Abstract

BACKGROUND: Although evidence shows that co-use of cigarettes and cannabis is common, there is little research examining if co-use patterns vary depending on the regulatory environment for cannabis. This study examined patterns of co-use and perceptions of relative harm among cigarette smokers in four countries with different histories, and at different stages of cannabis legalization.

METHODS: Data are from the 2018 International Tobacco Control 4CV Survey and included 10035 adult cigarette smokers from Canada, United States (US), Australia, and England. At the time of the survey, Canada and the US had relatively more permissive cannabis regulations compared to Australia and England.

RESULTS: Among this sample of 10035 cigarette smokers, Canada had the highest rate of cannabis co-use in the last 12 months (36.3%), followed by the US (29.1%), England (21.6%), and Australia (21.4%). Among past 12 month co-users (n = 3134), the US (40.2%) and Canada (35.2%) had the highest rates of daily cannabis use, followed by smokers in England (26.3%) and Australia (21.7%); Australian co-users had the highest rate of infrequent (<monthly) cannabis use. The highest proportion of co-users who smoked daily and used cannabis daily was in the US (34.8%), followed by Canada (30.6%), England (25.8%), and Australia (22.7%). More co-users in the US (78.3%) and Canada (73.6%) perceived smoked cannabis to be less harmful than cigarettes than in Australia (65.5%) and England (60.8%). The majority of co-users who used cannabis in the last 30 days had smoked it (92.3%), with those in England more likely to smoke cannabis (95.7%) compared to Canada (88.6%); there were no other differences between countries (US: 92.0%, Australia: 93.0%). Co-users in England (90.4%) and Australia (86.0%) were more likely to mix tobacco with cannabis than co-users in Canada (38.5%) and the US (22.3%).

CONCLUSION: Patterns of tobacco and cannabis co-use differed between countries. Smokers in Canada and the US had higher rates of co-use, daily cannabis use, dual-daily use of both cannabis and cigarettes, and were more likely to perceive smoked cannabis as less harmful than cigarettes compared to England and Australia.

Abstract

This paper describes the methods of the Wave 1 (2018) International Tobacco Control (ITC) Japan Survey. The respondents were adults aged 20 years and older in one of four user groups: (1) cigarette-only smokers who smoked at least monthly and used heated tobacco products (HTPs) not at all or less than weekly, (2) HTP-only users who used HTPs at least weekly and smoked cigarettes not at all or less than monthly, (3) cigarette-HTP dual users who smoked at least monthly and used HTPs at least weekly, and (4) non-users who had never smoked or who smoked less than monthly and used HTPs less than weekly. Eligible respondents were recruited by a commercial survey firm from its online panel. Respondents were allocated proportionally to sample strata based on demographic, geographic, and user type specifications benchmarked to a national reference. Survey weights, accounting for smoking/HTP use status, sex, age, education, and geography, were calibrated to benchmarks from a nationally representative survey in Japan. Response rate was 45.1% and cooperation rate was 96.3%. The total sample size was 4615 (3288 cigarette smokers, 164 exclusive HTP users, 549 cigarette-HTP dual users, and 614 non-users). The 2018 ITC Japan Survey sampling design and survey data collection methods will allow analyses to examine prospectively the use of cigarettes and HTPs in Japan and factors associated with the use of both products and of transitions between them.

Abstract

In Japan, the tobacco industry promotes heated tobacco products (HTPs) as a reduced-risk tobacco product. This study examines: (1) smokers’ harm perceptions of HTPs relative to combustible cigarettes; (2) differences in relative harm perceptions between exclusive smokers and smokers who use HTPs (concurrent users) and between concurrent users based on frequency of product use; and (3) if smokers who were exposed to HTP advertising hold beliefs that are consistent with marketing messages of lower harmfulness. This cross-sectional study included 2614 adult exclusive cigarette smokers and 986 concurrent users who reported their perceptions of harmfulness of HTPs compared to cigarettes, as well as their exposure to HTP advertising in the last six months. Among all smokers, 47.5% perceive that HTPs are less harmful than cigarettes, 24.6% perceive HTPs to be equally as harmful, 1.8% perceive HTPs as more harmful, and 26.1% did not know. Concurrent users are more likely than exclusive smokers to believe that HTPs are less harmful (62.1% versus 43.8%, p < 0.0001) and less likely to report that they did not know (14.3% versus 29.4%, p < 0.0001). Frequent HTP users are more likely than infrequent users to believe that HTPs are less harmful (71.7% versus 57.1%, p ≤ 0.001). Believing that HTPs are less harmful than cigarettes was associated with noticing HTP advertising on TV (p = 0.0005), in newspapers/magazines (p = 0.0001), on posters/billboards (p < 0.0001), in stores where tobacco (p < 0.0001) or where HTPs (p < 0.0001) are sold, on social media (p < 0.0001), or in bars/pubs (p = 0.04). HTP users were significantly more likely than non-HTP users to believe that HTPs are less harmful than cigarettes, with this belief being more prominent among frequent users. Smokers who have been exposed to HTP advertising were more likely to perceive HTPs as less harmful than cigarettes.

