Citation

Hammond, D., Reid, J.L., Burkhalter, R., East, K.A. (2024). Use of disposable e-cigarettes among youth who vape in Canada, England and the United States: Repeat cross-sectional surveys, 2017-2023. Addiction, [Published online Jul 1, doi: 10.1111/add.16596].

Abstract

Aims: To measure changes over time (between 2017 and 2023) in disposable e-cigarette use and popular brands among youth in Canada, England and the United States (US) who vaped.

Design: Nine waves of repeat cross-sectional data from the International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Survey.

Setting: Online surveys conducted in Canada, England and the US between 2017 and 2023.

Participants: Youth aged 16 to 19 years who had vaped in the past 30 days (n=19 710).

Measurements: Usual type (disposable, cartridge/pod, tank) and brand of e-cigarette used; covariates sex at birth, age, race/ethnicity, cigarette smoking status, vaping on less than or equal to 20 of the past 30 days.

Findings: In 2017, the majority of youth who vaped in the past 30 days reported using refillable tank e-cigarettes, whereas disposable e-cigarettes were the least commonly used product type in Canada (10.0%), England (8.6%) and the US (14.4%). Cartridge/pods overtook tank devices in Canada and the US by 2020; however, by 2023, disposables were the leading type of e-cigarette used by youth who vaped in all three countries (Canada = 58.5%; England = 83.2%; US = 67.3%). The shift to disposables occurred among all socio-demographic groups, with few differences by vaping and smoking status. The percentage of youth who vaped that reported ‘no usual’ brand also decreased substantially from 2017 (29% to 42%) to 2023 (11% to 17%). The rise of disposable e-cigarettes appeared to be driven primarily by individual brands in the US (Puff Bar in 2020/2021, Elf Bar in 2022/2023) and England (Elf Bar in 2022/2023).

Conclusions: The e-cigarette market has evolved rapidly with notable shifts in the types of e-cigarettes used by youth who vape in Canada, England and the United States. Although the timing differed across countries, major shifts in device types appear to be driven by individual brands and were often accompanied by increases in vaping prevalence among youth.

Citation

Le Grande, M., Borland, R., Gravely, S., Cummings, K.M., McNeill, A., Yong, H.H., Gartner, C. (2024). Support for banning sale of smoked tobacco products among adults who smoke: findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2018-2020). Tobacco Control, [Published online 17 Jun, doi: 10.1136/tc-2023-058532].

Abstract

Background: Many people continue to smoke despite strong policies to deter use, thus stronger regulatory measures may be required. In four high-income countries, we examined whether people who smoke would support a total ban on smoked tobacco products under two differing policy scenarios.

Methods: Data were from 14 363 adults (≥18) who smoked cigarettes (≥monthly) and participated in at least one of the 2018, 2020 or 2022 International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England and the USA. In 2018, respondents were asked whether they would support a law that totally bans smoked tobacco if the government provides smoking cessation assistance (Cessation Assistance scenario). In 2020 and 2022, respondents were asked a slightly different question as to whether they would support a law that totally bans smoked tobacco if the government encourages people who smoke to use alternative nicotine products like vaping products and nicotine replacement products instead (substitution scenario). Responses (support vs oppose/don't know) were estimated on weighted data.

Results: Support was greater for the cessation assistance scenario (2018, 36.6%) than the nicotine substitution scenario (2020, 26.9%; 2022, 26.3%, both p<0.0001). In the longitudinal analysis, there was a significant scenario by country interaction effect with lower support in Canada, the USA and Australia under the substitution scenario than in the cessation scenario, but equivalent levels in England under both scenarios. The strongest correlates of support under both scenarios were planning to quit smoking within 6 months, wanting to quit smoking 'a lot' and recent use of nicotine replacement therapy.

Conclusions: Opposition to banning smoked tobacco predominates among people who smoke, but less with a cessation assistance scenario than one encouraging nicotine substitution. Wanting to quit a lot was the strongest indicator of support.

Citation

Kyriakos, C.N., Filippidis, F. T., East, K.A., Reid, J.L., Driezen, P., & Hammond, D. (2024). Use of Menthol Cigarettes and Accessories Among Youth Who Smoked After the Menthol Cigarette Ban in England and Canada, 2021: Implications for Health Equity. Nicotine & Tobacco Research, 26(Supplement_2), S133–S142. doi: 10.1093/ntr/ntad112.

Abstract

Introduction: This study examined menthol cigarette use among youth who smoked, after menthol cigarette bans were implemented in England (May 2020) and Canada (October 2017).

Aims and methods: Cross-sectional data come from 2021 ITC Youth Tobacco and Vaping Survey respondents aged 16-19 who smoked in the past 30 d in England (N = 715) and Canada (N = 419). Adjusted logistic regression models, estimated separately for each country, examined sociodemographic correlates of usually smoking menthol cigarettes (reporting currently most often smoking menthol cigarettes) overall, and by past 30-d use of any menthol accessories (e.g., filters, capsules). Youth reported the cigarette variety they smoked most often, coded as menthol or nonmenthol.

Results: Almost no youth who smoked in the past 30 d reported most often smoking a cigarette variety coded as menthol. However, 34.5% (95% CI: 30.4% to 38.9%) of youth who smoke in England and 30.9% (26.0%-36.3%) in Canada reported usually smoking menthol cigarettes, with greater odds of use among those identifying as black, or other race/ethnicity, respectively, compared to white in England (60.0%, aOR = 3.08, p = .001; 47.4%, aOR = 2.27, p = .011) and Canada (43.6%, aOR = 2.44, p = .046; 51.2%, aOR = 2.92, p = .001). Among those who reported usually smoking menthol cigarettes in England (N = 223) and Canada (N = 108), 71.7% (64.0%-78.2%) and 51.5% (41.1%-61.7%) reported using menthol accessories.

