Citation

Licht, A.S., Hyland, A., O’Connor, R.J., Chaloupka, F., Borland, R., Fong, G.T., Nargis, N., Cummings, K.M. (2011). How do price minimizing behaviors impact smoking cessation? Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(5), 1671-1691.

Abstract

This paper examines how price minimizing behaviors impact efforts to stop smoking. Data on 4,988 participants from the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey who were smokers at baseline (wave 5) and interviewed at a 1 year follow-up were used. We examined whether price minimizing behaviors at baseline predicted: (1) cessation, (2) quit attempts, and (3) successful quit attempts at one year follow up using multivariate logistic regression modeling. A subset analysis included 3,387 participants who were current smokers at waves 5 and 6 and were followed through wave 7 to explore effects of changing purchase patterns on cessation. Statistical tests for interaction were performed to examine the joint effect of SES and price/tax avoidance behaviors on cessation outcomes. Smokers who engaged in any price/tax avoidance behaviors were 28% less likely to report cessation. Persons using low/untaxed sources were less likely to quit at follow up, those purchasing cartons were less likely to make quit attempts and quit, and those using discount cigarettes were less likely to succeed, conditional on making attempts. Respondents who utilized multiple behaviors simultaneously were less likely to make quit attempts and to succeed. SES did not modify the effects of price minimizing behaviors on cessation outcomes. The data from this paper indicate that the availability of lower priced cigarette alternatives may attenuate public health efforts aimed at to reduce reducing smoking prevalence through price and tax increases among all SES groups.

Citation

Kasza, K.A., Hyland, A., Brown, A., Siahpush, M., Yong, H.H., McNeill, A., Li, L., Cummings, K.M. (2011). The effectiveness of tobacco marketing regulations on reducing smokers' exposure to advertising and promotion: Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(2), 321-340.

Abstract

Exposure to tobacco product marketing promotes the initiation, continuation, and reuptake of cigarette smoking and as a result the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) has called upon member Parties to enact comprehensive bans on tobacco advertising and promotion. This study examines the immediate and long term effectiveness of advertising restrictions enacted in different countries on exposure to different forms of product marketing, and examines differences in exposure across different socioeconomic status (SES) groups. Nationally representative data from the United Kingdom, Canada, Australia, and the United States, collected from adult smokers between 2002 and 2008 using the International Tobacco Control Four Country Survey (ITC-4), were used in this study (N = 21,615). In light of the specific marketing regulation changes that occurred during the course of this study period, changes in awareness of tobacco marketing via various channels were assessed for each country, and for different SES groups within countries. Tobacco marketing regulations, once implemented, were associated with significant reductions in smokers’ reported awareness of prosmoking cues, and the observed reductions were greatest immediately following the enactment of regulations. Changes in reported awareness were generally the same across different SES groups, although some exceptions were noted. While tobacco marketing regulations have been effective in reducing exposure to certain types of product marketing there still remain gaps, especially with regard to in-store marketing and price promotions.

Citation

Licht, A.S., Hyland, A., O’Connor, R.J., Chaloupka, F., Borland, R., Fong, G.T., Nargis, N., Cummings, K.M. (2011). Socio-economic variation in price minimizing behaviors: Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(1), 234-252.

Abstract

This paper examines how socio-economic status (SES) modifies how smokers adjust to changes in the price of tobacco products through utilization of multiple price minimizing techniques. Data come from the International Tobacco Control Policy Evaluation (ITC) Four Country Survey, nationally representative samples of adult smokers and includes respondents from Canada, the United States, the United Kingdom and Australia. Cross-sectional analyses were completed among 8,243 respondents (7,038 current smokers) from the survey wave conducted between October 2006 and February 2007. Analyses examined predictors of purchasing from low/untaxed sources, using discount cigarettes or roll-your-own (RYO) tobacco, purchasing cigarettes in cartons, and engaging in high levels of price and tax avoidance at last purchase. All analyses tested for interactions with SES and were weighted to account for changing and under-represented demographics. Relatively high levels of price and tax avoidance behaviors were present; 8% reported buying from low or untaxed source; 36% used discount or generic brands, 13.5% used RYO tobacco, 29% reported purchasing cartons, and 63% reported using at least one of these high price avoidance behaviors. Respondents categorized as having low SES were approximately 26% less likely to report using low or untaxed sources and 43% less likely to purchase tobacco by the carton. However, respondents with low SES were 85% more likely to report using discount brands/RYO compared to participants with higher SES. Overall, lower SES smokers were 25% more likely to engage in at least one or more tax avoidance behaviors compared to their higher SES counterparts. Price and tax avoidance behaviors are relatively common among smokers of all SES strata, but strategies differed with higher SES groups more likely to report traveling to a low-tax location to avoid paying higher prices, purchase duty free tobacco, and purchase by cartons instead of packs all of which were less commonly reported by low SES smokers. Because of the strategies lower SES respondents are more likely to use, reducing price differentials between discount and premium brands may have a greater impact on them, potentially increasing the likelihood of quitting.

