Citation

East, K.A., Reid, J., Burkhalter, R., Wackowski, O.A., Thrasher, J.F., Tattan-Birch, H., Boudreau, C., Bansal-Travers, M., Liber, A.C., McNeill, A., Hammond, D. (2022). Exposure to negative news stories about vaping, and harm perceptions of vaping, among youth in England, Canada, and the United States before and after the outbreak of E-cigarette or Vaping-Associated Lung Injury (EVALI). Nicotine and Tobacco Research, 24(9), 1386-1395. doi: https://doi.org/10.1093/ntr/ntac088.

Abstract

Introduction: Little is known about the international impact of ‘EVALI’ on youth perceptions of vaping harms.

Methods: Repeat cross-sectional online surveys of youth aged 16-19 in England, Canada, and the US before (2017, 2018), during (2019Aug/Sept), and after (2020Feb/Mar, 2020Aug) the ‘EVALI’ outbreak (N=63,380). Logistic regressions assessed trends, country differences, and associations between exposure to negative news stories about vaping and vaping harm perceptions.

Results: Exposure to negative news stories increased between 2017 and Feb/Mar 2020 in England (12.6% to 34.2%), Canada (16.7% to 56.9%), and the US (18.0% to 64.6%), accelerating during (2019) and immediately after (Feb/Mar 2020) the outbreak (p<.001) before returning to 2019 levels by Aug 2020. Similarly, accurate perception that vaping is less harmful than smoking declined between 2017 and Feb/Mar 2020 in England (77.3% to 62.2%), Canada (66.3% to 43.3%), and the US (61.3% to 34.0%), again accelerating during and immediately after the outbreak (p<.001). Perception that vaping takes less than a year to harm users’ health and worry that vaping will damage health also doubled over this period (p≤.001). Time trends were most pronounced in the US. Exposure to negative news stories predicted perception that vaping takes less than a year to harm health (AOR=1.55, 1.48-1.61) and worry that vaping will damage health (AOR=1.32, 1.18-1.48).

Conclusions: Between 2017 and February/March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. Effects were seen in all countries but were most pronounced in the US.

Implications: This is the first study to examine changes in exposure to news stories about vaping, and perceptions of vaping harms, among youth in England, Canada, and the US before, during, and after ‘EVALI’. Between 2017 and February/March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. By August 2020, exposure to negative news stories returned to 2019 levels, while perceptions of harm were sustained. Exposure to negative news stories also predicted two of three harm perceptions measures. Overall, findings suggest ‘EVALI’ may have exacerbated youth’s perceptions of vaping harms internationally.

Citation

Gravely, S., Smith, D.M., Liber, A.C., Cummings, K.M., East, K., Hammond, D., Hyland, A., O’Connor, R.J., Kasza, K.A., Quah, A.C.K., Loewen, R., Martin, N., Meng, G., Ouimet, J., Thompson, M.E., Boudreau, C., McNeill, A., Sweanor, D., Fong, G.T. (2022). Responses to potential nicotine vaping product flavor restrictions among regular vapers using non-tobacco flavors: Findings from the 2020 ITC Smoking and Vaping Survey in Canada, England and the United States. Addictive Behaviors, 125, 107152.

Abstract

Introduction: Some jurisdictions have implemented nicotine vaping product (NVP) flavor restrictions because of concerns about rising adolescent use. However, little is known how these restrictions may impact adult vapers. This study describes the level of support and predictive behavioral responses to a hypothetical NVP ban on non-tobacco flavors among regular adult vapers who only use flavors that would be banned.

Methods: Data came from 851 regular vapers (all current or ex-smokers) participating in the 2020 ITC Four Country Smoking and Vaping Survey in Canada, England, and the United States (US). A random sample of respondents in each country received and completed the questions about flavor bans: (1) do you support or oppose a ban on all non-tobacco flavors; and (2) what would you do if all flavors were banned, with the exception of tobacco in the US, and tobacco and menthol in Canada and England. Those who used tobacco-flavored or unflavored NVPs were excluded from all analyses, and additionally, vapers of menthol flavor in Canada and England were excluded from Aim 2.

Results: Overall, 53.6% of vapers were strongly opposed to flavor bans, 28.2% were opposed, 9.3% were in support, 3.6% were in strong support, and 5.2% did not know. Predicted behavioral responses were: 28.8% would continue vaping an available flavor, 28.3% would find a way to get their banned flavor(s), 17.1% would stop vaping and smoke instead, 12.9% said that they would stop vaping and not smoke, and 12.9% do not know what they would do. Responses to a potential flavor ban largely varied by smoking and vaping status, and by the level of support of a flavor restriction policy.

Conclusions: At this time, it is not clear what net population-level consequences would occur if non-tobacco flavored NVPs were prohibited. While a majority of vapers in this study opposed this policy, and many vapers would not be willing to switch to available flavors, there was considerable variability in predicted behavioral responses.

Citation

Cho, Y. J., Thrasher, J. F., Driezen, P., Hitchman, S. C., Reid, J. L., & Hammond, D. (2022). Trends in exposure to and perceptions of e-cigarette marketing among youth in England, Canada and the United States between 2017 and 2019. Health education research, 36(6), 657–668. https://doi.org/10.1093/her/cyab039

Abstract

E-Cigarette marketing may influence e-cigarette use among youth. This study examined reported exposure to and perceptions of e-cigarette marketing among youth between 2017 and 2019 across countries with varying e-cigarette marketing restrictions. Cross-sectional online surveys were conducted with 35 490 youth aged 16-19 from England, Canada and the United States in 2017, 2018 and 2019. Weighted logistic regression models examined trends in the adjusted prevalence of self-reported exposure to e-cigarette marketing and the perceived appeal of e-cigarette ads between 2017 and 2019, by country and by smoking/vaping status. Reports of frequent exposure to e-cigarette marketing increased between 2017 and 2019 in all countries, but less so in England, where e-cigarette marketing is more restricted. Perceiving e-cigarette marketing as appealing increased from 2017 to 2019 in Canada and the United States, but not in England. In England, exposure to e-cigarette marketing did not increase in prohibited channels between 2017 and 2019. Between 2017 and 2019, never-users' reports increased for exposure to and appeal of e-cigarette marketing. The results suggest some effectiveness of e-cigarette marketing bans in England and receptivity to e-cigarette marketing among youth never users.

Citation

Borland, R., Le Grande, M., Heckman, B., Fong, G.T., Bickel, W.K., Stein, J., East, K., Hall, P.A., Cummings, K.M. (2022). The predictive utility of valuing the future for smoking cessation: Findings from the ITC Four Country Smoking and Vaping Surveys. International Journal of Environmental Research and Public Health, 19(2), 631.

