Citation

Braak, D., Cummings, K.M., Nahhas, G.J., Heckman, B.W., Borland, R., Fong, G.T., Hammond, D., Boudreau, C., McNeill, A., Levy, D.T., Shang, C. (2019). Where do vapers buy their vaping supplies? Findings from the International Tobacco Control (ITC) 4 Country Smoking and Vaping Survey. International Journal of Environmental Research and Public Health, 16(3), 338.

Abstract

Aim: This study examines where vapers purchase their vaping refills in countries having different regulations over such devices, Canada (CA), the United States (US), England (EN), and Australia (AU).

Methods: Data were available from 1899 current adult daily and weekly vapers who participated in the 2016 (Wave 1) International Tobacco Control Four Country Smoking and Vaping. The outcome was purchase location of vaping supplies (online, vape shop, other). Adjusted odds ratios and 95% confidence intervals were reported for between country comparisons.

Results: Overall, 41.4% of current vapers bought their vaping products from vape shops, 27.5% bought them online, and 31.1% from other retail locations. The vast majority of vapers (91.1%) reported using nicotine-containing e-liquids. In AU, vapers were more likely to buy online vs other locations compared to CA (OR = 6.4, 2.3–17.9), the US (OR = 4.1, 1.54–10.7), and EN (OR = 7.9, 2.9–21.8). In the US, they were more likely to buy from vape shops (OR = 3.3, 1.8–6.2) or online (OR = 1.9, 1.0–3.8) vs other retail locations when compared to those in EN. In CA, vapers were more likely to purchase at vape shops than at other retail locations when compared to vapers in EN (5.9, 3.2–10.9) and the US (1.87, 1.0–3.1).

Conclusions: The regulatory environment and enforcement of such regulations appear to influence the location where vapers buy their vaping products. In AU, banning the retail sale of nicotine vaping products has led vapers to rely mainly on online purchasing sources, whereas the lack of enforcement of the same regulation in CA has allowed specialty vape shops to flourish.

Citation

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

Abstract

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

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

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

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

Citation

McDermott, M., Li, G., McNeill, A., Hammond, D., Thrasher, J.F., O’Connor, R.J., Cummings, K.M., Borland, R., Fong, G.T., Hitchman, S.C. (2019). Exposure to and perceptions of health warning labels on nicotine vaping products: Findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 134-143.

Abstract

Background and Aims: The presence and content of health warning labels (HWLs) on nicotine vaping products (NVPs), such as electronic cigarettes, varies by country and manufacturer. We compared proportions of people who report (i) noticing HWLs on NVPs and (ii) feeling concerned having noticed HWLs, by country and by smoking or vaping status. We also examined recall of HWL content and whether this varies by country.

Design: Cross‐sectional survey

Setting: Australia (AU), Canada (CA), England (EN), and the United States (US). At the time of data collection, HWLs on NVPs were only mandatory in EN.

Participants: A total of 11561 respondents from the following samples in the 2016 International Tobacco Control 4‐Country Project: (1) re‐contacted smokers and quitters who had participated in the previous wave of the project; (2) newly recruited current smokers and recent quitters, and (3) newly recruited current vapers from CA, EN and US.

Measurements: Outcomes included: 1) having noticed HWLs on NVPs, 2) feeling concerned having noticed HWLs, and 3) recall of HWL message content.

Findings: Compared with respondents in EN, respondents in CA were more likely to report having noticed HWLs (OR=1.58, p=0.02) whereas respondents in AU (OR=0.76, p=1.00) and the US (OR=1.54, p=0.09) were not significantly more or less likely to report having noticed HWLs. Compared with concurrent smokers and vapers, daily smokers, non‐daily smokers, and quitters were less likely to report having noticed HWLs, (ORs=0.21, 0.33 and 0.19 respectively, all p<0.001). There were no significant differences in reports of noticing HWLs when comparing concurrent smokers and vapers with daily (OR=1.62, p=0.91) or non‐daily (OR=1.15, p=1.00) vapers. There were no significant differences by country in reporting that HWLs made them concerned about using NVPs. Daily vapers were less likely to report feeling concerned than concurrent users (OR=0.11, p=0.017). Among those who reported reading HWLs (n=688), there was little evidence of differences in recall of the HWL content.

Conclusions: Respondents in England, where health warning labels on nicotine vaping products are not mandatory, were not significantly more likely to report having noticed such warnings than those in Australia, Canada and the US where warnings are not mandatory.

Citation

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

Abstract

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

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

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

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

Citation

East, K., Hitchman, S.C., McDermott, M., McNeill, A., Herbeć, A., Tountas, Y., Bécuwe, N., Demjén, T., Fu, M., Fernández, E., Mons, U., Trofor, A., Zatoński, W., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2019). Social norms towards smoking and electronic cigarettes among adult smokers in seven European Countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 172-183.

Abstract

Introduction: This study explores whether current smokers’ social norms towards smoking and electronic cigarettes (e-cigarettes) vary across seven European countries alongside smoking and e-cigarette prevalence rates. At the time of surveying, England had the lowest current smoking prevalence and Greece the highest. Hungary, Romania and Spain had the lowest prevalence of any e-cigarette use and England the highest.

Methods: Respondents were adult (≥18 years) current smokers from the 2016 EUREST-PLUS ITC (Romania, Spain, Hungary, Poland, Greece, Germany) and ITC 4CV England Surveys (N=7779). Using logistic regression, associations between country and (a) smoking norms and (b) e-cigarette norms were assessed, adjusting for age, sex, income, education, smoking status, heaviness of smoking, and ecigarette status.