Citation

King, B., Hyland, A., Borland, R., McNeill, A., Cummings, K.M. (2011). Socioeconomic variation in the prevalence, introduction, retention, and removal of smoke-free policies among smokers: Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(2), 411-434.

Abstract

Introduction: Exposure to secondhand smoke causes premature death and disease in non-smokers and indoor smoke-free policies have become increasingly prevalent worldwide. Although socioeconomic disparities have been documented in tobacco use and cessation, the association between socioeconomic status (SES) and smoke-free policies is less well studied.

Methods: Data were obtained from the 2006 and 2007 Waves of the International Tobacco Control Four Country Survey (ITC-4), a prospective study of nationally representative samples of smokers in Canada, the United States, the United Kingdom, and Australia. Telephone interviews were administered to 8,245 current and former adult smokers from October 2006 to February 2007. Between September 2007 and February 2008, 5,866 respondents were re-interviewed. Self-reported education and annual household income were used to create SES tertiles. Outcomes included the presence, introduction, and removal of smoke-free policies in homes, worksites, bars, and restaurants.

Results: Smokers with high SES had increased odds of both having [OR: 1.54, 95% CI: 1.27–2.87] and introducing [OR: 1.49, 95% CI: 1.04–2.13] a total ban on smoking in the home compared to low SES smokers. Continuing smokers with high SES also had decreased odds of removing a total ban [OR: 0.44, 95% CI: 0.26–0.73]. No consistent association was observed between SES and the presence or introduction of bans in worksites, bars, or restaurants.

Conclusions: The presence, introduction, and retention of smoke-free homes increases with increasing SES, but no consistent socioeconomic variation exists in the presence or introduction of total smoking bans in worksites, bars, or restaurants. Opportunities exist to reduce SES disparities in smoke-free homes, while the lack of socioeconomic differences in public workplace, bar, and restaurant smoke-free policies suggest these measures are now equitably distributed in these four countries.

Citation

Wakefield, M.A., Spittal, M.J., Yong, H.H., Durkin, S.J., Borland, R. (2011). Effects of mass media campaign exposure intensity and durability on quit attempts in a population-based cohort study. Health Education Research, 26(6), 988-997.

Abstract

Objective: To assess the extent to which intensity and timing of televised anti-smoking advertising emphasizing the serious harms of smoking influences quit attempts.

Methods: Using advertising gross rating points (GRPs), we estimated exposure to tobacco control and nicotine replacement therapy (NRT) advertising in the 3, 4-6, 7-9 and 10-12 months prior to follow-up of a replenished cohort of 3037 Australian smokers during 2002-08. Using generalized estimating equations, we related the intensity and timing of advertising exposure from each source to the likelihood of making a quit attempt in the 3 months prior to follow-up.

Results: Tobacco control advertising in the 3-month period prior to follow-up, but not in more distant past periods, was related to a higher likelihood of making a quit attempt. Each 1000 GRP increase per quarter was associated with an 11% increase in making a quit attempt [odds ratio (OR) = 1.11, 95% confidence interval (CI) 1.03-1.19, P = 0.009)]. NRT advertising was unrelated to quit attempts.

Conclusions: Tobacco control advertising emphasizing the serious harms of smoking is associated with short-term increases in the likelihood of smokers making a quit attempt. Repeated cycles of higher intensity tobacco control media campaigns are needed to sustain high levels of quit attempts.

Citation

Zhang, J.Y., Borland, R., Coghill, K., Petrovic-Lazarevic, S., Young, D., Yeh, C.H., Bedingfield, S. (2011). Evaluating the effect of health warnings in influencing Australian smokers' psychosocial and quitting behaviours using fuzzy causal network. Expert Systems with Applications, 38(6), 6430-6438.

Abstract

This paper explores the application of fuzzy causal networks (FCNs) to evaluating effect of health warnings in influencing Australian smokers’ psychosocial and quitting behaviour. The sample data used in this study are selected from the International Tobacco Control Policy Evaluation Survey project. Our research findings have demonstrated that new health warnings implemented in Australia have obvious impacts on smokers’ psychosocial and quitting behaviours. FCN is a useful framework to investigate such impacts that overcome the limitation of using traditional statistical techniques, such as linear regression and logistics regression, to analyse non-linear data.

Citation

Hitchman, S.C., Fong, G.T., Zanna, M.P., Hyland, A., Bansal-Travers, M. (2011). Support and correlates of support for banning smoking in cars with children: Findings from the ITC Four Country Survey. European Journal of Public Health, 21(3), 360-365.

Abstract

Background: Since 2006, banning smoking in cars with children has become a rapidly growing tobacco control policy. However, to date, there have been few studies examining support and correlates of support for car smoking bans, and none of the existing studies have been international in nature. We conducted such a study among smokers in four countries.

Methods: 6716 adult current smokers from the 2007 Wave of the International Tobacco Control Four Country Survey, a nationally representative, longitudinal cohort telephone survey of smokers in the USA, Canada, UK and Australia. Controlling for demographics, heaviness of smoking, smoking health knowledge/beliefs and quit intentions, we compared support and correlates of support for banning smoking in cars with children across the four countries.

