Citation

Hall, P.A., Fong, G.T., Meng, G. (2014). Time perspective as a determinant of smoking cessation in four countries: Direct and mediated effects from the International Tobacco Control (ITC) 4-Country Surveys. Addictive Behaviours, 39(7), 1183-1190.

Abstract

Background: Future oriented time perspective predicts a number of important health behaviors and outcomes, including smoking cessation. However, it is not known how future orientation exerts its effects on such outcomes, and no large scale cross-national studies have examined the question prospectively. The aim of the current investigation was to examine the relationship between time perspective and success in smoking cessation, and social cognitive mediators of the association.

Methods: The ITC-4 is a multi-wave, four country survey (Australia, Canada, United States, United Kingdom) of current smokers (N=9772); the survey includes baseline measurements of time perspective, intentions, quit attempts, and self-reported quit status at follow-up over 8years. We examined the predictive power of time perspective for smoking cessation, as mediated through strength of quit intentions and prior history of quit attempts.

Results: Findings indicated that those smokers with a stronger future orientation at baseline were more likely to have successfully quit at follow-up. This effect was partially explained by intention-mediated effects of future orientation on quit attempts. CONCLUSIONS: Future orientation predicts smoking cessation across four English-speaking countries; the cessation-facilitating effects of future orientation may be primarily due to future oriented individuals' motivated and sustained involvement in the quit cycle over time.

Citation

Hitchman, S.C., Fong, G.T., Zanna, M.P., Thrasher, J.F., Laux, F. (2014). The relation between number of smoking friends, and quit intentions, attempts, and success: Findings from the International Tobacco Control (ITC) Four Country Survey. Psychology of Addictive Behaviours, 28(4), 1144-1152.

Abstract

Smokers who inhabit social contexts with a greater number of smokers may be exposed to more positive norms toward smoking and more cues to smoke. This study examines the relation between number of smoking friends and changes in number of smoking friends, and smoking cessation outcomes. Data were drawn from Wave 1 (2002) and Wave 2 (2003) of the International Tobacco Control (ITC) Project Four Country Survey, a longitudinal cohort survey of nationally representative samples of adult smokers in Australia, Canada, United Kingdom, and United States (N = 6,321). Smokers with fewer smoking friends at Wave 1 were more likely to intend to quit at Wave 1 and were more likely to succeed in their attempts to quit at Wave 2. Compared with smokers who experienced no change in their number of smoking friends, smokers who lost smoking friends were more likely to intend to quit at Wave 2, attempt to quit between Wave 1 and Wave 2, and succeed in their quit attempts at Wave 2. Smokers who inhabit social contexts with a greater number of smokers may be less likely to successfully quit. Quitting may be particularly unlikely among smokers who do not experience a loss in the number of smokers in their social context.

Citation

Shang, C., Chaloupka, F., Zahra, N., Fong, G.T. (2014). The distribution of cigarette prices under different tax structures: Findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 23(Suppl 1), i23-i29.

Abstract

Background: The distribution of cigarette prices has rarely been studied and compared under different tax structures. Descriptive evidence on price distributions by countries can shed light on opportunities for tax avoidance and brand switching under different tobacco tax structures, which could impact the effectiveness of increased taxation in reducing smoking.

Objective: This paper aims to describe the distribution of cigarette prices by countries and to compare these distributions based on the tobacco tax structure in these countries.

Methods: We employed data for 16 countries taken from the International Tobacco Control Policy Evaluation Project to construct survey-derived cigarette prices for each country. Self-reported prices were weighted by cigarette consumption and described using a comprehensive set of statistics. We then compared these statistics for cigarette prices under different tax structures. In particular, countries of similar income levels and countries that impose similar total excise taxes using different tax structures were paired and compared in mean and variance using a two-sample comparison test.

Findings: Our investigation illustrates that, compared with specific uniform taxation, other tax structures, such as ad valorem uniform taxation, mixed (a tax system using ad valorem and specific taxes) uniform taxation, and tiered tax structures of specific, ad valorem and mixed taxation tend to have price distributions with greater variability. Countries that rely heavily on ad valorem and tiered taxes also tend to have greater price variability around the median. Among mixed taxation systems, countries that rely more heavily on the ad valorem component tend to have greater price variability than countries that rely more heavily on the specific component. In countries with tiered tax systems, cigarette prices are skewed more towards lower prices than are prices under uniform tax systems. The analyses presented here demonstrate that more opportunities exist for tax avoidance and brand switching when the tax structure departs from a uniform specific tax.

Citation

Huang, J., Chaloupka, F., Fong, G.T. (2014). Cigarette graphic warning labels and smoking preference in Canada: A critical examination and reformulation of the FDA regulatory impact analysis. Tobacco Control, 23(Suppl 1), i7-i12.

Abstract

Background: The estimated effect of cigarette graphic warning labels (GWL) on smoking rates is a key input to the Food and Drug Administration's (FDA) regulatory impact analysis (RIA), required by law as part of its rulemaking process. However, evidence on the impact of GWLs on smoking prevalence is scarce.

Objective: The goal of this paper is to critically analyse FDA's approach to estimating the impact of GWLs on smoking rates in its RIA, and to suggest a path forward to estimating the impact of the adoption of GWLs in Canada on Canadian national adult smoking prevalence.

