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.

Citation

Siahpush, M., Yong, H.H., Borland, R., Reid, J., Hammond, D. (2009). Smokers with financial stress are more likely to want to quit but less likely to try or succeed: Findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 104(8), 1382-1390.

Abstract

Objective: To examine the association of financial stress with interest in quitting smoking, making a quit attempt and quit success.

Design and participants: The analysis used data from 4984 smokers who participated in waves 4 and 5 (2005–07) of the International Tobacco Control (ITC) Four Country Survey, a prospective study of a cohort of smokers in the United States, Canada, the United Kingdom and Australia.

Measurement: The outcomes were interest in quitting at wave 4, making a quit attempt and quit success at wave 5. The main predictor was financial stress at wave 4: ‘. . . because of a shortage of money, were you unable to pay any important bills on time, such as electricity, telephone or rent bills?’. Additional socio-demographic and smoking-related covariates were also examined.

Findings: Smokers with financial stress were more likely than others to have an interest in quitting at baseline [odds ratio (OR): 1.63; 95% confidence interval (CI): 1.22–2.19], but were less likely to have made a quit attempt at follow-up (OR: 0.74; 95% CI: 0.57–0.96). Among those who made a quit attempt, financial stress was associated with a lower probability of abstinence at follow-up (OR: 0.53; 95% CI: 0.33–0.87).

Conclusions: Cessation treatment efforts should consider assessing routinely the financial stress of their clients and providing additional counseling and resources for smokers who experience financial stress. Social policies that provide a safety net for people who might otherwise face severe financial problems, such as not being able to pay for rent or food, may have a favorable impact on cessation rates.

Citation

Hyland, A., Higbee, C., Borland, R., Travers, M.J., Hastings, G., Fong, G.T., Cummings, K.M. (2009). Attitudes and beliefs about secondhand smoke and smoke-free policies in four countries: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 11(6), 642-649.

Abstract

Introduction: This paper describes the varying levels of smoking policies in nationally representative samples of smokers in four countries and examines how these policies are associated with changes in attitudes and beliefs about secondhand smoke over time.

Methods: We report data on 5,788 respondents to Wave 1 of the International Tobacco Control Four Country Survey who were employed at the time of the survey. A cohort of these respondents was followed up with two additional survey waves approximately 12 months apart. Respondents ’ attitudes and beliefs about secondhand smoke as well as self-reported policies in their workplace and in bars and restaurants in their community were assessed at all waves.

Results: The level of comprehensive smoke-free policies in workplaces, restaurants, and bars increased over the study period for all countries combined and was highest in Canada (30%) and lowest in the United Kingdom (0%) in 2004. In both crosssectional and longitudinal analyses, stronger secondhand smoke policies were associated with more favorable attitudes and support for comprehensive regulations. The associations were the strongest for smokers who reported comprehensive policies in restaurants, bars, and their workplace for all three survey waves.

Discussion: Comprehensive smoke-free policies are increasing over time, and stronger policies and the public education opportunities surrounding their passage are associated with more favorable attitudes toward secondhand smoke regulations. The implication for policy makers is that, although the initial debate over smoke-free policies may be tumultuous, once people understand the rationale for implementing smoke-free policies and experience their benefits, public support increases even among smokers, and compliance with smoke-free regulations increases over time.

Citation

Li, L., Yong, H.H., Borland, R., Fong, G.T., Thompson, M.E., Jiang, Y., Yang, Y., Sirirassamee, B., Hastings, G., Harris, F. (2009). Reported awareness of tobacco advertising and promotion in China compared to Thailand, Australia and the USA. Tobacco Control, 18(3), 222-227.

Abstract

Background: China currently does not have comprehensive laws or regulations on tobacco advertising and promotion, although it ratified the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in October 2005 and promised to ban all tobacco advertising by January 2011. Much effort is needed to monitor the current situation of tobacco advertising and promotion in China.

Objective: This study aims to examine levels of awareness of tobacco advertising and promotion among smokers in China as compared to other countries with different levels of restrictions.

Methods: One developing country (Thailand) and two developed countries (Australia and the USA) were selected for comparison. All four countries are part of the International Tobacco Control (ITC) Policy Evaluation Survey project. Between 2005 and 2006, parallel ITC surveys were conducted among adult smokers (at least smoked weekly) in China (n=4763), Thailand (n=2000), Australia (n=1767) and the USA (n=1780). Unprompted and prompted recall of noticing tobacco advertising and promotion were measured.

