Citation

Mus, S., Barrientos-Gutiérrez, I., Vidaña-Pérez, D., Monzon, J., Barnoya, J., Page, M.K., Block, A.,Goniewicz, M.L., O’Connor, R.J., Thrasher, J.F. (2024). Chemicals in cigarette flavor capsules from Guatemala and Mexico. Nicotine and Tobacco Research, 26(5), 545-551. doi: 10.1093/ntr/ntad216.

Abstract

Background: The global market share for cigarettes with flavor capsules has grown exponentially over the last decade, particularly in Latin America. When smoking, consumers crush a liquid capsule in the filter that flavors the smoke. Little is known about the chemical constituents of the liquids in capsules or their potential health risks.

Methods: Based on consumer data and availability in Mexico and Guatemala, 31 flavor capsule brands were purchased (19 and 12, respectively) in 2020. Since some cigarettes included multiple capsules in a stick (up to 2) or pack (up to 4), the final analytic sample included 50 capsules. We conducted qualitative and quantitative analyses using gas chromatography with mass spectrometry (GC-MS, Agilent Technologies, Inc)

Results: The qualitative analysis detected 296 compounds (range = 9–67 per capsule), and all capsules contained menthol. Among the compounds detected in more than half the sample were limonene, menthone, benzaldehyde, eucalyptol, and triacetin. Traces of nicotine were found in 22% of the capsules. In the quantitative analysis, menthol concentrations were 33 times greater than the next most common compound (limonene). Benzyl alcohol and vanillin were also found in high concentrations. Comparing same-brand varieties across countries showed substantial variability in the concentration of menthol and other compounds.

Conclusions: Menthol is an omnipresent constituent in capsule cigarettes, perhaps because of its anesthetizing and reinforcing addictive properties. Other compounds found are toxic, potentially carcinogenic, and may enhance addictiveness. Variance in the presence and concentrations of such compounds highlights the importance of product standards to regulate capsule content.

Implications: This study evaluated the chemical content of capsule cigarettes from two Latin American countries that have two of the highest market shares for capsule cigarettes worldwide. Compared to other studies, our assessment included brand varieties from two countries to compare the differences in chemical content by country. Our results yield that menthol is found in all capsules, and that other chemicals found may prolong nicotine exposure and therefore reinforce the addictive properties of cigarettes.

Citation

Cruz-Jiménez, L., Barrientos-Gutiérrez, I., Zavala-Arciniega, L., Arillo-Santillan, E., Gallegos-Carrillo, K., Rodrigues-Bolanos, R., Gravley, S., Thrasher, J.F. (2022). Heated tobacco product use, its correlates, and reasons for use among Mexican smokers. Drug and Alcohol Dependence, 232(2022), 1092983. Doi: 10.1016/j.drugalcdep.2022.109283

Abstract

Background: Little is known about the use of novel heated tobacco products (HTPs) in low- and middle-income countries. We examined among smokers in Mexico the prevalence and correlates of HTP use, as well as reasons for using HTPs.

Methods: We analyzed data from five surveys (November 2019-March 2021) of an open cohort of adult smokers (n = 6500), including an oversample of those who also use e-cigarettes. Mixed-effects multinomial logistic models were used to estimate associations between study variables and current HTP use or prior HTP trial relative to never trying HTPs.

Results: The weighted prevalence of current HTP use was 1.1%. Independent correlates of current HTP use included smoking frequency, intention to quit, e-cigarette use, having partners/family-members who use e- cigarettes, friends who use HTPs, and exposure to HTP information inside/outside tobacco shops. Having partners/family members who smoke and not knowing about the harm of HTPs relative to cigarettes were associated with lower likelihood of current HTP use. Having tried HTPs was more likely among light daily smokers, those with family who use HTPs and exposure to HTP information outside shops and on newspapers/magazines. Among current users, the top reasons for using HTPs were greater social acceptability (50.6%) and lower perceived harm (34.9%) relative to cigarettes.

Conclusions: Uptake of HTPs appears relatively low among Mexican smokers, and correlates of use are similar to those for e-cigarette use. Further research is needed to determine if HTPs use promotes or impedes smoking cessation, given current HTP users are also likely to use various nicotine products.

Citation

Sánchez-Romero, L.M., Zavala-Arciniega, L., Reynales-Shigematsu, L.M., Sáenz de Miera-Juárez, B., Yuan, Z., Li, Y., Lau, Y.K., Fleischer, N.L., Meza, R., Thrasher, J.F., Levy, D.T. (2021). The Mexico SimSmoke tobacco control policy model: Development of a simulation model of daily and nondaily cigarette smoking. PLoS One, 16(6), e0248215. doi: 10.1371/journal.pone.0248215.

Abstract

Background: Nondaily smoking has been on the rise, especially in Mexico. While Mexico has strengthened its tobacco control policies, their effects on nondaily smokers have gone largely unexamined. We developed a simulation model to estimate the impact of tobacco control policies on daily and nondaily smoking in Mexico.

Methods: A previously validated Mexico SimSmoke model that estimated overall trends in smoking prevalence from 2002 through 2013 was extended to 2018 and adapted to distinguish daily and nondaily smoking prevalence. The model was then validated using data from Mexican surveys through 2016. To gauge the potential effects of policies, we compared the trends in smoking under current policies with trends from policies kept at their 2002 levels.