Methods: A quasi-experimental methodology was employed to examine the impact of adoption of GWLs in Canada in 2000, using the USA as a control.

Findings: We found a statistically significant reduction in smoking rates after the adoption of GWLs in Canada in comparison with the USA. Our analyses show that implementation of GWLs in Canada reduced smoking rates by 2.87-4.68 percentage points, a relative reduction of 12.1-19.6%; 33-53 times larger than FDA's estimates of a 0.088 percentage point reduction. We also demonstrated that FDA's estimate of the impact was flawed because it is highly sensitive to the changes in variable selection, model specification, and the time period analysed.

Conclusions: Adopting GWLs on cigarette packages reduces smoking prevalence. Applying our analysis of the Canadian GWLs, we estimate that if the USA had adopted GWLs in 2012, the number of adult smokers in the USA would have decreased by 5.3-8.6 million in 2013. Our analysis demonstrates that FDA's approach to estimating the impact of GWLs on smoking rates is flawed. Rectifying these problems before this approach becomes the norm is critical for FDA's effective regulation of tobacco products.

Citation

Yong, H.H., Thompson, M.E., Thrasher, J.F., Borland, R., Fong, G.T., Hammond, D., Cummings, K.M., Nagelhout, G.E., Meng, G., McNeill, A. (2014). Mediational pathways of the impact of cigarette warning labels on quit attempts. Health Psychology, 33(11), 1410-1420.

Abstract

Objective: To test and develop, using structural equation modeling, a robust model of the mediational pathways through which health warning labels exert their influence on smokers' subsequent quitting behavior.

Method: Data come from the International Tobacco Control Four-Country Survey, a longitudinal cohort study conducted in Australia, Canada, the United Kingdom, and the United States. Waves 5-6 data (n = 4,988) were used to calibrate the hypothesized model of warning label impact on subsequent quit attempts via a set of policy-specific and general psychosocial mediators. The finalized model was validated using Waves 6-7 data (n = 5065).

Results: As hypothesized, warning label salience was positively associated with thoughts about risks of smoking stimulated by the warnings (β = .58, p < .001), which in turn were positively related to increased worry about negative outcomes of smoking (β = .52, p < .001); increased worry in turn predicted stronger intention to quit (β = .39, p < .001), which was a strong predictor of subsequent quit attempts (β = .39, p < .001). This calibrated model was successfully replicated using Waves 6-7 data.

Conclusion: Health warning labels seem to influence future quitting attempts primarily through their ability to stimulate thoughts about the risks of smoking, which in turn help to raise smoking-related health concerns, which lead to stronger intentions to quit, a known key predictor of future quit attempts for smokers. By making warning labels more salient and engaging, they should have a greater chance to change behavior.

Citation

Mutti, S., Kennedy, R.D., Thompson, M.E., Fong, G.T. (2014). Prepaid monetary incentives - Predictors of taking the money and completing the survey: Results from the International Tobacco Control (ITC) Four-Country Survey. Sociological Methods & Research, 43(2), 338-355.

Abstract

Prepaid monetary incentives are used to address declining response rates in random-digit dial surveys. There is concern among researchers that some respondents will accept the prepayment but not complete the survey. There is little research to understand check cashing and survey completing behaviors among respondents who receive prepayment. Data from the International Tobacco Control Four-Country Study—a longitudinal survey of smokers in Canada, the United States, the United Kingdom, and Australia—were used to examine the impact of prepayment (in the form of checks, approximately US$10) on sample profile. Approximately 14 percent of respondents cashed their check, but did not complete the survey, while about 14 percent did not cash their checks, but completed the survey. Younger adults (Canada and United States), those of minority status (United States), and those who had been in the survey for only two waves or less (Canada and United States) were more likely to cash their checks and not complete the survey.

Citation

Hitchman, S.C., Fong, G.T., Zanna, M.P., Thrasher, J.F., Chung-Hall, J., Siahpush, M. (2014). Socioeconomic status and smokers' number of smoking friends: Findings from the International Tobacco Control (ITC) Four Country Survey. Drug and Alcohol Dependence, 143, 158-166.

Abstract

Background: Smoking rates are higher among low socioeconomic (SES) groups, and there is evidence that inequalities in smoking are widening over time in many countries. Low SES smokers may be more likely to smoke and less likely to quit because smoking is heavily concentrated in their social contexts. This study investigated whether low SES smokers (1) have more smoking friends, and (2) are more likely to gain and less likely to lose smoking friends over time. Correlates of having more smoking friends and gaining or losing smoking friends were also considered.

Method: Respondents included 6321 adult current smokers (at recruitment) from Wave 1 (2002) and Wave 2 (2003) of the International Tobacco Control Project (ITC) Four Country Survey, a nationally representative longitudinal cohort survey of smokers in Australia, Canada, UK, and US.

Results: Low SES smokers reported more smoking friends than moderate and high SES smokers. Low SES smokers were also more likely to gain smoking friends over time compared with high SES smokers. Smokers who were male, younger, and lived with other smokers reported more smoking friends, and were also more likely to gain and less likely to lose smoking friends. Smoking behaviours, such as higher nicotine dependence were related to reporting more smoking friends, but not to losing or gain smoking friends.