Abstract

Background: Delay discounting (DD) and time perspective (TP) are conceptually related constructs that are theorized as important determinants of the pursuit of future outcomes over present inclinations. This study explores their predictive relationships for smoking cessation.

Methods: 5006 daily smokers at a baseline wave provided 6710 paired observations of quitting activity between two waves. Data are from the International Tobacco Control (ITC) smoking and vaping surveys with samples from the USA, Canada, England, and Australia, across three waves conducted in 2016, 2018 and 2020. Smokers were assessed for TP and DD, plus smoking-specific predictors at one wave of cessation outcomes defined as either making a quit attempt and/or success among those who tried to quit which was ascertained at the subsequent survey wave.

Results: TP and DD were essentially uncorrelated. TP predicted making quit attempts, both on its own and controlling for other potential predictors but was negatively associated with quit success. By contrast, DD was not related to making quit attempts, but high DD predicted relapse. The presence of financial stress at baseline resulted in some moderation of effects.

Conclusions: Understanding the mechanisms of action of TP and DD can advance our understanding of, and ability to enhance, goal-directed behavioural change. TP appears to contribute to future intention formation, but not necessarily practical thought of how to achieve goals. DD is more likely an index of capacity to effectively generate competing future possibilities in response to immediate gratification.

Citation

Driezen, P., Gravely, S., Wadsworth, E., Smith, D.M., Loewen, R., Hammond, D., Li, L., Abramovici, H., McNeill, A., Borland, R., Cummings, K.M., Thompson, M.E., Fong, G.T. (2022). Increasing cannabis use is associated with poorer cigarette smoking cessation outcomes: Findings from the ITC Four Country Smoking and Vaping Surveys, 2016-2018. Nicotine and Tobacco Research, 24(1), 53-59.

Abstract

Introduction: Concurrent use (co-use) of tobacco and cannabis may impede successful cigarette smoking cessation. This study examined whether changes in cannabis use frequency were associated with smoking cessation.

Methods: Nationally representative samples of adult cigarette smokers from Canada (n=1455), the United States (n=892), England (n=1416), and Australia (n=717) were surveyed in 2016 and 2018. In each year, smokers reported how often they used cannabis in the previous 12 months. Reports were compared to determine whether cannabis use increased, remained unchanged, or decreased. Smoking cessation outcomes, measured in 2018, were (1) any attempt to quit in the previous year, (2) currently quit, and (3) currently quit for at least 6 months. Weighted multivariable logistic regression estimated the association between changes in cannabis use and cessation outcomes.

Results: Cigarette smokers who increased their frequency of cannabis use were significantly less likely to be currently quit than non-cannabis using smokers (adjusted odds ratio (aOR) = 0.52, 95% CI: 0.31, 0.86); they were also less likely to have quit for at least 6 months (aOR = 0.30; 95% CI: 0.15, 0.62).

Conclusions: Smokers who increase their frequency of cannabis use have poorer smoking cessation outcomes compared to non-cannabis using smokers. It will be important to monitor the impact of cannabis legalization on patterns of cannabis use, and whether this influences cigarette smoking cessation rates.

Citation

Miller, C., Sutanto, E., Smith, D.M., Hitchman, S.C., Gravely, S., Yong, H.H., Borland, R., O’Connor, R.J., Cummings, K.M., Fong, G.T., Hyland, A., Quah, A.C.K., Goniewicz, M. (2022). Awareness, trial, and use of heated tobacco products among adult cigarette smokers and e-cigarettes users: Findings from the 2018 ITC Four Country Smoking & Vaping Survey. Tobacco Control, 31(1), 11-18.

Abstract

Objective:

To evaluate heated tobacco product (HTP) awareness, trial and current use among adult cigarette smokers and vaping product users in four countries with varying regulations governing HTP sales.

Design:

Data came from Wave 2 of the ITC Four Country Smoking and Vaping Survey, collected from February to July 2018. Respondents were current and former smokers and/or users of vaping products (18 years or older) from Canada (CA; n=3778), England (EN; n=4848), the USA (US; n=2846) and Australia (AU; n=1515). At the time of the survey, only Canada and England permitted the sale of contemporary HTPs (eg, IQOS).

Results:

Overall, 30.2% of respondents reported being aware of HTPs (CA=30.4%; EN=31.0%; US=30.2%; AU=27.4%; p=0.346), 2.4% had ever tried HTPs (CA=3.3%; EN=2.4%; US=2.0%; AU=0.9%; p=0.001) and 0.9% currently used HTPs at least monthly (CA=0.8%; EN=1.2%; US=0.7%; AU=0.2%; p<0.001). Trial and current use were higher among those who concurrently smoked and vaped (at least monthly) versus other nicotine use categories (trial: 10.9% v. 1.2%-2.0%, p><0.001; current use: 8.4% v. 0.1%-1.0%, p><0.001). In multivariable analyses, HTP awareness did not differ across countries, whereas odds of trial and current use were lower where HTPs were unavailable. Odds of HTP trial did not differ by regulatory environment when restricting analysis to HTP-aware concurrent smokers-vapers.

Conclusion:

Approximately one third of respondents were aware of HTPs, even in the USA and Australia, where contemporary HTPs were not yet on the market. Trial and use were uncommon, except among concurrent smokers-vapers. Restrictions on availability may have limited HTP use generally, but less so for concurrent smokers-vapers.

Citation

Przewoźniak, K., Kyriakos, C.N., Hiscock, R., Radu-Loghin, C., Fong, G.T. (2021). Effects of and challenges to bans on menthol and other flavours in tobacco products. Tobacco Prevention & Cessation, 7, 68.

Abstract

In May 2020, the European Tobacco Products Directive (TPD), which bans characterizing flavors in cigarettes and roll-your-own tobacco (RYO) in the European Union (EU), extended its application to menthol1,2. Countries which were early adopters of flavor bans include Brazil, Canada, Ethiopia, the United Kingdom (UK), amongst others3. Two main regulatory approaches exist: a ban on characterizing flavors that allows for the presence of additives but not at detectable sensory levels (e.g. EU, UK), and a total ban on flavor additives that eliminates their presence altogether (e.g. Brazil, Canada). As more countries work towards adopting tobacco flavor bans, it is critical to understand how these policies are implemented, ascertain their population-level impact, and identify the regulatory challenges.