Results: Compared with England, smoking norms were higher in all countries: reporting that at least three of five closest friends smoke (19% vs 65–84% [AOR=6.9–24.0; Hungary–Greece]), perceiving that people important to them approve of smoking (8% vs 14–57% [1.9–51.1; Spain–Hungary]), perceiving that the public approves of smoking (5% vs 6–37% [1.7–15.8; Spain–Hungary]), disagreeing that smokers are marginalised (9% vs 16–50% [2.3–12.3; Poland–Greece]) except in Hungary. Compared with England: reporting that at least one of five closest friends uses e-cigarettes was higher in Poland (28% vs 36% [2.7]) but lower in Spain and Romania (28% vs 6–14% [0.3–0.6]), perceiving that the public approves of e-cigarettes was higher in Poland, Hungary and Greece (32% vs 36–40% [1.5–1.6]) but lower in Spain and Romania in unadjusted analyses only (32% vs 24–26%), reporting seeing e-cigarette use in public at least some days was lower in all countries (81% vs 12–55% [0.1–0.4]; Spain–Greece).

Conclusions: Smokers from England had the least pro-smoking norms. Smokers from Spain had the least pro-e-cigarette norms. Friend smoking and disagreeing that smokers are marginalised broadly aligned with country-level current smoking rates. Seeing e-cigarette use in public broadly aligned with countrylevel any e-cigarette use. Generally, no other norms aligned with product prevalence.

Citation

Chan, C.K.G., Morphett, K., Gartner, C., Leung, J., Yong, H.H., Hall, W., Borland, R. (2019). Predicting vaping uptake, vaping frequency and ongoing vaping among daily smokers using longitudinal data from the International Tobacco Control (ITC) Four Country Surveys. Addiction, 114(Suppl 1), 61-70.

Abstract

Aim: To assess (1) how far smoking patterns, depression and smoking‐related beliefs and intentions predict vaping uptake, current vaping and vaping frequency among daily smokers; and (2) how far the aforementioned predictors and baseline vaping frequency predict current vaping among those who reported ever vaped.

Design: Analysis of data from six waves of a longitudinal survey over 8 years. Longitudinal associations between predictors and outcomes were examined using multi‐level models.

Setting: United Kingdom, United States, Canada and Australia.

Participants: A total of 6296 daily smokers (53% females) who contributed data to at least two consecutive survey waves.

Measurements: The outcome variables were vaping uptake, vaping frequency and current vaping at follow‐up. The key predictor variables, measured in previous waves, were time to first cigarette, cigarettes smoked per day, depressive symptoms, intention to quit smoking, quitting self‐efficacy and worry about adverse health effects of smoking.

Findings: Number of cigarettes smoked daily was associated with (1) subsequent vaping uptake [odds ratio (OR) = 1.69, 95% confidence interval (CI) = 1.19, 2.39 for 30+ cigarette per day; reference category: 0–10 cigarettes] and (2) a higher frequency of current vaping (OR = 1.97, 95% CI = 1.36, 2.85 for 30+ cigarettes). Intention to quit was associated with a higher frequency of current vaping (OR = 1.48, 95% CI = 1.21, 1.82). Among those who reported ever vaped, higher baseline vaping frequency (OR = 11.98, 95% CI = 6.00, 23.93 for daily vaping at baseline; reference category: vaped less than monthly) predicted current vaping.

Conclusion: Among daily smokers, amount smoked and intention to quit smoking appear to predict subsequent vaping uptake. Vaping frequency at baseline appears to predict current vaping at follow‐up.

Citation

Zatoński, M., Herbec, A., Zatoński, W., Przewoźniak, K., Janik-Koncewicz, K., Mons, U., Fong, G.T., Demjén, T., Tountas, Y., Trofor, A., Fernández, E., McNeill, A., Willemsen, M.C., Hummel, K., Quah, A.C.K., Kyriakos, C.N., Vardavas, C. (2018). Characterising smokers of menthol and flavoured cigarettes, their attitudes towards tobacco regulation, and the anticipated impact of the Tobacco Products Directive on their smoking and quitting behaviours: The EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 34-46.

Abstract

Introduction: Little research exists on the sociodemographic characteristics of menthol and flavoured cigarette (MFC) smokers in Europe. This study assessed the proportion of MFC smokers in Europe, their sociodemographic characteristics, and their attitudes towards tobacco control measures.

Methods: Cross-sectional data were collected in 2016 among 10760 adult current smokers from 8 European countries (ITC Europe Project and EUREST-PLUS). Smokers of menthol, other flavoured, unflavoured tobacco, or no usual brand were compared on sociodemographic characteristics, attitudes towards a range of tobacco control measures (e.g. ban on flavouring), and on intentions regarding their smoking behaviour following the ban on flavoured tobacco. Data were analysed in SPSS Complex Samples Package using univariate analyses.

Results: Among the respondents, 7.4% smoked menthol cigarettes and 2.9% other flavoured tobacco, but large differences existed between countries (e.g. 0.4% smokers smoked menthol cigarettes in Spain vs 12.4% in England). Compared to other groups, menthol cigarette smokers were younger, more likely to be female, better educated, had higher household income, and smoked fewer cigarettes (all p<0.001). A quarter of menthol smokers supported a ban on additives, compared with almost half of all other smokers (p<0.001). In case of a ban on flavourings, around a fifth of all MFC smokers intended to switch to another brand, and a third to reduce the amount they smoked or to quit smoking, but there was no consistent pattern across MFC smokers among the countries.

