Scientific Journal Articles
Showing 1-25 of 49 Results
van Mourik, et al. 2019. Quasi-experimental study examining the impact of introducing pictorial tobacco health warning labels: findings from the International Tobacco Control (ITC) Surveys in the Netherlands, Australia, Canada, United Kingdom, and the United States [access full article]
Background: Our study evaluated the short-term impact of introducing European Union’s tobacco pictorial health warnings (PHWs).
Methods: Longitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N = 3,487) and analyzed using Generalized Estimating Equations.
Results: Between both time-points, only Dutch smokers showed increases in noticing health warnings (β = 0.712, p < 0.001), self-reports of health warnings leading to a cognitive response such as thinking about smoking health-risks (SHRs) (OR = 1.834, p < 0.001), knowledge about SHRs (β = 0.369, p < 0.001), and avoiding health warnings (OR = 9.869, p < 0.001). However, Dutch smokers showed no changes in attitude towards smoking (β = 0.035, p = 0.518), intention to quit smoking (OR = 0.791, p = 0.157), self-efficacy to quit smoking (β=-0.072, p = 0.286), or reporting that health warnings helped them to resist having a cigarette (OR = 1.091, p = 0.714).
Conclusions: Results suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.[download PDF]
Hummel, et al. 2019. The role of income and psychological distress in the relationship between work loss and smoking cessation: Findings from three International Tobacco Control (ITC) Europe countries [access full article]
Introduction: The relationship between work loss and smoking has not been studied extensively, and underlying factors are often not examined. The aim of this study was to test two hypotheses. First, work loss is associated with greater intention to quit and more likelihood of smoking cessation, and this relationship is moderated by a decrease in income. Second, work loss is associated with lower quit intention and lower rates of smoking cessation, and this relationship is moderated by an increase in psychological distress.
Methods: We used pooled data from three countries participating in the ITC Project: France, Germany and the Netherlands (n=2712). We measured unemployment, income and psychological distress at two consecutive survey waves, and calculated changes between survey waves. We first conducted multiple logistic regression analyses to examine the association between work loss and smoking cessation behavior. Next, we added income decrease and psychological distress increase to the models. Finally, we added interaction terms of work loss by income decrease and work loss by distress increase to the model.
Results: Work loss was not associated with quit intention, quit attempts, and quit success. When income decrease and psychological distress increase were added to the model, we found a positive association between distress increase and quit attempts. The interactions, however, were not statistically significant.
Conclusions: Our results indicate that smokers who become unemployed and face a decrease in income are not less likely to quit smoking than smokers who are employed.[download PDF]
van Mourik, et al. 2019. How the New European Union’s (Pictorial) Tobacco Health Warnings Influence Quit Attempts and Smoking Cessation: Findings from the 2016–2017 International Tobacco Control (ITC) Netherlands Surveys [access full article]
In 2016, the Netherlands was required to introduce new European Union (EU)’s (pictorial) tobacco health warnings. Our objective was to describe the pathways through which the new EU tobacco health warnings may influence quit attempts and smoking cessation among Dutch smokers. Longitudinal data from 2016 and 2017 from the International Tobacco Control (ITC) Netherlands Survey were used. Smokers who participated in both surveys were included (N = 1017). Structural equation modeling was applied to examine the hypothesized pathways. Health warning salience was positively associated with more health worries (β = 0.301, p < 0.001) and a more positive attitude towards quitting (β = 0.180, p < 0.001), which, in turn, were associated with a stronger quit intention (health worries: β = 0.304, p < 0.001; attitude: β = 0.340, p < 0.001). Quit intention was a strong predictor of quit attempts (β = 0.336, p = 0.001). Health warning salience was also associated with stronger perceived social norms towards quitting (β = 0.166, p < 0.001), which directly predicted quit attempts (β = 0.141, p = 0.048). Quit attempts were positively associated with smoking cessation (β = 0.453, p = 0.043). Based on these findings, we posit that the effect of the EU’s tobacco health warnings on quit attempts and smoking cessation is mediated by increased health worries and a more positive attitude and perceived social norms towards quitting. Making tobacco health warnings more salient (e.g., by using plain packaging) may increase their potential to stimulate quitting among smokers.[download PDF]
Herbec, et al. 2019. Dependence, plans to quit, quitting self-efficacy and past cessation behaviours among menthol and other flavoured cigarette users in Europe – The EUREST-PLUS ITC Europe Surveys [access full article]
Introduction: This study characterises smoking and cessationrelated behaviours among menthol and other flavoured cigarette users in Europe prior to the implementation of the European Tobacco Products Directive (TPD) ban on the sale of flavoured cigarettes.
