Citation

Kasza, K.A., Hammond, D., Gravely, S., O’Connor, R.J., Meng, G., East, K.A., Borland, R., Cummings, K.M., Fong, G.T., Hyland, A. (2023). Associations between nicotine vaping uptake and cigarette smoking cessation vary by smokers’ plans to quit: Longitudinal findings from the International Tobacco Control (ITC) Four Country Smoking and Vaping Surveys. Addiction, 118(2), 340-352.

Abstract

Background and aims: Most population studies that evaluate the relationship between nicotine vaping and cigarette cessation focus on limited segments of the smoker population. We evaluated vaping uptake and smoking cessation considering differences in smokers' plans to quit.

Design: Longitudinal ITC Four Country Smoking and Vaping Surveys conducted in 2016, 2018, and 2020. Setting: US, Canada, England, Australia.

Participants: Adult daily cigarette smokers who had not vaped in the past 6 months at baseline and had participated in two or more consecutive waves of the ITC Four Country Smoking and Vaping Surveys (n= 2,815).

Measurements: Plans to quit cigarette smoking at baseline (within 6 months, beyond 6 months, not planning to quit) and at follow-up (within 6 months versus not within 6 months); cigarette smoking cessation at follow-up (smoking less than monthly [including complete cessation] versus daily/weekly/monthly smoking); inter-wave vaping uptake (none, only nondaily vaping, any daily vaping). Generalized estimating equations were used to evaluate whether inter-wave vaping uptake was associated with smoking cessation at follow-up, and with planning to quit at follow-up, each stratified by plans to quit smoking at baseline.

Findings: Overall, 12.7% of smokers quit smoking. Smokers not initially planning to quit within 6 months experienced higher odds of smoking cessation when they took up daily vaping (32.4%) versus no vaping (6.8%; adjusted odds ratio [AOR]=8.58, 95% confidence interval [CI]:5.06-14.54). Among smokers planning to quit, smoking cessation rates were similar between those who did and did not take up daily vaping (25.1% vs. 16.8%; AOR=1.91, 95%CI:0.91-4.00), though we could not account for potential use of cessation aids. Daily vaping uptake was associated with planning to quit smoking at follow-up among those initially not planning to quit (AOR=6.32, 95%CI:4.17-9.59).

Conclusions: Uptake of nicotine vaping appears to be strongly associated with cigarette smoking cessation among smokers with no initial plans to quit smoking. Excluding smokers not planning to quit from studies on vaping and smoking cessation may underestimate potential benefit of daily vaping for daily smokers.

Citation

Fix, B.V., O’Connor, R.J., Goniewicz, M.L., Leigh, N.J., Cummings, K.M., Hitchman, S.C., Fong, G.T., Nahhas, G.J., Hammond, D., McNeill, A., Borland, R., King, B., Palumbo, M. (2023). Characterisation of vaping liquids used in vaping devices across four countries: Results from an analysis of selected vaping liquids reported by users in the 2016 ITC Four Country Smoking and Vaping Survey. Tobacco Control, 32(1), 51-59.

Abstract

Objectives: This study presents an analysis of vaping products (VPs) purchased in the USA, Canada, England and Australia and assesses whether differences in regulations were associated with differences in the chemical composition of the VPs.

Methods: April-September 2017, a total of 234 VP refill liquids and prefilled cartridges were purchased in convenience samples of retail locations in each country. Products were chosen from brands and styles most commonly reported by current VP users in the 2016 ITC Four Country Smoking and Vaping Survey. All products were tested for nicotine, tobacco-specific nitrosamines (TSNAs), minor tobacco alkaloids, organic acids and flavouring chemicals.

Results: Consistent with the laws in Canada and Australia at the time of product purchase, nicotine was not detected in any of the VPs (n=10 in Canada; n=15 in Australia). US liquids (n=54) had a mean nicotine concentration of 16.2 mg/mL, (range=0.0-58.6) and English liquids (n=166) had a mean concentration of 11.9 mg/mL ((range=0.0-31.2) F(3244)=12.32, p<0.001). About 5% of English samples exceeded the UK's 20 mg/mL nicotine limit. Substantial country differences were observed in levels ofTSNAs, with the USA being higher than elsewhere. Of all products tested, 18.8% contained at least one organic acid. Liquids purchased in England contained far more identifiable flavouring chemicals than those in the other countries.

Conclusions: VP composition, particularly with respect to nicotine and flavouring, varies by country, likely reflecting both marketplace preferences and country-specific regulations. There are differences between nicotine levels claimed on the package and actual levels, particularly in England.

Citation

Hammond, D., Reid, J., Burkhalter, R., O’Connor, R.J., Goniewicz, M.L., Wackowski, O.A., Thrasher, J.F., Hitchman, S.C. (2023). Trends in e-cigarette brands, devices and the nicotine profile of products used by youth in England, Canada and the USA: 2017-2019. Tobacco Control, 32(1), 19-29. doi: 10.1136/tobaccocontrol-2020-056371

Abstract

Background: The e-cigarette market has rapidly evolved, with a shift towards higher nicotine concentration and salt-based products, such as JUUL; however, the implications for youth vaping remain unclear.

Methods: Repeat cross-sectional online surveys were conducted in 2017, 2018 and 2019, with national samples of youth aged 16–19 years recruited from commercial panels in Canada (n=12 018), England (n=11 362) and the USA (n=12 110). Regression models examined differences between countries and over time in the types of e-cigarette products used (design and nicotine content), reasons for using brands and differences in patterns of use, sociodemographics and dependence symptoms by brand/nicotine content.

