Citation

Chun, H., Fong, G.T., Gravely, S., Xu, S.S., Quah, A.C.K., Kang, H., Yoon, W., Seo, H.G., Kim, Y., Lee, S., Kim, G., Kim, S.-Y., Lim, S., Yan, M., Cho, S. (2025). An examination of the relationship between perceptions that cigarette smoking increases the severity of COVID-19 illness and reduction in smoking during the COVID-19 pandemic: Findings from the 2021 ITC Korea Survey. Tobacco Induced Diseases.doi: 10.18332/tid/205468.

Abstract

Introduction: This study examined whether Korean adults who smoked cigarettes during the COVID-19 pandemic decreased their smoking because of COVID-19, with a focus on whether perceptions of susceptibility and severity of COVID-19 disease were associated with reduced smoking.

Methods: Data came from 1506 Korean adults (aged =19 years) who exclusively smoked cigarettes (weekly) and participated in the 2021 International Tobacco Control (ITC) Korea Survey. Weighted analyses assessed pandemic-related changes in smoking and whether reductions in smoking were related to: 1) perceived susceptibility to contracting COVID-19; 2) perceiving that smoking increases the severity of COVID-19 disease; and 3) general worry about getting a smoking-related disease.

Results: Korean adults were significantly more likely to have reduced their smoking because of COVID-19 (18.9%) than increased their smoking (6.3%) (p<0.001); 74.8% made no changes to their smoking. Reducing smoking was associated with being very worried about contracting COVID-19 (adjusted odds ratio, AOR=4.25; 95% CI: 1.65-10.99) and believing that smoking increases COVID-19 severity (AOR=2.34; 95% CI: 1.19-4.61). General worry about getting smoking-related diseases was not associated with smoking reduction (p=0.53). We also found an interaction between perceived severity and worry about getting COVID-19; those who were very worried about getting COVID-19 and perceive smoking as increasing its severity, were more likely to reduce smoking (p=0.049).

Conclusions: In response to the COVID-19 pandemic, Korean adults who smoked were much more likely to reduce than increase their smoking, unlike in most countries where there was no net change. The higher smoking reduction rate in Korea may reflect successful and strong communication by the Korean government regarding the importance of reducing smoking during the pandemic, compared to the general future threat of health risks from smoking.

Citation

Tran, T.P.T., Nguyen, T.N.P., Tran, T.P.T., Nguyen, B.N., Nguyen, T.L., Phan, T.H., Luong, N.K., The, S.D., Lim, M.K., Quah, A.C.K., Thompson, M.E., Fong, G.T., Hoang, V.M., Oh, J.K. (2025). What cigarette price would drive Vietnamese people who smoke to quit smoking? Findings from 2019-2020 the ITC Vietnam Surveys. Tobacco Control, [Published online Jun 12, doi: doi:10.1136/tc-2024-059029].

Abstract

Background

Tobacco taxation is the most effective strategy for reducing tobacco consumption, yet it remains underused globally, especially in low- and middle-income countries. This study aimed to investigate the price that would lead Vietnamese people who smoke to quit smoking and examine the impact of non-tax tobacco control policies on this price.

Methods

Cross-sectional data from Waves 2 and 3 of the International Tobacco Control Project in Vietnam were analysed. The price to quit was assessed by a question ’What price for a pack of cigarettes would make you try to quit smoking?’. Tobit models were used to examine the association between non-tax policies (ie, noticing health warnings, anti-smoking advertising, use of cessation services and workplace smoke-free policies) and the price to quit.

Results

The weighted median of the price to quit for a cigarette pack was Vietnam dong (VND)20 000 (US$0.86), which doubled the weighted median of the purchased price of VND10 000 (US$0.43). If cigarette prices increased by VND2000 or VND5000, 27.4% and 42.8% of people who smoke would intend to quit smoking, respectively. Price increases that doubled or tripled current prices would lead 70.7% and 82.9% of people who smoke to consider quitting smoking, respectively. Smoke-free policies at workplace were associated with a lower price to quit.

Conclusion

Given that the current cigarette prices are very low and affordable, substantial price increases are needed to motivate quitting. Adding specific taxes in addition to the existing ad valorem system could enhance the effectiveness of tobacco taxation.

Citation

Leinberger-Jabari, A., Ahmad, A., Lindson, N., Hartmann-Boyce, J., Fong, G.T., Ali, R., Idaghdour, Y., Sherman, S. (2025). Factors associated with single, dual and poly combustible tobacco use among Emirati adults in the United Arab Emirates: The UAE Healthy Future and ITC Survey results (2016 – 2023). Nicotine and Tobacco Research.doi: doi.org/10.1093/ntr/ntaf113.

Abstract

Introduction

Forms of combustible tobacco, such as shisha and pipe tobacco, are popular in the Middle East. Poly use of combustible tobacco products increases exposure to the harmful toxicants in them. Little is known about patterns of tobacco use behaviors in Middle Eastern countries and the potential harms due to particular types and concurrent versus single-use.

Methods

We analyzed data on tobacco use from 7,535 Emirati adults as part of the UAE Healthy Future Study, a longitudinal cohort study in the United Arab Emirates. We examined associations between single, dual, or poly combustible tobacco use and sociodemographic and clinical factors, including markers of cardiovascular disease (CVD). We also examined associations between the type of tobacco used and markers of CVD.

Results

Age-adjusted prevalence of combustible tobacco use was 34%. Single, dual, and poly use were 47%, 35%, and 18%, respectively. Parental tobacco use was associated with any kind of combustible tobacco use, and was strongly associated with poly use (RRRp=4.4, 95% CI=1.2, 16.8). Those who used one or more combustible tobacco products had higher levels of some CVD markers, notably HDL and Apolipoprotein A. Use of any type of tobacco was associated with increased risk for markers of CVD.

Conclusions

Any amount of tobacco used was associated with differences in CVD markers. Associations were strongest for poly tobacco users. Future studies are needed to understand relationships between single, dual and poly combustible tobacco use, different combustible tobacco types, and disease risk.

Implications

All forms of tobacco were associated with markers of CVD, signaling that there is no safer form of combustible tobacco. The study is one of the largest to characterize tobacco use behaviors in a Middle Eastern population, and should provide an important benchmark for further research on different, and sometimes co-occurring, forms of tobacco use.

