Evidence from qualitative studies of youth about the impacts of

tobacco control policy on young people in Europe: a systematic

review.

Authors:

Natalie Papanastasiou, PhD

UK Centre for Tobacco and Alcohol Studies

Usher Institute for Population Health Sciences and Informatics

University of Edinburgh

Edinburgh

UK

Sarah Hill, PhD

Global Public Health Unit

University of Edinburgh

Edinburgh

UK

Amanda Amos, PhD

UK Centre for Tobacco and Alcohol Studies

Usher Institute for Population Health Sciences and Informatics

University of Edinburgh

Edinburgh

UK

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Correspondence to:

Professor Amanda Amos

UK Centre for Tobacco and Alcohol Studies

Usher Institute for Population Health Sciences and Informatics

Teviot Place

EH8 9AG

Edinburgh

UK

Tel: +44(0)131650 3236

Email: Amanda.amos@ed.ac.uk

Word count: 4219

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ABSTRACT Introduction: A range of tobacco control policies endeavour to prevent

smoking uptake in young people, yet relatively little is known about how

such interventions impact young people’s engagement with smoking. We

reviewed existing qualitative evidence on young people and smoking in

Europe in order to assess whether, in what ways and why young people

comply with, adapt to, resist or circumvent tobacco control policies in

their respective countries..

Methods: We undertook a systematic review of academic literature

presenting qualitative research from Europe on smoking and young

people (11-18 years), published from 2000 - 2015. Bibliographic searches

(PubMed, PsycInfo, SSCI) produced 1357 records, from which 43

relevant papers were assessed for quality and 39 included in the review.

Results: Most studies were from the UK (27), with a small number (one

or two each) from other European countries (Denmark, Sweden,

Switzerland, Belgium, Cyprus, Greece, Hungary, Ireland and Spain). Only

16 articles (11 from UK) provided any evidence about the impacts of

tobacco control policies on young people’s smoking. These focussed on

smoke-free legislation (four), age of sale laws (four), plain packaging

(three), and black market tobacco (one).

Conclusions: There is very little qualitative evidence exploring the

impacts of tobacco control on youth smoking in Europe. To develop more

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effective smoking prevention policies that take account of local political,

social and cultural contexts, more qualitative research from a wider

range of European countries is needed in order to understand how

tobacco control impacts on young people’s social worlds and smoking

behaviours.

IMPLICATIONS

Smoking is the leading cause of premature mortality in Europe. However,

there is little qualitative evidence exploring the impact of tobacco control

policies on young people in Europe. Most comes from the UK and focuses

on a narrow range of policies. Thus we have a limited understanding of

how and in what ways tobacco control policies reach young people, their

engagement with these, and how local context affects their impact. More

qualitative research is needed, from a wider range of countries and on a

broader range of tobacco control policies, in order to strengthen the

evidence-base for reducing youth smoking.

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INTRODUCTION

Smoking is the most important preventable cause of premature death in

Europe (1). While smoking uptake in many countries continues until the

mid-20s, most smokers in Europe start to smoke before the age of 18,

with an estimated three-quarters of smokers in the European Union (2–4)

and two-thirds in the UK thought to start before the age of 18 (5).

Preventing young people from starting to smoke is therefore the most

effective way of decreasing smoking prevalence in future European

generations. This is reflected in the ways many tobacco control policies

are aimed at protecting young people from pro-smoking influences. Such

approaches include reducing young people’s exposure to tobacco

promotion (e.g. banning advertising, sponsorship and point-of-sale

displays; mandatory standardised packaging), reducing the affordability

(e.g. taxation, banning small packs) and availability (e.g. minimum age of

sale) of cigarettes, increasing the awareness of health risks (e.g. media

campaigns, health warnings), and protecting young people from exposure

to secondhand smoke and reducing the social acceptability of smoking

(eg smokefree public places and cars) (6-8). However, countries in

Europe vary considerably in both the extent and implementation of such

policies (9). There are also significant differences between countries in

Europe in youth smoking prevalence and the rates of decline in youth

smoking (10, 11). Understanding the effectiveness or not of tobacco

control policies, and the reasons for this, is instrumental to addressing

smoking as a public health risk in young people.

