Citation

Sontag, J, Wackowski, O, Hammond, D. (2019). Baseline assessment of noticing e-cigarette health warnings among youth and young adults in the United States, Canada and England, and associations with harm perceptions, nicotine awareness and warning recall. Preventive Medicine Reports, 16, 100966. doi: 10.1016/j.pmedr.2019.100966

Abstract

Health warnings on tobacco products can inform users of potential risks. However, little is known about young people's exposure to health warnings on e-cigarette products. This baseline assessment of young people's noticing e-cigarette warnings uses nationally representative data from three countries. Data were collected under Wave 1 of the ITC Youth Tobacco and E-cigarette Survey, conducted in Canada, England, and the US. Online surveys were completed by 16-19-year-olds in July/August 2017 (n = 12,064), when warnings were either newly required (England) or voluntarily carried by some manufacturers (US, Canada). Analyses examined prevalence and correlates of noticing warnings and associations between noticing warnings and product perceptions, adjusting for country, sex, age, race/ethnicity, and cigarette/e-cigarette use status. About 12% reported noticing warnings on e-cigarette packaging in the past 30 days. Noticing warnings was significantly more likely among youth in England (AOR = 1.3, p < .01) and the US (AOR = 1.3, p < .01) versus Canada, and was most likely among dual ecigarette/cigarette users (AOR = 4.69, p < .001) versus nonusers. Unaided recall of the keyword nicotine was low among those who noticed warnings (7.5%). However, ever e-cigarette users who noticed warnings had higher odds of knowing whether e-cigarettes contained nicotine (AOR = 2.26, p < .001). Noticing warnings was significantly associated with higher odds of believing e-cigarettes cause at least some harm to users (AOR = 1.19), are as harmful as cigarettes (AOR = 1.45), and can be addictive (AOR = 1.43). Baseline assessment reveals that youth's noticing of e-cigarette warnings and recall of nicotineaddiction messages was low. Research should track exposure over time as warning requirements are implemented across different countries.

Citation

Hammond, D., Reid, J., Rynard, V.L., Fong, G.T., Cummings, K.M., McNeill, A., Hitchman, S.C., Thrasher, J.F., Goniewicz, M., Bansal-Travers, M., O’Connor, R.J., Levy, D., Borland, R., White, C. (2020). Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross-sectional surveys. BMJ, 370, m2579. doi: https://www.bmj.com/content/370/bmj.m2579

Abstract

Objective: To examine differences in vaping and smoking prevalence among adolescents in Canada, England, and the United States.

Design: Repeat cross sectional surveys.

Setting: Online surveys in Canada, England, and the US.

Participants: National samples of 16 to 19 year olds in 2017 and 2018, recruited from commercial panels in Canada (n=7891), England (n=7897), and the US (n=8140).

Main outcome measures: Prevalence of vaping and smoking was assessed for use ever, in the past 30 days, in the past week, and on 15 days or more in the past month. Use of JUUL (a nicotine salt based electronic cigarette with high nicotine concentration) and usual vaping brands were also assessed. Logistic regression models examined differences in vaping and smoking between countries and over time.

Results: The prevalence of vaping in the past 30 days, in the past week, and on 15 days or more in the past month increased in Canada and the US between 2017 and 2018 (P<0.001 for all), including among non-smokers and experimental smokers, with no changes in England. Smoking prevalence increased in Canada (P<0.001 for all measures), with modest increases in England, and no changes in the US. The percentage of ever vapers who reported more frequent vaping increased in Canada and the US (P<0.01 for all), but not in England. The use of JUUL increased in all countries, particularly the US and Canada—for example, the proportion of current vapers in the US citing JUUL as their usual brand increased threefold between 2017 and 2018.

Conclusions: Between 2017 and 2018, among 16 to 19 year olds the prevalence of vaping increased in Canada and the US, as did smoking in Canada, with little change in England. The rapidly evolving vaping market and emergence of nicotine salt based products warrant close monitoring.

Citation

Li, L., Borland, R., O’Connor, R., Fong, G.T., McNeill, A., Driezen, P., Cummings, K.M. (2019). How are self-reported physical and mental health conditions related to vaping activities among smokers and quitters: Findings from the ITC Four Country Smoking and Vaping Wave 1 Survey. International Journal of Environmental Research and Public Health, 16(8), e1412.

Abstract

This study examines whether having health conditions or concerns related to smoking is associated with use of vaping products. Data came from the 2016 wave of the International Tobacco Control Four Country Smoking and Vaping Survey. Smokers and recent quitters (n = 11,344) were asked whether they had a medical diagnosis for nine health conditions (i.e., depression, anxiety, alcohol problems, severe obesity, chronic pain, diabetes, heart disease, cancer, and chronic lung disease) and concerns about past and future health effects of smoking, and their vaping activities. Respondents with depression and alcohol problems were more likely to be current vapers both daily (Adjusted odds ratio, AOR = 1.42, 95% confidence interval, CI 1.09–1.85, p < 0.05 for depression; and AOR = 1.52, 95% CI 1.02–2.27, p < 0.05 for alcohol) and monthly (AOR = 1.32, 95% CI 1.11–1.57 for depression, p < 0.01; and AOR = 1.43, 95% CI 1.06–1.90, p < 0.05 for alcohol). Vaping was more likely at monthly level for those with severe obesity (AOR = 1.77, 95% CI 1.29–2.43, p < 0.001), cancer (AOR = 5.19, 95% CI 2.20–12.24, p < 0.001), and concerns about future effects of smoking (AOR = 1.83, 95% CI 1.47–2.28, p < 0.001). Positive associations were also found between chronic pain and concerns about past health effects of smoking and daily vaping. Only having heart disease was, in this case negatively, associated with use of vaping products on their last quit attempt (AOR = 0.72, 95% CI 0.43–0.91, p < 0.05). Self-reported health condition or reduced health associated with smoking is not systematically leading to increased vaping or increased likelihood of using vaping as a quitting strategy.