Methods: An analysis of cross-sectional data from the 2016 EUREST-PLUS ITC Europe Surveys was conducted among a sample of 10760 adult smokers from eight European Union Member States. Respondents were classified as menthol, other flavoured, unflavoured, or no usual flavour cigarette users and compared on smoking and cessation behaviours and characteristics. Data were analysed in SPSS Complex Samples Package using bivariate and multivariate regression analyses adjusted for sociodemographic characteristics, dependence, and country.
Results: In bivariate analyses, cigarette flavour was significantly associated with all outcomes (p<0.001). After adjusting for sociodemographic characteristics, these associations attenuated but remained significant and in the same direction for dependence, self-efficacy, plans to quit, past quit attempts, and ever e-cigarette use. In fully adjusted models, compared to smokers of non-flavoured cigarettes, menthol smokers were less likely to smoke daily (AOR=0.47, 95% CI: 0.32–0.71), smoke within 30 min of waking (0.52,0.43–0.64), consider themselves addicted (0.74,0.59–0.94), and more likely to have ever used e-cigarettes (1.26,1.00–1.57); other flavoured cigarette smokers were less likely to smoke daily (0.33,0.15–0.77), and have higher self-efficacy (1.82,1.20–2.77); no usual flavour smokers were less likely to smoke daily (0.34,0.22–0.51), smoke within 30 min of waking (0.66,0.55–0.80), consider themselves addicted (0.65,0.52–0.78), have ever made a quit attempt (0.69,0.58– 0.84), have ever used e-cigarettes (0.66,0.54–0.82), and had higher self-efficacy (1.46,1.19–1.80).
Conclusions: Smokers of different cigarette flavours in Europe differ on smoking and cessation characteristics. The lower dependence of menthol cigarette smokers could lead to greater success rates if quit attempts are made, however cross-country differences in smoking behaviours and quitting intentions could lead to the TPD ban on cigarette flavours having differential impact if not accompanied by additional measures, such as smoking cessation support.[download PDF]
van Mourik, et al. 2019. Did E-Cigarette Users Notice the New European Union’s E-Cigarette Legislation? Findings from the 2015–2017 International Tobacco Control (ITC) Netherlands Survey [access full article]
This study examined to what extent e-cigarette users noticed the European Union’s new legislation regarding e-cigarettes, and whether this may have influenced perceptions regarding addictiveness and toxicity. Data were obtained from yearly surveys (2015–2017) of the International Tobacco Control (ITC) Netherlands Survey. Descriptive statistics and Generalized Estimating Equations were applied. About a third of the e-cigarette users noticed the text warning (28%) and the leaflet (32%). When compared to tobacco-only smokers, e-cigarette users showed greater increases in perceptions regarding addictiveness (β = 0.457, p = 0.045 vs. β = 0.135, p < 0.001) and toxicity (β = 0.246, p = 0.055 vs. β = 0.071, p = 0.010). In conclusion, the new legislation’s noticeability should be increased.[download PDF]
Passos, et al. 2019. Dynamic, data-driven typologies of long-term smoking, cessation and their correlates: Findings from the International Tobacco Control (ITC) Netherlands Survey [access full article]
Rationale: Efforts towards tobacco control are numerous, but relapse rates for smoking cessations remain high. Behavioral changes necessary for continuous cessation appear complex, variable and subject to social, biological, psychological and environmental determinants. Currently, most cessation studies concentrate on short-to midterm behavioral changes. Besides, they use fixed typologies, thereby failing to capture the temporal changes in smoking/cessation behaviors, and its determinants.
Objective: To obtain long-term, data-driven longitudinal patterns or profiles of smoking, cessation, and related determinants in a cohort of adult smokers, and to investigate their dynamic links. Methods: The dataset originated from the International Tobacco Control (ITC) Netherlands Project, waves 2008 to 2016. Temporal dynamics of smoking/cessation, psychosocial constructs, and time-varying determinants of smoking were extracted with Group-Based Trajectory Modeling technique. Their associations were investigated via multiple regression models.
Results: Substantial heterogeneity of smoking and cessation behaviors was unveiled. Most respondents were classified as persistent smokers, albeit with distinct levels of consumption. For a minority, cessation could be sustained between 1 and 8 years, while others showed relapsing or fluctuating smoking behavior. Links between smoking/cessation trajectories with those of psychosocial and sociodemographic variables were diverse. Notably, changes in two variables were aligned to behavioral changes towards cessation: decreasing number of smoking peers and attaining a higher self-perceived control.