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Qualitative research, through exploring the lived experience and social

worlds of young people, has provided important insights and

understanding about the role and meaning of smoking in their lives. For

example, qualitative studies have revealed how smoking can play an

important role in peer relationships and socialising (12-16), and in family

relationships where smoking initiation is facilitated by older siblings and

parents (17). For some young people creating a smoking identity has

been found to be an important way of building social and cultural capital

among their peer group, where smoking is used both to project an

identity to distinguish between groups and to build internal group bonds

e.g. through sharing cigarettes (12, 18). In addition, qualitative research

can go further and explore not only how and in what ways tobacco

control policies reach young people through, for example, disrupting

their social worlds and the social meaning of smoking, but also their

responses to and engagement with these effects, both positive and

negative. For example, studies in the UK, US and New Zealand have

facilitated a more nuanced examination of the effect of age of sale laws

on young people’s cigarette sources. These have shown that when retail

access is restricted young smokers identify and target amenable tobacco

retailers, buy cigarettes through intermediaries (i.e. proxy purchases)

and/or access social sources such as friends and family or through social

sales in schools (19-25). Furthermore, these sources are inter-related,

with the social availability of cigarettes contingent on some young people

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buying cigarettes from shops (24). Such studies help understand how

some young smokers are able to circumvent age of sale laws, and the

implications for polices aimed at reducing youth access to cigarettes.

However, as far as we are aware, there has been no review of the

qualitative evidence assessing the impact of tobacco control policies on

how young people engage with smoking - ie. whether, in what ways and

why young people may comply with, adapt to, resist or circumvent such

policies. This paper seeks to address this knowledge gap by presenting

the findings from a systematic review which aimed to explore how

tobacco control policies in Europe shape young people’s engagement

with smoking. Focussing on studies undertaken in countries in Europe

may have particular policy relevance at both the national and EU levels.

Not only is there considerable variation in the strength of tobacco control

policies across Europe (9), but there may be important socioeconomic

and cultural differences, including social norms, which are likely to

influence how young people understand and respond to these policies in

different contexts and countries, and thus their effectiveness. In order

to be as inclusive and comprehensive as possible this review includes

evidence from qualitative studies with young people (aged 11-18) in

Europe relating to smoking perceptions and behaviours published since

2000, whether or not studies explicitly set out to assess the effect of

tobacco control policies. The review is part of a European project

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(SILNE-R http://ensp.org/node/1168 ) which explores the effectiveness of

policies for preventing youth smoking.

METHODS

This review follows the Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA) reporting guidelines (see

Supplementary File 1)

Search strategy and study selection

A search strategy was implemented on 17 November 2015 in three

electronic databases, PubMed, PsycInfo and Social Science Citation

Index (SSCI), to identify qualitative research on how young people

engage with smoking. Database specific terms and key words were used

to combine a number of search strings for qualitative, smoking, and

young people (Table 1). Members of SILNE-R were also contacted to

assist with identifying any further studies. The search led to the

production of a database of references which was independently

screened by two of the authors who assessed titles and abstracts to

ensure consistency in the screening process (Figure 1). Any

disagreements were discussed and resolved by all the authors.

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Eligibility criteria

Papers needed to be peer reviewed journal articles based on qualitative

or mixed-methods studies that included primary qualitative data from

young people aged between 11 and 18, and an abstract in English. All

forms of qualitative research methods were included, such as interviews,

focus groups and photovoice. Another criterion was that studies needed

to include a focus on young people’s ‘engagement with smoking’. The

latter was intentionally broad in order to fit with the exploratory aims of

qualitative research and to allow for unexpected findings. This led to the

inclusion of studies that covered topics such as access to cigarettes,

smoking at school, gendered smoking behaviours, and attempts to quit

smoking. Finally, studies needed to be from European countries, as

defined by WHO, and published from the year 2000 onwards in order to

reflect contemporary trends and policy contexts in relation to tobacco

and young people.