Citation

Ngo, A., Fong, G.T., Craig, L., Shang, C. (2019). Analysis of gender differences in the impact of taxation and taxation structure on cigarette consumption in 17 ITC countries. International Journal of Environmental Research and Public Health, 16(7), e1275.

Abstract

Although increasing taxes has been established as the most effective tobacco control policy, it is not clear whether these policies reduce cigarette consumption equally among women and men. In this study, we examine whether the association between taxation/taxation structure and cigarette consumption differs by gender. The data is from the International Tobacco Control Policy Evaluation (ITC) Projects in 17 countries. Cigarette consumption was measured by gender for each ITC country. Generalized estimating equations (GEE) were employed to investigate gender differences in the association between cigarette consumption and tax structures, while controlling for time-variant demographic characteristics such as unemployment rates, proportions of adults, and percent of female population. Tiered tax structures are associated with higher cigarette consumption among both males and females. Female smokers are more responsive to an average tax increase than male smokers. Among males, higher ad valorem share in excise taxes is associated with lower cigarette consumption, but it is not the case for females. Females may not be as responsive to the prices raised by ad valorem taxes, despite being responsive to average taxes, suggesting that smokers by gender may face different prices.

Citation

Wackowski, O, Sontag, J, Hammond, D. (2019). Youth and young adult exposure to and perceptions of news media coverage about e-cigarettes in the United States, Canada and England. Preventative Medicine, 121, 7-10. doi: 10.1016/j.ypmed.2019.01.013

Abstract

News media coverage has the potential to shape awareness and perceptions of e-cigarettes, but little is known about youth and young adult exposure to e-cigarette news. We analyzed news exposure measures on Wave 1 of the ITC Youth Tobacco and E-cigarette Survey, conducted in Canada, England, and the U.S. Web-based surveys were completed by 16-19-year-olds in July/August 2017 (n = 12,064). The prevalence of exposure to e-cigarette news and its perceived valence is provided. Logistic regression was used to model the odds of news exposure, and the association between news exposure and e-cigarette harm perceptions, susceptibility, and quitting intentions. Overall, 17.1% of young people reported hearing or seeing e-cigarette news at least 'sometimes' in the past 30 days. The majority of those exposed (n = 2052) perceived the content of the news stories to be mostly negative (35.7%) or mixed (34.8%) about e-cigarettes, versus mostly positive (19%). Perceived exposure to mostly negative e-cigarette stories was lower among past 30-day e-cigarette users and youth in England. Participants exposed to mostly negative e-cigarette news were more likely to perceive that e-cigarettes cause at least some harm and, among past 30 day users, have intentions to quit e-cigarettes in the next month. Exposure to mostly positive news was associated with higher odds of e-cigarette susceptibility among never triers. Young people report exposure to e-cigarette news with varied perceptions of its valence. E-cigarette news exposure may shape e-cigarette harm perceptions and use intentions, as well as reflect existing beliefs and product interest.

Citation

Yong, H.H., Borland, R., Cummings, K.M., Gravely, S., Thrasher, J., McNeill, A., Hitchman, S.C., Greenhalgh, B., Thompson, M.E., Fong, G.T. (2019). Reasons for regular vaping and for its discontinuation among smokers and recent ex-smokers: findings from the 2016 ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 35-48.

Abstract

Aims: To examine current and ex‐ smokers’ reasons for continuing or discontinuing regular use of nicotine vaping products (NVPs).

Design and participants: Cross‐sectional study of 2,722 current daily/weekly, and 921 ex‐daily/weekly, adult vapers who were either current or ex‐cigarette smokers when surveyed.

Setting: 2016 ITC Four Country Smoking and Vaping Wave 1 (4CV1) surveys conducted in the United States (n=1159), England (n=1269), Canada (n=964), and Australia (n=251).

Measurements: Current vapers were asked about the following reasons for regular NVP use: less harmful to others, social acceptance, enjoyment, use in smoke‐free areas, affordability, and managing smoking behaviour. Ex‐vapers were asked about the following reasons for discontinuing regular NVP use: addiction concerns, affordability, negative experiences, perceived social unacceptability, safety concerns, product dissatisfaction, inconvenience, unhelpfulness for quitting, unhelpfulness for managing cravings, and not needed for smoking relapse prevention. Possible correlates of NVP use and discontinuation, including smoking status, smoking/vaping frequency, quit duration (ex‐smokers only), country, age, and type of NVP device used, were examined using multivariate logistic regression models.

Findings: For current smokers, the top three reasons for current regular NVP use were: helpful for cutting down smoking (86%), less harmful to others (78%), and helpful for quitting smoking (77%). The top three reasons for discontinuing vaping were: not being satisfying (78%), unhelpfulness for cravings (63%), and unhelpfulness for quitting smoking (52%). For ex‐smokers, the top three reasons for current vaping were: enjoyment (91%), less harmful to others (90%) and affordability (90%); and for discontinuing were: not needed to stay quit (77%), not being satisfying (50%) and safety concerns (44%). Reported reasons varied by user characteristics, including age, country and NVP device‐type.

Conclusions: Regular use of nicotine vaping products is mainly motivated by its perceived benefits, especially for reducing or quitting smoking, whereas its discontinuation is motivated by perceived lack of such benefits, with some variation by user characteristics.

Citation

Borland, R., Murray, K., Gravely, S., Fong, G.T., Thompson, M.E., McNeill, A., O’Connor, R.J., Goniewicz, M., Yong, H.H., Levy, D., Heckman, B., Cummings, K.M. (2019). A new classification system for describing concurrent use of nicotine vaping products alongside cigarettes (so-called "dual use"): Findings from the ITC 4-Country Smoking and Vaping Wave 1 Survey. Addiction, 114(Suppl 1), 24-34.

Abstract

Aims: To determine whether a simple combination of level of smoking and level of vaping results in a useful typology for characterising smoking and vaping behaviours.

