Citation

Levy, D.T., Cadham, C., Yuan, Z., Li, Y., Gravely, S., Cummings, K.M. (2023). Comparison of smoking prevalence in Canada before and after nicotine vaping product access using the SimSmoke model. Canadian Journal of Public Health, 114(6), 992-1005. doi: 10.17269/s41997-023-00792-3.

Abstract

Objectives: The public health impact of nicotine vaping products (NVPs) is subject to complex transitions between NVP and cigarette use. To circumvent the data limitations and parameter instability challenges in modeling transitions, we indirectly estimate NVPs impact on smoking prevalence and resulting smoking attributable deaths using the SimSmoke simulation model.

Methods: Canada SimSmoke uses age and sex specific data on Canadian population, smoking prevalence and tobacco control policies. The model incorporates the impact of cigarette oriented policies on smoking prevalence but not the explicit contribution of NVPs. The model was calibrated from 1999 to 2012, thereby projecting smoking prevalence before NVPs were widely used in Canada. The NVP impact on smoking prevalence is inferred by comparing projected 2012 2020 smoking trends absent NVPs to corresponding trends from two Canadian national surveys. We further distinguish impacts before and after NVPs became regulated in 2018 and more available.

Results: Comparing 2012-2020 survey data of post NVP to SimSmoke projected smoking prevalence trends, one survey indicated an NVP related relative reduction of 15% (15%) for males (females) age 15+, but 32% (52%) for those ages 15 24. The other survey indicated a 14% (19%) NVP related smoking reduction for ages 18+, but 42% (53%) for persons ages 18 24. Much of the gain occurre d since Canada relaxed NVP restrictions. NVP related 2012 2020 smoking reductions yielded 100,000 smoking attributable deaths averted from 2012 to 2060. Conclusion: Smoking prevalence in Canada, especially among younger adults, declined more rapidly once NVPs became readily available. The emergence of NVPs into the Canadian marketplace has not slowed the decline in smoking.

Conclusion: Smoking prevalence in Canada, especially among younger adults, declined more rapidly once NVPs became readily available. The emergence of NVPs into the Canadian marketplace has not slowed the decline in smoking.

Citation

Tildy, B., McNeill, A., East, K.A., Gravely, S., Fong, G.T., Cummings, K.M., Borland, R., Chan, C.K.G., Lim, C., Gartner, C., Yong, H.H., Brose, L.S. (2023). Self-reported depression and anxiety and healthcare professional interactions regarding smoking cessations and nicotine vaping: Findings from 2018 International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. Tobacco Prevention & Cessation, 9(August), 26. doi: 10.18332/tpc/168288.

Abstract

Introduction: People with mental health conditions are disproportionately affected by smoking-related diseases and death. The aim of this study was to assess whether health professional (HP) interactions regarding smoking cessation and nicotine vaping products (NVPs) differ by mental health condition.

Methods: The cross-sectional 2018 International Tobacco Control Four Country (Australia, Canada, England, United States) Smoking and Vaping Survey data included 11040 adults currently smoking or recently quit. Adjusted weighted logistic regressions examined associations between mental health (self-reported current depression and/or anxiety) and visiting a HP in last 18 months; receiving advice to quit smoking; discussing NVPs with a HP; and receiving a recommendation to use NVPs.

Results: Overall, 16.1% self-reported depression and anxiety, 7.6% depression only, and 6.6% anxiety only. Compared with respondents with no depression/anxiety, those with depression (84.7%, AOR=2.65; 95% CI: 2.17–3.27), anxiety (82.2%, AOR=2.08; 95% CI: 1.70–2.57), and depression and anxiety (87.6%, AOR=3.74; 95% CI: 3.19–4.40) were more likely to have visited a HP. Among those who had visited a HP, 47.9% received advice to quit smoking, which was more likely among respondents with depression (AOR=1.58; 95% CI: 1.34–1.86), and NVP discussions were more likely among those with depression and anxiety (AOR=1.63; 95% CI: 1.29–2.06). Of the 6.1% who discussed NVPs, 33.5% received a recommendation to use them, with no difference by mental health.

Conclusions: People with anxiety and/or depression who smoke were more likely to visit a HP than those without, but only those with depression were more likely to receive cessation advice, and only those with depression and anxiety were more likely to discuss NVPs. There are missed opportunities for HPs to deliver cessation advice. NVP discussions and receiving a positive recommendation to use them were rare overall.

Citation

Liu, C., Yong, H.H., Gravely, S., East, K.A., Kasza, K., Gartner, C., Cummings, K.M., Fong, G.T. (2023). Gender differences in cigarette smoking cessation attempts among adults who smoke and drink alcohol at high levels: Findings from the 2018-2020 International Tobacco Control Four Country Smoking and Vaping Surveys. Addictive Behaviours, 147, 107817. doi: 10.1016/j.addbeh.2023.107817.

Abstract

Background: This study examined the association between alcohol consumption and smoking cessation behaviour of adults who smoke in four countries.

Methods: Data came from 4275 adults (≥18 years) who smoked tobacco ≥ monthly and participated in the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping Surveys (Australia: n = 720; Canada: n = 1250; US: n = 1011; England: n = 1294). The 2018 Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) survey data coded into three levels ('never/low', 'moderate' or 'heavy' consumption) were analysed using multivariable logistic regression models to predict any smoking cessation attempts and successful cessation by 2020 survey, and whether this differed by gender and country.

Results: Compared to never/low alcohol consumers, only those who drink heavily were less likely to have made a quit smoking attempt (40.4 % vs. 43.8 %; AOR = 0.69, 95 % CI = 0.57-0.83, p < .001). The association differed by gender and country (3-way interaction, p < .001), with females who drink heavily being less likely to attempt to quit smoking in England (AOR = 0.27, 95 % CI = 0.15-0.49, p < .001) and Australia (AOR = 0.38, 95 % CI = 0.19-0.77, p = .008), but for males, those who drink moderately (AOR = 2.18, 95 % CI = 1.17-4.06, p = .014) or heavily (AOR = 2.61, 95 % CI = 1.45-4.68, p = .001) were more likely to make a quit attempt in England only. Alcohol consumption did not predict quit success.

Conclusion: Heavy alcohol use among adults who smoke appears to only undermine the likelihood of trying to quit smoking with some variation by gender and country of residence, but not their chances of succeeding if they tried.

Citation

Lemos, M.K., Taylor, E., Wadsworth, E., Reid, J.L., Hammond, D., East, K.A. (2023). Perceptions of cannabis use risk to mental health among youth in Canada, England, and the United States from 2017 to 2021. Drug and Alcohol Dependence, 250, 110904. doi: 10.1016/j.drugalcdep.2023.110904.

Abstract

Background: There is little research examining perceptions of cannabis use risk to mental health in countries with differing cannabis regulations. This study therefore examines such perceptions among youth between 2017 and 2021 in Canada (non-medical cannabis legalized in October 2018), England (highly-restricted medical cannabis legalized November 2018), and the US (non-medical cannabis legal in some states).