Conclusions: The ban on flavourings introduced by the EU Tobacco Products Directive (extended to 2020 for menthols) will affect one in ten smokers in the countries surveyed, which provides an opportunity for targeting these groups with cessation programmes. However, smokers of menthol and flavoured cigarettes in the different European countries are a heterogeneous group and may need different approaches.

Citation

Thompson, M.E., Fong, G.T., Boudreau, C., Driezen, P., Li, G., Gravely, S., Cummings, K.M., Heckman, B.W., O’Connor, R.J., Thrasher, J.F., Nahhas, G., Borland, R., Yong, H.H., McNeill, A., Hitchman, S.C., Quah, A.C.K. (2019). Methods of the ITC Four Country Smoking and Vaping Survey, Wave 1 (2016). Addiction, 114(Suppl 1) 6-14.

Abstract

Aim: To describe the methods of the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey, conducted in 2016 in Australia (AU), Canada (CA), England (EN) and the United States (US).

Methods: The respondents were cigarette smokers, former smokers (quit within the previous 2 years), and at‐least‐weekly vapers, aged 18 years and older. Eligible cohort members from the ITC Four Country Survey (4C) were retained. New respondents were sampled by commercial firms from their panels. Where possible, ages 18–24 and vapers were oversampled. Data were collected online, and respondents were remunerated. Survey weights were calibrated to benchmarks from nationally representative surveys.

Results: Response rates by country for new recruits once invited ranged from 15.2 to 49.6%. Sample sizes for smokers/former smokers were 1504 in AU, 3006 in CA, 3773 in EN and 2239 in the US. Sample sizes for additional vapers were 727 in CA, 551 in EN and 494 in the US.

Conclusion: The International Tobacco Control Four Country Smoking and Vaping Survey design and data collection methods allow analyses to examine prospectively the use of cigarettes and nicotine vaping products in jurisdictions with different regulatory policies. The effects on the sampling designs and response quality of recruiting the respondents from commercial panels are mitigated by the use of demographic and geographic quotas in sampling; by quality control measures; and by the construction of survey weights taking into account smoking/vaping status, sex, age, education and geography.

Citation

Gravely, S., Thrasher, F.J., Cummings, K.M., Ouimet, J., McNeill, A., Meng, G., Lindblom, E.N., Loewen, R., O’Connor, R., Thompson, M.E., Hitchman, S., Hammond, D., Heckman, B.W., Borland, R., Yong, H.H., Elton-Marshall, T., Bansal-Travers, M., Gartner, C., Fong, G.T. (2019). Discussions between health professionals and smokers about nicotine vaping products: Results from the 2016 ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 71-85.

Abstract

Background and Aims: Debate exists about whether health professionals (HPs) should advise smokers to use nicotine vaping products (NVPs) to quit smoking. The objectives were to examine in four countries: (1) the prevalence of HP discussions and recommendations to use an NVP; (2) who initiated NVP discussions; (3) the type of HP advice received about NVPs; and (4) smoker's characteristics related to receiving advice about NVPs.

Design: Cross‐sectional study using multivariable logistic regression analyses on weighted data from the 2016 ITC Four Country Smoking and Vaping Survey (ITC 4CV1).

Setting: Four countries with varying regulations governing the sale and marketing of NVPs: ‘most restrictive’ (Australia), ‘restrictive’ (Canada) or ‘less restrictive’ (England and United States).

Participants: A total of 6615 adult smokers who reported having visited an HP in the last year (drawn from the total sample of 12 294 4CV1 respondents, of whom 9398 reported smoking cigarettes daily or weekly). Respondents were from the United States (n = 1518), England (n = 2116), Australia (n = 1046), and Canada (n = 1935).

Measurements: Participants’ survey responses indicated if they were current daily or weekly smokers and had visited an HP in the past year. Among those participants, further questions asked participants to report (1) whether NVPs were discussed, (2) who raised the topic, (3) advice received on use of NVPs and (4) advice received on quitting smoking.

Findings: Among the 6615 smokers who visited an HP in the last year, 6.8% reported discussing NVPs with an HP and 2.1% of smokers were encouraged to use an NVP (36.1% of those who had a discussion). Compared with Australia (4.3%), discussing NVPs with an HP was more likely in the United States [8.8%, odds ratio (OR) = 2.15, 95% confidence interval (CI) = 1.41–3.29] and Canada (7.8%, OR = 1.87, 95% CI = 1.26–2.78). Smokers in Australia were less likely to discuss NVPs than smokers in England (6.2%), although this was not statistically significant (OR = 1.47, 95% CI = 0.98–2.20). Overall, the prevalence of HPs recommending NVPs was three times more likely in the United States than in Australia (OR = 3.07, 95% CI = 1.45–6.47), and twice as likely in Canada (OR = 2.28, 95% CI = 1.06–4.87) than in Australia. Australia and England did not differ (OR = 1.76, 95% CI = 0.83–3.74). Just over half (54%) of respondents brought up NVPs themselves; there were no significant differences among countries.

Conclusions: Discussions in Australia, Canada, England, and the United States between smokers and health professionals about nicotine vaping products appear to be infrequent, regardless of the regulatory environment. A low percentage of health professionals recommended vaping products. This was particularly evident in Australia, which has the most restrictive regulatory environment of the four countries studied.

Citation

Branston, J.R., McNeill, A., Gilmore, A., Hiscock, R., Partos, T.R. (2018). Keeping smoking affordable in higher tax environments via smoking thinner roll-your-own cigarettes: Findings from the International Tobacco Control Four Country Survey 2006–15. Drug and Alcohol Dependence, 193, 110-116.