Abstract

Use of heated tobacco products (HTPs) among current smokers is becoming increasingly popular in Japan. This study aims to compare characteristics and tobacco-related behaviors among concurrent users of HTPs and combustible cigarettes (n = 644) with exclusive smokers (n = 3194) or exclusive HTP users (n = 164). The secondary aim was to explore heterogeneity within concurrent use subgroups. Data were from Wave 1 of the ITC Japan Survey, a nationally representative web survey conducted from February to March 2018. Concurrent cigarette-HTP users were younger and wealthier than exclusive smokers. However, there were no difference in the frequency of smoking, number of cigarettes per day, and smoking cessation behaviors between the two groups, suggesting that HTPs reinforce nicotine dependence. Compared to exclusive HTP users, concurrent cigarette-HTP users reported higher frequency of non-daily HTP use, and lower number of tobacco-containing inserts per day. Almost all concurrent cigarette-HTP users smoked every day (93.9%); 48.4% both smoked and used HTPs daily (dual daily users, n = 396), while 45.5% were daily smokers and non-daily HTP users (predominant smokers, n = 213). Concurrent user subgroups differed from each other on age, tobacco use behaviors, and quit intention. Alongside heterogeneity between concurrent and exclusive product users, differences across concurrent use subgroups highlight the importance of considering frequency of use in characterizing poly-tobacco users.

Abstract

Background: The EUREST-PLUS ITC Europe surveys aim to evaluate the impact of the European Union’s Tobacco Products Directive (EU TPD) implementation within the context of the WHO FCTC. This article describes the methodology of the 2016 (Wave 1) and 2018 (Wave 2) International Tobacco Control 6 European (6E) Country Survey in Germany, Greece, Hungary, Poland, Romania and Spain; the England arm of the 2016 (Wave 1) and 2018 (Wave 2) ITC 4 Country Smoking and Vaping (4CV) Survey; and the 2016 (Wave 10) and 2017 (Wave 11) ITC Netherlands (NL) Survey. All three ITC surveys covering a total of eight countries are prospective cohort studies with nationally representative samples of smokers.

Methods: In the three surveys across the eight countries, the recruited respondents were cigarette smokers who smoked at least monthly, and were aged 18 and older. At each survey wave, eligible cohort members from the previous waves were retained, regardless of smoking status, and dropouts were replaced by a replenishment sample.

Results: Retention rates between the two waves of the ITC 6E Survey by country were 70.5% for Germany, 41.3% for Greece, 35.7% for Hungary, 45.6% for Poland, 54.4% for Romania and 71.3% for Spain. The retention rate for England between ITC 4CV1 and ITC 4CV2 was 39.1%; the retention rates for the ITC Netherlands Survey were 76.6% at Wave 10 (2016) and 80.9% at Wave 11 (2017).

Conclusion: The ITC sampling design and data collection methods in these three ITC surveys allow analyses to examine prospectively the impact of policy environment changes on the use of cigarettes and other tobacco products in each country, to make comparisons across the eight countries.

Abstract

Health warnings are an effective strategy for communicating the health harms of smoking, encouraging quitting, and preventing smoking initiation. This study examines the effectiveness of existing text-only health warnings, identifies key predictors of warning effectiveness, and assesses support for pictorial warnings in Japan. Data are from the 2018 International Tobacco Control (ITC) Japan Survey, a cohort survey of adult cigarette smokers (n = 3306), dual users of cigarettes and heated tobacco products (n = 555), and non-cigarette smokers (n = 823). Weighted multivariable logistic regression models were used to assess predictors of warning effectiveness and support for pictorial warnings. Overall, 15.6% of respondents noticed warnings, and 7.9% read or looked closely at warnings. Overall, 10.3% of smokers and dual users said the warnings stopped them from having a cigarette, and 7.2% avoided warnings. Overall, 27.5% of respondents said the warnings made them think about health risks of smoking, but only 2.7% of smokers and dual users said the warnings made them more likely to quit. Overall, 57.6% of respondents supported pictorial warnings. The weak effectiveness of Japan’s text-only warnings is consistent with that in other countries with similar warnings. There is majority support for pictorial warnings in Japan, although the level of support is lower than in other countries.

