Citation

Yoon, W., Seo, H.G., Lee, S., Lee, E.S., Xu, S.S., Meng, G., Quah, A.C.K., Fong, G.T., Lim, S., Kim, G., Kim, S.Y., Cho, S. (2024). Reasons for using e-cigarettes among adults who smoke: Comparing the findings from the 2016 and 2020 ITC Korea Surveys. Tobacco Control, [Published online 15 Jun, doi: 10.1136/tc-2023-058506].

Abstract

Introduction: Dual use of e-cigarettes and cigarettes is a growing usage pattern in adults, but little is known about the motivations underlying this trend. We investigated the reasons for e-cigarette use among adults who smoke, considering variation in sociodemographic subgroups.

Methods: This repeated cross-sectional study analysed adults who smoked at least weekly and vaped at any frequency. Data were from the International Tobacco Control Korea Surveys conducted in 2016 (n=164) and 2020 (n=1088). Fourteen reasons for e-cigarette use were assessed in both waves. Subgroup analyses were performed by age, sex and educational level.

Results: The top reasons for e-cigarette use in 2020 were curiosity (62.8%), less harmful than smoking (45.4%) and taste (43.2%). Curiosity was the most cited across age, sex and education subgroups. Significant differences were observed in 2020 compared with 2016, with lower percentages in goal-oriented reasons: helping quit smoking (36.3% vs 48.9%; p=0.017), helping cut down smoking (35.3% vs 52.7%; p=0.001), less harmful to others (39.0% vs 54.6%; p=0.003) and more acceptable (31.6% vs 61.2%; p<0.001). By contrast, non-goal-oriented reasons showed higher percentages in 2020, such as curiosity (62.8% vs 27.9%; p<0.001), taste (43.2% vs 22.1%; p<0.001) and enjoyment (26.8% vs 8.6%; p<0.001). In 2020, a majority of adults who smoked and vaped (53.3%) reported no intention to quit or reduce smoking.

Conclusions: E-cigarette use for curiosity and pleasure predominated among adults who smoked. The reasons for dual use in adults have shifted from goal-oriented to non-goal-oriented.

Citation

Lee, S., Xu, S.S., Yan, M., Gravely, S., Quah, A.C.K., Seo, H.G., Lim, S., Cho, S., Kim, Y., Fong, G.T. (2024). Patterns of cigarette, heated tobacco product, and nicotine vaping product use among Korean adults: Findings from the 2020 ITC Korea Survey. Tobacco Induced Diseases, 22(April):63, 1-11. doi: 10.18332/tid/186273.

Abstract

Introduction: Non-combustible nicotine products (NCNPs), such as heated tobacco products (HTPs) and nicotine vaping products (NVPs) have gained a significant nicotine market share in South Korea. This descriptive study examined patterns of regular cigarette and NCNP use among South Korean adults.

Methods: Data were from the 2020 International Tobacco Control Korea Survey and included 4016 adults (aged ≥19 years) in the Republic of Korea who were regularly (at least weekly) using at least one NCNP (NVP/HTP, n=2117) and/or smoked cigarettes (n=3763) at the time of the survey. Weighted descriptive estimates were computed to assess respondents' nicotine product use among all respondents (exclusive, dual, or triple use). Thereafter, we identified sociodemographic characteristics associated with NCNP use (n=2117).

Results: Among Korean adults who were smoking cigarettes, 83.1% (95% CI: 81.6-84.6) did so exclusively, and 16.9% (95% CI: 15.4-18.4) smoked cigarettes and used NCNPs. Among those who used HTPs (n=1877), 14.9% (95% CI: 11.5-18.4) did so exclusively, 59.6% used HTPs and smoked cigarettes (95% CI: 55.4-63.1), 4.2% used HTPs and vaped (95% CI: 11.5-18.4), and 21.6% (95% CI: 18.9-24.2) used all three products. Of adults who used HTPs and smoked cigarettes, 86.6% smoked daily. Among those who vaped (n=865), 13.3% did so exclusively (95% CI: 9.4-17.1), 55.6% (95% CI: 49.6-61.5) vaped and smoked cigarettes, 5.1% (95% CI: 1.7-8.6) used HTPs and vaped, and 26.1% (95% CI: 22.1-30.1) used all three products. Of adults who vaped and smoked cigarettes, 82.4% (95% CI: 77.1-87.7) smoked daily.

Conclusions: Cigarettes remain the most commonly used nicotine product in South Korea, and among adults using heated tobacco and/or vaping products, the majority were also smoking. Research is urgently needed to assess whether adults who are using an NCNP are doing so to quit, or rather to complement their cigarette smoking.