Conclusions: Smoking is highly concentrated in the social networks of lower SES smokers and this concentration may be increasing over time. Cessation interventions should consider how the structure of low SES smokers' social networks affects quitting.

Citation

Gravely, S., Fong, G.T., Cummings, K.M., Yan, M., Quah, A.C.K., Borland, R., Yong, H.H., Hitchman, S.C., McNeill, A., Hammond, D., Thrasher, J.F., Willemsen, M.C., Seo, H.G., Jiang, Y., Cavalcante, T.M., Perez, C., Omar, M., Hummel, K. (2015). Awareness, trial, and current use of electronic cigarettes in 10 countries: findings from the ITC Project. International Journal of Environmental Research and Public Health, 12(5), 4631-4637.

Abstract

Background: In recent years, electronic cigarettes (e-cigarettes) have generated considerable interest and debate on the implications for tobacco control and public health. Although the rapid growth of e-cigarettes is global, at present, little is known about awareness and use. This paper presents self-reported awareness, trial and current use of e-cigarettes in 10 countries surveyed between 2009 and 2013; for six of these countries, we present the first data on e-cigarettes from probability samples of adult smokers.

Methods: A cross-sectional analysis of probability samples of adult (≥ 18 years) current and former smokers participating in the International Tobacco Control (ITC) surveys from 10 countries. Surveys were administered either via phone, face-to-face interviews, or the web. Survey questions included sociodemographic and smoking-related variables, and questions about e-cigarette awareness, trial and current use.

Results: There was considerable cross-country variation by year of data collection and for awareness of e-cigarettes (Netherlands (2013: 88%), Republic of Korea (2010: 79%), United States (2010: 73%), Australia (2013: 66%), Malaysia (2011: 62%), United Kingdom (2010: 54%), Canada (2010: 40%), Brazil (2013: 35%), Mexico (2012: 34%), and China (2009: 31%)), in self-reports of ever having tried e-cigarettes (Australia, (20%), Malaysia (19%), Netherlands (18%), United States (15%), Republic of Korea (11%), United Kingdom (10%), Mexico (4%), Canada (4%), Brazil (3%), and China (2%)), and in current use (Malaysia (14%), Republic of Korea (7%), Australia (7%), United States (6%), United Kingdom (4%), Netherlands (3%), Canada (1%), and China (0.05%)).

Conclusions: The cross-country variability in awareness, trial, and current use of e-cigarettes is likely due to a confluence of country-specific market factors, tobacco control policies and regulations (e.g., the legal status of e-cigarettes and nicotine), and the survey timing along the trajectory of e-cigarette awareness and trial/use in each country. These ITC results constitute an important snapshot of an early stage of what appears to be a rapid progression of global e-cigarette use.

Abstract

Introduction: The Heaviness of Smoking Index (HSI) is the measure of dependence most strongly predictive of relapse. However, recent research suggests it may not be predictive of longer term relapse. Our aim was to examine its predictive power over the first 2 years after quitting and explore whether use of stop-smoking medications is a moderator.

Methods: Data (n = 7,093) came from the first 7 waves (2002-2009) of the International Tobacco Control Four-Country Survey, an annual cohort survey of smokers in Canada, United States, United Kingdom, and Australia. HSI and its 2 components (cigarettes per day [CPD] and time to first cigarette [TTFC]) were used to predict smoking relapse risk in the 2 years after the start of a quit attempt.

Results: Scores on HSI and its components all strongly predicted relapse, but there was an interaction with time (p < .001). These measures were strong predictors of relapse within the first week of quitting (hazard ratios [HR] = 1.17, 1.24, and 1.30 for HSI, CPD, and TTFC, respectively, all p < .001), less predictive of relapse occurring between 1 week and 1 month, and not clearly predictive beyond 1 month. Among those using medication to quit, hazard ratio for HSI (HR = 1.11, p < .001) was significantly lower than for those not using (HR = 1.24, p < .001) in the first week, but not beyond.

Conclusions: HSI and its 2 components are strong predictors of short-term smoking relapse, but they rapidly lose predictive power over the first weeks of an attempt, becoming marginally significant at around 1 month, and not clearly predictive beyond that.

Citation

Balmford, J., Swift, E., Borland, R. (2014). Reported planning before and after quitting and quit success: Retrospective data from the ITC 4-Country Survey. Psychology of Addictive Behaviours, 28(3), 899-906

Abstract

Planning before quitting smoking is widely believed to be beneficial and is usually recommended in cessation counseling, but there is little evidence on the efficacy of specific planning activities. Using data from 1140 respondents who reported quit attempts at Wave 8 of the ITC 4-Country Survey, we analyzed use of 8 specific planning strategies before (5) and after (3) implementation of a quit attempt, in relation to cessation outcomes, delay in implementation of the attempt, and recent quitting history. Most participants reported some planning both before and after quitting, even among those reporting quitting ‘spontaneously.’ Younger smokers, those who cut down before quitting, and users of stop-smoking medication were more likely to report planning. Those who planned prequit were also more likely to plan postquit. Unexpectedly, we found no clear benefit of planning on short-term (1 month) cessation outcomes, whereas one prequit strategy (practicing not smoking) was negatively related to outcome. There was evidence for a predicted moderating effect of recent quitting experience on planning for the prequit task ‘practice replacement strategies.’ This predicted quit success among those with multiple quit attempts in the past year, but failure among those without. This finding suggests that the quality of planning may be critical. More research, particularly on the moderating effect of quit experience, and where measures of planning are collected before outcomes become evident, is needed before clear recommendations can be made on the utility of various forms of planning for the success of quit attempts.