Citation

Miller, C., Sutanto, E., Smith, D.M., Hitchman, S.C., Gravely, S., Yong, H.H., Borland, R., O’Connor, R., Cummings, K.M., Fong, G.T., Hyland, A., Quah, A.C.K., Goniewicz, M. (2022). Characterizing heated tobacco product use among adult cigarette smokers and nicotine vaping product users in the 2018 ITC Four Country Smoking & Vaping Survey. Nicotine and Tobacco Research, 24(4), 493-502. doi: 10.1093/ntr/ntab27.

Abstract

Introduction: Heated tobacco products (HTP) have diversified global tobacco markets, and user characteristics remain understudied. This study evaluated sociodemographic characteristics, nicotine-related perceptions and behaviors of current HTP users within a sample of adult (18+ years) nicotine users across four countries.

Methods: Data were from current smokers or nicotine vaping product (NVP; known as "e-cigarettes") users from Canada, England, the United States and Australia (n=11,421) who participated in the 2018 ITC Four Country Smoking and Vaping Survey. Current (at-least-monthly) HTP users were characterized (n=441), and weighted multivariable logistic regressions examined correlates of HTP use.

Results: Compared to non-users, current HTP users were younger (mean age: 44.4 vs 31.0 years; p<0.001) and had higher socioeconomic status (p<0.001). A majority of current HTP users used HTPs non-daily (daily: 40.3% vs non-daily: 59.7%). Most HTP users concurrently used both cigarettes and NVPs (90.5%). Among concurrent cigarette-HTP-NVP users, 36.2% used all three products daily. Use of other combusted tobacco products (cigars, cigarillos, pipe, waterpipe/hookah), cannabis, and binge drinking were each associated with current HTP use. HTP use was more common among smokers intending to quit within 6 months or reporting a quit attempt in the past 18 months, and vapers who had experienced negative side effects.

Conclusion: HTP users in this sample tended to be younger and more affluent. Most reported concurrent use of multiple nicotine products and other substances. Those cigarette smokers who used HTPs appeared more interested in smoking cessation, while some characteristics of concurrent HTP-NVP users were suggestive of dissatisfaction with NVPs.

Implications: Few studies have scrutinized characteristics of HTP early-adopters in emerging markets. Our results indicate that in 2018, characteristics of established nicotine users who adopted HTP use in four high-income Western countries mirror those of HTP users in East Asian markets (South Korea and Japan) where HTPs are popular. HTP users reported high levels of concurrent use of non-cigarette combusted tobacco products (e.g., cigars, pipe tobacco). These findings point to the need for future longitudinal studies of HTP use given the implications of those use patterns on the harm reduction potential of HTPs. HTP user characteristics may yield important information to consider in regulation of these products.

Citation

East, K., Reid, J., Rynard, V.L., Hammond, D. (2021). Trends and patterns of tobacco and nicotine product use among youth in Canada, England, and the US from 2017-2019. Journal of Adolescent Health, 69(3), 447-456. doi: 10.1016/j.jadohealth.2021.02.011.

Abstract

Purpose: The tobacco and nicotine market is diversifying. Implications for public health will depend on trends in use, including overall use, and who is using these products. This study examined differences over time (2017–2019), across countries (Canada, England, the United States (US)), and by smoking and vaping, in use of other tobacco/nicotine products and overall use.

Methods: The study includes online repeat cross-sectional surveys of youth aged 16–19 years in Canada (N = 11,714), England (N = 11,170), US (N = 11,838) in 2017, 2018, and 2019. Past 30-day use of tobacco/nicotine products (any, cigarette, e-cigarette, other combusted [cigars/cigarillos/waterpipe], other non-combusted [smokeless tobacco/nicotine replacement therapies) were examined by country, year, and, for other combusted and non-combusted products, past 30-day cigarette smoking and vaping. Use of emerging products (IQOS, nicotine pouches) was explored in 2018–2019.

Results: From 2017 to 2019, use of any product increased in Canada (17.1%–23.2%, AOR = 1.07 [95% CI = 1.04–1.09]) and the US (18.0%–24.0%, AOR = 1.06 [1.04–1.09]) but not England (20.8%–21.7%, AOR = 1.01 [.99–1.03]). Use of other combusted products (cigars/cigarillos/waterpipe) showed little change (Canada: 8.1%–7.8%; England: 6.3%–7.3%; US: 8.6%–8.5%; p ≥ .151). Use of other non-combusted products (smokeless/nicotine replacement therapies) increased in all countries (Canada: 1.5%–3.2%, AOR = 1.02 [1.01–1.02]; England: 1.4%–2.6%, AOR = 1.02 [1.01–1.03]; US: 3.3%–4.9%, AOR = 1.02 [1.01–1.02]). Vaping increased in all countries (Canada: 8.4%–17.8%; England: 8.7%–12.6%; United States: 11.1%–18.5%; all p < .001). Smokers and vapers reported greater use of other combusted and non-combusted products than those who neither smoked/vaped (p < .001). Emerging product use was rare (≤1.5%).

Conclusions: Youth past 30-day tobacco and nicotine product use increased from 2017 to 2019 in Canada and the United States, largely due to increases in vaping and other non-combusted products. “Other” tobacco/nicotine products were used predominantly by youth who smoked cigarettes and/or vaped.

Citation

Li, L., Borland, R., Cummings, K.M., Gravely, S., Quah, A.C.K., Fong, G.T., Miller, C.R., Goniewicz, M.L., Le Grande, M., McNeill, A. (2021). Patterns of non-cigarette tobacco and nicotine use among current cigarette smokers and recent quitters: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 23(9), 1611-1616. doi: https://doi.org/10.1093/ntr/ntab040.

Abstract

Introduction: This study explores patterns of use of non-cigarette tobacco and nicotine products among adult cigarette smokers and recent ex-smokers. Along with cigarette smoking status we explore differences as a function of countries with different product regulations, gender and age.

Methods: Data came from the ITC Four Country Smoking and Vaping Wave 3 Survey conducted between February-June 2020. The analytic sample consisted of 9112 current cigarette smokers (at least monthly) and 1184 recent ex-smokers (quit cigarettes ≤ 2 years) from Australia, Canada, England, and the US. Respondents were asked about their cigarette smoking and current use of the following non-cigarette products: combustible tobacco (cigars, cigarillos, pipe, waterpipe); non-combustible tobacco (smokeless tobacco, and heated tobacco products (HTPs)); and non-tobacco nicotine products (nicotine vaping products (NVPs), nicotine replacement therapy (NRT), and nicotine pouches)).