Methods: Cross‐sectional data from adults (≥18 years) in the 2016 Wave 1 ITC Four Country Smoking and Vaping Survey in the United States (n=2291), England (n=3591), Australia (n=1376), and Canada (n=2784) were used. Participants who either smoked, vaped or concurrently used both at least monthly were included and divided into 8 groups based on use frequency of each product (daily, non‐daily, no current use). This resulted in 4 concurrent use groups (predominant smokers, dual daily users, predominant vapers and concurrent non‐daily users). These groups were compared with each other and with the 4 exclusive use groups, on socio‐demographics, nicotine dependence, beliefs and attitudes about both products, and quit‐related measures using data weighted to reference population surveys in each country.

Results: 10.8% of the sample were concurrent users, with daily smokers vaping non‐daily (predominant smokers) constituting 51.6% of this group. All 8 categories differed from other categories on at least some measures. Concurrent daily nicotine users reported higher levels of indicators of nicotine dependence, and generally more positive attitudes toward both smoking and vaping than concurrent non‐daily users. Among daily nicotine users, compared with exclusive daily smokers, reports of interest in quitting were higher in all concurrent use groups. Dual daily users had the most positive attitudes about smoking overall, and saw it as the least denormalised, and at the same time were equally interested in quitting as other concurrent users and were most likely to report intending to continue vaping.

Conclusions: In Australia, Canada, England and the United States in 2016, daily nicotine users differed considerably from non‐daily nicotine users. Among daily nicotine users, dual daily users (those who smoke and vape concurrently) should be treated as a distinct grouping when studying relationships between smoking and vaping. The 8 level typology characterising concurrent and exclusive use of smoking and vaping should be considered when studying both products.

Citation

Cheng, K.-W., Chaloupka, F.J., Shang, C., Ngo, A., Fong, G.T., Borland, R., Heckman, B.W., Levy, D.T., Cummings, K.M. (2019). Prices, use restrictions and electronic cigarette use—evidence from Wave 1 (2016) US data of the ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 115-122.

Abstract

Aims: To determine if there are associations between changes in the explicit (i.e., price) and implicit (i.e., use restrictions in public places) costs of cigarettes and nicotine vaping products (NVPs) and their use patterns in the United States.

Methods: Data came from the Wave 1 (2016) US data of the ITC Four Country Smoking and Vaping Survey (ITC US 4CV1) and Nielsen Scanner Track database. A multiple logistic regression model was applied to estimate the likelihoods of NVP use (vaping at least monthly), cigarette/NVP concurrent use (vaping and smoking at least monthly), and switch from cigarettes to NVPs (had quit smoking < 24 months and currently vape) among ever smokers, conditioning upon cigarette/NVP prices, use restrictions and socio‐demographics.

Results: Living in places where vaping is allowed in smoke‐free areas was significantly associated with an increase in the likelihood of vaping (Marginal Effect, M.E. = 0.17; p<0.05) and the concurrent use of cigarettes and NVPs (M.E. = 0.11; p<0.05). Higher NVP prices were associated with decreased likelihood of NVP use, concurrent use, and complete switch (P>0.05). Higher cigarette prices were associated with greater likelihood of cigarette and NVP concurrent use (P>0.05). Working in places where vaping is banned is associated with lower likelihood of vaping and NVP and cigarette concurrent use (P>0.05).

Conclusions: Higher prices for nicotine vaping products (NVPs) and vaping restrictions in public places are associated with less NVP use and less concurrent use of vaping and smoking. Public policies that increase prices for vaping devices and supplies (i.e., regulations, taxes) and restrict where vaping is allowed are likely to suppress vaping.

Citation

Braak, D., Cummings, K.M., Nahhas, G.J., Heckman, B.W., Borland, R., Fong, G.T., Hammond, D., Boudreau, C., McNeill, A., Levy, D.T., Shang, C. (2019). Where do vapers buy their vaping supplies? Findings from the International Tobacco Control (ITC) 4 Country Smoking and Vaping Survey. International Journal of Environmental Research and Public Health, 16(3), 338.

Abstract

Aim: This study examines where vapers purchase their vaping refills in countries having different regulations over such devices, Canada (CA), the United States (US), England (EN), and Australia (AU).

Methods: Data were available from 1899 current adult daily and weekly vapers who participated in the 2016 (Wave 1) International Tobacco Control Four Country Smoking and Vaping. The outcome was purchase location of vaping supplies (online, vape shop, other). Adjusted odds ratios and 95% confidence intervals were reported for between country comparisons.

Results: Overall, 41.4% of current vapers bought their vaping products from vape shops, 27.5% bought them online, and 31.1% from other retail locations. The vast majority of vapers (91.1%) reported using nicotine-containing e-liquids. In AU, vapers were more likely to buy online vs other locations compared to CA (OR = 6.4, 2.3–17.9), the US (OR = 4.1, 1.54–10.7), and EN (OR = 7.9, 2.9–21.8). In the US, they were more likely to buy from vape shops (OR = 3.3, 1.8–6.2) or online (OR = 1.9, 1.0–3.8) vs other retail locations when compared to those in EN. In CA, vapers were more likely to purchase at vape shops than at other retail locations when compared to vapers in EN (5.9, 3.2–10.9) and the US (1.87, 1.0–3.1).

Conclusions: The regulatory environment and enforcement of such regulations appear to influence the location where vapers buy their vaping products. In AU, banning the retail sale of nicotine vaping products has led vapers to rely mainly on online purchasing sources, whereas the lack of enforcement of the same regulation in CA has allowed specialty vape shops to flourish.

Citation

Gravely, S., Driezen, P., Ouimet, J., Quah, A.C.K., Cummings, K.M., Thompson, M.E., Boudreau, C., Hammond, D., McNeill, A., Borland, R., Thrasher, J.F., Edwards, R., Omar, M., Hitchman, S., Yong, H-H., Barrientos-Gutierrez, T., Willemsen, M.C., Bianco, E., Boado, M., Goma, F., Seo, H.G., Nargis, N., Jiang, Y., Perez, C., & Fong, G.T. (2019). Prevalence of awareness, ever-use, and current use of nicotine vaping products (NVPs) among adult current smokers and ex-smokers in 14 countries with differing regulations on sales and marketing of NVPs: Cross-sectional findings from the ITC Project. Addiction, 114(6), 1060-1073.

