Citation

Yong, H.H., Borland, R., Hyland, A., Siahpush, M. (2008). How does a failed quit attempt among regular smokers affect their cigarette consumption? Findings from the International Tobacco Control Four Country Survey (ITC-4). Nicotine & Tobacco Research, 10(5), 897-905.

Abstract

Recent cross-sectional data suggests that smokers tend to reduce smoking following a failed selfinitiated quit attempt, possibly motivated by the need to reduce harms or to facilitate future quitting or both. This study prospectively examined changes in cigarette consumption among adult smokers who relapsed from a quit attempt. It uses data from the first three waves of the International Tobacco Control Four-Country Survey (ITC-4), a random digit-dialed telephone survey of a cohort of over 9,000 adult smokers from the United Kingdom, United States, Canada, and Australia, followed up annually. Compared with those who did not make a quit attempt, relapsers were more likely to reduce consumption (average reduction of 0.7 vs. 3.4, respectively) over a mean period of 7 months between waves 1 and 2. Of the relapsers, 52% reduced their consumption by 5% or more, but 22% increased it. Smokers who smoked heavily at baseline, whose last quit attempt ended more recently, was of longer duration, and quit via a gradual cutdown method were all independently associated with reducing smoking following a failed attempt. These findings were similar across all four countries and were successfully replicated using waves 2–3 data. Change in consumption between waves 1 and 2 (whether increase or decrease) was maintained by a substantial number a year later (wave 3), but change did not undermine nor promote quitting between waves 2 and 3.

Citation

Shahab, L., Hammond, D., O’Connor, R.J., Cummings, K.M., Borland, R., King, B., McNeill, A. (2008). The reliability and validity of self-reported puffing behavior: Evidence from a cross-national study. Nicotine & Tobacco Research,10(5), 867-874.

Abstract

Self-reported puffing behavior has considerable potential as an indicator of smoking intensity, particularly in survey research evaluating population-based changes in smoking patterns. However, little is known about the reliability and validity of self-reported puffing behavior. This study compared smokers’ perceptions of their puffing behavior with measures of both machinedetermined puffing behavior and nicotine uptake to assess the utility of self-report. We assessed self-reported puffing behavior as well as demographic and smoking characteristics of 118 smokers from Australia, Canada, the United Kingdom, and the United States. At two visits, participants were asked to provide a saliva sample and to smoke a cigarette through a portable smoking topography device, the CReSSmicro, to measure puffing behavior. Saliva samples were assayed for cotinine, a measure of nicotine uptake, to provide estimates of smoke exposure. Intraclass coefficients for all measures of self-reported general puffing behavior were above .6, indicating that self-reported measures had fair-to-good test–retest reliability. Self-report, in particular of interpuff interval and number of cigarette puffs, was correlated only moderately with machine-determined puffing measures (.2<r<.4), and no self-report measure related to smoke exposure as measured by cotinine. Self-reported measures of puffing behavior appear to be fairly reliable but are correlated only weakly with objective measures of smoking topography. Results suggest that smokers have a better perception of the time spent between puffs and of the number of puffs taken than of the intensity and depth of each puff or their actual smoke exposure.

Citation

O’Connor, R.J., Hyland, A., Giovino, G.A., Fong, G.T., Cummings, K.M. (2005). Smoker awareness of and beliefs about supposedly less-harmful tobacco products. American Journal of Preventive Medicine, 29(2), 85-90.

Abstract

Background: Cigarette manufacturers in the United States have begun marketing cigarette brands claiming to reduce smokers' exposure to selected toxins in tobacco smoke. Little data exist on smokers' awareness, use, and beliefs about these products.

Methods: Data from the U.S. arm of the International Tobacco Control Policy Four-Country Survey (ITC-4), a telephone survey of 2028 adult current cigarette smokers in the United States conducted between May and September 2003, were analyzed. Respondents were asked to report their awareness, beliefs, and use of products marketed as less harmful than traditional cigarettes and of smokeless tobacco (SLT) products.

Results: Close to 39% of smokers were aware of "less-harmful" cigarettes, but only 27% of them could name a specific brand of such cigarettes. The brand named most often was Quest (25.7%), followed by Eclipse (7.6%), Winston (5.7%), herbal cigarettes (3.3%), "smoke-free" cigarettes (2.9%), Marlboro Blend #27 (1.9%), and Omni (1.9%). Of those who named a brand, 25% believed such products were less harmful than "ordinary cigarettes." In contrast, 82% of cigarette smokers were aware of SLT products, but only 10.7% of these believed that SLTs were less harmful than ordinary cigarettes.

Conclusions: Smokers hold beliefs about the relative safety of supposedly less-harmful tobacco products that are opposite to existing scientific evidence. These results highlight the need to educate smokers about the risks of alternatives to conventional cigarettes, and the need to regulate the advertising and promotion of such alternatives.

Citation

Hammond, D., Reid, J., Driezen, P., Cummings, K.M., Borland, R., Fong, G.T., McNeill, A. (2008). Smokers' use of nicotine replacement therapy for reasons other than stopping smoking: Findings from the ITC Four Country Survey. Addiction, 103(10), 1696-1703.