Results: Chinese respondents reported noticing tobacco advertisements in a range of channels and venues, with highest exposure levels on television (34.5%), billboards (33.4%) and in stores (29.2%). A quarter of respondents noticed tobacco sponsorships, and a high level of awareness of promotion was reported. Cross-country comparison reveals that overall reported awareness was significantly higher in China than in Thailand (particularly) and Australia, but lower than in the USA.

Conclusions: There is a big gap between China and the better-performing countries such as Thailand and Australia regarding tobacco promotion restrictions. China needs to do more, including enhanced policy and more robust enforcement.

Citation

Borland, R., Yong, H.H., Balmford, J., Fong, G.T., Zanna, M.P., Hastings, G. (2009). Do risk-minimizing beliefs about smoking inhibit quitting? Findings from the International Tobacco Control (ITC) Four Country Survey. Preventive Medicine, 19(2-3), 219-223.

Abstract

Objective: To replicate findings that risk-minimizing and self-exempting beliefs lower quit intentions, and to extend this by testing their capacity to prospectively predict smoking cessation.

Method: 13,324 adult (≥ 18 years) cigarette smokers from the USA, Canada, UK, and Australia from one of the first three waves (2002-2004) of the International Tobacco Control 4-Country survey were employed for the predictive analysis where beliefs measured in one wave (1-3) of a cohort were used to predict cessation outcomes in the next wave (2-4).

Results: Both types of belief were negatively associated with both intention to quit in the same wave and making a quit attempt at the next wave. When taken together and controlling for demographic factors, the risk-minimizing beliefs continued to be predictive, but the self-exempting belief was not. Some of the effects of risk-minimizing beliefs on quit attempts seem to be independent of intentions, but not consistently independent of other known predictors. There were no consistent predictive effects on sustained cessation among those who made attempts to quit for either measure.

Conclusions: Countering risk-minimizing beliefs may facilitate increased quitting, but this may not be so important for self-exempting beliefs.

Citation

Borland, R., Wilson, N., Fong, G.T., Hammond, D., Cummings, K.M., Yong, H.H., Hosking, W., Hastings, G., Thrasher, J.F., McNeill, A. (2009). Impact of graphic and text warnings on cigarette packs: Findings from four countries over five years. Tobacco Control, 18(5), 358-364.

Abstract

Objectives: To examine the impact of health warnings on smokers by comparing the short-term impact of new graphic (2006) Australian warnings with: (i) earlier (2003) United Kingdom larger text-based warnings; (ii) and Canadian graphic warnings (late 2000); and also to extend our understanding of warning wear-out.

Methods: The International Tobacco Control Policy Evaluation Survey (ITC Project) follows prospective cohorts (with replenishment) of adult smokers annually (five waves: 2002–2006), in Canada, United States, UK and Australia (around 2000 per country per wave; total n=17 773). Measures were of pack warning salience (reading and noticing); cognitive responses (thoughts of harm and quitting); and two behavioural responses: forgoing cigarettes and avoiding the warnings.

Results: All four indicators of impact increased markedly among Australian smokers following the introduction of graphic warnings. Controlling for date of introduction, they stimulated more cognitive responses than the UK (textonly) changes, and were avoided more, did not significantly increase forgoing cigarettes, but were read and noticed less. The findings also extend previous work showing partial wear-out of both graphic and text-only warnings, but the Canadian warnings have more sustained effects than UK ones.

Conclusions: Australia’s new health warnings increased reactions that are prospectively predictive of cessation activity. Warning size increases warning effectiveness and graphic warnings may be superior to text-based warnings. While there is partial wear-out in the initial impact associated with all warnings, stronger warnings tend to sustain their effects for longer. These findings support arguments for governments to exceed minimum FCTC requirements on warnings.

Citation

Borland, R., Yong, H.H., Wilson, N., Fong, G.T., Hammond, D., Cummings, K.M., Hosking, W., McNeill, A. (2009). How reactions to cigarette packet health warnings influence quitting: Findings from the ITC Four Country Survey. Addiction, 104(4), 669-675.

Abstract

Objectives: To examine prospectively the impact of health warnings on quitting activity.

Design: Five waves (2002–06) of a cohort survey where reactions to health warnings at one survey wave are used to predict cessation activity at the next wave, controlling for country (proxy for warning differences) and other factors. These analyses were replicated on four wave-to-wave transitions.