Abstract

Aims: This paper presents updated prevalence estimates of awareness, ever‐use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing.

Design, setting, participants and measurements: A cross‐sectional analysis of adult (≥18 years) current smokers and ex‐smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013 to 2017. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs): not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs): not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand (NZ); (3) less restrictive policies (LRPs): legal to be sold and marketed with regulations: England, Netherlands, Republic of Korea, United States (US); (4) no regulatory policies (NRPs): Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country‐specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily vs. non‐daily).

Findings: NVP awareness and use were lowest in NRP countries. Generally, ever‐ and current use of NVPs were lower in MRP countries [ever‐use: 7.1% to 48.9%; current use: 0.3% to 3.5%] relative to LRP countries [ever‐use: 38.9% to 66.6%; current use: 5.5% to 17.2%] and RP countries [ever‐use: 10.0% to 62.4%; current use: 1.4% to 15.5%]. NVP use was highest among high income countries, followed by upper‐middle income countries, and then by lower‐middle income countries.

Conclusions: With a few exceptions, awareness and use of nicotine vaping products (NVPs) varies by the strength of national regulations governing NVP sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in NVPs in these countries where smoking populations are predominantly poorer. The higher awareness and use of NVPs in high income countries with moderately (e.g., Canada, NZ) and less (e.g., England, US) restrictive policies, is likely due to the greater availability and affordability of NVPs.

Citation

McDermott, M., Li, G., McNeill, A., Hammond, D., Thrasher, J.F., O’Connor, R.J., Cummings, K.M., Borland, R., Fong, G.T., Hitchman, S.C. (2019). Exposure to and perceptions of health warning labels on nicotine vaping products: Findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 134-143.

Abstract

Background and Aims: The presence and content of health warning labels (HWLs) on nicotine vaping products (NVPs), such as electronic cigarettes, varies by country and manufacturer. We compared proportions of people who report (i) noticing HWLs on NVPs and (ii) feeling concerned having noticed HWLs, by country and by smoking or vaping status. We also examined recall of HWL content and whether this varies by country.

Design: Cross‐sectional survey

Setting: Australia (AU), Canada (CA), England (EN), and the United States (US). At the time of data collection, HWLs on NVPs were only mandatory in EN.

Participants: A total of 11561 respondents from the following samples in the 2016 International Tobacco Control 4‐Country Project: (1) re‐contacted smokers and quitters who had participated in the previous wave of the project; (2) newly recruited current smokers and recent quitters, and (3) newly recruited current vapers from CA, EN and US.

Measurements: Outcomes included: 1) having noticed HWLs on NVPs, 2) feeling concerned having noticed HWLs, and 3) recall of HWL message content.

Findings: Compared with respondents in EN, respondents in CA were more likely to report having noticed HWLs (OR=1.58, p=0.02) whereas respondents in AU (OR=0.76, p=1.00) and the US (OR=1.54, p=0.09) were not significantly more or less likely to report having noticed HWLs. Compared with concurrent smokers and vapers, daily smokers, non‐daily smokers, and quitters were less likely to report having noticed HWLs, (ORs=0.21, 0.33 and 0.19 respectively, all p<0.001). There were no significant differences in reports of noticing HWLs when comparing concurrent smokers and vapers with daily (OR=1.62, p=0.91) or non‐daily (OR=1.15, p=1.00) vapers. There were no significant differences by country in reporting that HWLs made them concerned about using NVPs. Daily vapers were less likely to report feeling concerned than concurrent users (OR=0.11, p=0.017). Among those who reported reading HWLs (n=688), there was little evidence of differences in recall of the HWL content.

Conclusions: Respondents in England, where health warning labels on nicotine vaping products are not mandatory, were not significantly more likely to report having noticed such warnings than those in Australia, Canada and the US where warnings are not mandatory.

Citation

Green, A., Driezen, P., Hammond, D., Soar, S., Fong, G.T. (2019). The impact of adding and removing warning label messages from cigarette packages on adult smokers’ awareness about the health harms of smoking: Findings from the ITC Canada Survey. Tobacco Control, 28(e1), 356-63.

Abstract

Introduction: Adding messages to cigarette health warning labels (HWLs) about the harms of smoking increases awareness of these health facts, but little is known about the impact of removing messages. This is the first study to directly investigate the impact of adding and removing messages from cigarette HWLs on smokers’ awareness of harms.

Methods: Data were drawn from nine waves of the International Tobacco Control (ITC) Canada Survey, a national representative cohort of adult smokers (n=5863) conducted nearly annually between 2002 and 2013–2014. Two analytical approaches were conducted: generalised estimating equation (GEE) regression models estimated adjusted percentages of correct smoking-related health statements at each wave and segmented regression analyses modelled temporal trends in awareness before and after the revisions by measuring the difference in slopes.

Results: Adding messages to HWLs significantly increased awareness that smoking causes blindness (OR=3.36 (95% CI 2.71 to 4.18); p<0.001; estimated increase of 1.01 million smokers in Canada) and bladder cancer (OR=2.14 (95% CI 1.71 to 2.66), p<0.001; estimated increase of 1.09 million smokers). Adding the warning that nicotine causes addiction did not significantly impact smokers’ awareness. Removing messages was shown to decrease awareness that cigarette smoke contains carbon monoxide (OR=0.53 (95% CI 0.41 to 0.70), p<0.001; estimated decrease of 342 000 smokers) and smoking causes impotence (p=0.007 for the difference in slopes; estimated decrease of 354 000 smokers).

Conclusions: Adding messages to HWLs increases smokers’ awareness of health facts, but removing messages decreases awareness. These findings demonstrate the importance of carefully considering the implications of adding and especially removing messages from HWLs and the importance of regularly revising warnings.

Citation

Fleischer, N.L., Lozano, P., Wu, Y.H., Hardin, J.W., Meng, G., Liese, A.D., Fong, G.T., Thrasher, J.F. (2019). Disentangling the roles of point-of-sale bans, tobacco retailer density and proximity on cessation and relapse among a cohort of smokers: findings from ITC Canada Survey. Tobacco Control, 28(1), 81-87.