Abstract

Aims: To measure the prevalence and correlates of nicotine replacement therapy (NRT) use for reasons other than quitting smoking among smokers in four countries.

Design and setting: Population-based, cross-sectional telephone survey with nationally representative samples of adult smokers in Canada, the United States, the United Kingdom and Australia, conducted in 2005.

Participants: A total of 6532 adult daily smokers in Canada (n = 1660), the United States (n = 1664), the United Kingdom (n = 1617) and Australia (n = 1591).

Measurements: Survey questions included demographics, smoking behaviour, use of NRT and reasons for NRT use, as well as access and availability of NRT.

Findings: Approximately 17% of smokers surveyed had used NRT in the past year. Among NRT users, approximately one-third used NRT for a reason other than quitting smoking, including temporary abstinence or reducing the number of cigarettes smoked. The prevalence of non-standard NRT use was remarkably consistent across countries. Using NRT for reasons other than quitting was associated with higher education level, heavier smoking, having no quit intentions, having no past-year quit attempts, the type of NRT product used and accessing NRT without a prescription.

Conclusions: The use of NRT for purposes other than quitting smoking is fairly common and may help to explain the difficulty in detecting significant quitting benefits associated with NRT use in population studies. Tobacco control policies, including the accessibility of NRT, may have important implications for patterns of NRT use.

Citation

Hyland, A., Higbee, C., Hassan, L.M., Fong, G.T., Borland, R., Cummings, K.M., Hastings, G. (2008). Does smoke-free Ireland have more smoking inside the home and less in pubs than the United Kingdom? Findings from the International Tobacco Control Policy Evaluation Project. European Journal of Public Health, 18(1), 63-65.

Abstract

Background: In March 2004, Ireland implemented comprehensive smoke-free regulations. Some were concerned this would cause pub patrons to move their smoking and drinking from inside pubs to inside homes. This article aims to assess whether nationwide smoke-free policies are associated with more smoking or drinking inside the home.

Methods: Participants were 1917 adult smokers (> 18-years old) from Ireland (n = 582), Scotland (n = 507) and the rest of the United Kingdom (n = 828), which did not have smoke-free laws at the time of the interview, who completed a random digit-dialed telephone survey in February to March 2006. The percentage of alcoholic drinks consumed in the home versus pubs was compared by country as well as the percentage of daily cigarette consumption occurring in the home after work.

Results: Irish respondents reported a significantly lower percentage of alcoholic drinks consumed in the home compared to Scotland and the rest of the United Kingdom, and cigarette consumption in the home was comparable in all three regions.

Conclusions: Smoking and drinking in the home was not greater in smoke-free Ireland than in the United Kingdom, where there was not a smoke-free law at the time of the survey. These findings add further support to the enactment of comprehensive smoke-free laws, as called for in the Framework Convention on Tobacco Control.

Citation

Borland, R., Fong, G.T., Yong, H.H., Cummings, K.M., Hammond, D., King, B., Siahpush, M., McNeill, A., Hastings, G., O’Connor, R.J., Elton-Marshall, T., Zanna, M.P. (2008). What happened to smokers' beliefs about light cigarettes when "light/mild" brand descriptors were banned in the UK? Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 17(4), 256-262.

Abstract

Aim: This paper examines how beliefs of smokers in the UK were affected by the removal of “light” and “mild” brand descriptors, which came into effect on 30 September 2003 for Member States of the European Union (EU).

Participants: The data come from the first four waves (2002–2005) of the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey, an annual cohort telephone survey of adult smokers in Canada, USA, UK and Australia (15 450 individual cases).

Design: The UK ban on misleading descriptors occurred around the second wave of data collection in the ITC survey, permitting us to compare beliefs about light cigarettes among adult smokers in the UK before and after the ban, with beliefs in the three other ITC countries unaffected by the ban.

Results: There was a substantial decline in reported beliefs about the benefits of light cigarettes in the UK following the policy change and an associated public information campaign, but by 2005 (ie, wave 4), these beliefs rebounded slightly and the change in beliefs was no greater than in the USA, where there was no policy change.

Conclusions: The findings reveal that high levels of misperceptions about light cigarettes existed among smokers in all four countries before and after the EU ban took effect. We cannot conclude that the policy of removing some aspects of misleading labels has been effective in changing beliefs about light cigarettes. Efforts to correct decades of consumer misperceptions about light cigarettes must extend beyond simply removing “light” and “mild” brand descriptors.

Citation

Hassan, L.M., Shiu, E., Thrasher, J.F., Fong, G.T., Hastings, G. (2008). Exploring the effectiveness of cigarette warning labels: Findings from the United States and United Kingdom arms of the International Tobacco Control (ITC) Four Country Survey. International Journal of Nonprofit and Voluntary Sector Marketing, 13(3), 263-274.