Results: The majority of smokers supported banning smoking in cars with children. Support was highest in Australia (83%), followed by the UK (75%) and Canada (74%); support was lower—but still high—in the USA (60%). Support was highest among smokers who: had stronger quit intentions, were lighter smokers, had lower education, had no children in the home, believed that cigarette smoke is dangerous to non-smokers and could cause asthma in children, and were concerned about modelling smoking to children.

Conclusions: These findings indicate that a majority of smokers in the four countries support banning smoking in cars with children, and lend support to banning smoking in cars with children. Additionally, they suggest that support may be increased by educating smokers about the dangers of cigarette smoke exposure.

Citation

Balmford, J., Borland, R., Hammond, D., Cummings, K.M. (2011). Adherence to and reasons for premature discontinuation from stop-smoking medications: Data from the ITC Four-Country Survey. Nicotine & Tobacco Research, 13(2), 94-102.

Abstract

Introduction: Nicotine replacement therapies (NRTs) have been demonstrated to be effective in clinical trials but may have lower efficacy when purchased over-the-counter (OTC). Premature discontinuation and insufficient dosing have been offered as possible explanations. The aims are to (a) investigate the prevalence of and reasons for premature discontinuation of stop-smoking medications (including prescription only) and (b) how these differ by type, duration of use, and source (prescription or OTC).

Methods: The sample includes 1,219 smokers or recent quitters who had used medication in the last year (80.5% NRT, 19.5% prescription only). Data were from Waves 5 and 6 of the International Tobacco Control (ITC) Four-Country Survey.

Results: Most of the sample (69.1%) discontinued medication use prematurely. This was more common among NRT users (71.4%) than in users of bupropion and varenicline (59.6%). OTC NRT users were particularly likely to discontinue (76.3%). Relapse back to smoking was the most common reason for discontinuation of medication reported by 41.6% of respondents. Side effects (18.3%) and believing that the medication was no longer needed (17.1%) were also commonly reported. Of those who completed treatment, 37.9% achieved 6-month continuous abstinence compared with 15.6% who discontinued prematurely. Notably, 65.6% who discontinued because they believed the medication had worked were abstinent.

Conclusions: Premature discontinuation of stop-smoking medications is common but is not a plausible reason for poorer quit outcomes for most people. Encouraging persistence of medication use after relapse or in the face of minor side effects may help increase long-term cessation outcomes.

Citation

Kennedy, R.D., Spafford, M., Parkinson, C., Fong, G.T. (2011). Knowledge about the relationship between smoking and blindness in Canada, the United States, the United Kingdom, and Australia: Results from the International Tobacco Control Four-Country Project. Optometry, 82(5), 310-317.

Abstract

Purpose: Smoking is causally associated with certain prevalent visually impairing eye diseases, including age-related macular degeneration and cataract. Studies have found that people are afraid of ‘‘going blind’’ and may be motivated to quit smoking if they know that vision loss is associated with smoking behavior.

Methods: A random-digit dialed telephone survey was used to measure health knowledge of adult smokers in Canada (n=2,765), the United States (n=3,178), the United Kingdom (n=2,767), and Australia (n=2,623) as part of the International Tobacco Control Four-Country Project.

Results: A low proportion of smokers from Canada (13.0%), the United States (9.5%), and the United Kingdom (9.7%) believed that smoking can cause blindness. In contrast, 47.2% of Australian smokers believed that smoking causes blindness. Australia was the only country during the sampling period to have national awareness campaigns about smoking and its effects on eye health.

Conclusion: These findings point to the need across countries to educate the public on this important consequence of smoking. There is an opportunity for the public health and eye health communities to work to educate the public about the impacts smoking has on eye health to improve quit rates and help discourage people from starting to smoke.

Citation

Thrasher, J.F., Quah, A.C.K., Dominick, G., Borland, R., Driezen, P., Awang, R., Omar, M., Hosking, W., Sirirassamee, B., Boado Martinez, M. (2011). Using cognitive interviewing and behavioral coding to determine measurement equivalence across linguistic and cultural groups: An example from the International Tobacco Control Policy Evaluation Project. Field Methods, 23(4), 439-460.

Abstract

This study examined and compared results from two questionnaire pretesting methods (i.e., behavioral coding and cognitive interviewing [CI]) to assess systematic measurement bias in survey questions for adult smokers across six countries (United States, Australia, Uruguay, Mexico, Malaysia, and Thailand). Protocol development and translation involved multiple bilingual partners in each linguistic/cultural group. The study was conducted with convenience samples of 20 adult smokers in each country. Behavioral coding and CI methods produced similar conclusions regarding measurement bias for some questions; however, CI was more likely to identify potential response errors than behavioral coding. Coordinated qualitative pretesting of survey questions (or postsurvey evaluation) is feasible across cultural groups and can provide important information on comprehension and comparability. The CI appears to be a more robust technique than behavioral coding, although combinations of the two might be even better.