Conclusions: After menthol cigarette bans in England and Canada, approximately one-third of youth who smoked reported usually smoking menthol cigarettes, with disproportionately higher use among those identifying as black and other race/ethnicity. Menthol accessories accounted for most menthol cigarette use. Closing regulatory loopholes is critical to advancing public health equity.

Implications: Use of menthol cigarette accessories (eg, filters, cards, capsules) among youth who smoked was prevalent after implementation of menthol cigarette bans in England and Canada, and there was disproportionately higher use among those who identified as black and any other race/ethnicity. Efforts are therefore required to close regulatory loopholes of menthol cigarette bans. Findings further support countries, such as the United States, proposing menthol cigarette bans which extend coverage to accessories. More comprehensive menthol bans that also restrict accessories are likely to be more effective in reducing flavored tobacco use among young people and in advancing health equity.

Citation

Brose, L.S., Reid, J.L., Robson, D., McNeill, A., & Hammond, D. (2024). Associations between vaping and self-reported respiratory symptoms in young people in Canada, England and the US. BMC Medicine, 22(1):213, 1-11. doi: 10.1186/s12916-024-03428-6.

Abstract

Background: Prevalence of youth nicotine vaping has increased, heightening concerns around negative health effects. This study aimed to compare self-reported respiratory symptoms among youth by vaping behaviours.

Methods: Participants (n = 39,214) aged 16-19 from the 2020 and 2021 International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Surveys (Canada, England, US). Weighted multivariable logistic regression assessed associations between reporting any of five respiratory symptoms in the past week (shortness of breath, wheezing, chest pain, phlegm, cough) and: past 30-day smoking and/or vaping; lifetime/current vaping. Among past-30-day vapers (n = 4644), we assessed associations between symptoms and vaping frequency, use of nicotine salts, usual flavour and device type(s).

Results: Overall, 27.8% reported experiencing any of the five respiratory symptoms. Compared with youth who had only vaped, those who had only smoked had similar odds of symptoms [adjusted odds ratio, OR (95% confidence interval, CI): 0.97 (0.85-1.10)], those who both smoked and vaped had higher odds [1.26 (1.12-1.42)], and those who had done neither, lower odds [0.67 (0.61-0.72)]. Compared with those who had never vaped, past use, experimentation and current regular or occasional use were all associated with higher odds. Reporting usually using nicotine salts was associated with higher odds of symptoms [1.43 (1.22-1.68)] than non-salt but was often uncertain. Compared with tobacco flavour (including with menthol), menthol/mint and sweets flavours were associated with similar odds; fruit [1.44 (1.07-1.93)], multiple [1.76 (1.30-2.39)] and 'other' [2.14 (1.45-3.16)] flavours with higher odds. All device types were associated with similar odds.

Conclusions: Among youth, vaping was associated with increased reporting of past-week respiratory symptoms. Among those who vaped, some flavour types and potentially nicotine salts were associated with respiratory symptoms.

Citation

Gomes, M.N., Reid, J.L., Rynard, V.L., East, K.A., Goniewicz, M.L., Piper, M.E., Hammond, D. (2024). Comparison of indicators of dependence for vaping and smoking: Trends between 2017 and 2022 among youth in Canada, England, and the United States. Nicotine and Tobacco Research, ntae060, doi: 10.1093/ntr/ntae060.

Abstract

Introduction: The current study sought to examine trends in indicators of dependence for youth vaping and smoking during a period of rapid evolution in the e-cigarette market.

Methods: Data are from repeat cross-sectional online surveys conducted between 2017 and 2022 among youth aged 16-19 in Canada, England, and the USA. Participants were 23,145 respondents who vaped and/or smoked in the past 30 days. Four dependence indicators were assessed for smoking and vaping (perceived addiction, frequent strong urges, time to first use after waking, days used in past month) and two for vaping only (use events per day, E-cigarette Dependence Scale). Regression models examined differences by survey wave and country, adjusting for sex, age, race, and exclusive/dual use.

Results: All six indicators of dependence increased between 2017 and 2022 among youth who vaped in the past 30 days (p<.001 for all). For example, more youth reported strong urges to vape at least most days in 2022 than in 2017 (Canada: 26.5% to 53.4%; England: 25.5% to 45.4%; USA: 31.6% to 50.3%). In 2017, indicators of vaping dependence were substantially lower than for smoking; however, by 2022, youth vaping was associated with a greater number of days used in the past month (Canada, USA), shorter time to first use (all countries), and a higher likelihood of frequent strong urges (Canada, USA) compared to youth smoking.

Conclusions: From 2017 to 2022, indicators of vaping dependence increased substantially. By 2022, vaping dependence indices were comparable to those of smoking.

Implications: Indicators of vaping dependence among youth have increased substantially since 2017 to levels that are comparable to cigarette dependence among youth who smoke. Future research should examine factors underlying the increase in dependence among youth who vape, including changes to the nicotine profile and design of e-cigarette products.

