Abstract

Introduction

Involuntary exposure to secondhand smoke most frequently occurs at home, which is problematic for residents of multiunit housing (MUH). The primary objective of this study was to estimate the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their homes but lived in buildings where smoking is allowed.

Methods

We used data from Wave 9 of the International Tobacco Control Four Country Survey. We estimated 1) the prevalence of complete smoking bans among smokers living in single-family homes vs MUH in the United States (n = 3,208), Canada (n = 1,592), and the United Kingdom (n = 1,403) from 2013 to 2015; 2) the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their units but lived in buildings that allow smoking; and 3) MUH smokers’ preferences for complete smoking bans in MUH. Weighted multivariable logistic regression estimated the country-specific adjusted prevalence of all outcomes.

Results

Overall, 53.0% of smokers living in single-family homes completely banned smoking in their homes, compared with 44.8% of smokers in MUH. Across all 3 countries, only 27.8% of MUH smokers reported that smoking was completely prohibited in their building. A similar percentage of MUH smokers who banned smoking in their home but lived in buildings allowing smoking reported a secondhand smoke incursion into their home in the United States (29.9%; 95% CI, 20.4%–41.5%), Canada (38.4%; 95% CI, 26.7%–51.6%), and the United Kingdom (24.7%; 95% CI, 15.7%–36.7%). Across all 3 countries, 36.1% (95% CI, 33.4%–38.9%) of smokers in MUH reported they preferred a complete smoking ban in all building areas.

Conclusion

A need remains to educate MUH operators and residents about the benefits of comprehensive smoke-free policies.

Abstract

Study objectives: To compare the prices paid for nicotine vaping products (NVPs) and supplies among current NVP users to prices paid for cigarettes among current smokers.

Data: The 2016 International Tobacco Control Four Country Vaping and Smoking Survey (4CV1). Key measures included: (1) self-reported prices paid for reusable NVPs (eg, rechargeable devices with cartridges and tank system devices with e-liquids) in the 3-month period prior to the survey among current NVP users, (2) prices paid for disposable NVPs, cartridges and e-liquids purchased in the last 30 days among current NVP users and (3) self-reported prices paid for cigarettes among current smokers.

Results: Disposable NVP price was higher than the price of a comparable unit for combustible cigarettes in England (EN), USA and Canada (CA). Prefilled cartridge price was higher than the price of a comparable unit of cigarettes in USA and CA, but lower in EN and Australia. E-liquid price was consistently lower than the price of a comparable unit of cigarettes across four countries. For start-up costs, price of a rechargeable device is approximately 3–5 times higher than a pack of cigarettes in four countries.

Conclusion: NVP prices were generally higher than prices of combustible cigarettes, especially the high upfront NVP devices. The high upfront costs of purchasing a reusable NVP may discourage some smokers from switching to vaping. However, the average lower costs of cartridges and e-liquids relative to a package of cigarettes make switching to a NVP an attractive alternative to smoking in the long term so long as smokers switch completely to vaping.

Abstract

Introduction: This study examined whether non-tobacco flavors are more commonly used by vapers (ecigarette users) compared to tobacco flavor, described which flavors are most popular, and tested whether flavors are associated with: vaping satisfaction relative to smoking, level of enjoyment with vaping, reasons for using e-cigarettes, and making an attempt to quit smoking by smokers.

Methods: This cross sectional study included 1,603 adults from Canada and the US who vaped at least weekly, and were either current smokers (concurrent users) or former smokers (exclusive vapers). Respondents were categorized into one of seven flavors they used most in the last month: tobacco, tobacco-menthol, unflavored, or one of the non-tobacco flavors: menthol/mint, fruit, candy, or ‘other’ (e.g. Coffee).