Citation

Goulette, M. R., Gravely, S., Xu, S. S., Meng, G., Quah, A. C., Lee, S. Cho, S., Kim, Y., Lim, S., Bansal-Travers, M., Hyland, A., Fong, G.T., & Seo, H.G. (2023). Perceptions of harmfulness of heated tobacco and nicotine vaping products compared to cigarettes, and the association of advertising exposure on harm perceptions among adults who smoke in South Korea: Cross-sectional findings from the 2020 ITC Korea Survey. Tobacco Induced Diseases, 21(September), 121. doi: 10.18332/tid/170252.

Abstract

Introduction: Heated tobacco products (HTPs) and nicotine vaping products (NVPs) both are legal consumer products in the Republic of Korea. Little is known about perceptions of harmfulness of HTPs and NVPs relative to cigarettes in South Korea among adults who smoke, and how exposure to marketing may be associated with harmfulness perceptions.

Methods: This study used data from the 2020 International Tobacco Control (ITC) Korea Survey, and included 3713 adult (aged 19 years) cigarette smokers who were: 1) exclusive smokers (n=1845); 2) dual HTP + cigarette consumers (n=1130); 3) dual NVP + cigarette consumers (n=224); and 4) triple consumers (all three products, n=514). Weighted multinomial regression models were conducted to estimate smokers’ perceptions of harmfulness of HTPs and NVPs compared to cigarettes, NVPs to HTPs, and self-reported exposure to HTP/NVP advertising. Analyses compared the perceptions of harmfulness between the four different consumer groups, and tested whether exposure to HTP/NVP advertising was associated with perceptions of lower relative harm.

Results: Among all respondents, 27.5% believe that HTPs are less harmful than cigarettes and 23.4% believe that NVPs are less harmful than cigarettes. Exclusive cigarettes smokers were significantly less likely to perceive that HTPs and NVPs are less harmful than cigarettes compared to dual HTP + cigarette consumers, dual NVP + cigarette consumers, and triple consumers (all p<0.001). Half of respondents perceive NVPs as equally harmful as HTPs (14.1% perceive NVPs as more harmful than HTPs). Exposure to HTP/NVP advertising was associated with perceiving these products as less harmful than cigarettes.

Conclusions: About one-quarter of Korean cigarette smokers perceive HTPs and NVPs as less harmful than cigarettes. Further investigation is required to understand how harm perceptions and HTP/NVP advertising are related to changes in product use, such as switching between products, using multiple products, or discontinuing all product use.

Citation

Seo, H.G., Xu, S.S., Li, G., Gravely, S., Quah, A.C.K., Lee, S., Lim, S., Cho, S., Kim, Y., Lee, E.S., Choi, Y.J., Miller, C., Goniewicz, M.L., O’Connor, R.J., Fong, G.T. (2023). Reasons for initiation and regular use of heated tobacco products among current and former smokers in South Korea: Findings from the 2020 ITC Korea Survey. International Journal of Environmental Research and Public Health, 20(6), 49-63. doi: 10.3390/ijerph20064963

Abstract

South Korea is the world’s second-largest heated tobacco product (HTP) market after Japan. HTP sales in South Korea have increased rapidly since May 2017, accounting for 10.6% of the total tobacco market in 2020. Despite this, little is known as to why HTP consumers who were current and former smokers started using HTPs and used them regularly. We analyzed cross-sectional data for 1815 adults (aged 19+) who participated in the 2020 International Tobacco Control (ITC) Korea Survey, of whom 1650 were HTP-cigarette consumers (those who reported smoking cigarettes and using HTPs ≥ weekly) and 165 were exclusive HTP consumers (using HTPs ≥ weekly) who were former or occasional smokers (smoking cigarette < weekly). Respondents were asked to report the reason(s) they used HTPs, with 25 possible reasons for HTP-cigarette consumers and 22 for exclusive HTP consumers. The most common reasons for initiating HTP use among all HTP consumers were out of curiosity (58.9%), family and friends use HTPs (45.5%), and they like the HTP technology (35.9%). The most common reasons for regularly using HTPs among all HTP consumers were that they were less smelly than cigarettes (71.3%), HTPs are less harmful to own health than cigarettes (48.6%), and stress reduction (47.4%). Overall, 35.4% of HTP-cigarette consumers reported using HTPs to quit smoking, 14.7% to reduce smoking but not to quit, and 49.7% for other reasons besides quitting or reducing smoking. In conclusion, several common reasons for initiating and regularly using HTPs were endorsed by all HTP consumers who were smoking, had quit smoking completely, or occasionally smoked. Notably, only about one-third of HTP-cigarette consumers said they were using HTPs to quit smoking, suggesting that most had no intention of using HTPs as an aid to quit smoking in South Korea.