Results: Between 2002 and 2016, Mexico SimSmoke underestimated the reduction in male and female daily smoking rates. For nondaily smoking, SimSmoke predicted a decline among both males and females, while survey rates showed increasing rates in both genders, primarily among ages 15–44. Of the total reduction in smoking rates predicted by the model by 2018, tax policies account for more than 55%, followed by health warnings, cessation treatment, smoke-free air laws, and tobacco control spending.

Conclusions: Although Mexico SimSmoke did not successfully explain trends in daily and nondaily smoking, it helps to identify gaps in surveillance and policy evaluation for nondaily smokers. Future research should consider appropriate measures of nondaily smoking prevalence, trajectories between daily and nondaily smoking, and the separate impact of tobacco control policies on each group.

Citation

van Mourik, D.J.A., Nagelhout, G.E., de Vries, H., van den Putte, B., Cummings, K.M., Borland, R., Fong, G.T., Willemsen, M.C. (2020). Quasi-experimentally examining the impact of introducing tobacco pictorial health warnings: Findings from the International Tobacco Control (ITC) 4C and Netherlands surveys in the Netherlands, Australia, Canada, United Kingdom, and the United States. Drug and Alcohol Dependence, 207, 107818.

Abstract

Background: Tobacco control policies and other denormalization strategies may reduce tobacco use by stigmatizing smoking. This raises an important question: Does perceived smoking-related stigma contribute to a smoker's decision to quit? The aim of this study was to evaluate if perceived smoking-related stigma was associated with smoking cessation outcomes among smokers in Mexico and Uruguay.

Methods: We analyzed prospective data from a panel of adult smokers who participated in the 2008-2012 administrations of the International Tobacco Control Policy Evaluation Surveys in Mexico and Uruguay. We defined two analytic samples of participants: the quit behavior sample (n=3896 Mexico; n=1525 Uruguay) and the relapse sample (n=596 Mexico). Generalized estimating equations were used to evaluate if different aspects of perceived stigma (i.e., discomfort, marginalization, and negative stereotype) at baseline were associated with smoking cessation outcomes at follow-up.

Results: We found that perceived smoking-related stigma was associated with a higher likelihood of making a quit attempt in Uruguay, but with a lower likelihood of successful quitting in Mexico.

Conclusions: This study suggests that perceived smoking-related stigma may be associated with more quit attempts, but less successful quitting among smokers. It is possible that once stigma is internalized by smokers, it may function as a damaging force. Future studies should evaluate the influence of internalized stigma on smoking behavior.

Implications: While perceived smoking-related stigma may prompt smokers to quit smoking, smoking stigma may also serve as a damaging force for some individuals, making quitting more difficult. This study found that perceived smoking-related stigma was associated with a higher likelihood of making a quit attempt in Uruguay, but with a lower likelihood of successful quitting in Mexico.

Citation

Nargis, N., Yong, H.H., Driezen, P., Mbulo, L., Zhao, L., Fong, G.T., Thompson, M.E., Borland, R., Palipudi, K.M., Giovino, G.A., Thrasher, J.F., Siahpush, M. (2019). Socioeconomic patterns of smoking cessation behavior in low and middle-income countries: Emerging evidence from the Global Adult Tobacco Surveys and International Tobacco Control Surveys. PLOS One, 14(9), e0220223.

Abstract

Introduction: Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs.

Methods: Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008–2011) and the International Tobacco Control Surveys (2009–2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country.

Results: Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10).

Conclusion: Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes.

Citation

Ngo, A., Fong, G.T., Craig, L., Shang, C. (2019). Analysis of gender differences in the impact of taxation and taxation structure on cigarette consumption in 17 ITC countries. International Journal of Environmental Research and Public Health, 16(7), e1275.

Abstract

Although increasing taxes has been established as the most effective tobacco control policy, it is not clear whether these policies reduce cigarette consumption equally among women and men. In this study, we examine whether the association between taxation/taxation structure and cigarette consumption differs by gender. The data is from the International Tobacco Control Policy Evaluation (ITC) Projects in 17 countries. Cigarette consumption was measured by gender for each ITC country. Generalized estimating equations (GEE) were employed to investigate gender differences in the association between cigarette consumption and tax structures, while controlling for time-variant demographic characteristics such as unemployment rates, proportions of adults, and percent of female population. Tiered tax structures are associated with higher cigarette consumption among both males and females. Female smokers are more responsive to an average tax increase than male smokers. Among males, higher ad valorem share in excise taxes is associated with lower cigarette consumption, but it is not the case for females. Females may not be as responsive to the prices raised by ad valorem taxes, despite being responsive to average taxes, suggesting that smokers by gender may face different prices.

Citation

Gravely, S., Driezen, P., Ouimet, J., Quah, A.C.K., Cummings, K.M., Thompson, M.E., Boudreau, C., Hammond, D., McNeill, A., Borland, R., Thrasher, J.F., Edwards, R., Omar, M., Hitchman, S., Yong, H-H., Barrientos-Gutierrez, T., Willemsen, M.C., Bianco, E., Boado, M., Goma, F., Seo, H.G., Nargis, N., Jiang, Y., Perez, C., & Fong, G.T. (2019). Prevalence of awareness, ever-use, and current use of nicotine vaping products (NVPs) among adult current smokers and ex-smokers in 14 countries with differing regulations on sales and marketing of NVPs: Cross-sectional findings from the ITC Project. Addiction, 114(6), 1060-1073.

Abstract

Aims: This paper presents updated prevalence estimates of awareness, ever‐use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing.