Results: In 2019, the use of pod- or cartridge-style e-cigarettes was greater in Canada and the USA than England, with Smok and JUUL the leading brands in all countries. In 2019, youth vapers in England were less likely to report using e-cigarettes with ≥2% nicotine (12.8%) compared with Canada (40.5%; adjusted OR (AOR)=4.96; 95% CI 3.51 to 7.01) and the USA (37.0%; AOR=3.99, 95% CI 2.79 to 5.71) and less likely to report using nicotine salt-based products (12.3%) compared with Canada (27.1%; AOR=2.77, 95% CI 1.93 to 3.99) and the USA (21.9%; AOR=2.00, 95% CI 1.36 to 2.95). In 2019, self-reported use of products with higher nicotine concentration was associated with significantly greater frequency of vaping, urges to vape and perceived vaping addiction (p<0.05 for all).

Conclusions: The use of high-nicotine salt-based products is associated with greater symptoms of dependence, including JUUL and other higher-nicotine brands. Greater use of high-nicotine salt-based products may account for recent increases in the frequency of vaping among youth in Canada and the USA.

Citation

Li, L., Borland, R., Cummings, K.M., Fong, G.T., Hyland, A., Le Grande, M., McNeill, A. (2023). Non-cigarette combustible tobacco use and its associations with subsequent cessation of smoking among daily cigarette smokers: Findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2016-2020). Addiction, 118(1), 140-148. doi: 10.1111/add.16023.

Abstract

Aims: To examine whether poly-use of cigarettes and other smoked products (poly-smoking) is predictive of quit attempts and quit success.

Design: A prospective multi-country cohort design.

Setting: Australia, Canada, England and the US.

Participants: 3983 adult daily cigarette smokers were surveyed in 2016 (Wave 1 of data collection) and were recontacted in 2018 (Wave 2) (i.e., Wave 1–Wave 2 cohort) in the International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys; and 3736 smokers were surveyed in 2018 and recontacted in 2020 (Wave 3) (i.e., Wave 2–Wave 3 cohort).

Measurements: Participants were asked about their cigarette smoking and use of cigars, cigarillos, pipes, and waterpipes. Outcomes were quit attempts between two survey waves and success, defined as having quit smoking all the combustible tobacco at the subsequent survey for 1 month or more.

Findings: Levels of poly-smoking were 12.7% in the Wave 1–Wave 2 cohort and 10.5% for the Wave 2–Wave 3 cohort. Compared with cigarette-only smokers, poly-smokers were more likely to attempt between Waves 1 and 2 (54.9% vs. 42.7%, adjusted odds ratio (aOR)=1.37, 95% confidence interval [CI] 1.08-1.74, p<0.01), but not between Waves 2 and 3 (43.8% vs. 40.1%, aOR=0.94, 95%CI 0.72-1.22). Poly-smoking predicted reduced likelihood of success in both cohorts among attempters and the overall samples. Between Waves 2 and 3 there were significantly more transitions to non-daily smoking among the poly-smokers (12.4% vs. 5.3%, 2=40.4, p<0.001).

Conclusions: There is a consistent association between poly-smoking (use of cigarettes along with other smoked products) and reduced quit success for combustible tobacco, but it is likely due to increased likelihood of transitioning to non-daily use rather than complete cessation.

Citation

Gravely, S., Driezen, P., McClure, E., Hammond, D., Cummings, K.M., Chan, G.C.K., Hyland, A., Borland, R., East, K., Fong, G.T., Schauer, G.L., Quah, A.C.K., Ouimet, J., Smith, D.M. (2022). Differences between adults who smoke cigarettes daily and do and do not co-use cannabis: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Addictive Behaviours, 135, 107434. doi: 10.1016/j.addbeh.2022.107434.

Abstract

Background: Little is known about population-level differences between adults who exclusively smoke cigarettes and those who smoke cigarettes and also use cannabis (co-consumers). Thus, this study describes differences on sociodemographic, cigarette-dependence, health and behavioral variables, and risk perceptions associated with smoking cannabis.

Methods: This cross-sectional study included 6941 respondents from the 2020 ITC Four Country Smoking and Vaping Survey (US, Canada, Australia, England). Adult daily cigarette smokers were included and categorized as: cigarette-only smokers (never used cannabis/previously used cannabis, but not in the past 12 months, n=4857); occasional co-consumers (cannabis use in the past 12 months, but<weekly use, n=739); or regular co-consumers (use cannabis ≥weekly, n=1345). All outcomes were self-reported. Regression models were conducted on weighted data.

Results: Overall, 19.9% of respondents reported regular cannabis co-use and 10.1% reported occasional co-use. Regular co-use was highest in Canada (27.2%), followed by the US (24.4%), England (12.7%) and Australia (12.3%). Compared to cigarette-only smokers, regular co-consumers were more likely to be male and report chest/breathing problems (p<0.001). All co-consumers were more likely to be younger, have lower income, be experiencing financial stress, reside in Canada, have depressive symptoms, use alcohol more frequently and binge drink, use other tobacco/nicotine products, and perceive smoking cannabis as low health risk and less harmful than smoking cigarettes (all p><0.001). Cigarette dependence measures were similar between co-consumers and cigarette-only smokers (all p≥0.05).

Conclusions: Although there were no differences on cigarette dependence measures between daily cigarette smokers who do and do not use cannabis, there are several other risk factors that may affect tobacco use and abstinence among co-consumers (e.g., greater depression, high-risk alcohol consumption). Thus, tobacco cessation treatment may require multi-pronged strategies to address other health behaviors. Continued surveillance is needed to determine the nature and health implications of co-use considering changing policies, markets, and products.

Citation

Freitas Lemos, R., Stein, J.S., Tegge, A.N., Kaplan, B.A., Heckman, B.W., McNeill, A., Cummings, K.M., Fong, G.T., Bickel, W.K. (2022). The Illegal Experimental Tobacco Marketplace II: Effects of vaping product bans - findings from the 2020 International Tobacco Control Project. Tobacco Control, 31(Suppl 3), s214-s222.