Citation

East, K.A., Taylor, E., Simonavicius, E., Nottage, M., Burkhalter, R., Brose, L.S., Wackowski, O.A., Liber, A.C., McNeill, A., Hammond, D. (2024). Noticing education campaigns or public health messages about vaping among youth in the US, Canada, and England from 2018 to 2022. Health Education Research, 39(1), 12-28. doi: 10.1093/her/cyad044.

Abstract

Public health campaigns have the potential to correct vaping misperceptions. However, campaigns highlighting vaping harms to youth may increase misperceptions that vaping is equally/more harmful than smoking. Vaping campaigns have been implemented in the United States and Canada since 2018 and in England since 2017 but with differing focus: youth vaping prevention (United States/Canada) and smoking cessation (England). We therefore examined country differences and trends in noticing vaping campaigns among youth and, using 2022 data only, perceived valence of campaigns and associations with harm perceptions. Seven repeated cross-sectional surveys of 16–19 year-olds in United States, Canada and England (2018–2022, n = 92 339). Over half of youth reported noticing vaping campaigns, and noticing increased from August 2018 to February 2020 (United States: 55.2% to 74.6%, AOR = 1.21, 95% CI = 1.18-1.24; Canada: 52.6% to 64.5%, AOR = 1.13, 1.11-1.16; England: 48.0% to 53.0%, AOR = 1.05, 1.02-1.08) before decreasing (Canada) or plateauing (England/United States) to August 2022. Increases were most pronounced in the United States, then Canada. Noticing was most common on websites/social media, school and television/radio. In 2022 only, most campaigns were perceived to negatively portray vaping and this was associated with accurately perceiving vaping as less harmful than smoking among youth who exclusively vaped (AOR = 1.46, 1.09-1.97). Consistent with implementation of youth vaping prevention campaigns in the United States and Canada, most youth reported noticing vaping campaigns/messages, and most were perceived to negatively portray vaping.

Citation

Li, L., Borland, R., Le Grande, M., & Gartner, C. (2024). Future nicotine use preferences of current cigarette smokers: Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey. Drug and Alcohol Review. 43(2), 359-370. doi: 10.1111/dar.13791.

Abstract

Introduction: Consumer preferences should be important factors that are considered when developing health policies and interventions. This paper examines the prevalence of, and factors associated with, consumer preferences regarding smoking behaviour 1 to 2 years in the future.

Methods: At least weekly cigarette smokers in the 2020 wave of the International Tobacco Control Four Country Smoking and Vaping Survey (USA, Canada, England and Australia) (N=8642) were asked if they preferred to continue to smoke or to quit with or without an alternative nicotine product (ANP) over the next 1–2 years.

Results: Country-specific weighted data showed 21.5% preferred to continue smoking and 8.0% were uncertain, leaving 70.6% preferring to quit: 13.7% using an ANP and 56.9% completely quitting nicotine. Apart from interest in quitting, the main predictors of preferring to quit were history of vaping, being aged 55 and over, smoking weekly, worrying about smoking harms, regretting starting and believing vaping is less harmful relative to smoking. Among those preferring to quit, preferring to use ANPs in future was very strongly associated with current vaping (especially daily), being younger, living in England, reporting strong urges to smoke, believing vaping is much less harmful than smoking, and not strongly regretting starting to smoke, and not wanting to quit.

Discussion and Conclusions: A significant minority of smokers preferred not to quit, at least in the next year or two. Both interest in quitting and preference for ANPs over complete cessation were associated with similar covariates, including interest in vaping.

Citation

Fairman, R.T., Cho, Y., Popova, L., Cummings, K.M., Smith, T., Fong, G.T., Gravely, S., Borland, R., McNeill, A., Gartner, C., Morphett, K., Thrasher, J.F. (2023). Support for nicotine reduction in cigarettes: Findings from the 2016 and 2020 ITC Four Country Smoking and Vaping Surveys. Tobacco Control, doi: 10.1136/tc-2023-058128.

Abstract

Introduction: The USA and New Zealand have sought to establish a product standard to set a maximum nicotine level for cigarettes to reduce their addictiveness. This study examined support for very low nicotine cigarettes (VLNCs) in Australia, Canada, England and the USA between 2016 and 2020.

Methods: Repeated cross-sectional data were analysed from participants who currently smoke, formerly smoked or vaped and/or currently vape in the 2016 (n=11?150) and/or 2020 (n=5432) International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. Respondents were asked if they would support a law that reduces the amount of nicotine in cigarettes to make them less addictive. Adjusted and weighted logistic regression analyses estimated the prevalence and predictors of support, such as country, age, sex, education, income, race and smoking/vaping status for VLNCs (support vs oppose/do not know).

Results: A majority of respondents supported a VLNC law, with support highest in Canada (69%; 2016 and 2020 combined), followed by England (61%), Australia (60%) and the USA (58%). Overall, support decreased from 62% in 2016 to 59% in 2020 (p=0.004), which did not differ by country. Levels of support differed by smoking/vaping status, where those who exclusively smoked daily showed the lowest level of support (59%) and those who exclusively vaped non-daily had the highest level of support (72%).

Conclusion: More than half of respondents in all four countries—including those who smoked daily—supported a hypothetical VLNC standard to render cigarettes less addictive. It is important to examine if support is sustained after policies are implemented.

Citation

Gravely, S., Driezen, P., Shahab, L., McClure, E., Hyland, A., Cummings, K.M., East, K.A., Chan, C.K.G., Walsh, H., Benowitz, N.L., Gartner, C., Fong, G.T., Quah, A.C.K., Smith, D.M. (2023). Associations of cannabis use, high-risk alcohol use, and depressive symptomology with motivation and attempts to quit cigarette smoking among adults: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. International Journal of Mental Health and Addiction, doi: 10.1007/s11469-023-01214-8.