Methods: Seven repeat cross-sectional online surveys were conducted between July 2017 to August 2021 among youth aged 16-19 in Canada (N=29,420), England (N=28,155), and the US (N=32,974). Logistic regression models, stratified by country, were used to examine perceptions of cannabis use risk to mental health over time, adjusting for age group, sex, race/ethnicity, cannabis use and, for the US only, state-level cannabis legalization.

Results: Perceptions that cannabis use posed “no risk” to mental health decreased between July 2017 and August 2021 in Canada (6.1% to 4.4%; AOR=0.64, 95% CI=0.52-0.78) and the US (14.0% to 11.3%; AOR=0.74, 0.65-0.84) but not England (3.7% to 4.5%; AOR=1.21, 0.97-1.52). No significant changes were observed from immediately before (August 2018) to after (August 2019) legalization of non-medical cannabis in Canada (AOR=0.99, 0.83-1.20) or highly-restricted medical cannabis in England (AOR=0.90, 0.70-1.17). In the US, perceptions of “no risk” were more likely in states where cannabis use was illegal (15.0%) compared with legal non-medical (12.2%) (AOR=0.68, 0.63-0.74).

Conclusion: There were modest decreases in perceptions that cannabis use poses no risk to mental health in Canada and the US between 2017 and 2021 but no clear association with cannabis legalization status.

Citation

Gravely, S., Driezen, P., McClure, E., Smith, D.M., Fong, G.T. (2023). Prevalence of depressive symptoms and cannabis use among adult cigarette smokers in Canada: cross-sectional findings from the 2020 International Tobacco Control Policy Evaluation Project Canada Smoking and Vaping Survey. Canadian Medical Association Journal Open, 11(3), E516-E526. doi: 10.9778/cmajo.20220081.

Abstract

Background: Tobacco smoking and cannabis use are independently associated with depression, and evidence suggests that people who use both tobacco and cannabis (co-consumers) are more likely to report mental health problems, greater nicotine dependence and alcohol misuse than those who use either product exclusively. We examined prevalence of cannabis use and depressive symptoms among Canadian adults who smoke cigarettes and tested whether co-consumers of cannabis and tobacco were more likely to report depressive symptoms than cigarette-only smokers; we also tested whether cigarette-only smokers and co-consumers differed on cigarette dependence measures, motivation to quit smoking and risky alcohol use by the presence or absence of depressive symptoms.

Methods: We analyzed cross-sectional data from adult (age ≥ 18 yr) current (≥ monthly) cigarette smokers from the Canadian arm of the 2020 International Tobacco Control Policy Evaluation Project Four Country Smoking and Vaping Survey. Canadian respondents were recruited from Leger’s online probability panel across all 10 provinces. We estimated weighted percentages for depressive symptoms and cannabis use among all respondents and tested whether co-consumers (≥ monthly use of cannabis and cigarettes) were more likely to report depressive symptoms than cigarette-only smokers. Weighted multivariable regression models were used to identify differences between co-consumers and cigarette-only smokers with and without depressive symptoms.

Results: A total of 2843 current smokers were included in the study. The prevalence of past-year, past-30-day and daily cannabis use was 44.0%, 33.2% and 16.1%, respectively (30.4% reported using cannabis at least monthly). Among all respondents, 30.0% screened positive for depressive symptoms, with co-consumers being more likely to report depressive symptoms (36.5%) than those who did not report current cannabis use (27.4%, p < 0.001). Depressive symptoms were associated with planning to quit smoking (p = 0.01), having made multiple attempts to quit smoking (p < 0.001), the perception of being very addicted to cigarettes (p < 0.001) and strong urges to smoke (p = 0.001), whereas cannabis use was not (all p ≥ 0.05). Cannabis use was associated with high-risk alcohol consumption (p < 0.001), whereas depressive symptoms were not (p = 0.1).

Interpretation: Co-consumers were more likely to report depressive symptoms and high-risk alcohol consumption; however, only depression, and not cannabis use, was associated with greater motivation to quit smoking and greater perceived dependence on cigarettes. A deeper understanding of how cannabis, alcohol use and depression interact among people who smoke cigarettes is needed, as well as how these factors affect cessation activity over time.

Citation

Gravely, S., Yong, H.H., Reid, J.L., East, K.A., Liber, A.C., Cummings, K.M., Quah, A.C.K., Fong, G.T., Hammond, D. (2023). An examination of quitting smoking as a reason for vaping by the type of nicotine vaping device used most often among adults who smoke and vape: Findings from the Canada, England and the United States 2020 ITC Smoking and Vaping Survey. Preventive Medicine Reports, 33, 102201. doi: 10.1016/j.pmedr.2023.102201.

Abstract

Several nicotine vaping product (NVP) device types are available to consumers, and many people who smoke report vaping to help them quit. This study included data from the Wave 3 (2020) ITC Smoking and Vaping Survey in the US, Canada, and England and included 2324 adults who were smoking cigarettes and vaping at least weekly. Device types currently used most often (disposables, cartridges/pods, or tank systems) were assessed using weighted descriptive statistics. Multivariable regression analyses were used to compare differences between respondents who reported vaping to quit smoking (‘yes’ vs. ‘no/don’t know’) by device type, overall and by country. Overall, 71.3% of respondents reported vaping to help them quit smoking, with no country differences (p = 0.12). Those using tanks (78.7%, p < 0.001) and cartridges/pods (69.5%, p = 0.02) were more likely to report this reason for vaping than those using disposables (59.3%); respondents using tanks were also more likely than those using cartridges/pods (p = 0.001) to report this reason. By country, respondents in England using cartridges/pods or tanks (vs. disposables) were more likely to report vaping to quit smoking (with no difference between cartridges/pods and tanks). In Canada, respondents using tanks were more likely to report vaping to quit smoking than those using cartridges/pods or disposables (no difference between disposables and cartridges/pods). No significant differences by device type were found in the US. In conclusion, most adult respondents who smoked and vaped reported using either cartridges/pods or tanks, which were associated with greater odds of vaping for the purpose of quitting smoking versus disposables, with some country variations.

Citation

Gallien, M., Occhiali, G., Ross, H. (2023). An overlooked market: loose cigarettes, informal vendors and their implications for tobacco taxation. Tobacco Control, [Published online May 23, doi: 10.1136/tc-2023-057965].

Abstract

Objective: To examine the features of markets for loose cigarettes in several low-income and middle-income countries and their effects on tobacco control policies, particularly taxation.

Design: An analysis of survey data targeting people who smoke in two African, one Southeast Asian and two South Asian countries and retailers across 16 African countries to study loose cigarette markets and examine how prices in these markets move relative to the prices for cigarette packs.