Conclusion: The unveiled heterogeneity of smoking behavior over time and the varied cross-dependencies between smoking data-driven typologies and those of underlying risk factors underscore the need of individually tailored approaches for motivational quitting.[download PDF]
Ngo, et al. 2019. Analysis of gender differences in the impact of taxation and taxation structure on cigarette consumption in 17 ITC countries [access full article]
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.[download PDF]
Fix, et al. 2019. Cannabis use among a nationally representative cross-sectional sample of smokers and non-smokers in The Netherlands: Results from the 2015 ITC Netherlands Gold Magic Survey [access full article]
Objectives: Existing evidence shows that co-occurring use of tobacco and cannabis is widespread. Patterns of co-use of tobacco and cannabis may change as more jurisdictions legalise medicinal and/or recreational cannabis sales. This analysis examined predictors of current cannabis use and characterised methods of consumption among smokers and non-smokers in a context where cannabis use is legal.
Setting: The 2015 International Tobacco Control Netherlands—Gold Magic Survey conducted between July and August 2015.
Participants: Participants (n=1599; 1003 current smokers, 283 former smokers and 390 non-smokers) were asked to report their current (past 30-day) use of cigarettes and cannabis. Cigarette smokers reported whether they primarily used factory made of roll-your-own cigarettes. Those who reported any cannabis use in the last 30 days were asked about forms of cannabis used. X2and logistic regression analyses were used to assess relationships among combustible tobacco and cannabis use.
Results: Past 30-day cannabis use was somewhat higher among current tobacco (or cigarette) smokers (n=57/987=5.8%) than among former or never smokers (n=10/288=3.5% and n=6/316=1.9%, respectively). Joints were the most commonly used form of cannabis use for both current cigarette smokers (96.9%) and non-smokers (76.5%). Among those who smoked cannabis joints, 95% current smokers and 67% of non-smokers reported that they ‘always’ roll cannabis with tobacco.
Conclusions: In this Netherlands-based sample, most cannabis was reported to be consumed via smoking joints, most often mixed with tobacco. This behaviour may present unique health concerns for non-cigarette smoking cannabis users, since tobacco use could lead to nicotine dependence. Moreover, many non-cigarette smoking cannabis users appear to be misclassified as to their actual tobacco/nicotine exposure.[download PDF]
Gravely, et al. 2019. Prevalence of awareness, ever-use, and current use of 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 [access full article]
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.[download PDF]
van den Brand, et al. 2019. Does free or lower cost smoking cessation medication stimulate quitting? Findings from the International Tobacco Control (ITC) Netherlands and UK Surveys
Objective: To investigate whether mentioning free or lower cost smoking cessation medication as a trigger for thinking about quitting is related to higher medication use, more quit attempts and quit success, and whether these associations are modified by education and income.
Methods: Data were derived from the 2013 and 2014 surveys of the International Tobacco Control Netherlands (n=1164) and UK (n=768) cohort. Logistic regression analyses were used to assess associations between mentioning in 2013 that free/lower cost smoking cessation medication was a trigger for thinking about quitting smoking and the use of medication, quit attempts and smoking cessation in 2014.
Results: 37.0% of smokers in the UK and 24.9% of smokers in the Netherlands mentioned free/lower cost medication as a trigger for thinking about quitting. Smokers who mentioned this trigger were more likely to have used cessation medication during a quit attempt both in the UK (OR=4.19, p<0.001) and in the Netherlands (OR=2.14, p=0.033). The association between mentioning free/lower cost medication as a trigger for thinking about quitting and actual quit attempts was significant in the UK (OR=1.45, p=0.030), but not in the Netherlands (OR=1.10, p=0.587). There was no significant association with quit success. Associations did not differ across income and education groups.
Conclusion: Free/lower cost smoking cessation medication may increase the use of cessation medication and stimulate quit attempts among smokers with low, moderate and high education and income.[download PDF]
Shang, et al. 2019. Association between tax structure and cigarette consumption: findings from the International Tobacco Control Policy Evaluation (ITC) Project [access full article]
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.[download PDF]
Zatonski, et al. 2018. Characterising smokers of menthol and flavoured cigarettes, their attitudes towards tobacco regulation, and the anticipated impact of the Tobacco Products Directive on their smoking and quitting behaviours: The EUREST-PLUS ITC Europe Surveys [access full article]
Introduction: Little research exists on the sociodemographic characteristics of menthol and flavoured cigarette (MFC) smokers in Europe. This study assessed the proportion of MFC smokers in Europe, their sociodemographic characteristics, and their attitudes towards tobacco control measures.