Setting and participants: Smokers from Australia, Canada, the United Kingdom and the United States. Samples were waves 1–2: n = 6525; waves 2–3: n = 5257; waves 3–4: n = 4439; and waves 4–5: n = 3993.

Measures: Warning salience, cognitive responses (thoughts of harm and of quitting), forgoing of cigarettes and avoidance of warnings were examined as predictors of quit attempts, and of quitting success among those who tried (1 month sustained abstinence), replicated across four wave-to-wave transitions.

Results: All four responses to warnings were independently predictive of quitting activity in bivariate analyses. In multivariate analyses, both forgoing cigarettes and cognitive responses to the warnings predicted prospectively making quit attempts in all replications. However, avoiding warnings did not add predictive value consistently, and there was no consistent pattern for warning salience. There were no interactions by country. Some, but not all, the effects were mediated by quitting intentions. There were no consistent effects on quit success.

Conclusions: This study adds to the evidence that forgoing cigarettes as a result of noticing warnings and quit-related cognitive reactions to warnings are consistent prospective predictors of making quit attempts. This work strengthens the evidence base for governments to go beyond the Framework Convention on Tobacco Control to mandate health warnings on tobacco products that stimulate the highest possible levels of these reactions.

Citation

Fong, G.T., Hammond, D., Hitchman, S.C. (2009). The impact of pictures on the effectiveness of tobacco warnings. Bulletin of the World Health Organization, 87(8), 640-643.

Abstract

Cigarette packages in most countries carry a health warning; however, the position, size and general strength of these warnings vary considerably across jurisdictions.1 Article 11 of the WHO Framework Convention on Tobacco Control (FCTC) and the Article 11 Guidelines adopted at the Third Conference of the Parties in November 2008 have put the spotlight on the inclusion of pictures on tobacco package health warnings. Beginning with Canada in 2001, 28 countries have introduced pictorial warnings and many other countries are in the process of drafting regulations for pictorial warnings (Box 1 and Box 2). This paper presents a brief review of the research studies that support pictorial warnings, reviewed in greater depth by Hammond and by the International Tobacco Control (ITC) Policy Evaluation Project.

Citation

Thomson, G., Wilson, N. (2009). Public attitudes to laws for smoke-free private vehicles: A brief review. Tobacco Control, 18(4), 256-261.

Abstract

As smoke-free car policy is a frontier domain for tobacco control, attitudes to smoke-free private car laws are briefly reviewed. Medline and Google Scholar searches for the period up to midNovember 2008, from English language sources, were undertaken. Studies were included that contained data from national and subnational populations (eg, in states and provinces), but not for smaller administrative units, eg, cities or councils. Jurisdiction, sample size and survey questions were assessed. One reviewer conducted the data extraction and both authors conducted assessments. A total of 15 relevant studies (from 1988) were identified, set in North America, the UK and Australasia. The available data indicates that, for the jurisdictions with data, there is majority public support for laws requiring cars that contain children to be smoke free. There appears to be an increase over time in this support. In five surveys in 2005 or since (in California, New Zealand and Australia), the support from smokers was 77% or more. The high levels of public (and smoker) support for smokefree car laws found in the studies to date suggest that this can be a relatively non-controversial tobacco control intervention. Survey series on attitudes to such laws are needed, and surveys in jurisdictions where the issue has not been investigated to date.

Citation

Herd, N., Borland, R., Hyland, A. (2009). Predictors of smoking relapse by duration of abstinence: Findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 104(12), 2088-2099.

Abstract

Aim: To explore predictors of smoking relapse and how predictors vary according to duration of abstinence.

Design, setting and participants: A longitudinal survey of 1296 ex-smokers recruited as part of the International Tobacco Control (ITC) Four Country Survey (Australia, Canada, United Kingdom and United States).

Measurements: Quitters were interviewed by telephone at varying durations of abstinence (from 1 day to approximately 3 years) and then followed-up approximately 1 year later. Theorized predictors of relapse (i.e. urges to smoke; outcome expectancies of smoking and quitting; and abstinence self-efficacy) and nicotine dependence were measured in the survey.

Findings: Relapse was associated with lower abstinence self-efficacy and a higher frequency of urges to smoke, but only after the first month or so of quitting. Both these measures mediated relationships between perceived benefits of smoking and relapse. Perceived costs of smoking and benefits of quitting were unrelated to relapse.

