Abstract

Introduction: To date, no studies have explored how different regulatory environments may influence the effectiveness of ECs as a smoking cessation aid.

Objective: This study compares the real-world effectiveness of adult smokers using ECs for quitting compared with quitting unassisted or quitting with NRT and/or prescription medications in two countries with restrictive policies towards ECs (i.e., Canada and Australia) versus two countries with less restrictive policies (i.e., US and UK).

Methods: Data were drawn from the International Tobacco Control Four Country surveys, from the US and Canada (2 waves, n=318 and 380, respectively), the UK (3 waves, n=439) and Australia (4 waves, n=662), collected 2010-2014. Smokers at baseline wave who reported making a quit attempt at follow-up were included. The primary outcome was self-reported abstinence for at least 30 days regardless of smoking status at follow-up assessment. Data across waves were combined and analysed using generalised estimating equations.

Results: Compared to unassisted quitting (i.e. no medications or ECs), smokers who used ECs for quitting from countries with less restrictive EC policy environments were more likely (OR=1.95, 95%CI=1.19-3.20, p<0.01), whereas smokers who used ECs for quitting from countries with more restrictive EC policies were less likely (OR=0.36, 95%CI=0.18-0.72, p<0.01), to report sustained abstinence for at least 30 days.

Conclusion: Use of ECs in the real world during a quit attempt appears only effective for sustaining smoking abstinence in a less restrictive EC environment suggesting that the benefits of ECs for smoking cessation are likely highly dependent on the regulatory environment.

Implications: What this study adds: This is the first study to examine the impact of regulatory environment for electronic cigarettes (ECs) on their real-world effectiveness for smoking cessation. This study shows that in a less restrictive EC regulatory environment, use of ECs during a quit attempt facilitates, but in a more restrictive environment, it inhibits, short-term sustained abstinence. The findings underscore the need for careful consideration on how best to regulate this emerging product so that EC benefits for smoking cessation are maximised and its risks to public health are minimised.

Citation

Kasza, K.A., Hyland, A., Borland, R., McNeill, A., Fong, G.T., Carpenter, M.J., Partos, T.R., Cummings, K.M. (2017). Cross-country comparison of smokers’ reasons for thinking about quitting over time: Findings from the International Tobacco Control Four Country Survey (ITC-4C), 2002-2015. Tobacco Control, 26(6), 641-648.

Abstract

Objective: To explore between-country differences and within-country trends over time in smokers' reasons for thinking about quitting and the relationship between reasons and making a quit attempt.

Methods: Participants were nationally representative samples of adult smokers from the UK (N=4717), Canada (N=4884), the USA (N=6703) and Australia (N=4482), surveyed as part of the International Tobacco Control Four Country Survey between 2002 and 2015. Generalised estimating equations were used to evaluate differences among countries in smokers' reasons for thinking about quitting and their association with making a quit attempt at follow-up wave.

Results: Smokers' concern for personal health was consistently the most frequently endorsed reason for thinking about quitting in each country and across waves, and was most strongly associated with making a quit attempt. UK smokers were less likely than their counterparts to endorse health concerns, but were more likely to endorse medication and quitline availability reasons. Canadian smokers endorsed the most reasons, and smokers in the USA and Australia increased in number of reasons endorsed over the course of the study period. Endorsement of health warnings, and perhaps price, appears to peak in the year or so after the change is introduced, whereas other responses were not immediately linked to policy changes.

Conclusions: Differences in reasons for thinking about quitting exist among smokers in countries with different histories of tobacco control policies. Health concern is consistently the most common reason for quitting and the strongest predictor of future attempts.

Citation

Kasza, K.A., Hyland, A., Cummings, K.M., Carpenter, M.J., Fong, G.T., Borland, R., McNeill, A. (2017). A cross-country comparison of smokers’ reasons for thinking about quitting over time: Findings from the International Tobacco Control Four Country Survey (ITC-4C), 2002-2015. Tobacco Control, 26(6), 641-48.

Abstract

Objective: To explore between-country differences and within-country trends over time in smokers' reasons for thinking about quitting and the relationship between reasons and making a quit attempt.

Methods: Participants were nationally representative samples of adult smokers from the UK (N=4717), Canada (N=4884), the USA (N=6703) and Australia (N=4482), surveyed as part of the International Tobacco Control Four Country Survey between 2002 and 2015. Generalised estimating equations were used to evaluate differences among countries in smokers' reasons for thinking about quitting and their association with making a quit attempt at follow-up wave.

Results: Smokers' concern for personal health was consistently the most frequently endorsed reason for thinking about quitting in each country and across waves, and was most strongly associated with making a quit attempt. UK smokers were less likely than their counterparts to endorse health concerns, but were more likely to endorse medication and quitline availability reasons. Canadian smokers endorsed the most reasons, and smokers in the USA and Australia increased in number of reasons endorsed over the course of the study period. Endorsement of health warnings, and perhaps price, appears to peak in the year or so after the change is introduced, whereas other responses were not immediately linked to policy changes.

Conclusions: Differences in reasons for thinking about quitting exist among smokers in countries with different histories of tobacco control policies. Health concern is consistently the most common reason for quitting and the strongest predictor of future attempts.

Citation

Levy, D., Borland, R., Lindblom, E., Goniewicz, M., Meza, R., Holford, T.R., Yuan, Z., Luo, Y., O’Connor, R.J., Niaura, R., Abrams, D.B. (2018). Potential deaths averted in USA by replacing cigarettes with e-cigarettes. Tobacco Control, 27(1), 18-25.