Abstract

Comprehensive smoke-free policies such as those called for by the WHO FCTC are the only way to protect the public effectively from the harms of secondhand smoke (SHS), yet Japan has been slow to implement this important health measure. This study examines baseline levels of smoking and SHS exposure in public places and support for smoking bans in Japan prior to the implementation of the 2018 national smoke-free law. Data are from the International Tobacco Control (ITC) Japan Wave 1 Survey (Feb–Mar 2018), a web survey of adult cigarette smokers, heated tobacco product users, dual users, and non-users (total N = 4684). Measures included prevalence of smoking (whether respondents noticed people smoking inside restaurants and bars at their last visit, and workplaces in the last month), and support for complete smoking bans in these venues. Smoking prevalence in each venue was high overall in 2018 (49% of workplaces, 55% of restaurants, and 83% of bars), even higher than in China, the country with the greatest toll of SHS. Support for complete smoking bans was very high overall (81% for workplaces, 78% for restaurants, and 65% for bars). Non-users were less likely to be exposed to SHS and had higher support for smoking bans than tobacco users. These findings point to the ineffectiveness of partial smoke-free laws in Japan and reinforce the call for comprehensive smoke-free laws, which even smokers would support at higher levels than in many other ITC countries.

Abstract

Background: Our study evaluated the short-term impact of introducing European Union’s tobacco pictorial health warnings (PHWs).

Methods: Longitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N = 3,487) and analyzed using Generalized Estimating Equations.

Results: Between both time-points, only Dutch smokers showed increases in noticing health warnings (β = 0.712, p < 0.001), self-reports of health warnings leading to a cognitive response such as thinking about smoking health-risks (SHRs) (OR = 1.834, p < 0.001), knowledge about SHRs (β = 0.369, p < 0.001), and avoiding health warnings (OR = 9.869, p < 0.001). However, Dutch smokers showed no changes in attitude towards smoking (β = 0.035, p = 0.518), intention to quit smoking (OR = 0.791, p = 0.157), self-efficacy to quit smoking (β=-0.072, p = 0.286), or reporting that health warnings helped them to resist having a cigarette (OR = 1.091, p = 0.714).

Conclusions: Results suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.

Abstract

The effectiveness of tax increase in reducing tobacco use depends on the extent to which the industry passes on the tax to consumers. Evidence suggests that tobacco industry may absorb or raise the price more than the tax increase depending on the price segment of tobacco products. In this paper, we examined the industry's pricing strategy by price segment of the cigarette market in Bangladesh by observing the deviation between the market retail prices (MRP) of cigarettes faced by consumers and government recommended retail prices (RRP) used as tax base in a four-tiered ad valorem tax structure. The RRPs by brands were collected from government sources. The MRPs by brands were collected by the International Tobacco Control Bangladesh Wave 3 Survey 2011-12 and Wave 4 Survey 2014-15. Applying linear regression to the deviation of MRP from RRP by price tiers, we found MRPs were higher than RRPs for higher-price brands allowing extra profit margin from the high end while lowering the relative price of and expanding demand for cheaper brands. Bangladesh cigarette industry adopted a differential pricing strategy that undermined the intended effect of tax policy change in reducing cigarette consumption and improving public health. This pricing strategy was supported by the tiered excise tax structure which should be replaced with a uniform specific excise system. In the face of growing cigarette affordability, it is crucial that the specific tax be increased routinely by an amount that induces cigarette price increases large enough to make cigarettes less affordable over time.

Abstract

Background: The availability of contraband cigarettes provides incentives for price-sensitive smokers to reduce their monetary costs of smoking. The objectives of this study were to examine whether Canadian smokers’ geographic proximity to First Nations reserves and attempts to quit smoking influenced the likelihood of purchasing lower-cost cigarettes from reserves.

Methods: Data were from the International Tobacco Control (ITC) Canada Survey, a prospective survey of Canadian adult smokers conducted from 2002 to 2014 using telephone and online interviewing methods. Analysis was restricted to smokers from Ontario (n=2105) and Quebec (n=1427) participating in at least one survey wave. Smokers’ postal codes were used to calculate distance to the nearest reserve. Weighted logistic generalised estimating equations (GEE) regression examined the linear relationship between distance and the log odds of last purchasing cigarettes on reserve in each province. GEE models also examined the relationship between past-year quit attempts and the log odds of on-reserve purchasing.