Data extraction and quality assessment

In order to appraise the overall quality of the available evidence and

apply a minimum threshold for inclusion in our review, we assessed the

43 eligible studies against a quality evaluation checklist developed by

Hefler and Chapman (26). The checklist included criteria related to the

quality, clarity and justification of articles: title and abstract, introduction

and aims, method and data, sampling, data analysis, ethics and bias,

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results, transferability or generalisability, and implications and

relevance. Quality assessment was conducted for all studies by one

reviewer (NP); a sample of reviewing scores and all exclusions were

checked by another (AA). Studies could receive a maximum score of 36.

Four studies were excluded from the review on the basis of a low quality

assessment score (see Supplementary File 3).

For the 39 studies included in the review, data were extracted by one

reviewer (NP) and checked by another (AA or SH) using a template

adapted from a systematic review of qualitative research on smoking and

pregnancy (27). Information about the research aims, date of fieldwork,

and tobacco control policy context (as noted in the published article) was

recorded. The latter was defined as any information relating to

international, national or local legislation or programmes which aimed to

decrease smoking. In addition, details were extracted on any other policy

contexts which were mentioned in the studies, such as information

relating to national financial crises or political changes.

Data analysis and synthesis

How to synthesise findings from qualitative research is a contested and

evolving field (27-30). The choice of approach is informed by and reflects

not only theoretical and epistemological concerns and orientation, but

also the nature of the studies and data to be synthesised. The studies

included in this review were disparate in terms of their aims, their focus

(or not) on tobacco control polices, the qualitative methods used, and the

way in which the findings were analysed and presented (which ranged

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from in depth interpretative analysis to just lists of quotes with no

accompanying commentary). Therefore, a textual narrative rather than a

thematic approach was taken to analysis and synthesis, in which located

studies are described and similarities and differences between study

findings are highlighted (28, 30). The synthesis of the extracted data, ie

the findings and interpretations of the study authors’, was based on the

type of evidence provided in each article about the direct or indirect

effects of tobacco control policies on young people’s engagement with

smoking (Table 2). Each paper was assigned to one of these categories.

Tobacco control policies were defined as policies that had been

implemented by national or regional jurisdictions – the context described

in each paper is listed in Supplementary File 2.

RESULTS

PsycInfo and SSCI allowed for a composite search of all 12 combinations

of search terms (Table 1) whereas PubMed did not allow for this, leading

to 12 separate search results. The search produced 1357 results across

the three databases (Figure 1). Due to the 12 separate PubMed searches,

there was a very large number of duplicates. An additional two papers

were included following comments from external reviewers. The title and

abstract of these results were screened, and after this exclusion

procedure the full text of 43 articles was assessed for quality and data

extraction.

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Methodological characteristics and quality of included studies

Most articles performed well across the quality criteria with the

exception of the criterion on discussing ethical issues and researcher

bias, in which most articles received a very low score. Several articles

also scored poorly on the sampling criterion because they either did not

describe in detail how the research participants were selected or did not

justify why the participant profile was appropriate for the aims of the

study. The quality assessment and checklist of criteria can be found in

Supplementary File 3. Applying a checklist of criteria to qualitative

research will not reflect an ‘objective’ assessment of quality. Checklists

used in systematic reviews are usually underpinned by positivist

assumptions, such as the value of generalisability or providing clear

recommendations for policy, which are not necessarily compatible with

non-positivist ontological approaches. Many of the articles included here

adopted qualitative methods to explore the complex social worlds of

young people in their situated contexts which necessarily makes their

findings context-specific; any policy recommendations will therefore need

to be appropriately nuanced in their claims. The quality of articles was

thus assessed in such a way that did not penalise studies which did not

adopt a strictly positivist approach. For example, if an article described

its context and participants in detail, giving an in-depth understanding of

the social worlds being explored, it received a high score on

generalisability because readers would understand which other contexts

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the study’s findings might be meaningfully compared to. However, the