Abstract

Introduction: US tobacco control policies to reduce cigarette use have been effective, but their impact has been relatively slow. This study considers a strategy of switching cigarette smokers to e-cigarette use ('vaping') in the USA to accelerate tobacco control progress.

Methods: A Status Quo Scenario, developed to project smoking rates and health outcomes in the absence of vaping, is compared with Substitution models, whereby cigarette use is largely replaced by vaping over a 10-year period. We test an Optimistic and a Pessimistic Scenario, differing in terms of the relative harms of e-cigarettes compared with cigarettes and the impact on overall initiation, cessation and switching. Projected mortality outcomes by age and sex under the Status Quo and E-Cigarette Substitution Scenarios are compared from 2016 to 2100 to determine public health impacts.

Findings: Compared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. Under the Pessimistic Scenario, 1.6 million premature deaths are averted with 20.8 million fewer life years lost. The largest gains are among younger cohorts, with a 0.5 gain in average life expectancy projected for the age 15 years cohort in 2016.

Conclusions: The tobacco control community has been divided regarding the role of e-cigarettes in tobacco control. Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, even under pessimistic assumptions regarding cessation, initiation and relative harm

Citation

Heckman, B.W., Cummings, K.M., Kasza, K.A., Borland, R., Burris, J.L., Fong, G.T., McNeill, A., Carpenter, M.J. (2017). Effectiveness of switching smoking cessation medications following relapse: A population-based study. American Journal of Preventive Medicine, 53(2), e63-e70.

Abstract

Introduction: Nicotine dependence is a chronic disorder often characterized by multiple failed quit attempts (QAs). Yet, little is known about the sequence of methods used across multiple QAs or how this may impact future ability to abstain from smoking. This prospective cohort study examines the effectiveness of switching smoking-cessation medications (SCMs) across multiple QAs.

Methods: Adult smokers (aged ≥18 years) participating in International Tobacco Control surveys in the United Kingdom, U.S., Canada, and Australia (N=795) who: (1) completed two consecutive surveys between 2006 and 2011; (2) initiated a QA at least 1 month before each survey; and (3) provided data for the primary predictor (SCM use during most recent QA), outcome (1-month point prevalence abstinence), and relevant covariates. Analyses were conducted in 2016.

Results: Five SCM user classifications were identified: (1) non-users (43.5%); (2) early users (SCM used for initial, but not subsequent QA; 11.4%); (3) later users (SCM used for subsequent, but not initial QA; 18.4%); (4) repeaters (same SCM used for both QAs; 10.7%); and (5) switchers (different SCM used for each QA; 14.2%). Abstinence rates were lower for non-users (15.9%, OR=0.48, p=0.002), early users (16.6%, OR=0.27, p=0.03), and repeaters (12.4%, OR=0.36, p=0.004) relative to switchers (28.5%).

Conclusions: Findings suggest smokers will be more successful if they use a SCM in QAs and vary the SCM they use across time. That smokers can increase their odds of quitting by switching SCMs is an important message that could be communicated to smokers.

Citation

Partos, T.R., Gilmore, A., Hitchman, S.C., Hiscock, R., Branston, R., McNeill, A. (2018). Availability and use of cheap tobacco in the United Kingdom 2002-2014: findings from the International Tobacco Control Project. Nicotine and Tobacco Research, 20(6), 714-24.

Abstract

Introduction: Raising tobacco prices is the most effective population-level intervention for reducing smoking, but this is undermined by the availability of cheap tobacco. This study monitors trends in cheap tobacco use among adult smokers in the United Kingdom between 2002 and 2014 via changes in product type, purchase source, and prices paid.

Methods: Weighted data from 10 waves of the International Tobacco Control policy evaluation study were used. This is a longitudinal cohort study of adult smokers with replenishment; 6169 participants provided 15812 responses. Analyses contrasted (1) product type: roll-your-own (RYO) tobacco, factory-made packs (FM-P), and factory-made cartons (FM-C); (2) purchase source: UK store-based sources (e.g., supermarkets and convenience stores) with non-UK/nonstore sources representing tax avoidance/evasion (e.g., outside the UK, duty free, and informal sellers); and (3) prices paid (inflation-adjusted to 2014 values). Generalized estimating equations tested linear changes over time.

Results: (1) RYO use increased significantly over time as FM decreased. (2) UK store-based sources constituted approximately 80% of purchases over time, with no significant increases in tax avoidance/evasion. (3) Median RYO prices were less than half that of FM, with FM-C cheaper than FM-P. Non-UK/nonstore sources were cheapest. Price increases of all three product types from UK store-based sources from 2002 to 2014 were statistically significant but not substantial. Wide (and increasing for FM-P) price ranges meant each product type could be purchased in 2014 at prices below their 2002 medians from UK store-based sources.

Conclusions: Options exist driving UK smokers to minimize their tobacco expenditure; smokers do so largely by purchasing cheap tobacco products from UK stores.

Implications: The effectiveness of price increases as a deterrent to smoking is being undermined by the availability of cheap tobacco such as roll-your-own tobacco and cartons of packs of factory-made cigarettes. Wide price ranges allowed smokers in 2014 to easily obtain cigarettes at prices comparable to 12 years prior, without resorting to tax avoidance or evasion. UK store-based sources accounted for 80% or more of all tobacco purchases between 2002 and 2014, suggesting little change in tax avoidance or evasion over time. There was a widening price range between the cheapest and most expensive factory-made cigarettes.

