Despite substantial modelling research assessing the impact of cigarette taxes on smoking rates across income groups, few studies have examined the broader financial effects and unintended consequences on very low-income smokers. This study explored how socioeconomically disadvantaged smokers in a high-income country manage smoking costs on limited budgets. Semi-structured face-to-face interviews were conducted with 20 smokers recruited from a welfare organization in NSW, Australia. Participants discussed perceived impact of tobacco costs on their essential household expenditure, smoking behaviour and quit cognitions. Interviews were audio-taped, transcribed verbatim and analysed using thematic framework analysis. Instances of smoking-induced deprivation and financial stress, such as going without meals, substituting food choices and paying bills late in order to purchase cigarettes were reported as routine experiences. Price-minimization strategies and sharing tobacco resources within social networks helped to maintain smoking. Participants reported tobacco price increases were good for preventing uptake, and that larger price rises and subsidized cessation aids were needed to help them quit. Socioeconomically disadvantaged smokers engage in behaviours that exacerbate deprivation to maintain smoking, despite the consequences. These data do not suggest a need to avoid tobacco taxation, rather a need to consider how better to assist socioeconomically disadvantaged smokers who struggle to quit.

Background. Smoke-free environment policies limit or eliminate the use of smoke-producing tobacco in designated areas thereby reducing second hand smoke. Enforcement is perceived as critical to the successful adoption of a smoke-free policy. However, there is limited guidance available regarding effective enforcement strategies. A systematic review was conducted to examine the effectiveness of enforcement strategies at increasing compliance with and enforcement of smoke-free policies; and to determine circumstances other than enforcement strategies that are associated with compliance with smoke-free policies. Design. Medline, Medline in Process, The Cochrane Library, Embase, PsycInfo and CINAHL databases were searched using MeSH and keywords for relevant studies published between January 1980 and August 2017. A narrative synthesis and methodological quality assessment of included studies was undertaken. Results. Policy promotion and awareness-raising activities, signage, enforcement officers, and penalties for violations were the enforcement strategies most frequently cited as being associated with successful policy enforcement. Additionally, awareness of the laws, non-smoking management and lower staff smoking rates, and membership of a network guiding the policy enforcement contributed to higher compliance with smoke-free policies. Conclusions. There is weak evidence of the effectiveness of strategies associated with compliance with smoke-free policies. Given the evidence base is weak, well-designed trials utilizing appropriate evaluation designs are needed. Overall enforcement strategies associated with total smoke-free bans resulted in higher levels of compliance than strategies for policies that had only partial smoke-free bans.

Financial stress is associated with fewer quit attempts and higher relapse rates. This study aimed to compare financial stress among smokers, ex-smokers and never smokers in a highly socioeconomically disadvantaged sample. The study also aimed to determine whether specific indicators of financial stress differ according to smoking status. Adult clients seeking welfare assistance from two Social and Community Service Organisation sites in New South Wales, Australia, were invited to complete a cross-sectional survey between March 2012 and December 2013. Responses to a financial stress scale, smoking status and demographics were collected. Linear and logistic regression modelling was used to examine associations between smoking status and financial stress. A total of 1463 participants completed the survey. Current smokers had significantly higher total financial stress scores than ex-smokers and non-smokers respectively. Current smokers also had higher odds of severe financial stress indicators, such as going without meals (Odds Ratio = 2.2 and 2.0), than both non-smokers and ex-smokers. Even among a highly socioeconomically disadvantaged sample with high levels of financial stress, smoking status further exacerbates experiences of deprivation. Given the relationship between financial stress, socioeconomic disadvantage and difficulty quitting, it is important to provide enhanced cessation support to smokers experiencing financial stress.

Background: The aim of this trial was to evaluate the effectiveness of an online health behaviour change intervention—Prevent 2nd Stroke (P2S)—at improving health-related quality of life (HRQoL) amongst stroke survivors at 6 months of follow-up. Methods and findings: A prospective, blinded-endpoint randomised controlled trial, with stroke survivors as the unit of randomisation, was conducted between March 2018 and November 2019. Adult stroke survivors between 6 and 36 months post-stroke with capacity to use the intervention (determined by a score of ≥4 on the Modified Rankin Scale) and who had access and willingness to use the internet were recruited via mail-out invitations from 1 national and 1 regional stroke registry. Participants completed baseline (n = 399) and 6-month follow-up (n = 356; 89%) outcome assessments via computer-assisted telephone interviewing (CATI). At baseline the sample had an average age of 66 years (SD 12), and 65% were male. Randomisation occurred at the end of the baseline survey; CATI assessors and independent statisticians were blind to group allocation. The intervention group received remote access for a 12-week period to the online-only P2S program (n = 199; n = 28 lost at follow-up). The control group were emailed and posted a list of internet addresses of generic health websites (n = 200; n = 15 lost at follow-up). The primary outcome was HRQoL as measured by the EuroQol Visual Analogue Scale (EQ-VAS; self-rated global health); the outcome was assessed for differences between treatment groups at follow-up, adjusting for baseline measures. Secondary outcomes were HRQoL as measured by the EQ-5D (descriptive health state), diet quality, physical activity, alcohol consumption, smoking status, mood, physical functioning, and independent living. All outcomes included the variable ‘stroke event (stroke/transient ischaemic attack/other)’ as a covariate, and analysis was intention-to-treat. At 6 months, median EQ-VAS HRQoL score was significantly higher in the intervention group than the control group (85 vs 80, difference 5, 95% CI 0.79–9.21, p = 0.020). The results were robust to the assumption the data were missing at random; however, the results were not robust to the assumption that the difference in HRQoL between those with complete versus missing data was at least 3 points. Significantly higher proportions of people in the intervention group reported no problems with personal care (OR 2.17, 95% CI 1.05–4.48, p = 0.0359) and usual activities (OR 1.66, 95% CI 1.06–2.60, p = 0.0256) than in the control group. There were no significant differences between groups on all other secondary outcomes. The main limitation of the study is that the sample comprises mostly ‘well’ stroke survivors with limited to no disability. Conclusions: The P2S online healthy lifestyle program improved stroke survivors’ self-reported global ratings of HRQoL (as measured by EQ-VAS) at 6-month follow-up. Online platforms represent a promising tool to engage and support some stroke survivors. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12617001205325.

Television advertisements, packaging regulations and health warning labels (HWLs) are designed to communicate anti-smoking messages to large number of smokers. However, only a few studies have examined how high smoking prevalence groups respond to these warnings. This study explored how socioeconomically disadvantaged smokers engage with health risk and cessation benefit messages. Six focus groups were conducted over September 2012–April 2013 with adult clients of welfare organizations in regional New South Wales, Australia who were current smokers (n = 51). Participants discussed HWLs, plain packaging and anti-smoking television advertisements. Discussions were audio-taped, transcribed verbatim and analysed using thematic analysis. Highly emotive warnings delivering messages of negative health effects were most likely to capture the attention of the study participants; however, these warning messages did not prompt quit attempts and participants were sceptical about the effectiveness of cessation programmes such as telephone quitlines. Active avoidance of health warning messages was common, and many expressed false and self-exempting beliefs towards the harms of tobacco. Careful consideration of message content and medium is required to communicate the anti-smoking message to disadvantaged smokers who consider themselves desensitized to warnings. Health communication strategies should continue to address false beliefs about smoking and educate on cessation services that are currently underutilized.