Abstract

Objective: To examine how point-of-sale (POS) display bans, tobacco retailer density and tobacco retailer proximity were associated with smoking cessation and relapse in a cohort of smokers in Canada, where provincial POS bans were implemented differentially over time from 2004 to 2010.

Methods: Data from the 2005 to 2011 administrations of the International Tobacco Control (ITC) Canada Survey, a nationally representative cohort of adult smokers, were linked via residential geocoding with tobacco retailer data to derive for each smoker a measure of retailer density and proximity. An indicator variable identified whether the smoker’s province banned POS displays at the time of the interview. Outcomes included cessation for at least 1 month at follow-up among smokers from the previous wave and relapse at follow-up among smokers who had quit at the previous wave. Logistic generalised estimating equation models were used to determine the relationship between living in a province with a POS display ban, tobacco retailer density and tobacco retailer proximity with cessation (n=4388) and relapse (n=866).

Results: Provincial POS display bans were not associated with cessation. In adjusted models, POS display bans were associated with lower odds of relapse which strengthened after adjusting for retailer density and proximity, although results were not statistically significant (OR 0.66, 95% CI 0.41 to 1.07, p=0.089). Neither tobacco retailer density nor proximity was associated with cessation or relapse.

Conclusions: Banning POS retail displays shows promise as an additional tool to prevent relapse, although these results need to be confirmed in larger longitudinal studies.

Citation

Shang, C., Myung Lee, H., Chaloupka, F., Fong, G.T., Thompson, M.E., O’Connor, R.J. (2019). Association between tax structure and cigarette consumption: findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 28(Suppl 1), S31-S36.

Abstract

Background: Recent studies show that greater price variability and more opportunities for tax avoidance are associated with tax structures that depart from a specific uniform one. These findings indicate that tax structures other than a specific uniform one may lead to more cigarette consumption.

Objective: This paper aims to examine how cigarette tax structure is associated with cigarette consumption.

Methods: We used survey data taken from the International Tobacco Control Policy Evaluation Project in 17 countries to conduct the analysis. Self-reported cigarette consumption was aggregated to average measures for each surveyed country and wave. The effect of tax structures on cigarette consumption was estimated using generalised estimating equations after adjusting for sociodemographic characteristics, average taxes and year fixed effects.

Findings: Our study provides important empirical evidence of a relationship between tax structure and cigarette consumption. We find that a change from a specific to an ad valorem structure is associated with a 6%–11% higher cigarette consumption. In addition, a change from uniform to tiered structure is associated with a 34%–65% higher cigarette consumption. The results are consistent with existing evidence and suggest that a uniform and specific tax structure is the most effective tax structure for reducing tobacco consumption.

Citation

Chan, C.K.G., Morphett, K., Gartner, C., Leung, J., Yong, H.H., Hall, W., Borland, R. (2019). Predicting vaping uptake, vaping frequency and ongoing vaping among daily smokers using longitudinal data from the International Tobacco Control (ITC) Four Country Surveys. Addiction, 114(Suppl 1), 61-70.

Abstract

Aim: To assess (1) how far smoking patterns, depression and smoking‐related beliefs and intentions predict vaping uptake, current vaping and vaping frequency among daily smokers; and (2) how far the aforementioned predictors and baseline vaping frequency predict current vaping among those who reported ever vaped.

Design: Analysis of data from six waves of a longitudinal survey over 8 years. Longitudinal associations between predictors and outcomes were examined using multi‐level models.

Setting: United Kingdom, United States, Canada and Australia.

Participants: A total of 6296 daily smokers (53% females) who contributed data to at least two consecutive survey waves.

Measurements: The outcome variables were vaping uptake, vaping frequency and current vaping at follow‐up. The key predictor variables, measured in previous waves, were time to first cigarette, cigarettes smoked per day, depressive symptoms, intention to quit smoking, quitting self‐efficacy and worry about adverse health effects of smoking.

Findings: Number of cigarettes smoked daily was associated with (1) subsequent vaping uptake [odds ratio (OR) = 1.69, 95% confidence interval (CI) = 1.19, 2.39 for 30+ cigarette per day; reference category: 0–10 cigarettes] and (2) a higher frequency of current vaping (OR = 1.97, 95% CI = 1.36, 2.85 for 30+ cigarettes). Intention to quit was associated with a higher frequency of current vaping (OR = 1.48, 95% CI = 1.21, 1.82). Among those who reported ever vaped, higher baseline vaping frequency (OR = 11.98, 95% CI = 6.00, 23.93 for daily vaping at baseline; reference category: vaped less than monthly) predicted current vaping.

Conclusion: Among daily smokers, amount smoked and intention to quit smoking appear to predict subsequent vaping uptake. Vaping frequency at baseline appears to predict current vaping at follow‐up.

Citation

Thompson, M.E., Fong, G.T., Boudreau, C., Driezen, P., Li, G., Gravely, S., Cummings, K.M., Heckman, B.W., O’Connor, R.J., Thrasher, J.F., Nahhas, G., Borland, R., Yong, H.H., McNeill, A., Hitchman, S.C., Quah, A.C.K. (2019). Methods of the ITC Four Country Smoking and Vaping Survey, Wave 1 (2016). Addiction, 114(Suppl 1) 6-14.

Abstract

Aim: To describe the methods of the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey, conducted in 2016 in Australia (AU), Canada (CA), England (EN) and the United States (US).

Methods: The respondents were cigarette smokers, former smokers (quit within the previous 2 years), and at‐least‐weekly vapers, aged 18 years and older. Eligible cohort members from the ITC Four Country Survey (4C) were retained. New respondents were sampled by commercial firms from their panels. Where possible, ages 18–24 and vapers were oversampled. Data were collected online, and respondents were remunerated. Survey weights were calibrated to benchmarks from nationally representative surveys.

Results: Response rates by country for new recruits once invited ranged from 15.2 to 49.6%. Sample sizes for smokers/former smokers were 1504 in AU, 3006 in CA, 3773 in EN and 2239 in the US. Sample sizes for additional vapers were 727 in CA, 551 in EN and 494 in the US.

