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

Kasza, K.A., Hammond, D., Gravely, S., O’Connor, R.J., Meng, G., East, K., Borland, R., Cummings, K.M., Fong, G.T., Hyland, A. (2022). 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, [Published online, doi:10.1111/add.16050].

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

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

Li, L., Borland, R., Cummings, K.M., Fong, G.T., Hyland, A., Le Grande, M., McNeill, A. (2022). 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, [Published online August 8, 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

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, [Published online July 6, 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, [Published online, 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., 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 US before and after the outbreak of E-cigarette or Vaping-Associated Lung Injury (EVALI). Nicotine and Tobacco Research, [Published online April 3, 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.

Citation

Borland, R., Le Grande, M., Heckman, B., Fong, G.T., Bickel, W.K., Stein, J., East, K., Hall, P.A., Cummings, K.M. (2022). The predictive utility of valuing the future for smoking cessation: Findings from the ITC Four Country Smoking and Vaping Surveys. International Journal of Environmental Research and Public Health, 19(2), 631.

Abstract

Background: Delay discounting (DD) and time perspective (TP) are conceptually related constructs that are theorized as important determinants of the pursuit of future outcomes over present inclinations. This study explores their predictive relationships for smoking cessation.

Methods: 5006 daily smokers at a baseline wave provided 6710 paired observations of quitting activity between two waves. Data are from the International Tobacco Control (ITC) smoking and vaping surveys with samples from the USA, Canada, England, and Australia, across three waves conducted in 2016, 2018 and 2020. Smokers were assessed for TP and DD, plus smoking-specific predictors at one wave of cessation outcomes defined as either making a quit attempt and/or success among those who tried to quit which was ascertained at the subsequent survey wave.

Results: TP and DD were essentially uncorrelated. TP predicted making quit attempts, both on its own and controlling for other potential predictors but was negatively associated with quit success. By contrast, DD was not related to making quit attempts, but high DD predicted relapse. The presence of financial stress at baseline resulted in some moderation of effects.

Conclusions: Understanding the mechanisms of action of TP and DD can advance our understanding of, and ability to enhance, goal-directed behavioural change. TP appears to contribute to future intention formation, but not necessarily practical thought of how to achieve goals. DD is more likely an index of capacity to effectively generate competing future possibilities in response to immediate gratification.

Citation

Miller, C., Sutanto, E., Smith, D.M., Hitchman, S.C., Gravely, S., Yong, H.H., Borland, R., O’Connor, R.J., Cummings, K.M., Fong, G.T., Hyland, A., Quah, A.C.K., Goniewicz, M. (2022). Awareness, trial, and use of heated tobacco products among adult cigarette smokers and e-cigarettes users: Findings from the 2018 ITC Four Country Smoking & Vaping Survey. Tobacco Control, 31(1), 11-18.

Abstract

Objective:

To evaluate heated tobacco product (HTP) awareness, trial and current use among adult cigarette smokers and vaping product users in four countries with varying regulations governing HTP sales.

Design:

Data came from Wave 2 of the ITC Four Country Smoking and Vaping Survey, collected from February to July 2018. Respondents were current and former smokers and/or users of vaping products (18 years or older) from Canada (CA; n=3778), England (EN; n=4848), the USA (US; n=2846) and Australia (AU; n=1515). At the time of the survey, only Canada and England permitted the sale of contemporary HTPs (eg, IQOS).

Results:

Overall, 30.2% of respondents reported being aware of HTPs (CA=30.4%; EN=31.0%; US=30.2%; AU=27.4%; p=0.346), 2.4% had ever tried HTPs (CA=3.3%; EN=2.4%; US=2.0%; AU=0.9%; p=0.001) and 0.9% currently used HTPs at least monthly (CA=0.8%; EN=1.2%; US=0.7%; AU=0.2%; p<0.001). Trial and current use were higher among those who concurrently smoked and vaped (at least monthly) versus other nicotine use categories (trial: 10.9% v. 1.2%-2.0%, p><0.001; current use: 8.4% v. 0.1%-1.0%, p><0.001). In multivariable analyses, HTP awareness did not differ across countries, whereas odds of trial and current use were lower where HTPs were unavailable. Odds of HTP trial did not differ by regulatory environment when restricting analysis to HTP-aware concurrent smokers-vapers.

Conclusion:

Approximately one third of respondents were aware of HTPs, even in the USA and Australia, where contemporary HTPs were not yet on the market. Trial and use were uncommon, except among concurrent smokers-vapers. Restrictions on availability may have limited HTP use generally, but less so for concurrent smokers-vapers.