Results: Controlling for other factors, from 2002–2014, smokers from Ontario who lived 10 km closer to reserves than otherwise similar smokers had significantly higher odds of last purchasing on reserve (OR ranged from 1.16 to 1.65). Distance had little effect on smokers’ purchasing behaviours in Quebec. Moreover, in Ontario, for every 10 km increase in distance, smokers who did not try to quit had significantly greater odds of purchasing from a reserve than smokers who tried to quit (p=0.002).

Conclusion: In order for tobacco taxation policies to achieve their maximal benefit, governments must limit potential sources of lower-cost cigarettes. Collaborative governance arrangements can ensure tobacco products sold on reserve to non-Indigenous people are appropriately taxed while allowing First Nations communities to keep the revenue generated by such taxes.

Abstract

Background: Our study evaluated the short-term impact of introducing European Union’s tobacco pictorial health warnings (PHWs).

Methods: Longitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N = 3,487) and analyzed using Generalized Estimating Equations.

Results: Between both time-points, only Dutch smokers showed increases in noticing health warnings (β = 0.712, p < 0.001), self-reports of health warnings leading to a cognitive response such as thinking about smoking health-risks (SHRs) (OR = 1.834, p < 0.001), knowledge about SHRs (β = 0.369, p < 0.001), and avoiding health warnings (OR = 9.869, p < 0.001). However, Dutch smokers showed no changes in attitude towards smoking (β = 0.035, p = 0.518), intention to quit smoking (OR = 0.791, p = 0.157), self-efficacy to quit smoking (β=-0.072, p = 0.286), or reporting that health warnings helped them to resist having a cigarette (OR = 1.091, p = 0.714).

Conclusions: Results suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.

Abstract

Objectives: To examine trends in smoking prevalence in key venues (workplaces, restaurants, bars) and in public support for comprehensive smoke-free laws, with comparisons between cities and rural areas in China.

Design: Data are from Waves 3–5 (2009–2015) of the International Tobacco Control (ITC) China Survey, a cohort survey of smokers and non-smokers. Logistic regression analyses employing generalised estimating equations assessed changes in smoking prevalence and support for smoke-free laws over time; specific tests assessed whether partial smoking bans implemented in three cities between Waves 3 and 4 had greater impact.

Setting: Face-to-face surveys were conducted in seven cities (Beijing, Changsha, Guangzhou, Kunming, Shanghai, Shenyang and Yinchuan) and five rural areas (Changzhi, Huzhou, Tongren, Yichun and Xining).

Participants: In each survey location at each wave, a representative sample of approximately 800 smokers and 200 non-smokers (aged 18+) were selected using a multistage cluster sampling design.

Main outcome measures: Prevalence of smoking (whether respondents noticed smoking inside restaurants, bars and workplaces); smoking rules inside these venues; and support for complete smoking bans in these venues.

Results: Although smoking prevalence decreased and support increased over time, neither trend was greater in cities that implemented partial smoke-free laws. Smoking was higher in rural than urban workplaces (62% vs 44%, p<0.01), but was equally high in all restaurants and bars. There were generally no differences in secondhand smoke (SHS) exposure between smokers and non-smokers except in rural workplaces (74% vs 58%, p<0.05). Support for comprehensive bans was equally high across locations.

Conclusions: Partial laws have had no effect on reducing SHS in China. There is an urgent need for comprehensive smoke-free laws to protect the public from exposure to deadly tobacco smoke in both urban and rural areas. The high support among Chinese smokers for such a law demonstrates that public support is not a barrier for action.

Abstract

Introduction: This study aimed to systematically examine whether having health conditions or concerns related to smoking are associated with quitting activities among smokers across four western countries.

Methods: Data came from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey conducted in Australia, Canada, England and US. We asked smokers and recent quitters (n=11838) whether they had a medical diagnosis for heart disease, cancer, chronic lung disease, depression, anxiety, alcohol problems, diabetes, severe obesity and chronic pain (nine conditions), and whether they believed smoking had harmed/would harm their health, along with questions on quitting activities.

Results: General concerns about smoking harming health and all specific health conditions, except for alcohol problems, were positively associated with quit attempts, but the relationships between health conditions and other quitting measures (being abstinent, planning to quit, use of quitting medications) were less consistent. Positive associations between conditions and use of quitting medications were only significant for depression, anxiety and chronic pain (adjusted odds ratios ranged from 1.4 to 1.5). There was a general tendency to report lower self-efficacy for quitting among those with the health conditions.

Conclusions: While those with smoking related conditions are somewhat more aware of the links to their smoking, and are largely taking more action, the extent of this is lower than one might reasonably expect. Enhanced awareness campaigns are needed and health professionals need to do more to use health conditions to motivate quit attempts and to ensure they are made with the most effective forms of help.