Conclusion: The International Tobacco Control Four Country Smoking and Vaping Survey design and data collection methods allow analyses to examine prospectively the use of cigarettes and nicotine vaping products in jurisdictions with different regulatory policies. The effects on the sampling designs and response quality of recruiting the respondents from commercial panels are mitigated by the use of demographic and geographic quotas in sampling; by quality control measures; and by the construction of survey weights taking into account smoking/vaping status, sex, age, education and geography.

Citation

Gravely, S., Thrasher, F.J., Cummings, K.M., Ouimet, J., McNeill, A., Meng, G., Lindblom, E.N., Loewen, R., O’Connor, R., Thompson, M.E., Hitchman, S., Hammond, D., Heckman, B.W., Borland, R., Yong, H.H., Elton-Marshall, T., Bansal-Travers, M., Gartner, C., Fong, G.T. (2019). Discussions between health professionals and smokers about nicotine vaping products: Results from the 2016 ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 71-85.

Abstract

Background and Aims: Debate exists about whether health professionals (HPs) should advise smokers to use nicotine vaping products (NVPs) to quit smoking. The objectives were to examine in four countries: (1) the prevalence of HP discussions and recommendations to use an NVP; (2) who initiated NVP discussions; (3) the type of HP advice received about NVPs; and (4) smoker's characteristics related to receiving advice about NVPs.

Design: Cross‐sectional study using multivariable logistic regression analyses on weighted data from the 2016 ITC Four Country Smoking and Vaping Survey (ITC 4CV1).

Setting: Four countries with varying regulations governing the sale and marketing of NVPs: ‘most restrictive’ (Australia), ‘restrictive’ (Canada) or ‘less restrictive’ (England and United States).

Participants: A total of 6615 adult smokers who reported having visited an HP in the last year (drawn from the total sample of 12 294 4CV1 respondents, of whom 9398 reported smoking cigarettes daily or weekly). Respondents were from the United States (n = 1518), England (n = 2116), Australia (n = 1046), and Canada (n = 1935).

Measurements: Participants’ survey responses indicated if they were current daily or weekly smokers and had visited an HP in the past year. Among those participants, further questions asked participants to report (1) whether NVPs were discussed, (2) who raised the topic, (3) advice received on use of NVPs and (4) advice received on quitting smoking.

Findings: Among the 6615 smokers who visited an HP in the last year, 6.8% reported discussing NVPs with an HP and 2.1% of smokers were encouraged to use an NVP (36.1% of those who had a discussion). Compared with Australia (4.3%), discussing NVPs with an HP was more likely in the United States [8.8%, odds ratio (OR) = 2.15, 95% confidence interval (CI) = 1.41–3.29] and Canada (7.8%, OR = 1.87, 95% CI = 1.26–2.78). Smokers in Australia were less likely to discuss NVPs than smokers in England (6.2%), although this was not statistically significant (OR = 1.47, 95% CI = 0.98–2.20). Overall, the prevalence of HPs recommending NVPs was three times more likely in the United States than in Australia (OR = 3.07, 95% CI = 1.45–6.47), and twice as likely in Canada (OR = 2.28, 95% CI = 1.06–4.87) than in Australia. Australia and England did not differ (OR = 1.76, 95% CI = 0.83–3.74). Just over half (54%) of respondents brought up NVPs themselves; there were no significant differences among countries.

Conclusions: Discussions in Australia, Canada, England, and the United States between smokers and health professionals about nicotine vaping products appear to be infrequent, regardless of the regulatory environment. A low percentage of health professionals recommended vaping products. This was particularly evident in Australia, which has the most restrictive regulatory environment of the four countries studied.

Citation

Levy, D., Abrams, D.B., Yuan, Z., Lou, Y., Fong, G.T., Borland, R. (2019). A modeling approach to gauging the effects of nicotine vaping product use on cessation from cigarettes: What do we know, what do we need to know? Addiction, 114(Suppl 1), 86-96.

Abstract

Background and Aims: The long term population health impact of nicotine vaping products (NVPs) use among smokers is unknown and subject to a range of plausible assumptions about the use and health consequences of NVPs. While NVPs use may substitute for cigarette smoking and thereby aid in quitting cigarette use, it is also possible that smokers who would have otherwise quit would instead delay quitting cigarettes. We aimed to develop a cohort-specific simulation model of the impact of NVPs on smoking cessation by adult smokers and resulting premature deaths (PD) and life-years lost (LYL).

Design: A cohort-specific simulation model of the impact of NVPs on smoking cessation by adult smokers and resulting premature deaths (PD) and life-years lost (LYL) was developed by gender for two birth-cohorts, age 30 and age 50 in 2012. Extensive sensitivity analyses were conducted.

Setting: United States PARTICIPANTS: Smokers in two birth-cohorts, age 30 and age 50 in 2012 MEASUREMENTS: Data were from the 1965-2012 National Health Interview Surveys and the 2014/5 Tobacco Use Supplement of the Current Population Survey. The model incorporated a range of plausible assumptions from published literature about transition rates from regular smoking to exclusive NVP and dual use, from dual use to exclusive NVP use and from exclusive NVP use to no use.

Findings: Compared with the No-NVP scenario, the male (female) model projected 17.8% (19.3%) fewer PDs and 22.9% (26.6%) fewer LYL for the 1982 cohort and 5.4% (7.3%) fewer PDs and 7.9% (11.4%) fewer LYL for the 1962 cohort. These gains were sensitive to NVP use over time, age of initial NVP use, transitions from smoking to dual, exclusive NVP and no use, and relative NVP mortality risks.

Conclusions: Nicotine vaping product (NVP) use in the US is projected to have a net positive impact on population health over a wide range of plausible levels of NVP use, transitions to dual, exclusive NVP and no use, and NVP risks. However, net impact is sensitive to parameter estimates.