Citation

Driezen, P., Gravely, S., Wadsworth, E., Smith, D.M., Loewen, R., Hammond, D., Li, L., Abramovici, H., McNeill, A., Borland, R., Cummings, K.M., Thompson, M.E., Fong, G.T. (2022). Increasing cannabis use is associated with poorer cigarette smoking cessation outcomes: Findings from the ITC Four Country Smoking and Vaping Surveys, 2016-2018. Nicotine and Tobacco Research, 24(1), 53-59.

Abstract

Introduction: Concurrent use (co-use) of tobacco and cannabis may impede successful cigarette smoking cessation. This study examined whether changes in cannabis use frequency were associated with smoking cessation.

Methods: Nationally representative samples of adult cigarette smokers from Canada (n=1455), the United States (n=892), England (n=1416), and Australia (n=717) were surveyed in 2016 and 2018. In each year, smokers reported how often they used cannabis in the previous 12 months. Reports were compared to determine whether cannabis use increased, remained unchanged, or decreased. Smoking cessation outcomes, measured in 2018, were (1) any attempt to quit in the previous year, (2) currently quit, and (3) currently quit for at least 6 months. Weighted multivariable logistic regression estimated the association between changes in cannabis use and cessation outcomes.

Results: Cigarette smokers who increased their frequency of cannabis use were significantly less likely to be currently quit than non-cannabis using smokers (adjusted odds ratio (aOR) = 0.52, 95% CI: 0.31, 0.86); they were also less likely to have quit for at least 6 months (aOR = 0.30; 95% CI: 0.15, 0.62).

Conclusions: Smokers who increase their frequency of cannabis use have poorer smoking cessation outcomes compared to non-cannabis using smokers. It will be important to monitor the impact of cannabis legalization on patterns of cannabis use, and whether this influences cigarette smoking cessation rates.

Citation

Przewoźniak, K., Kyriakos, C.N., Hiscock, R., Radu-Loghin, C., Fong, G.T. (2021). Effects of and challenges to bans on menthol and other flavours in tobacco products. Tobacco Prevention & Cessation, 7, 68.

Abstract

In May 2020, the European Tobacco Products Directive (TPD), which bans characterizing flavors in cigarettes and roll-your-own tobacco (RYO) in the European Union (EU), extended its application to menthol1,2. Countries which were early adopters of flavor bans include Brazil, Canada, Ethiopia, the United Kingdom (UK), amongst others3. Two main regulatory approaches exist: a ban on characterizing flavors that allows for the presence of additives but not at detectable sensory levels (e.g. EU, UK), and a total ban on flavor additives that eliminates their presence altogether (e.g. Brazil, Canada). As more countries work towards adopting tobacco flavor bans, it is critical to understand how these policies are implemented, ascertain their population-level impact, and identify the regulatory challenges.

Citation

Miller, C., Sutanto, E., Smith, D.M., Hitchman, S.C., Gravely, S., Yong, H.H., Borland, R., O’Connor, R., Cummings, K.M., Fong, G.T., Hyland, A., Quah, A.C.K., Goniewicz, M. (2022). Characterizing heated tobacco product use among adult cigarette smokers and nicotine vaping product users in the 2018 ITC Four Country Smoking & Vaping Survey. Nicotine and Tobacco Research, 24(4), 493-502. doi: 10.1093/ntr/ntab27.

Abstract

Introduction: Heated tobacco products (HTP) have diversified global tobacco markets, and user characteristics remain understudied. This study evaluated sociodemographic characteristics, nicotine-related perceptions and behaviors of current HTP users within a sample of adult (18+ years) nicotine users across four countries.

Methods: Data were from current smokers or nicotine vaping product (NVP; known as "e-cigarettes") users from Canada, England, the United States and Australia (n=11,421) who participated in the 2018 ITC Four Country Smoking and Vaping Survey. Current (at-least-monthly) HTP users were characterized (n=441), and weighted multivariable logistic regressions examined correlates of HTP use.

Results: Compared to non-users, current HTP users were younger (mean age: 44.4 vs 31.0 years; p<0.001) and had higher socioeconomic status (p<0.001). A majority of current HTP users used HTPs non-daily (daily: 40.3% vs non-daily: 59.7%). Most HTP users concurrently used both cigarettes and NVPs (90.5%). Among concurrent cigarette-HTP-NVP users, 36.2% used all three products daily. Use of other combusted tobacco products (cigars, cigarillos, pipe, waterpipe/hookah), cannabis, and binge drinking were each associated with current HTP use. HTP use was more common among smokers intending to quit within 6 months or reporting a quit attempt in the past 18 months, and vapers who had experienced negative side effects.