Design, setting, participants and measurements: A cross‐sectional analysis of adult (≥18 years) current smokers and ex‐smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013 to 2017. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs): not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs): not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand (NZ); (3) less restrictive policies (LRPs): legal to be sold and marketed with regulations: England, Netherlands, Republic of Korea, United States (US); (4) no regulatory policies (NRPs): Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country‐specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily vs. non‐daily).

Findings: NVP awareness and use were lowest in NRP countries. Generally, ever‐ and current use of NVPs were lower in MRP countries [ever‐use: 7.1% to 48.9%; current use: 0.3% to 3.5%] relative to LRP countries [ever‐use: 38.9% to 66.6%; current use: 5.5% to 17.2%] and RP countries [ever‐use: 10.0% to 62.4%; current use: 1.4% to 15.5%]. NVP use was highest among high income countries, followed by upper‐middle income countries, and then by lower‐middle income countries.

Conclusions: With a few exceptions, awareness and use of nicotine vaping products (NVPs) varies by the strength of national regulations governing NVP sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in NVPs in these countries where smoking populations are predominantly poorer. The higher awareness and use of NVPs in high income countries with moderately (e.g., Canada, NZ) and less (e.g., England, US) restrictive policies, is likely due to the greater availability and affordability of NVPs.

Citation

Shang, C., Myung Lee, H., Chaloupka, F., Fong, G.T., Thompson, M.E., O’Connor, R.J. (2019). Association between tax structure and cigarette consumption: findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 28(Suppl 1), S31-S36.

Abstract

Background: Recent studies show that greater price variability and more opportunities for tax avoidance are associated with tax structures that depart from a specific uniform one. These findings indicate that tax structures other than a specific uniform one may lead to more cigarette consumption.

Objective: This paper aims to examine how cigarette tax structure is associated with cigarette consumption.

Methods: We used survey data taken from the International Tobacco Control Policy Evaluation Project in 17 countries to conduct the analysis. Self-reported cigarette consumption was aggregated to average measures for each surveyed country and wave. The effect of tax structures on cigarette consumption was estimated using generalised estimating equations after adjusting for sociodemographic characteristics, average taxes and year fixed effects.

Findings: Our study provides important empirical evidence of a relationship between tax structure and cigarette consumption. We find that a change from a specific to an ad valorem structure is associated with a 6%–11% higher cigarette consumption. In addition, a change from uniform to tiered structure is associated with a 34%–65% higher cigarette consumption. The results are consistent with existing evidence and suggest that a uniform and specific tax structure is the most effective tax structure for reducing tobacco consumption.

Citation

Lozano, P., Thrasher, J.F., Forthofer, L., Hardin, J., Reynales-Shigematsu, L.M., Santillian, E., Fleischer, N.L. (2019). The role of social norms and socioeconomic status in smoking-related stigma among smokers in Mexico and Uruguay. Critical Public Health, 29(2), 215-27.

Abstract

Policies that promote the social unacceptability of smoking may also result in smoking-related stigma. The aim of this study is to evaluate how norms against smoking and socioeconomic status (SES) are associated with stigma among smokers. We used data from a panel of adult smokers who participated in the 2008–2012 administrations of the International Tobacco Control Policy Evaluation Survey in Mexico (n = 6670 observations) and Uruguay (n = 3296 observations). Generalized estimating equations were used to account for correlations in the outcomes over time within individuals. We evaluated if injunctive smoking norms (i.e. significant other norms and societal norms), descriptive smoking norms (i.e. number of smoking friends), and two markers of SES (i.e. education and income) were associated with different aspects of smoking-related stigma (i.e. feeling uncomfortable, negative stereotype of smokers, and perceived marginalization). We found that stronger anti-smoking injunctive norms were associated with higher levels of all indicators of perceived stigma in Mexico and Uruguay. Having fewer smoking friends was associated with feeling uncomfortable and perceived marginalization in Mexico. Higher income and education were associated with a stronger negative stereotype of smokers in Mexico. Lower income and education were associated with a stronger negative stereotype of smokers in Uruguay. Study results suggest that factors that drive the social unacceptability of tobacco may stigmatize smokers, although further research is needed to determine whether policy-promoted stigmatization produces undesirable outcomes (e.g. lower cessation rates).

Citation

Cho, Y. J., Thrasher, J. F., Yong, H.-H., Szklo, A. S., O'Connor, R. J., Bansal-Travers, M., Hammond, D., Fong, G. T., Hardin, J., Borland, R. (2018). Path analysis of warning label effects on negative emotions and quit attempts: A longitudinal study of smokers in Australia, Canada, Mexico, and the US. Social Science & Medicine, 197, 226-234.

Abstract

Background: Cigarette pack health warning labels can elicit negative emotions among smokers, yet little is known about how these negative emotions influence behavior change.

Objective: Guided by psychological theories emphasizing the role of emotions on risk concern and behavior change, we investigated whether smokers who reported stronger negative emotional responses when viewing warnings reported stronger responses to warnings in daily life and were more likely to try to quit at follow-up.

Methods: We analyzed data from 5439 adult smokers from Australia, Canada, Mexico, and the US, who were surveyed every four months from September 2012 to September 2014. Participants were shown warnings already implemented on packs in their country and reported negative emotional responses (i.e., fear, disgust, worry), which were averaged (range = 1 to 9). Country-stratified logistic and linear generalized estimating equations were used to analyze the effect of negative emotional responses on self-reported responses to warnings in daily life (i.e., attention, risk concern, avoidance of warnings, forgoing planned cigarettes) and quit attempts at follow-up. Models were adjusted for socio-demographic and smoking-related characteristics, survey wave, and the number of prior surveys answered.