Citation

Borland, R., Cooper, J., McNeill, A., O’Connor, R.J., Cummings, K.M. (2011). Trends in beliefs about the harmfulness and use of stop-smoking medications and smokeless tobacco products among cigarettes smokers: Findings from the ITC Four-Country Survey. Harm Reduction Journal, 8(1), 21-31.

Abstract

Background: Evidence shows that smokers are generally misinformed about the relative harmfulness of nicotine, and smokeless forms of nicotine delivery in relation to smoked tobacco. This study explores changing trends in the beliefs about the harmfulness and use of stop smoking medications and smokeless tobacco in adult smokers in four countries where public education and access to alternative forms of nicotine is varied (Canada, the US, the UK and Australia).

Methods: Data are from seven waves of the ITC-4 country study conducted between 2002 and 2009 with adult smokers from Canada, the US, the UK and Australia. For the purposes of this study, data were collected from 21,207 current smokers. Using generalised estimating equations to control for multiple response sets, multivariate models were tested to look for main effects of country, and trends across time, controlling for demographic variables.

Results: Knowledge remained low in all countries, although UK smokers tended to be better informed. There was a small but significant improvement across time in the UK, but mixed effects in the other three countries. At the final wave, between 37.5% (US) and 61.4% (UK) reported that NRT is a lot less harmful than cigarettes. In Canada and the US, where smokeless tobacco is marketed, only around one in six believed some smokeless tobacco products could be less harmful than cigarettes.

Conclusions: Many smokers continue to be misinformed about the relative safety of nicotine and alternatives to smoked tobacco, especially in the US and Canada. Concerted efforts to educate UK smokers have probably improved their knowledge. Further research is required to assess whether misinformation deters smokers from appropriate use of alternative forms of nicotine.

Citation

Cooper, J., Borland, R., Yong, H.H. (2011). Australian smokers increasingly use help to quit, but number of attempts remains stable: Findings from the International Tobacco Control Study 2002-09. Australian and New Zealand Journal of Public Health, 35(4), 368-376.

Abstract

Objective: To assess interest in quitting smoking and quitting activity, and the use of pharmacotherapy and behavioural cessation support, among Australian smokers between 2002 and 2009.

Methods: Data were taken from 3303 daily smokers taking part in a minimum of two consecutive waves of the International Tobacco Control Four Country Survey. Using weighted data to control for sampling and attrition, we explored any effects due to age, sex, whether living in a metropolitan or regional area, and nicotine dependence.

Results: Around 40% of smokers reported trying to quit and, of these, about 23% remained abstinent for at least one month when surveyed. Low socioeconomic smokers were less likely to be interested in quitting and less likely to make a quit attempt. Reported use of prescription medication to quit smoking rose sharply at the last wave with the addition of varenicline to the pharmaceutical benefits scheme. Among those who tried, use of help rose gradually from 37% in 2002 to almost 59% in 2009 (including 52% using pharmacotherapy and 15% using behavioural forms of support).

Implications: Use of help to quit is now the norm, especially among more dependent smokers. This may reflect a realization among smokers that quitting unassisted is more likely to fail than quitting with help, as well as the cumulative effect of promoting the use of help. Given the continuing high levels of failed quit attempts, services need to be able to expand to meet this increasing demand.

Citation

Fix, B.V., Hyland, A., Rivard, C., McNeill, A., Fong, G.T., Borland, R., Hammond, D., Cummings, K.M. (2011). Usage patterns of stop smoking medications in Australia, Canada, the United Kingdom, and the United States: Findings from the 2006-2008 International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(1), 222-233.

Abstract

Varenicline is a new prescription stop smoking medication (SSM) that has been available in the United States since August 1, 2006, in the United Kingdom and other European Union countries since December 5, 2006, in Canada since April 12, 2007, and in Australia since January 1, 2008. There are few population-based studies that have examined use rates of varenicline and other stop smoking medications. We report data from the ITC Four Country survey conducted with smokers in the US, UK, Canada, and Australia who reported an attempt to quit smoking in past year in the 2006 survey (n = 4,022 participants), 2007 (n = 3,790 participants), and 2008 surveys (n = 2,735 participants) Respondents reported use of various stop smoking medications to quit smoking at each survey wave, along with demographic and smoker characteristics. The self-reported use of any stop smoking medication has increased significantly over the 3 year period in all 4 countries, with the sharpest increase occurring in the United States. Varenicline has become the second most used stop smoking medication, behind NRT, in all 4 countries since being introduced. Between 2006 and 2008, varenicline use rates increased from 0.4% to 21.7% in the US, 0.0% to 14.8% in Canada, 0.0% to 14.5% in Australia, and 0.0% to 4.4% in the UK. In contrast, use of NRT and bupropion remained constant in each country. Males and non-whites were significantly less likely to report using any SSM, while more educated smokers were significantly more likely to use any SSM, including varenicline. Our findings suggest that the introduction of varenicline led to an increase in the number of smokers who used evidence-based treatment during their quit attempts, rather than simply gaining market share at the expense of other medications. From a public health perspective, messages regarding increased success rates among medication users and the relative safety of stop smoking medications should be disseminated widely so as to reach all smokers of all socioeconomic classifications equally.