Citation

He, Y., Fong, G.T., Cummings, K.M., Hyland A., Freitas-Lemos, R., Shang, C. (2025). The Economic Factors that Determine Smoking Abstinence: A Survival and Mediation Analysis. International Journal of Drug Policy.doi: 10.1016/j.drugpo.2025.104852.

Abstract

Background: Higher taxes stimulate quit attempts and higher rates of smoking abstinence. Additionally, taxes on tobacco cigarettes and e-cigarettes (ECs) may influence consumers’ perceptions of the relative costs of these products. Understanding the relationship between cigarette and EC taxes, cost perceptions, and smoking abstinence is therefore crucial.

Methods: This study utilized longitudinal data from the US arm of the 2016–2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys and implemented a survival analysis to explore the impact of cigarette and EC taxes on smoking abstinence. A mediation analysis was also performed to test whether the effects of taxes are influenced by individuals’ perceptions about the relative cost differences between ECs and cigarettes.

Results: A 10 % increase in cigarette taxes was associated with an 11.1 % increase in smoking abstinence. EC taxes were not associated with smoking abstinence among the overall sample. However, higher EC taxes were associated with greater odds of smoking abstinence among individuals over 40 and lower odds of smoking abstinence among individuals under 40. Relative cost perception did not mediate the effect of taxes on smoking abstinence. Additionally, the odds of quitting were higher among individuals in the high-income group and those who used ECs daily, and lower among individuals in older age groups.

Conclusions: Cigarette taxes have a direct impact on smoking abstinence, independent of cost perceptions. To enhance cessation rates, policymakers should implement targeted strategies such as increasing access to cessation programs, providing financial incentives for quitting, and tailoring tax policies to better support older individuals and those with lower incomes.

Citation

Tattan-Birch, H., East, K.A., Cox, S., Jackson, S., Brown, J., Simonavicius, E., Reid, J.L., Hammond, D., Taylor, E.V. (2025). Impact of standardising the colour and branding of vape devices on product appeal among young people: a randomised experiment in England, Canada, and the US. Tobacco Control, [Published online May 13, doi: doi:10.1136/tc-2024-059210].

Abstract

Objective

To estimate the impact of standardising the colour and branding of disposable vaping devices on young people’s interest in trying them.

Design, setting and participants

Data were from national surveys of 16–29-year-olds in Canada, England and the United States in 2023 (N=15?259).

Interventions

Respondents were randomised (1:1) to view images of either four branded disposable vapes (N=7638) or four standardised white disposable vapes (n=7621) and asked which they would be interested in trying.

Main outcome measures

The primary outcome was selecting “no interest in trying” rather than any of the vapes displayed. We also examined whether the impact of standardisation differed by five potential moderators. Results A greater proportion of participants reported “no interest in trying” the white standardised than branded vapes (67.1% vs 62.8%; adjusted risk ratio (ARR) 1.127, 95% CI 1.085 to 1.169). Compared with those who had never smoked or vaped, the impact of standardisation on those reporting no interest was greater for those who had, in the past 30 days, only smoked (47.5% vs 37.5%, ARR 1.287, 95% CI 1.079 to 1.495), only vaped (19.9% vs 16.4%, ARR 1.220, 95% CI 1.002 to 1.438), dual used (13.5% vs 9.5%, ARR 1.420, 95% CI 1.017 to 1.822) or who had formerly vaped/smoked (72.6% vs 65.0%, ARR 1.119, 95% CI 1.071 to 1.167). The impact was also greatest in the oldest age group, but there were no other clear moderators.

Conclusions

Standardising the colour and branding of disposable vaping devices reduces young people’s interest in trying them. However, this includes a substantial impact on those who smoke.

Citation

Nip, J., Zhang, J., Stanley, J., Waa, A.M., Ball, J., Tautolo, E.S., Agar, T.K., Quah, A.C.K., Fong, G.T., Edwards, R. (2025). Patterns and experiences of smoking, electronic cigarettes (vapes), and heated tobacco use among people who smoke or who recently quit. New Zealand Medical Journal, 138(1612), 21-46. doi: DOI: 10.26635/6965.6789.

Abstract

Aim: The aim of this study is to understand patterns and experiences of smoking and electronic cigarette use, as well as related attitudes and behaviours among adults in Aotearoa New Zealand who smoke or recently stopped smoking.

Methods: We analysed data from the Evidence for Achieving Smokefree Aotearoa Equitably/International Tobacco Control New Zealand Survey (N=1,230), conducted between November 2020 and February 2021.

Results: Among people who smoked, 77.5% (95% confidence interval [CI] 74.0–80.8%) reported regretting having started smoking, 73.6% (95% CI 69.5–77.4) intended to quit, 87.3% (95% CI 84.1–89.9) reported being addicted to smoking and 86.3% (95% CI 83.3–88.8) had tried to quit smoking in the past. Among people who smoked, 24.8% (95% CI 21.3–28.6) used electronic cigarettes (ECs) daily and 4.6% (95% CI 3.3–6.6) used heated tobacco products (HTPs) daily. Among people who had recently stopped smoking, 33.4% (95% CI 25.6–42.2) used ECs daily and less than 1% used HTPs daily.

Conclusion: High levels of regret for starting smoking, addiction and intent to quit smoking highlight the importance of implementing effective and equitable smokefree measures to prevent people from starting to smoke and to support people to stop smoking

Citation

Hammond, D., Reid, J.L., Goniewicz, M.L., McNeill, A., O’Connor, R.J., Corsetti, D., Block, A.C., Brose, L.S., Robson, D. (2025). Nicotine exposure from smoking tobacco and vaping among adolescents. JAMA Network Open, 8(3), doi: doi:10.1001/jamanetworkopen.2024.62544.

Abstract

Importance

It remains unknown whether nicotine intake among youths who vape is lower, comparable, or higher than among youths who smoke.

Objective

To examine potential differences in biomarkers of exposure to nicotine (1) between adolescents who smoke tobacco, vape, both vape and smoke (dual use), or do not use; (2) between adolescents in 3 countries; and (3) by nicotine content and form in the vaping product last used among adolescents who exclusively vaped.

Design, Setting, and Participants

This population-based, observational cross-sectional study invited adolescents aged 16 to 19 years in Canada, England, and the US who had previously completed national surveys to participate in a biomarker study based on their vaping and smoking status. Participants completed questionnaires and self-collected urine samples between September 2019 and January 2022. Analyses were conducted in February 2023 and between January and June 2024.