Citation

Han, M., Seo, D.H., Kim, Y., Seo, H.G., Cho, S., Lee, S., Lim, S., Kaai, S.C., Quah, A.C.K., Yan, M., Xu, S.S., Fong, G.T. (2022). Factors associated with quit intentions among adult smokers in South Korea: Findings from the 2020 ITC Korea Survey. International Journal of Environmental Research and Public Health, 19(17), 10839. doi: 10.3390/ijerph191710839

Abstract

Background: South Korea has made substantial progress on tobacco control, but cigarette smoking prevalence is still high. Previous studies were conducted before the use of nicotine vaping products (NVPs) or heated tobacco products (HTPs) became popular. Thus, whether the concurrent use of NVPs or HTPs affects quit intentions among Korean smokers remains a question that needs to be explored. This study aims to identify predictors of quit intentions among cigarette-only smokers and concurrent users of cigarettes and NVPs or HTPs.

Methods: Data were from the 2020 International Tobacco Control Korea Survey. Included in the analysis were 3778 adult cigarette smokers: 1900 at-least-weekly exclusive smokers and 1878 at-least-weekly concurrent smokers and HTP or NVP users. Bivariate and multivariable logistic regression analyses were conducted.

Results: Quit intentions were reported by 66.4% of respondents. Factors significantly associated with quit intentions included younger age, having a spouse/partner, lower nicotine dependence, reporting a past quit attempt, regretting starting smoking, believing that smoking had damaged health, worrying that smoking will damage future health, and perceiving health benefits of quitting. Current use of NVPs or HTPs was not significantly associated with quit intentions.

Conclusions: This study contributes the following to current literature: intrinsic health-related beliefs were more important than societal norms in shaping quit intentions. These findings should be considered in shaping future smoking cessation policies, such as reinforcing education programs that emphasize the benefits of quitting for personal health reasons, lowering nicotine dependence, and encouraging multiple quit attempts and successful quitting.

Citation

Quah, A.C.K., Lee, S., Seo, H.G., Cho, S., Lim, S., Kim, Y., Xu, S.S., Grey, M., Yan, M., Boudreau, C., Thompson, M.E., Driezen, P., Fong, G.T. (2022). Methods of the 2020 (Wave 1) International Tobacco Control (ITC) Korea Survey. Tobacco Prevention & Cessation, 8(March), 13. doi: https://doi.org/10.18332/tpc/146685

Abstract

This article presents methods used in the 2020 International TC Korea Wave 1 (KRA1) Survey. To date, three cohorts of Korean respondents have participated in the larger ITC Korea Project (cohort 1: 2005–2014, cohort 2: 2016, and cohort 3: 2020–present). The overall objectives of the ITC KRA1 Survey were to examine the use of cigarettes, heated tobacco products (HTPs), e-cigarettes (ECs); whether HTPs might help smokers quit; and the effectiveness of tobacco control policies, such as large graphic warnings, high cigarette taxes, and smoking bans in public places. The KRA1 Survey measures were identical or functionally similar to those of the ITC Japan Survey and, to a lesser extent, those of other ITC countries. Key measures assessed sociodemographic characteristics of respondents; the use of combustible cigarettes, e-cigarettes, and heated tobacco products; and measures assessing policies of the WHO Framework Convention on Tobacco Control, including price and tax (Article 6), smoke-free laws (Article 8), health warnings (Article 11), education, communication and public awareness (Article 12), advertising, promotion, and sponsorship restrictions (Article 13), and support for cessation (Article 14). Adult tobacco and/or nicotine users aged ≥19 years in South Korea were recruited by a commercial survey firm from its online panel. Overall, 4794 respondents completed the KRA1 Survey. The cooperation rate was 97.4% and the response rate was 15.2%. The cohort design permits assessment of transitions in products used among users in South Korea and evaluations of the impact of policies on tobacco and/or nicotine products used and transitions in use.

Citation

Park, E., Cho, S., Seo, H.G., Kim, Y., Jung, H.S., Fong, G.T., Quah, A.C.K. (2019). Attitudes of Korean smokers toward smoke-free public places: Findings from the longitudinal ITC Korea Survey, 2005-2010. BMJ Open, 9, e025298.