Citation

Heckman, B.W., Cummings, K.M., Kasza, K.A., Borland, R., Burris, J.L., Fong, G.T., McNeill, A., Carpenter, M.J. (2017). Effectiveness of switching smoking cessation medications following relapse: A population-based study. American Journal of Preventive Medicine, 53(2), e63-e70.

Abstract

Introduction: Nicotine dependence is a chronic disorder often characterized by multiple failed quit attempts (QAs). Yet, little is known about the sequence of methods used across multiple QAs or how this may impact future ability to abstain from smoking. This prospective cohort study examines the effectiveness of switching smoking-cessation medications (SCMs) across multiple QAs.

Methods: Adult smokers (aged ≥18 years) participating in International Tobacco Control surveys in the United Kingdom, U.S., Canada, and Australia (N=795) who: (1) completed two consecutive surveys between 2006 and 2011; (2) initiated a QA at least 1 month before each survey; and (3) provided data for the primary predictor (SCM use during most recent QA), outcome (1-month point prevalence abstinence), and relevant covariates. Analyses were conducted in 2016.

Results: Five SCM user classifications were identified: (1) non-users (43.5%); (2) early users (SCM used for initial, but not subsequent QA; 11.4%); (3) later users (SCM used for subsequent, but not initial QA; 18.4%); (4) repeaters (same SCM used for both QAs; 10.7%); and (5) switchers (different SCM used for each QA; 14.2%). Abstinence rates were lower for non-users (15.9%, OR=0.48, p=0.002), early users (16.6%, OR=0.27, p=0.03), and repeaters (12.4%, OR=0.36, p=0.004) relative to switchers (28.5%).

Conclusions: Findings suggest smokers will be more successful if they use a SCM in QAs and vary the SCM they use across time. That smokers can increase their odds of quitting by switching SCMs is an important message that could be communicated to smokers.

Citation

Yong, H.H., Borland, R., Balmford, J., Hitchman, S.C., Cummings, K.M., Driezen, P., Thompson, M.E. (2017). Prevalence and correlates of the belief that electronic cigarettes are a lot less harmful than conventional cigarettes under the different regulatory environments of Australia and the United Kingdom. Nicotine & Tobacco Research, 19(2), 258-263.

Abstract

Introduction: The rapid rise in electronic cigarettes (ECs) globally has stimulated much debate about the relative risk and public health impact of this new emerging product category as compared to conventional cigarettes. The sale and marketing of ECs containing nicotine are banned in many countries (eg, Australia) but are allowed in others (eg, United Kingdom). This study examined prevalence and correlates of the belief that ECs are a lot less harmful than conventional cigarettes under the different regulatory environments in Australia (ie, more restrictive) and the United Kingdom (ie, less restrictive).

Methods: Australian and UK data from the 2013 survey of the International Tobacco Control Four-Country project were analyzed.

Results: More UK than Australian respondents (58.5% vs. 35.2%) believed that ECs are a lot less harmful than conventional cigarettes but more respondents in Australia than in the United Kingdom selected “Don’t Know” (36.5% vs. 17.1%). The proportion that responded “A little less, equally or more harmful” did not differ between countries. Correlates of the belief that ECs are “A lot less harmful” differed between countries, while correlates of “Don’t Know” response did not differ.

Conclusions: Consistent with the less restrictive regulatory environment affecting the sale and marketing of ECs, smokers and recent ex-smokers in the United Kingdom were more likely to believe ECs were less harmful relative to conventional cigarettes compared to those in Australia.

Implications: What this study adds: Among smokers and ex-smokers, this study found that the belief that ECs are (a lot) less harmful than conventional cigarettes was considerably higher in the United Kingdom than in Australia in 2013. The finding is consistent with the less restrictive regulatory environment for ECs in the United Kingdom, suggesting that the regulatory framework for ECs adopted by a country can affect smokers’ perceptions about the relative harmfulness of ECs, the group that stands to gain the most from having an accurate belief about the relative harms of ECs.

Citation

Levy, D., Borland, R., Fong, G.T., Villanti, A.C., Niaura, R., Meza, R., Holford, T.R., Cummings, K.M., Abrams, D.B. (2017). Developing consistent and transparent models of e-cigarette use: Reply to Glantz and Soneji et al. Nicotine and Tobacco Research, 19(2), 268-270.

There is no abstract available for this publication.

Citation

Fix, B.V., O’Connor, R., Benowitz, N.L., Heckman, B., Cummings, K.M., Fong, G.T., Thrasher, J.F. (2017). Nicotine Metabolite Ratio (NMR) prospectively predicts smoking relapse: longitudinal findings from ITC Surveys in five countries. Nicotine and Tobacco Research, 19(9), 1040-1047.

Abstract

Introduction: The ratio of trans 3’-hydroxycotinine (3HC) to cotinine (nicotine metabolite ratio, NMR) is a biomarker of the rate of nicotine metabolism, with higher NMR indicating faster metabolism. Higher NMR has been found to be associated with higher daily cigarette consumption and less success stopping smoking in cessation trials. This study examines differences in NMR among population-based samples of smokers in the 5 countries and explores the relationship between NMR and smoking abstinence.