Conclusions: Challenging perceived benefits of smoking may be an effective way to increase abstinence self-efficacy and reduce frequency of urges to smoke (particularly after the initial weeks of quitting), in order to reduce subsequent relapse risk.

Citation

Herd, N., Borland, R. (2009). The natural history of quitting smoking: Findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 104 (12), 2075-2087.

Abstract

Aims: To describe the long-term natural history of a range of potential determinants of relapse from quitting smoking.

Design setting and participants: A survey of 2502 ex-smokers of varying lengths of time quit recruited as part of the International Tobacco Control (ITC) Four Country Survey (Australia, Canada, United Kingdom, United States) across five annual waves of surveying.

Measurements: Quitters were interviewed by telephone at varying durations of abstinence, ranging from 1 to 1472 days (about 4 years) post-quitting. Smoking-related beliefs and experiences (i.e. urges to smoke; outcome expectancies of smoking and quitting; and abstinence self-efficacy) were included in the survey.

Findings: Most theorized determinants of relapse changed over time in a manner theoretically associated with reduced risk of relapse, except most notably the belief that smoking controls weight, which strengthened. Change in these determinants changed at different rates: from a rapidly asymptoting log function to a less rapidly asymptoting square-root function.

Conclusions: Variation in patterns of change across time suggests that the relative importance of each factor to maintaining abstinence may similarly vary.

Citation

Hosking, W., Borland, R., Yong, H.H., Fong, G.T., Zanna, M.P., Laux, F., Thrasher, J.F., Lee, W.B., Sirirassamee, B., Omar, M. (2009). The effects of smoking norms and attitudes on quitting intentions in Malaysia, Thailand and four western nations: A cross-cultural comparison. Psychology & Health, 24(1), 95-107.

Abstract

This research investigated the influence of smoking attitudes and norms on quitting intentions in two predominantly collectivistic countries (Malaysia and Thailand) and four predominantly individualistic Western countries (Canada, USA,UK and Australia). Data from the International Tobacco Control Project (N¼13,062) revealed that higher odds of intending to quit were associated with negative personal attitudes in Thailand and the Western countries, but not in Malaysia; with norms against smoking from significant others in Malaysia and the Western countries, but not in Thailand; and with societal norms against smoking in all countries. Our findings indicate that normative factors are important determinants of intentions, but they play a different role in different cultural and/or tobacco control contexts. Interventions may be more effective if they are designed with these different patterns of social influence in mind.

Citation

Kahler, C.W., Borland, R., Hyland, A., McKee, S., Thompson, M.E., Cummings, K.M. (2009). Alcohol consumption and quitting smoking in the International Tobacco Control (ITC) Four Country Survey. Drug and Alcohol Dependence, 100(3), 214-220.

Abstract

Although greater alcohol consumption has been associated with decreased odds of quitting smoking in prospective studies, the aspects of drinking most strongly associated with quitting have not been fully explored and examination of potential confounder variables has been limited. Further studies are needed to inform efforts to enhance smoking cessation among the substantial portion of smokers who drink alcohol. The present study examines (a) drinking frequency, average weekly quantity of alcohol consumption, and frequency of heavy drinking as prospective predictors of quit smoking behaviors, (b) difference across countries in this prediction, and (c) third variables that might account for the association between alcohol consumption and quitting smoking. 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 4,831 participants provided alcohol data at one study wave and were re-interviewed 1 year later. Individuals who drank heavily (4+/5+ drinks for women and men, respectively) more than once a week had significantly lower rates of quitting smoking than all other participants, in part due to the fact that a significantly lower proportion of those making a quit attempt remained quit for more than one month at follow-up. The role of frequent heavy drinking did not differ by country or sex and was not accounted for by demographics, smoking dependence, or attitudes regarding quitting smoking. Neither drinking frequency nor weekly quantity of consumption showed robust associations with quitting behaviors. Results indicate further study of interventions to address heavy drinking among smokers is warranted.

Citation

Shahab, L., Cummings, K.M., Hammond, D., Borland, R., West, R., McNeill, A. (2009). The impact of changing nicotine replacement therapy licensing laws in the United Kingdom: Findings from the International Tobacco Control Four Country Survey. Addiction, 104(8), 1420-1427.

Abstract

Aim: To evaluate the impact of a new licence for some nicotine replacement therapy products (NRT) for cutting down to stop (CDTS) on changes in the pattern of NRT use.