quality of four articles was significantly lower than others, and they were

therefore excluded from the review. (These four studies scored

particularly poorly in relation to information given on the selection of

study participants, the approach to data collection and analysis, and

discussion of ethical issues.) One other study received a borderline

quality assessment score, but a decision was made to include this since

the format of the publishing journal was an important contributing factor

(for example, the journal did not include abstracts). The national context

of the 39 remaining studies was: 27 from the UK, two each from Sweden,

Denmark and Switzerland, and one each from Ireland, Belgium, Hungary,

Spain, Greece and Cyprus.

Papers with direct evidence about tobacco policy effects

Eight papers focused on exploring the impact of a particular tobacco

control policy in relation to young people’s engagement with smoking

(classified as ‘direct evidence’ in relation to our research question). Four

of these studies focused on the effectiveness of under-age sales laws in

the UK. One study (22) in Scotland found that young people were able to

circumvent the age of sale law, which was 16 at that time, and that

greater access to retail sources was related to a higher smoking rate in

school pupils. Two studies (20, 31) focused on the effect of increasing the

age of sale in England and Scotland from 16 to 18. Both argued that this

policy was relatively easy to circumvent due to young people having

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multiple alternative sources of cigarettes. One study in Scotland (21)

explored the impact of a ban on proxy sales for under-18 year olds (ie

using an adult to buy cigarettes for an under-18 year old). It found that

proxy sales remained an important source of cigarettes for

disadvantaged young smokers. Three studies explored the potential

impact of plain or standardised packaging and products. One study

conducted in Scotland (32) used mixture of styles of packaging included

a ‘mocked-up’ plain brown pack, found that cigarette pack design can

have a powerful often positive influence on adolescent perceptions and

affective responses. In contrast, plain packaging reduced these perceived

benefits. The authors concluded that they may be effective in reducing

tobacco companies’ ability to communicate to adolescents through pack

design. Similarly, a study conducted in Belgium (33) using a similar

methodology found that plain packs were perceived to be less attractive,

cheap and unreliable. Because of their unattractiveness, young people

were more aware of the health warnings. The authors therefore

suggested that plain packaging could potentially reduce the number of

young people starting to smoke. The third study conducted in Scotland

found that adolescents viewed slim and superslim cigarettes more

positively ie less harmful and more attractive than standard sized

cigarettes (34). Therefore standardising cigarette size and appearance

could reduce the appeal of cigarettes and therefore smoking to

adolescents. Finally, a study examined youth attitudes prior to the

introduction of smoke-free legislation in Greece (35): the authors argued

that cynicism towards the government and cultural attitudes towards

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rebelling against the law contributed to the subsequent ineffectiveness of

the legislation.

Papers with indirect evidence about tobacco policy effects

Eight papers considered the findings of their studies in relation to the

tobacco control policy context in which the study was undertaken

(‘indirect evidence’). One paper explored symbolic values of smoking

amongst young people in Cyprus and suggested that Cypriot culture

being in favour of smoking contributed to the ineffectiveness of tobacco

control policies such as advertising bans and package warning labels

(36). A paper focussing on a disadvantaged community in England

argued that national and regional policies to reduce the prevalence of

illicit tobacco had had a limited impact on communities – including young

people – particularly in the context of a financial recession (37). This was

particularly pronounced in deprived communities where illicit tobacco

trade is a part of the local culture and economy. A study conducted

before the introduction of smoke-free legislation in Scotland revealed the

power of social influences on young people’s attitudes to smoking (38),

and reflected that “it is likely that smoke-free policies in schools,

colleges, universities, workplaces, pubs and bars will be important in

reducing smoking in this age group”. A different paper which drew on

two studies conducted in Scotland highlighted how tobacco and cannabis

use was closely interlinked in young people’s smoking habits (39). The

authors argued that tobacco control policies are less effective when

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young people can easily access cannabis because they continue to smoke