Abstract

Background: Roll-Your-Own tobacco (RYO) use is increasingly popular in many countries: it is generally cheaper than factory-made cigarettes (FM), and smokers can further reduce costs by adjusting the amount of tobacco in each cigarette. However, the level of risk of RYO compared with FM cigarettes is similar and does not meaningfully change with cigarette weight. We assessed the weight of tobacco in RYO cigarettes across jurisdictions with differing tobacco taxes/prices and over time.

Method: Six waves of the International Tobacco Control 4 Country longitudinal study of smokers and recent ex-smokers, providing 3176 observations from exclusive RYO users covering 2006-15, are used to calculate the weight of tobacco used in RYO cigarettes in the US, Canada, Australia, and the UK. Multilevel regression analyses were used to compare weights across countries, socio-demographic factors, and over time.

Results: Smokers in the UK and Australia, where tobacco is relatively expensive, show higher levels of exclusive RYO use (25.8% and 13.8% respectively) and lower mean weights of tobacco per RYO cigarette (0.51 g(sd 0.32 g) and 0.53 g(0.28 g)), compared with both Canada and especially the US (6.0% and 3.5%, and 0.76 g(0.45 g) and 1.07 g(0.51 g)). Smokers in the UK and Australia also exhibited a statistically significant year-on-year decrease in the mean weight of each RYO cigarette.

Conclusions: Taxation of RYO should increase considerably in the UK and Australia so that RYO and FM cigarettes are taxed equivalently to reduce RYO attractiveness and inequalities. Other measures to reduce the price differentials, including taxing RYO solely on weight, are also discussed.

Citation

Levy, D., Abrams, D.B., Yuan, Z., Lou, Y., Fong, G.T., Borland, R. (2019). A modeling approach to gauging the effects of nicotine vaping product use on cessation from cigarettes: What do we know, what do we need to know? Addiction, 114(Suppl 1), 86-96.

Abstract

Background and Aims: The long term population health impact of nicotine vaping products (NVPs) use among smokers is unknown and subject to a range of plausible assumptions about the use and health consequences of NVPs. While NVPs use may substitute for cigarette smoking and thereby aid in quitting cigarette use, it is also possible that smokers who would have otherwise quit would instead delay quitting cigarettes. We aimed to develop a cohort-specific simulation model of the impact of NVPs on smoking cessation by adult smokers and resulting premature deaths (PD) and life-years lost (LYL).

Design: A cohort-specific simulation model of the impact of NVPs on smoking cessation by adult smokers and resulting premature deaths (PD) and life-years lost (LYL) was developed by gender for two birth-cohorts, age 30 and age 50 in 2012. Extensive sensitivity analyses were conducted.

Setting: United States PARTICIPANTS: Smokers in two birth-cohorts, age 30 and age 50 in 2012 MEASUREMENTS: Data were from the 1965-2012 National Health Interview Surveys and the 2014/5 Tobacco Use Supplement of the Current Population Survey. The model incorporated a range of plausible assumptions from published literature about transition rates from regular smoking to exclusive NVP and dual use, from dual use to exclusive NVP use and from exclusive NVP use to no use.

Findings: Compared with the No-NVP scenario, the male (female) model projected 17.8% (19.3%) fewer PDs and 22.9% (26.6%) fewer LYL for the 1982 cohort and 5.4% (7.3%) fewer PDs and 7.9% (11.4%) fewer LYL for the 1962 cohort. These gains were sensitive to NVP use over time, age of initial NVP use, transitions from smoking to dual, exclusive NVP and no use, and relative NVP mortality risks.

Conclusions: Nicotine vaping product (NVP) use in the US is projected to have a net positive impact on population health over a wide range of plausible levels of NVP use, transitions to dual, exclusive NVP and no use, and NVP risks. However, net impact is sensitive to parameter estimates.

Citation

Heckman, B.W., Cummings, K.M., Stoltman, J.J.K., Dahne, J., Borland, R., Fong, G.T., Carpenter, M.J. (2019). Longer duration of smoking abstinence is associated with waning cessation fatigue. Behaviour Research and Therapy, 115, 12-18.

Abstract

Background: Cessation fatigue, a construct theorized to reflect exhaustion of coping resources due to quitting smoking, has been found to predict relapse. This study examines the association between cessation fatigue and duration of abstinence among 1397 adult former smokers who participated in the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Wave 1 Survey (4CV). We hypothesized lower levels of cessation fatigue will be correlated with longer duration of abstinence.

Method: Data for this cross-sectional study were collected in a web-based survey which recruited national samples from Australia, Canada, England, and United States. Former smokers were abstinent up to five years.

Results: Lower cessation fatigue was associated with longer duration of smoking abstinence. Cessation fatigue was highest in former smokers that had been quit for up to six months, with lower cessation fatigue found in those quit for at least seven months and another drop-off in fatigue observed for those quit for at least two years.

Conclusions: Cessation fatigue is highest soon after quitting smoking but declines over time for those who remain abstinent. Understanding the mechanisms by which cessation fatigue is related to abstinence could potentially offer insights into ways to help individuals sustain quitting.

Citation

Levy, D., Yuan, Z., Abrams, D.B. (2018). The relationship of e-cigarette use to cigarette quit attempts and cessation: insights from a large, nationally representative U.S. Survey. Nicotine and Tobacco Research, 20(8), 931-939.

Abstract

Objectives: While cessation from cigarettes is a top priority for public health, controversy surrounds the role of e-cigarettes for quitting cigarettes. This study examines the role of e-cigarettes in quit attempts and 3-month cigarette abstinence using a large, recent nationally representative US sample.