Abstract

This study assessed independent and interaction effects of the frequency of cannabis use, high-risk alcohol use, and depressive symptomology on motivation and attempts to quit cigarette smoking among adults who regularly smoked. Cross-sectional data are from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey and included 7044 adults (ages 18 + years) who smoked cigarettes daily in Australia (n = 1113), Canada (n = 2069), England (n = 2444), and the United States (USA) (n = 1418). Among all respondents, 33.1% of adults reported wanting to quit smoking “a lot,” and 29.1% made a past-year quit attempt. Cannabis use was not significantly associated with either outcome (both p ≥ 0.05). High-risk alcohol use was significantly associated with decreased odds of motivation to quit (p = 0.02) and making a quit attempt (p = 0.004). Depressive symptomology was associated with increased odds for both outcomes (both p < 0.001). There were no significant 2- or 3-way interactions between cannabis use, alcohol consumption, and depressive symptomatology. Overall, just over a quarter of adults who smoked daily reported making a recent quit attempt, and most were not highly motivated to quit. Longitudinal research should investigate whether there are linkages between cannabis use, risky alcohol consumption, and/or depression on successful long-term smoking cessation.

Citation

Roberson, A., Cummings, K.M., Reid, J.L., Burkhalter, R., Gravely, S., East, K.A., Thrasher, J.F., Hammond, D. (2023). Trends in e-cigarette and tobacco cigarette purchasing behaviors by youth in the United States, Canada, and England, 2017 2022. International Journal of Public Health, 68, doi: 10.3389/ijph.2023.1606234.

Abstract

Objectives: This paper describes trends in youth e-cigarette (EC) and tobacco cigarette (TC) purchasing behaviors in Canada, England, and the United States (US) in relationship to changing minimum legal age (MLA)

Methods: Data are from eight cross-sectional online surveys among national samples of 16 to 19 year olds in Canada, England, and the US conducted from 2017 to 2022 (N = 104,467). Average wave percentage change in EC and TC purchasing prevalence and purchase locations were estimated using Joinpoint regressions.

Results: EC purchasing increased between 2017 and 2022, although the pattern of change differed by country. EC purchasing plateaued in 2019 for the US and in 2020 for Canada, while increasing through 2022 for England. TC purchasing declined sharply in the US, with purchasing from traditional retail locations declining, while purchasing from social sources increased. Vape shops were the most common location for EC purchasing, although declining in England and the US.

Conclusion: Trends in EC and TC purchasing trends in the US are consistent with the expected impact of the federal MLA law increasing the legal age to 21 years in December 2019.

Citation

Hammond, D., Reid, J.L. (2023). Trends in vaping and nicotine product use among youth in Canada, England and the USA between 2017 and 2022: evidence to inform policy. Tobacco Control, doi: 10.1136/tc-2023-058241.

Abstract

Background: Preventing uptake of nicotine products among youth remains a central objective of tobacco control policy. Comparing trends in the use of nicotine across countries provides an opportunity to identify emergent product trends and to evaluate ‘natural experiments’ in policies.

Methods: Repeat cross-sectional data were analysed from eight waves of the International Tobacco Control Youth Tobacco and Vaping Survey, conducted between 2017 and 2022. Non-probability samples of youth aged 16–19 years in Canada, England and the USA (N=104?473) completed online surveys including measures on vaping, smoking and use of other nicotine products. This paper summarises findings across the 5-year period of the study, as part of a comprehensive report on key indicators of youth vaping in the three countries.

Results: The youth nicotine market has rapidly evolved across the three countries, with different patterns of combustible and non-combustible product use in Canada, the USA and England. These changes are primarily attributable to trends in youth vaping: following declines during the initial COVID-19 pandemic period, by 2022, vaping prevalence neared pre-pandemic levels in the USA and Canada, and reached record highs in England. Notable shifts also occurred in the types of vaping products used by youth, including increased use of disposable, nicotine salt-based products. Additional findings are reported on a range of policy-relevant indicators, including for vaping products, promotions and purchasing.

Conclusions: Patterns of nicotine use among youth have rapidly evolved in recent years due to the proliferation of nicotine products, the COVID-19 pandemic and the emerging impact of policy measures.

Citation

Cho, A., Scollo, M., Chan, C.K.G., Driezen, P., Hyland, A., Shang, C., Gartner, C. (2023). Tobacco purchasing in Australia during regular tax increases: findings from the International Tobacco Control Policy Evaluation Project. Tobacco Control, [Published online Aug 31, doi: 10.1136/tc-2023-058130].

Abstract

Objective: We examined Australian tobacco purchasing trends, the average self-reported price paid within each purchase type and the association between type of tobacco product purchased and participant characteristics, including quit intentions, between 2007 and 2020.

Methods: We analysed data collected from adults who smoked factory-made and/or roll-your-own (RYO) cigarettes in nine waves (2007–2020) of the International Tobacco Control Policy Evaluation Project Australia Survey (nsample =5452, nobservations =11 534). The main outcome measures were type of tobacco products purchased: RYO, carton, pack or pouch size and brand segment. Logistic regression, fit using generalised estimating equations, was estimated the association between the outcome and participant characteristics.