Abstract

Significance: Restrictive e-cigarette policies may increase purchases from illegal sources. The Illegal Experimental Tobacco Marketplace (IETM) allows examination of how restrictions impact illegal purchases. We investigated (1) the effect of a vaping ban, total flavour vaping ban and partial flavour vaping ban on the probability of purchasing illegal vaping products among different regulatory environments (USA, Canada and England) and tobacco user types (cigarette smokers, dual users and e-cigarette users); and (2) the relation between ban endorsement and illegal purchases.

Methods: Participants (N=459) from the International Tobacco Control Survey rated their support of bans and chose to purchase from a hypothetical legal experimental tobacco marketplace or IETM under control and the three ban conditions.

Results: In total, 25% of cigarette smokers, 67% of dual users and 79% of e-cigarette users made IETM purchases. Cross-country comparisons depicted dual users from Canada (OR: 19.8), and e-cigarette users from the USA (OR: 12.9) exhibited higher illegal purchases odds than the same user type in England. Within-country comparisons showed e-cigarette and dual users are more likely to purchase from the IETM than cigarette smokers in the most restrictive condition, with the largest effects in e-cigarette users (England-OR: 1722.6, USA-OR: 22725.3, Canada-OR: 6125.0). Increased opposition towards partial or total flavour ban was associated with increased IETM purchasing in the corresponding condition.

Conclusions: Vaping restrictions may shift users' preference to the illegal marketplace in a regulatory environment. Evidence of the IETM generalisability in a geographically dispersed sample enhances its utility in tobacco regulatory science.

Citation

Le Grande, M., Balmford, J., Borland, R., McNeill, A. (2022). Perceived health and capacity to cope with stress in recent ex-smokers: Impact of vaping vs quitting all nicotine. Nicotine and Tobacco Research, [Published online November 1, doi: 10.1093/ntr/ntac252].

Abstract

Background: Little is known about the continued use of nicotine following smoking cessation on perceived well-being in comparison to complete cessation of nicotine use. Aims: To explore aspects of perceived well-being and coping among recent ex-smokers as a function of vaping status.

Methods: Ever-daily smokers in the International Tobacco Control 4 country smoking and vaping surveys in 2016 (W1 N=883) and 2018 (W2 N=1088). Cross-sectional associations and longitudinal samples for those who quit between waves and those quit at W1 who maintained abstinence to W2.

Main outcome measures were: past 30 days depression symptoms, perceived stress, stress management since quitting and change in perceived day-to-day health.

Results: In the cross-sectional analyses vapers were more likely to report both improved stress management (aOR = 1.71, 95% CI 1.23-2.36) and perceived day-to-day health (aOR = 1.65, 95% CI 1.26-2.16) than nicotine abstainers. In the longitudinal analyses, smokers who switched to vaping between waves (n=372) were more likely to report depression symptoms at W2 (aOR = 2.00, 95% CI 1.09-3.65) but reported improved perceived health (aOR = 1.92, 95% CI 1.16-3.20). For the past daily smokers who remained quit between waves (n=382), vapers were more likely to report improved stress management relative to abstainers (RRR =5.05. 95% CI 1.19-21.40). There were no other significant differences between vapers and nicotine abstainers.

Conclusions: There is little evidence to support the view that perceptions of well-being deteriorate in vapers compared to complete nicotine abstainers in the immediate years after smoking cessation.

Implications: This study could find no conclusive evidence that the continued use of nicotine via e-cigarettes was detrimental to health compared to completely stopping nicotine intake altogether. Our results would suggest that continuing to use nicotine may even result in some benefits in the short term such as improved stress management, however further longitudinal studies are required to examine if these effects are restricted to the early post-quitting phase and whether other positive or negative effects on psychosocial health emerge in the future.

Citation

Gravely, S., Yong, H.H., Reid, J., East, K.A., Gartner, C., Levy, D.T., Cummings, K.M., Borland, R., Quah, A.C.K., Bansal-Travers, M., Ouimet, J., Fong, G.T. (2022). Do current smokers and ex-smokers who use nicotine vaping products daily versus weekly differ on their reasons for vaping? Findings from the ITC Four Country Smoking and Vaping Survey. International Journal of Environmental Research and Public Health, 19(21), 14130. doi: 10.3390/ijerph192114130.

Abstract

This study examined reasons why adults who currently smoke or formerly smoked cigarettes use nicotine vaping products (NVPs) by vaping frequency (daily vs. weekly) stratified by smoking status.

This crosssectional study included 3070 adults from the 2020 ITC Four Country Smoking and Vaping Survey (Australia, Canada, England, United States) who reported using a NVP (vaping) at least weekly and who either currently smoke (n = 2467) or formerly smoked (n = 603). Respondents were asked to select the reason(s) they use NVPs, including to manage their smoking (reduce/quit or remain quit) and/or for reasons unrelated to managing smoking (e.g., to save money, enjoyment, flavours).

We found that both current and former smokers endorsed an average of six reasons for vaping, with those vaping daily reporting significantly more reasons than those vaping weekly. Among current smokers, 72.8% reported vaping may help them quit smoking, 13.0% reported vaping to reduce smoking but not to quit, and 14.2% reported vaping only for reasons other than to reduce or quit smoking. The most common reason for vaping among current smokers was to reduce smoking (81.3%). Current smokers vaping daily were significantly more likely than those vaping weekly to report using a NVP to reduce smoking, for enjoyment, to reduce harm to themselves and others, to quit smoking, likeable flavours, and to save money. The most common reason cited for vaping by respondents who formerly smoked was enjoyment, with those who vaped daily more likely than those who vaped weekly to report vaping for enjoyment and to reduce harm to themselves. Nearly all reported vaping to help stay abstinent from smoking (92.3%), with no significant difference by vaping frequency.

In conclusion, a majority of respondents reported using NVPs to manage their smoking (reduce/quit smoking or remain quit), particularly those vaping daily. Those who were vaping daily also endorsed a greater number of reasons other than managing smoking relative to those who were vaping weekly.