Methods: Participants (N=874) provided saliva samples during International Tobacco Control (ITC) surveys in the US, UK, Mauritius, Mexico, and Thailand conducted in 2010/2011 with follow-up surveys in 2012/2013. When all samples were received, they were sent to a common laboratory for analysis using liquid chromatography and tandem mass spectroscopy.

Results: There was significant variation in NMR across countries (F=15.49, p<.001). Those who reported smoking at follow-up had a mean NMR of 0.32, compared to a mean NMR of 0.42 in participants who reported that they had stopped (F=8.93; p=0.003). Higher mean NMR values were also associated with longer quit duration (p=0.007). There was no substantial difference in NMR between current smokers who made a failed quit attempt and those who made no attempt – both had significantly lower NMR compared to those who quit and remained abstinent. Smokers with a higher NMR were more likely to report that they stopped smoking compared to those with a lower NMR (OR=2.67; 95%CI: 1.25-5.68).

Conclusions: These results suggest faster nicotine metabolizers may be less likely to relapse following a quit attempt. This finding differs from results of clinical trials testing stop smoking medications, where slower metabolizers have been found to be more likely to maintain abstinence from smoking.

Citation

Cooper, J., Borland, R., McKee, S., Yong, H.H., Dugué, P.A. (2016). Depression motivates quit attempts but predicts relapse: Differential findings for gender from the International Tobacco Control Study. Addiction, 111(8), 1438-47.

Abstract

Aims: To determine whether signs of current depression predict attempts to quit smoking, and short-term abstinence among those who try, and to test moderating effects of gender and cessation support (pharmacological and behavioural).

Design: Prospective cohort with approximately annual waves. Among smokers at one wave we assessed outcomes at the next wave using mixed-effects logistic regressions.

Setting: Waves 5-8 of the Four Country International Tobacco Control Study: a quasi-experimental cohort study of smokers from Canada, USA, UK and Australia.

Participants: A total of 6811 tobacco smokers who participated in telephone surveys.

Measurements: Three-level depression index: (1) neither low positive affect (LPA) nor negative affect (NA) in the last 4 weeks; (2) LPA and/or NA but not diagnosed with depression in the last 12 months; and (3) diagnosed with depression. Outcomes were quit attempts and 1-month abstinence among attempters.

Findings: Depression positively predicted quit attempts, but not after controlling for quitting history and motivational variables. Controlling for all covariates, depression consistently negatively predicted abstinence. Cessation support did not moderate this effect. There was a significant interaction with gender for quit attempts (P = 0.018) and abstinence (P = 0.049) after controlling for demographics, but not after all covariates. Depression did not predict abstinence among men. Among women, depressive symptoms [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.49-0.81] and diagnosis (OR = 0.46, 95% CI = 0.34-0.63) negatively predicted abstinence.

Conclusions: Smokers with depressive symptoms or diagnosis make more quit attempts than their non-depressed counterparts, which may be explained by higher motivation to quit, but they are also more likely to relapse in the first month. These findings are stronger in women than men.

Citation

Nagelhout, G.E., Willemsen, M.C., de Vries, H., Mons, U., Hitchman, S.C., Kunst, A. E., Guignard, R., Siahpush, M., Yong, H.H., van den Putte, B., Fong, G.T., Thrasher, J.F. (2016). Educational differences in the impact of pictorial cigarette warning labels on smokers: Findings from the International Tobacco Control (ITC) Europe Surveys. Tobacco Control, 25(3), 325-332.

Abstract

Objective: To examine (1) the impact of pictorial cigarette warning labels on changes in self-reported warning label responses: warning salience, cognitive responses, forgoing cigarettes and avoiding warnings, and (2) whether these changes differed by smokers’ educational level.

Methods: Longitudinal data of smokers from two survey waves of the International Tobacco Control (ITC) Europe Surveys were used. In France and the UK, pictorial warning labels were implemented on the back of cigarette packages between the two survey waves. In Germany and the Netherlands, the text warning labels did not change.

Findings: Warning salience decreased between the surveys in France (OR=0.81, p=0.046) and showed a non-significant increase in the UK (OR=1.30, p=0.058), cognitive responses increased in the UK (OR=1.34, p<0.001) and decreased in France (OR=0.70, p=0.002), forgoing cigarettes increased in the UK (OR=1.65, p<0.001) and decreased in France (OR=0.83, p=0.047), and avoiding warnings increased in France (OR=2.93, p<0.001) and the UK (OR=2.19, p<0.001). Warning salience and cognitive responses decreased in Germany and the Netherlands, forgoing did not change in these countries and avoidance increased in Germany. In general, these changes in warning label responses did not differ by education. However, in the UK, avoidance increased especially among low (OR=2.25, p=0.001) and moderate educated smokers (OR=3.21, p<0.001).

Conclusions: The warning labels implemented in France in 2010 and in the UK in 2008 with pictures on one side of the cigarette package did not succeed in increasing warning salience, but did increase avoidance. The labels did not increase educational inequalities among continuing smokers.

Citation

Cooper, J., Borland, R., Yong, H.H., Fotuhi, O. (2016). The impact of quitting smoking on depressive symptoms: Findings from the International Tobacco Control Four-Country Survey. Addiction, 111(8), 1448-1456.

Abstract

Aims: To determine whether abstinence or relapse on a quit attempt in the previous year is associated with current depressive symptoms.