Abstract

Objective: Prior to December 2012, restaurants in South Korea were required to implement only partial smoking bans. This study documents the changes in Korean smokers' attitudes towards smoking bans between 2005 and 2010 and explores the effects of anti-smoking advertising as a correlate of support for total smoking bans in public places.

Design: Longitudinal cohort study of Korean adult smokers.

Settomg: The data were derived from three waves (2005, 2008 and 2010) of the International Tobacco Control (ITC) Korea Survey.

Participants: The ITC Korea Survey respondents were a probability-based, nationally representative sample of Korean smokers aged 19 and older. The current analysis includes 995 smokers who participated in Wave 1 (2005), 1737 smokers who participated in Wave 2 (2008) and 1560 smokers who participated in Wave 3 (2010).

Primary and Secondary Outcome Measures: Changes in respondents' awareness of secondhand smoke (SHS) harm, attitudes towards smoking bans and personal rules for smoking in private homes and/or vehicles were analysed. Correlates of support for smoking bans in public places were examined using generalised estimating equation regression models.

Results: More than 80% of Korean smokers are aware of the harms of SHS. The proportion of smokers who support smoke-free restaurants or smoke-free bars increased twofold between 2005 and 2010. Smokers who were aware of the dangers of SHS were more likely to support a total smoking ban in workplaces. Noticing anti-smoking advertising or information was not significantly associated with support for a total smoking ban in public places.

Conclusions: Korean smokers became more supportive of smoking bans in public places between 2005 and 2008. These results show that smokers' attitudes towards smoking bans can change with the implementation of smoke-free policies, even in a country that has a high prevalence of smokers.

Citation

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

Abstract

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

Lee, E.S., Seo, H.G., Fong, G.T., Yan, M., Driezen, P. (2018). Awareness of Korean adult smokers about national smoking cessation programs in Korea: findings from the 2016 International Tobacco Control Policy Evaluation Korea Survey. Journal of the Korean Society for Research on Nicotine and Tobacco, 9(Suppl 1), S22-30.

Abstract

Background: There are effective intervention program for smoking cessation such as clinics at public health centres, quitlines, residential cessation program, and insurance program in South Korea. The purpose of this study is to investigate awareness and utilization of smoking cessation program in current smokers.
Methods: We analyzed data from the ITC Korea Survey, a telephone survey of a nationally representative sample of 2,000 adult smokers, conducted from June 2015 to June 2016. Frequency of awareness, intention to use, and utilization about smoking cessation program were reported in current smokers. To evaluate influence of smoking related factors like nicotine dependence on awareness, intention to use, and use about smoking cessation program of current smokers, logistic regression was used. All analyses were performed with use of STATA version 11.
Results: In case of the insurance program to help quit, current smokers have an awareness about it (36.9%) and an interest in using it (50.3%). The proportion of current smoker utilizing quit program was 32.3% for public clinic, 0.9% for residential program, 7.4% for insurance program to help quit, and 3.0% for Quitlines. Higher utilization was observed current smokers over 40 years of age, married, with daily smoking amount (above 10/d), with quit attempt in the last 1 year (OR 1.32, 95% CI 1.04-1.68), and with smoking cessation plan (OR 2.47, 95% CI 1.85-3.29).
Conclusion: A small percentage of current smokers participated the government providing smoking cessation program in Korea, even though their awareness is relatively good. Further strategy is necessary to encourage current smoker to participate smoking cessation program.

Citation

Seo, H.G., Kim, Y., Xu, S.S., Quah, A.C.K., Boudreau, C., Yan, M., Thompson, M.E., Fong, G.T. (2018). Tobacco control policies in the Republic of Korea and the methods of the ITC Korea Surveys. Journal of the Korean Society for Research on Nicotine and Tobacco, 9(Suppl 1), S1-10.

Abstract

Policies that promote the social unacceptability of smoking may also result in smoking-related stigma. The aim of this study is to evaluate how norms against smoking and socioeconomic status (SES) are associated with stigma among smokers. We used data from a panel of adult smokers who participated in the 2008–2012 administrations of the International Tobacco Control Policy Evaluation Survey in Mexico (n = 6670 observations) and Uruguay (n = 3296 observations).

Generalized estimating equations were used to account for correlations in the outcomes over time within individuals. We evaluated if injunctive smoking norms (i.e. significant other norms and societal norms), descriptive smoking norms (i.e. number of smoking friends), and two markers of SES (i.e. education and income) were associated with different aspects of smoking-related stigma (i.e. feeling uncomfortable, negative stereotype of smokers, and perceived marginalization). We found that stronger anti-smoking injunctive norms were associated with higher levels of all indicators of perceived stigma in Mexico and Uruguay. Having fewer smoking friends was associated with feeling uncomfortable and perceived marginalization in Mexico. Higher income and education were associated with a stronger negative stereotype of smokers in Mexico.