Conclusion: HTP users in this sample tended to be younger and more affluent. Most reported concurrent use of multiple nicotine products and other substances. Those cigarette smokers who used HTPs appeared more interested in smoking cessation, while some characteristics of concurrent HTP-NVP users were suggestive of dissatisfaction with NVPs.

Implications: Few studies have scrutinized characteristics of HTP early-adopters in emerging markets. Our results indicate that in 2018, characteristics of established nicotine users who adopted HTP use in four high-income Western countries mirror those of HTP users in East Asian markets (South Korea and Japan) where HTPs are popular. HTP users reported high levels of concurrent use of non-cigarette combusted tobacco products (e.g., cigars, pipe tobacco). These findings point to the need for future longitudinal studies of HTP use given the implications of those use patterns on the harm reduction potential of HTPs. HTP user characteristics may yield important information to consider in regulation of these products.

Citation

East, K., Reid, J., Rynard, V.L., Hammond, D. (2021). Trends and patterns of tobacco and nicotine product use among youth in Canada, England, and the US from 2017-2019. Journal of Adolescent Health, 69(3), 447-456. doi: 10.1016/j.jadohealth.2021.02.011.

Abstract

Purpose: The tobacco and nicotine market is diversifying. Implications for public health will depend on trends in use, including overall use, and who is using these products. This study examined differences over time (2017–2019), across countries (Canada, England, the United States (US)), and by smoking and vaping, in use of other tobacco/nicotine products and overall use.

Methods: The study includes online repeat cross-sectional surveys of youth aged 16–19 years in Canada (N = 11,714), England (N = 11,170), US (N = 11,838) in 2017, 2018, and 2019. Past 30-day use of tobacco/nicotine products (any, cigarette, e-cigarette, other combusted [cigars/cigarillos/waterpipe], other non-combusted [smokeless tobacco/nicotine replacement therapies) were examined by country, year, and, for other combusted and non-combusted products, past 30-day cigarette smoking and vaping. Use of emerging products (IQOS, nicotine pouches) was explored in 2018–2019.

Results: From 2017 to 2019, use of any product increased in Canada (17.1%–23.2%, AOR = 1.07 [95% CI = 1.04–1.09]) and the US (18.0%–24.0%, AOR = 1.06 [1.04–1.09]) but not England (20.8%–21.7%, AOR = 1.01 [.99–1.03]). Use of other combusted products (cigars/cigarillos/waterpipe) showed little change (Canada: 8.1%–7.8%; England: 6.3%–7.3%; US: 8.6%–8.5%; p ≥ .151). Use of other non-combusted products (smokeless/nicotine replacement therapies) increased in all countries (Canada: 1.5%–3.2%, AOR = 1.02 [1.01–1.02]; England: 1.4%–2.6%, AOR = 1.02 [1.01–1.03]; US: 3.3%–4.9%, AOR = 1.02 [1.01–1.02]). Vaping increased in all countries (Canada: 8.4%–17.8%; England: 8.7%–12.6%; United States: 11.1%–18.5%; all p < .001). Smokers and vapers reported greater use of other combusted and non-combusted products than those who neither smoked/vaped (p < .001). Emerging product use was rare (≤1.5%).

Conclusions: Youth past 30-day tobacco and nicotine product use increased from 2017 to 2019 in Canada and the United States, largely due to increases in vaping and other non-combusted products. “Other” tobacco/nicotine products were used predominantly by youth who smoked cigarettes and/or vaped.

Citation

Li, L., Borland, R., Cummings, K.M., Fong, G.T., Gravely, S., Smith, D.M., Goniewicz, M., O’Connor, R.J., Thompson, M.E., McNeill, A. (2021). How Does the Use of Flavored Nicotine Vaping Products Relate to Progression Toward Quitting Smoking? Findings From the 2016 and 2018 ITC 4CV Surveys. Nicotine and Tobacco Research, 23(9), 1490-1497. doi: https://doi.org/10.1093/ntr/ntab033.

Abstract

Introduction: There is limited research on the role of flavors in nicotine vaping products (NVPs) in relation to smoking. We examined patterns of flavor use in NVPs in relation to progression towards quitting.