Exposures

Vaping, tobacco smoking, dual use, or no use in the past 7 days.

Main Outcomes and Measures

Urine concentration of cotinine, trans-3′-hydroxycotinine (3OH-cotinine), and total nicotine equivalents (TNE-2; molar sum of cotinine and 3OH-cotinine), normalized for creatinine concentration.

Results

Among the 364 participants (mean [SD] age, 17.6 [1.1] years; 203 females [55.8%]) who provided usable urine samples and completed questionnaires, no differences in TNE-2 concentration were observed between adolescents who exclusively vaped (n = 73; geometric mean [SD], 3.10 [16.69] nmol/mg creatinine), exclusively smoked (n = 68; geometric mean [SD], 3.78 [18.00] nmol/mg creatinine), or both vaped and smoked (n = 77; geometric mean [SD], 6.07 [19.08] nmol/mg creatinine) in the past week, adjusting for creatinine concentration, age, sex, country, and cannabis use. All vaping and/or smoking groups had higher concentrations of TNE-2 than no use (n = 146; geometric mean [SD], 0.19 [1.14] nmol/mg creatinine; P < .001 for all contrasts). Among adolescents who exclusively vaped (n = 73), TNE-2 concentrations were not significantly different between those who reported using products containing more than 20 mg/mL nicotine (n = 33; geometric mean [SD], 4.35 [18.25] nmol/mg creatinine) and containing 20 mg/mL nicotine or less (n = 28; geometric mean [SD], 5.13 [15.64] nmol/mg creatinine). Reported use of vaping products containing nicotine salts (n = 23) was associated with higher concentration of TNE-2 (geometric mean [SD], 10.78 [18.03] nmol/mg creatinine) than reported use of products without nicotine salts (n = 29; geometric mean [SD], 2.72 [15.42] nmol/ng creatinine; P = .03) or reporting “don’t know” (n = 14; geometric mean [SD], 1.55 [15.01] nmol/ng creatinine; P = .009). Similar patterns of exposure were observed for cotinine and 3OH-cotinine.

Conclusions and Relevance

This cross-sectional study found that vaping was associated with similar nicotine exposure as smoking among adolescents. Reported use of a nicotine salt product was associated with higher nicotine exposure among those who exclusively vaped, consistent with findings from laboratory and population studies indicating greater dependence for nicotine salt e-cigarettes.

Citation

Hammond, D., Reid, J.L., Goniewicz, M.L., McNeill, A., O’Connor, R.J., Corsetti, D., Brose, L.S., Schurr, B., Robson, D. (2025). Biomarkers of toxicant exposure among youth in Canada, England and the United States who vaped and/or smoke cigarettes or do neither. Cancer Epidemiology Biomarkers & Prevention.doi: doi: 10.1158/1055-9965.EPI-24-1338.

Abstract

Background:

Few studies examine biomarkers of exposure to vaping and tobacco products among youth. We compared biomarkers for toxicants between youth who vape, smoke, 'dual-use', or neither.

Methods:

Participants aged 16-19 in Canada, England, and the United States (US) completed surveys and self-collected urine samples between September 2019 and January 2022 (N=364). Urine was tested for metabolites of tobacco-specific nitrosamine NNK and six volatile organic compounds (VOCs). Regression models examined differences in biomarker concentrations by past-week tobacco smoking and vaping, adjusting for creatinine, age, sex, country, and cannabis use.

Results:

Compared to no vaping/smoking, exclusive vaping was associated with similar exposure to acrolein and acrylonitrile, but higher exposure to toluene (p=.04) and acrylamide (p=.034, only in sensitivity analysis using past-24-hour measure). Compared to dual-use or exclusive smoking, exclusive vaping was associated with lower exposure to NNK, acrolein, acrylamide, and acrylonitrile (p≤.01), but higher toluene exposure than dual use (p=0.012). Exposure was similar for dual-use and exclusive smoking. Benzene and xylene biomarkers were detected in <5% and not compared. Among those smoking, NNK exposure was higher in the US (geometric mean=25.4pg/mg creatinine) versus Canada (16.1pg/mg; p=0.006) and England (14.1pg/mg; p=0.018).

Conclusions:

Youth exclusively vaping had similar exposure as no vaping/smoking except for two VOCs, and lower exposure than smoking or dual use except toluene. Higher NNK levels among US youth who smoke likely reflect differences in tobacco blend. Impact: Findings are generally consistent with literature indicating lower toxicant exposure from vaping versus smoking, but elevated exposure versus no use for some.

Citation

Nip, J., Stanley, J., Zhang, J.Y., Waa, A.M., Ball, J., Tautolo, E.S., Johnson, E., Agar, T.K., Quah, A.C.K., Fong, G.T., Edwards, R. (2025). Support for and likely impacts of endgame measures in the Smokefree Aotearoa Action Plan: Findings from the 2020-2021 International Tobacco Control New Zealand (EASE) Surveys. New Zealand Medical Journal, 138(1608), 40-83. doi: 10.26635/6965.6526.

Abstract

Aim: In February 2024, the Aotearoa New Zealand Government repealed legislation to mandate very low nicotine cigarettes (VLNCs), greatly reduce the number of tobacco retailers and disallow sale of tobacco products to people born after 2008 (smokefree generation). We investigated acceptability and likely impacts of these measures among people who smoke or who recently (=2 years) quit smoking.

Method: We analysed data from 1,230 participants from Wave 3 (conducted in late 2020 and early 2021) and 615 participants from Wave 3.5 (conducted in June/July 2021) of the New Zealand arm of the International Tobacco Control (ITC) Policy Evaluation Project. Data were weighted to represent the national population of people who smoke and who recently quit smoking.

Results: Support (excluding “Don’t know” responses) was 82.7% (95% confidence interval 77.9, 86.6) for a smokefree generation, 75.0% (95% CI 71.4, 78.3) for mandated VLNCs and 35.2% (95% CI 31.7, 38.9) for retailer reduction. Support was mostly similar by ethnicity, gender, age and evidence of financial hardship, but was higher among people who had recently quit smoking. Around half of the participants who smoked anticipated quitting completely, switching to vaping or cutting down the amount they smoke if mandated VLNCs or substantial retailer reductions were introduced. If VLNCs were mandated, 19% of people who smoked stated they would carry on smoking like they do now and find a way to get the cigarettes or tobacco they want to smoke.