Abstract

Although heated tobacco products (HTPs) have become increasingly popular in Japan, little is known about whether these emerging tobacco products are being used within indoor public spaces. Nationally representative data were obtained prior to implementation of a comprehensive smoke-free law in Japan as part of Wave 1 of the International Tobacco Control Japan Survey (February–March 2018). We estimated the weighted prevalence of HTP use within indoor public spaces among tobacco users and compared these to estimates for combustible cigarettes (CCs). Overall, 15.6% of current tobacco users in Japan declared that they used HTPs within indoor public spaces. Any HTP use within indoor public spaces was significantly lower than any CC use (80.1% vs. 96.7%). Dual HTP + CC users reported using CCs more frequently than using HTPs within indoor public spaces (97.7% vs. 76.0%). In conclusion, HTP use is less common than CC use within indoor public spaces. Findings of this study can inform the development of targeted smoke-free policies to benefit public health.

Abstract

Heated tobacco products (HTPs), such as IQOS, glo, and Ploom TECH, with a variety of flavored tobacco-containing inserts, have reportedly achieved a significant market share in Japan. We analyzed data from Wave 1 of the ITC Japan Survey, a nationally representative web survey conducted in February to March 2018 among 4684 adult participants to estimate the prevalence of HTP use, describe characteristics of HTP users, and explore user preferences for HTP device and flavor. The overall prevalence of monthly HTP use was 2.7% (1.7% daily use). Virtually all HTP users were current cigarette smokers (67.8%) or former smokers (25.0%); only 1.0% of HTP users were never smokers. Among HTP users, IQOS was the most frequently reported brand used (64.5%), and menthol was the most common flavor reported (41.5%). IQOS was used more by younger respondents and those who reported daily use, while Ploom TECH was more popular among older respondents and non-daily HTP users. This is one of the first non-industry funded studies to explore the use of HTPs in Japan.

Abstract

Introduction: The relationship between work loss and smoking has not been studied extensively, and underlying factors are often not examined. The aim of this study was to test two hypotheses. First, work loss is associated with greater intention to quit and more likelihood of smoking cessation, and this relationship is moderated by a decrease in income. Second, work loss is associated with lower quit intention and lower rates of smoking cessation, and this relationship is moderated by an increase in psychological distress.

Methods: We used pooled data from three countries participating in the ITC Project: France, Germany and the Netherlands (n=2712). We measured unemployment, income and psychological distress at two consecutive survey waves, and calculated changes between survey waves. We first conducted multiple logistic regression analyses to examine the association between work loss and smoking cessation behavior. Next, we added income decrease and psychological distress increase to the models. Finally, we added interaction terms of work loss by income decrease and work loss by distress increase to the model.

Results: Work loss was not associated with quit intention, quit attempts, and quit success. When income decrease and psychological distress increase were added to the model, we found a positive association between distress increase and quit attempts. The interactions, however, were not statistically significant.

Conclusions: Our results indicate that smokers who become unemployed and face a decrease in income are not less likely to quit smoking than smokers who are employed.

Abstract

In 2016, the Netherlands was required to introduce new European Union (EU)’s (pictorial) tobacco health warnings. Our objective was to describe the pathways through which the new EU tobacco health warnings may influence quit attempts and smoking cessation among Dutch smokers. Longitudinal data from 2016 and 2017 from the International Tobacco Control (ITC) Netherlands Survey were used. Smokers who participated in both surveys were included (N = 1017). Structural equation modeling was applied to examine the hypothesized pathways. Health warning salience was positively associated with more health worries (β = 0.301, p < 0.001) and a more positive attitude towards quitting (β = 0.180, p < 0.001), which, in turn, were associated with a stronger quit intention (health worries: β = 0.304, p < 0.001; attitude: β = 0.340, p < 0.001). Quit intention was a strong predictor of quit attempts (β = 0.336, p = 0.001). Health warning salience was also associated with stronger perceived social norms towards quitting (β = 0.166, p < 0.001), which directly predicted quit attempts (β = 0.141, p = 0.048). Quit attempts were positively associated with smoking cessation (β = 0.453, p = 0.043). Based on these findings, we posit that the effect of the EU’s tobacco health warnings on quit attempts and smoking cessation is mediated by increased health worries and a more positive attitude and perceived social norms towards quitting. Making tobacco health warnings more salient (e.g., by using plain packaging) may increase their potential to stimulate quitting among smokers.

Abstract

Background: The 2018 National Academies of Sciences, Engineering, and Medicine Report found substantial evidence that electronic cigarette use (vaping) by youth is strongly associated with an increased risk of ever using cigarettes (smoking) and moderately associated with progressing to more established smoking. However, the Report also noted that recent increases in vaping have been associated with declining rates of youth smoking. This paper examines the temporal relationship between vaping and youth smoking using multiple data sets to explore the question of whether vaping promotes smoking initiation in the USA.