Citation

Geboers, C., Nagelhout, G.E., de Vries, H., Candel, M.J.J.M., Driezen, P., Mons, U., Andler, R., Fong, G.T., Willemsen, M.C. (2022). Price minimizing behaviours by smokers in Europe (2006-2020): evidence from the International Tobacco Control Project. European Journal of Public Health, 32(6), 905-912. doi:10.1093/eurpub/ckac115

Abstract

Background: Effectiveness of tobacco taxation can be undermined through smokers applying price-minimizing behaviours rather than quitting or reducing consumption. Common price-minimizing strategies are buying cheaper tobacco [discount brands or roll-your-own (RYO) tobacco], bulk buying and cross-border purchasing. This study analyses trends in and factors associated with such behaviours in four European countries from 2006 to 2020.

Methods: Data came from adult smokers participating in the International Tobacco Control (ITC) Surveys conducted between 2006 and 2020 in England (9 waves, n = 768-4149), France (4 waves, n = 1415-1735), Germany (5 waves, n = 513-1515) and the Netherlands (10 waves, n = 1191-2177). Country-specific generalized estimating equation regression models were fit to assess trends in smoking RYO tobacco, discount brands, bulk buying and cross-border purchasing within the European Union.

Results: Buying discount brands or RYO tobacco was the most common strategy in all countries, except France. Except for buying discount brands, estimates of price-minimizing behaviours were highest in France (2019: RYO = 27.2%, discount brands = 17.3%, bulk buying = 34.1%, cross-border purchasing = 34.2%), and lowest in Germany (2018: RYO = 18.6%, discount brands = 43.7%, bulk buying = 8.0%, cross-border purchasing = 9.8%). Direction and magnitude of trends differed by country, and behaviour. Young smokers were less likely to buy in bulk. Low-income and low-education smokers were more likely to purchase RYO tobacco or discount brands. The association with discount brands was not found for French low-income smokers.

Conclusions: Smoking cheaper tobacco is the most prevalent price-minimizing strategy in three countries (England, Germany and Netherlands), and more prevalent among low-income individuals. Harmonizing prices across products and countries would reduce switching to cheaper tobacco.

Citation

East, K., Miller, C., Hitchman, S.C., McNeill, A., Tompkins, C. (2022). 'It's not what you'd term normal smoking': A qualitative exploration of language used to describe Heated Tobacco Product (HTP) use and associated user identity. Addiction, [Published online, doi:10.1111/add.16051]

Abstract

Background and aims: Tobacco and nicotine marketplaces have diversified over the past decade, including with the introduction of heated tobacco products (HTPs), such as the brand IQOS. HTPs typically heat tobacco to generate an aerosol that is inhaled. HTP nomenclature is lacking, and how HTP users define and identify themselves remains understudied. Research in this area is important because language can construct identity, and identity can shape behaviour. This study aimed to explore users' language choice when describing IQOS use, and how language relates to user identity.

Methods: Qualitative interviews in London, United Kingdom, with 30 adult current and former IQOS users. Analyses were guided by Iterative Categorization.

Results: Overall, participants expressed confusion and a lack of suitable terminology for how to describe IQOS use. Verbs such as heating and IQOSing were rarely endorsed. Most often, participants reverted to smoking when describing IQOS use and commonly referred to HEETS (tobacco sticks) as cigarettes. Yet the lack of combustion, electronic device, cleaner experience and perceived reductions in health risks led some to frame IQOS as distinct from smoking. Vaping was generally considered inappropriate for describing IQOS use. Participants also manipulated language to suit their circumstances and manage their identity, whereas some IQOS users embraced the terms smoking and smoker, most were eager to distinguish between using IQOS and being labelled a smoker because of the associated negative connotations and to align with perceptions of IQOS use as a better, less harmful behaviour. Instead, when describing their identity, IQOS users more willingly identified as vapers, or ex-smokers, or created new identities (e.g. HEET user).

Conclusions: People who use or have used IQOS (a brand of heated tobacco product) are ambiguous about IQOS terminology. Participants in this study commonly referred to IQOS use as smoking for lack of a more suitable term, but also resisted being labelled as smokers, a choice that may influence smoking cessation. Clear terminology must be used in surveys and by healthcare professionals when asking about cigarette smoking and e-cigarette and heated tobacco product use.

Citation

Yong, H.H., Chow, R., East, K.A., Thrasher, J.F., Hitchman, S.C., Borland, R., Cummings, K.M., Fong, G.T. (2022). Do social norms for cigarette smoking and nicotine vaping product use predict trying nicotine vaping products and attempts to quit cigarette smoking amongst adult smokers? Findings from the 2016-2020 ITC Four Country Smoking and Vaping Surveys. Nicotine and Tobacco Research, [Published online, doi:https://doi.org/10.1093/ntr/ntac212].

Abstract

Objectives: To examine whether perceived injunctive and descriptive social norms towards cigarette and nicotine vaping product (NVP) use predicted subsequent trying NVPs and attempts to quit cigarette smoking amongst current smokers, and whether associations varied across countries.

Method: Three waves of longitudinal cohort data from the International Tobacco Control Four Country Smoking and Vaping Survey collected between 2016 and 2020 from 2,290 adult smokers in Canada, Australia, England, and the United States who had never used NVPs at baseline (either Wave 1 or Wave 2) and followed up at the subsequent wave (Wave 2 or Wave 3, respectively) were analysed using Generalised Estimating Equations.

Results: Of the injunctive and descriptive norm measures for smoking and NVP use, NVP initiation was only independently predicted by the injunctive interpersonal norm for NVP use, with perceived approval of NVP use by important others predicting higher odds of trying NVPs (AOR=1.65, 95% CI=1.20-2.27). This predictive effect was independent of baseline quit intention with no country variations found. By contrast, making cigarette smoking quit attempts was independently predicted by both injunctive and descriptive interpersonal norms with perceived disapproval of smoking by important others (AOR=1.65, 95% CI=1.38-1.99) and close friends using NVPs (AOR=1.37, 95% CI=1.04-1.79), both associated with higher odds of smoking quit attempts.