Conclusion: Support for and anticipated actions in response to the smokefree legislation measures call into question the Government’s decision to repeal them.

Citation

Hackworth, E., Vidaña-Pérez, D., O'Neal, R., Minji, K., Hammond, D., Thrasher, J.F. (2025). Trends in Mental Health Symptoms, Nicotine Product Use, and their Association Over Time Among Adolescents in Canada, England, and the US: Findings from the ITC Adolescents Tobacco and Vaping Survey, 2020- 2023. Nicotine and Tobacco Research, [Published online Jan 17, doi: DOI: 10.1093/ntr/ntaf015].

Abstract

Introduction: There is a well-established bi-directional relationship between cigarette smoking and internalizing mental health (IMH) symptoms (e.g., symptoms of depression, symptoms of anxiety). However, it is unclear whether IMH symptoms are associated with using different types or combinations of nicotine products (e.g., combustible, non-combustible, exclusive product use or multi-product use). The purpose of this study is to improve our understanding of the relationship between adolescent IMH symptoms and use of a wide variety of nicotine products by examining the association between IMH symptoms and current nicotine use from 2020-2023.

Methods: Data come from the 2020-2023 waves of the International Tobacco Control (ITC) Adolescents Tobacco and Vaping Survey, an online repeat cross-sectional survey of adolescents aged 16-19 in Canada, England, and the US (n=80,427). Current nicotine use was examined in four categories: 1) no use, 2) exclusive non-combustible product use, 3) exclusive combustible product use, and 4) use of both product types. Respondents reported current symptoms of depression or anxiety, and we generated a dichotomous IMH symptoms variable (yes vs. no). We examined the association between IMH symptoms and current nicotine use using multinomial logistic regression models that adjusted for covariates.

Results: IMH symptoms were most strongly associated with use of both product types (adjusted relative risk ratio [ARRR]: 1.91, 95% confidence interval [CI] 1.80-2.03), followed by exclusive non-combustible use (ARRR: 1.70, 95% CI=1.61-1.80), and then exclusive combustible use (ARRR: 1.29, 95% CI=1.21- 1.37).

Conclusions: Adolescents with IMH symptoms are more likely to use nicotine products in general than adolescents without IMH symptoms. Specifically, non-combustible product use may have a particularly strong relationship with poor mental health among adolescents. Longitudinal research is needed to better understand directionality.

Citation

Yong, H. H., Hughes, L., Borland, R., Gravely, S., Cummings, K.M., Brose, L.S., Taylor, E.V., Bansal-Travers, M., Hyland, A. (2025). Prevalence and correlates of negative side effects from vaping: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Drug and Alcohol Dependence, 226, doi: 10.1016/j.drugalcdep.2024.112503.

Abstract

Introduction: This study examined prevalence and correlates of self-reported negative side effects from nicotine vaping product (NVP) use among people who currently or recently vape.

Methods: This crosssectional study analysed data from 3906 adults (aged 18+ years) from the 2020 ITC Four Country Smoking and Vaping Survey (Canada, US, England and Australia) who reported they had ever smoked cigarettes and were either currently vaping daily/weekly or had vaped in the last month. Participants were asked about experiencing and seeking medical advice for any negative side effects from vaping in the past month. Logistic regressions were used to estimate prevalence and identify correlates.

Results: Overall, 87.1 % reported no negative side effects from vaping. The most common side effects were throat irritation (5.8 %), cough (5.5 %), and mouth irritation (4.1 %). The top two that led to seeking medical advice were: mouth irritation (46.8 %) and loss of taste (45.2 %). Those more likely to self-report side effects were younger, male, currently smoking (vs quit), vaping for <6 months (vs >1 year), using disposables or cartridges/ pods (vs tanks), using vapes with nicotine (vs without nicotine), using menthol/mint flavour (vs sweet flavour), currently smoking (vs quit), believing vaping causes various diseases (e.g., heart disease), and believing that vaping is equally/more harmful than smoking.

Conclusion: Negative side effects associated with NVP use were rare and mainly minor in all four countries. Shorter duration of vaping, concurrent smoking while vaping and perceptions of greater vaping harms relative to smoking were associated with more reported negative side effects attributed to vaping.

Citation

Gravely, S., Sweanor, D.T., Driezen, P., Levy, D.T., Fong, G.T., Quah, A.C.K., Craig, L.V., Chung-Hall, J., Kaai, S.C., Cummings, K.M. (2025). Use of nicotine vaping products during an attempt to quit smoking among Canadian adults who smoke or recently quit: Findings from the 2022 Canada ITC Smoking and Vaping Survey. Health Promotion and Chronic Disease Prevention in Canada, 45(1), 54-60. doi: https://doi.org/10.24095/hpcdp.45.1.04.

Abstract

An analysis of 1771 Canadian adults who smoke or used to smoke cigarettes was conducted using data from the 2022 International Tobacco Control Four Country Smoking and Vaping Survey. Using weighted data, we estimated the prevalence of Canadian adults who tried to quit smoking between 2020 and 2022, and the use of a nicotine vaping product (NVP) and the flavours and devices used most often at their most recent quit attempt. Overall, 36.5% made a quit attempt; of those, 19.4% used an NVP. Those who were younger and quit smoking were more likely to have used an NVP. Prefilled cartridges or pods (36.3%) and fruit flavours (39.5%) were used most frequently.

Citation

Miller, Schneller-Najm, Leigh, N.J., Agar, T.K., Quah, A.C.K., Cummings, K.M., Fong, G.T., O’Connor, Goniewicz, M.L. (2024). Biomarkers of exposure to nicotine and selected toxicants in individuals who use alternative tobacco products sold in Japan and Canada in 2018-2019. Cancer Epidemiology Biomarkers & Prevention, [Published online Dec 5, doi: 10.1158/1055-9965.EPI-24-0836].

Abstract

Background: Comparisons of nicotine and toxicant exposure between people who use different alternative tobacco products remains underexplored.

Methods: This cross-sectional, multi-country study analyzed urinary metabolites of nicotine, NNK, and volatile organic compounds (acrolein, acrylamide, acrylonitrile) among established users (n=550) in Japan and Canada. Participants exclusively or concurrently used nicotine vaping products (NVPs; Canada only), heated tobacco products (HTPs; Japan only), and combustible cigarettes (CCs; Japan and Canada), or abstained (Japan and Canada).