Results: Smokers who reported stronger negative emotions were more likely to make quit attempts at follow-up (Adjusted ORs ranged from 1.09 [95% CI 1.04 to 1.14] to 1.17 [95% CI 1.12 to 1.23]; p < .001) than those who reported lower negative emotions. This relationship was mediated through attention to warnings and behavioral responses to warnings. There was no significant interaction of negative emotions with self-efficacy or nicotine dependence.

Conclusion: Negative emotions elicited by warnings encourage behavior change, promoting attention to warnings and behavioral responses that positively predict quit attempts.

Citation

Braverman-Bronstein, A., Thrasher, J.F., Hernández-Ávila, M., Reynales-Shigematsu, L.M., Barrientos-Gutierrez, T. (2018). Concentrations of nicotine, nitrosamines, and humectants in legal and illegal cigarettes in Mexico. Harm Reduction Journal, 15(1), 50.

Abstract

Background: Article 10 of the World Health Organization Framework Convention on Tobacco Control states the need for industry disclosure of tobacco contents and emissions. Currently, the profiles of key tobacco compounds in legal and illegal cigarettes are largely unknown. We aimed to analyze and compare concentrations of nicotine, nitrosamines, and humectants in legal and illegal cigarettes collected from a representative sample of smokers.

Methods: Participants of the International Tobacco Control cohort provided a cigarette pack of the brand they smoked during the 2014 wave. Brands were classified as legal or illegal according to the Mexican legislation. Nicotine, nitrosamines, glycerol, propylene glycol, and pH were quantified in seven randomly selected packs of each brand. All analyses were done blinded to legality status. Average concentrations per brand and global averages for legal and illegal brands were calculated. Comparisons between legal and illegal brands were conducted using t tests.

Results: Participants provided 76 different brands, from which 6.8% were illegal. Legal brands had higher nicotine (15.05 ± 1.89 mg/g vs 12.09 ± 2.69 mg/g; p < 0001), glycerol (12.98 ± 8.03 vs 2.93 ± 1.96 mg/g; p < 0.001), and N-nitrosanatabine (NAT) (1087.5 ± 127.0 vs 738.5 ± 338 ng/g; p = 0.006) concentrations compared to illegal brands. For all other compounds, legal and illegal brands had similar concentrations.

Conclusion: Compared to illegal cigarettes, legal brands seem to have higher concentrations of nicotine, NAT, and glycerol. Efforts must be made to implement and enforce Article 10 of the Framework Convention on Tobacco Control to provide transparent information to consumers, regulators, and policymakers; and to limit cigarette engineering from the tobacco industry.

Citation

Swayampakala, K., Fleisher, N.L., Hardin, J., Liu, J., Fong, G.T., Thrasher, J.F. (2015, June). Factors associated with changing cigarette consumption patterns among low-intensity smokers: Results from the ITC Mexico Survey. Oral presentation at the 48th Annual Society for Epidemiologic Research Meeting, Denver, Colorado, United States.

Abstract

Background: Light and intermittent smoking has become increasingly prevalent as smokers shift to lower consumption in response to tobacco control policies. We examined changes in cigarette consumption patterns over a four-year period and determined which factors were associated with smoking transitions.

Methods: We used data from a cohort of smokers from the 2008–2012 ITC Mexico Survey administrations to investigate transitions from non-daily (ND; n = 669), daily light (DL; ≤5 cigarettes per day (cpd); n = 643), and daily heavy (DH; >5 cpd; n = 761) smoking patterns. To identify which factors (i.e., sociodemographic measures, perceived addiction, quit behavior, social norms) were associated with smoking transitions, we stratified on smoking status at time t (ND, DL, DH) and used multinomial (ND, DL) and binomial (DH) logistic regression to examine transitions (quitting/reducing or increasing versus same level for ND and DL, quitting/reducing versus same level for DH).

Results: ND smokers were more likely to quit at follow-up than DL or DH smokers. DH smokers who reduced their consumption to ND were more likely to quit eventually compared to those who continued as DH. Smokers who perceived themselves as addicted had lower odds of quitting/reducing smoking consumption at follow-up compared to smokers who did not, regardless of smoking status at the prior survey. Quit attempts and quit intentions were also associated with quitting/reducing consumption.

Conclusions: Reducing consumption may eventually lead to cessation, even for heavier smokers. The findings that perceived addiction and quit behavior were important predictors of changing consumption for all groups may offer insights into potential interventions.

Citation

Fix, B.V., O’Connor, R., Benowitz, N.L., Heckman, B., Cummings, K.M., Fong, G.T., Thrasher, J.F. (2017). Nicotine Metabolite Ratio (NMR) prospectively predicts smoking relapse: longitudinal findings from ITC Surveys in five countries. Nicotine and Tobacco Research, 19(9), 1040-1047.

Abstract

Introduction: The ratio of trans 3’-hydroxycotinine (3HC) to cotinine (nicotine metabolite ratio, NMR) is a biomarker of the rate of nicotine metabolism, with higher NMR indicating faster metabolism. Higher NMR has been found to be associated with higher daily cigarette consumption and less success stopping smoking in cessation trials. This study examines differences in NMR among population-based samples of smokers in the 5 countries and explores the relationship between NMR and smoking abstinence.

Methods: Participants (N=874) provided saliva samples during International Tobacco Control (ITC) surveys in the US, UK, Mauritius, Mexico, and Thailand conducted in 2010/2011 with follow-up surveys in 2012/2013. When all samples were received, they were sent to a common laboratory for analysis using liquid chromatography and tandem mass spectroscopy.