Results: Overall, NVPs (13.7%) and NRT (10.9%) were the most reported nicotine products used, followed by cigars (5.3%), cigarillos (4.2%), and HTPs (3.5%). More than 21% current and recent ex-smokers of cigarettes reported using a non-tobacco nicotine product and non-combustible product, with respondents in England reporting the highest levels of use (>26%). Males, younger respondents, and current non-daily cigarette smokers were more likely to use non-cigarette nicotine products. Notably, 11.6% of ex-cigarette smokers were using other combustible tobacco.

Conclusion: Considerable percentages of current cigarette smokers and ex-smokers use non-cigarette nicotine products, and there are unexpectedly high levels of use of other combustible products by those recent ex-smokers of cigarettes which is concerning and has important implications for definitions of smoking cessation.

Implications: The tobacco product market has evolved to include new products which add to existing non-cigarette tobacco products creating a much more diverse nicotine market. This brief report provides a snapshot of use of various combustible and non-combustible nicotine containing products among current cigarette smokers and recent ex-smokers in four western countries. Our results indicate that use of non-cigarette tobacco and nicotine products among these cigarette smokers and recent ex-smokers is not low, particularly among males, younger and non-daily cigarette smokers. Use of other combustible tobacco among respondents that recently quit cigarette smoking is concerning and has important implications for definitions of smoking cessation. Increased emphasis on researching non-cigarette nicotine product use is warranted in tobacco control generally and smoking cessation in particular.

Citation

Li, L., Borland, R., Cummings, K.M., Fong, G.T., Gravely, S., Smith, D.M., Goniewicz, M., O’Connor, R.J., Thompson, M.E., McNeill, A. (2021). How Does the Use of Flavored Nicotine Vaping Products Relate to Progression Toward Quitting Smoking? Findings From the 2016 and 2018 ITC 4CV Surveys. Nicotine and Tobacco Research, 23(9), 1490-1497. doi: https://doi.org/10.1093/ntr/ntab033.

Abstract

Introduction: There is limited research on the role of flavors in nicotine vaping products (NVPs) in relation to smoking. We examined patterns of flavor use in NVPs in relation to progression towards quitting.

Methods: Data come from 886 concurrent users of NVPs (at least weekly) and cigarettes who were first surveyed in 2016 and then successfully recontacted in 2018 as part of the ITC 4CV Surveys conducted in Australia, Canada, England and the United States. Participants were asked about their main vaping flavor categorized as: 1) tobacco or unflavored, 2) menthol/mint flavored, and 3) “sweet” flavors (e.g., fruit/candy). We examined whether flavor was associated with progression towards quitting smoking between survey years.

Results: Overall, 11.1% of baseline concurrent users quit smoking by 2018. Compared to users of tobacco flavors, those vaping “sweet” flavors were more likely to quit smoking between surveys (13.8% vs. 9.6%; adjusted OR=1.61, 95% CI 1.01-2.58, p<0.05), but those using menthol flavors were no more likely to quit smoking (8.3% vs. 9.6%, aOR=0.87, 95% CI 0.43-1.47, p=0.69). Among those who had quit smoking in 2018, 52.0% were still vaping, which was lower than the 65.8% among continuing smokers (aOR=0.60, 95% CI 0.39-0.92, p=0.02). Sweet flavor users were no more likely to continue vaping compared to tobacco flavor users, either for those continuing smoking or those having quit smoking by 2018. There was a net shift away from tobacco flavor among those who continued to vape at follow-up.

Conclusions: Use of fruit and other sweet flavored e-liquids is positively related to smokers’ transition away from cigarettes.

Implications: With multiple jurisdictions considering limiting or banning the sale of flavored NVPs, it is important to consider how such policies may impact smokers using NVPs to transition away from cigarette smoking. Our results indicate that vapers who used sweet flavors were more likely to transition away from cigarette smoking and quit cigarette use, at least in the short term, compared to those who used tobacco or unflavored NVPs. Randomized clinical trials are needed to establish if the observed association between use of flavored e-liquids and smoking cessation is due to self-selection or is truly causal.

Citation

Felicione, N., Cummings, K.M., Gravely, S., Hammond, D., McNeill, A., Borland, R., Fong, G.T., O’Connor, R.J. (2021). “Don’t Know” responses for nicotine vaping product features among adult vapers: Findings from the 2018 and 2020 ITC Four Country Smoking and Vaping Surveys. International Journal of Environmental Research and Public Health, 18(15), 7928. doi: 10.3390/ijerph18157928.

Abstract

Nicotine vaping products (NVPs) have evolved rapidly, and some vapers have difficulty reporting about their NVP. NVP knowledge may be important for providing accurate survey data, understanding the potential risks of NVP use, and assessing legal and regulated products. This paper examines current vapers who responded “don’t know” (DK) regarding their NVP features. Data are from adult daily/weekly vapers in Waves Two (2018, n = 4192) and Three (2020, n = 3894) of the ITC Four Country Smoking and Vaping Survey. Analyses assessed DK responses for NVP features (e.g., type/appearance, nicotine) and consumption. A DK index score was computed based on the percent of all features with DK responses, which was tested for associations with demographics, smoking/vaping status, NVP features, purchase location, and knowledge of NVP relative risks. NVP description and appearance were easily identified, but DK was more common for features such as nicotine content (7.3–9.2%) and tank/cartridge volume capacity (26.6–30.0%). DK responses often differed by vaping/smoking status, NVP type/appearance, purchase location, and country. Vapers who are younger, use box-shaped NVPs, purchase online, and exclusive daily vapers were associated with lower DK index scores. Higher DK index scores were associated with poorer knowledge of relative health risks of NVP use. The diversity of the NVP market and wide variation in how products are used makes it challenging to capture information from users about device features, such as nicotine content and capacity, in population surveys.

Citation

Gravely, S., Cummings, K.M., Hammond, D., Borland, R., McNeill, A., East, K., Loewen, R., Martin, N., Yong, H.H., Li, L., Liber, A., Levy, D.T., Quah, A.C.K., Ouimet, J., Hitchman, S.C., Thompson, M.E., Boudreau, C., Fong, G.T. (2021). Self-reported quit aids and assistance used by smokers at their most recent quit attempt: Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey. Nicotine & Tobacco Research, 23(10), 1699-1707. doi: 10.1093/ntr/ntab068.

Abstract

Introduction: This study retrospectively describes smoking cessation aids, cessation services, and other types of assistance used by current and ex-smokers at last quit attempt (LQA) in four high-income countries.

