Citation

Hammond, D., Reid, J.L., Burkhalter, R., East, K. (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 1 Jul, 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 ≥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.. 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.

Citation

Lee, S., Xu, S.S., Yan, M., Gravely, S., Quah, A.C.K., Seo, H.G., Lim, S., Cho, S., Kim, Y., Fong, G.T. (2024). Patterns of cigarette, heated tobacco product, and nicotine vaping product use among Korean adults: Findings from the 2020 ITC Korea Survey. Tobacco Induced Diseases, 22(April):63, 1-11. doi: 10.18332/tid/186273.

Abstract

Introduction: Non-combustible nicotine products (NCNPs), such as heated tobacco products (HTPs) and nicotine vaping products (NVPs) have gained a significant nicotine market share in South Korea. This descriptive study examined patterns of regular cigarette and NCNP use among South Korean adults.

Methods: Data were from the 2020 International Tobacco Control Korea Survey and included 4016 adults (aged ≥19 years) in the Republic of Korea who were regularly (at least weekly) using at least one NCNP (NVP/HTP, n=2117) and/or smoked cigarettes (n=3763) at the time of the survey. Weighted descriptive estimates were computed to assess respondents' nicotine product use among all respondents (exclusive, dual, or triple use). Thereafter, we identified sociodemographic characteristics associated with NCNP use (n=2117).

Results: Among Korean adults who were smoking cigarettes, 83.1% (95% CI: 81.6-84.6) did so exclusively, and 16.9% (95% CI: 15.4-18.4) smoked cigarettes and used NCNPs. Among those who used HTPs (n=1877), 14.9% (95% CI: 11.5-18.4) did so exclusively, 59.6% used HTPs and smoked cigarettes (95% CI: 55.4-63.1), 4.2% used HTPs and vaped (95% CI: 11.5-18.4), and 21.6% (95% CI: 18.9-24.2) used all three products. Of adults who used HTPs and smoked cigarettes, 86.6% smoked daily. Among those who vaped (n=865), 13.3% did so exclusively (95% CI: 9.4-17.1), 55.6% (95% CI: 49.6-61.5) vaped and smoked cigarettes, 5.1% (95% CI: 1.7-8.6) used HTPs and vaped, and 26.1% (95% CI: 22.1-30.1) used all three products. Of adults who vaped and smoked cigarettes, 82.4% (95% CI: 77.1-87.7) smoked daily.

Conclusions: Cigarettes remain the most commonly used nicotine product in South Korea, and among adults using heated tobacco and/or vaping products, the majority were also smoking. Research is urgently needed to assess whether adults who are using an NCNP are doing so to quit, or rather to complement their cigarette smoking.

Citation

Driezen, P., Gravely, S., Kasza, K.A., Thompson, M.E., Cummings, K.M., Hyland, A., Fong, G.T. (2024). Prevalence of menthol cigarette use among adults who smoke from the United States by census division and demographic subgroup, 2002-2020: Findings from the International Tobacco Control (ITC) Project. Population Health Metrics, 22(1), 1-14. doi: 10.1186/s12963-024-00326-0.

Abstract

Background: Targeted marketing of menthol cigarettes in the US influences disparities in the prevalence of menthol smoking. There has been no analysis of sub-national data documenting differences in use across demographic subgroups. This study estimated trends in the prevalence of menthol use among adults who smoke in the nine US census divisions by sex, age, and race/ethnicity from 2002 to 2020.

Methods: Data from 12 waves of the US ITC Survey were used to estimate the prevalence of menthol cigarette use across census divisions and demographic subgroups using multilevel regression and poststratification (n = 12,020). Multilevel logistic regression was used to predict the prevalence of menthol cigarette use in 72 cross-classified groups of adults who smoke defined by sex, age, race/ethnicity, and socioeconomic status; division-level effects were fit with a random intercept. Predicted prevalence was weighted by the total number of adults who smoke in each cross-classified group and aggregated to divisions within demographic subgroup. Estimates were validated against the Tobacco Use Supplement to the Current Population Survey (TUS-CPS).