Results: There was significant variation in NMR across countries (F=15.49, p<.001). Those who reported smoking at follow-up had a mean NMR of 0.32, compared to a mean NMR of 0.42 in participants who reported that they had stopped (F=8.93; p=0.003). Higher mean NMR values were also associated with longer quit duration (p=0.007). There was no substantial difference in NMR between current smokers who made a failed quit attempt and those who made no attempt – both had significantly lower NMR compared to those who quit and remained abstinent. Smokers with a higher NMR were more likely to report that they stopped smoking compared to those with a lower NMR (OR=2.67; 95%CI: 1.25-5.68).

Conclusions: These results suggest faster nicotine metabolizers may be less likely to relapse following a quit attempt. This finding differs from results of clinical trials testing stop smoking medications, where slower metabolizers have been found to be more likely to maintain abstinence from smoking.

Citation

Thrasher, J.F., Abad-Vivero, E.N., Moodie, C., Hammond, D., Cummings, K.M., Yong, H.H., Salloum, R.G., Czoli, C., Reynales-Shigematsu, L.M. (2016). Cigarette brands with flavor capsules in the filter: Trends in the use and brand perceptions among smokers in the United States, Mexico, and Australia, 2012-2014. Tobacco Control, 25(3), 275-283.

Abstract

Objective: To describe trends, correlates of use and consumer perceptions related to the product design innovation of flavour capsules in cigarette filters.

Methods: Quarterly surveys from 2012 to 2014 were analysed from an online consumer panel of adult smokers aged 18–64, living in the USA (n=6865 observations; 4154 individuals); Mexico (n=5723 observations; 3366 individuals); and Australia (n=5864 observations; 2710 individuals). Preferred brand varieties were classified by price (ie, premium; discount) and flavour (ie, regular; flavoured without capsule; flavoured with capsule). Participants reported their preferred brand variety's appeal (ie, satisfaction; stylishness), taste (ie, smoothness, intensity), and harm relative to other brands and varieties. GEE models were used to determine time trends and correlates of flavour capsule use, as well as associations between preferred brand characteristics (ie, price stratum, flavour) and perceptions of relative appeal, taste and harm.

Results: Preference for flavour capsules increased significantly in Mexico (6% to 14%) and Australia (1% to 3%), but not in the USA (4% to 5%). 18–24 year olds were most likely to prefer capsules in the USA (10%) and Australia (4%), but not Mexico. When compared to smokers who preferred regular brands, smokers who preferred brands with capsules viewed their variety of cigarettes as having more positive appeal (all countries), better taste (all countries), and lesser risk (Mexico, USA) than other brand varieties.

Conclusions: Results indicate that use of cigarettes with flavour capsules is growing, is associated with misperceptions of relative harm, and differentiates brands in ways that justify regulatory action.

Citation

Lozano, P., Fleischer, N.L., Thrasher, J.F., Arillo-Santillán, E., Reynales-Shigematsu, L.M. (2016). Does neighborhood social cohesion modify the relationship between neighborhood social norms and smoking behaviors in Mexico? Health & Place, 40, 145–152.

Abstract

The aim of this study was to examine the separate and combined relationships of neighborhood social norms and neighborhood social cohesion with smoking behavior in a cohort of adult Mexican smokers. Neighborhood anti-smoking norms were measured as the proportion of residents in each neighborhood who believed that society disapproves of smoking. Perceived social cohesion was measured using a 5- item cohesion scale and aggregated to the neighborhood level. Higher neighborhood anti-smoking norms were associated with less successful quitting. Neighborhood social cohesion modified the relationship between neighborhood social norms and two smoking behaviors: smoking intensity and quit attempts. Residents of neighborhoods with weaker anti-smoking norms and higher social cohesion had lower smoking intensity and more quit attempts than residents living in other areas. Social cohesion may help buffer smoking behavior in areas with weak social norms.

Citation

Caruso, R.V., Fix, B.V., Thrasher, J.F., Cummings, K.M., Fong, G.T., Stephens, W.E., O’Connor, R.J. (2016). Differences in cigarette design and metal content across five countries: results from the International Tobacco Control (ITC) Project. Tobacco Regulatory Science, 2(2), 166-175.

Abstract

Objectives: We examined physical cigarette design characteristics and tobacco metal content of cigarettes obtained from 5 countries to determine how these properties vary for cigarette brands, both within and across countries with different dominant manufacturers.

Methods: Cigarette packs were collected from International Tobacco Control Policy Evaluation Survey (ITC) participants in the United States (US), the United Kingdom (UK), Mauritius, Mexico, and Thailand. Cigarettes were assessed for physical and design properties (eg, ventilation, pressure drop, rod density, weight) by published methods, and for metal content (As, Cd, Ni, Pb) by X-ray fluorescence spectrometry.

Results: Statistically significant differences in cigarette design and toxic metal concentrations were observed among countries and among manufacturers within countries. Filter ventilation, which is strongly predictive of machinemeasured tar and nicotine levels, varied most widely across countries. Ni and Cd were highest in Thailand (2.23ug/g and 1.64ug/g, respectively); As was highest in Mexico (0.29ug/g) and Pb was highest in the UK. (0.43 ug/g).

Conclusions: Parties to the FCTC should consider the adoption of uniform product standards related to cigarette design, emissions, and tobacco content that would reduce population health risks.