Methods: Data are from the Wave 3 (2020) International Tobacco Control Four Country Smoking and Vaping Survey in Australia, Canada, England, and the US. Eligible respondents were daily smokers or past-daily recent ex-smokers who made a quit attempt/quit smoking in the last 24-months, resulting in 3,614 respondents. Self-reported quit aids/assistance included: nicotine vaping products (NVPs), nicotine replacement therapy (NRT), other pharmacological therapies (OPT: varenicline/bupropion/cytisine), tobacco (non-combustible: heated tobacco product/smokeless tobacco), cessation services (quitline/counseling/doctor), other cessation support (e.g., mobile apps/website/pamphlets etc.), or no aid.

Results: Among all respondents, at LQA, 28.8% used NRT, 28.0% used an NVP, 12.0% used OPT, 7.8% used a cessation service, 1.7% used a tobacco product, 16.5% other cessation support, and 38.6% used no aid/assistance. Slightly more than half of all smokers and ex-smokers (57.2%) reported using any type of pharmacotherapy (NRT or OPT) and/or an NVP, half used NRT and/or an NVP (49.9%), and 38.4% used any type of pharmacotherapy (NRT and/or OPT). A quarter of smokers/ex-smokers used a combination of aids. NVPs and NRT were the most prevalent types of cessation aids used in all four countries; however, NRT was more commonly used in Australia, relative to NVPs, and in England, NVPs were more commonly used than NRT. The use of NVPs or NRT was more evenly distributed in Canada and the US.

Conclusions: It appears that many smokers are still trying to quit unassisted, rather than utilizing cessation aids or other forms of assistance. Of those who did use assistance, NRT and NVPs were the most common method, which appears to suggest that nicotine substitution is important for smokers when trying to quit smoking.

Citation

King, B., Borland, R., Le Grande, M., O’Connor, R.J., Fong, G.T., McNeill, A., Hatsukami, K., Cummings, K.M. (2021). Smokers’ awareness of filter ventilation, and how they believe it affects them: Findings from the ITC Four Country Smoking and Vaping Survey. Tobacco Control, [Published online June 15, doi: 10.1136/tobaccocontrol-2020-056134].

Abstract

Background: Filter ventilation creates sensations of ‘lightness’ or ‘smoothness’ and is also highly effective for controlling machine-tested yields of tar, nicotine and carbon monoxide. Nearly all factory-made cigarettes (FMC) now have filter ventilation in countries such as Australia, Canada, the UK and the USA. Research conducted before ‘light’ and ‘mild’ labelling was banned found low smoker awareness of filter ventilation and its effects. This study explores current levels of awareness of filter ventilation and current understanding of its effects in these four countries.

Methods: We used data from the 2018 wave of the ITC Four Country Smoking and Vaping Survey with samples from USA, England, Canada and Australia. Analyses were conducted initially on a weighted sample of 11 844, and subsequently on 7541 daily FMC smokers.

Findings: Only 40.3% of all respondents reported being aware of filter ventilation. Among daily FMC smokers, only 9.4% believed their cigarettes had filter ventilation. Believing that their usual cigarettes are smoother was positively associated with believing they are also less harmful. Both these beliefs independently predict believing their cigarettes are ventilated (smoother OR=1.97 (95% CI 1.50 to 2.59) and less harmful OR=2.41 (95% CI 1.66 to 3.49) in relation to those believing each characteristic is average.

Interpretation: Awareness of filter ventilation is currently low, despite decades of public ‘education efforts around the misleading nature of ‘light’ and ‘mild” descriptors. Few smokers realise that their cigarettes almost certainly are vented. Smokers who believed their cigarettes have filter ventilation were more likely to believe they were both smoother and less harmful. Awareness of the technology appears to be insufficient to prevent smokers being deceived by it. Filter ventilation is inherently misleading to smokers and it is time to ban it.

Citation

Gravely, S., Craig, L., Cummings, K.M., Ouimet, J., Loewen, R., Martin, N., Chung-Hall, J., Driezen, P., Hitchman, S.C., McNeill, A., Hyland, A., Quah, A.C.K., O’Connor, R.J., Borland, R., Thompson, M.E., Boudreau, C., Fong, G.T. (2021). Smokers’ cognitive and behavioural reactions during the early phase of the COVID-19 pandemic: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. PLoS One, 16(6), e0252427. doi: 10.1371/journal.pone.0252427.

July 14, 2021 | Press Release from University of Waterloo: Unlike other global crises, COVID-19 pandemic did not spark more smoking in its initial stage

Abstract

Introduction: COVID-19 is primarily a respiratory illness, and smoking adversely impacts the respiratory and immune systems; this confluence may therefore incentivize smokers to quit. The present study, conducted in four high-income countries during the first global wave of COVID-19, examined the association between COVID-19 and: (1) thoughts about quitting smoking; (2) changes in smoking (quit attempt, reduced or increased smoking, or no change); and (3) factors related to a positive change (making a quit attempt or reducing smoking) based on an adapted framework of the Health Belief Model.

Methods: This cross-sectional study included 6,870 adult smokers participating in the Wave 3 (2020) ITC Four Country Smoking and Vaping Survey conducted in Australia, Canada, England, and United States (US). These four countries had varying responses to the pandemic by governments and public health, ranging from advising voluntary social distancing to implementing national and subnational staged lockdowns. Considering these varying responses, and the differences in the number of confirmed cases and deaths (greatest in England and the US and lowest in Australia), smoking behaviours related to COVID-19 may have differed between countries. Other factors that may be related to changes in smoking because of COVID-19 were also explored (e.g., sociodemographics, nicotine dependence, perceptions about personal and general risks of smoking on COVID-19). Regression analyses were conducted on weighted data.

Results: Overall, 46.7% of smokers reported thinking about quitting because of COVID-19, which differed by country (p<0.001): England highest (50.9%) and Australia lowest (37.6%). Thinking about quitting smoking because of COVID-19 was more frequent among: females, ethnic minorities, those with financial stress, current vapers, less dependent smokers (non-daily and fewer cigarettes smoked/day), those with greater concern about personal susceptibility of infection, and those who believe COVID-19 is more severe for smokers. Smoking behaviour changes due to COVID-19 were: 1.1% attempted to quit, 14.2% reduced smoking, and 14.6% increased smoking (70.2% reported no change). Positive behaviour change (tried to quit/reduced smoking) was reported by 15.5% of smokers, which differed by country (p = 0.02), where Australia had significantly lower rates than the other three countries. A positive behavioural smoking change was more likely among smokers with: lower dependence, greater concern about personal susceptibility to infection, and believing that COVID-19 is more severe for smokers.

Conclusions: Though nearly half of smokers reported thinking about quitting because of COVID-19, the vast majority did not change their smoking behaviour. Smokers were more likely to try and quit or reduce their smoking if they had greater concern about susceptibility and severity of COVID-19 related to smoking. Smokers in Australia were least likely to reduce or try to quit smoking, which could be related to the significantly lower impact of COVID-19 during the early phase of the pandemic, relative to the other countries.