Results: All product groups showed substantial nicotine exposure. Both HTPs and NVPs exposed exclusive users to lower toxicant levels than exclusive CC use. Canadian participants who exclusively used NVPs exhibited lower NNK and acrolein exposure but higher acrylamide exposure than Japanese participants who exclusively used HTPs. Concurrent use of CCs alongside alternative products exposed users to higher toxicant levels compared to exclusive use of either alternative product.

Conclusions: Exclusive use of alternative tobacco products results in significant nicotine exposure but substantially lower toxicant exposure compared to exclusive CC use. People who use HTPs in Japan may experience higher exposure to nicotine and certain toxicants (NNK, acrolein) than people who use NVPs in Canada. Concurrent use results suggest that partially substituting CCs with alternative products may reduce toxicant exposure, but to a lesser extent than completely transitioning to alternative products. Impact: Exposure patterns between two popular alternative tobacco products differ. The overall toxicant exposure from these products is lower than CCs, providing critical data for regulatory decisions and public health considerations.

Citation

Gravely, S., Novotny, T., Cummings, K.M., East, K.A., Hyland, A., Driezen, P., Hoek, J., Morphett, K., Sellars, D., O’Connor, Quah, A.C.K., Fong, G.T., Gartner, C.E. (2024). Opposition to banning cigarette filters and the belief that removing filters makes cigarettes much more harmful among adults who smoke: Findings from the 2022 International Tobacco Control Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, [Published online Nov 16, doi: doi.org/10.1093/ntr/ntae270].

Abstract

Introduction: In line with historical tobacco industry marketing claims, many consumers perceive cigarettes with filters as less harmful than cigarette without filters. However, scientific evidence indicates that cigarette filters do not reduce the risks associated with smoking. We examined opposition to banning the sale of cigarettes with filters, beliefs about whether removing filters makes cigarettes much more harmful, and whether this belief is associated with opposition to banning filters among adults who smoke cigarettes from four high-income countries.

Methods: Data are from 2,980 adults who smoke cigarettes and participated in the 2022 ITC Smoking and Vaping Survey in Australia, Canada, England, and the United States (US). Weighted descriptives estimated opposition to a cigarette filter ban and the belief that removing filters makes cigarettes ‘much more’, ‘a little more’, ‘not more’ harmful, or ‘don’t know’. Adjusted regression analyses examined the association between opposition to banning filters (vs. support/don’t know) and the belief that removing filters would make cigarettes much more harmful (vs. otherwise).

Results: Across all counties, 69.3% opposed banning filters, 11.5% of respondents supported banning filters, and 19.1% did not know (main effect for country differences: p=0.001). Country differences remained significant after adjusting for covariates (p=0.047), with adults who smoke in Australia and the US being significantly more likely to oppose a filter ban than those in England. Canada did not differ significantly from any of the countries. Nearly half (45.9%) believe that removing filters would make cigarettes much more harmful, 28.6% reported a little more harmful, 15.3% were unsure, and 10.2% reported not more harmful (country differences: p=0.002). Country differences were no longer significant after adjustment (p=0.18). Believing that removing filters makes cigarettes much more harmful was strongly associated with opposing a filter ban (78.5%) (vs. otherwise: 62.1%, p<0.001).

Conclusions: Across all four countries, three-quarters of adults who smoke erroneously believe that removing filters would make cigarettes more harmful, and believing that doing so would make cigarettes much more harmful was the strongest predictor of opposing a filter ban.

Citation

Borland, R., Dhungel, B., Gartner, C.E., Fong, G.T., Hyland, A., Cummings, K.M., East, K.A. (2024). How is heated tobacco product use described by people who use them daily. Tobacco Control, [Published online Nov 1, doi: doi:10.1136/tc-2024-058969].

Abstract

Heated tobacco products (HTPs) heat tobacco, usually in the form of a stick of compacted, reconstituted tobacco rather than burning it, to produce an aerosol that contains nicotine and other tobacco constituents. In countries where these products are marketed, prevalence has increased, most notably Japan. HTPs deliver lower levels of toxicants than conventional cigarette smoke and are promoted as harm- reduced alternatives to smoking. It is unclear how HTP users describe the act of inhaling the aerosol generated. One qualitative study among adult HTP users found considerable confusion as to what term was appropriate, and although the term ‘smoking’ was commonly used, they resisted being labelled as ‘smokers’.

The continuing uncertainty about terms reinforces existing concerns about product classification, highlighting the need to clearly communicate category differences when asking about product use. We do this in ITC surveys. Accurate classification is particularly important as these products have different risk profiles and/or are subject to different regulatory requirements.

Citation

Togawa, K., Fong, G.T., Quah, A.C.K., Meng, G., Xu, S.S., Ouimet, J., Mochizuki, Y., Yoshimi, I., Odani, S., Tabuchi, T., Katanoda, K. (2024). Impacts of revised smoke-free regulations under the 2020 Japan Health Promotion Act on cigarette smoking and heated tobacco products use in indoor public places and homes: Findings from the 2018-2021 International Tobacco Control (ITC) Japan Surveys. Tobacco Control, [Published online Oct 17, doi: doi: 10.1136/tc-2024-058697].

Abstract

Background: In April 2020, Japan's revised Health Promotion Act (HPA) banned cigarette smoking and heated tobacco products (HTP) use in indoor public places but exempted small establishments and permitted smoking-designated/HTP-designated rooms. This pre-post study evaluated the effectiveness of the HPA.

Methods: Data were from waves 1 to 4 (2018-2021) of the International Tobacco Control Japan Surveys among a national cohort of adults who smoke cigarettes, use HTPs and do not use any tobacco products. The sample sizes in the respective surveys were 4615, 4222, 4387 and 4254. Multivariable logistic regression models employing generalised estimating equations estimated the prevalence of observed and self-reported indoor smoking/HTP use in key public venues (restaurants/cafés, bars/pubs and workplaces), smoke-free places, and homes, and smoke-free/HTP aerosol-free home policies (model 1). The models were additionally adjusted for waves 1-4 to estimate the impacts of the HPA (model 2).