Results: Overall modeled prevalence of menthol cigarette use was similar to TUS-CPS estimates. Prevalence among adults who smoke increased in each division from 2002 to 2020. By 2020, prevalence was highest in the Middle (46.3%) and South Atlantic (42.7%) and lowest in the Pacific (25.9%) and Mountain (24.2%) divisions. Prevalence was higher among adults aged 18-29 (vs. 50+) and females (vs. males). Prevalence among non-Hispanic Black people exceeded 80% in the Middle Atlantic, East North Central, West North Central, and South Atlantic in all years and varied most among Hispanic people in 2020 (Pacific: 26.5%, New England: 55.1%).

Conclusions: Significant geographic variation in the prevalence of menthol cigarette use among adults who smoke suggests the proposed US Food and Drug Administration (FDA) menthol cigarette ban will exert differential public health benefits and challenges across geographic and demographic subgroups.

Citation

Kyriakos, C.N., Erinoso, O., Driezen, P., Thrasher, J.F., Katanoda, K., Quah, A.C.K., Tabuchi, T., Perez, C., Seo, H.G., Kim, S.Y., Amer Nordin, A.S., Mohd Hairi, F., Fong, G.T., Filippidis, F.T. (2024). Prevalence and perceptions of flavour capsule cigarettes among adults who smoke in Brazil, Japan, Republic of Korea, Malaysia, and Mexico: Findings from the ITC Surveys. BMJ Open, 14(4), doi: 10.1136/bmjopen2023-083080.

Abstract

Introduction: The global market of flavour capsule cigarettes (FCCs) has grown significantly over the past decade; however, prevalence data exist for only a few countries. This study examined prevalence and perceptions of FCCs among adults who smoke across five countries.

Methods: Cross-sectional data among adults who smoked cigarettes came from the International Tobacco Control Policy Evaluation Project Surveys-Brazil (2016/2017), Japan (2021), Republic of Korea (2021), Malaysia (2020) and Mexico (2021). FCCs use was measured based on reporting one's usual/current brand or favourite variety has flavour capsule(s). Perceptions of the harmfulness of one's usual brand versus other brands were compared between those who used capsules versus no capsules. Adjusted logistic regression models examined correlates of FCC use.

Results: There were substantial differences in the prevalence of FCC use among adults who smoke across the five countries: Mexico (50.3% in 2021), Republic of Korea (31.8% in 2021), Malaysia (26.5% in 2020), Japan (21.6% in 2021) and Brazil (6.7% in 2016/2017). Correlates of FCC use varied across countries. Capsule use was positively associated with being female in Japan and Mexico, younger age in Japan, Republic of Korea and Malaysia, high education in Brazil, Japan and Mexico, non-daily smoking in Republic of Korea, and having plans to quit in Japan and Republic of Korea. There was no consistent pattern of consumer perceptions of brand harmfulness.

Conclusion: Our study documented the high prevalence of FCCs in some countries, pointing to the need to develop and implement regulatory strategies to control these attractive products.

Citation

Snelling, S., Yong, H.H., Kasza, K.A., Borland, R. (2024). Does alcohol consumption elevate smoking relapse risk of people who used to smoke? Differences by duration of smoking abstinence. Journal of Substance Use and Addiction Treatment, 159(209260), doi: 10.1016/j.josat.2023.209260

Abstract

Background: Past research indicates dual users of tobacco and alcohol find it harder to quit smoking and may be more likely to relapse. This study investigated whether post-quit alcohol use predicted smoking relapse among ex-smokers, and whether this relationship varied by length of smoking abstinence.

Method: The study included 1064 ex-smokers (18+ years) from Canada (n = 340), US (n = 314), England (n = 261), and Australia (n = 149) who participated in the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping Survey, and we conducted analyses using multivariable logistic regression. We assessed alcohol consumption in 2018 using AUDIT-C and coded as never/low, moderate or heavy level and used alcohol consumption to predict smoking status in 2020.

Results: Overall 26 % and 21 % of ex-smokers consumed alcohol at a moderate and heavy level, respectively. Compared to never/low alcohol consumption, risk of smoking relapse among those who consumed alcohol at a moderate level was significantly lower within the first year of abstinence (OR = 0.34, 95 % CI = 0.14–0.81, p = 0.015) but higher thereafter (OR = 2.44, 95 % CI = 1.13–5.23, p = 0.023). The pattern of results was similar for those who consumed alcohol at a heavy level.