Conclusions: Adult smokers who perceive NVP use as normative, either because such behaviour is socially approved or common within their close social networks, appear more inclined to try NVPs or make smoking quit attempts than smokers who do not.

Implications: What this study adds: Social norms can shape a person's behaviour and result in behaviour change. This study shows that initiation of NVP use behaviour among smokers can be reliably predicted by their perception of whether NVP use is acceptable to those important to them within their close social networks. Similarly, any attempts to stop cigarette smoking can be predicted by their perception of how acceptable cigarette smoking is among those who are important to them and whether any of their close friends use NVPs. Changing social norms towards cigarette smoking and NVP use could therefore be incorporated into smoking cessation interventions to help smokers to quit and/or switch to NVP use.

Citation

Gravely, S., Meng, G., Hammond, D., Hyland, A., Cummings, K.M., Borland, R., Kasza, K., Yong, H.H., Thompson, M.E., Quah, A.C.K., Ouimet, J., Martin, N., O’Connor, R.J., East, K.A., McNeill, A., Boudreau, C., Levy, D.T., Sweanor, D.T., Fong, G.T. (2022). Differences in cigarette smoking quit attempts and cessation between adults who did and did not take up nicotine vaping: Findings from the ITC Four Country Smoking and Vaping Surveys. Addictive Behaviors, 132, 107339.

Abstract

Introduction: There is mixed evidence as to whether nicotine vaping products (NVPs) can help adults who smoke transition away from cigarettes. This study investigated if rates of self-reported attempts to quit smoking and smoking cessation over a period of either 18 or 24 months differed between respondents who initiated nicotine vaping versus those who did not. Outcome comparisons were made between those who: (1) initiated vaping vs. those who did not; (2) initiated daily or non-daily vaping vs. those who did not; and (3) initiated daily or non-daily vaping between surveys and continued to vape at follow-up (daily or non-daily) vs. those who did not initiate vaping.

Methods: This cohort study included 3516 respondents from the ITC Four Country Smoking and Vaping Surveys (Australia, Canada, England, US), recruited at Wave 1 (2016) or 2 (2018) and followed up at Wave 2 (12 months) and/or 3 (2020, 24 months). Adults who smoked daily at baseline and did not have a history of regular vaping were included. Initiation of vaping was defined as beginning to vape at least monthly between surveys. Respondents indicated whether they made an attempt to quit smoking between surveys. Smoking cessation was defined as those who self-reported no longer smoking cigarettes at follow-up.

Results: Relative to those who did not initiate vaping, any daily vaping was associated with a greater likelihood of smokers making a cigarette quit attempt (p<0.001) and quitting smoking (p<0.001). Among smokers who attempted to quit smoking, any daily vaping was associated with a greater likelihood of being abstinent from smoking at follow-up (p=0.001). Respondents who initiated vaping between surveys and were vaping daily at follow up were significantly more likely to have attempted to quit smoking (p<0.001) and to have quit smoking (p<0.001) than those who did not initiate vaping. Respondents who initiated non-daily vaping did not differ significantly from those who did not initiate vaping on any of the outcome measures.

Conclusions: Daily NVP use was associated with increased attempts to quit smoking and abstinence from smoking cigarettes. These findings are consistent with the concept that complete cigarette substitution may be more likely to be achieved when smokers vape nicotine daily.

Citation

Li, L., Borland, R., Yong, H.H., Gravley, S., Fong, G.T., Cummings, K.M., East, K.A., Le Grande, M. (2022). Experienced effects on well-being following smoking cessation: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. International Journal of Environmental Research and Public Health, 19(16), 10037. doi: 10.3390/ijerph191610037

Abstract

Background and Aims: There has been limited research addressing changes in subjective well-being as a result of quitting smoking. This paper examines recent ex-smokers’ well-being related experiences overall and as a function of (1) duration of cessation and (2) continued nicotine use from vaping.

Methods: A sample of 1379 ever-daily smoking ex-smokers (quit for up to 5 years) from the 2020 ITC Four Country Smoking and Vaping Survey (Australia, Canada, the UK, and the US), of which 27.1% currently vaped daily. Well-being measures were perceived changes post-quitting in emotion coping (stress and negative emotions), enjoyment of life, and day-to-day functioning. We also assessed the level of persisting worry about past smoking leading to future health problems.

Results: Overall, among those answering all four well-being measures, 51.8% of the ex-smokers reported positive effects and no negatives, but 27.3% reported at least one negative effect, with the remainder reporting no change in any measure. Positive effects were greater among those who had quit more than 1 year prior. The largest improvement (56.3%) was for daily functioning, which showed improvement over time since having quit. Current daily vapers reported similar well-being as those not vaping; however, fewer daily vapers reported worsening ability to cope with stress (10.2% vs. 20.7%). Overall, 84% reported being worried about future negative health effects of smoking, with no clear differences by quitting duration or vaping status.

Conclusions: Most ex-smokers reported changes in their well-being since quitting, with more reporting improvements than declines. Well-being improved with duration of time since quitting, but did not appear to be influenced by daily vaping use, but stress coping may be better among vapers. Persisting worries about possible future health effects from smoking may be reducing the experienced benefits of quitting smoking for some.

Citation

East, K., Reid, J., Hitchman, S.C., Hammond, D. (2022). Purchasing and sourcing of e-cigarettes among youth in Scotland and England following Scotland's implementation of an e-cigarette retail register and prohibition of e-cigarette sales to under-18s. Qeios, [Published online, doi:10.32388/1JZU74].