Lower income and education were associated with a stronger negative stereotype of smokers in Uruguay. Study results suggest that factors that drive the social unacceptability of tobacco may stigmatize smokers, although further research is needed to determine whether policy-promoted stigmatization produces undesirable outcomes (e.g. lower cessation rates).

Abstract

Background: This paper aimed to present proportion of awareness and use of e-cigarettes and vaping behaviors among adult smokers in South Korea.

Methods: We used data of current adult smokers participating in the International Tobacco Control (ITC) survey Korea in 2016. The frequency analysis and cross analysis were used to present the proportion of awareness, experience, current use, reasons for use and vaping behaviors of e-cigarettes, and logistic regression analysis was used to present factors associated with awareness, experience, and current e-cigarette use. All data were submitted to complex sample survey data analysis using SPSS version 23.0 (SPSS Inc., Chicago, IL, USA) and weighted to represent the Korean population.

Results: Out of 2000 adult smokers, the proportion of awareness, experience, and current use e-cigarettes were 93.8%, 33.8%, and 5.5%, respectively. In multivariable logistic regression analysis, younger age groups were associated with increased odds ratios (ORs) for awareness, higher consumption of tobacco and no past quit attempt were associated with increased ORs for experience, and higher income groups were associated with increased ORs for current use of e-cigarettes. The common reasons for using e-cigarettes were because of thinking that using e-cigarettes were more acceptable than smoking and less harmful to other people, and makes it easier to cut down on smoking. Most e-cigarette users vaped nicotine-contained e-cigarettes and bought them at e-cigarettes shop.

Conclusion: E-cigarette awareness and use increased among Korean smokers especially among higher income groups. Careful monitoring of behavior of using e-cigarettes is needed.

Citation

Choi, Y.J., Seo, H.G., Kim, Y., Fong, G.T., Yan, M., Driezen, P. (2018). Tobacco related knowledge is associated with heaviness of smoking index (HSI) and intention to quit among Korean smokers: findings from 2016 ITC Korea Survey. Journal of the Korean Society for Research on Nicotine and Tobacco, 9(Suppl 1), S31-S38.

Abstract

Background: International Tobacco Control project (ITC) was performed in South Korea for evaluation of the effects of smoking control policies in compliance with FCTC. We tested the association between the level of knowledge and heaviness of smoking index (HSI), and intention to quit smoking.

Methods: The study followed the same methodology by ITC policy evaluation project. Trained call center staffs interviewed 2000 current smokers (1800 men and 200 women, aged 19-65) on the phone. Tobacco-related knowledge was evaluated by asking participants the diseases related with smoking such as stroke, impotence, visual loss, peripheral vascular disease, bladder cancer, and breast cancer. Multivariate logistic regression was used for statistical analysis, which was adjusted by age, sex, education level, annual household income, alcohol consumption frequency, and heaviness of smoking index.

Results: High HSI score (3-6) was associated with low knowledge score (Odds ratio (OR) 0.80, 95% confidence interval (CI) 0.65-0.99). Smokers who had intention to quit smoking in any future were also more likely to be in a high knowledge score group (10-14 vs. 0-9 out of 14) (OR 1.50, 95% CI 1.19-1.89).

Conclusion: Smokers who had higher HSI or had no intention to quit tended to have lower level of knowledge regarding health risk of smoking. This implies that education and public awareness on health risk of tobacco could be more effective when targeted to these smokers.

Citation

Kim, E.Y., Kim, Y., Choi, Y.J., Seo, H.G., Yan, M., Driezen, P., Fong, G.T. (2018). Change of support for smoke-free area and perception of effectiveness of smoking ban policy among Korean smokers: findings from the 2010, 2016 International Tobacco Control Policy Evaluation Survey in Korea. Journal of the Korean Society for Research on Nicotine and Tobacco, 9(Suppl 1), S39-50.

Abstract

Background: Smoke-free policies have been reinforced in recent years in South Korea. We investigated factors that influenced support for smoke-free area (SSA) and perception of effectiveness of smoking ban policy (PESP) and examined whether SSA and PESP changed between 2010 and 2016.

