidence interval [CI]=0.69, 0.81) in the odds of financial stress. Similarly, the data provided strong evidence (P<.001) that a smoker who quits is likely to experience an enhanced level of material well-being. CONCLUSIONS Our findings indicate that interventions to encourage smoking cessation are likely to improve standards of living and reduce deprivation. The findings provide grounds for encouraging the social services sector to incorporate smoking cessation efforts into their programs to enhance the material or financial conditions of disadvantaged groups. The findings also provide additional incentives for smokers to stop smoking and as such can be used in antismoking campaigns and by smoking cessation services.

Antismoking television advertising and socioeconomic variations in calls to Quitline

Objective: To assess the socioeconomic variations in call rates to the Quitline (Victoria, Australia) and in the impact of anti-tobacco television advertising on call rates. Design: The outcome measure was the number of calls to the Quitline in Victoria for each week for each socioeconomic group for the period January 2001 to March 2004. Socioeconomic status (SES) was derived from the caller’s postcode using the Index of Socioeconomic Disadvantage provided by the Australian Bureau of Statistics. The exposure measure was weekly Target Audience Rating Points (TARPs, a standard measure of television advertising weight) for anti-tobacco advertising broadcast in Victoria over the same period. Negative binomial regression was used to examine the interaction of SES and TARPs in their effect on the number of Quitline calls. Results: SES and call rates were positively associated. Adjusted call rate was 57% (95% CI 45% to 69%) higher in the highest than the lowest SES quintile. SES differences in call rates were stable over time. In the study period, the effect of the presence or increasing levels of antismoking TARPs on call rates did not vary across categories of SES. Conclusions: In the study period, different SES groups had a similar level of responsiveness to antismoking television advertisements, at least as measured by the rate of calls to the Quitline. However, the present media campaigns are not likely to diminish SES differences in call rates, and more needs to be done to encourage disadvantaged groups to call the Quitline.