Methods: Cross-sectional data were collected in 2016 among 10760 adult current smokers from 8 European countries (ITC Europe Project and EUREST-PLUS). Smokers of menthol, other flavoured, unflavoured tobacco, or no usual brand were compared on sociodemographic characteristics, attitudes towards a range of tobacco control measures (e.g. ban on flavouring), and on intentions regarding their smoking behaviour following the ban on flavoured tobacco. Data were analysed in SPSS Complex Samples Package using univariate analyses.
Results: Among the respondents, 7.4% smoked menthol cigarettes and 2.9% other flavoured tobacco, but large differences existed between countries (e.g. 0.4% smokers smoked menthol cigarettes in Spain vs 12.4% in England). Compared to other groups, menthol cigarette smokers were younger, more likely to be female, better educated, had higher household income, and smoked fewer cigarettes (all p<0.001). A quarter of menthol smokers supported a ban on additives, compared with almost half of all other smokers (p<0.001). In case of a ban on flavourings, around a fifth of all MFC smokers intended to switch to another brand, and a third to reduce the amount they smoked or to quit smoking, but there was no consistent pattern across MFC smokers among the countries.
Conclusions: The ban on flavourings introduced by the EU Tobacco Products Directive (extended to 2020 for menthols) will affect one in ten smokers in the countries surveyed, which provides an opportunity for targeting these groups with cessation programmes. However, smokers of menthol and flavoured cigarettes in the different European countries are a heterogeneous group and may need different approaches.[download PDF]
van Mourik, et al. 2018. Support for a point-of-sale cigarette display ban among smokers: findings from the International Tobacco Control (ITC) Netherlands Survey
Background: Displaying tobacco products at point-of-sale (PoS) has become an important marketing strategy for the tobacco industry. This study was designed to (1) examine how support for a PoS cigarette display ban changed among Dutch smokers between 2010 and 2015 and (2) identify the variables that predict support among smokers for a PoS cigarette display ban.
Methods: Longitudinal data from six annual survey waves (2010-2015) from the International Tobacco Control (ITC) Netherlands Survey were analyzed. The sample consisted of between 1279 and 1800 smokers per year. Smokers were asked whether they supported a complete ban on displays of cigarettes inside shops and stores.
Results: Support for a PoS cigarette display ban increased from 28.9% in 2010 to 42.5% in 2015 (OR = 1.40, p < 0.001). A multiple logistic regression analysis revealed that support for a PoS display ban of cigarettes was more likely among smokers who had more knowledge about the health risks of smoking (OR = 3.97, p < 0.001), believed smoking-related health risks to be severe (OR = 1.39, p < 0.001), had a more positive attitude towards quitting smoking (OR = 1.44, p = 0.006), reported stronger social norms to quit smoking (OR = 1.29, p = 0.035), had a higher self-efficacy for quitting smoking (OR = 1.31, p = 0.001), and had stronger intentions to quit smoking (OR = 1.23, p = 0.006).
Conclusions: This paper showed that support for a PoS display ban of cigarettes increased among smokers in the Netherlands over the years. To further increase support, educational campaigns about the dangers of smoking, and campaigns that encourage quitting may be needed.[download PDF]
Hummel, et al. 2018. Construct and predictive validity of three measures of intention to quit smoking: findings from the International Tobacco Control (ITC) Netherlands Survey
Introduction: The aim of the study was to compare the construct validity and the predictive validity of three instruments to measure intention to quit smoking: a Stages of Change measure, the Motivation To Stop Scale (MTSS) and a Likert scale. We used the Theory of Planned Behaviour as theoretical framework.
Methods: We used data from the International Tobacco Control (ITC) Netherlands Survey. We included smokers who participated in three consecutive survey waves (n=980). We measured attitude, subjective norm, and perceived behavioural control in 2012, intention to quit with three instruments in 2013, and having made a quit attempt in the last year in 2014. We conducted Structural Equation Modelling with three models for the instruments of intention separately, and with one model that included the three instruments simultaneously.
Results: All three instruments of intention were significantly and positively related to attitude and perceived behavioural control but none was related to subjective norm. All three instruments were significantly and positively related to making a quit attempt. The relation of the Likert scale with making a quit attempt (β=0.38) was somewhat stronger than that of the Stages of Change measure (β=0.35) and the MTSS (β=0.22). When entering the three instruments together into one model, only the Likert scale was significantly related to making a quit attempt.