Results: The reported price-minimising purchasing patterns increased from 2007 to 2020: any RYO (23.8–43.9%), large-sized pack (2007: 24.0% to 2016: 34.3%); shifting from large-sized to small-sized packs (2020: 37.7%), and economy brand (2007: 37.2% to 2020: 59.3%); shifting from large (2007: 55.8%) to small economy packs (2014: 15.3% to 2020: 48.1%). Individuals with a lower income, a higher nicotine dependence level and no quit intention were more likely to purchase RYO and large-sized packs.

Conclusion: RYO, large-sized packs and products with a low upfront cost (eg, small RYO pouches and small-sized economy brand packs) may appeal to people on low incomes. Australia’s diverse tobacco pack and pouch sizes allow the tobacco industry to influence tobacco purchases. Standardising pack and pouch sizes may reduce some price-related marketing and especially benefit people who have a low income, are highly addicted and have no quit intention.

Citation

Chung-Hall, J., Craig, L.V., Kyriakos, C.N., Fong, G.T. (2023). U.S. Food and Drug Administration must ban menthol cigarettes without delay: Lessons from other countries. American Journal of Preventive Medicine, 65(6), 1192-1195. doi: 10.1016/j.amepre.2023.08.001.

Abstract

No abstract.

Citation

Tildy, B., McNeill, A., East, K.A., Gravely, S., Fong, G.T., Cummings, K.M., Borland, R., Chan, C.K.G., Lim, C., Gartner, C., Yong, H.H., Brose, L.S. (2023). Self-reported depression and anxiety and healthcare professional interactions regarding smoking cessations and nicotine vaping: Findings from 2018 International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. Tobacco Prevention & Cessation, 9(August), 26. doi: 10.18332/tpc/168288.

Abstract

Introduction: People with mental health conditions are disproportionately affected by smoking-related diseases and death. The aim of this study was to assess whether health professional (HP) interactions regarding smoking cessation and nicotine vaping products (NVPs) differ by mental health condition.

Methods: The cross-sectional 2018 International Tobacco Control Four Country (Australia, Canada, England, United States) Smoking and Vaping Survey data included 11040 adults currently smoking or recently quit. Adjusted weighted logistic regressions examined associations between mental health (self-reported current depression and/or anxiety) and visiting a HP in last 18 months; receiving advice to quit smoking; discussing NVPs with a HP; and receiving a recommendation to use NVPs.

Results: Overall, 16.1% self-reported depression and anxiety, 7.6% depression only, and 6.6% anxiety only. Compared with respondents with no depression/anxiety, those with depression (84.7%, AOR=2.65; 95% CI: 2.17–3.27), anxiety (82.2%, AOR=2.08; 95% CI: 1.70–2.57), and depression and anxiety (87.6%, AOR=3.74; 95% CI: 3.19–4.40) were more likely to have visited a HP. Among those who had visited a HP, 47.9% received advice to quit smoking, which was more likely among respondents with depression (AOR=1.58; 95% CI: 1.34–1.86), and NVP discussions were more likely among those with depression and anxiety (AOR=1.63; 95% CI: 1.29–2.06). Of the 6.1% who discussed NVPs, 33.5% received a recommendation to use them, with no difference by mental health.

Conclusions: People with anxiety and/or depression who smoke were more likely to visit a HP than those without, but only those with depression were more likely to receive cessation advice, and only those with depression and anxiety were more likely to discuss NVPs. There are missed opportunities for HPs to deliver cessation advice. NVP discussions and receiving a positive recommendation to use them were rare overall.

Citation

Liu, C., Yong, H.H., Gravely, S., East, K.A., Kasza, K., Gartner, C., Cummings, K.M., Fong, G.T. (2023). Gender differences in cigarette smoking cessation attempts among adults who smoke and drink alcohol at high levels: Findings from the 2018-2020 International Tobacco Control Four Country Smoking and Vaping Surveys. Addictive Behaviours, 147, 107817. doi: 10.1016/j.addbeh.2023.107817.

Abstract

Background: This study examined the association between alcohol consumption and smoking cessation behaviour of adults who smoke in four countries.

Methods: Data came from 4275 adults (≥18 years) who smoked tobacco ≥ monthly and participated in the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping Surveys (Australia: n = 720; Canada: n = 1250; US: n = 1011; England: n = 1294). The 2018 Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) survey data coded into three levels ('never/low', 'moderate' or 'heavy' consumption) were analysed using multivariable logistic regression models to predict any smoking cessation attempts and successful cessation by 2020 survey, and whether this differed by gender and country.

Results: Compared to never/low alcohol consumers, only those who drink heavily were less likely to have made a quit smoking attempt (40.4 % vs. 43.8 %; AOR = 0.69, 95 % CI = 0.57-0.83, p < .001). The association differed by gender and country (3-way interaction, p < .001), with females who drink heavily being less likely to attempt to quit smoking in England (AOR = 0.27, 95 % CI = 0.15-0.49, p < .001) and Australia (AOR = 0.38, 95 % CI = 0.19-0.77, p = .008), but for males, those who drink moderately (AOR = 2.18, 95 % CI = 1.17-4.06, p = .014) or heavily (AOR = 2.61, 95 % CI = 1.45-4.68, p = .001) were more likely to make a quit attempt in England only. Alcohol consumption did not predict quit success.

Conclusion: Heavy alcohol use among adults who smoke appears to only undermine the likelihood of trying to quit smoking with some variation by gender and country of residence, but not their chances of succeeding if they tried.