Methods: We analyzed wave 3 (2010) and new wave 1 (2016) data from the International Tobacco Control (ITC) Survey in Korea. Telephone survey was conducted among Korean smokers aged ≥19 in 2010 (n=1,560) and 2016 (n=2,000). Differences between survey data in 2010 versus 2016 were evaluated by t-test. Multiple linear regression analysis was performed to analyze factors associated with SSA and PESP, and the changes of those factors over time.

Results: Smokers in 2016 had greater SSA and more positive PESP than in 2010. Respondents who were married, had plan to quit smoking within 6 months, initiated smoking later in their life, or had less nicotine dependency were more likely to present greater SSA and more positive PESP. Respondents had lesser SSA when they answered that smoking was allowed in bars and restaurants in their neighborhood, and workplace they belonged compared to those who experienced smoke-free policy in all three of the places. Older ages were associated with more positive PESP.

Conclusion: Smokers changed their SSA and PESP more positively in 2016 than 2010. Reinforced smoke-free policies would lead smokers to have more favorable SSA and PESP and possibly contribute to reduction in smoking rate.

Citation

Green, A., Fong, G.T., Borland, R., Quah, A.C.K., Seo, H.G., Kim, Y., Elton-Marshall, T. (2015). The importance of the belief that "light" cigarettes are smoother in misperceptions of the harmfulness of "light" cigarettes in the Republic of Korea: A cohort study. BioMed Central Public Health, 15(1), 1108.

Abstract

Background: A number of countries have banned misleading cigarette descriptors such as “light” and “low-tar” as called for by the WHO Framework Convention on Tobacco Control. These laws, however, do not address the underlying cigarette design elements that contribute to misperceptions about harm. This is the first study to examine beliefs about “light” cigarettes among Korean smokers, and the first to identify factors related to cigarette design that are associated with the belief that “light” cigarettes are less harmful.

Methods: We analysed data from Wave 3 of the ITC Korea Survey, a telephone survey of a nationally representative sample of 1,753 adult smokers, conducted October - December 2010. A multinomial logistic regression was used to examine which factors were associated with the belief that “light” cigarettes are less harmful than regular cigarettes.

Results: One quarter (25.0 %) of smokers believed that “light” cigarettes are less harmful than regular cigarettes, 25.8 % believed that smokers of “light” brands take in less tar, and 15.5 % held both of these beliefs. By far the strongest predictor of the erroneous belief that “light” cigarettes are less harmful was the belief that “light” cigarettes are smoother on the throat and chest (p < 0.001, OR = 44.8, 95 % CI 23.6- 84.9).

Conclusions: The strong association between the belief that “light” cigarettes are smoother on the throat and chest and the belief that “light” cigarettes are less harmful, which is consistent with previous research, provides further evidence of the need to not only ban “light” descriptors, but also prohibit cigarette design and packaging features that contribute to the perception of smoothness.

Citation

Park, E., Park, S., Cho, S., Kim, Y., Seo, H.G., Driezen, P., Quah, A.C.K., Fong, G.T. (2015). What cigarette price is required for smokers to attempt to quit smoking? Findings from the ITC Korea Waves 2 and 3 Survey. Tobacco Control, 24(Suppl 3), iii48-iii55.

Abstract

Objectives: We assess the cigarette price that would motivate smokers to quit. We also explore the factors associated with the required price, including exposures to non-tax tobacco control policies.

Methods: Cross-sectional analysis was conducted on data from 1257 male smokers, who participated in either Wave 2 or 3 of the ITC Korea Survey. Information was obtained on what cigarette price per pack would make them try to quit (‘price to quit’). Tobit regression on log-transformed price and logistic regression on non-quitting were conducted to identify associated factors.

Results: The median price to quit was KRW5854 (US$5.31)/pack, given the current price of KRW2500 (US$2.27)/pack. Younger age, higher education, lack of concern about the health effects of smoking, lack of quit attempts and more cigarettes consumed per day were related to a higher price needed for a quit attempt. Exposures to combinations of non-tax policies were significantly associated with lower price levels to be motivated to quit.

Conclusions: Considering the large price increase required for quit attempts, tax policy needs to be combined with other policies, particularly for certain groups, such as heavy smokers. Strengthening nontax policies is likely to facilitate greater responsiveness to tax policy.

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

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.

Citation

Sansone, N., Fong, G.T., Lee, W.B., Laux, F., Sirirassamee, B., Seo, H.G., Omar, M., Jiang, Y. (2013). Comparing the experience of regret and its predictors among smokers in four Asian countries: Findings from the ITC Surveys in Thailand, South Korea, Malaysia, and China. Nicotine & Tobacco Research, 15(10), 1663-1672.