Citation

Hitchman, S.C., Driezen, P., Logel, C., Hammond, D., Fong, G.T. (2014). Changes in effectiveness of cigarette health warnings over time in Canada and the United States, 2002 - 2011. Nicotine & Tobacco Research, 16(5), 536-543.

Abstract

Introduction: Article 11 of the World Health Organization's Framework Convention on Tobacco Control (FCTC) requires countries to implement health warnings on tobacco products. The Article 11 Guidelines advise countries to periodically rotate warnings to prevent “wearout” of the health warnings. This study investigates potential wearout of cigarette health warnings over a period of 9 years in 2 countries: Canada, where larger pictorial warnings were implemented approximately 1 year prior to the study, and in the United States, where small text-only warnings were in place for 17 years at the beginning of the study.

Methods: Data were drawn from national samples of smokers from the International Tobacco Control (ITC) Surveys in Canada (N = 5,309), and the United States (N = 6,412) recruited originally by telephone using random digit dialing. Changes in 4 measures of health warning effectiveness and in a composite Labels Impact Index were examined over 8 waves of survey data (2002-2011). Analyses were conducted in 2012.

Results: The health warning effectiveness measures and the Labels Impact Index indicated that the effectiveness of both the Canadian, and the U.S. warnings declined significantly over time. The Canadian warnings showed greater declines in effectiveness than the U.S. warnings, likely due to the initial novelty of the Canadian warnings. Despite the greater decline in Canada, the Canadian pictorial warnings were significantly more effective than the U.S. text-only warnings throughout the study.

Conclusions: Health warnings decline in effectiveness over time. Health warnings on tobacco products should be changed periodically to maintain effectiveness.

Citation

Li, L., Borland, R., Fong, G.T., Thrasher, J.F., Hammond, D., Cummings, K.M. (2013). Impact of point-of-sale tobacco display bans: Findings from the International Tobacco Control Four Country Survey. Health Education Research, 28(5), 898-910.

Abstract

This study examined the impact of point-of-sale (POS) tobacco marketing restrictions in Australia and Canada, in relation to the United Kingdom and the United States where there were no such restrictions during the study period (2006–10). The data came from the International Tobacco Control Four Country Survey, a prospective multi-country cohort survey of adult smokers. In jurisdictions where POS display bans were implemented, smokers’ reported exposure to tobacco marketing declined markedly. From 2006 to 2010, in Canada, the percentages noticing POS tobacco displays declined from 74.1 to 6.1% [adjusted odds ratio (OR)¼0.26, P<0.001]; and reported exposure to POS tobacco advertising decreased from 40.3 to 14.1% (adjusted OR¼0.61, P<0.001). Similarly, in Australia, noticing of POS displays decreased from 73.9 to 42.9%. In contrast, exposure to POS marketing in the United States and United Kingdom remained high during this period. In parallel, there were declines in reported exposures to other forms of advertising/promotion in Canada and Australia, but again, not in the United States or United Kingdom. Impulse purchasing of cigarettes was lower in places that enacted POS display bans. These findings indicate that implementing POS tobacco display bans does result in lower exposure to tobacco marketing and less frequent impulse purchasing of cigarettes.

Citation

Nargis, N., Fong, G.T., Chaloupka, F., Li, Q. (2014). The choice of discount brand cigarettes: A comparative analysis of International Tobacco Control Surveys in Canada and the United States (2002-05). Tobacco Control, 23(Suppl 1), i86-i96.

Abstract

Background: Increasing tobacco taxes to increase price is a proven tobacco control measure. This article investigates how smokers respond to tax and price increases in their choice of discount brand cigarettes versus premium brands.

Objective: To estimate how increase in the tax rate can affect smokers' choice of discount brands versus premium brands.

Methods: Using data from International Tobacco Control surveys in Canada and the USA, a logit model was constructed to estimate the probability of choosing discount brand cigarettes in response to its price changes relative to premium brands, controlling for individual-specific demographic and socioeconomic characteristics and regional effects. The self-reported price of an individual smoker is used in a random-effects regression model to impute price and to construct the price ratio for discount and premium brands for each smoker, which is used in the logit model.

Findings: An increase in the ratio of price of discount brand cigarettes to the price of premium brands by 0.1 is associated with a decrease in the probability of choosing discount brands by 0.08 in Canada. No significant effect is observed in case of the USA.

Conclusions: The results of the model explain two phenomena: (1) the widened price differential between premium and discount brand cigarettes contributed to the increased share of discount brand cigarettes in Canada in contrast to a relatively steady share in the USA during 2002-2005 and (2) increasing the price ratio of discount brands to premium brands-which occurs with an increase in specific excise tax-may lead to upward shifting from discount to premium brands rather than to downward shifting. These results underscore the significance of studying the effectiveness of tax increases in reducing overall tobacco consumption, particularly for specific excise taxes.