Methods: Data from the 2014/15 Tobacco Use Supplement-Current Population Survey (TUS-CPS) on cigarette and e-cigarette use and individual characteristics were supplemented with information on state tobacco control policies. We estimated frequencies and multivariate logistic equations for making a quit attempt among those who smoked 1 year earlier and for remaining abstinent at least 3 months among those making a quit attempt. These two outcomes were related to demographic characteristics, tobacco control policies and different frequency measures of e-cigarette use (ever, at least 1, 5, 20 of the last 30 days, a continuous measure of days use).

Results: Having made a quit attempt was more likely among smokers using e-cigarettes than non-users. Among those making at least one quit attempt, quit success was lower among ever users, but higher among those with at least 5 days use of e-cigarettes in the last month. Both quit attempts and quit success were linearly related to the frequency of e-cigarette use.

Conclusions: Consistent with randomized trials and those observational studies that measure frequency of e-cigarette use, both quit attempts and quit success were positively associated with increased frequency of e-cigarette use. Frequency of e-cigarette use was important in gauging the nature of these relationships.

Implications: Previous studies have obtained mixed results regarding the relationship of e-cigarette use to cigarette smoking cessation. This study provides a more precise methodology for considering the relationship of e-cigarette use to quit attempts and to quit success, and finds that quit attempts and quit success increase with the number of days use in the past month.

Citation

Partos, T.R., Branston, J.R., Hiscock, R., Gilmore, A., McNeill, A. (2019). Individualised tobacco affordability in the UK 2002-2014: Findings from the International Tobacco Control Policy Evaluation Project. Tobacco Control, 28(Suppl 1), S9-S19.

Abstract

Objective: The existing measures of tobacco affordability (smokers' purchasing power for tobacco) use national estimates of income and average cigarette prices, and exclude roll-your-own (RYO) tobacco. This study developed an individualised measure of tobacco affordability using smokers' own incomes and factory-made (FM) or RYO tobacco purchase prices, and explored how it was impacted by taxation changes, individual characteristics and purchase patterns.

Design: Cross-sectional survey data collated from 10 waves of a longitudinal cohort study.

Data Sources: Adult smokers (n=4062) from the International Tobacco Control Policy Evaluation Project United Kingdom (UK), surveyed between 2002 and 2014, providing 8943 observations over 10 surveys.

Analysis: Affordability was calculated as the percentage of annual income remaining with the individuals after their annual tobacco expenditure. Multilevel linear regression models were used with affordability as the outcome using time, sex, age, geographical region, ethnicity, education, nicotine dependence and tobacco purchase source as the predictor variables.

Results: Affordability of FM cigarettes decreased significantly from 91.5% (±95% CI: 91.0% to 91.9%) in 2002 to 87.8% (87.0% to 88.5%) in 2014; and RYO from 96.3% (95.7% to 96.9%) in 2006 to 93.7% (93.0% to 94.4%) in 2014. Affordability was significantly lower for FM than RYO. Year-on-year decreases were not statistically significant. Tobacco was more affordable for males, those with higher education, less dependent smokers and those purchasing from non-store (potentially illicit) or non-UK sources.

Conclusions: An individualised measure of tobacco affordability provided useful insights on the impact of tobacco taxes, social inequalities and purchase patterns in the UK. Although tobacco became less affordable, the annual rate of decline was low, suggesting annual tax rises were not large enough.

Citation

Wadsworth, E., McNeill, A., Li, L., Hammond, D., Thrasher, J.F., Yong, H.H., Cummings, K.M., Fong, G.T., Hitchman, S.C. (2018). Reported exposure to e-cigarette advertising and promotion in different regulatory environments: findings from the International Tobacco Control Four Country (ITC-4C) Survey. Preventive Medicine, 112, 130-37.

Abstract

Electronic cigarette (e-cigarette) advertising regulations differ across countries. This study examines how differences in e-cigarette advertising regulations influence exposure to e-cigarette advertising, and perceptions about what participants had seen and read about e-cigarettes. Data come from the ITC Four Country Survey (Canada [CA], United States [US], Australia [AU] and United Kingdom [UK]) carried out between August 2013 and March 2015 (n = 3460). In 2014, AU and CA had laws prohibiting the retail sale of e-cigarettes containing nicotine while the US and UK had no restrictions, although a voluntary agreement restricting advertising in the UK was introduced during fieldwork. Smokers and ex-smokers were asked whether in the last six months they had noticed e-cigarettes advertisements and received free samples/special offers (promotion), and about their perceptions (positive or otherwise) of what they had seen or read about e-cigarettes. Data were analyzed in 2017. US and UK participants were more likely to report that they had noticed e-cigarette advertisements and received promotions compared to CA or AU participants. For TV and radio advertisements, reported exposure was higher in US compared to UK. For all types of advertisements, reported exposure was higher in CA than AU. Overall, nearly half of AU (44.0%) and UK (47.8%) participants perceived everything they had seen and read about e-cigarettes to be positive, with no significant differences between AU and UK. Participants in countries with permissive e-cigarette advertising restrictions and less restrictive e-cigarette regulations were more likely to notice advertisements than participants in countries with more restrictive e-cigarette regulations.

Citation

Yong, H.H., Borland, R., Cummings, K.M., Partos, T. (2018). Do predictors of smoking relapse change as a function of duration of abstinence? Findings from the United States, Canada, United Kingdom and Australia. Addiction, 113(7), 1295-1304.

Abstract

Aims: To estimate predictors of time to smoking relapse and test if prediction varied by quit duration.

Design: Longitudinal cohort data from the International Tobacco Control Four-Country survey with annual follow up collected between 2002 and 2015.

Setting: Canada, United States, United Kingdom and Australia.