Citation

Lemos, M.K., Taylor, E., Wadsworth, E., Reid, J.L., Hammond, D., East, K.A. (2023). Perceptions of cannabis use risk to mental health among youth in Canada, England, and the United States from 2017 to 2021. Drug and Alcohol Dependence, 250, 110904. doi: 10.1016/j.drugalcdep.2023.110904.

Abstract

Background: There is little research examining perceptions of cannabis use risk to mental health in countries with differing cannabis regulations. This study therefore examines such perceptions among youth between 2017 and 2021 in Canada (non-medical cannabis legalized in October 2018), England (highly-restricted medical cannabis legalized November 2018), and the US (non-medical cannabis legal in some states).

Methods: Seven repeat cross-sectional online surveys were conducted between July 2017 to August 2021 among youth aged 16-19 in Canada (N=29,420), England (N=28,155), and the US (N=32,974). Logistic regression models, stratified by country, were used to examine perceptions of cannabis use risk to mental health over time, adjusting for age group, sex, race/ethnicity, cannabis use and, for the US only, state-level cannabis legalization.

Results: Perceptions that cannabis use posed “no risk” to mental health decreased between July 2017 and August 2021 in Canada (6.1% to 4.4%; AOR=0.64, 95% CI=0.52-0.78) and the US (14.0% to 11.3%; AOR=0.74, 0.65-0.84) but not England (3.7% to 4.5%; AOR=1.21, 0.97-1.52). No significant changes were observed from immediately before (August 2018) to after (August 2019) legalization of non-medical cannabis in Canada (AOR=0.99, 0.83-1.20) or highly-restricted medical cannabis in England (AOR=0.90, 0.70-1.17). In the US, perceptions of “no risk” were more likely in states where cannabis use was illegal (15.0%) compared with legal non-medical (12.2%) (AOR=0.68, 0.63-0.74).

Conclusion: There were modest decreases in perceptions that cannabis use poses no risk to mental health in Canada and the US between 2017 and 2021 but no clear association with cannabis legalization status.

Citation

Gravely, S., Yong, H.H., Reid, J.L., East, K.A., Liber, A.C., Cummings, K.M., Quah, A.C.K., Fong, G.T., Hammond, D. (2023). An examination of quitting smoking as a reason for vaping by the type of nicotine vaping device used most often among adults who smoke and vape: Findings from the Canada, England and the United States 2020 ITC Smoking and Vaping Survey. Preventive Medicine Reports, 33, 102201. doi: 10.1016/j.pmedr.2023.102201.

Abstract

Several nicotine vaping product (NVP) device types are available to consumers, and many people who smoke report vaping to help them quit. This study included data from the Wave 3 (2020) ITC Smoking and Vaping Survey in the US, Canada, and England and included 2324 adults who were smoking cigarettes and vaping at least weekly. Device types currently used most often (disposables, cartridges/pods, or tank systems) were assessed using weighted descriptive statistics. Multivariable regression analyses were used to compare differences between respondents who reported vaping to quit smoking (‘yes’ vs. ‘no/don’t know’) by device type, overall and by country. Overall, 71.3% of respondents reported vaping to help them quit smoking, with no country differences (p = 0.12). Those using tanks (78.7%, p < 0.001) and cartridges/pods (69.5%, p = 0.02) were more likely to report this reason for vaping than those using disposables (59.3%); respondents using tanks were also more likely than those using cartridges/pods (p = 0.001) to report this reason. By country, respondents in England using cartridges/pods or tanks (vs. disposables) were more likely to report vaping to quit smoking (with no difference between cartridges/pods and tanks). In Canada, respondents using tanks were more likely to report vaping to quit smoking than those using cartridges/pods or disposables (no difference between disposables and cartridges/pods). No significant differences by device type were found in the US. In conclusion, most adult respondents who smoked and vaped reported using either cartridges/pods or tanks, which were associated with greater odds of vaping for the purpose of quitting smoking versus disposables, with some country variations.

Citation

Gallien, M., Occhiali, G., Ross, H. (2023). An overlooked market: loose cigarettes, informal vendors and their implications for tobacco taxation. Tobacco Control, [Published online May 23, doi: 10.1136/tc-2023-057965].

Abstract

Objective: To examine the features of markets for loose cigarettes in several low-income and middle-income countries and their effects on tobacco control policies, particularly taxation.

Design: An analysis of survey data targeting people who smoke in two African, one Southeast Asian and two South Asian countries and retailers across 16 African countries to study loose cigarette markets and examine how prices in these markets move relative to the prices for cigarette packs.

Results: Markets for loose cigarettes are large, and their consumer base tends to differ from the wider population of people who smoke. Loose cigarette prices are on average higher than those of cigarettes bought in packs, and they respond differently to tax increases, at least partially due to a denomination effect.

Conclusions: The features of the loose cigarette markets present a challenge for tobacco control policy, especially tobacco tax policy. One way to overcome this challenge is to aim for large, rather than incremental, tax increases.

Citation

Yong, H.H., Karmakar, C., Motin, M. A., Borland, R., Cummings, K.M., Gravely, S., Fong, G.T. (2023). Individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies relative to combustible cigarettes among people who smoke: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 25(9), 1594-1602. doi: 10.1093/ntr/ntad075.

Abstract

Introduction: This study examined individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies (NRTs) relative to combustible cigarettes (CCs).