Design: Quasi-experimental design comparing changes in NRT use across two waves of a population-based, replenished-panel, telephone survey conducted before and after the introduction of new licensing laws in the United Kingdom with changes in NRT use in three comparison countries (Australia, Canada and United States) without a licensing change.

Participants: A total of 7386 and 7013 smokers and recent ex-smokers participating in the 2004 and/or 2006/7 survey.

Measurements: Data were collected on demographic and smoking characteristics as well as NRT use and access. In order to account for interdependence resulting from some participants being present in both waves, generalized estimation equations with an exchangeable correlation matrix were used to assess within-country changes and linear and logistic regressions to assess betweencountry differences in adjusted analyses.

Findings: NRT use was more prevalent in the United Kingdom and increased across waves in all countries but nowave x country interaction was observed. There was no evidence that the licensing change increased the prevalence of CDTS or the use of NRT (irrespective of how it was accessed) for CDTS in the United Kingdom relative to comparison countries. There was also no evidence for a change in concurrent smoking and NRT use among smokers not attempting to stop in the United Kingdom relative to comparison countries.

Conclusion: The addition of the CDTS licence for some NRT products in the United Kingdom appears to have had very limited, if any, impact on NRT use in the first year after the licence change.

Citation

Yong, H.H., Borland, R. (2008). Functional beliefs about smoking and quitting activity among adult smokers in four countries: Findings from the International Tobacco Control Four Country Survey. Health Psychology, 27(Suppl 3), S216-223.

Abstract

Objective: To examine the psychometric properties, distributions, and predictive utility for quitting behavior of six functional beliefs about smoking among adult smokers.

Design: Data was from the first three waves of the International Tobacco Control Four-Country Survey (ITC-4), a random-digit dialed telephone survey of a cohort of over 8,000 adult current smokers from the United Kingdom, United States, Canada, and Australia followed up annually.

Main Outcome Measures: Quitting attempts and the success of such attempts at the next wave.

Results: The six functional belief measures are modestly correlated with each other and are moderately stable over time. Smoking for enjoyment and life enhancement were significantly negatively related to quitting attempts, at least partly mediated by quitting intention and dependence. Smoking for stress management appeared to reduce quit success among those who tried, an effect mediated by quitting self-efficacy and dependence. Smoking for weight control, social facilitation, and as an aid to concentration were not independently associated with cessation.

Conclusion: Positive reasons for smoking may discourage quitting, but stress management is the only function that appears to prospectively predict quit success. Interventions should target those beliefs, and review the value of intervening on beliefs that are unrelated to cessation outcomes.

Citation

Shahab, L., Hammond, D., O’Connor, R.J., Cummings, K.M., Borland, R., King, B., McNeill, A. (2008). The reliability and validity of self-reported puffing behavior: Evidence from a cross-national study. Nicotine & Tobacco Research,10(5), 867-874.

Abstract

Self-reported puffing behavior has considerable potential as an indicator of smoking intensity, particularly in survey research evaluating population-based changes in smoking patterns. However, little is known about the reliability and validity of self-reported puffing behavior. This study compared smokers’ perceptions of their puffing behavior with measures of both machinedetermined puffing behavior and nicotine uptake to assess the utility of self-report. We assessed self-reported puffing behavior as well as demographic and smoking characteristics of 118 smokers from Australia, Canada, the United Kingdom, and the United States. At two visits, participants were asked to provide a saliva sample and to smoke a cigarette through a portable smoking topography device, the CReSSmicro, to measure puffing behavior. Saliva samples were assayed for cotinine, a measure of nicotine uptake, to provide estimates of smoke exposure. Intraclass coefficients for all measures of self-reported general puffing behavior were above .6, indicating that self-reported measures had fair-to-good test–retest reliability. Self-report, in particular of interpuff interval and number of cigarette puffs, was correlated only moderately with machine-determined puffing measures (.2<r<.4), and no self-report measure related to smoke exposure as measured by cotinine. Self-reported measures of puffing behavior appear to be fairly reliable but are correlated only weakly with objective measures of smoking topography. Results suggest that smokers have a better perception of the time spent between puffs and of the number of puffs taken than of the intensity and depth of each puff or their actual smoke exposure.