tobacco through mixing it with cannabis. A paper focussing on a study

conducted in Switzerland had similar findings (40). In the context of

several newly-implemented national tobacco control policies, including

smoke-free legislation, young people expressed a desire to quit smoking

tobacco. However, their habit of mixing tobacco with their cannabis

joints meant that they continued to smoke tobacco. One Scottish study

(41) revealed how young people were aware that it was not illegal for

them to smoke. This led to them emphasising their individual right to

smoke and made them more defiant about smoking on school grounds. A

paper which explored young people’s experiences and attitudes towards

smoking in Scotland prior to the introduction of smoke-free legislation

argued that if smoke-free policies were extended to all workplaces

(including colleges, universities, pubs and bars) that this would likely

help prevent older adolescents who are social smokers from becoming

regular smokers as having to go outside to smoke could disrupt the

perceived social role and value of smoking in these contexts (12). Finally,

when reflecting on its qualitative findings, one Scottish study argued that

legislation against smoking in cars would only partially protect young

people but it would help to increase awareness amongst parents that

there is no safe level of secondhand smoke (42).

Papers with very little or no evidence about tobacco policy effects

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The papers in this category fell into one of two groups: those that

included some reference to the policy context but did not relate this to

the study’s empirical material; and those making no mention of the

study’s policy context.

Policy context not related to empirical material

Seven papers were included in this category. One paper applied the

‘attitude, social influence, self-efficacy’ (ASE) model to examine the

smoking behaviours of young people in Denmark (43). It mentioned

Denmark’s 2007 smoking ban in public places, but made no link between

this policy context and the discussion of the data. A paper which explored

the social role of smoking in young people’s everyday lives in England

made reference to the ‘recent smoking ban in public venues’ but did not

relate this policy to the study’s findings (44). A study conducted in

England (18) explored the pathways to smoking in a disadvantaged

community and, although one young person referred to the age of sale

being 18 years, the article did not expand or elaborate on this. A different

paper that explored gendered meanings in smoking among Scottish

young people mentioned the importance of incorporating a gender-

sensitive approach into national prevention strategies (14). However, it

did not directly relate this to the qualitative data or discuss what this

implied for the effect of tobacco control policies on the ways young

people engage with cigarettes. One paper investigated the processes

through which young people started experimenting with cigarettes in

Sweden (45). Despite the paper outlining a number of tobacco control

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policies that had been implemented in Sweden, such as the 1993-4

Tobacco Act that banned smoking on school premises and the 2005

smoking ban in restaurants, bars and cafes, this policy context was not

related to the study’s data. A Scottish study (46) exploring children’s

accounts of family smoking made reference to the existing smoke-free

public places legislation, however this was not discussed in light of the

study’s results. Finally, a study (47) which aimed to explore young

people’s perceptions of smoking in Ireland mentioned a national ban on

smoking in the workplace but did not link this to the findings.

No mention of the policy context

Fourteen papers did not include any mention of the policy context in

which their studies took place and therefore contained no evidence about

how tobacco control policies affect the ways young people engage with

cigarettes (48-61). Indeed, only four of these stated the date when

fieldwork had been conducted (48, 50, 55, 56), underlining the lack of

engagement with policy context in the study design and analysis.

Papers with no substantive evidence about smoking / that

considered smoking only in combination with other drugs

Two papers met our inclusion criteria but had no substantive evidence

about smoking in young people or considered smoking only in

combination with other drug use. One of these papers focussed on young

British Asians’ tobacco and alcohol use in Scotland but its discussion

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made little distinction between smoking and drinking behaviours, and it

made no reference to the policy context (62). Another paper that had

very little evidence about smoking was based on a study in Switzerland

which focused on cannabis users who did not smoke cigarettes (63).