Results: Markets for loose cigarettes are large, and their consumer base tends to differ from the wider population of people who smoke. Loose cigarette prices are on average higher than those of cigarettes bought in packs, and they respond differently to tax increases, at least partially due to a denomination effect.

Conclusions: The features of the loose cigarette markets present a challenge for tobacco control policy, especially tobacco tax policy. One way to overcome this challenge is to aim for large, rather than incremental, tax increases.

Citation

Yong, H.H., Karmakar, C., Motin, M. A., Borland, R., Cummings, K.M., Gravely, S., Fong, G.T. (2023). Individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies relative to combustible cigarettes among people who smoke: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 25(9), 1594-1602. doi: 10.1093/ntr/ntad075.

Abstract

Introduction: This study examined individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies (NRTs) relative to combustible cigarettes (CCs).

Methods: Data analyzed came from 8,642 adults (18+ years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n=1213), Canada (n=2633), England (n=3057), and United States (US, n=1739). Respondents were asked: Compared to smoking cigarettes, how harmful do you think nicotine replacement products are? Responses were dichotomised into much less vs. otherwise for analysis using multivariable logistic regression models, complemented by decision-tree analysis to identify conjoint factors.

Results: Percentages believing that NRTs are much less harmful than CCs were 29.7% (95% CI:26.2-33.5%) in Australia, 27.4% (95% CI=25.1-29.8%) in England, 26.4% (95% CI=24.4-28.4%) in Canada and 21.7% (95% CI=19.2-24.3%) in the US. Across all countries, believing nicotine is not at all/slightly harmful to health (aOR=1.53-2.27), endorsing nicotine vaping products as less harmful than CCs (much less harmful: aOR=7.24-14.27; somewhat less harmful: aOR=1.97-3.23), and possessing higher knowledge of smoking harms (aOR=1.23-1.88) were individual factors associated with increased odds of believing NRTs are much less harmful than CCs. With some country variations, these nicotine-related measures also interacted with each other and socio-demographic variables to serve as conjoint factors associated with the likelihood of accurate NRT relative harm belief.

Conclusions: Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors.

Implications: This study demonstrates that despite past efforts to educate people who smoke about the harms of NRTs relative to CCs, misperceptions around the relative harmfulness of NRTs remain substantial. In all four studied countries, subgroups of people who smoke regularly who are misinformed about the relative harmfulness of NRTs, and who may be reluctant to use NRTs for smoking cessation can be reliably identified for corrective interventions based o n their understanding of the harms related to nicotine, NVPs and smoking along with sociodemographic markers. The identified subgroup information can be used to prioritize and inform the development of effective interventions to specifically address the gaps in knowledge and understanding of the various subgroups identified. Our results suggest these may need to be tailored for each country.

Citation

Reid, J., Burkhalter, R., Kasza, K.A., Seo, Y., East, K.A., Hyland, A., Hammond, D. (2023). Minimum legal age laws and perceived access to cigarettes, e-cigarettes, and other substances among youth in Canada, England, and the United States: 2017-2021. International Journal of Drug Policy, 115, 104003. doi: 10.1016/j.drugpo.2023.104003.

Abstract

Background: Minimum legal age (MLA) restrictions are a core policy to reduce youth use of tobacco, e-cigarettes, and other substances. We examined trends in perceived ease of access to tobacco and other substances across three countries with differing MLA policies, including the United States (US), which increased the federal MLA for tobacco products from 18 to 21 in 2019.

Methods: Repeat cross-sectional data were analyzed from seven waves of the International Tobacco Control (ITC) Youth Tobacco and Vaping Survey conducted between 2017 and 2021. Online surveys were conducted with non-probability samples of 91,647 youth aged 16-19 in Canada, England, and the US. Regression models were used to examine differences in perceived ease of accessing each of 7 substances (analyzed as "very easy" or "fairly easy" versus else), and differences between countries and over time (including before and after any MLA changes) for cigarettes, e-cigarettes, cannabis, and alcohol; additional models examined sub-national variation in MLA.

Results: Perceived access varied by substance and across countries: in August/September 2021, perceived ease of accessing cigarettes and e-cigarettes was greater in Canada where MLA was 18-19 (61.7% cigarettes, 66.4% e-cigarettes) and England where MLA was 18 (66.9%, 69.6%), compared to the US where MLA was 21 (48.0%, 60.9%; p < 0.001 for all). Perceived ease of accessing cannabis was greatest in Canada (53.3%), followed by the US (44.1%) and England (34.0%; p < 0.001 for all). Following the federal MLA increase for tobacco products in the US, perceived ease of access decreased significantly for cigarettes (65.1% in 2019Aug to 59.7% in 2020Feb; aOR=0.80 (95%CI=0.71-0.89)) and e-cigarettes (72.4% in 2019Aug to 69.4% in 2020Feb; aOR=0.87 (95%CI=0.77-0.98)).

Conclusions: Higher MLA was strongly associated with fewer youth perceiving easy access to substances: perceived access varied between countries with differing MLA, as well as within-country before and after changes to MLA.

Citation

Yimsaard, P., Gravely, S., Meng, G., Fong, G.T., Cummings, K.M., Hyland, A., Borland, R., Hammond, D., Kasza, K.A., Li, L., Quah, A.C.K. (2023). Differences in smoking cessation behaviours and vaping status among adult daily smokers with or without depression, anxiety, hazardous alcohol use: Findings from the 2018 and 2020 ITC Four Country Smoking and Vaping Survey. International Journal of Mental Health and Addiction. doi:10.1007/s11469-023-01058.

Abstract

This study examined differences in quit attempts, 1-month quit success, and vaping status at follow-up among a cohort of 3709 daily smokers with and without depression, anxiety, and regular alcohol use who participated in both the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys. At baseline, a survey with validated screening tools was used to classify respondents as having no, or one or more of the following: 1) depression, 2) anxiety, and 3) regular alcohol use. Multivariable adjusted regression analyses were used to examine whether baseline (2018) self-report conditions were associated with quit attempts; quit success; and vaping status by follow-up (2020). Results showed that respondents who reported depressive symptoms were more likely than those without to have made a quit attempt (aOR = 1.32, 95% CI:1.03–1.70, p = 0.03), but were less likely to have quit (aOR = 0.55, 95% CI:0.34–0.89, p = 0.01). There were no differences in quit attempts or quit success between those with and without self-reported anxiety diagnoses or regular alcohol use. Among successful quitters, respondents with baseline depressive symptoms and self-reported anxiety diagnoses were more likely than those without to report vaping at follow-up (aOR = 2.58, 95% CI:1.16–5.74, p = 0.02, and aOR = 3.35 95% CI:1.14–9.87, p = 0.03). In summary, it appears that smokers with depression are motivated to quit smoking but were less likely to manage to stay quit, and more likely to be vaping if successfully quit. As smoking rates are higher among people with mental health conditions, it is crucial for healthcare professionals to identify these vulnerable groups and offer tailored smoking cessation support and continued support during their quit attempt.