Citation

Mutti, S., Hammond, D., Borland, R., Cummings, K.M., O’Connor, R.J., Fong, G.T. (2011). Beyond light and mild: Cigarette brand descriptors and perceptions of risk in the International Tobacco Control (ITC) Four Country Survey. Addiction, 106(6), 1166-1175.

Abstract

Aims: To examine perceptions of risk related to type of cigarette brand.

Design and setting: Cross-sectional findings from wave 5 of the ITC Four Country Survey, conducted with nationally representative samples of smokers in 2006.

Participants: A total of 8243 current and former adult (≥18 years) smokers from Canada (n = 2022), the United States (n = 2034), the United Kingdom (n = 2019) and Australia (n = 2168).

Measurements: Outcomes included beliefs about the relative risks of cigarettes, including perceptions of ‘own’ brand. Correlates included sociodemographic, smoking-related covariates and brand characteristics.

Findings: One-fifth of smokers believed incorrectly that ‘some cigarette brands could be less harmful’ than others. False beliefs were higher in both the United States and United Kingdom compared to Canada and Australia. Smokers of ‘light/mild’, ‘slim’ and 100 mm/120 mm cigarettes were more likely to believe that some cigarettes could be less harmful [odds ratio (OR) = 1.29, 95% confidence interval (CI) = 1.12–1.48 and that their own brand might be a little less harmful (OR = 2.61, 95% CI = 2.01–3.41). Smokers of ‘gold’, ‘silver’, ‘blue’ or ‘purple’ brands were more likely to believe that their ‘own brand might be a little less harmful’ compared to smokers of ‘red’ or ‘black’ brands (OR = 12.48, 95% CI = 1.45–107.31).

Conclusions: Despite current prohibitions on the words ‘light’ and ‘mild’, smokers in western countries continue to falsely believe that some cigarette brands may be less harmful than others. These beliefs are associated with descriptive words and elements of package design that have yet to be prohibited, including the names of colours and long, slim cigarettes.

Citation

Seidenberg, A.B., Rees, V.W., Alpert, H.R., O’Connor, R.J., Connolly, G.N. (2011). Ignition strength of 25 international cigarette brands. Tobacco Control, 20(1), 77-80.

Abstract

Background: Cigarette-ignited fires are a leading cause of fire death and injury throughout the world and remain a global public health and safety problem. To reduce this harm, a small number of countries now require cigarettes to have reduced ignition propensity (RIP). It is not known if cigarette manufacturers are voluntarily introducing RIP cigarettes in other countries to help save lives.

Methods: Using the ASTM E2187-04 test method, per cent full length burn (%FLB) was measured for three popular brands from each of seven countries that did not have RIP legislation at the time of purchase. Results were compared with %FLB measurements from four popular US brands purchased in a jurisdiction (Vermont) with an RIP law. SRM 1082 reference cigarette was also tested to assure laboratory quality control.

Results: All cigarette brands purchased in countries not requiring fire safety standards for cigarettes exceeded 75% FLB. In contrast, none of the cigarette brands from the USA exceeded 10% FLB. The SRM 1082 reference cigarette demonstrated 5% FLB.

Conclusion: Cigarette ignition propensity can be greatly reduced through legislation that requires cigarette fire safety standards. RIP cigarettes have the potential to significantly decrease the number of fire deaths, injuries and destruction of property caused by cigarette-ignited fires. Appropriate standards should be applied in cigarette markets globally.

Citation

Cooper, J., Borland, R., Yong, H.H., McNeill, A., Murray, R.L., O’Connor, R.J., Cummings, K.M. (2010). To what extent do smokers make spontaneous quit attempts and what are the implications for smoking cessation maintenance? Findings from the International Tobacco Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S51-57.

Abstract

Aim: To assess the extent to which quit attempts are spontaneous and to evaluate if this is a determinant of smoking cessation maintenance, with better control for memory effects.

Methods: We use data from 3,022 smokers who made quit attempts between Waves 4 and 5 and/or Waves 5 and 6 of the International Tobacco Control Four country survey. Outcomes (quitting for 6 months) were confirmed at the next wave for cases where the attempt began within the previous 6 months. We assessed the length of delay between the decision to quit and implementation and whether the attempt followed a “spur-of-the-moment” decision or some serious prior consideration. Outcomes were modeled using generalized estimating equations.

Results: Prior consideration of quitting was unrelated to the outcome, but there were complex relationships for the delay between choosing a quit day and implementation. Those who reported quitting on the day they decided and those who delayed for 1 week or more had comparable rates of 6-month abstinence. Delaying for 1–6 days was associated with a greater relapse rate than those who quit on the day, although this effect became non-significant in multivariate analyses.