Citation

Smith, T., Nahhas, G., Borland, R., Cho, Y., Chung-Hall, J., Fairman, R.T., Fong, G.T., McNeill, A., Popova, L., Thrasher, J.F., Cummings, K.M. (2021). Which tobacco control policies do smokers support? Findings from the International Tobacco Control Smoking and Vaping Survey. Preventive Medicine, 149, 106600 .

Abstract

As governments consider policy action to reduce smoking, a key factor in creating political will is the level of public support, particularly among smokers who are most affected by the policies. The goal of this paper is to assess and compare the level of support in Canada, the United States, England, and Australia for five smoking control policies: 1) banning menthol in cigarettes, 2) banning cigarette additives, 3) reducing nicotine in cigarettes to make them less addictive, 4) raising the minimum age to purchase cigarettes to 21 years and older, and 5) requiring pictorial warning labels on cigarette packs (examined in the US only). Data for these analyses come from 8165 daily cigarette smokers who responded to the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. In all countries, the highest level of support was for raising the legal age for purchase to 21 years and older (62-70%) and reducing the nicotine content of cigarettes to make them less addictive (57-70%). Smokers who were less dependent on cigarettes and those expressing interest in quitting were more likely to support all policies. When asked how they would respond to a nicotine reduction policy, the most common response given was to try the non-nicotine cigarettes to see how they liked them (42-48%), with the next most common response being to quit smoking entirely (16-24%). The high level of support for these proposed policies among daily smokers provides important evidence for policymakers to counteract claims that such policies would be unpopular.

Citation

Yimsaard, P., McNeill, A., Yong, H.H., Cummings, K.M., Chung-Hall, J., Hawkins, S., Quah, A.C.K., Fong, G.T., O’Connor, R.J., Hitchman, S.C. (2021). Gender differences in reasons for using electronic cigarettes and product characteristics: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 23(4), 678-686.

Abstract

Introduction:

Little is known about why males are more likely to use electronic cigarettes (ECs) compared to females. This study examined gender differences in reasons for vaping and characteristics of EC used (device type, device capacity, e-liquid nicotine strength, and flavour).

Methods:

Data from 3,938 current adult (18+ years) at-least-weekly EC users who participated in Wave 2 (2018) ITC Four Country Smoking and Vaping Survey in Canada, the United States, England, and Australia.

Results:

Of the sample, 54% were male. The most commonly cited reasons for vaping in females were ‘less harmful to others’ (85.8%) and in males were ‘less harmful than cigarettes’ (85.5%), with females being more likely to cite ‘less harmful to others’ (adjusted odds ratio (aOR)=1.64, p=0.001) and ‘help cut down on cigarettes’ (aOR=1.60, p=0.001) than males. Significant gender differences were found in EC device type used (χ2=35.05, p=0.043). Females were less likely to report using e-liquids containing >20 mg/ml of nicotine, and tank devices with >2ml capacity (aOR=0.41, p<0.001 and aOR=0.65, p=0.026, respectively) than males. There was no significant gender difference in use of flavoured e-liquids, with fruit being the most common flavour for both males (54.5%) and females (50.2%).

Conclusion:

There were some gender differences in reasons for vaping and characteristics of the product used. Monitoring of gender differences in patterns of EC use would be useful to inform outreach activities and interventions for EC use.

Implications:

Our findings provide some evidence of gender differences in reasons for vaping and characteristics of EC used. The most common reason for vaping reported by females was ‘less harmful to others’, which may reflect greater concern by female vapers about the adverse effects of second-hand smoke compared to male vapers. Gender differences might be considered when designing gender sensitive smoking cessation policies. Regarding characteristics of EC products used, we found gender differences in preferences for e-liquid nicotine strength and device capacity. Further studies should examine whether the observed gender differences in EC use reasons and product characteristics are predictive of smoking cessation. Furthermore, studies monitoring gender-based marketing of ECs may be considered.

Citation

Hammond, D., Wadsworth, E., Reid, J., Burkhalter, R. (2021). Prevalence and modes of cannabis use among youth in Canada, England, and the US, 2017 to 2019. Drug and Alcohol Dependence, 219, 108505.

Abstract

Objective: Cannabis markets are evolving in terms of greater diversity and potency of products. The current study examined changes in cannabis use and modes of consumption among 16- to 19-year-olds in three markets with different regulatory frameworks: England, Canada, and the United States (US).

Methods: Repeat cross-sectional online surveys were conducted in 2017, 2018, and 2019, with samples of 16- to 19-year-olds recruited from commercial panels in Canada (n = 11,779), England (n = 11,117), and the US (n = 11,869). Regression models examined changes in the prevalence of any cannabis use and use of seven modes of consumption, across the countries.

Results: Cannabis use among youth was more prevalent among respondents in Canada and the US than in England in all years and increased to a greater extent between 2017 and 2019 (p < .001 for all contrasts). Among past 30-day cannabis consumers, the prevalence of vaping oils/liquids and the use of cannabis extracts (oil, wax and shatter) increased in all countries, and was significantly higher in Canada and US. For example, the prevalence of vaping oils/liquids increased from 24.2 % in 2017 to 52.1 % in 2019 among past 30-day cannabis consumers in the US (AOR = 3.46, 95 %CI = 2.57-4.66).

Conclusion: Prevalence is increasing for the most potent categories of cannabis products, particularly among youth in Canada and the US. Future research should examine the potential risks of these products and whether shifts in modes of cannabis reflect recent permissive changes to cannabis policy.

Citation

Le Grande, M., Borland, R., Yong, H.H., Cummings, K.M., McNeill, A., Thompson, M.E., Fong, G.T. (2021). Predictive power of dependence measures for quitting smoking: Findings from the 2016-2018 ITC Four Country Smoking and Vaping Surveys. Nicotine and Tobacco Research, 23(2), 276-285.

Abstract

Objective: To test whether urges to smoke and perceived addiction to smoking, have independent predictive value for quit attempts and short-term quit success over and above the Heaviness of Smoking Index (HSI). Methods: Data were from the International Tobacco Control Four Country Smoking and Vaping Wave 1 (2016) and Wave 2 (2018) surveys. 3661 daily smokers (daily vapers excluded) provided data in both waves. A series of multivariable logistic regression models assessed the association of each dependence measure on odds of making a quit attempt and ≥1 month smoking abstinence.