Design: Prospective cohort with approximately annual waves. Mixed effect logistic regressions tested whether Time 2 (T2) quitting status was associated with reporting symptoms at T2, and whether Time 1 (T1) symptoms moderated this relationship.

Setting: Waves 5 to 8 of the Four Country International Tobacco Control Study: a quasi-experimental cohort study of smokers from Canada, USA, UK and Australia.

Participants: 6978 smokers who participated in telephone surveys.

Measurements: T1 and T2 depressive symptoms in the last 4 weeks assessed with two screening items from the PRIME-MD questionnaire. Quitting status at T2: 1) No attempt since T1; 2) Attempted and relapsed; 3) Attempted and abstinent at T2.

Findings: Compared with no attempt, relapse was associated with reporting T2 symptoms (OR = 1.46, 95% CI:1.33,1.59). Associations between T2 quitting status and T2 symptoms were moderated by T1 symptoms. Relapse was positively associated with T2 symptoms for those without T1 symptoms (OR = 1.71, 95% CI:1.45,2.03) and those with T1 symptoms (OR = 1.45, 95% CI:1.23,1.70). Abstinence was positively associated for those without T1 symptoms (OR = 1.37, 95% CI:1.10,1.71) and negatively associated for those with T1 symptoms (OR = 0.74, 95% CI:0.59,0.94). Age significantly moderated these associations. Relapse did not predict T2 symptoms for those aged 18 to 39 irrespective of T1 symptoms. The negative effect of abstinence on T2 symptoms for those with T1 symptoms was significant only for those aged 18 to 39 (OR = 0.61, 95% CI = 0.40, 0.94) and 40 to 55 (OR = 0.58, 95% CI = 0.40, 0.84). The positive effect of abstinence on T2 symptoms for those without T1 symptoms was significant only for those aged over 55 (OR = 1.97, 95% CI = 1.35, 2.87).

Conclusions: Most people who stop smoking appear to be at no greater risk of developing symptoms of depression than if they had continued smoking. However, people over age 55 who stop smoking may be at greater risk of developing symptoms of depression than if they had continued smoking.

Citation

Caruso, R.V., Fix, B.V., Thrasher, J.F., Cummings, K.M., Fong, G.T., Stephens, W.E., O’Connor, R.J. (2016). Differences in cigarette design and metal content across five countries: results from the International Tobacco Control (ITC) Project. Tobacco Regulatory Science, 2(2), 166-175.

Abstract

Objectives: We examined physical cigarette design characteristics and tobacco metal content of cigarettes obtained from 5 countries to determine how these properties vary for cigarette brands, both within and across countries with different dominant manufacturers.

Methods: Cigarette packs were collected from International Tobacco Control Policy Evaluation Survey (ITC) participants in the United States (US), the United Kingdom (UK), Mauritius, Mexico, and Thailand. Cigarettes were assessed for physical and design properties (eg, ventilation, pressure drop, rod density, weight) by published methods, and for metal content (As, Cd, Ni, Pb) by X-ray fluorescence spectrometry.

Results: Statistically significant differences in cigarette design and toxic metal concentrations were observed among countries and among manufacturers within countries. Filter ventilation, which is strongly predictive of machinemeasured tar and nicotine levels, varied most widely across countries. Ni and Cd were highest in Thailand (2.23ug/g and 1.64ug/g, respectively); As was highest in Mexico (0.29ug/g) and Pb was highest in the UK. (0.43 ug/g).

Conclusions: Parties to the FCTC should consider the adoption of uniform product standards related to cigarette design, emissions, and tobacco content that would reduce population health risks.

Citation

Yong, H.H., Borland, R., Balmford, J., McNeill, A., Hitchman, S.C., Driezen, P., Thompson, M.E., Fong, G.T., Cummings, K.M. (2015). Trends in e-cigarette awareness, trial, and use under the different regulatory environments of Australia and the UK. Nicotine & Tobacco Research, 17(10), 1203-1211.

Abstract

Introduction: E-cigarettes (ECs) have gained significant attention in recent years. They have been introduced in jurisdictions with divergent existing laws that affect their legality. This provides the opportunity for natural experiments to assess effects of such laws in some cases independent of any formulated government policy. We compare patterns of EC awareness and use over a three year period in Australia where laws severely restrict EC availability, with awareness and use in the UK where ECs are readily available.

Methods: Data analysed come from Waves 8 and 9 (collected in 2010 and 2013, respectively) of the International Tobacco Control (ITC) surveys in Australia and the UK (approximately 1500 respondents per wave per country).

Results: Across both waves, EC awareness, trial, and use among current and former smokers was significantly greater in the UK than in Australia, but all three of these measures increased significantly between 2010 and 2013 in both countries, and the rate of increase was equivalent between countries. 73% of UK respondents reported that their current brands contained nicotine as did 43% in Australia even though sale, possession and/or use of nicotine-containing ECs without a permit is illegal in Australia. EC use was greater among smokers in both countries, at least in part due to less uptake by ex-smokers.

Conclusions: EC awareness and use have risen rapidly between 2010 and 2013 among current and former smokers in both Australia and the UK despite different EC regulatory environments. Substantial numbers in both countries are using ECs that contain nicotine.