Citation

Usidame, O., Meng, G., Thrasher, J.F., Thompson, M.E., Fong, G.T., Fleischer, N.L. (2023). Examining the effectiveness of the 2012 Canadian graphic warning label policy change by sex, income, and education. Nicotine and Tobacco Research, 25(4), 763-772. doi: 10.1093/ntr/ntac235.

Abstract

Background: We examined the differential impact of the 2012 Canadian GWL policy changes on key indicators of warning label impact and quit intentions using national cohorts of Canadian and US adults who smoke.

Methods: We used data from all waves of the International Tobacco Control surveys (2002-2020) in Canada and the US. Our key measures were quit intentions and an index of warning label effectiveness (salience, cognitive and behavioral reactions). We estimated overall policy impact by comparing Canada (treatment group) with the US (control group) using controlled interrupted time series (CITS) regression models, with interactions to examine whether policy impact varied by sex, education, and income.

Results: The CITS model showed a statistically significant increase in the warning label effectiveness in Canada post-policy, compared to the US (β= 0.84, 95% CI 0.35,1.33). Similarly, the odds of quit intentions were relatively higher among adults who smoked in Canada compared to the US (OR= 1.89, 95% CI 1.51,2.36) post-policy. The three-way interaction model showed that these associations were greater among adults from low socioeconomic status (SES) groups than in high SES groups.

Discussion: The 2012 change in the Canadian GWL policy was associated with stronger cognitive and behavioral responses to GWLs and higher odds of quit intentions among adults who smoked in Canada when compared to the US, specifically among individuals from low SES groups, suggesting a positive equity impact. Our findings affirm the need for countries to implement or enhance GWLs, in line with the WHO Framework Convention on Tobacco Control.

Implications: The evidence on the potential health equity benefit of GWL policies is mixed. To further understand the influence of GWL policies on tobacco use disparities, more systematic research using pre/post policy designs with control groups is needed. Using a controlled interrupted time series model, we aimed to strengthen the available evidence on the causal influence of this tobacco control approach. Our findings show that the 2012 GWL policy change had a greater impact on adults who smoked from low SES groups than it did on adults who smoked from high SES groups, indicating a potentially positive equity impact and confirming the need for countries to implement or maximize the size of GWLs, as recommended by the WHO Framework Convention on Tobacco Control.

Citation

Yong, H.H., Chow, R., East, K.A., Thrasher, J.F., Hitchman, S.C., Borland, R., Cummings, K.M., Fong, G.T. (2023). Do social norms for cigarette smoking and nicotine vaping product use predict trying nicotine vaping products and attempts to quit cigarette smoking amongst adult smokers? Findings from the 2016-2020 ITC Four Country Smoking and Vaping Surveys. Nicotine and Tobacco Research, 25(3), 505-513. doi: 10.1093/ntr/ntac212.

Abstract

Objectives: To examine whether perceived injunctive and descriptive social norms towards cigarette and nicotine vaping product (NVP) use predicted subsequent trying NVPs and attempts to quit cigarette smoking amongst current smokers, and whether associations varied across countries.

Method: Three waves of longitudinal cohort data from the International Tobacco Control Four Country Smoking and Vaping Survey collected between 2016 and 2020 from 2,290 adult smokers in Canada, Australia, England, and the United States who had never used NVPs at baseline (either Wave 1 or Wave 2) and followed up at the subsequent wave (Wave 2 or Wave 3, respectively) were analysed using Generalised Estimating Equations.

Results: Of the injunctive and descriptive norm measures for smoking and NVP use, NVP initiation was only independently predicted by the injunctive interpersonal norm for NVP use, with perceived approval of NVP use by important others predicting higher odds of trying NVPs (AOR=1.65, 95% CI=1.20-2.27). This predictive effect was independent of baseline quit intention with no country variations found. By contrast, making cigarette smoking quit attempts was independently predicted by both injunctive and descriptive interpersonal norms with perceived disapproval of smoking by important others (AOR=1.65, 95% CI=1.38-1.99) and close friends using NVPs (AOR=1.37, 95% CI=1.04-1.79), both associated with higher odds of smoking quit attempts.

Conclusions: Adult smokers who perceive NVP use as normative, either because such behaviour is socially approved or common within their close social networks, appear more inclined to try NVPs or make smoking quit attempts than smokers who do not.

Implications: What this study adds: Social norms can shape a person's behaviour and result in behaviour change. This study shows that initiation of NVP use behaviour among smokers can be reliably predicted by their perception of whether NVP use is acceptable to those important to them within their close social networks. Similarly, any attempts to stop cigarette smoking can be predicted by their perception of how acceptable cigarette smoking is among those who are important to them and whether any of their close friends use NVPs. Changing social norms towards cigarette smoking and NVP use could therefore be incorporated into smoking cessation interventions to help smokers to quit and/or switch to NVP use.

Citation

Gravely, S., Chung-Hall, J., Craig, L.V., Fong, G.T., Cummings, K.M., Borland, R., Yong, H.H., Loewen, R., Martin, N., Quah, A.C.K., Hammond, D., Ouimet, J., Boudreau, C., Thompson, M.E., Driezen, P. (2023). Evaluating the impact of plain packaging among Canadian smokers: Findings from the 2018 and 2020 ITC Smoking and Vaping Surveys. Tobacco Control, 32(2), 153-162. doi:10.1136/tobaccocontrol-2021-056635.

Related resources from the Health Canada Supported Dissemination Project (ITC Canada Survey Findings)

Mar 30, 2021 | Impact of Plain Packaging in Canada

Mar 30, 2021 | Incidence de l'emballage neutre au Canada

Sep 22, 2021 | Impact of Plain Packaging in Canada | Infographic | English

Sept 22, 2021 | Press Release from University of Waterloo: Plain packaging on cigarette packs in Canada advanced efforts for reducing smoking

Abstract

Background: In February 2020, Canada implemented plain packaging without any changes to the size and content of health warning labels (HWLs), which were last updated in 2012 (pictorial HWLs on 75% of the pack front and back). This pre-post evaluation study assessed the impact of plain packaging in Canada on: (1) pack appeal; (2) HWL effectiveness; and (3) support for plain packaging. Additionally, a quasi–experimental design was used to assess the Canadian results relative to two comparator countries: Australia, where plain packaging (with new larger HWLs) was implemented in 2012, and the United States (USA), where plain packaging has not been implemented and the same text warnings have appeared on cigarette packs since 1985.

Methods: Data are from adult smokers who participated in the 2018 and/or 2020 International Tobacco Control Smoking and Vaping Surveys in Canada (n=4600), Australia (n=1834) and the USA (n=3046). Online surveys were conducted before (February to July 2018) and after (February to June 2020) the implementation of plain packaging in Canada. Adjusted regression analyses were conducted on weighted data.