Abstract

This paper explores the effectiveness of cigarette warning labels across two countries, one (the UK) with new and stricter legislation where text based labels have been made more prominent and one (the USA) with less stringent regulation, where labels are less visible. Using longitudinal data from the two countries, the research seeks to investigate the impact of the different types of warning labels on the information processing by consumers. This paper assesses the effectiveness of warning labels in terms of: consumer attention, elaboration, contemplation on quitting and behavioural compliance. This study provides a comprehensive examination of these key factors in a fixed causal sequence. Structural equation modelling was used to test this model based on longitudinal panel survey data from the International Tobacco Control (ITC) Four Country Survey. Analysis of a sample of 901 US smokers and 1459 UK smokers yielded results in full support of all hypothesised relationships in the model proposed for both countries. Findings suggest that the new European Union policy of more prominent warning labels has a direct effect on influencing behavioural compliance by smokers.

Citation

Hammond, D., Fong, G.T., Borland, R., Cummings, K.M., McNeill, A., Driezen, P. (2007). Communicating risk to smokers: The impact of health warnings on cigarette packages. American Journal of Preventive Medicine, 32(3), 202-209.

Abstract

Background: Health warnings on cigarette packages provide smokers with universal access to information on the risks of smoking. However, warnings vary considerably among countries, ranging from graphic depictions of disease on Canadian packages to obscure text warnings in the U.S. The current study examined the effectiveness of health warnings on cigarette packages in four countries.

Methods: Quasi-experimental design. Telephone surveys were conducted with representative cohorts of adult smokers (N= 14,975): Canada (n =3687); the U.S. (n =4273); the UK (n= 3634); and Australia (n =3381). Surveys were conducted between 2002 and 2005, before and at three time points following new warnings on UK packages.

Results: At Wave 1, Canadian smokers reported the highest levels of awareness and impact for health warnings among the four countries, followed by Australian smokers. Following the implementation of new UK warnings at Wave 2, UK smokers reported greater levels of awareness and impact, although Canadian smokers continued to report higher levels of impact after adjusting for the implementation date. U.S. smokers reported the lowest levels of effectiveness for almost every measure recorded at each survey wave.

Conclusions: Large, comprehensive warnings on cigarette packages are more likely to be noticed and rated as effective by smokers. Changes in health warnings are also associated with increased effectiveness. Health warnings on U.S. packages, which were last updated in 1984, were associated with the least effectiveness.

Citation

Young, D., Borland, R., Siahpush, M., Hastings, G., Fong, G.T., Cummings, K.M. (2007). Australian smokers support stronger regulatory controls on tobacco: Findings from the ITC Four-Country Survey. Australian and New Zealand Journal of Public Health, 31(2), 164-169.

Abstract

Objective: To examine Australian smokers’ attitudes towards regulation of the tobacco industry and to compare their attitudes with those of three similar countries – the United Kingdom (UK), the United States (US), and Canada

Method: A telephone survey of 2,056 adult Australian smokers and 6,166 Canadian, US, and UK smokers was conducted in 2004 as the third wave of the International Tobacco Control Policy Evaluation Four- Country Survey.

Results: Australian smokers display the strongest support for regulation. Only 16% believe that tobacco companies should be allowed to advertise/promote cigarettes as they please, 70% agree that tobacco products should be more tightly regulated, and 64% agree that governments should do more to tackle the harms of smoking. Smokers see government failure to do so in cynical terms – 77% agree that governments do not really care about smoking because of money from tobacco taxes. Opposition comes largely from smokers who hold self-exempting beliefs about smoking’s risks, have a positive attitude to smoking, do not accept that smoking is socially denormalised, and do not hold tobacco companies responsible for harms caused by smoking.

Conclusions and Implications: The majority of Australian smokers believe that the tobacco industry is partly responsible for the predicament they find themselves in and want governments to act more strongly in their real interests. The strong relationship between support for regulation and cynicism about government inaction should stimulate governments into action.

Citation

Cheong, Y., Yong, H.H., Borland, R. (2007). Does how you quit affect success? A comparison between abrupt and gradual methods using data from the International Tobacco Control Policy Evaluation Study. Nicotine & Tobacco Research, 9(8), 801-810.

Abstract

Two recommended quit methods in standard cessation programs involve either gradual reduction of smoking prior to complete abstinence ("cut down") or abrupt abstinence from cigarettes ("cold turkey"). This study examined the reported use, characteristics of users, and the impact of self-selected strategy choice on quitting success and relapse of adult smokers who reported quitting on their own. Data came from the first three waves of the International Tobacco Control Policy Evaluation 4-Country Survey (ITC-4). The ITC-4 is a random-digit-dialed telephone survey of a cohort of more than 8,000 adult smokers from the United Kingdom, the United States, Canada, and Australia, with a 75% follow-up rate. The results indicated that 68.5% of the smokers who had made a quit attempt between waves reported using the cold-turkey method. Of those who used the cold turkey method, 22% and 27% succeeded at Waves 2 and 3, respectively, compared with the 12% and 16%, respectively, who used the cut-down method. Multivariate analyses revealed that cold-turkey users were more likely to be aged 25-39 years, male, from the United Kingdom, and smoking heavily, and had lower perceived dependence. Controlling for sociodemographic and known predictors of quitting including use of medications, we found that smokers who used the cold-turkey method to quit were almost twice as likely to abstain for a month or more in their attempt. Overall, we cautiously conclude that cold turkey should be the recommended strategy for smokers who want to quit on their own.