Conclusions: All three instruments showed reasonable construct validity and comparable predictive validity. Under the studied conditions, the Likert scale performed slightly better than the Stages of Change measure and the MTSS.
Implications: An assessment of the Stages of Change, the Motivation To Stop Scale (MTSS) and a Likert scale showed comparable predictive and construct validity as measures for intention to quit smoking. All three instruments can be used in future research; however, under the studied theoretical framework, i.e. the Theory of Planned Behaviour, the Likert scale performed slightly better than the other two instruments.[download PDF]
Meijer, et al. 2018. A longitudinal study into the reciprocal effects of identities and smoking behaviour: findings from the ITC Netherlands Survey
Objective: Although it has been found that identity constructs related to smoking are associated with changes in smoking behaviour, the direction of causal associations is as yet unclear. This study aims to clarify the nature and direction of these associations.
Methods: In this longitudinal study we examined the reciprocal relations between identity constructs (i.e., smoker self-identity, quitter self-identity and smoker group-identity), intention to quit and smoking and quitting behaviour among a sample of 1036 smokers and ex-smokers, using cross-lagged structural equation modelling. Moreover, we tested whether these relations differed by socio-economic status (SES).
Results: Identity and smoking behaviour were reciprocally related in that in intention to quit and smoking behaviour consistently predicted identity change, and identity predicted (changes in) intentions to quit and smoking behaviour. Behaviour appears more important for identity change than identity for behaviour change. Furthermore, quitter self-identity appears more important than smoker self- and group-identity. Relationships did not differ significantly between SES-groups. The findings were replicated using a crossvalidation sample.
Conclusion: Results imply that changing smoking behaviour may be a vehicle to change smoking-related identity. Moreover, strengthening identification with quitting is more crucial for quit success than decreasing smoker identities. The finding that behaviour may be more important for identity than vice versa, if replicated, may call for additions to identity theories.[download PDF]
Hummel, et al. 2018. Quitting activity and use of cessation assistance reported by smokers in eight European countries: Findings from the EUREST-PLUS ITC Europe Surveys [access full article]
Introduction: There is clear evidence that the use of cessation aids significantly increases the likelihood of successful smoking cessation. The aim of this study was to examine quitting activity and use of cessation aids among smokers from various European countries. Subgroup differences were also examined for sex, income, education, and age in each country.
Methods: Cross-sectional data were collected in 2016 from 10683 smokers in eight European countries participating in the ITC Project: England (n=3536), Germany (n=1003), Greece (n=1000), Hungary (n=1000), the Netherlands (n=1136), Poland (n=1006), Romania (n=1001), and Spain (n=1001). We measured quitting activity, including quit attempts in the previous 12 months and intention to quit, use of cessation aids (i.e. medication, quitlines, internet, local services, e-cigarettes), and whether respondents had received advice from health professionals about quitting and e-cigarettes.
Results: Quit attempts were most common in England (46.3%) and least common in Hungary (10.4%). Quit intention was highest in England and lowest in Greece. Use of e-cigarettes to quit was highest in England (51.6%) and lowest in Spain (5.0%). Use of cessation aids was generally low across all countries; in particular this was true for quitlines, internet based support, and local services. Receiving health professional advice to quit was highest in Romania (56.5%), and lowest in Poland (20.8%); few smokers received advice about e-cigarettes from health professionals. No clear differences were found for sex and income groups. Across countries, smokers with lower education reported less quitting activity.
Conclusions: Quitting activity and use of cessation methods were low in most countries. Greater quit attempts and use of cessation aids were found in England, where large investments in tobacco control and smoking cessation have been made. Health professionals are important for motivating smokers to quit and promoting the effectiveness of various methods, but overall, few smokers get advice to quit.[download PDF]
Kahnert, et al. 2018. Extent and correlates of self-reported exposure to tobacco advertising, promotion, and sponsorship in smokers: Findings from the EUREST-PLUS ITC Europe Surveys
Introduction: Tobacco advertising, promotion and sponsorship (TAPS) are known to promote tobacco consumption and to discourage smoking cessation. Consequently, comprehensive TAPS bans are effective measures to reduce smoking. The objective of this study was to investigate to what extent smokers are exposed to TAPS in general, and in various media and localities, in different European countries.
Methods: A cross-sectional analysis of national representative samples of adult smokers in 2016 from Germany, Greece, Hungary, Poland, Romania, and Spain (EUREST-PLUS Project, n=6011), as well as England (n=3503) and the Netherlands (n=1213) (ITC Europe Surveys) was conducted. Prevalence of self-reported TAPS exposure is reported by country, and socioeconomic correlates were investigated using logistic regression models.