Participants: A total of 9171 eligible adult smokers who had made at least one quit attempt during the study period.

Measurements: Time to relapse was the main outcome. Predictor variables included pre-quit baseline measures of nicotine dependence, smoking and quitting-related motivations, quitting capacity and social influence, and also two post-quit measures, use of stop-smoking medications and quit duration (1–7 days, 8–14 days, 15–31 days, 1–3 months, 3–6 months, 6–12 months, 1–2 years and 2+ years), along with socio-demographics.

Findings: All factors were predictive of relapse within the first 6 months of quitting but only wanting to quit, quit intentions and number of friends who smoke were still predictive of relapse in the 6–12-month period of quitting [hazard ratios (HR) = 1.20, P < 0.05; 1.13, P < 0.05; and 1.21, P < 0.001, respectively]. Number of friends smoking was the only remaining predictor of relapse in the 1–2 years quit period (HR = 1.19, P = 0.001) with none predictive beyond the 2-year quit period. Use of stop-smoking medications during quit attempts was related negatively to relapse during the first 2 weeks of quitting (HR = 0.71–0.84), but related positively to relapse in the 1–6-month quit period (HR = 1.29–1.54). Predictive effects of all factors showed significant interaction with quit duration except for perceiving smoking as an important part of life, prematurely stubbing out a cigarette and wanting to quit.

Conclusions: Among adult smokers in the United States, Canada, United Kingdom and Australia, factors associated with smoking relapse differ between the early and later stages of a quit attempt, suggesting that the determinants of relapse change as a function of abstinence duration.

Citation

Ma, B., Yong, H.H., Borland, R., McNeill, A., Hitchman, S.C. (2018). Factors associated with future intentions to use personal vaporizers among those with some experience of vaping. Drug and Alcohol Review, 37(2), 216-225.

Abstract

Introduction and Aims. Personal vaporisers (PV), including e‐cigarettes, may be a harm reduction strategy for tobacco control. This study aims to identify factors associated with future intentions to vape among smokers and ex‐smokers in Australia and the UK.

Design and Methods. Cross‐sectional data of smokers and ex‐smokers (n = 1199, mean age = 45.3 years, 44.8% male), collected in 2014/2015 and divided into four subgroups: smoking past vapers (SPV), smoking vapers (SV), ex‐smoking past vapers (ESPV) and ex‐smoking vapers (ESV), from the International Tobacco Control Australia and UK surveys were analysed by using regression models.

Results. Higher vaping satisfaction increased vaping intentions for all groups except ESPV. Perceiving PVs as less harmful predicted intentions to vape for all groups except ESV. The importance of PVs for stopping smoking predicted lower intentions to continue vaping for SV, but higher intentions to initiate vaping for SPV. The importance of PVs for cutting down smoking was a positive predictor only for SPV. Among ex‐smokers, importance for maintaining not smoking was a positive predictor for ESPV, but not for ESV. The importance of perceiving vapour being less harmful also depended on vaping status for ex‐smokers. The only country interaction was that only in the UK was perceiving PVs as less harmful associated with intention among SPV.

Discussion and Conclusion. Factors influencing intentions vary by smoking and/or vaping status, with greater differences between the ex‐smoker subgroups. This is consistent with PVs being seen as a way of managing smoking, rather than something that has intrinsic value, for all except the ex‐smoking vapers.

Citation

Ma, B., Yong, H.H., Borland, R., McNeill, A., Hitchman, S.C. (2018). Factors associated with future intentions to use personal vaporizers among those with some experience of vaping. Drug and Alcohol Review, 37(2), 216-225.

Abstract

Introduction and Aims: Personal vaporisers (PV), including e-cigarettes, may be a harm reduction strategy for tobacco control. This study aims to identify factors associated with future intentions to vape among smokers and ex-smokers in Australia and the UK.

Design and Methods: Cross-sectional data of smokers and ex-smokers (n = 1199, mean age = 45.3 years, 44.8% male), collected in 2014/2015 and divided into four subgroups: smoking past vapers (SPV), smoking vapers (SV), ex-smoking past vapers (ESPV) and ex-smoking vapers (ESV), from the International Tobacco Control Australia and UK surveys were analysed by using regression models.

Results: Higher vaping satisfaction increased vaping intentions for all groups except ESPV. Perceiving PVs as less harmful predicted intentions to vape for all groups except ESV. The importance of PVs for stopping smoking predicted lower intentions to continue vaping for SV, but higher intentions to initiate vaping for SPV. The importance of PVs for cutting down smoking was a positive predictor only for SPV. Among ex-smokers, importance for maintaining not smoking was a positive predictor for ESPV, but not for ESV. The importance of perceiving vapour being less harmful also depended on vaping status for ex-smokers. The only country interaction was that only in the UK was perceiving PVs as less harmful associated with intention among SPV.

Discussion and Conclusion: Factors influencing intentions vary by smoking and/or vaping status, with greater differences between the ex-smoker subgroups. This is consistent with PVs being seen as a way of managing smoking, rather than something that has intrinsic value, for all except the ex-smoking vapers.

Citation

El-Toukhy, S., Choi, K., Hitchman, S.C., Bansal-Travers, M., Thrasher, J.F., Yong, H.H., O’Connor, R.J., Shang, C. (2018). Banning tobacco price promotions, smoking-related beliefs, and behaviour: findings from the International Tobacco Control Four Country (ITC 4C) Survey. Tobacco Control, 27(3), 310-318.

Abstract

Background: Ecological models emphasise multilevel influences on health behaviours. While studies show that exposure to price promotions is associated with smoking behaviour and its antecedents, less is known about whether these associations differ by macro-level factors such as national price promotion policies.