Results: Of the 3661 participants, 1594 (43.5%) reported a quit attempt. Of those who reported a quit attempt, 546 (34.9%) reported short-term quit success. Fully adjusted models showed that making quit attempts was associated with lower HSI [adjusted odds ratio (aOR) = 0.81, 95% confidence interval (CI) = 0.73-0.90, P < 0.001), stronger urges to smoke (aOR = 1.08, 95% CI = 1.04-1.20, P = 0.002), and higher perceived addiction to smoking (aOR =0.52, 95% CI 0.32-0.84, P =0.008). Lower HSI (aOR = 0.57, 95% CI = 0.40–0.87, P < 0.001) weaker urges to smoke (aOR = 0.85, 95% CI = 0.76–0.95, P = 0.006), and lower perceived addiction to smoking (aOR = 0.55, 95% CI =0.32-0.91, P = 0.021) were associated with greater odds of short-term quit success. In both cases overall R2 was around 0.5.

Conclusions: The two additional dependence measures were complementary to HSI adding explanatory power to smoking cessation models, but variance explained remains small.

Implications: Strength of urges to smoke and perceived addiction to smoking may significantly improve prediction of cessation attempts and short-term quit success over and above routinely assessed demographic variables and the HSI. Stratification of analyses by age group is recommended since the relationship between dependence measures and outcomes differ significantly for younger (age 18-39) compared to older (age over 40) participants. Even with the addition of these extra measures of dependence, the overall variance explained in predicting smoking cessation outcomes remains very low. These measures can only be thought of as assessing some aspects of dependence. Current understanding of the factors that ultimately determine quit success remains limited.

Citation

East, K., Hitchman, S.C., McNeill, A., Ferguson, S., Yong, H.H., Cummings, K.M., Fong, G.T., Borland, R. (2021). Trends in social norms towards smoking between 2002 and 2015 among daily smokers: Findings from the International Tobacco Control Four Country Survey (ITC 4C). Nicotine and Tobacco Research, 23(1), 203-211. doi: 10.1093/ntr/ntz179

Abstract

Objective: To assess trends in daily smokers’ social norms and opinions of smoking between 2002 and 2015 in Canada, US, UK and Australia.

Method: Data were from Waves-1 (2002) to -9 (2013-2015) of the longitudinal International Tobacco Control Four Country Survey (Canada, US, UK, Australia), involving 23,831 adult daily smokers. Generalised estimating equation logistic regression models, adjusted for demographics and survey design effects, assessed associations of Wave and country with outcomes: (i) over half of five closest friends smoke, (ii) agreeing that people important to you believe you should not smoke, (iii) agreeing that society disapproves of smoking, and (iv) negative opinion of smoking.

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

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

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

Citation

Yong, H.H., Karmakar, C., Kusmakar, S., Borland, R., Cummings, K.M., Fong, G.T., McNeill, A. (2021). Identifying factors that conjointly influence nicotine vaping product relative harm perception among smokers and recent ex-smokers: Findings from the 2016 ITC Four Country Smoking and Vaping Survey. Drug and Alcohol Dependence, 218, 108370.

Abstract

Background: Use of nicotine vaping products (NVPs) to replace smoking is often influenced by perceived harmfulness of these products relative to smoking. This study aimed to identify factors that conjointly influenced NVP relative harm perception among smokers and ex-smokers.

Methods: Data (n = 11,838) from adult smokers and ex-smokers (quit < 2 years) who participated in the 2016 ITC 4 Country Smoking and Vaping Surveys in Australia, Canada, England and the US were analyzed. Decision tree models were used to classify respondents into those who perceived vaping as less harmful than smoking (correct perception) versus otherwise (incorrect perception) based on their socio-demographic, smoking and vaping related variables.

Results: Decision tree analysis identified nicotine replacement therapy (NRT) harmfulness perceptions relative to smoking, perceived vaping portrayal in the media and other sources as positive, negative or balanced, recency of seeking online vaping information, and age as the key variables that interacted conjointly to classify respondents into those with correct versus incorrect harm perceptions of vaping relative to smoking (model performance accuracy = 0.70-0.74). In all countries, NRT relative harmfulness perception and vaping portrayal perception were consistently the two most important classifying variables, with other variables showing some country differences.

Conclusions: In all four countries, perception of NVP relative harmfulness among smokers and recent ex-smokers is strongly influenced by a combination of NRT relative harmfulness perception and vaping portrayal in the media and other sources. These conjoint factors can serve as useful markers for identifying subgroups more vulnerable to misperception about NVP relative harmfulness to benefit from corrective intervention.

Citation

Cheng, K.-W., Shang, C., Lee, H.M., Chaloupka, F.J., Fong, G.T., Borland, R., Heckman, B.W., Hithchman, S.C., O’Connor, R.J., Levy, D.T., Cummings, K.M. (2021). Costs of vaping: Evidence from ITC Four Country Smoking and Vaping Survey. Tobacco Control, 30(1), 94-97.

Abstract

Study objectives: To compare the prices paid for nicotine vaping products (NVPs) and supplies among current NVP users to prices paid for cigarettes among current smokers.

Data: The 2016 International Tobacco Control Four Country Vaping and Smoking Survey (4CV1). Key measures included: (1) self-reported prices paid for reusable NVPs (eg, rechargeable devices with cartridges and tank system devices with e-liquids) in the 3-month period prior to the survey among current NVP users, (2) prices paid for disposable NVPs, cartridges and e-liquids purchased in the last 30 days among current NVP users and (3) self-reported prices paid for cigarettes among current smokers.

Results: Disposable NVP price was higher than the price of a comparable unit for combustible cigarettes in England (EN), USA and Canada (CA). Prefilled cartridge price was higher than the price of a comparable unit of cigarettes in USA and CA, but lower in EN and Australia. E-liquid price was consistently lower than the price of a comparable unit of cigarettes across four countries. For start-up costs, price of a rechargeable device is approximately 3–5 times higher than a pack of cigarettes in four countries.

Conclusion: NVP prices were generally higher than prices of combustible cigarettes, especially the high upfront NVP devices. The high upfront costs of purchasing a reusable NVP may discourage some smokers from switching to vaping. However, the average lower costs of cartridges and e-liquids relative to a package of cigarettes make switching to a NVP an attractive alternative to smoking in the long term so long as smokers switch completely to vaping.

Citation

Driezen, P., Fong, G.T., Hyland, A., Craig, L., Sansone, G., Hitchman, S.C., Cummings, K.M. (2020). Self-reported exposure to secondhand smoke and support for complete smoking bans in multiunit housing among smokers from the United States, Canada, and the United Kingdom. Preventing Chronic Disease, 17, E147

Abstract

Introduction

Involuntary exposure to secondhand smoke most frequently occurs at home, which is problematic for residents of multiunit housing (MUH). The primary objective of this study was to estimate the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their homes but lived in buildings where smoking is allowed.