Citation

Partos, T.R., Borland, R., Yong, H.H., Thrasher, J.F., Hammond, D. (2013). Cigarette packet warning labels can prevent relapse: Findings from the International Tobacco Control 4-Country Policy Evaluation Cohort Study. Tobacco Control, 22(1), 43-50.

Abstract

Objectives: To investigate the links between health warning labels (WLs) on cigarette packets and relapse among recently quit smokers.

Design: Prospective longitudinal cohort survey.

Setting: Australia, Canada, the UK and the USA.

Participants: 1936 recent ex-smokers (44.4% male) from one of the first six waves (2002–2007) of the International Tobacco Control 4-Country policy evaluation survey, who were followed up in the next wave.

Main outcome measures: Whether participants had relapsed at follow-up (approximately 1 year later).

Results: In multivariate analysis, very frequent noticing of WLs among ex-smokers was associated with greater relapse 1 year later (OR: 1.52, 95% CI 1.11 to 2.09, p<0.01), but this effect disappeared after controlling for urges to smoke and self-efficacy (OR: 1.29, 95% CI 0.92 to 1.80, p=0.135). In contrast, reporting that WLs make staying quit ‘a lot’ more likely (compared with ‘not at all’ likely) was associated with a lower likelihood of relapse 1 year later (OR: 0.65, 95% CI 0.49 to 0.86, p<0.01) and this effect remained robust across all models tested, increasing in some.

Conclusions: This study provides the first longitudinal evidence that health warnings can help ex-smokers stay quit. Once the authors control for greater exposure to cigarettes, which is understandably predictive of relapse, WL effects are positive. However, it may be that ex-smokers need to actively use the health consequences that WLs highlight to remind them of their reasons for quitting, rather than it being something that happens automatically. Ex-smokers should be encouraged to use pack warnings to counter urges to resume smoking. Novel warnings may be more likely to facilitate this.

Citation

McKee, S., Young-Wolff, K.C., Harrison, E.L., Cummings, K.M., Borland, R., Kahler, C.W., Fong, G.T., Hyland, A. (2013). Longitudinal associations between smoking cessation medications and alcohol consumption among smokers in the International Tobacco Control Four Country Survey. Alcoholism Clinical and Experimental Research, 37(5), 804-810.

Abstract

Background: Available evidence suggests that quitting smoking does not alter alcohol consumption. However, smoking cessation medications may have a direct impact on alcohol consumption independent of any effects on smoking cessation. Using an international longitudinal epidemiological sample of smokers, we evaluated whether smoking cessation medications altered alcohol consumption independent of quitting smoking.

Methods: Longitudinal data were analyzed from the International Tobacco Control Four Country (ITC-4) Survey between 2007 and 2008, a telephone survey of nationally representative samples of smokers from the United Kingdom, Australia, Canada, and the United States (n = 4,995). Quantity and frequency of alcohol consumption, use of smoking cessation medications (varenicline, nicotine replacement [NRT], and no medications), and smoking behavior were assessed across 2 yearly waves. Controlling for baseline drinking and changes in smoking status, we evaluated whether smoking cessation medications were associated with reduced alcohol consumption.

Results: Varenicline was associated with a reduced likelihood of any drinking compared with nicotine replacement (OR = 0.56; 95% CI = 0.34 to 0.94), and consuming alcohol once a month or more compared to nicotine replacement (OR = 0.43; 95% CI = 0.27 to 0.69) or no medication (OR = 0.63; 95% CI = 0.41 to 0.99). Nicotine replacement was associated with an increased likelihood of consuming alcohol once a month or more compared to no medication (OR = 1.14; 95% CI = 1.03 to 1.25). Smoking cessation medications were not associated with more frequent drinking (once a week or more) or typical quantity consumed per episode. Medication effects on drinking frequency were independent of smoking cessation.

Conclusions: This epidemiological investigation demonstrated that varenicline was associated with a reduced frequency of alcohol consumption. Continued work should clarify under what conditions nicotine replacement therapies may increase or decrease patterns of alcohol consumption.

Citation

Adkison, S., O’Connor, R.J., Bansal-Travers, M., Hyland, A., Borland, R., Yong, H.H., Cummings, K.M., McNeill, A., Thrasher, J.F., Hammond, D., Fong, G.T. (2013). Electronic nicotine delivery systems: International Tobacco Control Four-Country Survey. American Journal of Preventive Medicine, 44(3), 207-215.

Abstract

Background: Electronic nicotine delivery systems (ENDS) initially emerged in 2003 and have since become widely available globally, particularly over the Internet.

Purpose: Data on ENDS usage patterns are limited. The current paper examines patterns of ENDS awareness, use, and product-associated beliefs among current and former smokers in four countries.

Methods: Data come from Wave 8 of the International Tobacco Control Four-Country Survey, collected July 2010 to June 2011 and analyzed through June 2012. Respondents included 5939 current and former smokers in Canada (n_1581); the U.S. (n_1520); the United Kingdom (UK; n_1325); and Australia (n_1513).