Citation

Thrasher, J.F., Osman, A., Moodie, C., Hammond, D., Bansal-Travers, M., Cummings, K.M., Borland, R., Yong, H.H., Hardin, J. (2015). Promoting cessation resources through cigarette package warning labels: A longitudinal survey with adult smokers in Canada, Australia and Mexico. Tobacco Control, 24 (e1), 23-31.

Abstract

Introduction: Health warning labels (HWLs) on tobacco packaging can be used to provide smoking cessation information, but the impact of this information is not well understood.

Methods: Online consumer panels of adult smokers from Canada, Australia and Mexico were surveyed in September 2012, January 2013 and May 2013; replenishment was used to maintain sample sizes of 1000 participants in each country at each wave. Country-stratified logistic Generalised Estimating Equation (GEE) models were estimated to assess correlates of citing HWLs as a source of information on quitlines and cessation websites. GEE models also regressed having called the quitline, and having visited a cessation website, on awareness of these resources because of HWLs.

Results: At baseline, citing HWLs as a source of information about quitlines was highest in Canada, followed by Australia and Mexico (33%, 19% and 16%, respectively). Significant increases over time were only evident in Australia and Mexico. In all countries, citing HWLs as a source of quitline information was significantly associated with self-report of having called a quitline. At baseline, citing HWLs as a source of information about cessation websites was higher in Canada than in Australia (14% and 6%, respectively; Mexico was excluded because HWLs do not include website information), but no significant changes over time were found for either country. Citing HWLs as a source of information about cessation websites was significantly associated with having visited a website in both Canada and Australia.

Conclusions: HWLs are an important source of cessation information.

Citation

Hall, M., Fleischer, N., Reynales-Shigematsu, L.M., Arillo-Santillán, E., Thrasher, J.F. (2015). Increasing availability and consumption of single cigarettes: Trends and implications for smoking cessation from the ITC Mexico Survey. Tobacco Control, 24(Suppl 3), iii64-iii70.

Abstract

Objective: Determine (1) trends in single cigarette availability and purchasing in Mexico and (2) the association between neighbourhood access to singles and cessation behaviour among adult Mexican smokers.

Methods: We analysed data from Wave 4 (2010), Wave 5 (2011) and Wave 6 (2012) of the Mexican International Tobacco Control Policy Evaluation Survey. We used data from all three waves to examine time trends in singles availability and purchasing. To explore the association between neighbourhood access to singles and cessation behaviour, we used data from participants who were smokers at Wave 5 and followed up at Wave 6 (n=1272).

Findings: The percentage of participants who saw singles sold daily (45.2% in 2010; 51.4% in 2011; 64.9% in 2012), who bought singles at least once a week (22.3% in 2010; 29.1% in 2011; 29.1% in 2012) and whose last cigarette purchase was a single (16.6% in 2010; 20.7% in 2011; 25.8% in 2012) increased significantly from 2010 to 2012 (all p<0.001). The average percentage of residents who reported seeing singles sold daily in their neighbourhood in 2012 was 60% (SD=25%). In adjusted analyses, smokers living in neighbourhoods with higher access to singles were less likely to make a quit attempt (risk ratio (RR)=0.72; 95% CI 0.46 to 1.12), and more likely to relapse (RR=1.30; CI 0.94 to 1.82), but these results were not statistically significant.

Conclusions: Single cigarettes appear widely accessible in Mexico and growing in availability. Future research should explore potential explanations, consequences and effective methods for reducing the availability of single cigarettes.

Citation

Fleischer, N., Thrasher, J.F., Saenz-de-Miera Juarez, B., Reynales-Shigematsu, L.M., Arillo-Santillán, E., Osman, A., Siahpush, M., Fong, G.T. (2015). Neighbourhood deprivation and smoking and quit behaviour among smokers in Mexico: Findings from the ITC Mexico Survey. Tobacco Control, 24(Suppl 3), iii56-iii63.

Abstract

Background: In high-income countries (HICs), higher neighbourhood socioeconomic deprivation is associated with higher levels of smoking. Few studies in low-income and middle-income countries (LMICs) have investigated the role of the neighbourhood environment on smoking behaviour.

Objective: To determine whether neighbourhood socioeconomic deprivation is related to smoking intensity, quit attempts, quit success and smoking relapse among a cohort of smokers in Mexico from 2010 to 2012.

Methods: Data were analysed from adult smokers and recent ex-smokers who participated in waves 4- 6 of the International Tobacco Control (ITC) Mexico Survey. Data were linked to the Mexican government's composite index of neighbourhood socioeconomic deprivation, which is based on 2010 Mexican Census data. We used generalised estimating equations to determine associations between neighbourhood deprivation and individual smoking behaviours.

Findings: Contrary to past findings in HICs, higher neighbourhood socioeconomic deprivation was associated with lower smoking intensity. Quit attempts showed a U-shaped pattern whereby smokers living in high/very high deprivation neighbourhoods and smokers living in very low deprivation neighbourhoods were more likely to make a quit attempt than smokers living in other neighbourhoods. We did not find significant differences in neighbourhood deprivation on relapse or successful quitting, with the possible exception of people living in medium-deprivation neighbourhoods having a higher likelihood of successful quitting than people living in very low deprivation neighbourhoods (p=0.06).

Conclusions: Neighbourhood socioeconomic environments in Mexico appear to operate in an opposing manner to those in HICs. Further research should investigate whether rapid implementation of strong tobacco control policies in LMICs, as occurred in Mexico during the follow-up period, avoids the concentration of tobacco-related disparities among socioeconomically disadvantaged groups.