Citation

Siahpush, M., Borland, R., Yong, H.H. (2007). Sociodemographic and psychosocial correlates of smoking-induced deprivation and its effect on quitting: Findings from the International Tobacco Control Policy Evaluation Survey. Tobacco Control, 16(2), 106-113.

Abstract

Aims: To determine the prevalence and characteristics of smokers who experience smoking-induced deprivation (SID), and to examine its effect on quit attempts, relapse and cessation.

Methods: Waves 2 and 3 (2003-5) of the International Tobacco Control Policy Evaluation Survey were used, which is a prospective study of a cohort of smokers in the US, Canada, UK and Australia. SID was measured with the question "In the last six months, have you spent money on cigarettes that you knew would be better spent on household essentials like food?" A total of 7802 smokers participated in the survey in wave 2, of whom 5408 were also interviewed in wave 3.

Findings: The proportion of smokers who reported SID was highest in Australia (33%) and lowest in the UK (20%). Younger age, minority status and low income were associated with a higher probability of SID. Some of the other factors related to a higher probability of SID were higher level of nicotine dependence, having an intention to quit, and smoking to help one socialise or control weight. The relationship between SID and quit attempt was mediated by having an intention to quit and worrying that smoking would damage health and reduce the quality of life. The relationship between SID and relapse was mediated by perceived stress. SID was not associated with successful cessation.

Conclusions: Many smokers experience deprivation that is the result of their smoking. Strategies to reduce the prevalence of smoking probably effect a general improvement in standards of living and reduction in deprivation.

Citation

O’Connor, R.J., McNeill, A., Borland, R., Hammond, D., King, B., Boudreau, C., Cummings, K.M. (2007). Smokers' beliefs about the relative safety of other tobacco products: Findings from the ITC collaboration.Nicotine & Tobacco Research, 9(10), 1033-1042.

Abstract

Most tobacco control efforts in western countries focus on the factory-made, mass-produced (FM) cigarette, whereas other tobacco products receive relatively little attention. Noncombusted tobacco products (i.e., referred to as smokeless tobacco), particularly Swedish-style snus, carry lower disease risks, compared with combusted tobacco products such as cigarettes. In this context, it is important to know what tobacco users believe about the relative harmfulness of various types of tobacco products. Data for this study came from random-digit-dialed telephone surveys of current smokers aged 18 or older in Australia, Canada, the United Kingdom, and the United States. Three waves of data, totaling 13,322 individuals, were assessed. Items assessed use of and beliefs about the relative harms of cigars, pipes, smokeless tobacco, and FM and roll-your-own cigarettes, as well as sociodemographics and smoking behaviors. Cigars (2.8%-12.7%) were the other tobacco products most commonly used by current cigarette smokers, followed by pipes (0.3%-2.1%) and smokeless tobacco (0.0%-2.3%). A significant minority of smokers (12%-21%) used roll-your-own cigarettes at least some of the time. About one-quarter of smokers believed that pipes, cigars, or roll-your-own cigarettes were safer than FM cigarettes, whereas only about 13% responded correctly that smokeless tobacco was less hazardous than cigarettes. Multivariate analyses showed that use of other tobacco products was most strongly related to beliefs about the reduced harm of these other products. Use of other tobacco products was low but may be growing among smokers in the four countries studied. Smokers are confused about the relative harms of tobacco products. Health education efforts are needed to correct smoker misperceptions.

Citation

O’Connor, R.J., Kozlowski, L.T., Borland, R., Hammond, D., McNeill, A. (2006). Relationship between constituent labelling and reporting of tar yields among smokers in four countries. Journal of Public Health, 28(4), 324-329.

Abstract

Countries have adopted different approaches to disseminating cigarette tar, nicotine, and carbon monoxide (CO) levels to consumers, with some (e.g. EU member states, Canada, Australia, but not the United States) requiring disclosure of results from the International Organization for Standardization (ISO) test method on packs. Cross-country comparisons can provide insight into how smokers use yields when information is presented differently. We examined whether smokers in four different countries could recall the tar yield of their brand of cigarettes, using data from the third wave of the International Tobacco Control Four Country Survey (ITC-4). Of current smokers in the United States, Canada, Australia and the United Kingdom, 33.6% gave a numeric response when asked to report the tar yield of their brand, whereas 66.4% responded ‘I don’t know.’ American participants (9.2%) were less likely than Canadian (28.0%), UK (36.5%) or Australian (68.2%) smokers to give an answer, even after controlling for sociodemographic and smoking behaviour factors. Constituent labelling policies can affect whether smokers report a tar yield for their cigarette brand. Pack labelling appears to be useful for conveying information about cigarettes to smokers; however, there is an urgent need to develop more meaningful information on toxic constituents of cigarette smoke.

Citation

Hyland, A., Laux, F., Higbee, C., Hastings, G., Ross, H., Chaloupka, F., Fong, G.T., Cummings, K.M. (2006). Cigarette purchase patterns in four countries and the relationship with cessation: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii59-iii64.