Results: Overall, 46.6% were aware of ENDS (U.S.: 73%, UK: 54%, Canada: 40%, Australia: 20%); 7.6% had tried ENDS (16% of those aware of ENDS); and 2.9% were current users (39% of triers). Awareness of ENDS was higher among younger, non-minority smokers with higher incomes who were heavier smokers. Prevalence of trying ENDS was higher among younger, nondaily smokers with a high income and among those who perceived ENDS as less harmful than traditional cigarettes. Current use was higher among both nondaily and heavy (_20 cigarettes per day) smokers. In all, 79.8% reported using ENDS because they were considered less harmful than traditional cigarettes; 75.4% stated that they used ENDS to help them reduce their smoking; and 85.1% reported using ENDS to help them quit smoking.

Conclusions: Awareness of ENDS is high, especially in countries where they are legal (i.e., the U.S. and UK). Because trial was associated with nondaily smoking and a desire to quit smoking, ENDS may have the potential to serve as a cessation aid.

Citation

Partos, T.R., Borland, R., Yong, H.H., Hyland, A., Cummings, K.M. (2013). The quitting rollercoaster: How recent quitting history affects future cessation outcomes (data from the International Tobacco Control 4-Country Cohort Study). Nicotine & Tobacco Research, 15(9), 1578-1587.

Abstract

Introduction: Most smokers have a history of unsuccessful quit attempts. This study used data from 7 waves (2002–2009) of the International Tobacco Control 4-country cohort study to examine the role of smokers’ quitting history (e.g., recency, length, and number of previous quit attempts) on their subsequent likelihood of making a quit attempt and achieving at least 6 months of sustained abstinence.

Methods: Generalized estimating equations were used, allowing for estimation of relationships between variables across repeated observations while controlling for correlations from multiple responses by the same individual (29,682 observations from 13,417 individuals).

Results: The likelihood of a future quit attempt increased independently with recency and number of prior attempts. By contrast, the likelihood of achieving sustained abstinence of at least 6 months was reduced for smokers with a failed quit attempt within the last year (15.1% vs. 27.1% for those without, p < .001). Two or more failed attempts (vs. only one) in the previous year were also associated with a lower likelihood of achieving sustained abstinence (OR: 0.57, 95% CI: 0.38–0.85). Effects persisted after controlling for levels of addiction, self-efficacy to quit, and use of stop-smoking medications.

Conclusions: There appears to be a subset of smokers who repeatedly attempt but fail to remain abstinent from tobacco. Understanding why repeated attempts might be less successful in the long term is an important research priority because it implies a need to tailor treatment approaches for those who are motivated to quit but persistently relapse back to smoking.

Citation

Kasza, K.A., Hyland, A., Borland, R., McNeill, A., Bansal-Travers, M., Fix, B.V., Hammond, D., Fong, G.T., Cummings, K.M. (2013). Effectiveness of stop-smoking medications: Findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 108(1), 193-202.

Abstract

Aim: To evaluate the population effectiveness of stop-smoking medications while accounting for potential recall bias by controlling for quit attempt recency.

Design: Prospective cohort survey.

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

Participants: A total of 7436 adult smokers (18+ years) selected via random digit dialling and interviewed as part of the International Tobacco Control Four Country Survey (ITC-4) between 2002 and 2009. Primary analyses utilized the subset of respondents who participated in 2006 or later (n = 2550).

Measurements: Continuous abstinence from smoking for 1 month/6 months.

Findings: Among participants who recalled making a quit attempt within 1 month of interview, those who reported using varenicline, bupropion or nicotine patch were more likely to maintain 6-month continuous abstinence from smoking compared to those who attempted to quit without medication [adjusted odds ratio (OR) 5.84, 95% confidence interval (CI) (2.12–16.12), 3.94 (0.87–17.80), 4.09 (1.72–9.74), respectively]; there were no clear effects for oral NRT use. Those who did not use any medication when attempting to quit tended to be younger, to be racial/ethnic minorities, to have lower incomes and to believe that medications do not make quitting easier.

Conclusions: Consistent with evidence from randomized controlled trials, smokers in the United Kingdom, Canada, Australia and the United States are more likely to succeed in quit attempts if they use varenicline, bupropion or nicotine patch. Previous population studies that failed to find an effect failed to control adequately for important sources of bias.

Citation

Cooper, J., Borland, R., Yong, H.H., Hyland, A., Cummings, K.M. (2013). Variations in daily cigarette consumption on work days compared with nonwork days and associations with quitting: Findings from the International Tobacco Control Four-Country Survey. Nicotine & Tobacco Research, 15(1), 192-198.

Abstract

Introduction: We explore whether reported daily cigarette consumption differs between work days and nonwork days and whether variation in consumption between work days and nonwork days influences quitting and abstinence from smoking. We also explore whether effects are independent of measures of addiction and smoking restrictions at work and home.

Methods: Data were from 5,732 respondents from the first five waves of the International Tobacco Control FourCountry Survey, occurring between 2002 and 2006. Respondents were current smokers employed outside the home. Variation in daily cigarette consumption on work days compared with nonwork days at one wave was used to predict the likelihood of making an attempt and the likelihood of maintaining a quit attempt for at least a month at the next wave. Generalized estimating equations were used to combine data for multiple waves.

Results: Just under half reported smoking more on a nonwork day, a little over a third reported no difference, and around one fifth reported smoking more on a work day. Controlling for possible confounding factors, smoking more on a work day was associated with making quit attempts. Among people who made a quit attempt, variation in consumption did not consistently predict one month's abstinence, being positive in Australia, but negative in the United Kingdom.