Abstract

Background. Scotland implemented new e-cigarette regulations in April 2017 prohibiting sales to under18s, requiring age verification, and requiring retailer registration. This study examined purchasing and sourcing of e-cigarettes among minors aged 16-17, and youth aged 18-19, in the short- (4 months) and longer-term (16 months) after regulations were implemented, compared with England.

Methods. Data were from the July/August 2017 and August/September 2018 cross-sectional online ITC Youth Tobacco and Vaping Surveys of 16- to 19-year-olds in Scotland (n2017/2018=434/377) and England (n2017/2018=3,791/3,743). Logistic regressions were used to examine differences in past-12- month purchasing, past-12-month sale refusal, and past-30-day sourcing of e-cigarettes between 2017 and 2018, by country and age group.

Results. Among vapers aged 16-17 in Scotland, from 4 to 16 months post-regulations, e-cigarette purchasing increased from 21% to 50% and sale refusal increased from 14% to 16%, but these changes were not significant and did not differ from changes observed in 18-19-year-olds or England (p>.05). Purchasing and sale refusal were most common in vape shops. Purchasing from a vape shop increased among vapers aged 16-17 in Scotland from 4 to 16 months post-regulations (17% to 85%, p=.003) but not among 18-19-year-olds or in England (p>.05). Among past-30-day vapers, social sources were most common.

Conclusions. Youth vapers in Scotland showed no significant changes in overall purchasing, sale refusal, or sourcing of e-cigarettes, from 4 to 16 months post-regulations, and changes did not differ by age group or from England. Findings suggest low compliance with age-of-sale regulations in Scotland and England.

Citation

Yong, H.H., Gravely, S., Borland, R., Gartner, C., Cummings, K.M., East, K., Tagliaferri, S., Elton-Marshall, T., Hyland, A., Bansal-Travers, M., Fong, G.T. (2022). Do smokers’ perceptions of the harmfulness of nicotine replacement therapy and nicotine vaping products as compared to cigarettes influence their use as an aid for smoking cessation? Findings from the ITC Four Country Smoking and Vaping Surveys. Nicotine & Tobacco Research, 24(9), 1413-1421. doi: 10.1093/ntr/ntac087.

Abstract

Aim: This study examined whether smokers' harm perceptions of nicotine replacement therapy (NRT) and nicotine vaping products (NVPs) relative to cigarettes predicted their subsequent use as smoking cessation aids during their last quit attempt (LQA).

Methods: We analyzed data from 1,315 current daily smokers (10+ cigarettes per day) who were recruited at Wave 1 (2016), and who reported making a quit attempt by Wave 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the US. We used multinomial logistic regression models to examine prospective associations between harm perceptions of a) NRT and b) NVPs and their use at LQA, controlling for socio-demographic and other potential confounders.

Results: Smokers who perceive that a) NRT and b) NVPs are much less harmful than cigarettes were more likely to subsequently use the respective product as an aid than using no aid or other aids during LQA (adjusted relative risk ratio [aRRR]=3.79, 95%CI=2.16-6.66; and aRRR=2.11, 95%CI=1.29-3.45, respectively) compared to smokers who perceive these products as equally or more harmful. Additionally, those who perceive NVPs as much less harmful than cigarettes were less likely to use NRT as a quit aid (aRRR=0.34, 95%CI=0.20-0.60). No country variations for these associations were found.

Conclusion: This study found that smokers' perceptions of the harmfulness of a) NRT and b) NVPs relative to cigarettes predicted the respective product use when trying to quit smoking. Corrective education targeting misperceptions of nicotine products' relative harmfulness may facilitate their use for smoking cessation.

Implications: What this study adds: Nicotine replacement therapy and nicotine vaping products are two commonly used smoking cessation aids. This study demonstrates that misperceptions of the harms of nicotine products relative to cigarettes influence their use for smoking cessation. Believing that nicotine vaping products are much less harmful than cigarette smoking may lead some smokers to prefer these products over nicotine replacement therapy to aid smoking cessation. Education targeting misperceptions of nicotine products' harmfulness relative to cigarettes may enable smokers to make informed choices about which are appropriate to aid smoking cessation.

Citation

Felicione, N., Fix, B., McNeill, A., Cummings, K.M., Goniewicz, M.L., Hammond, D., Borland, R., Heckman, B.W., Bansal-Travers, M., Gravely, S., Hitchman, S.C., Levy, D.T., Fong, G.T., O’Connor, R.J. (2022). Characteristics and changes over time of nicotine vaping products used by participants in the 2016 and 2018 ITC Four Country Smoking and Vaping Surveys. Tobacco Control, 31(e1), e66-e73. doi: 10.1136/tobaccocontrol-2020-056239

Abstract

Objectives: Regulation of nicotine vaping products (NVPs) varies between countries, impacting the availability and use of these products. This study updated the analyses of O'Connor et al on types of NVPs used and examined changes in NVP features used over 18 months in four countries with differing regulatory environments.

Design: Data are from 4,734 adult current vapers in Australia, Canada, England, and the USA from Waves 1 (2016) and 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Survey. NVP characteristics included device description, adjustable voltage, nicotine content and tank size. Longitudinal analyses (n=1,058) assessed movement towards or away from more complex/modifiable NVPs. A logistic regression was used to examine factors associated with changes in device description from 2016 to 2018.

Results: Like 2016, box-tanks were the most popular NVP (37.3%) in all four countries in 2018. Over 80% of vapers continued using the same NVP and nicotine content between waves, though movement tended towards more complex/modifiable devices (14.4% of vapers). Box-tank users, exclusive daily vapers and older vapers were most likely to continue using the same device description. Certain NVPs and features differed by country, such as higher nicotine contents in the USA (11.5% use 21+ mg/mL) and greater device stability over time in Australia (90.8% stability).

Conclusions: Most vapers continued using the same vaping device and features over 18 months. Differences in NVP types and features were observed between countries, suggesting that differing NVP regulations affect consumer choices regarding the type of vaping device to use.