Abstract

Background: Higher cigarette prices result in decreased cigarette consumption, but some smokers may seek lower-taxed cigarette sources. This price avoidance behaviour likely dampens the health impact of higher cigarette prices although it has not been thoroughly studied.

Objective: To describe the characteristics of smokers who purchase low/untaxed cigarettes and to examine how this behaviour is associated with subsequent changes in smoking behaviours.

Methods: Telephone survey data from 8930 smokers from the International Tobacco Control (ITC) Four Country Survey (ITC-4) were used to assess cigarette purchase patterns and smoking behaviours in Wave 1 conducted from October to December 2002 and subsequently followed seven months later in Wave 2. Respondents’ smoking status, attempts to quit, amount smoked, and cigarette purchase patterns were assessed in both waves.

Results: Rates of purchase from a low/untaxed source at the respondents’ last cigarette purchase differed notably between countries at Wave 1, from less than 1% in Australia to 15% in the United Kingdom. In the UK, but not the other countries, this increased significantly to 20% at Wave 2. Smokers who were older, white/English speakers, had higher incomes, and had higher levels of education were more likely to report purchasing cigarettes from a low/untaxed source on their last purchase. Those who reported purchasing from a low/untaxed source on their last purchase at Wave 1 were less likely to have tried to quit smoking quit smoking by Wave 2 (relative risk 0.70, p , 0.01), while no overall significant association with smoking cessation was observed.

Conclusion: Data from this study indicate that there are lower levels of making a quit attempt among purchasers of low/untaxed cigarettes compared to purchasers of full-priced cigarettes. The availability of low/untaxed cigarettes may mitigate the influence of increases in cigarette prices.

Citation

Hammond, D., Fong, G.T., McNeill, A., Borland, R., Cummings, K.M. (2006). Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii19-iii25.

Abstract

Background: Health warnings on cigarette packages are among the most common means of communicating the health risks of smoking. However, few studies have evaluated the impact of package warnings on consumer knowledge about tobacco risks.

Objective: The aim of the current study was to use nationally representative samples of adult smokers from the United States (USA), the United Kingdom (UK), Canada (CAN), and Australia (AUS) from the International Tobacco Control Four Country Survey (ITC-4) to examine variations in smokers’ knowledge about tobacco risks and the impact of package warnings.

Methods: A telephone survey was conducted with 9058 adult smokers from the following countries: USA (n  =  2138), UK (n  =  2401), CAN (n  =  2214) and AUS (n  =  2305). Respondents were asked to state whether they believed smoking caused heart disease, stroke, impotence, lung cancer in smokers, and lung cancer in non-smokers. Respondents were also asked whether the following chemicals are found in cigarette smoke: cyanide, arsenic and carbon monoxide.

Findings: Smokers in the four countries exhibited significant gaps in their knowledge of the risks of smoking. Smokers who noticed the warnings were significantly more likely to endorse health risks, including lung cancer and heart disease. In each instance where labelling policies differed between countries, smokers living in countries with government mandated warnings reported greater health knowledge. For example, in Canada, where package warnings include information about the risks of impotence, smokers were 2.68 (2.41–2.97) times more likely to agree that smoking causes impotence compared to smokers from the other three countries.

Conclusion: Smokers are not fully informed about the risks of smoking. Warnings that are graphic, larger, and more comprehensive in content are more effective in communicating the health risks of smoking.

Citation

Thrasher, J.F., Chaloupka, F., Hammond, D., Fong, G.T., Borland, R., Hastings, G., Cummings, K.M. (2006). Evaluación de las políticas contra el tabaquismo en paises Latino Americanos en la era del Convenio Marco para el Control del Tabaco [Evaluating tobacco control policy in Latin American countries during the era of the Framework Convention on Tobacco Control]. Salud Publica de Mexico, 48(Suppl 1), S155-S166.

Abstract

Objective: The Framework Convention on Tobacco Control (FCTC) aims to coordinate tobacco control policies around the world that reduce tobacco consumption. The FCTC's recommended policies are likely to be effective in low- and middle-income countries. Nevertheless, policy evaluation studies are needed to determine policy impact and potential synergies across policies.

Materials and methods: The International Tobacco Control Policy Evaluation Project (ITC) is an international collaboration to assess the psychosocial and behavioral impact of the FCTC's policies among adult smokers in nine countries. The ITC evaluation framework utilizes multiple country controls, a longitudinal design, and a theory-driven conceptual model to test hypotheses about the anticipated effects of given policies.

Results: ITC Project results generally confirm previous studies that form the evidence base for FCTC policy recommendations, in particular: the use of graphic warning labels; banning of "light" and "mild" descriptors; smoking bans; increasing tax and price; banning advertising; and using new cigarette product testing methods.

Conclusions: Initial findings from the ITC Project suggest that Latin American countries could use similar methods to monitor and evaluate their own tobacco control policies while contributing to the evidence base for policy interventions in other countries.

Citations

Siahpush, M., McNeill, A., Borland, R., Fong, G.T. (2006). Socioeconomic variations in nicotine dependence, self-efficacy, and intention to quit across four countries: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii71-iii75.