Citation

Branston, J.R., McNeill, A., Gilmore, A., Hiscock, R., Partos, T.R. (2018). Keeping smoking affordable in higher tax environments via smoking thinner roll-your-own cigarettes: Findings from the International Tobacco Control Four Country Survey 2006–15. Drug and Alcohol Dependence, 193, 110-116.

Abstract

Background: Roll-Your-Own tobacco (RYO) use is increasingly popular in many countries: it is generally cheaper than factory-made cigarettes (FM), and smokers can further reduce costs by adjusting the amount of tobacco in each cigarette. However, the level of risk of RYO compared with FM cigarettes is similar and does not meaningfully change with cigarette weight. We assessed the weight of tobacco in RYO cigarettes across jurisdictions with differing tobacco taxes/prices and over time.

Method: Six waves of the International Tobacco Control 4 Country longitudinal study of smokers and recent ex-smokers, providing 3176 observations from exclusive RYO users covering 2006-15, are used to calculate the weight of tobacco used in RYO cigarettes in the US, Canada, Australia, and the UK. Multilevel regression analyses were used to compare weights across countries, socio-demographic factors, and over time.

Results: Smokers in the UK and Australia, where tobacco is relatively expensive, show higher levels of exclusive RYO use (25.8% and 13.8% respectively) and lower mean weights of tobacco per RYO cigarette (0.51 g(sd 0.32 g) and 0.53 g(0.28 g)), compared with both Canada and especially the US (6.0% and 3.5%, and 0.76 g(0.45 g) and 1.07 g(0.51 g)). Smokers in the UK and Australia also exhibited a statistically significant year-on-year decrease in the mean weight of each RYO cigarette.

Conclusions: Taxation of RYO should increase considerably in the UK and Australia so that RYO and FM cigarettes are taxed equivalently to reduce RYO attractiveness and inequalities. Other measures to reduce the price differentials, including taxing RYO solely on weight, are also discussed.

Citation

Heckman, B.W., Cummings, K.M., Stoltman, J.J.K., Dahne, J., Borland, R., Fong, G.T., Carpenter, M.J. (2019). Longer duration of smoking abstinence is associated with waning cessation fatigue. Behaviour Research and Therapy, 115, 12-18.

Abstract

Background: Cessation fatigue, a construct theorized to reflect exhaustion of coping resources due to quitting smoking, has been found to predict relapse. This study examines the association between cessation fatigue and duration of abstinence among 1397 adult former smokers who participated in the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Wave 1 Survey (4CV). We hypothesized lower levels of cessation fatigue will be correlated with longer duration of abstinence.

Method: Data for this cross-sectional study were collected in a web-based survey which recruited national samples from Australia, Canada, England, and United States. Former smokers were abstinent up to five years.

Results: Lower cessation fatigue was associated with longer duration of smoking abstinence. Cessation fatigue was highest in former smokers that had been quit for up to six months, with lower cessation fatigue found in those quit for at least seven months and another drop-off in fatigue observed for those quit for at least two years.

Conclusions: Cessation fatigue is highest soon after quitting smoking but declines over time for those who remain abstinent. Understanding the mechanisms by which cessation fatigue is related to abstinence could potentially offer insights into ways to help individuals sustain quitting.

Citation

Levy, D., Yuan, Z., Abrams, D.B. (2018). The relationship of e-cigarette use to cigarette quit attempts and cessation: insights from a large, nationally representative U.S. Survey. Nicotine and Tobacco Research, 20(8), 931-939.

Abstract

Objectives: While cessation from cigarettes is a top priority for public health, controversy surrounds the role of e-cigarettes for quitting cigarettes. This study examines the role of e-cigarettes in quit attempts and 3-month cigarette abstinence using a large, recent nationally representative US sample.

Methods: Data from the 2014/15 Tobacco Use Supplement-Current Population Survey (TUS-CPS) on cigarette and e-cigarette use and individual characteristics were supplemented with information on state tobacco control policies. We estimated frequencies and multivariate logistic equations for making a quit attempt among those who smoked 1 year earlier and for remaining abstinent at least 3 months among those making a quit attempt. These two outcomes were related to demographic characteristics, tobacco control policies and different frequency measures of e-cigarette use (ever, at least 1, 5, 20 of the last 30 days, a continuous measure of days use).

Results: Having made a quit attempt was more likely among smokers using e-cigarettes than non-users. Among those making at least one quit attempt, quit success was lower among ever users, but higher among those with at least 5 days use of e-cigarettes in the last month. Both quit attempts and quit success were linearly related to the frequency of e-cigarette use.

Conclusions: Consistent with randomized trials and those observational studies that measure frequency of e-cigarette use, both quit attempts and quit success were positively associated with increased frequency of e-cigarette use. Frequency of e-cigarette use was important in gauging the nature of these relationships.

Implications: Previous studies have obtained mixed results regarding the relationship of e-cigarette use to cigarette smoking cessation. This study provides a more precise methodology for considering the relationship of e-cigarette use to quit attempts and to quit success, and finds that quit attempts and quit success increase with the number of days use in the past month.

Citation

Wadsworth, E., McNeill, A., Li, L., Hammond, D., Thrasher, J.F., Yong, H.H., Cummings, K.M., Fong, G.T., Hitchman, S.C. (2018). Reported exposure to e-cigarette advertising and promotion in different regulatory environments: findings from the International Tobacco Control Four Country (ITC-4C) Survey. Preventive Medicine, 112, 130-37.