Citation

Hummel, K., Nagelhout, G.E., Willemsen, M.C., Driezen, P., Springvloet, L., Mons, U., Kunst, A.E., Guignard, R., Allwright, S., van den Putte, B., Hoving, C., Fong, G.T., McNeill, A., Siahpush, M., de Vries, H. (2015). Trends and socioeconomic differences in policy triggers for thinking about quitting smoking: Findings from the International Tobacco Control (ITC) Europe Surveys. Drug and Alcohol Dependence, 155, 154-162.

Abstract

Introduction: The aim of the current study is to investigate trends and socioeconomic differences in policy triggers for thinking about quitting in six European countries.

Methods: Data were derived from all available survey waves of the International Tobacco Control (ITC) Europe Surveys (2003-2013). France conducted three survey waves (n=1420-1735), Germany three waves (n=515-1515), The Netherlands seven waves (n=1420-1668), Ireland three waves (n=582-1071), Scotland two waves (n=461-507), and the rest of the United Kingdom conducted seven survey waves (n=861-1737). Smokers were asked whether four different policies (cigarette price, smoking restrictions in public places, free or lower cost medication, and warning labels on cigarette packs) influenced them to think about quitting. Generalized Estimating Equation (GEE) models were estimated for each country.

Results: Cigarette price was mentioned most often in all countries and across all waves as trigger for thinking about quitting. Mentioning cigarette price and warning labels increased after the implementation of price increases and warning labels in some countries, while mentioning smoking restrictions decreased after their implementation in four countries. All studied policy triggers were mentioned more often by smokers with low and/or moderate education and income than smokers with high education and income. The education and income differences did not change significantly over time for most policies and in most countries.

Conclusions: Tobacco control policies work as a trigger to increase thoughts about quitting, particularly in smokers with low education and low income and therefore have the potential to reduce health inequalities in smoking.

Citation

Smith, P.H., Kasza, K.A., Hyland, A., Fong, G.T., Borland, R., McNeill, A., Brady, K., Carpenter, M.J., Hartwell, K., Prohmmo, A., McKee, S. (2015). Gender differences in medication use and cigarette smoking cessation: Results from the ITC Four Country Survey. Nicotine & Tobacco Research, 17(4), 463-472

Abstract

Introduction: There is conflicting evidence for gender differences in smoking cessation, and there has been little research on gender differences in smoking cessation medication (SCM) use and effectiveness. Using longitudinal data from the International Tobacco Control Four Country Surveys (ITC-4) conducted in the United Kingdom, the United States, Canada, and Australia, we examined gender differences in the incidence of quit attempts, reasons for quitting, use of SCMs, reasons for discontinuing use of SCMs, and rates of smoking cessation.

Methods: Data were analyzed from adult smokers participating in the ITC-4, annual waves 2006-2011 (n = 7,825), as well as a subsample of smokers (n = 1,079) who made quit attempts within 2 months of survey. Adjusted modeling utilized generalized estimating equations.

Results: There were no gender differences in the likelihood of desire to quit, plans to quit, or quit attempts between survey waves. Among quit attempters, women had 31% lower odds of successfully quitting (OR = 0.69; 95% CI = 0.51, 0.94). Stratified by medication use, quit success was lower among women who did not use any SCMs (OR = 0.59; 95% CI = 0.39, 0.90), and it was no different from men when medications were used (OR = 0.73; 95% CI = 0.46, 1.16). In particular, self-selected use of nicotine patch and varenicline contributed to successful quitting among women.

Conclusions: Women may have more difficulty quitting than men, and SCMs use may help attenuate this difference.

Citation

Brown, A., Nagelhout, G.E., van den Putte, B., Willemsen, M.C., Mons, U., Guignard, R., Thompson, M.E. (2015). Trends and socioeconomic differences in roll-your-own tobacco use: Findings from the ITC Europe Surveys.Tobacco Control, 24(Suppl 3), iii11-iii16.

Abstract

Objectives: To examine if exclusive Roll-Your-Own (RYO) tobacco use relative to factory-made (FM) cigarette use has been rising over time, to determine the extent to which economic motives and perceptions that RYO cigarettes are less harmful act as primary motivations for use, and to examine the association of income and education with the level of RYO tobacco use among smokers in four European countries.

Methods: Data were obtained from the International Tobacco Control (ITC) Europe Surveys, and a cohort sample of 7070 smokers from the Netherlands, Germany, France and UK were interviewed between June 2006 and December 2012. Generalised estimating equations (GEE) were used to assess trends in RYO use, and whether RYO consumption varied by socioeconomic variables.

Results: Exclusive RYO use over the study period has increased significantly in the UK from 26.4% in 2007 to 32.7% in 2010 (p<0.001); France from 12.2% in 2006 to 19.1% in 2012 (p<0.001); and Germany from 12.7% in 2007 to 18.6% in 2011 (p=0.031), with increased borderline significantly in the Netherlands (31.7% to 34.3%, p=0.052), from 2008 to 2010. Over three-quarters of users in each of the study countries indicated that lower price was a reason why they smoked RYO. Just over a fourth of smokers in the UK, less than a fifth in France, and around a tenth in Germany and the Netherlands believed that RYO is healthier. Compared with exclusive FM users, exclusive RYO users were more likely to have lower incomes and lower education.

Conclusions: Effective tobacco tax regulation is needed in the European Union and elsewhere to eliminate or reduce the price advantage of RYO tobacco. Additional health messages are also required to correct the misperception that RYO tobacco is healthier than FM cigarettes.