Citation

Cho, Y., Thrasher, J.F., Gravely, S., Alberg, A.J., Borland, R., Yong, H.H., Cummings, K.M., Hitchman, S.C., Fong, G.T. (2022). Adult smokers’ discussions about vaping with health professionals and subsequent behavior change: a cohort study. Addiction, 117(11), 2933-2942. doi: 10.1111/add.15994.

Abstract

Aims: To measure the prevalence and changes in smokers' discussions with health professionals (HPs) about nicotine vaping products (NVPs) and HPs' recommendations about NVPs between 2016 and 2020, and their associations with tobacco product use transitions.

Design: Cohort study using multinomial logistic regression analyses on data from Waves 1 (2016), 2 (2018), and 3 (2020) from the International Tobacco Control Four Country Smoking and Vaping Surveys.

Setting: Four countries with varying NVP regulatory environments: 'most restrictive' (Australia), 'somewhat restrictive' (Canada), and 'less restrictive' (England and the US).

Participants: Adult exclusive daily smokers who did not report NVP use at the time of their baseline survey and had visited a HP in the last 12-24 months. Prevalence data came from 4,125, 4,503, and 4,277 respondents respectively for each year. Longitudinal data were from 4,859 respondents who participated in at least two consecutive surveys.

Measurements: (1) Prevalence of self-reported discussions with HPs and recommendations from HPs about NVPs and (2) longitudinal transitions from smoking to vaping (either exclusively or concurrently with smoking) and quitting (regardless of NVP uptake).

Findings: The prevalence of NVP discussions was low across countries with varying regulatory environments and study waves (range=1.4%-6.2%). In 2020, a low percentage of smokers who discussed NVPs with a HP reported that their HPs recommended they use NVPs in the US (14.7%), Australia (20.2%), Canada (25.7%), with a higher percentage in England (55.7%) where clinical guidelines for smoking cessation include NVPs. Compared with 12.0% of smokers who reported no discussion, 37.0% of those whose HPs recommended NVPs transitioned to vaping at follow-up. Transition to quitting was 9.6% with HPs' recommendation of NVPs versus 13.5% without discussion, a non-significant difference.

Conclusions: In Australia, Canada, England, and the United States between 2016 and 2020, health professionals' discussions with smokers about nicotine vaping products (NVPs) were infrequent. NVP discussions were associated with NVP uptake, but not with quitting smoking.

Citation

Zhao, Y., Yong, H., Borland, R., Cummings, K.M., Thrasher, J., Hitchman, S.C., Bansal-Travers, M., Fong, G.T. (2022). Do numbers of smoking friends and changes over time predict smoking relapse? Findings from the International Tobacco Control Four-Country Survey. Journal of Substance Abuse Treatment, 138, 108763.

Abstract

Background: Past research indicates that smokers with a large number of smoking friends within their social network are less interested in quitting, less likely to attempt to quit, and less likely to successfully quit. The extent to which a pro-smoking social network may increase relapse risk among ex-smokers is unclear. This study investigated among ex-smokers whether the number of close friends who smoke and changes in this number influence relapse risk.

Methods: The study was a prospective cohort study of 551 adults who participated in the Australian and UK arms of the International Tobacco Control (ITC) project and were ex-smokers at wave 9 (2013) and followed up to wave 10 (2014). Logistic models regressed smoking relapse at follow-up on the baseline number of their five closest friends who smoked and changes in this number over time.

Results: Ex-smokers who reported having 4 or 5 smokers among their five closest friends were more likely to relapse than those who had no smokers among their five closest friends (adjusted odds ratio [AOR] = 4.86, 95% confidence interval [CI] = 1.48-15.99, p = .009). Ex-smokers who gained smoking friends over time, but not those who lost smoking friends, were also more likely to relapse compared to those with the same number of smoking friends over time (AOR = 4.52, 95% CI = 2.15-9.52, p < .001; AOR = 1.08, 95% CI = 0.49-2.36, p = .848, respectively).

Conclusions: This study demonstrated that relapse risk was elevated among ex-smokers who had more smokers among their close friends and also among those where the number of smokers in their social network increased over time.

Citation

Taylor, E., Aleyan, S., East, K., Cummings, K.M., Thrasher, J.F., Fong, G.T., Quah, A.C.K., Li, G., Borland, R., Hammond, D., Hitchman, S.C. (2022). Associations between noticing nicotine vaping product health warning labels, harm perceptions, and use among adult vapers, current and former smokers: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 24(7), 1020-1027.

Abstract

Background: The number of countries mandating a nicotine addiction warning label (‘warnings’) on nicotine vaping products (NVPs) has been increasing. This study examined associations between noticing NVP warnings, perceptions of NVPs, and intentions to use NVPs.

Methods: Cross-sectional analysis of 12,619 adult NVP users, cigarette smokers, concurrent users of both cigarettes and NVPs, and quitters who participated in the 2018 International Tobacco Control (ITC) Project Four Country Smoking and Vaping Survey (England, Australia, Canada, US). Logistic regression analyses examined associations between noticing warnings in the past 30 days and perceptions of nicotine harm, NVP harm relative to cigarettes, and NVP addictiveness relative to cigarettes. Associations were also explored between noticing warnings and intentions to use NVPs.

Results: Noticing warnings was higher among NVP users (18.8%) than non-users (2.1%). Noticing warnings was associated with perceiving nicotine to pose little or no harm to health among NVP users, but there was no association among non-users. There was little evidence of an association between noticing warnings and perceptions of NVP harms relative to smoking among NVP users and non-users. Noticing warnings was associated with perceiving NVPs as less addictive than cigarettes among non-users but not NVP users. Among exclusive smokers, noticing warnings was associated with intending to start using NVPs. Among NVP users, there was little evidence of an association between noticing warnings and intentions to continue using/stopping NVPs.