Conclusion: Those who smoke more on work days try to quit more. Country differences for success may be related to the extent of bans on smoking, with those smoking more on work days more likely to succeed where bans in workplaces and public places were more prevalent, such as Australia at the time.

Citation

Adkison, S., O’Connor, R.J., Borland, R., Yong, H.H., Cummings, K.M., Hammond, D., Fong, G.T. (2013). Impact of reduced ignition propensity cigarette regulation on consumer smoking behavior and quit intentions: Evidence from 6 waves (2004–11) of the ITC Four Country Survey. Tobacco Induced Diseases, 11(1), 26.

Abstract

Background: Although on the decline, smoking-related fires remain a leading cause of fire death in the United States and United Kingdom and account for over 10% of fire-related deaths worldwide. This has prompted lawmakers to enact legislation requiring manufacturers to implement reduced ignition propensity (RIP) safety standards for cigarettes. The current research evaluates how implementation of RIP safety standards in different countries influenced smokers’ perceptions of cigarette selfextinguishment, frequency of extinguishment, and the impact on consumer smoking behaviors, including cigarettes smoked per day and planning to quit.

Methods: Participants for this research come from Waves 3 through 8 of the International Tobacco Control (ITC) Four Country Survey conducted longitudinally from 2004 through 2011 in the United States, United Kingdom, Australia, and Canada.

Results: Perceptions of cigarette self-extinguishment and frequency of extinguishment increased concurrently with an increase in the prevalence of RIP safety standards for cigarettes. Presence of RIP safety standards was also associated with a greater intention to quit smoking, but was not associated with the number of cigarettes smoked per day. Intention to quit was higher among those who were more likely to report that their cigarettes self-extinguish sometimes and often, but we found no evidence of an interaction between frequency of extinguishment and RIP safety standards on quit intentions.

Conclusions: Overall, because these standards largely do not influence consumer smoking behavior, RIP implementation may significantly reduce the number of cigarette-related fires and the associated death and damages. Further research should assess how implementation of RIP safety standards has influenced smoking-related fire incidence, deaths, and other costs associated with smoking-related fires.

Citation

Caleyachetty, A., Lewis, S., McNeill, A., Leonardi-Bee, J. (2012). Struggling to make ends meet: Exploring pathways to understand why smokers in financial difficulties are less likely to quit successfully. European Journal of Public Health, 22(Suppl 1), 41-48.

Abstract

Background: In high-income countries, those with low-to-middle incomes have been observing stagnating median wages and marginal improvements in their living standards. Smokers in financial difficulties appear to be less likely to quit smoking. Understanding the reasons for this is essential to intervening to improve cessation outcomes in this population, and reduce smoking-related health inequalities.

Methods: We used longitudinal data from Waves 4 to 7 of the ITC Four Country Survey (ITC-4), and included those with data from at least two consecutive waves. Associations between financial difficulties and making a quit attempt, and quit success were analysed using generalised estimating equations, with adjustment for confounders. Mediation analysis was conducted to identify potential mediators of the observed effects of financial difficulties on cessation outcomes.

Results: Having financial difficulties had little impact on making quit attempts (adjusted OR 0.84, 95% CI 0.70-1.01). Smokers with financial difficulties were substantially less likely to succeed at quitting (adjusted OR 0.55, 95% CI 0.39-0.76); an effect which was consistent over the survey years. Among the potential mediators examined, those relating to cognition of health-related and quality of life-related consequences of smoking were the most important mediators, though the proportion of the effect mediated by the largest mediator was small (6.8%).

Conclusion: Having financial difficulties remains an important barrier to smokers achieving quit success. This effect does not appear to be due to anticipated factors such as reduced use of cessation services or treatment. Further research is required to determine strong mediators of the financial difficulties effect on quit success and to tailor more effective cessation programmes.

Citation

Fotuhi, O., Fong, G.T., Zanna, M.P., Borland, R., Yong, H.H., Cummings, K.M. (2013). Patterns of cognitive dissonance-reducing beliefs among smokers: A longitudinal analysis from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 22(1), 52-58.

Abstract

Objective: The purpose of this paper is to assess whether smokers adjust their beliefs in a pattern that is consistent with Cognitive Dissonance Theory. This is accomplished by examining the longitudinal pattern of belief change among smokers as their smoking behaviours change.

Methods: A telephone survey was conducted of nationally representative samples of adult smokers from Canada, the USA, the UK and Australia from the International Tobacco Control Four Country Survey. Smokers were followed across three waves (October 2002 to December 2004), during which they were asked to report on their smoking-related beliefs and their quitting behaviour.

Findings: Smokers with no history of quitting across the three waves exhibited the highest levels of rationalisations for smoking. When smokers quit smoking, they reported having fewer rationalisations for smoking compared with when they had previously been smoking. However, among those who attempted to quit but then relapsed, there was once again a renewed tendency to rationalise their smoking. This rebound in the use of rationalisations was higher for functional beliefs than for risk-minimising beliefs, as predicted by social psychological theory.