Citation

Cowie, G.A., Swift, E., Partos, T.R., Borland, R. (2015). Quitting activity and tobacco brand switching: Findings from the ITC-4 Country Survey. Australian and New Zealand Journal of Public Health, 39(2), 109-113.

Abstract

Objective: Among Australian smokers, to examine associations between cigarette brand switching, quitting activity and possible causal directions by lagging the relationships in different directions.

Methods: Current smokers from nine waves (2002 to early 2012) of the ITC-4 Country Survey Australian dataset were surveyed. Measures were brand switching, both brand family and product type (roll-your-own versus factory-made cigarettes) reported in adjacent waves, interest in quitting, recent quit attempts, and one month sustained abstinence.

Results: Switching at one interval was unrelated to concurrent quit interest. Quit interest predicted switching at the following interval, but the effect disappeared once subsequent quit attempts were controlled for. Recent quit attempts more strongly predicted switching at concurrent (OR 1.34, 95%CI=1.18-1.52, p<0.001) and subsequent intervals (OR 1.31, 95%CI=1.12-1.53, p=0.001) than switching predicted quit attempts, with greater asymmetry when both types of switching were combined. One month sustained abstinence and switching were unrelated in the same interval; however, after controlling for concurrent switching and excluding type switchers, sustained abstinence predicted lower chance of switching at the following interval (OR=0.66, 95%CI=0.47-0.93, p=0.016).

Conclusions: The asymmetry suggests brand switching does not affect subsequent quitting.

Implications: Brand switching does not appear to interfere with quitting.

Citation

Shang, C., Chaloupka, F., Fong, G.T., Thompson, M.E., Siahpush, M., Ridgeway, W. (2014, June). Weight control belief and its impact on cigarettes consumption and quit attempts: Findings from the ITC Project. Oral presentation at the American Society of Health Economists Conference, Los Angeles, California, United States.

Abstract

Background: Weight concerns are widely documented as one of the major barriers for girls and young adult women to quit smoking. Therefore, it is important to investigate whether smokers who have weight concerns respond to tobacco control policies differently than smokers who do not in terms of quit attempts, and how this difference varies by gender and country.

Objective: This study aims to investigate, by gender and country, whether smokers who believe that smoking helps control weight are less responsive to tobacco control policies with regards to quit attempts than those who do not.

Methods: We use longitudinal data from the International Tobacco Control Policy Evaluation Project in the USA, Canada, the UK and Australia to conduct the analysis. We first constructed a dichotomous indicator for smokers who have the weight control belief and then examined the disparity in policy responsiveness in terms of quit attempts by directly estimating the interaction terms of policies and the weight control belief indicator using generalised estimating equations.

Findings: We find that weight control belief significantly attenuates the policy impact of tobacco control measures on quit attempts among US female smokers and among UK smokers. This pattern was not found among smokers in Canada and Australia.

Conclusions: Although our results vary by gender and country, the findings suggest that weight concerns do alter policy responsiveness in quit attempts in certain populations. Policy makers should take this into account and alleviate weight concerns to enhance the effectiveness of existing tobacco control policies on promoting quitting smoking.

Citation

Springvloet, L., Willemsen, M.C., Mons, U., van den Putte, B., Kunst, A.E., Guignard, R., Hummel, K., Allwright, S., Siahpush, M., de Vries, H., Nagelhout, G.E. (2015). Educational differences in associations of noticing anti-tobacco information with smoking-related attitudes and quit intentions: Findings from the International Tobacco Control (ITC) Europe Surveys. Health Education Research, 30(5), 719-730.

Abstract

This study examined educational differences in associations of noticing anti-tobacco information with smoking-related attitudes and quit intentions among adult smokers. Longitudinal data (N = 7571) from two waves of six countries of the International Tobacco Control (ITC) Europe Surveys were included. Generalized estimating equation analyses and multiple linear and logistic regression analyses were conducted. Higher educated smokers noticed anti-tobacco information slightly more often than lower educated smokers (F(2) = 25.78, P < 0.001). Noticing anti-tobacco information was associated with more negative smoking-related attitudes (β = 0.05, P < 0.001) and more quit intentions (OR = 1.08, P < 0.001). Among smokers without a quit intention at baseline, a positive association was found for noticing antitobacco information at baseline with follow-up quit intention (OR = 1.14, P = 0.003). No other longitudinal associations were found. No educational differences were found in the association of noticing antitobacco information with smoking-related attitudes but associations with quit intentions were found only among low (OR = 1.12, P = 0.001) and high educated respondents (OR = 1.11, P < 0.001) and not among moderate educated respondents (OR = 1.02, P = 0.43). Noticing anti-tobacco information may positively influence quit intentions and possibly smoking-related attitudes. Lower educated smokers were as likely to be influenced by anti-tobacco information as higher educated smokers but noticed antitobacco information less often; increasing reach of anti-tobacco information may increase impact in this group.

Citation

Li, L., Borland, R., Yong, H.H., Prohmmo, A., Thrasher, J.F., Hitchman, S.C., Fong, G.T., Hammond, D., Bansal-Travers, M. (2015). Longer term impact of cigarette package warnings in Australia compared to the United Kingdom and Canada: Findings from the International Tobacco Control (ITC) Four Country Survey. Health Education Research, 30(1), 67-80.