DISCUSSION

This systematic review examined qualitative research published since

2000 exploring the impact of tobacco control policies on young people’s

engagement with smoking in Europe. Only 39 articles of sufficient quality

were identified for inclusion in the review, and only 16 of these provided

direct (8 papers) or indirect (8 papers) evidence about the effect of

tobacco control policies on young people’s engagement with smoking.

The evidence was dominated by British research. Three-quarters of both

the review articles (27 of 39) and the articles providing in/direct evidence

(11 of 16) were based in the UK. Very few other countries (only 10 of the

53 countries in the European Region) were represented in the review via

a relatively small number of studies. This raises concerns about the

transferability of the evidence base to countries in Europe at different

stages of the tobacco epidemic, and with different levels of smoking

prevention policies.

Given the limited number of studies it is difficult to draw any conclusions

about the impact of different types of tobacco control policies on young

people’s engagement with smoking, or to comment on differences

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between countries and/or regions or amongst diverse groups of young

people (e.g. by age, gender, ethnicity, or socioeconomic status).

However, the papers that were identified show that important insights

can been gleaned from qualitative studies about how young people may

conform to, adapt, resist and/or circumvent specific policies. For

example, the four studies from the UK exploring the impacts of laws

aimed at reducing young people’s retail access to cigarettes (20-22, 31)

showed how it is easier to circumvent these laws in disadvantaged areas

where under-18 year olds may more readily find retailers willing to sell

them cigarettes and/or intermediaries willing to make proxy purchases

on their behalf. The importance of wider cultural and social attitudes and

norms was demonstrated when comparing the contrasting views of young

people in Greece and Scotland about national smoke-free public places

legislation, which may help explain the differing levels of compliance in

these countries (12, 35, 38).

These findings highlight the importance of qualitative studies in

understanding the impacts of tobacco control policies on young people,

including the ways in which contextual factors may influence the success

of specific policies. Such factors include the extent to which interventions

are supported by complementary tobacco control measures; social and

cultural norms (at both national and local level); and the broader

economic and political environment. In addition, the three studies on

plain packaging in Scotland and Belgium showed how qualitative

methods can be used creatively to explore the potential impact of new

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tobacco control measures, in this case standardised packs and cigarettes.

Our review also highlights some key areas in which the reporting of

qualitative research can be improved, however. Several potentially

relevant studies had to be excluded on quality grounds due to insufficient

explanation of the sampling strategy via which participants were

identified, the approach to data analysis, and/or an inadequate account of

relevant ethical issues and how the researchers addressed these. The

potential value of some included studies was undermined by a lack of

information on the study context, including specific aspects of the policy

environment (such as the extent of smokefree legislation, age of sale

restrictions) with direct bearing on the interpretation of the results.

These findings highlight the importance of good practice in reporting on

qualitative research (64).

Strengths and weaknesses

We are not aware of any other systematic reviews which have evaluated

qualitative evidence of the effect of tobacco control policies on young

people’s engagement with cigarettes in the European context. Wide

inclusion criteria based on a review by Hefler and Chapman (26) were

used to encompass the broadest range of qualitative evidence on young

people’s engagement with tobacco control policies. However, it is

possible that some papers that analysed qualitative data were not

included because this was not explicitly mentioned in their abstracts. Our

focus on adolescents (11-18 years) means we may have excluded some

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potentially relevant research undertaken in young adults (aged over 18),

such as studies examining the potential impacts of plain packaging (65-

67). Non-English language articles whose title or abstract had not been

translated into English may also have been missed. Only peer-reviewed

journal articles were included in the search. It is possible that grey

literature may contain further evidence on the research question, which

has been excluded from this discussion.