Methods: Using publicly available, nationally representative data on smoking and vaping among youth and young adults, we conducted a trend line analysis of deviations from long-term trends in smoking starting from when vaping became more prevalent.

Results: There was a substantial increase in youth vaping prevalence beginning in about 2014. Time trend analyses showed that the decline in past 30-day smoking prevalence accelerated by two to four times after 2014. Indicators of more established smoking rates, including the proportion of daily smokers among past 30-day smokers, also decreased more rapidly as vaping became more prevalent.

Conclusions: The inverse relationship between vaping and smoking was robust across different data sets for both youth and young adults and for current and more established smoking. While trying electronic cigarettes may causally increase smoking among some youth, the aggregate effect at the population level appears to be negligible given the reduction in smoking initiation during the period of vaping’s ascendance.

Abstract

Aims: To examine whether norms towards nicotine vaping product (NVP) use varied between Australia, Canada, England and the United States and by socio‐demographics, smoking and NVP status.

Design: Cross‐sectional data from the 2016 ITC Four Country Smoking and Vaping Survey.

Setting: Four countries with distinct regulatory policies relating to the sale and advertising of NVPs: Australia (most restrictive), Canada (restrictive), England and the United States (least restrictive).

Participants: A total of 10900 adult (age 18+) current smokers, former smokers, or at least weekly NVP users. Respondents were from Australia (n = 1366), Canada (n = 3309), England (n = 3835) and the United States (n = 2390).

Measurements: Questions permitted the categorization of respondents as current smokers, former smokers, NVP users and socio‐demographic categories (sex, age, country, ethnicity, income and education). Further questions were asked regarding the frequency of exposure to NVPs in public, whether they had a partner or close friends who vaped and whether they believed society or those considered important to them approved of NVPs.

Findings: Adjusting for relevant covariates, compared with Australian respondents, those in England, Canada and the United States were more likely to report frequent exposure to NVPs in public (83.1%, 57.3% and 48.3%, respectively, compared to 19.8% in Australia; P < 0.0001), having a partner who vaped (13.8%, 7.1% and 7.7%, respectively, compared to 2.1% in Australia; P < 0.0001) and having close friend(s) who vaped (31.7%, 25.3%, 20.9%, respectively, compared to 10.0% in Australia; P < 0.0001). Compared with Australian respondents, respondents from England were more likely to report that society (27.6% compared to 12.3% in Australia; P < 0.0001) and people important to them approved of NVP use (28.9% compared to 14.3% in Australia; P < 0.0001).

Conclusions: Norms towards nicotine vaping product (NVP) use appear to vary among countries with different regulatory contexts regarding sales and advertising.

No abstract is available.

Abstract

Aims: To examine rules about smoking and vaping in the home in relation to beliefs about the relative harm of second-hand vapor (SHV) compared with second-hand smoke (SHS) in four countries: Canada, United States, England and Australia.

Design: Data were available from 12 294 adults (18+) who participated in the 2016 (wave 1) International Tobacco Control Four Country Smoking and Vaping (ITC 4CV1) Survey.

Participants: All participants were current or recent former adult smokers.

Measurements: Data were analyzed by weighted logistic regression on rules about smoking and vaping in the home; odds ratios and 95% confidence intervals were reported, adjusted for demographic and behavioral variables.

Findings: Of all respondents, 37.4% allowed smoking inside their home. Among a subset who were current vapers (n = 6135), 60.4% allowed vaping in their homes. After controlling for demographic and behavioral characteristics, beliefs about the harm of SHV compared with SHS was not associated with allowing smoking in the home, but was associated with allowing vaping in the home [odds ratio (OR) = 2.86 in Canada, OR = 1.82 in the United States and OR = 1.68 in England]. Characteristics that were associated with rules about vaping inside the home included daily vaping (OR = 2.95, 2.04-4.26; OR = 7.00, 4.12-11.87; OR = 5.50, 3.40-8.88; OR = 7.78, 1.90-31.80), living with a spouse who vapes (OR = 2.48, 1.54-3.98; OR = 2.69, 1.42-5.11; OR = 4.67, 2.74-7.95; OR = 21.82, 2.16-220.9) and living with children aged under 18 years (OR = 0.50, 0.37-0.68; OR = 0.89, 0.48-1.65; OR = 0.76, 0.53-1.09; OR = 0.26, = 0.11-0.61) in Canada, the United States, England and Australia, respectively. Similar characteristics were associated with rules about smoking inside the home.