Abstract

Objective: To examine the effect of socioeconomic status (SES) on nicotine dependence, self-efficacy, and intention to quit.

Design setting and participants: Data were from the first wave (2002) of the International Tobacco Control (ITC) Four Country Survey (ITC-4), a panel study of over 2000 adult smokers from each of four countries: the United States, Canada, the United Kingdom, and Australia. Data were collected via telephone interviews.

Main outcome measures: Nicotine dependence, intention to quit, and self-efficacy to quit smoking were the main outcome measures used in this study.

Results: Lower levels of education were associated with higher nicotine dependence. The effect of lower income on higher heaviness of smoking index (HIS) scores was significant in Canada, the UK, and Australia. Respondents with low education had 35% larger odds of low self-efficacy than those with high education. Respondents with low education had 40% larger odds of having no intention to quit than those with high education. Respondents with low income had 23% larger odds of having no intention to quit than those with high income. Country was not a moderator of the association of SES with self-efficacy and intention to quit.

Conclusion: To the extent that lower SES smokers are more addicted, they are likely to need more intensive support if they are to be successful in their attempts to quit. Given their lower incomes, this places a special responsibility on government to provide or subsidise such services. This should include access to the widest possible range of effective pharmacotherapies complemented with evidence based counselling and support.

Citation

Haw, S.J., Gruer, L., Amos, A., Currie, C., Fischbacher, C., Fong, G.T., Hastings, G., Malam, S., Scott, C., Semple, S. (2006). Legislation on smoking in enclosed public places in Scotland: How will we evaluate the impact? Journal of Public Health, 28(1), 24-30.

Abstract

Background: From 26 March 2006, smoking will be prohibited in wholly and substantially enclosed public places in Scotland, and it will be an offence to permit smoking or to smoke in no-smoking premises. We anticipate that implementation of the smoke-free legislation will result in significant health gains associated with reductions in exposure to both environmental tobacco smoke (ETS) and personal tobacco consumption as well as other social and economic impacts.

Methods: Health Scotland in conjunction with the Information Services Division (ISD) Scotland and the Scottish Executive have developed a comprehensive evaluation strategy to assess the expected short-term, intermediate and long-term outcomes. Using routine health, behavioural and economic data and commissioned research, we will assess the impact of the smoke-free legislation in eight key outcome areas – knowledge and attitudes, ETS exposure, compliance, culture, smoking prevalence and tobacco consumption, tobacco-related morbidity and mortality, economic impacts on the hospitality sector and health inequalities.

Conclusion: The findings from this evaluation will make a significant contribution to the international understanding of the health effects of exposure to ETS and the broader social, cultural and economic impacts of smoke-free legislation.

Citation

Hammond, D., Fong, G.T., Zanna, M.P., Thrasher, J.F., Borland, R. (2006). Tobacco denormalization and industry beliefs among smokers from four countries. American Journal of Preventive Medicine, 31(3), 225-232.

Abstract

Background: Tobacco denormalization is an important concept for understanding smoking behavior. The present study sought to assess beliefs about the tobacco industry and the social acceptability of smoking among nationally representative samples of adult smokers from four countries, and to assess the relationship of these measures to cessation behavior and tobacco-control policy.

Design: A longitudinal survey of 9058 adult smokers from Canada (n = 2214), the United States (n = 2138), the United Kingdom (n = 2401), and Australia (n = 2305), was conducted in October-December 2002 and again in June and August 2003 (75% follow-up rate). The analyses were conducted in 2005.

Results: The findings indicate that few smokers perceive approval for their smoking, and most hold relatively antagonistic beliefs toward the tobacco industry. For example, 80% of smokers reported that society disapproves of smoking, and more than three quarters reported that tobacco companies cannot be trusted to tell the truth. Social and industry denormalization were independently associated with intentions to quit smoking. Baseline levels of social denormalization were associated with abstinence at the 8-month follow-up, as were changes in industry denormalization beliefs between baseline and follow-up. Anti-industry beliefs at baseline did not predict abstinence at follow-up. A similar pattern of findings was observed across all four countries. In addition, social denormalization and anti-industry beliefs were significantly associated with tobacco-control policies, such as noticing health warnings on packages and greater workplace smoking restrictions.

Conclusions: Tobacco denormalization constructs were independently linked to cessation-related outcomes among adults from four countries. Tobacco-industry denormalization themes in mass media campaigns may help to reduce tobacco use above and beyond more traditional communications that target social norms.

Citation

Fong, G.T., Hyland, A., Borland, R., Hammond, D., Hastings, G., McNeill, A., Anderson, S., Cummings, K.M., Allwright, S., Mulcahy, M., Clancy, L., Thompson, M.E., Connolly, G.N., Driezen, P. (2006). Reductions in tobacco smoke pollution and increases in support for smoke-free public places following the implementation of comprehensive smoke-free workplace legislation in the Republic of Ireland: Findings from the ITC Ireland/UK Survey.Tobacco Control, 15(Suppl 3), iii51-iii58.

Abstract

Objective: To evaluate the psychosocial and behavioural impact of the first ever national level comprehensive workplace smoke-free law, implemented in Ireland in March 2004.