Methods: Data come from 886 concurrent users of NVPs (at least weekly) and cigarettes who were first surveyed in 2016 and then successfully recontacted in 2018 as part of the ITC 4CV Surveys conducted in Australia, Canada, England and the United States. Participants were asked about their main vaping flavor categorized as: 1) tobacco or unflavored, 2) menthol/mint flavored, and 3) “sweet” flavors (e.g., fruit/candy). We examined whether flavor was associated with progression towards quitting smoking between survey years.

Results: Overall, 11.1% of baseline concurrent users quit smoking by 2018. Compared to users of tobacco flavors, those vaping “sweet” flavors were more likely to quit smoking between surveys (13.8% vs. 9.6%; adjusted OR=1.61, 95% CI 1.01-2.58, p<0.05), but those using menthol flavors were no more likely to quit smoking (8.3% vs. 9.6%, aOR=0.87, 95% CI 0.43-1.47, p=0.69). Among those who had quit smoking in 2018, 52.0% were still vaping, which was lower than the 65.8% among continuing smokers (aOR=0.60, 95% CI 0.39-0.92, p=0.02). Sweet flavor users were no more likely to continue vaping compared to tobacco flavor users, either for those continuing smoking or those having quit smoking by 2018. There was a net shift away from tobacco flavor among those who continued to vape at follow-up.

Conclusions: Use of fruit and other sweet flavored e-liquids is positively related to smokers’ transition away from cigarettes.

Implications: With multiple jurisdictions considering limiting or banning the sale of flavored NVPs, it is important to consider how such policies may impact smokers using NVPs to transition away from cigarette smoking. Our results indicate that vapers who used sweet flavors were more likely to transition away from cigarette smoking and quit cigarette use, at least in the short term, compared to those who used tobacco or unflavored NVPs. Randomized clinical trials are needed to establish if the observed association between use of flavored e-liquids and smoking cessation is due to self-selection or is truly causal.

Citation

Li, L., Borland, R., Cummings, K.M., Gravely, S., Quah, A.C.K., Fong, G.T., Miller, C.R., Goniewicz, M.L., Le Grande, M., McNeill, A. (2021). Patterns of non-cigarette tobacco and nicotine use among current cigarette smokers and recent quitters: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 23(9), 1611-1616. doi: https://doi.org/10.1093/ntr/ntab040.

Abstract

Introduction: This study explores patterns of use of non-cigarette tobacco and nicotine products among adult cigarette smokers and recent ex-smokers. Along with cigarette smoking status we explore differences as a function of countries with different product regulations, gender and age.

Methods: Data came from the ITC Four Country Smoking and Vaping Wave 3 Survey conducted between February-June 2020. The analytic sample consisted of 9112 current cigarette smokers (at least monthly) and 1184 recent ex-smokers (quit cigarettes ≤ 2 years) from Australia, Canada, England, and the US. Respondents were asked about their cigarette smoking and current use of the following non-cigarette products: combustible tobacco (cigars, cigarillos, pipe, waterpipe); non-combustible tobacco (smokeless tobacco, and heated tobacco products (HTPs)); and non-tobacco nicotine products (nicotine vaping products (NVPs), nicotine replacement therapy (NRT), and nicotine pouches)).

Results: Overall, NVPs (13.7%) and NRT (10.9%) were the most reported nicotine products used, followed by cigars (5.3%), cigarillos (4.2%), and HTPs (3.5%). More than 21% current and recent ex-smokers of cigarettes reported using a non-tobacco nicotine product and non-combustible product, with respondents in England reporting the highest levels of use (>26%). Males, younger respondents, and current non-daily cigarette smokers were more likely to use non-cigarette nicotine products. Notably, 11.6% of ex-cigarette smokers were using other combustible tobacco.

Conclusion: Considerable percentages of current cigarette smokers and ex-smokers use non-cigarette nicotine products, and there are unexpectedly high levels of use of other combustible products by those recent ex-smokers of cigarettes which is concerning and has important implications for definitions of smoking cessation.

Implications: The tobacco product market has evolved to include new products which add to existing non-cigarette tobacco products creating a much more diverse nicotine market. This brief report provides a snapshot of use of various combustible and non-combustible nicotine containing products among current cigarette smokers and recent ex-smokers in four western countries. Our results indicate that use of non-cigarette tobacco and nicotine products among these cigarette smokers and recent ex-smokers is not low, particularly among males, younger and non-daily cigarette smokers. Use of other combustible tobacco among respondents that recently quit cigarette smoking is concerning and has important implications for definitions of smoking cessation. Increased emphasis on researching non-cigarette nicotine product use is warranted in tobacco control generally and smoking cessation in particular.