Abstract

This study examines the effects of different cigarette package warnings in Australia, Canada and the United Kingdom up to 5 years post-implementation. The data came from the International Tobacco Control Surveys. Measures included salience of warnings, cognitive responses, forgoing cigarettes and avoiding warnings. Although salience of the UK warnings was higher than the Australian and Canadian pictorial warnings, this did not lead to greater levels of cognitive reactions, forgoing or avoiding. There was no difference in ratings between the Australian and UK warnings for cognitive responses and forgoing, but the Canadian warnings were responded to more strongly. Avoidance of the Australian warnings was greater than to UK ones, but less than to the Canadian warnings. The impact of warnings declined over time in all three countries. Declines were comparable between Australia and the United Kingdom on all measures except avoiding, where Australia had a greater rate of decline; and for salience where the decline was slower in Canada. Having two rotating sets of warnings does not appear to reduce wear-out over a single set of warnings. Warning size may be more important than warning type in preventing wear-out, although both probably contribute interactively.

Citation

Partos, T.R., Borland, R., Thrasher, J.F., Li, L., Yong, H.H., O’Connor, R.J., Siahpush, M. (2014). The predictive utility of micro indicators of concern about smoking: Data from the International Tobacco Control Four Country Survey. Addictive Behaviours, 39(8), 1235-1242.

Abstract

This study explored the association between six “micro indicators” of concern about smoking (1. stubbing out cigarettes before finishing; 2. forgoing cigarettes due to packet warning labels; thinking about… 3. the harms to oneself of smoking; 4. the harms to others of one's smoking; 5. the bad conduct of tobacco companies; and 6. money spent on cigarettes) and cessation outcomes (making quit attempts, and achieving at least six months of sustained abstinence) among adult smokers from Australia, Canada, the United Kingdom, and the United States of America. Participants were 12,049 individuals from five survey waves of the International Tobacco Control Four Country Survey (interviewed between 2002 and 2006, and followed-up approximately one year later). Generalized estimating equation logistic regression analysis was used, enabling us to control for within participant correlations due to possible multiple responses by the same individual over different survey waves. The frequency of micro indicators predicted making quit attempts, with premature stubbing out, forgoing, and thinking about the harms to oneself of smoking being particularly strong predictors. An interaction effect with expressed intention to quit was observed, such that stubbing out and thinking about the harms on oneself predicted quit attempts more strongly among smokers with no expressed plans to quit. In contrast, there was a negative association between some micro indicators and sustained abstinence, with more frequent stubbing out, forgoing, and thinking about money spent on cigarettes associated with a reduced likelihood of subsequently achieving sustained abstinence. In countries with long-established tobacco control programs, micro indicators index both high motivation by smokers to do something about their smoking at least partly independent of espoused intention and, especially those indicators not part of a direct pathway to quitting, reduced capacity to quit successfully.

Citation

Hall, P.A., Fong, G.T., Meng, G. (2014). Time perspective as a determinant of smoking cessation in four countries: Direct and mediated effects from the International Tobacco Control (ITC) 4-Country Surveys. Addictive Behaviours, 39(7), 1183-1190.

Abstract

Background: Future oriented time perspective predicts a number of important health behaviors and outcomes, including smoking cessation. However, it is not known how future orientation exerts its effects on such outcomes, and no large scale cross-national studies have examined the question prospectively. The aim of the current investigation was to examine the relationship between time perspective and success in smoking cessation, and social cognitive mediators of the association.

Methods: The ITC-4 is a multi-wave, four country survey (Australia, Canada, United States, United Kingdom) of current smokers (N=9772); the survey includes baseline measurements of time perspective, intentions, quit attempts, and self-reported quit status at follow-up over 8years. We examined the predictive power of time perspective for smoking cessation, as mediated through strength of quit intentions and prior history of quit attempts.

Results: Findings indicated that those smokers with a stronger future orientation at baseline were more likely to have successfully quit at follow-up. This effect was partially explained by intention-mediated effects of future orientation on quit attempts. CONCLUSIONS: Future orientation predicts smoking cessation across four English-speaking countries; the cessation-facilitating effects of future orientation may be primarily due to future oriented individuals' motivated and sustained involvement in the quit cycle over time.

Citation

Hitchman, S.C., Fong, G.T., Zanna, M.P., Thrasher, J.F., Laux, F. (2014). The relation between number of smoking friends, and quit intentions, attempts, and success: Findings from the International Tobacco Control (ITC) Four Country Survey. Psychology of Addictive Behaviours, 28(4), 1144-1152.

Abstract

Smokers who inhabit social contexts with a greater number of smokers may be exposed to more positive norms toward smoking and more cues to smoke. This study examines the relation between number of smoking friends and changes in number of smoking friends, and smoking cessation outcomes. Data were drawn from Wave 1 (2002) and Wave 2 (2003) of the International Tobacco Control (ITC) Project Four Country Survey, a longitudinal cohort survey of nationally representative samples of adult smokers in Australia, Canada, United Kingdom, and United States (N = 6,321). Smokers with fewer smoking friends at Wave 1 were more likely to intend to quit at Wave 1 and were more likely to succeed in their attempts to quit at Wave 2. Compared with smokers who experienced no change in their number of smoking friends, smokers who lost smoking friends were more likely to intend to quit at Wave 2, attempt to quit between Wave 1 and Wave 2, and succeed in their quit attempts at Wave 2. Smokers who inhabit social contexts with a greater number of smokers may be less likely to successfully quit. Quitting may be particularly unlikely among smokers who do not experience a loss in the number of smokers in their social context.