Citation

Yong, H.H., Borland, R., Hyland, A., Siahpush, M. (2008). How does a failed quit attempt among regular smokers affect their cigarette consumption? Findings from the International Tobacco Control Four Country Survey (ITC-4). Nicotine & Tobacco Research, 10(5), 897-905.

Abstract

Recent cross-sectional data suggests that smokers tend to reduce smoking following a failed selfinitiated quit attempt, possibly motivated by the need to reduce harms or to facilitate future quitting or both. This study prospectively examined changes in cigarette consumption among adult smokers who relapsed from a quit attempt. It uses data from the first three waves of the International Tobacco Control Four-Country Survey (ITC-4), a random digit-dialed telephone survey of a cohort of over 9,000 adult smokers from the United Kingdom, United States, Canada, and Australia, followed up annually. Compared with those who did not make a quit attempt, relapsers were more likely to reduce consumption (average reduction of 0.7 vs. 3.4, respectively) over a mean period of 7 months between waves 1 and 2. Of the relapsers, 52% reduced their consumption by 5% or more, but 22% increased it. Smokers who smoked heavily at baseline, whose last quit attempt ended more recently, was of longer duration, and quit via a gradual cutdown method were all independently associated with reducing smoking following a failed attempt. These findings were similar across all four countries and were successfully replicated using waves 2–3 data. Change in consumption between waves 1 and 2 (whether increase or decrease) was maintained by a substantial number a year later (wave 3), but change did not undermine nor promote quitting between waves 2 and 3.

Citation

O’Connor, R.J., Hyland, A., Giovino, G.A., Fong, G.T., Cummings, K.M. (2005). Smoker awareness of and beliefs about supposedly less-harmful tobacco products. American Journal of Preventive Medicine, 29(2), 85-90.

Abstract

Background: Cigarette manufacturers in the United States have begun marketing cigarette brands claiming to reduce smokers' exposure to selected toxins in tobacco smoke. Little data exist on smokers' awareness, use, and beliefs about these products.

Methods: Data from the U.S. arm of the International Tobacco Control Policy Four-Country Survey (ITC-4), a telephone survey of 2028 adult current cigarette smokers in the United States conducted between May and September 2003, were analyzed. Respondents were asked to report their awareness, beliefs, and use of products marketed as less harmful than traditional cigarettes and of smokeless tobacco (SLT) products.

Results: Close to 39% of smokers were aware of "less-harmful" cigarettes, but only 27% of them could name a specific brand of such cigarettes. The brand named most often was Quest (25.7%), followed by Eclipse (7.6%), Winston (5.7%), herbal cigarettes (3.3%), "smoke-free" cigarettes (2.9%), Marlboro Blend #27 (1.9%), and Omni (1.9%). Of those who named a brand, 25% believed such products were less harmful than "ordinary cigarettes." In contrast, 82% of cigarette smokers were aware of SLT products, but only 10.7% of these believed that SLTs were less harmful than ordinary cigarettes.

Conclusions: Smokers hold beliefs about the relative safety of supposedly less-harmful tobacco products that are opposite to existing scientific evidence. These results highlight the need to educate smokers about the risks of alternatives to conventional cigarettes, and the need to regulate the advertising and promotion of such alternatives.

Citation

Ding, X., Bedingfield, S., Yeh, C.H., Borland, R., Young, D., Zhang, J.Y., Petrovic-Lazarevic, S, Coghill, K. (2008). A decision tree approach for predicting smokers’ quit intentions. Journal of Electronic Science and Technology of China, 6(3), 220-224.

Abstract

This paper presents a decision tree approach for predicting smokerspsila quit intentions using the data from the International Tobacco Control Four Country Survey. Three rule-based classification models are generated from three data sets using attributes in relation to demographics, warning labels, and smokerspsila beliefs. Both demographic attributes and warning label attributes are important in predicting smokerspsila quit intentions. The modelpsilas ability to predict smokerspsila quit intentions is enhanced, if the attributes regarding smokerspsila internal motivation and beliefs about quitting are included.

Citation

Hammond, D., Reid, J., Driezen, P., Cummings, K.M., Borland, R., Fong, G.T., McNeill, A. (2008). Smokers' use of nicotine replacement therapy for reasons other than stopping smoking: Findings from the ITC Four Country Survey. Addiction, 103(10), 1696-1703.

Abstract

Aims: To measure the prevalence and correlates of nicotine replacement therapy (NRT) use for reasons other than quitting smoking among smokers in four countries.