Results: The implementation of the HPA significantly reduced observed indoor smoking in bars/pubs (model 1: 82.2% (pre) to 55.5% (post), model 2: p=0.04) but not in restaurants/cafés (model 1: 53.0%-24.9%, model 2: p=0.15) or workplaces (model 1: 35.3%-30.1%, model 2: p=0.62). Observed indoor HTP use was also common postimplementation (restaurants/cafés: 19.6%, bars/pubs: 53.9%, workplaces: 36.4%). The implementation of the HPA was associated with a significant increase in observed HTP use in smoke-free places (model 1: 26.3%-33.3%, model 2: p=0.001) and a suggestive increase in homes without HTP aerosol-free policies among adults who smoke (model 1: 64.0%-77.0%, model 2: p=0.09).

Conclusions: The implementation of the HPA was limited in its effectiveness. Comprehensive regulations with no exemptions are needed in Japan.

Citation

Gravely, S., Smith, T.T., Toll, B.A., Ashley, D.L., Driezen, P., Levy, D.T., Quah, A.C.K., Fong, G.T., Cummings, K.M. (2024). Electronic nicotine delivery system flavors, devices, and brands used by adults in the United States who smoke and formerly smoked in 2022. Preventive Medicine Reports, [Published online Oct 16, doi: doi.org/10.1016/j.pmedr.2024.102905]

Abstract

Objective: This study estimated prevalence of current electronic nicotine delivery systems (ENDS) used by US adults who smoked cigarettes or formerly smoked in 2022 and assessed ENDS flavors, devices, and brands used most often.

Methods: Data are from the 2022 US ITC Smoking and Vaping Survey. Respondents were recruited from a web panel of a nationally representative sample of US adults ages 18+ who smoked, formerly smoked, and/or vaped ENDS. Using weighted data, we estimated prevalence of current vaping among adults who smoke or formerly smoked (N = 2,016). Among the subset who vaped (n = 554), we assessed flavors and devices used most often. Using unweighted data, we assessed the frequency (count) of reported brands used most often.

Results: In 2022, 22.0 % of US adults who smoked or formerly smoked were vaping at least monthly. A significantly higher proportion of adults who formerly smoked and/or were younger (18–39) were vaping than adults who were smoking and/or were older (40+) (both p < 0.001). Tank devices were used most often (34.7 %), followed by disposables (27.4 %), pre-filled pods/cartridges (23.0 %), and refillable pods/cartridges (14.9 %). The five most commonly used flavors were fruit (33.9 %), tobacco (20.1 %), menthol (12.2 %), candy/sweets (10.8 %), and mixed ice flavors (10.0 %). The top 5 brands were JUUL, Smok, Vuse, Geekvape, and Blu.

Conclusions: In 2022, a majority of adults who smoked cigarettes or who had quit smoking used a variety of flavors and devices that go beyond the choices that FDA currently has authorized for sale.

Citation

Hammond, D., Reid, J.L., Burkhalter, R., East, K.A. (2024). Use of disposable e-cigarettes among youth who vape in Canada, England and the United States: Repeat cross-sectional surveys, 2017-2023. Addiction, [Published online Jul 1, doi: 10.1111/add.16596].

Abstract

Aims: To measure changes over time (between 2017 and 2023) in disposable e-cigarette use and popular brands among youth in Canada, England and the United States (US) who vaped.

Design: Nine waves of repeat cross-sectional data from the International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Survey.

Setting: Online surveys conducted in Canada, England and the US between 2017 and 2023.

Participants: Youth aged 16 to 19 years who had vaped in the past 30 days (n=19 710).

Measurements: Usual type (disposable, cartridge/pod, tank) and brand of e-cigarette used; covariates sex at birth, age, race/ethnicity, cigarette smoking status, vaping on less than or equal to 20 of the past 30 days.

Findings: In 2017, the majority of youth who vaped in the past 30 days reported using refillable tank e-cigarettes, whereas disposable e-cigarettes were the least commonly used product type in Canada (10.0%), England (8.6%) and the US (14.4%). Cartridge/pods overtook tank devices in Canada and the US by 2020; however, by 2023, disposables were the leading type of e-cigarette used by youth who vaped in all three countries (Canada = 58.5%; England = 83.2%; US = 67.3%). The shift to disposables occurred among all socio-demographic groups, with few differences by vaping and smoking status. The percentage of youth who vaped that reported ‘no usual’ brand also decreased substantially from 2017 (29% to 42%) to 2023 (11% to 17%). The rise of disposable e-cigarettes appeared to be driven primarily by individual brands in the US (Puff Bar in 2020/2021, Elf Bar in 2022/2023) and England (Elf Bar in 2022/2023).

Conclusions: The e-cigarette market has evolved rapidly with notable shifts in the types of e-cigarettes used by youth who vape in Canada, England and the United States. Although the timing differed across countries, major shifts in device types appear to be driven by individual brands and were often accompanied by increases in vaping prevalence among youth.

Citation

Levy, D.T., Issabakhsh, M., Warner, K., Liber, A.C., Meza, R., Cummings, K.M. (2024). Evaluating trends in cigarette and HTP use in Japan and measurement issues in the National Health and Nutrition Survey. Tobacco Control, 0, 1-5. doi: 10.1136/tc-2023-058526.

Abstract

Introduction: Studies have reported that the rapid rise in heated tobacco product (HTP) sales in Japan accompanied an accelerated decline in cigarette sales. However, these studies do not distinguish whether those who previously smoked cigarettes became dual users with HTPs (smoking fewer cigarettes) or instead switched completely to HTPs. If HTPs present lower health risks than cigarettes, replacing cigarettes with HTPs is more likely to improve public health than cigarette users continuing as dual users.

Methods: To evaluate the role of HTP introduction relative to smoking prevalence, we examine trends in cigarette prevalence as related to trends in HTP use using Japan’s National Health and Nutrition Survey (NHNS) from 2011 to 2019. We develop measures of relative changes in smoking prevalence use by age and gender in the pre-HTP and post-HTP periods. We then analyse prevalence data by year using joinpoint regression to statistically distinguish changes in trend.

Results: Compared with the pre-HTP 2011–2014 period, cigarette prevalence decreased more rapidly during the post-HTP 2014–2017 period, particularly among younger age groups. However, the changing format of NHNS questions limits our ability to determine the impact on smoking prevalence, particularly after 2017.

Conclusions: While suggesting that HTPs helped some people who smoke to quit smoking, this study also shows the difficulties in eliciting accurate survey responses about product use and distinguishing the impact of a potentially harm-reducing product in an environment subject to rapidly evolving patterns of use.