Results: Plain packaging was associated with a significant increase in the percentage of Canadian smokers who did not like the look of their cigarette pack (2018: 28.6% vs 2020: 44.7%, p<0.001), whereas no change in pack appeal was observed among smokers in Australia and the USA over the same period. Plain packaging was not associated with changes in HWL effectiveness in Canada. Support for plain packaging increased significantly among Canadian smokers (2018: 25.6% vs 2020: 33.7%, p><0.001).

Conclusions: Plain packaging in Canada substantially reduced pack appeal and increased support for the policy among adult smokers; however, there was no increase in the effectiveness of Canada’s 8-year-old HWLs. The impact of plain packaging on health warning effectiveness may depend on the design of the warnings and length of time since implementation.

Citation

Le Grande, M.R., Balmford, J., Borland, R., McNeill, A. (2023). Perceived health and capacity to cope with stress in recent ex-smokers: Impact of vaping versus quitting all nicotine. Nicotine and Tobacco Research, 25(3), 553-562. doi: 10.1093/ntr/ntac252.

Abstract

Introduction: Little is known about the continued use of nicotine following smoking cessation on perceived well-being in comparison to complete cessation of nicotine use.

Aims and Methods: To explore aspects of perceived well-being and coping among recent ex-smokers as a function of vaping status. Ever-daily smokers in the International Tobacco Control 4 country smoking and vaping surveys in 2016 (w1 N = 883) and 2018 (w2 N = 1088). Cross-sectional associations and longitudinal samples for those who quit between waves and those who quit at w1 and maintained abstinence to w2. Main outcome measures were: Past 30 days of depression symptoms, perceived stress, stress management since quitting, and change in perceived day-to-day health.

Results: In the cross-sectional analyses vapers were more likely to report both improved stress management (aOR = 1.71, 95% CI 1.23–2.36) and perceived day-to-day health (aOR = 1.65, 95% CI 1.26–2.16) than nicotine abstainers. In the longitudinal analyses, smokers who switched to vaping between waves (n = 372) were more likely to report depression symptoms at w2 (aOR = 2.00, 95% CI 1.09–3.65) but reported improved perceived health (aOR = 1.92, 95% CI 1.16–3.20). For the past daily smokers who remained quit between waves (n = 382), vapers were more likely to report improved stress management relative to abstainers (RRR = 5.05. 95% CI 1.19–21.40). There were no other significant differences between vapers and nicotine abstainers.

Conclusions: There is little evidence to support the view that perceptions of well-being deteriorate in vapers compared to complete nicotine abstainers in the immediate years after smoking cessation.

Implications: This study could find no conclusive evidence that the continued use of nicotine via e-cigarettes was detrimental to health compared to completely stopping nicotine intake altogether. Our results would suggest that continuing to use nicotine may even result in some benefits in the short term such as improved stress management, however further longitudinal studies are required to examine if these effects are restricted to the early post-quitting phase and whether other positive or negative effects on psychosocial health emerge in the future.

Citation

Kasza, K.A., Hammond, D., Gravely, S., O’Connor, R.J., Meng, G., East, K.A., Borland, R., Cummings, K.M., Fong, G.T., Hyland, A. (2023). Associations between nicotine vaping uptake and cigarette smoking cessation vary by smokers’ plans to quit: Longitudinal findings from the International Tobacco Control (ITC) Four Country Smoking and Vaping Surveys. Addiction, 118(2), 340-352. doi: 10.1111/add.16050.

Abstract

Background and aims: Most population studies that evaluate the relationship between nicotine vaping and cigarette cessation focus on limited segments of the smoker population. We evaluated vaping uptake and smoking cessation considering differences in smokers' plans to quit.

Design: Longitudinal ITC Four Country Smoking and Vaping Surveys conducted in 2016, 2018, and 2020. Setting: US, Canada, England, Australia.

Participants: Adult daily cigarette smokers who had not vaped in the past 6 months at baseline and had participated in two or more consecutive waves of the ITC Four Country Smoking and Vaping Surveys (n= 2,815).

Measurements: Plans to quit cigarette smoking at baseline (within 6 months, beyond 6 months, not planning to quit) and at follow-up (within 6 months versus not within 6 months); cigarette smoking cessation at follow-up (smoking less than monthly [including complete cessation] versus daily/weekly/monthly smoking); inter-wave vaping uptake (none, only nondaily vaping, any daily vaping). Generalized estimating equations were used to evaluate whether inter-wave vaping uptake was associated with smoking cessation at follow-up, and with planning to quit at follow-up, each stratified by plans to quit smoking at baseline.

Findings: Overall, 12.7% of smokers quit smoking. Smokers not initially planning to quit within 6 months experienced higher odds of smoking cessation when they took up daily vaping (32.4%) versus no vaping (6.8%; adjusted odds ratio [AOR]=8.58, 95% confidence interval [CI]:5.06-14.54). Among smokers planning to quit, smoking cessation rates were similar between those who did and did not take up daily vaping (25.1% vs. 16.8%; AOR=1.91, 95%CI:0.91-4.00), though we could not account for potential use of cessation aids. Daily vaping uptake was associated with planning to quit smoking at follow-up among those initially not planning to quit (AOR=6.32, 95%CI:4.17-9.59).

Conclusions: Uptake of nicotine vaping appears to be strongly associated with cigarette smoking cessation among smokers with no initial plans to quit smoking. Excluding smokers not planning to quit from studies on vaping and smoking cessation may underestimate potential benefit of daily vaping for daily smokers.

Citation

Chung-Hall, J., Fong, G.T., Meng, G., Craig, L.V. (2023). Illicit cigarette purchasing after implementation of menthol ban in Canada: Findings from the 2016-2018 ITC Four Country Smoking and Vaping Surveys. Tobacco Control, [Published online, doi:10.1136/tc-2022-057697].

Abstract

Objective: To examine the impact of menthol cigarette bans on use and purchasing of illicit cigarettes among menthol and non-menthol smokers in seven Canadian provinces.

Methods: Data from 1098 non-menthol smokers and 138 menthol smokers in Canada who completed the ITC Four Country Smoking and Vaping Survey in 2016 (pre-ban) and 2018 (post-ban). Brand validation analysis was conducted to (1) compare self-reported use of menthols versus actual use of menthols as regular brand, and verify self-reported purchasing of menthols among pre-ban menthol smokers at post-ban; and (2) assess pre-post ban changes in purchasing of illicit cigarettes from First Nations reserves among non-menthol smokers and menthol smokers.

Results: Among the subset of 138 pre-ban menthol smokers, 36 (19.5%) reported smoking menthols at post-ban. Brand validation analyses showed that 19 (9.0%) were actually using a non-menthol brand; of the 17 (10.5%) who were actually using a menthol brand, 13 (7.9%) bought a menthol brand at last purchase, and 4 (2.6%) bought a non-menthol brand. Among the full sample of smokers who purchased cigarettes from First Nations reserves at both pre-ban and post-ban, there was no change in purchasing of menthols (n=9 menthol smokers; 51.2% vs 51.2%, p=1.00), non-menthols (n=1024 non-menthol smokers; 9.1% vs 8.7%, p=0.69) or all cigarettes (menthol+non-menthol) (n=1086 smokers; 9.7% vs 9.2%, p=0.56).