Abstract

Introduction: Nearly all smokers in high-income Western countries report that they regret smoking (Fong, G. T., Hammond, D., Laux, F. L., Zanna, M. P., Cummings, M. K., Borland, R., & Ross, H. [2004]. The near-universal experience of regret among smokers in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Nicotine and Tobacco Research, 6, S341–S351. doi:10.1080/14622200412331320743), but no research to date has examined the prevalence of regret among smokers in non-Western, low- and middle-income countries.

Methods: Data were from the International Tobacco Control (ITC) Surveys of smokers in 4 Asian countries (China, Malaysia, South Korea, and Thailand); N = 9,738. Regret was measured with the statement: “If you had to do it over again, you would not have started smoking.”

Results: Prevalence of regret in 3 countries (South Korea = 87%, Malaysia = 77%, and China = 74%) was lower than that found by Fong et al. in the United States, Australia, Canada, and the United Kingdom (89%–90%); but was higher in Thailand (93%). These significant country differences in regret corresponded with differences in tobacco control and norms regarding smoking. The predictors of regret in the Asian countries were very similar to those in the 4 Western countries: Regret was more likely to be experienced by smokers who smoked fewer cigarettes per day, perceived greater benefits of quitting and higher financial costs of smoking, had more prior quit attempts, worried that smoking would damage their health, and felt that their loved ones and society disapproved of smoking. Regret was also positively associated with intentions to quit (r = 0.23, p < .001).

Conclusions: Across the Asian countries and high-income Western countries, the prevalence of regret varies, but the factors predicting regret are quite consistent. Regret may be an important indicator of tobacco control and is related to factors associated with future quitting.

Citation

Myung, S.K., Seo, H.G., Cheong, Y., Park, S., Lee, E.S., Fong, G.T. (2012). Association of socio-demographic factors, smoking-related beliefs, and smoking restrictions with intention to quit smoking in Korean adults: Findings from the ITC Korea Survey. Journal of Epidemiology, 22(1), 21-27.

Abstract

Background: Few studies have reported the factors associated with intention to quit smoking among
Korean adult smokers. This study aimed to examine sociodemographic characteristics, smoking-related
beliefs, and smoking restriction variables associated with intention to quit smoking among Korean adult
smokers.

Methods: We used data from the International Tobacco Control Korea Survey, which was conducted
from November through December 2005 by using random-digit dialing and computer-assisted telephone
interviewing of male and female smokers aged 19 years or older in 16 metropolitan areas and provinces
of Korea. We performed univariate analysis and multiple logistic regression analysis to identify predictors
of intention to quit.

Results: A total of 995 respondents were included in the final analysis. Of those, 74.9% (n = 745)
intended to quit smoking. In univariate analyses, smokers with an intention to quit were younger, smoked
fewer cigarettes per day, had a higher annual income, were more educated, were more likely to have a
religious affiliation, drank less alcohol per week, were less likely to have self-exempting beliefs, and were
more likely to have self-efficacy beliefs regarding quitting, to believe that smoking had damaged their
health, and to report that smoking was never allowed anywhere in their home. In multiple logistic
regression analysis, higher education level, having a religious affiliation, and a higher self-efficacy
regarding quitting were significantly associated with intention to quit.

Conclusion: Sociodemographic factors, smoking-related beliefs, and smoking restrictions at home were
associated with intention to quit smoking among Korean adults.

Citation

Borland, R., Li, L., Driezen, P., Wilson, N., Hammond, D., Thompson, M.E., Fong, G.T., Mons, U., Willemsen, M.C., McNeill, A., Thrasher, J.F., Cummings, K.M. (2012). Cessation assistance reported by smokers in 15 countries participating in the International Tobacco Control (ITC) Policy Evaluation Survey. Addiction, 107(1), 197-205.

Abstract

Aims: To describe some of the variability across the world in levels of quit smoking attempts and use of various forms of cessation support.

Design: Use of the International Tobacco Control Policy Evaluation Project surveys of smokers, using the 2007 survey wave (or later, where necessary).

Settings: Australia, Canada, China, France, Germany, Ireland, Malaysia, Mexico, the Netherlands, New Zealand, South Korea, Thailand, United Kingdom, Uruguay and United States.

Participants: Samples of smokers from 15 countries.

Measurements: Self-report on use of cessation aids and on visits to health professionals and provision of cessation advice during the visits.