Results: Self-reported exposure to TAPS varied widely among the countries, from 15.4 % in Hungary to 69.2 % in the Netherlands. In most countries, tobacco advertising was most commonly seen at the point of sale, and rarely noticed in mass media. The multivariate analysis revealed some variation in exposure to TAPS by sociodemographic factors. Age showed the greatest consistency across countries with younger smokers (18–24 years) being more likely to notice TAPS than older smokers.
Conclusions: TAPS exposure tended to be higher in countries with less restrictive regulation but was also reported in countries with more comprehensive bans, although at lower levels. The findings indicate the need for a comprehensive ban on TAPS to avoid a shift of marketing efforts to less regulated channels, and for stronger enforcement of existing bans.[download PDF]
Heckman, et al. 2017. A novel method for evaluating the acceptability of substitutes for cigarettes: The experimental tobacco marketplace
Objectives: We tested the substitutability of nicotine replacement therapy (NRT), electronic cigarettes (ECs), and very low nicotine cigarettes (VLNCs) in the context of an online experimental tobacco marketplace (ETM) that was designed to mimic the choices of smokers under 4 policy scenarios.
Methods: Dutch cigarette smokers (N = 840) completed an online survey in July 2015. The ETM was comprised of conventional cigarettes, VLNCs, ECs (disposable/cartridge/tank systems), and NRT (lozenges/patches/tabs). All participants completed a scenario in which conventional cigarettes were banned. To test additional policy scenarios participants were randomized to one of 3 experiments: (1) no VLNCs; (2) all products available; or (3) no ECs. Hypothetical weekly purchases were made when the cost for conventional cigarettes was one-half market price (MP), MP, 2x MP, and 4x MP. We measured substitutability by the change in estimated consumption as cigarette prices increased.
Results: Tank and cartridge ECs and VLNCs were stronger cigarette substitutes than disposable ECs and NRT products. Substitution of ECs and NRT for cigarettes was dampened when VLNCs were available.
Conclusions: The ETM offers a method to predict how smokers might respond to policies that alter the availability of potentially substitutable products available in the marketplace.[download PDF]
Meijer, et al. 2017. Identity changes among smokers and ex-smokers: Findings from the International Tobacco Control (ITC) Netherlands Survey
Successful smoking cessation appears to be facilitated by identity change, that is, when quitting or nonsmoking becomes part of smokers’ and ex-smokers’ self-concepts. The current longitudinal study is the first to examine how identity changes over time among smokers and ex-smokers and whether this can be predicted by socioeconomic status (SES) and psychosocial factors (i.e., attitude, perceived health damage, social norms, stigma, acceptance, self-evaluative emotions, health worries, expected social support). We examined identification with smoking (i.e., smoker self-identity) and quitting (i.e., quitter selfidentity) among a large sample of smokers (n = 742) and ex-smokers (n = 201) in a cohort study with yearly measurements between 2009 and 2014. Latent growth curve modeling was used as an advanced statistical technique. As hypothesized, smokers perceived themselves more as smokers and less as quitters than do ex-smokers, and identification with smoking increased over time among smokers and decreased among ex-smokers. Furthermore, psychosocial factors predicted baseline identity and identity development. Socioeconomic status (SES) was particularly important. Specifically, lower SES smokers and lower SES ex-smokers identified more strongly with smoking, and smoker and quitter identities were more resistant to change among lower SES groups. Moreover, stronger proquitting social norms were associated with increasing quitter identities over time among smokers and ex-smokers and with decreasing smoker identities among ex-smokers. Predictors of identity differed between smokers and exsmokers. Results suggest that SES and proquitting social norms should be taken into account when developing ways to facilitate identity change and, thereby, successful smoking cessation.[download PDF]
Hummel, et al. 2017. External validation of the Motivation to Stop Scale (MTSS): findings from the International Tobacco Control (ITC) Netherlands Survey
Background: The Motivation To Stop Scale (MTSS) is a single-item instrument which has been shown to predict quit attempts in the next 6 months in a previous validation study conducted in England. The aim of the current study was to determine the external validity of the MTSS among Dutch smokers in predicting quit attempts in the next 12 months. A secondary aim was to compare the discriminative accuracy of the MTSS with that of a Stages of Change assessment.