Methods

We used data from Wave 9 of the International Tobacco Control Four Country Survey. We estimated 1) the prevalence of complete smoking bans among smokers living in single-family homes vs MUH in the United States (n = 3,208), Canada (n = 1,592), and the United Kingdom (n = 1,403) from 2013 to 2015; 2) the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their units but lived in buildings that allow smoking; and 3) MUH smokers’ preferences for complete smoking bans in MUH. Weighted multivariable logistic regression estimated the country-specific adjusted prevalence of all outcomes.

Results

Overall, 53.0% of smokers living in single-family homes completely banned smoking in their homes, compared with 44.8% of smokers in MUH. Across all 3 countries, only 27.8% of MUH smokers reported that smoking was completely prohibited in their building. A similar percentage of MUH smokers who banned smoking in their home but lived in buildings allowing smoking reported a secondhand smoke incursion into their home in the United States (29.9%; 95% CI, 20.4%–41.5%), Canada (38.4%; 95% CI, 26.7%–51.6%), and the United Kingdom (24.7%; 95% CI, 15.7%–36.7%). Across all 3 countries, 36.1% (95% CI, 33.4%–38.9%) of smokers in MUH reported they preferred a complete smoking ban in all building areas.

Conclusion

A need remains to educate MUH operators and residents about the benefits of comprehensive smoke-free policies.

Citation

Gravely, S., Cummings, K.M., Hammond, D., Lindblom, E., Smith, D.M., Martin, N., Loewen, R., Borland, R., Hyland, A., Thompson, M.E., Boudreau, C., Kasza, K.A., Ouimet, J., Quah, A.C.K., O’Connor, R.J., Fong, G.T. (2020). The association of e-cigarette flavors with satisfaction, enjoyment, and trying to quit or stay abstinent from smoking among regular adult vapers from Canada and the United States: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 22(10), 1831-1841.

Abstract

Introduction: This study examined whether non-tobacco flavors are more commonly used by vapers (ecigarette users) compared to tobacco flavor, described which flavors are most popular, and tested whether flavors are associated with: vaping satisfaction relative to smoking, level of enjoyment with vaping, reasons for using e-cigarettes, and making an attempt to quit smoking by smokers.

Methods: This cross sectional study included 1,603 adults from Canada and the US who vaped at least weekly, and were either current smokers (concurrent users) or former smokers (exclusive vapers). Respondents were categorized into one of seven flavors they used most in the last month: tobacco, tobacco-menthol, unflavored, or one of the non-tobacco flavors: menthol/mint, fruit, candy, or ‘other’ (e.g. Coffee).

Results: Vapers use a wide range of flavors, with 63.1% using a non-tobacco flavor. The most common flavor categories were fruit (29.4%) and tobacco (28.7%), followed by mint/menthol (14.4%) and candy (13.5%). Vapers using candy (41.0%, p<0.0001) or fruit flavors (26.0%, p=0.01) found vaping more satisfying (compared to smoking) than vapers using tobacco flavor (15.5%) and rated vaping as very/extremely enjoyable (fruit: 50.9%; candy: 60.9%) than those using tobacco flavor (39.4%). Among concurrent users, those using fruit (74.6%, p=0.04) or candy flavors (81.1%, p=0.003) were more likely than tobacco flavor users (63.5%) to vape in order to quit smoking. Flavor category was not associated with the likelihood of a quit attempt (p=0.46). Among exclusive vapers, tobacco and non-tobacco flavors were popular; however, those using tobacco (99.0%) were more likely than those using candy (72.8%, p=0.002) or unflavored (42.5%, p=0.005) to vape in order to stay quit.

Conclusions: A majority of regular vapers in Canada and the US use non-tobacco flavors. Greater satisfaction and enjoyment with vaping is higher among fruit and candy flavor users. While it does not appear that certain flavors are associated with a greater propensity to attempt to quit smoking among concurrent users, non-tobacco flavors are popular among former smokers who are exclusively vaping. Future research should determine the likely impact of flavor bans on those who are vaping to quit smoking or to stay quit.

Implications: Recent concerns about the attractiveness of e-cigarette flavors among youth have resulted in flavor restrictions in some jurisdictions of the United States and Canada. However, little is known about

the possible consequences for current and former smokers if they no longer have access to their preferred flavors. This study shows that a variety of nontobacco flavors, especially fruit, are popular among adult vapers, particularly among those who have quit smoking and are now exclusively vaping. Limiting access to flavors may therefore reduce the appeal of e-cigarettes among adults who are trying to quit smoking or stay quit.

Citation

Li, L., Borland, R., Cummings, K.M., McNeill, A., Heckman, B.W., Fong, G.T., O’Connor, R.J., Driezen, P. (2020). Are health conditions and concerns about health effects of smoking predictive of quitting? Findings from the ITC 4CV Survey (2016-2018). Tobacco Prevention & Cessation, 6(October), 60.

Abstract

Introduction:

Limited research has investigated the relationship between multiple health conditions and subsequent quitting activities at the population level. This study examines whether nine health conditions and concerns related to smoking are predictive of quit attempts and success among those who tried.

Methods:

Data came from the International Tobacco Control Four Country Smoking and Vaping Survey conducted in Australia, Canada, England and the US. A total of 3998 daily smokers were surveyed in 2016 and recontacted in 2018. Respondents were asked in 2016 whether they had a medical diagnosis for depression, anxiety, alcohol problems, obesity, chronic pain, diabetes, heart disease, cancer, and chronic lung disease, and whether they had concerns about past/future health effects of smoking. Outcomes were quit attempts and success (having been abstinent for at least one month between surveys).

Results:

Across all four countries, 44.4% of smokers tried to quit between the two survey years, and of these 36.8% were successful. Concerns about past (adjusted odds ratio, AOR=1.66, 95% CI: 1.32–2.08, p<0.001) and future effects of smoking (AOR=2.17, 95% CI: 1.62–2.91, p<0.001) and most health conditions predicted quit attempts, but were mostly unrelated to quit success, with concerns about future effects (AOR=0.59, 95% CI: 0.35–0.99, p<0.05), chronic lung conditions (AOR=0.56, 95% CI: 0.37–0.86, p<0.01) and chronic pain (with a trend) being associated with lower success.

Conclusions:

Having a major chronic health condition does, generally, motivate making quit attempts, but in some cases it is associated with failure among those who try. More effective cessation support is required for these high priority groups.