Methods: Current and former smokers (N=4698) from the International Tobacco Control Policy Evaluation Project four-country cohort were included in weighted multivariate logistic regression models to examine individual-level associations between exposure to price promotions at waves 7 and 8 (conducted in 2008–2009 and 2010–2011) and beliefs (social and injunctive norms, functional value of smoking, misconceptions around smoking and beliefs of tobacco industry and its regulations) and behaviour at wave 8, stratified by whether countries allow (Australia and USA) or ban (Canada and UK) price promotions.

Results: Associations between exposure to price promotions and smoking-related beliefs and behaviour differed by national price promotion policies. In countries that allow price promotions, participants repeatedly exposed to price promotions at waves 7 and 8 were more likely to associate functional values to smoking (ie, calms down when stressed (adjusted OR (AOR) 1.83) and to be current smokers at wave 8 (AOR 1.94). In countries that ban price promotions, participants repeatedly exposed to price promotions were less likely to hold misconceptions around smoking (ie, harsher smoke is more dangerous).

Conclusions: Differential associations emerged between exposure to price promotions, smoking-related beliefs and behaviour across countries with and without a price promotions ban. Adopting price promotion bans could ameliorate the associations between exposure to price promotions and smoking beliefs and behaviours.

Citation

Levy, D., Tam, J., Kuo, C., Fong, G.T., Chaloupka, F.J. (2018). The impact of implementing tobacco control policies: the 2017 tobacco control policy scorecard. Journal of Public Health Management and Practice, 24(5), 448-457.

Abstract

The Tobacco Control Scorecard, published in 2004, presented estimates of the effectiveness of different policies on smoking rates. Since its publication, new evidence has emerged. We update the Scorecard to include recent studies of demandreducing tobacco policies for high-income countries. We include cigarette taxes, smoke-free air laws, media campaigns, comprehensive tobacco control programs, marketing bans, health warnings, and cessation treatment policies. To update the 2004 Scorecard, a narrative review was conducted on reviews and studies published after 2000, with additional focus on 3 policies in which previous evidence was limited: tobacco control programs, graphic health warnings, and marketing bans. We consider evaluation studies that measured the effects of policies on smoking behaviors. Based on these findings, we derive estimates of short-term and long-term policy effect sizes. Cigarette taxes, smoke-free air laws, marketing restrictions, and comprehensive tobacco control programs are each found to play important roles in reducing smoking prevalence. Cessation treatment policies and graphic health warnings also reduce smoking and, when combined with policies that increase quit attempts, can improve quit success. The effect sizes are broadly consistent with those previously reported for the 2004 Scorecard but now reflect the larger evidence base evaluating the impact of health warnings and advertising restrictions.

Citation

Hummel, K., Nagelhout, G.E., Fong, G.T., Vardavas, C., Papadakis, S., Herbec, A., Mons, U., van den Putte, B., Borland, R., Fernández, E., de Vries, H., McNeill, A., Gravely, S., Przewoźniak, K., Kovacs, P., Trofor, A., Willemsen, M.C., on behalf of the EUREST-PLUS Consortium. (2018). Quitting activity and use of cessation assistance reported by smokers in eight European countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 57-73.

Abstract

Introduction: There is clear evidence that the use of cessation aids significantly increases the likelihood of successful smoking cessation. The aim of this study was to examine quitting activity and use of cessation aids among smokers from various European countries. Subgroup differences were also examined for sex, income, education, and age in each country.

Methods: Cross-sectional data were collected in 2016 from 10683 smokers in eight European countries participating in the ITC Project: England (n=3536), Germany (n=1003), Greece (n=1000), Hungary (n=1000), the Netherlands (n=1136), Poland (n=1006), Romania (n=1001), and Spain (n=1001). We measured quitting activity, including quit attempts in the previous 12 months and intention to quit, use of cessation aids (i.e. medication, quitlines, internet, local services, e-cigarettes), and whether respondents had received advice from health professionals about quitting and e-cigarettes.

Results: Quit attempts were most common in England (46.3%) and least common in Hungary (10.4%). Quit intention was highest in England and lowest in Greece. Use of e-cigarettes to quit was highest in England (51.6%) and lowest in Spain (5.0%). Use of cessation aids was generally low across all countries; in particular this was true for quitlines, internet based support, and local services. Receiving health professional advice to quit was highest in Romania (56.5%), and lowest in Poland (20.8%); few smokers received advice about e-cigarettes from health professionals. No clear differences were found for sex and income groups. Across countries, smokers with lower education reported less quitting activity.

Conclusions: Quitting activity and use of cessation methods were low in most countries. Greater quit attempts and use of cessation aids were found in England, where large investments in tobacco control and smoking cessation have been made. Health professionals are important for motivating smokers to quit and promoting the effectiveness of various methods, but overall, few smokers get advice to quit.

Citation

Kahnert, S., Demjén, T., Tountas, Y., Trofor, A., Przewoźniak, K., Zatónski, W.A., Fernández, E., McNeill, A., Willemsen, M.C., Kyriakos, C.N., Fong, G.T., Vardavas, C. Mons, U., on behalf of the EUREST-PLUS Consortium. (2018). Extent and correlates of self-reported exposure to tobacco advertising, promotion, and sponsorship in smokers: findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 74-84.

Abstract

Introduction: Tobacco advertising, promotion and sponsorship (TAPS) are known to promote tobacco consumption and to discourage smoking cessation. Consequently, comprehensive TAPS bans are effective measures to reduce smoking. The objective of this study was to investigate to what extent smokers are exposed to TAPS in general, and in various media and localities, in different European countries.