Conclusions: Overall, baseline alcohol consumption of ex-smokers did not predict their smoking relapse risk. As expected, risk differed by smoking abstinence duration. However, the pattern was unexpected among the short-term quitters as the subgroup who drank moderately/heavily had lower relapse risk than their counterparts who never drink or at low level, underscoring the need to replicate this unexpected finding

Citation

Mat Noh, M.A., Mohd Hairi, F., Amer Nordin, A.S., Yee, A., Ahmad Tajuddin, N.A., Hasan, S.I., Danaee, M., Kamaludin, I.S., Subramaniyan, M., Pravinassh, R., Kaai, S.C., Driezen, P., Yan, M., Xu, S.S., Quah, A.C.K., Fong, G.T. (2024). Prevalence and reasons for use of heated tobacco products among Malaysian adults who smoked: Findings from the 2020 International Tobacco Control Malaysia Survey. Drug and Alcohol Dependence, 257, 1-8. doi: 10.1016/j.drugalcdep.2024.111131.

Abstract

Introduction: There have been rapid expansions in heated tobacco products (HTPs) outside of Japan and the Republic of Korea. In November 2018, HTPs were first introduced in Malaysia and since then, no studies have been conducted on Malaysians' use of HTPs. This study is the first to examine the prevalence of HTP use and reasons for use among Malaysian adults who smoked cigarettes.

Methods: Data came from the 2020 ITC Malaysia Survey, a web-based survey of a nationally representative sample of adults who smoked (n=1047) aged 18 and older. They were asked on ever heard of, ever used, and currently using HTPs, and their reasons for using HTPs.

Results: Overall, 25.4% (n= 324; 95% CI:22.3%-28.7%) of Malaysians who smoked reported ever used HTPs with 6.7% (n=85; 95% CI:22.3%-28.7%) were using them daily and 8.1% (n=110; 95% CI:6.4% -10.2%) were using HTPs non-daily. Most of them (57.2%) who dual use were of aged 25-39 and 97.3% were males. Among those who smoked daily, almost half (49.3%) were also using HTP daily. Among those who used HTPs daily and non-daily, curiosity (84.2%, 95% CI:78.4%-90.0%), taste (83.2%, 95% CI:77.3%-89.1%), and appealing technology (78.5%, 95% CI:71.3%-85.6%) were the most reported reasons. Among those who used HTPs daily, curiosity was the top reason (87.9%, 95% CI:78.9%-93.4%), while among non-daily, taste good was the top reason (81.9%, 95% CI:71.9%-88.8%).

Conclusions: The very high use of HTPs among Malaysians who smoked requires continued public health surveillance that can inform the regulation of these novel tobacco products.

Citation

Gomes, M.N., Reid, J.L., Rynard, V.L., East, K.A., Goniewicz, M.L., Piper, M.E., Hammond, D. (2024). Comparison of indicators of dependence for vaping and smoking: Trends between 2017 and 2022 among youth in Canada, England, and the United States. Nicotine and Tobacco Research, ntae060, doi: 10.1093/ntr/ntae060.

Abstract

Introduction: The current study sought to examine trends in indicators of dependence for youth vaping and smoking during a period of rapid evolution in the e-cigarette market.

Methods: Data are from repeat cross-sectional online surveys conducted between 2017 and 2022 among youth aged 16-19 in Canada, England, and the USA. Participants were 23,145 respondents who vaped and/or smoked in the past 30 days. Four dependence indicators were assessed for smoking and vaping (perceived addiction, frequent strong urges, time to first use after waking, days used in past month) and two for vaping only (use events per day, E-cigarette Dependence Scale). Regression models examined differences by survey wave and country, adjusting for sex, age, race, and exclusive/dual use.

Results: All six indicators of dependence increased between 2017 and 2022 among youth who vaped in the past 30 days (p<.001 for all). For example, more youth reported strong urges to vape at least most days in 2022 than in 2017 (Canada: 26.5% to 53.4%; England: 25.5% to 45.4%; USA: 31.6% to 50.3%). In 2017, indicators of vaping dependence were substantially lower than for smoking; however, by 2022, youth vaping was associated with a greater number of days used in the past month (Canada, USA), shorter time to first use (all countries), and a higher likelihood of frequent strong urges (Canada, USA) compared to youth smoking.

Conclusions: From 2017 to 2022, indicators of vaping dependence increased substantially. By 2022, vaping dependence indices were comparable to those of smoking.