Citation

Le Grande, M., Borland, R., Gravely, S., Cummings, K.M., McNeill, A., Yong, H.H., Gartner, C. (2024). Support for banning sale of smoked tobacco products among adults who smoke: findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2018-2020). Tobacco Control, [Published online 17 Jun, doi: 10.1136/tc-2023-058532].

Abstract

Background: Many people continue to smoke despite strong policies to deter use, thus stronger regulatory measures may be required. In four high-income countries, we examined whether people who smoke would support a total ban on smoked tobacco products under two differing policy scenarios.

Methods: Data were from 14 363 adults (≥18) who smoked cigarettes (≥monthly) and participated in at least one of the 2018, 2020 or 2022 International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England and the USA. In 2018, respondents were asked whether they would support a law that totally bans smoked tobacco if the government provides smoking cessation assistance (Cessation Assistance scenario). In 2020 and 2022, respondents were asked a slightly different question as to whether they would support a law that totally bans smoked tobacco if the government encourages people who smoke to use alternative nicotine products like vaping products and nicotine replacement products instead (substitution scenario). Responses (support vs oppose/don't know) were estimated on weighted data.

Results: Support was greater for the cessation assistance scenario (2018, 36.6%) than the nicotine substitution scenario (2020, 26.9%; 2022, 26.3%, both p<0.0001). In the longitudinal analysis, there was a significant scenario by country interaction effect with lower support in Canada, the USA and Australia under the substitution scenario than in the cessation scenario, but equivalent levels in England under both scenarios. The strongest correlates of support under both scenarios were planning to quit smoking within 6 months, wanting to quit smoking 'a lot' and recent use of nicotine replacement therapy.

Conclusions: Opposition to banning smoked tobacco predominates among people who smoke, but less with a cessation assistance scenario than one encouraging nicotine substitution. Wanting to quit a lot was the strongest indicator of support.

Citation

Yoon, W., Seo, H.G., Lee, S., Lee, E.S., Xu, S.S., Meng, G., Quah, A.C.K., Fong, G.T., Lim, S., Kim, G., Kim, S.Y., Cho, S. (2024). Reasons for using e-cigarettes among adults who smoke: Comparing the findings from the 2016 and 2020 ITC Korea Surveys. Tobacco Control, [Published online 15 Jun, doi: 10.1136/tc-2023-058506].

Abstract

Introduction: Dual use of e-cigarettes and cigarettes is a growing usage pattern in adults, but little is known about the motivations underlying this trend. We investigated the reasons for e-cigarette use among adults who smoke, considering variation in sociodemographic subgroups.

Methods: This repeated cross-sectional study analysed adults who smoked at least weekly and vaped at any frequency. Data were from the International Tobacco Control Korea Surveys conducted in 2016 (n=164) and 2020 (n=1088). Fourteen reasons for e-cigarette use were assessed in both waves. Subgroup analyses were performed by age, sex and educational level.

Results: The top reasons for e-cigarette use in 2020 were curiosity (62.8%), less harmful than smoking (45.4%) and taste (43.2%). Curiosity was the most cited across age, sex and education subgroups. Significant differences were observed in 2020 compared with 2016, with lower percentages in goal-oriented reasons: helping quit smoking (36.3% vs 48.9%; p=0.017), helping cut down smoking (35.3% vs 52.7%; p=0.001), less harmful to others (39.0% vs 54.6%; p=0.003) and more acceptable (31.6% vs 61.2%; p<0.001). By contrast, non-goal-oriented reasons showed higher percentages in 2020, such as curiosity (62.8% vs 27.9%; p<0.001), taste (43.2% vs 22.1%; p<0.001) and enjoyment (26.8% vs 8.6%; p<0.001). In 2020, a majority of adults who smoked and vaped (53.3%) reported no intention to quit or reduce smoking.

Conclusions: E-cigarette use for curiosity and pleasure predominated among adults who smoked. The reasons for dual use in adults have shifted from goal-oriented to non-goal-oriented.

Citation

Kyriakos, C.N., Filippidis, F. T., East, K.A., Reid, J.L., Driezen, P., & Hammond, D. (2024). Use of Menthol Cigarettes and Accessories Among Youth Who Smoked After the Menthol Cigarette Ban in England and Canada, 2021: Implications for Health Equity. Nicotine & Tobacco Research, 26(Supplement_2), S133–S142. doi: 10.1093/ntr/ntad112.

Abstract

Introduction: This study examined menthol cigarette use among youth who smoked, after menthol cigarette bans were implemented in England (May 2020) and Canada (October 2017).

Aims and methods: Cross-sectional data come from 2021 ITC Youth Tobacco and Vaping Survey respondents aged 16-19 who smoked in the past 30 d in England (N = 715) and Canada (N = 419). Adjusted logistic regression models, estimated separately for each country, examined sociodemographic correlates of usually smoking menthol cigarettes (reporting currently most often smoking menthol cigarettes) overall, and by past 30-d use of any menthol accessories (e.g., filters, capsules). Youth reported the cigarette variety they smoked most often, coded as menthol or nonmenthol.

Results: Almost no youth who smoked in the past 30 d reported most often smoking a cigarette variety coded as menthol. However, 34.5% (95% CI: 30.4% to 38.9%) of youth who smoke in England and 30.9% (26.0%-36.3%) in Canada reported usually smoking menthol cigarettes, with greater odds of use among those identifying as black, or other race/ethnicity, respectively, compared to white in England (60.0%, aOR = 3.08, p = .001; 47.4%, aOR = 2.27, p = .011) and Canada (43.6%, aOR = 2.44, p = .046; 51.2%, aOR = 2.92, p = .001). Among those who reported usually smoking menthol cigarettes in England (N = 223) and Canada (N = 108), 71.7% (64.0%-78.2%) and 51.5% (41.1%-61.7%) reported using menthol accessories.

Conclusions: After menthol cigarette bans in England and Canada, approximately one-third of youth who smoked reported usually smoking menthol cigarettes, with disproportionately higher use among those identifying as black and other race/ethnicity. Menthol accessories accounted for most menthol cigarette use. Closing regulatory loopholes is critical to advancing public health equity.