Conclusions: Quitting is on most smokers’ minds regularly and most attempts are not preceded by a long lead in period following the decision to try. Neither prior consideration nor delay between the decision to quit and implementation was clearly related to outcomes. Previous findings of greater success for spontaneous quit attempts may be because they conflate setting a date in advance with planning and also perhaps some differential memory effects.

Citation

Reid, J., Hammond, D., Boudreau, C., Fong, G.T., Siahpush, M. (2010). Socioeconomic disparities in quit intentions, quit attempts, and smoking abstinence among smokers in four western countries: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S20-33.

Abstract

Introduction: Lower socioeconomic status (SES) groups have higher rates of tobacco use, are less likely to successfully quit, and may also be less likely to intend or attempt to quit. However, results are inconsistent for some outcomes, and little is known about how socioeconomic disparities vary across countries and over time.

Methods: This study examined the associations between SES and quitting-related behaviors among representative samples of smokers in Canada, the United States, the United Kingdom, and Australia, using data from the first five waves (2002–2006/2007) of the International Tobacco Control Four Country Survey (35,532 observations from 16,458 respondents). Generalized estimating equations modeling was used to examine whether education and income were related to intentions to quit, incidence of quit attempts, and smoking abstinence. Potential differences in the associations over time and across countries were also considered.

Results: Smokers with higher education were more likely to intend to quit, to make a quit attempt, and to be abstinent for at least 1 and 6 months; smokers with higher income were more likely to intend to quit and to be abstinent for at least 1 month. Some between-country differences were observed: U.K. and U.S. smokers were less likely to intend to quit than Australians and Canadians; and, although U.K. respondents were least likely to attempt to quit, those that did were more likely to be abstinent.

Discussion: The results suggest that socioeconomic disparities exist at multiple stages in the path to smoking cessation. Potential effects on socioeconomic disparities should be considered when implementing cessation interventions.

Citation

Gibson, J.E., Murray, R.L., Borland, R., Cummings, K.M., Fong, G.T., Hammond, D., McNeill, A. (2010). The impact of the United Kingdom's national smoking cessation strategy on quit attempts and use of cessation services: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S64-71.

Abstract

Introduction: The World Health Organization Framework Convention on Tobacco Control recommends that provision of cessation support should be included in national tobacco control strategies. This study examines the impact of the United Kingdom’s national smoking cessation strategy on quit attempts, use of treatment and short-term abstinence, relative to the United States, Canada, and Australia where less support is provided.

Methods: Data on quitting behavior and use of support were obtained for all smokers enrolled in the International Tobacco Control 4 Country Survey between 2002 and 2005. Generalized estimating equations were used to calculate the relative odds (adjusted by age, sex, and Heaviness of Smoking Index) that smokers in each country made quit attempts, used behavioral or pharmacological support, and to compare rates of short-term (28 days) abstinence between countries and users of different forms of support.

Results: U.K. smokers were less likely to have attempted to quit smoking than those in Australia (odds ratio [OR] = 1.25, 95% CI: 1.12–1.40), Canada (OR = 1.50, 95% CI: 1.34–1.67), and the United States (OR = 1.25, 95% CI: 1.11–1.40) but were more likely to use pharmacotherapy and/or support from a clinic, helpline, or health professional when attempting to quit than smokers in the other countries. U.K. smokers making quit attempts were significantly more likely to achieve 28-day abstinence than those in Australia (OR = 0.59, 95% CI: 0.49–0.71), Canada (OR = 0.72, 95% CI: 0.61–0.87), and the United States (OR = 0.51, 95% CI: 0.42–0.62).

Conclusions: U.K. smokers report fewer quit attempts but are more likely to use support when quitting and to achieve short-term abstinence.

Citation

Cooper, J., Borland, R., Yong, H.H., Hyland, A. (2010). Compliance and support for bans on smoking in licensed venues in Australia: Findings from the International Tobacco Control Four Country Survey. Australian and New Zealand Journal of Public Health, 34(4), 379-385.

Abstract

Objective: To examine attitudes towards and compliance with the recent Australian bans on smoking in licensed venues, and to explore effects on smoking behaviour.

Methods: Three Australian states (Queensland, Tasmania and Western Australia) implemented a total ban on smoking in all enclosed licensed premises in 2006, and two others (Victoria and New South Wales) did so in mid-2007. We used data from smokers residing in these states for each of the six waves of the ITC-4 country survey (2002-2007; average n=1,694).

Results: Consistent with the majority of international findings, observed compliance was reported by more than 90% of smokers from a pre-ban situation of indoor smoking being the norm. Attitudes became more positive in the year before the ban, but more than doubled in the year the bans were implemented. The associations found for the leading states were replicated by the lagging states a year later. We found no evidence for any increase in permitting smoking inside the home after the bans took effect. Further, we were unable to find any evidence of reductions in daily cigarette consumption or any increase in quitting activity due to the bans.

Implications: These results add to a growing body of international research that suggests that smokers are readily able to comply with, and increasingly support, smoke-free bars, though the bans may have limited effect on their smoking habits.