Implications: Indicators of vaping dependence among youth have increased substantially since 2017 to levels that are comparable to cigarette dependence among youth who smoke. Future research should examine factors underlying the increase in dependence among youth who vape, including changes to the nicotine profile and design of e-cigarette products.

Citation

Gomes, M.N., Reid, J.L., Hammond, D. (2024). The effect of branded versus standardized e-cigarette packaging and device designs: an experimental study of youth interest in vaping products. Public Health, 230, 223-230. doi: 10.1016/j.puhe.2024.02.001.

Abstract

Objectives: Standardized ('plain') packaging is effective in reducing the appeal of cigarettes among young people. This study examined the impact of plain packaging and brand imagery on interest in trying ecigarettes among youth.

Study design: Experimental design.

Methods: Two online experiments were conducted in February 2020 as part of the ITC Youth Tobacco & Vaping Survey, conducted with 13,624 16- to 19-year-olds in Canada, England, and the USA. In the between-group Experiment 1, participants were randomized to view a set of 3 e-cigarette brands, in either their original external packaging ('branded' condition) or standardized olive-green packaging ('standardized' condition), and asked to select the product they would be most interested in trying. The within-group Experiment 2 examined brand imagery directly on devices, including potential differences in appeal among subgroups. Each participant viewed 4 pod-style e-cigarette devices: one 'plain' and 3 in colourful 'skins'. Logistic regression models were conducted to test the effect of condition, adjusting for demographics, smoking and vaping status.

Results: In Experiment 1, participants in the 'standardized' packaging condition were significantly more likely to indicate 'I have no interest in trying any of these products' (72.3%) than those in the 'branded' condition (66.9%, AOR 1.45, 95% CI 1.33-1.59). Experiment 2 results indicated differences in e-cigarette appeal by sex in the selection of male- and female-oriented designs, and by cannabis use for a Rastafarian-themed design.

Conclusions: Brand imagery on e-cigarettes can target products to specific subgroups. Removal of imagery, in the form of standardized packaging, has the potential to reduce interest in trying e-cigarettes among young people.

Citation

Ma, S., Kaareen, A., Park, H., He, Y., Jiang, S., Qiu. Z., Xie, Z., Li, D., Chen, J., O'Connor, R.J., Fong, GT., Shang, C. (2024). How to identify e-cigarette brands available in the United States during 2020-2022: Development and usability study. Journal of Medical Internal Research (JIMR) Formative Research, 8(1), doi: 10.2196/47570.

Background: Prior studies have demonstrated that the e-cigarette market contains a large number of brands. Identifying these existing e-cigarette brands is a key element of market surveillance, which will further assist in policy making and compliance checks.

Objective: To facilitate the surveillance of the diverse product landscape in the e-cigarette market, we constructed a semantic database of e-cigarette brands that have appeared in the US market as of 2020- 2022.

Methods: In order to build the brand database, we searched and compiled e-cigarette brands from a comprehensive list of retail channels and sources, including (1) e-liquid and disposable brands sold in web-based stores, (2) e-cigarette brands sold in brick-and-mortar stores and collected by the Nielsen Retail Scanner Data, (3) e-cigarette brands compiled by Wikipedia, (4) self-reported e-cigarette brands from the 2020 International Tobacco Control Four-Country Smoking and Vaping (ITC 4CV) US survey, and (5) e-cigarette brands on Twitter. We also estimated the top 5 e-cigarette brands by sales volume in brick-and-mortar stores, by the frequency and variety of offerings in web-based shops, and by the frequency of self-reported brands from the 2020 ITC 4CV US survey.

Results: As of 2020-2022, a total of 912 e-cigarette brands have been sold by various retail channels. During 2020-2022, the top 5 brands are JUUL, vuse, njoy, blu, and logic in brick-and-mortar stores; blu, king, monster, twist, and air factory for e-liquids in web-based stores; hyde, pod mesh, suorin, vaporlax, and xtra for disposables sold in web-based stores; and smok, aspire, vaporesso, innokin, and eleaf based on self-reported survey data.

Conclusions: As the US Food and Drug Administration enforces the premarket tobacco market authorization, many e-cigarette brands may become illegal in the US market. In this context, how ecigarette brands evolve and consolidate in different retail channels will be critical for understanding the regulatory impacts on product availability. Our semantic database of e-cigarette brands can serve as a useful tool to monitor product and marketplace development, conduct compliance checks, assess manufacturers' marketing behaviors, and identify regulatory impacts.