Abstract

Electronic cigarette (e-cigarette) advertising regulations differ across countries. This study examines how differences in e-cigarette advertising regulations influence exposure to e-cigarette advertising, and perceptions about what participants had seen and read about e-cigarettes. Data come from the ITC Four Country Survey (Canada [CA], United States [US], Australia [AU] and United Kingdom [UK]) carried out between August 2013 and March 2015 (n = 3460). In 2014, AU and CA had laws prohibiting the retail sale of e-cigarettes containing nicotine while the US and UK had no restrictions, although a voluntary agreement restricting advertising in the UK was introduced during fieldwork. Smokers and ex-smokers were asked whether in the last six months they had noticed e-cigarettes advertisements and received free samples/special offers (promotion), and about their perceptions (positive or otherwise) of what they had seen or read about e-cigarettes. Data were analyzed in 2017. US and UK participants were more likely to report that they had noticed e-cigarette advertisements and received promotions compared to CA or AU participants. For TV and radio advertisements, reported exposure was higher in US compared to UK. For all types of advertisements, reported exposure was higher in CA than AU. Overall, nearly half of AU (44.0%) and UK (47.8%) participants perceived everything they had seen and read about e-cigarettes to be positive, with no significant differences between AU and UK. Participants in countries with permissive e-cigarette advertising restrictions and less restrictive e-cigarette regulations were more likely to notice advertisements than participants in countries with more restrictive e-cigarette regulations.

Citation

Yong, H.H., Borland, R., Cummings, K.M., Partos, T. (2018). Do predictors of smoking relapse change as a function of duration of abstinence? Findings from the United States, Canada, United Kingdom and Australia. Addiction, 113(7), 1295-1304.

Abstract

Aims: To estimate predictors of time to smoking relapse and test if prediction varied by quit duration.

Design: Longitudinal cohort data from the International Tobacco Control Four-Country survey with annual follow up collected between 2002 and 2015.

Setting: Canada, United States, United Kingdom and Australia.

Participants: A total of 9171 eligible adult smokers who had made at least one quit attempt during the study period.

Measurements: Time to relapse was the main outcome. Predictor variables included pre-quit baseline measures of nicotine dependence, smoking and quitting-related motivations, quitting capacity and social influence, and also two post-quit measures, use of stop-smoking medications and quit duration (1–7 days, 8–14 days, 15–31 days, 1–3 months, 3–6 months, 6–12 months, 1–2 years and 2+ years), along with socio-demographics.

Findings: All factors were predictive of relapse within the first 6 months of quitting but only wanting to quit, quit intentions and number of friends who smoke were still predictive of relapse in the 6–12-month period of quitting [hazard ratios (HR) = 1.20, P < 0.05; 1.13, P < 0.05; and 1.21, P < 0.001, respectively]. Number of friends smoking was the only remaining predictor of relapse in the 1–2 years quit period (HR = 1.19, P = 0.001) with none predictive beyond the 2-year quit period. Use of stop-smoking medications during quit attempts was related negatively to relapse during the first 2 weeks of quitting (HR = 0.71–0.84), but related positively to relapse in the 1–6-month quit period (HR = 1.29–1.54). Predictive effects of all factors showed significant interaction with quit duration except for perceiving smoking as an important part of life, prematurely stubbing out a cigarette and wanting to quit.

Conclusions: Among adult smokers in the United States, Canada, United Kingdom and Australia, factors associated with smoking relapse differ between the early and later stages of a quit attempt, suggesting that the determinants of relapse change as a function of abstinence duration.

Abstract

Background: The Canadian government has committed to an endgame target of less than 5% tobacco use by 2035. The aims of this study were to assess baseline levels of support for potential endgame policies among Canadian smokers, by province/region, demographic characteristics and smoking-related correlates, and to identify predictors of support.

Methods: We analyzed data for 3215 adult (age ≥ 18 yr) smokers from the Canadian arm of the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. We estimated weighted percentages of support for endgame measures for 6 provinces/regions of the country. We used weighted logistic regression models to identify predictors of support for 14 endgame strategies.

Results: Among cigarette endgame policies, support was highest for reducing nicotine content (70.2%), raising the legal age for purchase (69.8%), increasing access to alternative nicotine products (65.8%) and banning marketing (58.5%). Among e-cigarette policies, there was majority support for restricting youth access (86.1%), restricting nicotine content (64.9%), prohibiting use in smokefree places (63.4%) and banning marketing (54.8%). The level of support for other endgame measures ranged from 28.9% to 45.2%. Support for cigarette and e-cigarette policies was generally higher among smokers with intentions to quit and those from Quebec. Support for e-cigarette policies was generally lower among smokers who also used e-cigarettes daily.

Interpretation: There is considerable support among Canadian smokers for endgame policies that go beyond current approaches to tobacco control. Our findings provide a baseline for evaluating future trends in smokers’ support for innovative measures to radically reduce smoking rates in Canada.

Citation

El-Toukhy, S., Choi, K., Hitchman, S.C., Bansal-Travers, M., Thrasher, J.F., Yong, H.H., O’Connor, R.J., Shang, C. (2018). Banning tobacco price promotions, smoking-related beliefs, and behaviour: findings from the International Tobacco Control Four Country (ITC 4C) Survey. Tobacco Control, 27(3), 310-318.

Abstract

Background: Ecological models emphasise multilevel influences on health behaviours. While studies show that exposure to price promotions is associated with smoking behaviour and its antecedents, less is known about whether these associations differ by macro-level factors such as national price promotion policies.

Methods: Current and former smokers (N=4698) from the International Tobacco Control Policy Evaluation Project four-country cohort were included in weighted multivariate logistic regression models to examine individual-level associations between exposure to price promotions at waves 7 and 8 (conducted in 2008–2009 and 2010–2011) and beliefs (social and injunctive norms, functional value of smoking, misconceptions around smoking and beliefs of tobacco industry and its regulations) and behaviour at wave 8, stratified by whether countries allow (Australia and USA) or ban (Canada and UK) price promotions.

Results: Associations between exposure to price promotions and smoking-related beliefs and behaviour differed by national price promotion policies. In countries that allow price promotions, participants repeatedly exposed to price promotions at waves 7 and 8 were more likely to associate functional values to smoking (ie, calms down when stressed (adjusted OR (AOR) 1.83) and to be current smokers at wave 8 (AOR 1.94). In countries that ban price promotions, participants repeatedly exposed to price promotions were less likely to hold misconceptions around smoking (ie, harsher smoke is more dangerous).

Conclusions: Differential associations emerged between exposure to price promotions, smoking-related beliefs and behaviour across countries with and without a price promotions ban. Adopting price promotion bans could ameliorate the associations between exposure to price promotions and smoking beliefs and behaviours.