Design and setting: Population-based, cross-sectional telephone survey with nationally representative samples of adult smokers in Canada, the United States, the United Kingdom and Australia, conducted in 2005.

Participants: A total of 6532 adult daily smokers in Canada (n = 1660), the United States (n = 1664), the United Kingdom (n = 1617) and Australia (n = 1591).

Measurements: Survey questions included demographics, smoking behaviour, use of NRT and reasons for NRT use, as well as access and availability of NRT.

Findings: Approximately 17% of smokers surveyed had used NRT in the past year. Among NRT users, approximately one-third used NRT for a reason other than quitting smoking, including temporary abstinence or reducing the number of cigarettes smoked. The prevalence of non-standard NRT use was remarkably consistent across countries. Using NRT for reasons other than quitting was associated with higher education level, heavier smoking, having no quit intentions, having no past-year quit attempts, the type of NRT product used and accessing NRT without a prescription.

Conclusions: The use of NRT for purposes other than quitting smoking is fairly common and may help to explain the difficulty in detecting significant quitting benefits associated with NRT use in population studies. Tobacco control policies, including the accessibility of NRT, may have important implications for patterns of NRT use.

Citation

Borland, R., Fong, G.T., Yong, H.H., Cummings, K.M., Hammond, D., King, B., Siahpush, M., McNeill, A., Hastings, G., O’Connor, R.J., Elton-Marshall, T., Zanna, M.P. (2008). What happened to smokers' beliefs about light cigarettes when "light/mild" brand descriptors were banned in the UK? Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 17(4), 256-262.

Abstract

Aim: This paper examines how beliefs of smokers in the UK were affected by the removal of “light” and “mild” brand descriptors, which came into effect on 30 September 2003 for Member States of the European Union (EU).

Participants: The data come from the first four waves (2002–2005) of the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey, an annual cohort telephone survey of adult smokers in Canada, USA, UK and Australia (15 450 individual cases).

Design: The UK ban on misleading descriptors occurred around the second wave of data collection in the ITC survey, permitting us to compare beliefs about light cigarettes among adult smokers in the UK before and after the ban, with beliefs in the three other ITC countries unaffected by the ban.

Results: There was a substantial decline in reported beliefs about the benefits of light cigarettes in the UK following the policy change and an associated public information campaign, but by 2005 (ie, wave 4), these beliefs rebounded slightly and the change in beliefs was no greater than in the USA, where there was no policy change.

Conclusions: The findings reveal that high levels of misperceptions about light cigarettes existed among smokers in all four countries before and after the EU ban took effect. We cannot conclude that the policy of removing some aspects of misleading labels has been effective in changing beliefs about light cigarettes. Efforts to correct decades of consumer misperceptions about light cigarettes must extend beyond simply removing “light” and “mild” brand descriptors.

Citation

King, B., Borland, R., Fowles, J. (2007). Mainstream smoke emissions of Australian and Canadian cigarettes. Nicotine & Tobacco Research, 9(8), 835-844.

Abstract

We investigated how mainstream smoke emissions vary and interrelate in 15 Australian and 21 Canadian brands,using public emissions disclosures from 2001. These disclosures provided emission data for 40 hazardous agents under both standard and intensive ISO testing conditions. Our analyses focused on ‘‘adjusted emissions’’ (i.e., emissions per milligram of nicotine yield) for 13 selected agents. Adjusted emissions differed significantly by ISO testing condition for 9 of the 13 selected agents. Intensive condition adjusted emissions were strongly negatively correlated for several agent pairs. Country and manufacturer variables were the strongest predictors of intensive condition adjusted emissions for 8 of the 13 selected agents and significant predictors for all of them. Taken together, these results suggest potential for the intent of emission limits to be undermined by risk swapping (in which one specific exposure is reduced within a group at the cost of another’s exposure increasing) and risk shifting (in which a specific exposure is reduced within a group at the cost of that exposure’s increasing within another group).

Citation

Hammond, D., Fong, G.T., Borland, R., Cummings, K.M., McNeill, A., Driezen, P. (2007). Communicating risk to smokers: The impact of health warnings on cigarette packages. American Journal of Preventive Medicine, 32(3), 202-209.

Abstract

Background: Health warnings on cigarette packages provide smokers with universal access to information on the risks of smoking. However, warnings vary considerably among countries, ranging from graphic depictions of disease on Canadian packages to obscure text warnings in the U.S. The current study examined the effectiveness of health warnings on cigarette packages in four countries.