Citation

Fix, B.V., O’Connor, R.J., Hammond, D., King, B., McNeill, A., Thrasher, J.F., Boado Martinez, M., Cummings, K.M., Yong, H.H., Thompson, M.E., Hyland, A. (2010). ITC spit and butts pilot study: The feasibility of collecting saliva and cigarette butt samples from smokers to evaluate policy. Nicotine & Tobacco Research, 12(3), 185-190.

Abstract

Introduction: Large-scale epidemiological surveys have frequently relied upon clinic-based sample collection to incorporate biological data, which can be costly and result in non-representative data. Collecting samples in a nonclinical setting (i.e., through postal mail or at the subject’s home) offers an alternative option that is minimally invasive and can be incorporated into large population-based studies.

Objectives: (a) To assess the feasibility of collecting biological data from a cohort of smokers in the International Tobacco Control (ITC) study, through the mail and in the home; (b) to examine whether participants are representative of the population under consideration; and (c) to evaluate how the added burden of providing biomarker samples might impact subsequent participation in a follow-up survey.

Methods: Participants were asked to provide a saliva sample and five cigarette butts from cigarettes smoked on a single day, using standardized procedures. Sample collection kits were mailed to a random sample of 400 daily cigarette smokers who were involved in the 2006 annual ITC Four Country (United Kingdom, United States, Canada, and Australia) telephone survey and agreed to participate in sample collection. A random sample of 179 daily smokers who participated in a face-to-face ITC survey in Mexico and Uruguay and agreed to participate in sample collection were also asked to provide samples.

Results: Samples were collected from 96% of invited participants in the face-to-face surveys and 52% of participants in the telephone survey. The added burden of the sample collection did not reduce survey retention rates. Participants who initially agreed to participate in the sample collection were more likely to participate in the subsequent survey than participants who were not asked or declined to participate (odds ratio [OR] = 1.28; 95% CI = 1.01–1.62, p = .021). Further, those who provided samples were also more likely to participate in the subsequent survey than those who did not (OR = 2.78; 95% CI = 1.71–4.52, p < .001).

Discussion: Collecting saliva and cigarette butt samples from a group of smokers is feasible, yields a representative sample, and the added participant burden does not reduce subsequent survey response rates.

Citation

Borland, R., Yong, H.H., Balmford, J., Cooper, J., Cummings, K.M., O’Connor, R.J., McNeill, A., Zanna, M.P., Fong, G.T. (2010). Motivational factors predict quit attempts but not maintenance of smoking cessation: Findings from the International Tobacco Control Four Country Project. Nicotine & Tobacco Research, 12(Suppl 1), S4-11.

Abstract

Aim: To explore whether measures of motivation to quit smoking have different predictive relationships with making quit attempts and the maintenance of those attempts.

Methods: Data are from three wave-to-wave transitions of the International Tobacco Control Four (ITC-4) country project. Smokers' responses at one wave were used to predict the likelihood of making an attempt and among those trying the likelihood of maintaining an attempt for at least a month at the next wave. For both outcomes, hierarchical logistic regressions were used to explore the predictive capacity of seven measures of motivation to quit smoking, controlling for a range of other known or possible predictors.

Results: Bivariate analyses indicate that measures of motivation to quit are predictive of making quit attempts, but they predict relapse among those making attempts. Multivariate analyses identified wanting to quit and frequency of prematurely butting out cigarettes as the main positive predictors of making attempts, but this was reduced by intention and recency of last attempt. For maintenance, premature butting out was the main motivation variable predicting relapse and was essentially unaffected by other measures.

Discussion: The findings show that it is wrong to suggest that all one needs to quit is to be motivated to do so. The reality is that one needs to be motivated to prompt action to stop smoking, but this is not sufficient in and of itself to ensure that cessation is maintained. These findings call attention to the importance of understanding the differential roles that prequit and postquit experiences play in smoking cessation and of providing help to smokers to stay off cigarettes.

Citation

Borland, R., Yong, H.H., O’Connor, R.J., Hyland, A., Thompson, M.E. (2010). The reliability and predictive validity of the Heaviness of Smoking Index and its two components: Findings from the International Tobacco Control Four Country Study. Nicotine & Tobacco Research, 12(Suppl 1), S45-50.

Abstract

Background: There is increasing recognition that the two measures in the Heaviness of Smoking Index (HSI), time to first cigarette of the day (TTFC) and daily consumption (cigarettes per day [CPD]), are strong predictors of quitting behavior.

Methods: Use of Waves 1-4 of International Tobacco Control cohort with around 8,000 respondents per wave and 6,000 for prediction of quit outcomes at the next wave. We measured TTFC and CPD at each wave and quit outcomes at the next wave. We also looked at the relative utility of the standard categorical scoring compared with a continuous score using the square root of CPD minus the natural log of TTFC in minutes.