Citation

He, Y., Fong, G.T., Cummings, K.M., Hyland, A., Shang, C. (2024). The association between excise taxes and smoking and vaping transitions – Findings from the 2016-2020 ITC United States Surveys. International Journal of Drug Policy, 126, doi: 10.1016/j.drugpo.2024.104372

Abstract

Background: While a growing number of studies examined the effect of e-cigarette (EC) excise taxes on tobacco use behaviors using cross-sectional surveys or sales data, there are currently no studies that evaluate the impact of EC taxes on smoking and vaping transitions.

Methods: Using data from the US arm of the 2016-2020 International Tobacco Control Four Country Smoking and Vaping Survey (ITC 4CV), we employed a multinomial logit model with two-way fixed effects to simultaneously estimate the impacts of cigarette/EC taxes on the change in smoking and vaping frequencies.

Results: Our benchmark model suggests that a 10 % increase in cigarette taxes led to an 11 % reduction in smoking frequencies (p < 0.01), while EC taxes did not have a significant effect on smoking frequencies.

Conclusion: Our findings suggest that increasing cigarette taxes may serve as an effective means of encouraging people who smoke to cut back on smoking or quit smoking. The impact of increasing EC taxes on smoking transitions is less certain at this time.

Citation

Leigh, N.J., Page, M.K., Robinson, D., Heldwein, S.D., O’Connor, R.J., Goniewicz, M.L. (2024). Nicotine humectants, and tobacco-specific nitrosamines (TSNAs) in IQOS heated tobacco products (HTPs): a cross-country study. Toxics, 12(3), 1-10. doi: 10.3390/toxics12030180.

Abstract

Heated Tobacco Products (HTPs) purport to reduce exposure to tobacco-related toxicants compared to combustible cigarettes. This cross-sectional study examined the content of nicotine, two humectants (propylene glycol (PG) and vegetable glycerin (VG)), and four tobacco-specific nitrosamines (TSNAs: NNN, NNK, NAT, and NAB) in the tobacco filler of a popular HTP brand (IQOS). Non-menthol and menthol IQOS sticks were purchased from nine countries between 2017 and 2020 and were classified into two versions (“Bold” and “Light”) using Philip Morris’s flavor descriptors. The average nicotine concentration was 4.7 ± 0.5 mg/stick, and the highest nicotine concentration was found in products from Japan (5.1 ± 0.2 mg/stick). VG was the dominant humectant found in all sticks, with an average concentration of (31.5 ± 2.3 mg/stick). NNN, NNK, and NAT were substantially higher in the “Bold” sticks than the “Light” sticks. Significant differences between countries for TSNAs were also observed: the NAT and NAB contents were the highest in the “Light” products from Canada (192.5 ± 24.1 and 22.9 ± 1.0 ng/stick, respectively); the NNK concentration was the highest in the “Bold” products from Poland (64.8 ± 7.9 ng/stick); and the highest NNN concentrations were observed in the “Bold” products from South Africa (488.9 ± 26.7 ng/stick). As NNN and NNK are known human carcinogens, and as humectants like PG and VG can degrade into toxic carbonyl compounds upon heating, monitoring the concentration of these chemicals in HTPs is important for protecting users’ health and ensuring compliance with regulations.

Citation

Kang, H., Yoon, W., Seo, H.G., Lee, S., Lim, S., Kim, G., Kim, S.Y., Xu, S.S., Yan, M., Quah, A.C.K., Chung-Hall, J., Craig, L.V., Gartner, C., Fong, G.T., Cho, S. (2024). Public support for tobacco endgame policies in South Korea: Findings from the 2020 International Tobacco Control Korea Survey. Tobacco Control, 10.1136/tc-2023-058454.

Abstract

Background: Strong public support can increase the likelihood of adopting tobacco control policies. We assessed support for six commercial tobacco endgame policies in South Korea: limiting the nicotine in cigarettes, banning all additives in cigarettes, restricting the number of places where cigarettes are sold, and banning the manufacture and sales of cigarettes (unconditionally, with the provision of cessation support and with alternative tobacco products available).