Methods: We analysed data from three consecutive waves of the International Tobacco Control (ITC) Netherlands Survey (n = 1272). We conducted logistic regression analyses with the baseline score of the MTSS (measured in 2012 or 2013) predicting a quit attempt in the next 12 months (measured in 2013 or 2014). We furthermore compared the area under the Receiver Operating Characteristics (ROCAUC) curves of the MTSS and a Stages of Change measure.
Results: A total of 450 smokers (35.4%) made a quit attempt between baseline and 12-month follow-up. The regression analysis showed a positive relationship between scoring on the MTSS and quit attempts (odds ratio = 18.15, 95% confidence interval = 8.12–40.58 for the most vs. least motivated group). The discriminative accuracy of the MTSS (ROCAUC = 0.68) was marginally higher than that of a Stages of Change assessment (ROCAUC = 0.65), but not statistically significant (P = 0.21).
Conclusion: The MTSS is an externally valid instrument to predict quit attempts in the next 12 months.[download PDF]
Nagelhout, et al. 2016. E-cigarette advertisements, and associations with use of e-cigarettes and disapproval or quitting smoking: Findings from the International Tobacco Control (ITC) Netherlands Survey [access full article]
Background: Much attention has been directed towards the possible effects of e-cigarette advertisements on adolescent never smokers. However, e-cigarette advertising may also influence perceptions and behaviors of adult smokers. The aim of our study was to examine whether noticing e-cigarette advertisements is associated with current use of e-cigarettes, disapproval of smoking, quit smoking attempts, and quit smoking success.
Methods: We used longitudinal data from two survey waves of the ITC Netherlands Survey among smokers aged 16 years and older (n = 1198). Respondents were asked whether they noticed e-cigarettes being advertised on television, on the radio, and in newspapers or magazines in the previous 6 months.
Results: There was a significant increase in noticing e-cigarette advertisements between 2013 (13.3%) and 2014 (36.0%), across all media. The largest increase was for television advertisements. There was also a substantial increase in current use of e-cigarettes (from 3.1% to 13.3%), but this was not related to noticing advertisements in traditional media (OR = 0.99, p = 0.937). Noticing advertisements was bivariately associated with more disapproval of smoking (Beta = 0.05, p = 0.019) and with a higher likelihood of attempting to quit smoking (OR = 1.37, p = 0.038), but these associations did not reach significance in multivariate analyses. There was no significant association between noticing advertisements and quit smoking success in either the bivariate or multivariate regression analysis (OR = 0.92, p = 0.807).
Conclusion: Noticing e-cigarette advertisements increased sharply in the Netherlands between 2013 and 2014 along with increased e-cigarette use, but the two appear unrelated. The advertisements did not seem to have adverse effects on disapproval of smoking and smoking cessation.[download PDF]
Nagelhout, et al. 2016. Educational differences in the impact of pictorial cigarette warning labels on smokers: Findings from the International Tobacco Control (ITC) Europe Surveys
Objective: To examine (1) the impact of pictorial cigarette warning labels on changes in self-reported warning label responses: warning salience, cognitive responses, forgoing cigarettes and avoiding warnings, and (2) whether these changes differed by smokers’ educational level.
Methods: Longitudinal data of smokers from two survey waves of the International Tobacco Control (ITC) Europe Surveys were used. In France and the UK, pictorial warning labels were implemented on the back of cigarette packages between the two survey waves. In Germany and the Netherlands, the text warning labels did not change.
Findings: Warning salience decreased between the surveys in France (OR=0.81, p=0.046) and showed a non-significant increase in the UK (OR=1.30, p=0.058), cognitive responses increased in the UK (OR=1.34, p<0.001) and decreased in France (OR=0.70, p=0.002), forgoing cigarettes increased in the UK (OR=1.65, p<0.001) and decreased in France (OR=0.83, p=0.047), and avoiding warnings increased in France (OR=2.93, p<0.001) and the UK (OR=2.19, p<0.001). Warning salience and cognitive responses decreased in Germany and the Netherlands, forgoing did not change in these countries and avoidance increased in Germany. In general, these changes in warning label responses did not differ by education. However, in the UK, avoidance increased especially among low (OR=2.25, p=0.001) and moderate educated smokers (OR=3.21, p<0.001).
Conclusions: The warning labels implemented in France in 2010 and in the UK in 2008 with pictures on one side of the cigarette package did not succeed in increasing warning salience, but did increase avoidance. The labels did not increase educational inequalities among continuing smokers.[download PDF]
Zethof, et al. 2016. Attrition analysed in five waves of a longitudinal yearly survey of smokers: Findings from the ITC Netherlands Survey
Background: Attrition bias can affect the external validity of findings. This article analyses attrition bias and assesses the effectiveness of replenishment samples on demographic and smoking-related characteristics for the International Tobacco Control Netherlands Survey, a longitudinal survey among smokers.