Results: We found considerable consistency of the measures across years with a small decrease as duration between measurements increased. For a 3-year gap, the correlations were .72 and .70 for the continuous and categorical composite HSI measures, respectively, and were at least .63 for the individual components. Both TTFC and CPD independently predicted maintenance of quit attempts (for at least 1 month) in each of the three wave-to-wave replications, and these effects were maintained when controlling for demographic factors. CPD also predicted making attempts consistently, but the results for TTFC was not consistently significant.

Discussion: Both TTFC and CPD are fairly reliable over time and are important predictors of quitting. There are only small effects of mode of computing the scores, and the two items can be used either individually or combined as the HSI.

Citation

Hitchman, S.C., Fong, G.T., Borland, R., Hyland, A. (2010). Predictors of smoking in cars with nonsmokers: Findings from the 2007 Wave of the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(4), 374-380.

Abstract

Objective: This study examines the proportion and characteristics of smokers who smoke in cars with nonsmokers across four countries and the potentially modifiable correlates of this behavior.

Methods: Respondents included a total of 6,786 current adult smokers from Wave 6 (September 2007– February 2008) of the International Tobacco Control Four Country Survey, a random digit-dial telephone survey of nationally representative samples of adult smokers in Australia, the United Kingdom, Canada, and the United States.

Results: Reports of smoking in cars with nonsmokers ranged from a low of 29% in Australia and the United Kingdom, to 34% in Canada, and to a high of 44% in the United States. Daily smokers who were from the United States, male, and younger were the most likely to smoke in cars with nonsmokers. Several potentially modifiable factors were also found to be related to this behavior, including smoke-free homes and beliefs about the dangers of cigarette smoke exposure to nonsmokers.

Conclusions: A considerable proportion of smokers continue to smoke in cars with nonsmokers across the four countries, particularly in the United States. Public health campaigns should educate smokers about the hazards of cigarette smoke exposure and promote the need for smoke-free cars. These findings provide a foundation of evidence relevant for jurisdictions

Citation

Kahler, C.W., Borland, R., Hyland, A., McKee, S., O’Connor, R.J., Fong, G.T., Cummings, K.M. (2010). Quitting smoking and change in alcohol consumption in the International Tobacco Control (ITC) Four Country Survey. Drug and Alcohol Dependence, 110(1-2), 101-107.

Abstract

Although frequent heavy drinking has been associated with decreased odds of quitting smoking, the extent to which smoking cessation is associated with decreased alcohol consumption is less clear. The present study examined over a 2-year period whether individuals who quit smoking for at least 6 months, compared to those making a quit attempt but continuing to smoke and to those not making any attempt to quit smoking, showed greater reductions in drinking frequency, average weekly quantity of alcohol consumption, and frequency of heavy drinking. Data were drawn from the International Tobacco Control Four Country Survey, a prospective cohort study of smokers in Australia, Canada, the UK, and the US. A total of 3614 participants provided alcohol data at one study wave and were re-interviewed 2 years later regarding smoking and alcohol use. Consistent with prior studies, individuals who drank heavily (4+/5+ drinks for women and men, respectively) more than once a week had especially low rates of quitting smoking. There was little evidence, however, that those who achieved sustained smoking cessation made greater reductions in drinking compared to those who continued to smoke. These results were consistent across countries and sexes and did not differ significantly by heaviness of smoking. Results indicate that quitting smoking, in and of itself, does not lead to meaningful changes in alcohol use. Therefore, interventions and policies directed towards increasing smoking cessation are unlikely to affect rates of hazardous drinking unless they include specific elements that address alcohol consumption.

Citation

Yong, H.H., Borland, R., Cooper, J., Cummings, K.M. (2010). Postquitting experiences and expectations of adult smokers and their association with subsequent relapse: Findings from the International Tobacco Control (ITC) Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S12-19.

Abstract

Introduction: This paper explores postquitting experiences and expectations of adult ex-smokers and their utility as predictors of smoking relapse after prolonged abstinence.

Methods: Data are from 1,449 ex-smokers (providing 2,234 observations) recruited as smokers as part of the International Tobacco Control (ITC) Four Country Survey (Australia, Canada, the United Kingdom, and the United States) but surveyed after they had quit. Controlling for length of time quit, reported postquitting experiences, and expectations assessed at one of three waves were used as predictors. Smoking status (whether they had relapsed) at the next wave was used as the outcome of interest.

Results: Postquitting experiences and expectations, such as capacity to enjoy life’s simple pleasures, ability to cope with stress, ability to control negative emotions, and health concerns, changed systematically over time but at different rates. The trajectory of change for life enjoyment and health concerns followed a rapidly asymptoting logarithmic function, while that of stress and negative affect coping followed a slower asymptoting square root function. After controlling for sociodemographic and abstinence duration, only reported decline in capacity to control negative affect since quitting was associated with increased relapse risk.

Discussion: The varying patterns of change in postquitting experiences suggest that psychological gains over time following smoking cessation do not all occur at the same rate. The relative importance of each factor in maintaining abstinence is also not the same with deficits in perceived control of negative emotions being the only one predictive of subsequent relapse. Strategies to improve impulse control over negative emotions postquitting may help to reduce relapse risk.