CONCLUSION

Very few qualitative studies have been undertaken in Europe to explore

how young people engage with tobacco control policies, and most of

these are British. We therefore have very little understanding of whether,

in what ways and why young people may comply with, adapt, resist or

circumvent such policies, and the implications for their effectiveness in

reducing the uptake of smoking. Nor do we understand how and why this

engagement may differ by age, gender, ethnicity or socioeconomic status,

or between different countries and contexts. This is an important

omission in the tobacco control literature: we know that smoking uptake

across Europe is increasingly linked to social disadvantage, yet very little

is known about what measures might be effective in reducing this equity

gap (11, 68). There is therefore an urgent need for more qualitative

research which takes into account how the tobacco control policy context

intersects with young people’s social worlds and for analysis which

explores the implications of this research for tobacco control policy

development and implementation.

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SUPPLEMENTARY MATERIAL

Supplementary Files 1, 2 and 3 can be found online at ……..

FUNDING

This study is part of the project ‘Enhancing the effectiveness of programs

and strategies to prevent smoking by adolescents: a realist evaluation

comparing seven European countries (SILNE-R)’, which is funded by the

European Commission, Horizon 2020 – the Framework Programme for

Research and Innovation (2014-2020).

DECLARATION OF INTERESTS

None declared.

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35

Table 1: Electronic database search strategies

Conducted on 17 November 2015.

MEDLINE PubMed & Social Science Citation Index Search Terms

“qualitative” + “smoking” + “young people”

“qualitative” + “smoking” + “youth”

“qualitative” + “smoking” + “adolescent”

“qualitative” + “smoking” + “young adult”

“qualitative” + “smoking” + “children”

“qualitative” + “smoking” + “teenagers”

“qualitative” + “tobacco” + “young people”

“qualitative” + “tobacco” + “youth”

“qualitative” + “tobacco” + “adolescent”

“qualitative” + “tobacco” + “young adult”

“qualitative” + “tobacco” + “children”

“qualitative” + “tobacco” + “teenagers”

PsycINFO Thesaurus and Search Terms

Thesaurus terms: qualitative research, tobacco smoking, adolescent

attitudes

Search terms (note:.sh [subject heading] .ti[title] .ab [abstract])

Qualitative research.sh OR qualitative.ti OR qualitative.ab

Tobacco smoking.sh OR tobacco.ti OR tobacco.ab OR smoking.ti

OR smoking.ab

Adolescent attitudes.sh OR adolescent.ti OR adolescent.ab OR

36

young people.ti OR young people.ab OR youth.ti OR youth.ab OR

young adult.ti OR young adult.ab OR children.ti OR children.ab

OR teenagers.ti OR teenagers.ab

Table 2: Type of evidence about the effect of national and/or regional tobacco control policies

Papers with direct evidence: papers which explored the

effectiveness of a specific tobacco control policy in relation to

young people’s engagement with smoking.

Papers with indirect evidence: papers which related the

study’s qualitative findings to the tobacco control policy context

in which the study was undertaken.

Papers with very little or no evidence: papers which either

mentioned the tobacco control policy context of the study but

did not link it to the research findings or papers which made no

mention of the tobacco control policy context – both types

provided no evidence for the research question.

Papers with no substantive evidence about smoking / that

considered smoking only in combination with other drugs:

papers which provided no evidence for the research question

37

Figure 1: PRISMA flow diagram

* We accepted one paper with a borderline score (24) because the style of the publishing journal contributed to the low score (for example, the journal that didn’t use an abstract - which accounts for 2 points in the quality assessment score).

38

# Records identified through database

searching (PubMed, PSYCInfo, and SSCI)

N = 1357

# Records screened on basis of title /abstract and, if necessary, full

text.N = 1363

Records excluded due to data not being qualitative, no focus on smoking, article published before 2000, participants not 11-18 years old, primary data not from young people, data from other age ranges

merged with 11-18-year-old participant data, duplicate articles.

N = 1211

# Records full text assessed for quality appraisal

N = 43

Records excluded as scored below 24 on quality appraisal*

N = 4

# Records screened to identify European studies

N= 152

Records excluded as country of study non-EuropeanN = 110

# Records includedN = 39

# Records identified

through other sources

N = 6