Conclusions: Smokers are motivated to rationalise their behaviour through the endorsement of more positive beliefs about smoking, and these beliefs change systematically with changes in smoking status. More work is needed to determine if this cognitive dissonance-reducing function has an inhibiting effect on any subsequent intentions to quit.

Citation

Brown, A., Boudreau, C., Moodie, C., Fong, G.T., Li, Q., McNeill, A., Thompson, M.E., Hassan, L.M., Hyland, A., Thrasher, J.F., Yong, H.H., Borland, R., Hastings, G., Hammond, D. (2012). Support for removal of point-of-purchase tobacco advertising and displays: Findings from the International Tobacco Control (ITC) Canada Survey. Tobacco Control, 21(6), 555-559.

Abstract

Background: Although most countries now have at least some restrictions on tobacco marketing, the tobacco industry meet these restrictions by re-allocating expenditure to unregulated channels, such as at point-of-purchase.

Methods: Longitudinal data from 10 Canadian provinces in the International Tobacco Control Survey was analysed to examine adult smokers' support for a ban on tobacco advertising and displays in stores and whether this support is associated with noticing either advertising or displays in stores, and quit intentions, over time. In total, there were 4580 respondents in wave 5 (October 2006 to February 2007), wave 6 (September 2007 to February 2008) and wave 7 (October 2008 to June 2009). The surveys were conducted before, during and in some cases after the implementation of display bans in most Canadian provinces and territories.

Results: Smokers in all provinces showed strong support for a ban on tobacco displays over the study period. Levels of support for an advertising and display ban were comparable between Canadian provinces over time, irrespective of whether they had been banned or not. Noticing tobacco displays and signs in-store was demonstrably less likely to predict support for display (OR=0.73, p=0.005) and advertising (OR=0.78, p=0.02) ban, respectively. Smokers intending to quit were more likely to support advertising and display bans over time.

Conclusion: This study serves as a timely reminder that the implementation of tobacco control measures, such as the removal of tobacco displays, appear to sustain support among smokers, those most likely to oppose such measures.

Citation

Young, D., Yong, H.H., Borland, R., Shahab, L., Hammond, D., Cummings, K.M., Wilson, N. (2012). Trends in roll your own smoking: Findings from the ITC Four Country Survey (2002-2008). Journal of Environmental and Public Health, 2012, 1-7.

Abstract

Objective: To establish the trends in prevalence, and correlates, of roll-your-own (RYO) use in Canada, USA, UK and Australia, 2002–2008.

Methods: Participants were 19,456 cigarette smokers interviewed during the longitudinal International Tobacco Control (ITC) Four-Country Survey in Canada, USA, UK, and Australia.

Results: “Predominant” RYO use (i.e., >50% of cigarettes smoked) increased significantly in the UK and USA as a proportion of all cigarette use (both P < .001) and in all countries as a proportion of any RYO use (all P < .010). Younger, financially stressed smokers are disproportionately contributing to “some” use (i.e., ≤50% of cigarettes smoked). Relative cost was the major reason given for using RYO, and predominant RYO use is consistently and significantly associated with low income.

Conclusion: RYO market trends reflect the price advantages accruing to RYO (a product of favourable taxation regimes in some jurisdictions reinforced by the enhanced control over the amount of tobacco used), especially following the impact of the Global Financial Crisis; the availability of competing low-cost alternatives to RYO; accessibility of duty-free RYO tobacco; and tobacco industry niche marketing strategies. If policy makers want to ensure that the RYO option does not inhibit the fight to end the tobacco epidemic, especially amongst the disadvantaged, they need to reduce the price advantage, target additional health messages at (young) RYO users, and challenge niche marketing of RYO by the industry.

Citation

Borland, R., Partos, T.R., Cummings, K.M. (2012). Systematic biases in cross-sectional community studies may underestimate the effectiveness of stop-smoking medications. Nicotine & Tobacco Research, 14(12), 1483-1487.

Abstract

Introduction: Randomized, controlled trials typically indicate stop-smoking medications (SSMs: e.g., Varenicline, Bupropion, and over-the-counter nicotine replacement therapies) to be effective, whereas cross-sectional community-based studies have found them to be less effective, ineffective, or even associated with higher risk of relapse. Consequently, some critics have suggested SSMs have no useful applications in “real-world” settings. This discrepancy may, however, be due to systematic biases affecting cross-sectional survey outcomes. Namely, failed quit attempts where SSMs were used may be better recalled than failed unassisted attempts. Moreover, smokers who choose to quit using SSMs may be more addicted and thus less likely to succeed. Either of these factors would lead to an overrepresentation of failed quit attempts among SSM users in cross-sectional surveys even if there were real benefits.

Methods: We report on data from the International Tobacco Control 4-country cohort study to examine the relationship between SSM use, level of nicotine addiction, and the reported date since the start of participants’ (N = 1,101) most recent quit attempt.

Results: The last quit attempt was reported to have begun longer ago among participants who used SSMs than those who did not. Scores on the Heaviness of Smoking Index, measuring addiction severity, were also higher among SSM users, with no interactions.

Conclusion: Better recall of quit attempts and stronger addiction to nicotine are two characteristics found more often among smokers using SSMs compared with self-quitters, which could potentially bias the assessed effects of SSMs on cessation outcomes in cross-sectional surveys.