Conclusions: Among current and former smokers in 2016 in Canada, the United States, England and Australia, 37.4% allowed smoking in the home; 60.4% of current vapers allowed vaping. Both concurrent users and exclusive vapers were more likely to allow vaping than smoking inside the home. Allowing vaping inside the home was correlated with the belief that second-hand vapor is less harmful than second-hand smoke.

Abstract

Background and Aims: The regulatory environment for nicotine vaping products (NVPs) varies widely across countries and this will probably affect the devices used, nicotine content and usage, and hence the ability of NVPs to substitute for cigarettes. We aimed to describe the types of NVPs used by current vapers in four countries with varying regulatory and enforcement approaches toward the marketing and sale of NVPs.

Methods: Data are from wave 1 (July–November 2016) of the ITC Four Country Smoking and Vaping Survey (4CV1), conducted among a cohort of current and former smokers, and current NVP users (n = 5147 adults; ≥ 18 years) in Australia (AU), Canada (CA), England (EN) and the United States (US) reporting either current daily, weekly or occasional NVP use. Devices were described by type, brand, voltage variability and refill capacity. Refill solutions were described by flavour and nicotine content. Descriptive statistics and bivariate analyses were conducted on the overall sample and stratified by country. A multinomial logistic regression examined factors associated with device preference across the whole sample.

Results: The types of NVPs used differed by pattern of use and country. Exclusive, daily vapers were more likely to use refillable pen‐shaped devices [odds ratio (OR) = 10.0] or refillable box‐shaped devices (OR = 5.4) than disposable cigalike devices, when compared with other (non‐daily/dual) users. Nearly all respondents reported using flavoured NVPs, fruit (28.3%) being the most common flavour. Refillable devices were the most popular: refillable box‐shaped devices were more commonly reported by vapers in AU (36.8%) and US (31.4%), whereas in EN (47.4%) and CA (29.7%), vapers more often reported using refillable pen‐style devices. Most users also reported that their products contained nicotine, even in CA (87.8%) and AU (91.2%), where vaping products containing nicotine were technically illegal.

Conclusions: In Australia, Canada, England and the United States in 2016, refillable nicotine vaping products were the most common type of nicotine vaping products used by daily vapers. Most daily vapers reported using flavoured e‐liquids/refills (with variance across countries) and most reported using products that contain nicotine, even where vaping products with nicotine were banned.

Abstract

Background and Aims: It has been proposed that many smokers switch to vaping because their nicotine addiction makes this their only viable route out of smoking. We compared indicators of prior and current cigarette smoking dependence and of relapse in former smokers who were daily users of nicotine vaping products (‘vapers’) or who were not vaping at the time of survey (‘non‐vapers’).

Design: Cross‐sectional survey‐based comparison between vaping and non‐vaping former smokers, including a weighted logistic regression of vaping status onto predictor variables, adjusting for covariates specified below.

Setting: United States, Canada, Australia and England.

Participants: A total of 1070 people aged 18+ years from the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Wave 1 Survey who reported having ever been daily smokers but who stopped less than 2 years ago and who were currently vapers or non‐vapers.

Measurements: Dependent variable was current vaping status. Predictor variables were self‐reported: (1) smoking within 5 minutes of waking and usual daily cigarette consumption, both assessed retrospectively; (2) current perceived addiction to smoking, urges to smoke and confidence in staying quit. Covariates: country, sample sources, sex, age group, ethnicity, income, education, current nicotine replacement therapy use and time since quitting.

Findings: Vapers were more likely than non‐vapers to report: (1) having smoked within 5 minutes of waking [34.3 versus 15.9%, adjusted odds ratio (aOR) = 3.74, 95% confidence interval (CI) = 1.99, 7.03), χ2 = 16.92, P < 0.001]; having smoked > 10 cigarettes/day (74.4 versus 47.2%, aOR = 4.39, 95% CI = 2.22, 8.68), χ2 = 18.18, P < 0.001); (2) perceiving themselves to be still very addicted to smoking (41.3 versus 26.2%, aOR = 2.89, 95% CI = 1.58, 5.30, χ2 = 11.87, P < 0.001) and feeling extremely confident about staying quit (62.1 versus 36.6%, aOR = 3.22, 95% CI = 1.86, 5.59, χ2 = 17.36, P < 0.001). Vapers were not more likely to report any urges to smoke than non‐vapers (27.7 versus 38.8%, aOR = 0.86, 95% CI = 0.44, 1.65, χ2 = 0.21, P = 0.643).

Conclusions: While former smokers who currently vape nicotine daily report higher levels of cigarette smoking dependence pre‐ and post‐cessation compared with former smokers who are current non‐vapers, they report greater confidence in staying quit and similar strength of urges to smoke.