Citation

Fleischer, N.L., Lozano, P., Arillo-Santillán, E., Reynales-Shigematsu, L.M., Thrasher, J.F. (2015). The impact of neighbourhood violence and social cohesion on smoking behaviours among a cohort of smokers in Mexico. Journal of Epidemiology and Community Health, 69(11), 1083-1090.

Abstract

Background: Recent increases in violent crime may impact a variety of health outcomes in Mexico. We examined relationships between neighbourhood-level violence and smoking behaviours in a cohort of Mexican smokers from 2011 to 2012, and whether neighbourhood-level social cohesion modified these relationships.

Methods: Data were analysed from adult smokers and recent ex-smokers who participated in waves 5 and 6 of the International Tobacco Control Mexico survey. Self-reported neighbourhood violence and social cohesion were asked of wave 6 survey participants (n=2129 current and former smokers, n=150 neighbourhoods). Neighbourhood-level averages for violence and social cohesion (ranges 4–14 and 10– 25, respectively) were assigned to individuals. We used generalised estimating equations to determine associations between neighbourhood indicators and individual-level smoking intensity, quit behaviours and relapse.

Results: Higher neighbourhood violence was associated with higher smoking intensity (risk ratio (RR)=1.17, 95% CI 1.02 to 1.33), and fewer quit attempts (RR=0.72, 95% CI 0.61 to 0.85). Neighbourhood violence was not associated with successful quitting or relapse. Higher neighbourhood social cohesion was associated with more quit attempts and more successful quitting. Neighbourhood social cohesion modified the association between neighbourhood violence and smoking intensity: in neighbourhoods with higher social cohesion, as violence increased, smoking intensity decreased and in neighbourhoods with lower social cohesion, as violence increased, so did smoking intensity.

Conclusions: In the context of recent increased violence in Mexico, smokers living in neighbourhoods with more violence may smoke more cigarettes per day and make fewer quit attempts than their counterparts in less violent neighbourhoods. Neighbourhood social cohesion may buffer the impact of violence on smoking intensity.

Citation

Shang, C., Chaloupka, F., Zahra, N., Fong, G.T. (2014). The distribution of cigarette prices under different tax structures: Findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 23(Suppl 1), i23-i29.

Abstract

Background: The distribution of cigarette prices has rarely been studied and compared under different tax structures. Descriptive evidence on price distributions by countries can shed light on opportunities for tax avoidance and brand switching under different tobacco tax structures, which could impact the effectiveness of increased taxation in reducing smoking.

Objective: This paper aims to describe the distribution of cigarette prices by countries and to compare these distributions based on the tobacco tax structure in these countries.

Methods: We employed data for 16 countries taken from the International Tobacco Control Policy Evaluation Project to construct survey-derived cigarette prices for each country. Self-reported prices were weighted by cigarette consumption and described using a comprehensive set of statistics. We then compared these statistics for cigarette prices under different tax structures. In particular, countries of similar income levels and countries that impose similar total excise taxes using different tax structures were paired and compared in mean and variance using a two-sample comparison test.

Findings: Our investigation illustrates that, compared with specific uniform taxation, other tax structures, such as ad valorem uniform taxation, mixed (a tax system using ad valorem and specific taxes) uniform taxation, and tiered tax structures of specific, ad valorem and mixed taxation tend to have price distributions with greater variability. Countries that rely heavily on ad valorem and tiered taxes also tend to have greater price variability around the median. Among mixed taxation systems, countries that rely more heavily on the ad valorem component tend to have greater price variability than countries that rely more heavily on the specific component. In countries with tiered tax systems, cigarette prices are skewed more towards lower prices than are prices under uniform tax systems. The analyses presented here demonstrate that more opportunities exist for tax avoidance and brand switching when the tax structure departs from a uniform specific tax.

Citation

Saenz-de-Miera Juarez, B., Thrasher, J.F., Reynales, L.M., Hernández-Ávila, M., Chaloupka, F. (2014). Tax, price and cigarette brand preferences: A longitudinal study of adult smokers from the ITC Mexico Survey. Tobacco Control, 23(Suppl 1), i80-i85.

Abstract

Background: Recent tax increases in Mexico differed in structure and provided an opportunity to better understand tobacco industry pricing strategies, as well as smokers' responses to any resulting price changes.

Objectives: To assess if taxes were passed onto consumers of different cigarette brands, the extent of brand switching and predictors of preference for cheaper national brands.

Methods: Using data from three waves of the Mexican administration of the International Tobacco Control Survey, we analysed self-reported brand and price paid at last cigarette purchase. Generalised estimating equations were used to determine predictors of price and preference for national brands.

Results: The average price of premium/international brands increased each year from 2008 to 2011; however, the price for discount/national brands increased only from 2010 to 2011. The percentage of smokers who smoked national brands remained stable between 2008 and 2010 but dropped in 2011. Factors related to smoking national brands as opposed to international brands included being male and having relatively older age, lower education, lower income and higher consumption.

Conclusions: Tobacco industry pricing strategies in the wake of ad valorem taxes implemented in Mexico prior to 2011 had the impact of segmenting the market into discount national brands and premium international brands. The specific tax increase implemented in 2011 reduced the price gap between these two segments by raising the price of the national brands relative to the international brands. Evidence for trading up was found after the 2011 tax increase. These results provide further evidence for the relevance of tax policy as a tobacco control strategy; in particular, they illustrate the importance of how specific rather than ad valorem taxes can reduce the potential for downward brand switching in the face of decreasing cigarette affordability.