Findings: Prevalence of quit attempts in the last year varied from less than 20% to more than 50% across countries. Similarly, smokers varied greatly in reporting visiting health professionals in the last year (<20% to over 70%), and among those who did, provision of advice to quit also varied greatly. There was also marked variability in the levels and types of help reported. Use of medication was generally more common than use of behavioural support, except where medications are not readily available.

Conclusions: There is wide variation across countries in rates of attempts to stop smoking and use of assistance with higher overall use of medication than behavioural support. There is also wide variation in the provision of brief advice to stop by health professionals.

Citation

Kwak, S.M., Seo, H.G., Myung, S.K., Kim, Y., Jung, H.S., Fong, G.T., Quah, A.C.K., Sansone, N., Lee, W.B. (2011). Analysis of smoking-related characteristics over time in Korean adult smokers: Findings from the International Tobacco Control (ITC) Korea Survey (Language: Korean). Korean Journal of Family Practice, 1(3), 192-203.

Abstract

Background: This study aimed to track changes in demographic and smoking-related characteristics, such as perception of smoking and health among Korean adult smokers.

Methods: We conducted the three waves of the International Tobacco Control (ITC) survey-Korea (2005/2008/2010) using random digit-dialing telephone interviews. The ITC sample for each survey included 1,002 respondents at Wave 1, 1,818 at Wave 2 (including 441 cohort respondents from Wave 1), and 1,753 at Wave 3 (including 284 cohort respondents from Wave 1 and 745 from Wave 2).

Results: The largest age group ranged from 40-49 to ≥60, and the percentage of female respondents also has increased from Wave 1 to Wave 3. Even though the mean number of cigarettes per day significantly decreased from 18.2 to 17 in men, the same figure showed an insignificant increase for women from 14.3 to 18.6. As for the knowledge of health risk, awareness regarding the danger of stroke (from 35.5% to 51.4%) and blindness (from 31.6% to 42.1%) due to smoking was significantly improved (P < 0.01), whereas that of impotence, skin wrinkling, and peripheral vascular disease was not improved. The rate of subjects who answered “Health status is poor” increased from 13.2% to 16.4%, whereas rate of subjects who answered “Smoking has damaged health” decreased from 90% to 75.2%.

Conclusion: This study indicates that different strategies for the elderly and women should be developed and implemented because of their increased smoking rates. In addition, efforts to increase cessation rates should aim at increasing awareness of smoking-related diseases and health concern regarding smoking. 

Citation

Seo, H.G., Cheong, Y., Myung, S.K., Kim, Y., Lee, W.B., Fong, G.T. (2008). Smoking-related characteristics in Korean adult smokers: Findings from the 2005 International Tobacco Control Policy Evaluation Survey-Korea (Language: Korean). Journal of Korean Academy of Family Medicine, 29(11), 844-853.

Abstract

Background: This study reports findings from the ITC Korea Survey, which was conducted to evaluate the characteristics in Korean adult smokers as part of the ITC Project.

Methods: Adult male and female smokers were randomly selected using telephone survey from November to December 2005. The ITC Korea Survey contained a wide range of questions on smoking behavior and smoking history. The data reported are weighted on the basis of age and gender, and they are nationally representative of smokers in Korea.

Results: A total of 1,002 smokers among the selected 1,402 subjects (71.5%) were interviewed; 96.2% were males. Daily smokers comprised 94.5% of the sample. The mean of cigarettes per day was 17.9. The average minutes after waking before the first cigarette was smoked was lower (50.6 minutes) than it was in other countries of the ITC Project. Over 90% considered themselves addicted to cigarettes and 86.5% expressed regret over smoking. Smokers reported that the norms against smoking in Korea were very strong both personal norms (89.4%) and perceived norms in Korean society (86.3%). Among the smokers, 80.8% had tried to quit smoking, and 76.1% were planning to quit. Only 5.8% of the Korean smokers indicated that the warning labels made them a lot more likely to quit smoking. When the price of cigarettes increased by 500 won (25%) in December 2004, 34.3% reported trying to quit smoking. Only 17.7% supported a complete workplace ban and 15.8% supported a complete ban in restaurants. Although knowledge of the harms of smoking was high, nearly 80% of the Koreans wrongly believed that “nicotine causes most of the cancer in smokers.” Finally, the great majority (85.2%) of smokers in Korea believed that “the government should do more to tackle the harm done by smoking” and 62.5% believed that “tobacco products should be more tightly regulated.”

Conclusion: The results from the baseline wave of the ITC Korea Survey have identified where tobacco control in Korea has been done. Future waves of the ITC Korea Survey will be able to evaluate the impact of important tobacco control policies that Korea will be required to implement over the next few years, as a party to the FCTC.