Methods: Data analyzed came from 8,642 adults (18+ years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n=1213), Canada (n=2633), England (n=3057), and United States (US, n=1739). Respondents were asked: Compared to smoking cigarettes, how harmful do you think nicotine replacement products are? Responses were dichotomised into much less vs. otherwise for analysis using multivariable logistic regression models, complemented by decision-tree analysis to identify conjoint factors.

Results: Percentages believing that NRTs are much less harmful than CCs were 29.7% (95% CI:26.2-33.5%) in Australia, 27.4% (95% CI=25.1-29.8%) in England, 26.4% (95% CI=24.4-28.4%) in Canada and 21.7% (95% CI=19.2-24.3%) in the US. Across all countries, believing nicotine is not at all/slightly harmful to health (aOR=1.53-2.27), endorsing nicotine vaping products as less harmful than CCs (much less harmful: aOR=7.24-14.27; somewhat less harmful: aOR=1.97-3.23), and possessing higher knowledge of smoking harms (aOR=1.23-1.88) were individual factors associated with increased odds of believing NRTs are much less harmful than CCs. With some country variations, these nicotine-related measures also interacted with each other and socio-demographic variables to serve as conjoint factors associated with the likelihood of accurate NRT relative harm belief.

Conclusions: Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors.

Implications: This study demonstrates that despite past efforts to educate people who smoke about the harms of NRTs relative to CCs, misperceptions around the relative harmfulness of NRTs remain substantial. In all four studied countries, subgroups of people who smoke regularly who are misinformed about the relative harmfulness of NRTs, and who may be reluctant to use NRTs for smoking cessation can be reliably identified for corrective interventions based o n their understanding of the harms related to nicotine, NVPs and smoking along with sociodemographic markers. The identified subgroup information can be used to prioritize and inform the development of effective interventions to specifically address the gaps in knowledge and understanding of the various subgroups identified. Our results suggest these may need to be tailored for each country.

Citation

Taylor, E., East, K.A., Reid, J., Hammond, D. (2023). Awareness and use of short-fill e-liquids by youth in England in 2021: Findings from the ITC Youth Survey. Tobacco Control, [Published online May 2, doi:10.1136/tc-2022-057871].

Abstract

Background: Refillable e-cigarettes were popular among youth in England in 2021. The UK Tobacco and Related Products Regulations (TRPR) limits e-liquids to 20 mg/mL of nicotine in a 10 mL bottle. Short-fill e-liquids, which are not covered by TRPR regulations, are typically nicotine-free and come in larger, underfilled bottles allowing customisation with the addition of ‘nicotine shots’. This paper investigates awareness, use, and reasons for use of short-fill e-liquids among youth in England.

Methods: Data are from the online 2021 International Tobacco Control Youth Survey, comprising 4224 youth (aged 16–19 years) in England. Weighted logistic regression models investigated associations between awareness and past 30-day use of short-fills by smoking status, vaping status, nicotine strength vaped and participant demographics. Reasons for use were also reported.

Results: Approximately one-quarter (23.0%) of youth in England reported awareness of short-fill e-liquids. Among youth who had vaped in the past 30 days, 22.1% had used short-fills in the past 30 days; use was most prevalent among those who were also smoking (43.2%) and those who reported usually vaping nicotine concentrations of 2.1% (21 mg/mL) or more (40.8%). ‘Convenience of a bigger bottle’ was the most selected reason for use (45.0%), followed by ‘less expensive than regular e-liquids’ (37.6%).

Conclusions: Awareness of short-fills was common among youth in 2021, including among those who had never vaped or smoked. Among youth who vaped in the past 30 days, short-fill use was more prevalent among those who also smoked and those who vaped nicotine-containing e-liquids. Integration of short-fill products into existing e-cigarette regulations should be considered.

Citation

Reid, J., Burkhalter, R., Kasza, K.A., Seo, Y., East, K.A., Hyland, A., Hammond, D. (2023). Minimum legal age laws and perceived access to cigarettes, e-cigarettes, and other substances among youth in Canada, England, and the United States: 2017-2021. International Journal of Drug Policy, 115, 104003. doi: 10.1016/j.drugpo.2023.104003.

Abstract

Background: Minimum legal age (MLA) restrictions are a core policy to reduce youth use of tobacco, e-cigarettes, and other substances. We examined trends in perceived ease of access to tobacco and other substances across three countries with differing MLA policies, including the United States (US), which increased the federal MLA for tobacco products from 18 to 21 in 2019.

Methods: Repeat cross-sectional data were analyzed from seven waves of the International Tobacco Control (ITC) Youth Tobacco and Vaping Survey conducted between 2017 and 2021. Online surveys were conducted with non-probability samples of 91,647 youth aged 16-19 in Canada, England, and the US. Regression models were used to examine differences in perceived ease of accessing each of 7 substances (analyzed as "very easy" or "fairly easy" versus else), and differences between countries and over time (including before and after any MLA changes) for cigarettes, e-cigarettes, cannabis, and alcohol; additional models examined sub-national variation in MLA.

Results: Perceived access varied by substance and across countries: in August/September 2021, perceived ease of accessing cigarettes and e-cigarettes was greater in Canada where MLA was 18-19 (61.7% cigarettes, 66.4% e-cigarettes) and England where MLA was 18 (66.9%, 69.6%), compared to the US where MLA was 21 (48.0%, 60.9%; p < 0.001 for all). Perceived ease of accessing cannabis was greatest in Canada (53.3%), followed by the US (44.1%) and England (34.0%; p < 0.001 for all). Following the federal MLA increase for tobacco products in the US, perceived ease of access decreased significantly for cigarettes (65.1% in 2019Aug to 59.7% in 2020Feb; aOR=0.80 (95%CI=0.71-0.89)) and e-cigarettes (72.4% in 2019Aug to 69.4% in 2020Feb; aOR=0.87 (95%CI=0.77-0.98)).