Design: Quasi-experimental prospective cohort survey: parallel cohort telephone surveys of national representative samples of adult smokers in Ireland (n = 769) and the UK (n = 416), surveyed before the law (December 2003 to January 2004) and 8-9 months after the law (December 2004 to January 2005).

Main outcome measures: Respondents' reports of smoking in key public venues, support for total bans in those key venues, and behavioural changes due to the law.

Results: The Irish law led to dramatic declines in reported smoking in all venues, including workplaces (62% to 14%), restaurants (85% to 3%), and bars/pubs (98% to 5%). Support for total bans among Irish smokers increased in all venues, including workplaces (43% to 67%), restaurants (45% to 77%), and bars/pubs (13% to 46%). Overall, 83% of Irish smokers reported that the smoke-free law was a "good" or "very good" thing. The proportion of Irish homes with smoking bans also increased. Approximately 46% of Irish smokers reported that the law had made them more likely to quit. Among Irish smokers who had quit at post-legislation, 80% reported that the law had helped them quit and 88% reported that the law helped them stay quit.

Conclusion: The Ireland smoke-free law stands as a positive example of how a population-level policy intervention can achieve its public health goals while achieving a high level of acceptance among smokers. These findings support initiatives in many countries toward implementing smoke-free legislation, particularly those who have ratified the Framework Convention on Tobacco Control, which calls for legislation to reduce tobacco smoke pollution.

Citation

Borland, R., Yong, H.H., Siahpush, M., Hyland, A., Campbell, S., Hastings, G., Cummings, K.M., Fong, G.T. (2006). Support for and reported compliance with smoke-free restaurants and bars by smokers in four countries: Findings from the International Tobacco Control (ITC) Four Country Survey.Tobacco Control, 15(Suppl 3), iii34-iii41.

Abstract

Objective: To explore determinants of support for and reported compliance with smoke-free policies in restaurants and bars across the four countries of the International Tobacco Control (ITC) Four Country Survey.

Design: Separate telephone cross-sectional surveys conducted between October and December 2002 with broadly representative samples of over 2000 adult (⩾ 18 years) cigarette smokers in each of the following four countries: the United States, Canada, the United Kingdom, and Australia.

Outcome measures: Support for smoke-free policies in restaurants and pubs/bars and reported compliance with existing policies.

Results: Reported total bans on indoor smoking in restaurants varied from 62% in Australia to 5% in the UK. Smoking bans in bars were less common, with California in the USA being the only major part of any country with documented bans. Support for bans in both restaurants and bars was related to the existence of bans, beliefs about passive smoking being harmful, lower average cigarette consumption, and older age. Self-reported compliance with a smoking ban was generally high and was associated with greater support for the ban.

Conclusions: Among current cigarette smokers, support for smoking bans was associated with living in a place where the law prohibits smoking. Smokers adjust and both accept and comply with smoke-free laws. Associates of support and compliance are remarkably similar across countries given the notably different levels of smoke-free policies.

Citation

Harris, F., MacKintosh, A.M., Anderson, S., Hastings, G., Borland, R., Fong, G.T., Hammond, D., Cummings, K.M. (2006). Effects of the 2003 advertising/promotion ban in the United Kingdom on awareness of tobacco marketing: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii26-iii33.

Abstract

Background: In February 2003, a comprehensive ban on tobacco promotion came into effect in the United Kingdom, which prohibited tobacco marketing through print and broadcast media, billboards, the internet, direct mail, product placement, promotions, free gifts, coupons and sponsorships.

Objective: To investigate the impact of the UK’s comprehensive ban on tobacco promotion on adult smokers’ awareness of tobacco marketing in the UK relative to Canada, the United States and Australia.

Design: A total of 6762 adult smokers participated in two waves of a random digit dialled telephone survey across the four countries. Wave 1 was conducted before the UK ban (October–December 2002) and Wave 2 was conducted after the UK ban (May–September 2003).

Key measures: Awareness of a range of forms of tobacco marketing.

Results: Levels of tobacco promotion awareness declined significantly among smokers in the UK after implementation of the advertising ban. Declines in awareness were greater in those channels regulated by the new law and change in awareness of tobacco promotions was much greater in the UK than the other three countries not affected by the ban. At least in the short term, there was no evidence that the law resulted in greater exposure to tobacco promotions in the few media channels not covered by the law. Notwithstanding the apparent success of the UK advertising ban and the controls in other countries, 9–22% of smokers in the four countries still reported noticing things that promoted smoking ‘‘often or very often’’ at Wave 2.

Conclusions: The UK policy to ban tobacco advertising and promotion has significantly reduced exposure to pro-tobacco marketing influences. These findings support the effectiveness of comprehensive bans on advertising and promotion, as included in the Framework Convention on Tobacco Control.

Citation

Young, D., Borland, R., Hammond, D., Cummings, K.M., Devlin, E., Yong, H.H., O’Connor, R.J. (2006). Prevalence and attributes of roll-your-own smokers in the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii76-iii82.