Conclusions: Noticing NVP warnings was not associated with increased NVP and nicotine harm perceptions or decreased intentions to use NVPs among adult smokers and vapers

Citation

Felicione, N., Schneller, L., Goniewicz, M.L., Hyland, A., Cummings, K.M., Bansal-Travers, M., Fong, G.T., O’Connor, R.J. (2022). Oral nicotine product awareness and use among people who smoke and vape in the US. American Journal of Preventive Medicine, 63(4), 611-618. doi: 10.1016/j.amepre.2022.04.019.

Abstract

Introduction: Tobacco-free oral nicotine products are an emerging class of noncombustible nicotine products. Oral nicotine product sales have increased since 2016, although little research has investigated consumer awareness, use, or correlates of oral nicotine product use. The purpose of this analysis was to assess the prevalence and correlates of oral nicotine product awareness and use.

Methods: This paper is a cross-sectional analysis of 2,507 U.S. participants from Wave 3 (February–June 2020) of the International Tobacco Control Four Country Smoking and Vaping Survey, a population-based survey of current and former cigarette smokers and nicotine vaping product users in the U.S. Oral nicotine product awareness and use prevalence were compared with those of heated tobacco products. Analyses conducted in late 2021 assessed the correlates of oral nicotine product awareness and use such as demographic characteristics, tobacco use (cigarettes, nicotine vaping products, smokeless tobacco), and tobacco quit attempts.

Results: Almost 1 in 5 respondents claimed to have heard of oral nicotine products, 3.0% reported ever use, and 0.9% were current users, all of which were lower than for heated tobacco products. Ever use of oral nicotine products was more common among younger adults (e.g., aged 18–24 years), males, and current users of smokeless tobacco. Oral nicotine product prevalence was higher among those who reported having made attempts to stop smoking or vaping.

Conclusions: Oral nicotine product use was low among current and former smokers and nicotine vaping product users. Oral nicotine product users were demographically similar to use among individuals who smoke/vape and also use smokeless tobacco. Future studies are needed to understand emerging oral nicotine products, particularly whether they are being used as product supplements (dual use), replacements (switching), or cessation aids (quitting).

Citation

Gorniak, B., Yong, H.H., Borland, R., Cummings, K.M., Thrasher, J.F., McNeill, A., Hyland, A., Fong, G.T. (2021). Do post-quitting experiences predict smoking relapse among former smokers in Australia and the United Kingdom? Findings from the International Tobacco Control Surveys. Drug and Alcohol Review, 41(4), 883-889.

Abstract

Introduction: Many smokers attempt to stop smoking every year, but the vast majority of quit attempts fail. This study examined prospectively the association between post-quitting experiences and smoking relapse among ex-smokers in Australia and the United Kingdom.

Methods: Data came from 584 adult ex-smokers from Australia and the United Kingdom who participated in Wave 9 of the International Tobacco Control Four Country Survey and successfully followed up a year later (Wave 10). Binary logistic regression was used to examine whether baseline post-quitting experiences predicted relapse back to smoking at follow-up.

Results: Ex-smokers who perceived their stress coping ability had gotten worse since quitting were more likely to relapse back to smoking compared to their counterparts who reported no change (odds ratio = 5.77, 95% confidence interval = 1.64, 20.31, P < 0.01). Ex-smokers who reported their homes had become fresher and cleaner post quitting were less likely to relapse compared to those who did not notice any change (odds ratio = 0.34, 95% confidence interval = 0.13, 0.93, P < 0.05). Perceived changes in life enjoyment, negative affect control, social confidence, work performance, leisure time and financial situation did not independently predict relapse. No country differences were found.

Discussion and conclusions: The study showed that ex-smokers' relapse risk was elevated if they perceived any negative impact of quitting on their stress coping whereas relapse risk was reduced if they perceived any positive impact of quitting on the home (e.g. fresher and cleaner). Helping ex-smokers to develop alternative stress coping strategies and highlighting the positive impacts of quitting smoking on the homes may help protect against smoking relapse.

Citation

Le Grande, M., Borland, R., Yong, H.H., McNeill, A., Fong, G.T., Cummings, K.M. (2022). Age related interactions on key theoretical determinants of smoking cessation: Findings from the ITC Four Country Smoking and Vaping Surveys (2016-2020). Nicotine & Tobacco Research, 24(5), 679-689. doi: 10.1093/ntr/ntab230

Abstract

Background: This paper explores whether plans to quit, wanting to quit and quit efficacy add predictive value over measures of habit strength and dependence in making quit attempts and/or attaining smoking abstinence.

Aims and methods: We used three waves of the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey conducted in 2016, 2018, and 2020. Baseline daily smokers (N=6710) who provided data for at least one wave-to-wave transition (W1 to W2, N=3511 or W2 to W3, N=3199) and providing outcome data at the next wave (follow-up) formed the analytic sample. Generalized estimating equations (GEE) logistic regression analyses examined predictors of quit attempts and abstinence at follow-up (1 and 6 months sustained abstinence).

Results: Wanting and planning to quit were significantly positively associated with making quit attempts, but negatively associated with smoking abstinence. A significant interaction between the Heaviness of Smoking Index and age warranted an age-stratified analysis for both abstinence outcomes. Lower HSI predicted abstinence in only the younger smokers Motivation and plans to quit were positively associated with abstinence in younger smokers, but surprisingly were negatively associated with abstinence in older smokers. Quit efficacy was associated with abstinence in the older, but not the younger smokers.

Conclusions: Models of smoking abstinence are significantly improved by including motivational predictors of smoking. Age was an important moderator of the association between abstinence for both dependence and motivational variables.

Implications: The findings from this large cohort study indicate there are age-related differences in predictors of smoking abstinence but not quit attempts. These associations may reflect differential experiences of older and younger cohorts of smokers, which may have implications for interventions to motivate and assist smokers in quitting.

Citation

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

Abstract

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

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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