Conclusions: Higher MLA was strongly associated with fewer youth perceiving easy access to substances: perceived access varied between countries with differing MLA, as well as within-country before and after changes to MLA.

Citation

Yimsaard, P., Gravely, S., Meng, G., Fong, G.T., Cummings, K.M., Hyland, A., Borland, R., Hammond, D., Kasza, K.A., Li, L., Quah, A.C.K. (2023). Differences in smoking cessation behaviours and vaping status among adult daily smokers with or without depression, anxiety, hazardous alcohol use: Findings from the 2018 and 2020 ITC Four Country Smoking and Vaping Survey. International Journal of Mental Health and Addiction. doi:10.1007/s11469-023-01058.

Abstract

This study examined differences in quit attempts, 1-month quit success, and vaping status at follow-up among a cohort of 3709 daily smokers with and without depression, anxiety, and regular alcohol use who participated in both the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys. At baseline, a survey with validated screening tools was used to classify respondents as having no, or one or more of the following: 1) depression, 2) anxiety, and 3) regular alcohol use. Multivariable adjusted regression analyses were used to examine whether baseline (2018) self-report conditions were associated with quit attempts; quit success; and vaping status by follow-up (2020). Results showed that respondents who reported depressive symptoms were more likely than those without to have made a quit attempt (aOR = 1.32, 95% CI:1.03–1.70, p = 0.03), but were less likely to have quit (aOR = 0.55, 95% CI:0.34–0.89, p = 0.01). There were no differences in quit attempts or quit success between those with and without self-reported anxiety diagnoses or regular alcohol use. Among successful quitters, respondents with baseline depressive symptoms and self-reported anxiety diagnoses were more likely than those without to report vaping at follow-up (aOR = 2.58, 95% CI:1.16–5.74, p = 0.02, and aOR = 3.35 95% CI:1.14–9.87, p = 0.03). In summary, it appears that smokers with depression are motivated to quit smoking but were less likely to manage to stay quit, and more likely to be vaping if successfully quit. As smoking rates are higher among people with mental health conditions, it is crucial for healthcare professionals to identify these vulnerable groups and offer tailored smoking cessation support and continued support during their quit attempt.

Citation

East, K.A., Miller, C., Hitchman, S.C., McNeill, A., Tompkins, C. (2023). 'It's not what you'd term normal smoking ': a qualitative exploration of language used to describe heated tobacco product use and associated user identity. Addiction, 118(3), 533-538. 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. (2023). 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, 25(3), 505-513. doi: 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

Lohner, V., McNeill, A., Schneider, S., Vollstädt-Klein, S., Andreas, M., Szafran, D., Grundinger, N., Demjén, T., Fernández, E., Przewoźniak, K., Tountas, Y., Trofor, A.C., Zatoński, W.A., Willemsen, M, Vardavas, C.I., Fong, G.T., Mons, U. (2023). Understanding perceived addiction to and addictiveness of electronic cigarettes among e-cigarette users – a cross-sectional analysis of the International Tobacco Control Smoking and Vaping (ITC 4CV) Europe Surveys. Addiction, 118(7), 1359-1369. doi: 10.1111/add.16162.

Abstract

Background and aims: The addictive potential of electronic cigarettes (e-cigarettes) remains to be fully understood. We identified patterns and correlates of perceived addiction to e-cigarettes and perceived addictiveness of e-cigarettes relative to tobacco cigarettes (relative addictiveness) in dual users as well as exclusive e-cigarette users.

Design, setting and participants: Observational study using cross-sectional survey data from England (2016) from the International Tobacco Control Project (ITC) Four Country Smoking and Vaping (4CV) survey. The study comprised 832 current e-cigarette users who had been vaping for at least 4 months.

Measurements: Perceived addiction to e-cigarettes and relative addictiveness of e-cigarettes were examined. Socio-demographic factors were age, gender and education; markers of addiction included urge to vape, time to first vape after waking and nicotine strength used; vaping and smoking characteristics included frequency and duration of e-cigarette use, intention to quit, adjustable power or temperature, enjoyment, satisfaction relative to tobacco cigarettes and tobacco cigarette smoking status.

Findings: A total of 17% of participants reported feeling very addicted to e-cigarettes, while 40% considered e-cigarettes equally/more addictive than tobacco cigarettes. Those who felt very addicted had higher odds of regarding e-cigarettes as more addictive than tobacco cigarettes (odds ratio 3.4, 95% confidence interval 2.3-5.1). All markers of addiction, daily use and enjoyment were associated with higher perceived addiction, whereas time to first vape after waking, daily vaping and perceiving vaping as less satisfying than smoking were associated with relative addictiveness.

Conclusions: Markers of addiction to e-cigarettes appear to correspond with perceived addiction to e-cigarettes, suggesting that self-reported perceived addiction might serve as an indicator of addiction. Prevalence both of markers of addiction and perceived addiction were comparatively low overall, suggesting a limited but relevant addictive potential of e-cigarettes. Additionally, positive and negative reinforcement, reflected here by enjoyment and relative satisfaction, might play a role in e-cigarette addiction.