Conclusions: Actual rates of brand-verified menthol smoking were substantially lower than self-reported rates at post-ban. After Canada’s menthol ban, there was no increase in illicit purchasing of menthol or non-menthol cigarettes from First Nations reserves.

Press:

January 12, 2023 | UW News | Study refutes industry claims that ban on menthol cigarettes leads to increased use of illegal smokes

Citation

Fix, B.V., O’Connor, R.J., Goniewicz, M.L., Leigh, N.J., Cummings, K.M., Hitchman, S.C., Fong, G.T., Nahhas, G.J., Hammond, D., McNeill, A., Borland, R., King, B., Palumbo, M. (2023). Characterisation of vaping liquids used in vaping devices across four countries: Results from an analysis of selected vaping liquids reported by users in the 2016 ITC Four Country Smoking and Vaping Survey. Tobacco Control, 32(1), 51-59. doi: 10.1136/tobaccocontrol-2020-056338.

Abstract

Objectives: This study presents an analysis of vaping products (VPs) purchased in the USA, Canada, England and Australia and assesses whether differences in regulations were associated with differences in the chemical composition of the VPs.

Methods: April-September 2017, a total of 234 VP refill liquids and prefilled cartridges were purchased in convenience samples of retail locations in each country. Products were chosen from brands and styles most commonly reported by current VP users in the 2016 ITC Four Country Smoking and Vaping Survey. All products were tested for nicotine, tobacco-specific nitrosamines (TSNAs), minor tobacco alkaloids, organic acids and flavouring chemicals.

Results: Consistent with the laws in Canada and Australia at the time of product purchase, nicotine was not detected in any of the VPs (n=10 in Canada; n=15 in Australia). US liquids (n=54) had a mean nicotine concentration of 16.2 mg/mL, (range=0.0-58.6) and English liquids (n=166) had a mean concentration of 11.9 mg/mL ((range=0.0-31.2) F(3244)=12.32, p<0.001). About 5% of English samples exceeded the UK's 20 mg/mL nicotine limit. Substantial country differences were observed in levels of TSNAs, with the USA being higher than elsewhere. Of all products tested, 18.8% contained at least one organic acid. Liquids purchased in England contained far more identifiable flavouring chemicals than those in the other countries.

Conclusions: VP composition, particularly with respect to nicotine and flavouring, varies by country, likely reflecting both marketplace preferences and country-specific regulations. There are differences between nicotine levels claimed on the package and actual levels, particularly in England.

Citation

Hammond, D., Reid, J., Burkhalter, R., O’Connor, R.J., Goniewicz, M.L., Wackowski, O.A., Thrasher, J.F., Hitchman, S.C. (2023). Trends in e-cigarette brands, devices and the nicotine profile of products used by youth in England, Canada and the USA: 2017-2019. Tobacco Control, 32(1), 19-29. doi: 10.1136/tobaccocontrol-2020-056371.

Abstract

Background: The e-cigarette market has rapidly evolved, with a shift towards higher nicotine concentration and salt-based products, such as JUUL; however, the implications for youth vaping remain unclear.

Methods: Repeat cross-sectional online surveys were conducted in 2017, 2018 and 2019, with national samples of youth aged 16–19 years recruited from commercial panels in Canada (n=12 018), England (n=11 362) and the USA (n=12 110). Regression models examined differences between countries and over time in the types of e-cigarette products used (design and nicotine content), reasons for using brands and differences in patterns of use, sociodemographics and dependence symptoms by brand/nicotine content.

Results: In 2019, the use of pod- or cartridge-style e-cigarettes was greater in Canada and the USA than England, with Smok and JUUL the leading brands in all countries. In 2019, youth vapers in England were less likely to report using e-cigarettes with ≥2% nicotine (12.8%) compared with Canada (40.5%; adjusted OR (AOR)=4.96; 95% CI 3.51 to 7.01) and the USA (37.0%; AOR=3.99, 95% CI 2.79 to 5.71) and less likely to report using nicotine salt-based products (12.3%) compared with Canada (27.1%; AOR=2.77, 95% CI 1.93 to 3.99) and the USA (21.9%; AOR=2.00, 95% CI 1.36 to 2.95). In 2019, self-reported use of products with higher nicotine concentration was associated with significantly greater frequency of vaping, urges to vape and perceived vaping addiction (p<0.05 for all).

Conclusions: The use of high-nicotine salt-based products is associated with greater symptoms of dependence, including JUUL and other higher-nicotine brands. Greater use of high-nicotine salt-based products may account for recent increases in the frequency of vaping among youth in Canada and the USA.

Citation

Li, L., Borland, R., Cummings, K.M., Fong, G.T., Hyland, A., Le Grande, M., McNeill, A. (2023). Non-cigarette combustible tobacco use and its associations with subsequent cessation of smoking among daily cigarette smokers: Findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2016-2020). Addiction, 118(1), 140-148. doi: 10.1111/add.16023.

Abstract

Aims: To examine whether poly-use of cigarettes and other smoked products (poly-smoking) is predictive of quit attempts and quit success.

Design: A prospective multi-country cohort design.

Setting: Australia, Canada, England and the US.

Participants: 3983 adult daily cigarette smokers were surveyed in 2016 (Wave 1 of data collection) and were recontacted in 2018 (Wave 2) (i.e., Wave 1–Wave 2 cohort) in the International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys; and 3736 smokers were surveyed in 2018 and recontacted in 2020 (Wave 3) (i.e., Wave 2–Wave 3 cohort).

Measurements: Participants were asked about their cigarette smoking and use of cigars, cigarillos, pipes, and waterpipes. Outcomes were quit attempts between two survey waves and success, defined as having quit smoking all the combustible tobacco at the subsequent survey for 1 month or more.

Findings: Levels of poly-smoking were 12.7% in the Wave 1–Wave 2 cohort and 10.5% for the Wave 2–Wave 3 cohort. Compared with cigarette-only smokers, poly-smokers were more likely to attempt between Waves 1 and 2 (54.9% vs. 42.7%, adjusted odds ratio (aOR)=1.37, 95% confidence interval [CI] 1.08-1.74, p<0.01), but not between Waves 2 and 3 (43.8% vs. 40.1%, aOR=0.94, 95%CI 0.72-1.22). Poly-smoking predicted reduced likelihood of success in both cohorts among attempters and the overall samples. Between Waves 2 and 3 there were significantly more transitions to non-daily smoking among the poly-smokers (12.4% vs. 5.3%, 2=40.4, p<0.001).