Abstract

Introduction: This study characterises smoking and cessation related behaviours among menthol and other flavoured cigarette users in Europe prior to the implementation of the European Tobacco Products Directive (TPD) ban on the sale of flavoured cigarettes.

Methods: An analysis of cross-sectional data from the 2016 EUREST-PLUS ITC Europe Surveys was conducted among a sample of 10760 adult smokers from eight European Union Member States. Respondents were classified as menthol, other flavoured, unflavoured, or no usual flavour cigarette users and compared on smoking and cessation behaviours and characteristics. Data were analysed in SPSS Complex Samples Package using bivariate and multivariate regression analyses adjusted for sociodemographic characteristics, dependence, and country.

Results: In bivariate analyses, cigarette flavour was significantly associated with all outcomes (p<0.001). After adjusting for sociodemographic characteristics, these associations attenuated but remained significant and in the same direction for dependence, self-efficacy, plans to quit, past quit attempts, and ever e-cigarette use. In fully adjusted models, compared to smokers of non-flavoured cigarettes, menthol smokers were less likely to smoke daily (AOR=0.47, 95% CI: 0.32–0.71), smoke within 30 min of waking (0.52,0.43–0.64), consider themselves addicted (0.74,0.59–0.94), and more likely to have ever used e-cigarettes (1.26,1.00–1.57); other flavoured cigarette smokers were less likely to smoke daily (0.33,0.15–0.77), and have higher self-efficacy (1.82,1.20–2.77); no usual flavour smokers were less likely to smoke daily (0.34,0.22–0.51), smoke within 30 min of waking (0.66,0.55–0.80), consider themselves addicted (0.65,0.52–0.78), have ever made a quit attempt (0.69,0.58– 0.84), have ever used e-cigarettes (0.66,0.54–0.82), and had higher self-efficacy (1.46,1.19–1.80).

Conclusions: Smokers of different cigarette flavours in Europe differ on smoking and cessation characteristics. The lower dependence of menthol cigarette smokers could lead to greater success rates if quit attempts are made, however cross-country differences in smoking behaviours and quitting intentions could lead to the TPD ban on cigarette flavours having differential impact if not accompanied by additional measures, such as smoking cessation support.

Abstract

Objective: To assess trends in daily smokers' social norms and opinions of smoking between 2002 and 2015 in Canada, the United States, the United Kingdom, and Australia.

Method: Data were from wave 1 (2002) to wave 9 (2013–2015) of the longitudinal International Tobacco Control Four Country Survey (Canada, the United States, the United Kingdom, Australia), involving 23 831 adult daily smokers. Generalized estimating equation logistic regression models, adjusted for demographics and survey design effects, assessed associations of wave and country with outcomes: (A) over half of five closest friends smoke, (B) agreeing that people important to you believe you should not smoke, (C) agreeing that society disapproves of smoking, and (D) negative opinion of smoking.

Results: Between 2002 and 2015, adjusting for covariates, (A) over half of five closest friends smoke did not change (56% vs. 55%; adjusted odds ratio [AOR] = 0.95 [95% Confidence Interval = 0.85–1.07]), (B) agreeing that people important to you believe you should not smoke generally decreased (89% vs. 82%; AOR = 0.54 [0.46–0.64]) despite an increase around 2006–2007, (C) agreeing that society disapproves of smoking increased between 2002 and 2006–2007 (83% vs. 87%; AOR = 1.38 [1.24–1.54]) then decreased until 2013–2015 (78%; AOR = 0.74 [0.63–0.88]), and (D) negative opinion of smoking decreased between 2002 and 2010–2011 (54% vs. 49%; AOR = 0.83 [0.75–0.91]) despite an increase around 2005–2006 and at the final wave (2013–2015). Except friend smoking, Canada had the greatest, and the United Kingdom the lowest, antismoking social norms and opinions.

Conclusions: Except friend smoking and opinion of smoking, daily smokers' social norms became less antismoking between 2002 and 2015 despite increases around 2006–2007. Several potential explanations are discussed yet remain undetermined.

Implications: Increasingly comprehensive tobacco control policies alongside decreasing smoking prevalence in Canada, the United States, the United Kingdom, and Australia have led to the assumption that smoking has become denormalized in these countries. Absent from the literature is any formal assessment of social norms towards smoking over time. Contrary to our hypotheses, this study found that the injunctive social norms of daily smokers became less antismoking between 2002 and 2015, despite increases around 2006–2007. There was no change over time in the proportion of daily smokers who report that over half of their five closest friends smoke.