Implications: Use of menthol cigarette accessories (eg, filters, cards, capsules) among youth who smoked was prevalent after implementation of menthol cigarette bans in England and Canada, and there was disproportionately higher use among those who identified as black and any other race/ethnicity. Efforts are therefore required to close regulatory loopholes of menthol cigarette bans. Findings further support countries, such as the United States, proposing menthol cigarette bans which extend coverage to accessories. More comprehensive menthol bans that also restrict accessories are likely to be more effective in reducing flavored tobacco use among young people and in advancing health equity.

Citation

Freitas-Lemos, R., Tegge, A.N., Shevorykin, A., Tomlinson, D.C., Athamneh, L.N., Stein, J.S., Sheffer, C.E., Shields, P.G., Hatsukami, D.K., Bickel, W.K. (2024). Selective reduction of socioeconomic disparities in the experimental tobacco marketplace: Effects of cigarette and e-cigarette flavor restrictions. Nicotine and Tobacco Research, 26(Supplement_2), S103-S111. doi: 10.1093/ntr/ntad070.

Abstract

Introduction: Cigarette smoking accounts for >30% of the socioeconomic gap in life expectancy. Flavored restrictions claim to promote equity; however, no previous studies have compared the effect of cigarette and e-cigarette flavor restrictions among individuals who smoke with lower and higher socioeconomic status (SES).

Aims and Methods: In a between-group within-subject design, individuals with lower (n = 155) and higher (n = 125) SES completed hypothetical purchasing trials in the experimental tobacco marketplace (ETM). Conditions were presented in a 2 × 2 factorial design (cigarette flavors restricted or unrestricted and e-cigarette flavors restricted or unrestricted) with increasing cigarette prices across trials.

Results: Results show (1) SES differences in cigarette, e-cigarette, and NRT purchases under unrestricted policies, with lower SES showing higher cigarette demand and lower e-cigarette and NRT substitution than higher SES, (2) cigarette restrictions decreased cigarette and increased NRT purchases among lower SES, but no significant changes among higher SES, (3) decreased SES differences in cigarette demand under cigarette restrictions, but persistence under e-cigarette restrictions or their combination, (4) persistence of SES differences in e-cigarette purchases when all restrictions were enforced, and (5) waning of SES differences in NRT purchasing under all restrictions.

Conclusions: Flavor restrictions differentially affected individuals based on SES. Within-group comparisons demonstrated restrictions significantly impacted lower SES, but not higher SES. Between-group comparisons showed SES differences in cigarette purchasing decreased under cigarette restrictions, but persisted under e-cigarette-restrictions or their combination. Additionally, SES differences in NRT substitution decreased under flavor restrictions. These findings highlight the utility of the ETM to investigate SES disparities.

Implications: With increasing trends of socioeconomic differences in smoking prevalence and cessation rates, smoking-related health disparities are expected to continue to widen. Restricting menthol flavor in cigarettes while enhancing the availability and affordability of NRT have the potential to alleviate SES disparities in tobacco use, therefore, positively impacting health equity. However, this effect may depend on flavor availability in other tobacco products

Citation

Brose, L.S., Reid, J.L., Robson, D., McNeill, A., & Hammond, D. (2024). Associations between vaping and self-reported respiratory symptoms in young people in Canada, England and the US. BMC Medicine, 22(1):213, 1-11. doi: 10.1186/s12916-024-03428-6.

Abstract

Background: Prevalence of youth nicotine vaping has increased, heightening concerns around negative health effects. This study aimed to compare self-reported respiratory symptoms among youth by vaping behaviours.

Methods: Participants (n = 39,214) aged 16-19 from the 2020 and 2021 International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Surveys (Canada, England, US). Weighted multivariable logistic regression assessed associations between reporting any of five respiratory symptoms in the past week (shortness of breath, wheezing, chest pain, phlegm, cough) and: past 30-day smoking and/or vaping; lifetime/current vaping. Among past-30-day vapers (n = 4644), we assessed associations between symptoms and vaping frequency, use of nicotine salts, usual flavour and device type(s).

Results: Overall, 27.8% reported experiencing any of the five respiratory symptoms. Compared with youth who had only vaped, those who had only smoked had similar odds of symptoms [adjusted odds ratio, OR (95% confidence interval, CI): 0.97 (0.85-1.10)], those who both smoked and vaped had higher odds [1.26 (1.12-1.42)], and those who had done neither, lower odds [0.67 (0.61-0.72)]. Compared with those who had never vaped, past use, experimentation and current regular or occasional use were all associated with higher odds. Reporting usually using nicotine salts was associated with higher odds of symptoms [1.43 (1.22-1.68)] than non-salt but was often uncertain. Compared with tobacco flavour (including with menthol), menthol/mint and sweets flavours were associated with similar odds; fruit [1.44 (1.07-1.93)], multiple [1.76 (1.30-2.39)] and 'other' [2.14 (1.45-3.16)] flavours with higher odds. All device types were associated with similar odds.

Conclusions: Among youth, vaping was associated with increased reporting of past-week respiratory symptoms. Among those who vaped, some flavour types and potentially nicotine salts were associated with respiratory symptoms.

Citation

Borland, R., Le Grande, M.R., Gartner, C., Morphett, K. (2024). Do Australians use the prescription pathway when using nicotine vaping products to quit smoking? International Journal of Drug Policy, 128, doi: 10.1016/j.drugpo.2024. 104460

Abstract

Background: In Australia, nicotine vaping products (NVPs) are only legally available to those with a prescription from a doctor. We investigated the proportion of people using NVPs to quit smoking who had a prescription, and whether this increased following regulatory changes in 2021 that strengthened the prescription requirement.

Methods: Australian data from the 2018, 2020 and 2022 International Tobacco Control (ITC) Project Survey were analysed using GEE models with Poisson regressions to analyze differences between years. Data from participants who reported making a quit attempt in the previous two years and reported use of NVPs on their last quit attempt were included (480 observations across 418 individuals). Participants reported whether they had a prescription for NVPs on their last quit attempt. In 2022, they were also asked whether they sourced their prescription from their usual medical practice.

Results: Among those using NVPs for a quit attempt, use with a prescription increased significantly from 2020 to 2022 (IRR=0.35 (0.17-0.73), p=0.005) but was still low at 16.5% (95% CI 11.4-23.1). In 2022, among the small number who reported getting a prescription for NVPs, 27% reported getting it from their regular practice; the remainder from a specialist online doctor service.

Conclusion: There was a modest increase in obtaining a prescription among those who used NVPs for their last quit attempt after regulations were strengthened, however most NVP use for quitting was without a prescription.