Methods: Attrition analyses were conducted for the first five survey waves (2008–12). We assessed, including and excluding replenishment samples, whether the demographic composition of the samples changed between the first and fifth waves. Replenishment samples were tailored to ensure the sample remained representative of the smoking population. We also constructed a multivariable survival model of attrition that included all five waves with replenishment samples.
Results: Of the original 1820 respondents recruited in 2008, 46% participated again in 2012. Demographic differences between waves due to attrition were generally small and replenishment samples tended to minimize them further. The multivariable survival analysis revealed that only two of the 10 variables analysed were significant predictors of attrition: a weak effect for gender (men dropped out more often) and weak to moderate effects for age (respondents aged 15–24 years dropped out more than aged 25–39 years, who dropped out more than those aged 40+ years).
Conclusions: Weak to moderate attrition effects were found for men and younger age groups. This information could be used to minimize respondent attrition. Our findings suggest that sampling weights and tailored replenishment samples can effectively compensate for attrition effects. This is already being done for the International Tobacco Control Netherlands Survey, including the categories that significantly predicted attrition in this study.[download PDF]
Hummel, et al. 2015. Trends and socioeconomic differences in policy triggers for thinking about quitting smoking: Findings from the International Tobacco Control (ITC) Europe Surveys [access full article]
Introduction: The aim of the current study is to investigate trends and socioeconomic differences in policy triggers for thinking about quitting in six European countries.
Methods: Data were derived from all available survey waves of the International Tobacco Control (ITC) Europe Surveys (2003-2013). France conducted three survey waves (n=1420-1735), Germany three waves (n=515-1515), The Netherlands seven waves (n=1420-1668), Ireland three waves (n=582-1071), Scotland two waves (n=461-507), and the rest of the United Kingdom conducted seven survey waves (n=861-1737). Smokers were asked whether four different policies (cigarette price, smoking restrictions in public places, free or lower cost medication, and warning labels on cigarette packs) influenced them to think about quitting. Generalized Estimating Equation (GEE) models were estimated for each country.
Results: Cigarette price was mentioned most often in all countries and across all waves as trigger for thinking about quitting. Mentioning cigarette price and warning labels increased after the implementation of price increases and warning labels in some countries, while mentioning smoking restrictions decreased after their implementation in four countries. All studied policy triggers were mentioned more often by smokers with low and/or moderate education and income than smokers with high education and income. The education and income differences did not change significantly over time for most policies and in most countries.
Conclusions: Tobacco control policies work as a trigger to increase thoughts about quitting, particularly in smokers with low education and low income and therefore have the potential to reduce health inequalities in smoking.[download PDF]
Brown, et al. 2015. Trends and socioeconomic differences in roll-your-own tobacco use: Findings from the ITC Europe Surveys [access full article]
Objectives: To examine if exclusive Roll-Your-Own (RYO) tobacco use relative to factory-made (FM) cigarette use has been rising over time, to determine the extent to which economic motives and perceptions that RYO cigarettes are less harmful act as primary motivations for use, and to examine the association of income and education with the level of RYO tobacco use among smokers in four European countries.
Methods: Data were obtained from the International Tobacco Control (ITC) Europe Surveys, and a cohort sample of 7070 smokers from the Netherlands, Germany, France and UK were interviewed between June 2006 and December 2012. Generalised estimating equations (GEE) were used to assess trends in RYO use, and whether RYO consumption varied by socioeconomic variables.
Results: Exclusive RYO use over the study period has increased significantly in the UK from 26.4% in 2007 to 32.7% in 2010 (p<0.001); France from 12.2% in 2006 to 19.1% in 2012 (p<0.001); and Germany from 12.7% in 2007 to 18.6% in 2011 (p=0.031), with increased borderline significantly in the Netherlands (31.7% to 34.3%, p=0.052), from 2008 to 2010. Over three-quarters of users in each of the study countries indicated that lower price was a reason why they smoked RYO. Just over a fourth of smokers in the UK, less than a fifth in France, and around a tenth in Germany and the Netherlands believed that RYO is healthier. Compared with exclusive FM users, exclusive RYO users were more likely to have lower incomes and lower education.
Conclusions: Effective tobacco tax regulation is needed in the European Union and elsewhere to eliminate or reduce the price advantage of RYO tobacco. Additional health messages are also required to correct the misperception that RYO tobacco is healthier than FM cigarettes.[download PDF]