Conclusions: There is a consistent association between poly-smoking (use of cigarettes along with other smoked products) and reduced quit success for combustible tobacco, but it is likely due to increased likelihood of transitioning to non-daily use rather than complete cessation.

Citation

Gravely, S., Driezen, P., McClure, E., Hammond, D., Cummings, K.M., Chan, G.C.K., Hyland, A., Borland, R., East, K., Fong, G.T., Schauer, G.L., Quah, A.C.K., Ouimet, J., Smith, D.M. (2022). Differences between adults who smoke cigarettes daily and do and do not co-use cannabis: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Addictive Behaviours, 135, 107434. doi: 10.1016/j.addbeh.2022.107434.

Abstract

Background: Little is known about population-level differences between adults who exclusively smoke cigarettes and those who smoke cigarettes and also use cannabis (co-consumers). Thus, this study describes differences on sociodemographic, cigarette-dependence, health and behavioral variables, and risk perceptions associated with smoking cannabis.

Methods: This cross-sectional study included 6941 respondents from the 2020 ITC Four Country Smoking and Vaping Survey (US, Canada, Australia, England). Adult daily cigarette smokers were included and categorized as: cigarette-only smokers (never used cannabis/previously used cannabis, but not in the past 12 months, n=4857); occasional co-consumers (cannabis use in the past 12 months, but<weekly use, n=739); or regular co-consumers (use cannabis ≥weekly, n=1345). All outcomes were self-reported. Regression models were conducted on weighted data.

Results: Overall, 19.9% of respondents reported regular cannabis co-use and 10.1% reported occasional co-use. Regular co-use was highest in Canada (27.2%), followed by the US (24.4%), England (12.7%) and Australia (12.3%). Compared to cigarette-only smokers, regular co-consumers were more likely to be male and report chest/breathing problems (p<0.001). All co-consumers were more likely to be younger, have lower income, be experiencing financial stress, reside in Canada, have depressive symptoms, use alcohol more frequently and binge drink, use other tobacco/nicotine products, and perceive smoking cannabis as low health risk and less harmful than smoking cigarettes (all p><0.001). Cigarette dependence measures were similar between co-consumers and cigarette-only smokers (all p≥0.05).

Conclusions: Although there were no differences on cigarette dependence measures between daily cigarette smokers who do and do not use cannabis, there are several other risk factors that may affect tobacco use and abstinence among co-consumers (e.g., greater depression, high-risk alcohol consumption). Thus, tobacco cessation treatment may require multi-pronged strategies to address other health behaviors. Continued surveillance is needed to determine the nature and health implications of co-use considering changing policies, markets, and products.

Citation

Freitas Lemos, R., Stein, J.S., Tegge, A.N., Kaplan, B.A., Heckman, B.W., McNeill, A., Cummings, K.M., Fong, G.T., Bickel, W.K. (2022). The Illegal Experimental Tobacco Marketplace II: Effects of vaping product bans - findings from the 2020 International Tobacco Control Project. Tobacco Control, 31(Suppl 3), s214-s222.

Abstract

Significance: Restrictive e-cigarette policies may increase purchases from illegal sources. The Illegal Experimental Tobacco Marketplace (IETM) allows examination of how restrictions impact illegal purchases. We investigated (1) the effect of a vaping ban, total flavour vaping ban and partial flavour vaping ban on the probability of purchasing illegal vaping products among different regulatory environments (USA, Canada and England) and tobacco user types (cigarette smokers, dual users and e-cigarette users); and (2) the relation between ban endorsement and illegal purchases.

Methods: Participants (N=459) from the International Tobacco Control Survey rated their support of bans and chose to purchase from a hypothetical legal experimental tobacco marketplace or IETM under control and the three ban conditions.

Results: In total, 25% of cigarette smokers, 67% of dual users and 79% of e-cigarette users made IETM purchases. Cross-country comparisons depicted dual users from Canada (OR: 19.8), and e-cigarette users from the USA (OR: 12.9) exhibited higher illegal purchases odds than the same user type in England. Within-country comparisons showed e-cigarette and dual users are more likely to purchase from the IETM than cigarette smokers in the most restrictive condition, with the largest effects in e-cigarette users (England-OR: 1722.6, USA-OR: 22725.3, Canada-OR: 6125.0). Increased opposition towards partial or total flavour ban was associated with increased IETM purchasing in the corresponding condition.

Conclusions: Vaping restrictions may shift users' preference to the illegal marketplace in a regulatory environment. Evidence of the IETM generalisability in a geographically dispersed sample enhances its utility in tobacco regulatory science.

Citation

Gravely, S., Yong, H.H., Reid, J., East, K.A., Gartner, C., Levy, D.T., Cummings, K.M., Borland, R., Quah, A.C.K., Bansal-Travers, M., Ouimet, J., Fong, G.T. (2022). Do current smokers and ex-smokers who use nicotine vaping products daily versus weekly differ on their reasons for vaping? Findings from the ITC Four Country Smoking and Vaping Survey. International Journal of Environmental Research and Public Health, 19(21), 14130. doi: 10.3390/ijerph192114130.

Abstract

This study examined reasons why adults who currently smoke or formerly smoked cigarettes use nicotine vaping products (NVPs) by vaping frequency (daily vs. weekly) stratified by smoking status.

This crosssectional study included 3070 adults from the 2020 ITC Four Country Smoking and Vaping Survey (Australia, Canada, England, United States) who reported using a NVP (vaping) at least weekly and who either currently smoke (n = 2467) or formerly smoked (n = 603). Respondents were asked to select the reason(s) they use NVPs, including to manage their smoking (reduce/quit or remain quit) and/or for reasons unrelated to managing smoking (e.g., to save money, enjoyment, flavours).

We found that both current and former smokers endorsed an average of six reasons for vaping, with those vaping daily reporting significantly more reasons than those vaping weekly. Among current smokers, 72.8% reported vaping may help them quit smoking, 13.0% reported vaping to reduce smoking but not to quit, and 14.2% reported vaping only for reasons other than to reduce or quit smoking. The most common reason for vaping among current smokers was to reduce smoking (81.3%). Current smokers vaping daily were significantly more likely than those vaping weekly to report using a NVP to reduce smoking, for enjoyment, to reduce harm to themselves and others, to quit smoking, likeable flavours, and to save money. The most common reason cited for vaping by respondents who formerly smoked was enjoyment, with those who vaped daily more likely than those who vaped weekly to report vaping for enjoyment and to reduce harm to themselves. Nearly all reported vaping to help stay abstinent from smoking (92.3%), with no significant difference by vaping frequency.

In conclusion, a majority of respondents reported using NVPs to manage their smoking (reduce/quit smoking or remain quit), particularly those vaping daily. Those who were vaping daily also endorsed a greater number of reasons other than managing smoking relative to those who were vaping weekly.