Methods: Quasi-experimental design. Telephone surveys were conducted with representative cohorts of adult smokers (N= 14,975): Canada (n =3687); the U.S. (n =4273); the UK (n= 3634); and Australia (n =3381). Surveys were conducted between 2002 and 2005, before and at three time points following new warnings on UK packages.

Results: At Wave 1, Canadian smokers reported the highest levels of awareness and impact for health warnings among the four countries, followed by Australian smokers. Following the implementation of new UK warnings at Wave 2, UK smokers reported greater levels of awareness and impact, although Canadian smokers continued to report higher levels of impact after adjusting for the implementation date. U.S. smokers reported the lowest levels of effectiveness for almost every measure recorded at each survey wave.

Conclusions: Large, comprehensive warnings on cigarette packages are more likely to be noticed and rated as effective by smokers. Changes in health warnings are also associated with increased effectiveness. Health warnings on U.S. packages, which were last updated in 1984, were associated with the least effectiveness.

Citation

Young, D., Borland, R., Siahpush, M., Hastings, G., Fong, G.T., Cummings, K.M. (2007). Australian smokers support stronger regulatory controls on tobacco: Findings from the ITC Four-Country Survey. Australian and New Zealand Journal of Public Health, 31(2), 164-169.

Abstract

Objective: To examine Australian smokers’ attitudes towards regulation of the tobacco industry and to compare their attitudes with those of three similar countries – the United Kingdom (UK), the United States (US), and Canada

Method: A telephone survey of 2,056 adult Australian smokers and 6,166 Canadian, US, and UK smokers was conducted in 2004 as the third wave of the International Tobacco Control Policy Evaluation Four- Country Survey.

Results: Australian smokers display the strongest support for regulation. Only 16% believe that tobacco companies should be allowed to advertise/promote cigarettes as they please, 70% agree that tobacco products should be more tightly regulated, and 64% agree that governments should do more to tackle the harms of smoking. Smokers see government failure to do so in cynical terms – 77% agree that governments do not really care about smoking because of money from tobacco taxes. Opposition comes largely from smokers who hold self-exempting beliefs about smoking’s risks, have a positive attitude to smoking, do not accept that smoking is socially denormalised, and do not hold tobacco companies responsible for harms caused by smoking.

Conclusions and Implications: The majority of Australian smokers believe that the tobacco industry is partly responsible for the predicament they find themselves in and want governments to act more strongly in their real interests. The strong relationship between support for regulation and cynicism about government inaction should stimulate governments into action.

Citation

O’Connor, R.J., McNeill, A., Borland, R., Hammond, D., King, B., Boudreau, C., Cummings, K.M. (2007). Smokers' beliefs about the relative safety of other tobacco products: Findings from the ITC collaboration.Nicotine & Tobacco Research, 9(10), 1033-1042.

Abstract

Most tobacco control efforts in western countries focus on the factory-made, mass-produced (FM) cigarette, whereas other tobacco products receive relatively little attention. Noncombusted tobacco products (i.e., referred to as smokeless tobacco), particularly Swedish-style snus, carry lower disease risks, compared with combusted tobacco products such as cigarettes. In this context, it is important to know what tobacco users believe about the relative harmfulness of various types of tobacco products. Data for this study came from random-digit-dialed telephone surveys of current smokers aged 18 or older in Australia, Canada, the United Kingdom, and the United States. Three waves of data, totaling 13,322 individuals, were assessed. Items assessed use of and beliefs about the relative harms of cigars, pipes, smokeless tobacco, and FM and roll-your-own cigarettes, as well as sociodemographics and smoking behaviors. Cigars (2.8%-12.7%) were the other tobacco products most commonly used by current cigarette smokers, followed by pipes (0.3%-2.1%) and smokeless tobacco (0.0%-2.3%). A significant minority of smokers (12%-21%) used roll-your-own cigarettes at least some of the time. About one-quarter of smokers believed that pipes, cigars, or roll-your-own cigarettes were safer than FM cigarettes, whereas only about 13% responded correctly that smokeless tobacco was less hazardous than cigarettes. Multivariate analyses showed that use of other tobacco products was most strongly related to beliefs about the reduced harm of these other products. Use of other tobacco products was low but may be growing among smokers in the four countries studied. Smokers are confused about the relative harms of tobacco products. Health education efforts are needed to correct smoker misperceptions.