Citation

Gravely, S., Fong, G.T., Cummings, K.M., Yan, M., Quah, A.C.K., Borland, R., Yong, H.H., Hitchman, S.C., McNeill, A., Hammond, D., Thrasher, J.F., Willemsen, M.C., Seo, H.G., Jiang, Y., Cavalcante, T.M., Perez, C., Omar, M., Hummel, K. (2015). Awareness, trial, and current use of electronic cigarettes in 10 countries: findings from the ITC Project. International Journal of Environmental Research and Public Health, 12(5), 4631-4637.

Abstract

Background: In recent years, electronic cigarettes (e-cigarettes) have generated considerable interest and debate on the implications for tobacco control and public health. Although the rapid growth of e-cigarettes is global, at present, little is known about awareness and use. This paper presents self-reported awareness, trial and current use of e-cigarettes in 10 countries surveyed between 2009 and 2013; for six of these countries, we present the first data on e-cigarettes from probability samples of adult smokers.

Methods: A cross-sectional analysis of probability samples of adult (≥ 18 years) current and former smokers participating in the International Tobacco Control (ITC) surveys from 10 countries. Surveys were administered either via phone, face-to-face interviews, or the web. Survey questions included sociodemographic and smoking-related variables, and questions about e-cigarette awareness, trial and current use.

Results: There was considerable cross-country variation by year of data collection and for awareness of e-cigarettes (Netherlands (2013: 88%), Republic of Korea (2010: 79%), United States (2010: 73%), Australia (2013: 66%), Malaysia (2011: 62%), United Kingdom (2010: 54%), Canada (2010: 40%), Brazil (2013: 35%), Mexico (2012: 34%), and China (2009: 31%)), in self-reports of ever having tried e-cigarettes (Australia, (20%), Malaysia (19%), Netherlands (18%), United States (15%), Republic of Korea (11%), United Kingdom (10%), Mexico (4%), Canada (4%), Brazil (3%), and China (2%)), and in current use (Malaysia (14%), Republic of Korea (7%), Australia (7%), United States (6%), United Kingdom (4%), Netherlands (3%), Canada (1%), and China (0.05%)).

Conclusions: The cross-country variability in awareness, trial, and current use of e-cigarettes is likely due to a confluence of country-specific market factors, tobacco control policies and regulations (e.g., the legal status of e-cigarettes and nicotine), and the survey timing along the trajectory of e-cigarette awareness and trial/use in each country. These ITC results constitute an important snapshot of an early stage of what appears to be a rapid progression of global e-cigarette use.

Citation

Thrasher, J.F., Naveli Abad-Vivero, E., Sebrie, E.M., Barrientos-Gutierrez, I., Boado Martinez, M., Yong, H.H., Arillo-Santillán, E., Bianco, E. (2013). Tobacco smoke exposure in public places and workplaces after smoke-free policy implementation: A longitudinal analysis of smoker cohorts in Mexico and Uruguay. Health & Policy Planning, 28(8), 789-798.

Abstract

Objective: To determine the prevalence, correlates and changes in secondhand smoke (SHS) exposure over the period after comprehensive smoke-free policy implementation in two Latin American countries.

Methods: Data were analysed from population-based representative samples of adult smokers and recent quitters from the 2008 and 2010 waves of the International Tobacco Control Policy Evaluation Survey in Mexico (n = 1766 and 1840, respectively) and Uruguay (n = 1379 and 1411, respectively). Prevalence of SHS exposure was estimated for regulated venues, and generalized estimating equations were used to determine correlates of SHS exposure.

Results: Workplace SHS exposure in the last month was similar within and across countries (range: Mexico 20–25%; Uruguay 14–29%). At the most recent restaurant visit, SHS exposure was lower where comprehensive smoke-free policies were implemented (range: Uruguay 6–9%; Mexico City 5–7%) compared with Mexican cities with weaker policies, where exposure remained higher but decreased over time (32–17%). At the most recent bar visit, SHS exposure was common (range: Uruguay 8–36%; Mexico City 23–31%), although highest in jurisdictions with weaker policies (range in other Mexican cities: 74–86%). In Uruguay, males were more likely than females to be exposed to SHS across venues, as were younger compared with older smokers in Mexico.

Conclusions: Comprehensive smoke-free policies are more effective than weaker policies, although compliance in Mexico and Uruguay is not as high as desired.

Citation

Mutti, S., Hammond, D., Reid, J., Thrasher, J.F. (2013). The efficacy of cigarette warning labels on health beliefs in the United States and Mexico. Journal of Health Communication, 18(10), 1180-1192.

Abstract

Concern over health risks is the most common motivation for quitting smoking. Health warnings on tobacco packages are among the most prominent interventions to convey the health risks of smoking. Face-to-face surveys were conducted in Mexico (n = 1,072), and a web-based survey was conducted in the US (n = 1,449) to examine the efficacy of health warning labels on health beliefs. Respondents were randomly assigned to view two sets of health warnings (each with one text-only warning and 5–6 pictorial warnings) for two different health effects. Respondents were asked whether they believed smoking caused 12 different health effects. Overall, the findings indicate high levels of health knowledge in both countries for some health effects, although significant knowledge gaps remained; for example, less than half of respondents agreed that smoking causes impotence and less than one third agreed that smoking causes gangrene. Mexican respondents endorsed a greater number of correct beliefs about the health effects of smoking than did the U.S. sample. In both countries, viewing related health warning labels increased beliefs about the health risks of smoking, particularly for less well-known health effects such as gangrene, impotence, and stroke.