Abstract

Background: Roll-your-own (RYO) cigarettes are often substantially less expensive than factory made (FM) cigarettes, and appear to be increasing in popularity—perhaps because smokers seek out less expensive options to maintain their nicotine addiction. There is surprisingly little research available on the actual prevalence of RYO cigarette usage, and even less on the attributes of those who smoke RYO cigarettes.

Objectives: This study has two objectives: (1) to compare the prevalence of RYO versus FM cigarette usage among adult smokers in Australia, Canada, the United Kingdom, and the United States; and (2) to compare the attributes of exclusive FM smokers, exclusive RYO smokers, and those who report “mixed” RYO and FM use.

Design: The data were collected from the International Tobacco Control (ITC) Four Country Survey (ITC-4), a random digit dialed telephone survey of representative samples of over 9046 adult smokers from the following four countries: Australia (n  =  2301), Canada (n  =  2,206), the UK (n  =  2400), and the USA (n  =  2,139), surveyed between October and December 2002, and on 6075 smokers followed-up, on average, seven months later.

Results: The prevalence of RYO cigarette usage varied widely across the four countries, with a low of 6.7% in the USA, to 28.4% in the UK. Exclusive use of RYO cigarettes was more common in the UK than in the other three countries. The use of RYO cigarettes was associated with having a lower annual income, male sex, younger average age, higher level of nicotine addiction, a stronger belief that RYO tobacco is less harmful compared to other forms of tobacco, and a more positive perception of tobacco use. Prevalence of RYO use was relatively stable within each of the four countries between the baseline and follow-up survey. RYO use was unrelated to quitting activity at follow-up, although mixed RYO users who had made a quit attempt were more likely to relapse than either exclusive FM or exclusive RYO smokers.

Conclusions: Patterns of RYO use vary considerably across Australia, Canada, the USA, and the UK. RYO smokers are a heterogeneous group; however, the factors associated with RYO use appear to be the same across the four countries studied.

Citation

Borland, R., Yong, H.H., Cummings, K.M., Hyland, A., Anderson, S., Fong, G.T. (2006). Determinants and consequences of smoke-free homes: Findings from the International Tobacco Control (ITC) Four Country Survey.Tobacco Control, 15(Suppl 3), iii42-iii50.

Abstract

Objective: To report on prevalence, trends and determinants of smoke-free home policies in smokers’ homes in different countries and to estimate the effects of these policies on smoking cessation.

Design: Two waves of the International Tobacco Control (ITC) Four Country Survey (ITC-4), a cohort survey of smokers conducted by telephone. Wave 1 was conducted in October/December 2002 with broadly representative samples of over 2000 adult (⩾ 18 years) cigarette smokers in each of the following four countries: Canada, the United States, the United Kingdom, and Australia, 75% of whom were followed up at Wave 2 on average seven months later.

Key measures: Levels of smoking restrictions in homes (both waves).

Results: Australian smokers were most likely to live in smoke-free homes and UK smokers least likely (34% v 15% at Wave 1). Levels of smoke-free homes increased between waves. Logistic regressions indicated that the main independent predictors of smokers reporting smoke-free homes or implementation of a smoke-free policy between waves included household factors such as having a child, particularly a young child, and having other non-smoking adults in the household. Positive attitudes to smoke-free public places and/or reported presence of smoke-free public places were independent predictors of having or implementing smoke-free homes, supporting a social diffusion model for smoking restrictions. Intentions to quit at Wave 1 and quitting activity between survey waves were associated with implementing bans between Waves 1 and 2. Presence of bans at Wave 1 was associated with significantly greater proportions of quit attempts, and success among those who tried at Wave 2. There was no significant interaction between the predictive models and country.

Conclusions: Smoke-free public places seem to stimulate adoption of smoke-free homes, a strategy associated with both increased frequency of quit attempts, and of the success of those attempts.

Citation

Siahpush, M., McNeill, A., Hammond, D., Fong, G.T. (2006). Socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: Results from the 2002 International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii65-iii70.

Abstract

Background: Socioeconomic status is strongly associated with smoking prevalence and social class differences contribute substantially to social inequalities in mortality. This research investigated socioeconomic and country variations in smokers’ knowledge that smoking causes heart disease, stroke, impotence and lung cancer, that smoke contains cyanide, mercury, arsenic and carbon monoxide, and whether nicotine causes most of the cancer.

Methods: Data were from the International Tobacco Control (ITC) Four Country Survey, a cohort survey of over suppl_ adult smokers from four countries: the United States, Canada, the United Kingdom, and Australia. Data were collected via telephone interviews in 2002.

Results: Higher education and income were associated with higher awareness. For example, the odds of knowing that smoking causes heart disease, stroke and lung cancer were respectively 71%, 34% and 83% larger for respondents with high versus low income. The odds of knowing that smoke contains cyanide, mercury, arsenic and carbon monoxide were respectively 66%, 26%, 44% and 108% larger for respondents with a university degree than those with a high school diploma or lower level of education. Results also revealed that awareness of harms of smoking was generally the highest in Canada and the lowest in the UK.

Conclusions: Lower socioeconomic status was associated with lower awareness of the harms of smoking and misunderstanding around nicotine. There is a need to improve knowledge of the dangers of smoking among the disadvantaged segments of the population.