Citation

Gravely, S., Meng, G., Hammond, D., Hyland, A., Cummings, K.M., Borland, R., Kasza, K., Yong, H.H., Thompson, M.E., Quah, A.C.K., Ouimet, J., Martin, N., O’Connor, R.J., East, K.A., McNeill, A., Boudreau, C., Levy, D.T., Sweanor, D.T., Fong, G.T. (2022). Differences in cigarette smoking quit attempts and cessation between adults who did and did not take up nicotine vaping: Findings from the ITC Four Country Smoking and Vaping Surveys. Addictive Behaviors, 132, 107339.

Abstract

Introduction: There is mixed evidence as to whether nicotine vaping products (NVPs) can help adults who smoke transition away from cigarettes. This study investigated if rates of self-reported attempts to quit smoking and smoking cessation over a period of either 18 or 24 months differed between respondents who initiated nicotine vaping versus those who did not. Outcome comparisons were made between those who: (1) initiated vaping vs. those who did not; (2) initiated daily or non-daily vaping vs. those who did not; and (3) initiated daily or non-daily vaping between surveys and continued to vape at follow-up (daily or non-daily) vs. those who did not initiate vaping.

Methods: This cohort study included 3516 respondents from the ITC Four Country Smoking and Vaping Surveys (Australia, Canada, England, US), recruited at Wave 1 (2016) or 2 (2018) and followed up at Wave 2 (12 months) and/or 3 (2020, 24 months). Adults who smoked daily at baseline and did not have a history of regular vaping were included. Initiation of vaping was defined as beginning to vape at least monthly between surveys. Respondents indicated whether they made an attempt to quit smoking between surveys. Smoking cessation was defined as those who self-reported no longer smoking cigarettes at follow-up.

Results: Relative to those who did not initiate vaping, any daily vaping was associated with a greater likelihood of smokers making a cigarette quit attempt (p<0.001) and quitting smoking (p<0.001). Among smokers who attempted to quit smoking, any daily vaping was associated with a greater likelihood of being abstinent from smoking at follow-up (p=0.001). Respondents who initiated vaping between surveys and were vaping daily at follow up were significantly more likely to have attempted to quit smoking (p<0.001) and to have quit smoking (p<0.001) than those who did not initiate vaping. Respondents who initiated non-daily vaping did not differ significantly from those who did not initiate vaping on any of the outcome measures.

Conclusions: Daily NVP use was associated with increased attempts to quit smoking and abstinence from smoking cigarettes. These findings are consistent with the concept that complete cigarette substitution may be more likely to be achieved when smokers vape nicotine daily.

Citation

Li, L., Borland, R., Yong, H.H., Gravley, S., Fong, G.T., Cummings, K.M., East, K.A., Le Grande, M. (2022). Experienced effects on well-being following smoking cessation: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. International Journal of Environmental Research and Public Health, 19(16), 10037. doi: 10.3390/ijerph191610037

Abstract

Background and Aims: There has been limited research addressing changes in subjective well-being as a result of quitting smoking. This paper examines recent ex-smokers’ well-being related experiences overall and as a function of (1) duration of cessation and (2) continued nicotine use from vaping.

Methods: A sample of 1379 ever-daily smoking ex-smokers (quit for up to 5 years) from the 2020 ITC Four Country Smoking and Vaping Survey (Australia, Canada, the UK, and the US), of which 27.1% currently vaped daily. Well-being measures were perceived changes post-quitting in emotion coping (stress and negative emotions), enjoyment of life, and day-to-day functioning. We also assessed the level of persisting worry about past smoking leading to future health problems.

Results: Overall, among those answering all four well-being measures, 51.8% of the ex-smokers reported positive effects and no negatives, but 27.3% reported at least one negative effect, with the remainder reporting no change in any measure. Positive effects were greater among those who had quit more than 1 year prior. The largest improvement (56.3%) was for daily functioning, which showed improvement over time since having quit. Current daily vapers reported similar well-being as those not vaping; however, fewer daily vapers reported worsening ability to cope with stress (10.2% vs. 20.7%). Overall, 84% reported being worried about future negative health effects of smoking, with no clear differences by quitting duration or vaping status.

Conclusions: Most ex-smokers reported changes in their well-being since quitting, with more reporting improvements than declines. Well-being improved with duration of time since quitting, but did not appear to be influenced by daily vaping use, but stress coping may be better among vapers. Persisting worries about possible future health effects from smoking may be reducing the experienced benefits of quitting smoking for some.

Citation

Yong, H.H., Gravely, S., Borland, R., Gartner, C., Cummings, K.M., East, K., Tagliaferri, S., Elton-Marshall, T., Hyland, A., Bansal-Travers, M., Fong, G.T. (2022). Do smokers’ perceptions of the harmfulness of nicotine replacement therapy and nicotine vaping products as compared to cigarettes influence their use as an aid for smoking cessation? Findings from the ITC Four Country Smoking and Vaping Surveys. Nicotine & Tobacco Research, 24(9), 1413-1421. doi: 10.1093/ntr/ntac087.

Abstract

Aim: This study examined whether smokers' harm perceptions of nicotine replacement therapy (NRT) and nicotine vaping products (NVPs) relative to cigarettes predicted their subsequent use as smoking cessation aids during their last quit attempt (LQA).

Methods: We analyzed data from 1,315 current daily smokers (10+ cigarettes per day) who were recruited at Wave 1 (2016), and who reported making a quit attempt by Wave 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the US. We used multinomial logistic regression models to examine prospective associations between harm perceptions of a) NRT and b) NVPs and their use at LQA, controlling for socio-demographic and other potential confounders.

Results: Smokers who perceive that a) NRT and b) NVPs are much less harmful than cigarettes were more likely to subsequently use the respective product as an aid than using no aid or other aids during LQA (adjusted relative risk ratio [aRRR]=3.79, 95%CI=2.16-6.66; and aRRR=2.11, 95%CI=1.29-3.45, respectively) compared to smokers who perceive these products as equally or more harmful. Additionally, those who perceive NVPs as much less harmful than cigarettes were less likely to use NRT as a quit aid (aRRR=0.34, 95%CI=0.20-0.60). No country variations for these associations were found.

Conclusion: This study found that smokers' perceptions of the harmfulness of a) NRT and b) NVPs relative to cigarettes predicted the respective product use when trying to quit smoking. Corrective education targeting misperceptions of nicotine products' relative harmfulness may facilitate their use for smoking cessation.

Implications: What this study adds: Nicotine replacement therapy and nicotine vaping products are two commonly used smoking cessation aids. This study demonstrates that misperceptions of the harms of nicotine products relative to cigarettes influence their use for smoking cessation. Believing that nicotine vaping products are much less harmful than cigarette smoking may lead some smokers to prefer these products over nicotine replacement therapy to aid smoking cessation. Education targeting misperceptions of nicotine products' harmfulness relative to cigarettes may enable smokers to make informed choices about which are appropriate to aid smoking cessation.