Methods: Data were obtained from 4740 adults who completed the 2020 International Tobacco Control Korea Survey. Participants were categorised based on their nicotine use: (1) did not use any products, (2) vaped and/or used heated tobacco products (HTPs) but did not smoke cigarettes, (3) smoked cigarettes only and (4) smoked cigarettes and vaped and/or used HTPs. Attitudes towards the policies were classified as supportive, undecided or opposed. Weighted multinomial logistic regression models assessed support levels according to nicotine use.

Results: Support was highest for limiting the nicotine content in cigarettes (68.4%; 95% CI 64.6% to 72.3%) and restricting the number of retailers (68.1%; 95% CI 64.5% to 71.7%), and lowest for banning cigarette sales if alternative products are made available (45.0%; 95% CI 40.9% to 49.1%). People who did not use any products were most likely to support endgame policies, except for banning cigarette sales with alternatives available. The proportion of undecided participants exceeded 10% (range 13%–25%) for all policies.

Conclusion: There is a strong public support for tobacco endgame policies in South Korea. Further research should prioritise the development of strategies to ensure the effective implementation of highly supported policies.

Citation

East, K.A., Taylor, E., Simonavicius, E., Reid, J.L., Burkhalter, R., McNeill, A., Hammond, D. (2024). Use of 'Elf Bar' among youth and young adults who currently vape in England: cross-sectional associations with demographics, dependence indicators, and reasons for use. Addiction, 1-9. doi: 10.1111/add.16463.

Abstract

Background and aims: Elf Bar is currently the leading e-cigarette (vape) brand in Great Britain. This study examined youth and young adults’ use of Elf Bar, socio-demographic characteristics and dependence indicators and reasons for use over other brands.

Design: Cross-sectional survey.

Setting and participants: Online 2022 International Tobacco Control Project Youth Tobacco and Vaping Survey (N = 1355 16-29-year-olds in England who had vaped in the past 30 days).

Measurements: Currently using Elf Bar most often (versus other brands) and associations with: sociodemographics, owning a vaping device, dependence indicators and reasons for brand choice. Logistic regressions were used.

Findings: Among 16–29-year-olds who vaped in the past 30?days, 48.4% (n?=?732) reported Elf Bar as the brand they used most often. Among 16–17-year-olds, 40.7% used Elf Bar over other brands; this was lower than among 18–19-year-olds (60.1%) and 20–29-year-olds (47.4%) (P?=?0.002). Using Elf Bar over other brands was higher among those who were female (55.2 versus 41.5% male), identified as White (53.1 versus 30.9% other/mixed), a student (54.5 versus 44.3% not), did not own a vape (66.7 versus 44.4% who did) and typically vaped 5–8 hours after waking (62.7 versus 36.8% within 5 min) (P?=?0.044). Most who vaped but had never smoked used Elf Bar (64.3%), although use did not significantly differ from those who currently (45.4%), formerly (42.3%) or experimentally (48.7%) smoked (all P?=?0.060). Popular reasons for choosing Elf Bar over other brands were better flavour/taste (47.5%), less expensive (28.7%), easier to get (26.1%), smoother to inhale (24.0%) and popularity (23.1%). ‘Better for quitting smoking’ (10.1%) was least frequently selected reason for choosing Elf Bar over other brands.

Conclusions: Elf Bar brand e-cigarettes were used by approximately half of 16–29-year-olds who vaped in England in 2022 and was mainly chosen over other brands for subjective responses (e.g. flavour/taste), rather than for quitting smoking.

Citation

Holdroyd, I., Puntambekar, N.K., Driezen, P., Gravely, S., Quah, A.C.K., Xu, S.S., Gupta, P.C., Fong, G.T., Pednekar, M.S. (2024). An evaluation of the effectiveness of the Indian Government's Policies to Strengthen Health Warning Labels on Smokeless Tobacco Products: Findings from the 2010-2019 Tobacco Control Project India Surveys. Tobacco Control, doi: 10.1136/tc-2023-058281.

Abstract

Background: Smokeless tobacco (SLT) packaging in India had a single symbolic (a scorpion) health warning label (HWL) in 2009 covering 40% of the front surface. In 2011, it was replaced with four pictorial images. In 2016, HWLs were enlarged to 85% on the front and back. This study aimed to assess the effectiveness of the old (symbolic and smaller images) and larger HWLs.