Methods: A cross-sectional analysis of national representative samples of adult smokers in 2016 from Germany, Greece, Hungary, Poland, Romania, and Spain (EUREST-PLUS Project, n=6011), as well as England (n=3503) and the Netherlands (n=1213) (ITC Europe Surveys) was conducted. Prevalence of self-reported TAPS exposure is reported by country, and socioeconomic correlates were investigated using logistic regression models.

Results: Self-reported exposure to TAPS varied widely among the countries, from 15.4 % in Hungary to 69.2 % in the Netherlands. In most countries, tobacco advertising was most commonly seen at the point of sale, and rarely noticed in mass media. The multivariate analysis revealed some variation in exposure to TAPS by sociodemographic factors. Age showed the greatest consistency across countries with younger smokers (18–24 years) being more likely to notice TAPS than older smokers.

Conclusions: TAPS exposure tended to be higher in countries with less restrictive regulation but was also reported in countries with more comprehensive bans, although at lower levels. The findings indicate the need for a comprehensive ban on TAPS to avoid a shift of marketing efforts to less regulated channels, and for stronger enforcement of existing bans.

Citation

Lee, C., Yong, H.H., Borland, R., McNeill, A., Hitchman, S.C. (2018). Acceptance and patterns of use of vaping in Australia and the United Kingdom: results from the International Tobacco Control Survey. Drug & Alcohol Dependence, 185, 142-48.

Abstract

Background: This study examined the prevalence and correlates of (1) perceived social acceptability of personal vaporizer (PV)/e-cigarette use, and (2) reported vaping in public and private places, in the UK and Australia with different regulatory environments for PVs.

Methods: Data analyzed come from 2849 smokers and recent ex-smokers in the UK and Australia who participated in the 2014 wave of the International Tobacco Control Survey.

Results: UK respondents were more likely to think vaping is socially acceptable than Australians (56.4% vs. 27.9%; p < 0.001). Having quit smoking, observing vaping in smoke-free (SF) public places, and believing vaping is less harmful than smoking was all significantly associated with greater perceived social acceptability of vaping in both countries. However, vaping status and that of friends and family were more influential in Australia than in the UK. Vaping was reported as much more common in private, than public, settings in both countries. UK vapers were more likely to report vaping in SF public places (OR = 2.66; 95% CI = 1.5-4.7; p < 0.01) and at home (OR = 2.44; 95% CI = 1.5-3.9; p < 0.001), but not in their car when controlling for demographic factors and vaping and smoking status.

Conclusion: The acceptability of vaping was greater among those who were more exposed to vaping and not just among those with some personal experience of vaping, suggesting no strong social barriers to increased use. Vaping in SF public places was less common than in homes, and both were more common in the UK than in Australia, suggesting some social constraints on use, particularly in Australia.

Citation

Levy, D. (2018). Communicating accurate and complete information. Addictive Behaviours, 76, 386-387.

Highlights:

• Consumers should be provided with the best information about the risks of different tobacco products to make informed choices.
• However, better information is needed about effectively communicating relative as well as absolute risks.
• In particular, studies are needed on communicating the risks of dual use.

Citation

Heckman, B., Fong, G.T., Borland, R., Hitchman, S.C., O’Connor, R.J., Bickel, W.K., Stein, J., Yong, H.H., Nahhas, G., Pope, D., Shang, C., Cheng, K.W., Levy, D., Cummings, K.M. (2019). The impact of vaping and regulatory environment on cigarette demand: Behavioral economic perspective across four countries. Addiction, 114(Suppl 1), 123-133.

Abstract

Background and Aims: Government regulations of nicotine vaping products (NVP) have evolved rapidly during the past decade. The impact of NVP regulatory environment and vaping on cigarette demand is unknown. The current study aims to investigate whether or not respondents’ reported cigarette demand, as measured by a hypothetical cigarette purchase task, varies with (1) smoking status, (2) vaping status or (3) NVP regulatory environment (country used as proxy).

Design: Cross‐sectional survey data from wave 1 of the International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey (2016).

Setting: Australia, Canada, England and the United States.

Participants: A total of 10 316 adult smokers.

Measurements: A hypothetical purchase task asked smokers to estimate how many cigarettes they would purchase for consumption in a single day across multiple cigarette prices. Responses were used to derive measures of cigarette demand. Overall sensitivity of cigarette consumption to price increases was quantified to index cigarette demand elasticity, whereas estimated consumption when cigarettes are free was used to index cigarette demand intensity.

Findings: A majority of the non‐daily smokers had previously smoked daily (72.3%); daily vapers were more likely to be former daily smokers (89.9%) compared to non‐daily vapers (70.1%) and non‐vapers (69.2%) (P < 0.001). The smoking status × vaping status interaction was significant for cigarette demand intensity (F = 4.93; P = 0.007) and elasticity (F = 7.30; P = 0.001): among non‐daily smokers, vapers reported greater intensity but lower elasticity (i.e. greater demand) relative to non‐vapers (Ps < 0.05). Among daily smokers, daily vapers reported greater intensity relative to non‐vapers (P = 0.005), but vaping status did not impact elasticity (Ps > 0.38). Intensity was higher in Australia compared with all other countries (Ps < 0.001), but elasticity did not vary by country (F = 2.15; P = 0.09).

Conclusions: In a hypothetical purchase task, non‐daily smokers showed lower price elasticity if they used e‐cigarettes than if they did not, while there was no clear difference in elasticity between e‐cigarette users and non‐users among daily smokers or according to regulatory environment of their country with regard to e‐cigarettes.