Methods: Data were from the Tobacco Control Project India Survey and included respondents who used SLT in Wave 1 (2010–2011, n=5911), Wave 2 (2012–2013, n=5613) and Wave 3 (2018–2019, n=5636). Using a repeated-measures design, weighted logistic regression models assessed whether there were changes in seven HWL effectiveness measures within the domains of awareness, salience, cognitive and behavioural responses. A cohort design was employed to test whether HWL effectiveness in Waves 1 and 2 was associated with quitting SLT in Waves 2 and 3, respectively.

Results: The 2011 HWL revision did not result in any significant changes in HWL effectiveness. There was no significant change in HWL awareness and salience after larger HWLs were introduced in 2016, but respondents were more likely to consider SLT health risks (Wave 2=17.9%, Wave 3=33.6%, p<0.001) and quitting SLT (Wave 2=18.9%, Wave 3=36.5, p<0.001). There was no change in HWLs stopping SLT use (Wave 2=36.6%, Wave 3=35.2%, p=0.829); however, respondents were more likely to avoid looking at HWLs (Wave 2=10.1%, Wave 3=40.2%, p<0.001). Effectiveness of older, symbolic and smaller pictorial HWLs was not associated with quitting SLT.

Discussion: There was no significant change in HWL effectiveness following the revision from a symbolic to a pictorial image, but enlarging pictorial images resulted in some improved cognitive and behavioural effects. Results suggested wear-out of HWL salience and that the effectiveness of warnings depends on both their design and time since implementation.

Citation

Kamaludin, I.S., Lim, S.H., Yee, A., Kaai, S.C., Yan, M., Danaee, M., Amer Nordin, A.S., Mohd Hairi, F., Ahmad Tajuddin, N.A., Hasan, S.I., Quah, A.C.K., Fong, G.T. (2024). Intentions to quit, quit attempts, and the use of cessation aids among Malaysian adult smokers: Findings from the 2020 ITC Malaysia Survey. Asia-Pacific Journal of Public Health, 36(1), 69-77. doi: 10.1177/10105395231220465

Abstract

This study examined quitting behavior and use of cessation aids (CAs) among Malaysian adult smokers aged ≥18 years (n = 1,047). Data were from the 2020 International Tobacco Control (ITC) Malaysia Survey were analyzed. A total of 79.9% of Malaysian smokers attempted to quit in the past 12 months and 85.2% intended to quit in the next 6 months. The most common CAs were e-cigarettes (ECs) (61.4%), medication/nicotine replacement therapies (NRTs; 51.0%), and printed materials (36.7%); the least common CA was infoline/quitline services (8.1%). Multivariable logistic regression analysis was performed to examine the association between sociodemographic variables and CAs use. Male smokers were more likely to use infoline/quitline services (adjusted odds ratio [aOR] = 3.27; P = .034). Malay smokers were more likely to use infoline/quitline services (aOR = 3.36; P = .002), ECs (aOR = 1.90; P = .004), printed materials (aOR = 1.79; P = .009), and in-person services (aOR = 1.75; P = .043). Most Malaysian smokers wanted to quit smoking. Furthermore, ECs were the most popular CAs, highlighting the need to assess the effectiveness of ECs for quitting smoking in Malaysia.

Citation

He, Y., Liber, A.C., Driezen, P., Thompson, M.E., Levy, D.T., Fong, G.T., Cummings, K.M., Shang, C. (2024). How do users compare the costs between nicotine vaping products and cigarettes? Findings from the 2016-2020 International Tobacco Control United States surveys. Addiction, 119(5), 885-897. doi: 10.1111/add.16425.

Abstract

Background and aims: Nicotine vaping products (NVPs) can potentially help adult tobacco users quit smoking. This study evaluated how adult consumers compare the costs between NVPs and cigarettes.

Method: We used data from the US arm of the 2016-2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) surveys to perform a multinomial logit model with two-way fixed effects to measure how perceived cost comparisons are associated with NVP and cigarette taxes, use patterns, NVP device types and individual sociodemographic factors.

Results: Higher cigarette taxes are associated with a greater likelihood of perceiving NVPs and cigarettes as costing the same for the overall population and among people who exclusively smoke, and a lower likelihood of perceiving NVPs as more expensive among people who exclusively vape, compared with lower cigarette taxes. Pre-filled cartridge and tank users are more likely to perceive NVPs as less expensive than cigarettes, compared with people who use other types of NVPs. The associations between taxes and perceived cost comparison were more pronounced among males, younger and low-income populations.

Conclusions: Higher cigarette taxes are associated with perceived financial incentives for nicotine vaping products (NVPs) over cigarettes, whereas NVP taxes are not associated with perceived cost comparison between NVPs and cigarettes.

Keywords: cigarette; cost comparison; device type; excise tax; nicotine vaping product (NVP); use frequency.

Citation

Zheng, C., Feng, Z., Pearce, J. (2024). A longitudinal analysis of the impact of the local tobacco retail availability and neighbourhood deprivation on male smoking behaviours in Shanghai, China. Journal of Health and Place, 85, 103171. doi: 10.1016/j.healthplace.2023.103171.

Abstract

Some evidence from Western high-income countries suggests local tobacco retail availability and neighbourhood deprivation may influence smoking behaviours. However, this assertion has not been considered in China, where 44% of males continue to smoke. Data were analysed from Chinese males (n = 2054) who participated in Waves 3–5 (2009–2015) of the International Tobacco Control (ITC) China Survey by linking information on tobacco retail availability (estimated through population weighted Kernel Density of tobacco retailers in 2019) and neighbourhood deprivation (calculated as a composite score derived from the 2010 Chinese census) across Shanghai. Generalised Estimating Equation models were fitted to examine the impacts of local tobacco availability and neighbourhood deprivation on smoking behaviours (current smoking versus current non-smoking, quitting versus current smoking, longer durations of smoking abstinence versus current smoking) using the longitudinal data. Examining the impacts separately, participants living in neighbourhoods with greater availability and higher levels of deprivation were less likely to maintain longer durations of smoking abstinence in both unadjusted and adjusted models. Neighbourhood deprivation, but not availability, was found to be associated with higher odds of being a current smoker. Examining the impacts jointly, neighbourhood deprivation was still positively associated with current smoking and negatively associated with longer durations of smoking abstinence, but the negative association between availability and longer durations of smoking abstinence disappeared. The findings offer some evidence that greater tobacco retail availability and deprivation are obstacles on prolonged smoking cessation among males in Shanghai, China. Policymakers should consider small-area level place-based restrictions in China, such as reducing the availability of tobacco, as part of a comprehensive tobacco control strategy aimed at addressing the high prevalence of smoking.

Citation

East, K.A., Taylor, E., Simonavicius, E., Nottage, M., Burkhalter, R., Brose, L.S., Wackowski, O.A., Liber, A.C., McNeill, A., Hammond, D. (2024). Noticing education campaigns or public health messages about vaping among youth in the US, Canada, and England from 2018 to 2022. Health Education Research, 39(1), 12-28. doi: 10.1093/her/cyad044.

Abstract

Public health campaigns have the potential to correct vaping misperceptions. However, campaigns highlighting vaping harms to youth may increase misperceptions that vaping is equally/more harmful than smoking. Vaping campaigns have been implemented in the United States and Canada since 2018 and in England since 2017 but with differing focus: youth vaping prevention (United States/Canada) and smoking cessation (England). We therefore examined country differences and trends in noticing vaping campaigns among youth and, using 2022 data only, perceived valence of campaigns and associations with harm perceptions. Seven repeated cross-sectional surveys of 16–19 year-olds in United States, Canada and England (2018–2022, n = 92 339). Over half of youth reported noticing vaping campaigns, and noticing increased from August 2018 to February 2020 (United States: 55.2% to 74.6%, AOR = 1.21, 95% CI = 1.18-1.24; Canada: 52.6% to 64.5%, AOR = 1.13, 1.11-1.16; England: 48.0% to 53.0%, AOR = 1.05, 1.02-1.08) before decreasing (Canada) or plateauing (England/United States) to August 2022. Increases were most pronounced in the United States, then Canada. Noticing was most common on websites/social media, school and television/radio. In 2022 only, most campaigns were perceived to negatively portray vaping and this was associated with accurately perceiving vaping as less harmful than smoking among youth who exclusively vaped (AOR = 1.46, 1.09-1.97). Consistent with implementation of youth vaping prevention campaigns in the United States and Canada, most youth reported noticing vaping campaigns/messages, and most were perceived to negatively portray vaping.