Results: Vapers use a wide range of flavors, with 63.1% using a non-tobacco flavor. The most common flavor categories were fruit (29.4%) and tobacco (28.7%), followed by mint/menthol (14.4%) and candy (13.5%). Vapers using candy (41.0%, p<0.0001) or fruit flavors (26.0%, p=0.01) found vaping more satisfying (compared to smoking) than vapers using tobacco flavor (15.5%) and rated vaping as very/extremely enjoyable (fruit: 50.9%; candy: 60.9%) than those using tobacco flavor (39.4%). Among concurrent users, those using fruit (74.6%, p=0.04) or candy flavors (81.1%, p=0.003) were more likely than tobacco flavor users (63.5%) to vape in order to quit smoking. Flavor category was not associated with the likelihood of a quit attempt (p=0.46). Among exclusive vapers, tobacco and non-tobacco flavors were popular; however, those using tobacco (99.0%) were more likely than those using candy (72.8%, p=0.002) or unflavored (42.5%, p=0.005) to vape in order to stay quit.

Conclusions: A majority of regular vapers in Canada and the US use non-tobacco flavors. Greater satisfaction and enjoyment with vaping is higher among fruit and candy flavor users. While it does not appear that certain flavors are associated with a greater propensity to attempt to quit smoking among concurrent users, non-tobacco flavors are popular among former smokers who are exclusively vaping. Future research should determine the likely impact of flavor bans on those who are vaping to quit smoking or to stay quit.

Implications: Recent concerns about the attractiveness of e-cigarette flavors among youth have resulted in flavor restrictions in some jurisdictions of the United States and Canada. However, little is known about

the possible consequences for current and former smokers if they no longer have access to their preferred flavors. This study shows that a variety of nontobacco flavors, especially fruit, are popular among adult vapers, particularly among those who have quit smoking and are now exclusively vaping. Limiting access to flavors may therefore reduce the appeal of e-cigarettes among adults who are trying to quit smoking or stay quit.

Abstract

Introduction:

Limited research has investigated the relationship between multiple health conditions and subsequent quitting activities at the population level. This study examines whether nine health conditions and concerns related to smoking are predictive of quit attempts and success among those who tried.

Methods:

Data came from the International Tobacco Control Four Country Smoking and Vaping Survey conducted in Australia, Canada, England and the US. A total of 3998 daily smokers were surveyed in 2016 and recontacted in 2018. Respondents were asked in 2016 whether they had a medical diagnosis for depression, anxiety, alcohol problems, obesity, chronic pain, diabetes, heart disease, cancer, and chronic lung disease, and whether they had concerns about past/future health effects of smoking. Outcomes were quit attempts and success (having been abstinent for at least one month between surveys).

Results:

Across all four countries, 44.4% of smokers tried to quit between the two survey years, and of these 36.8% were successful. Concerns about past (adjusted odds ratio, AOR=1.66, 95% CI: 1.32–2.08, p<0.001) and future effects of smoking (AOR=2.17, 95% CI: 1.62–2.91, p<0.001) and most health conditions predicted quit attempts, but were mostly unrelated to quit success, with concerns about future effects (AOR=0.59, 95% CI: 0.35–0.99, p<0.05), chronic lung conditions (AOR=0.56, 95% CI: 0.37–0.86, p<0.01) and chronic pain (with a trend) being associated with lower success.

Conclusions:

Having a major chronic health condition does, generally, motivate making quit attempts, but in some cases it is associated with failure among those who try. More effective cessation support is required for these high priority groups.

Abstract

Introduction:

Little is known about why males are more likely to use electronic cigarettes (ECs) compared to females. This study examined gender differences in reasons for vaping and characteristics of EC used (device type, device capacity, e-liquid nicotine strength, and flavour).

Methods:

Data from 3938 current adult (18+ years) at-least-weekly EC users who participated in Wave 2 (2018) ITC Four Country Smoking and Vaping Survey in Canada, the United States, England, and Australia. Results: Of the sample, 54% were male. The most commonly cited reasons for vaping in females were ‘less harmful to others’ (85.8%) and in males were ‘less harmful than cigarettes’ (85.5%), with females being more likely to cite ‘less harmful to others’ (adjusted odds ratio (aOR)=1.64, p=0.001) and ‘help cut down on cigarettes’ (aOR=1.60, p=0.001) than males. Significant gender differences were found in EC device type used (χ2=35.05, p=0.043). Females were less likely to report using e-liquids containing >20 mg/ml of nicotine, and tank devices with >2ml capacity (aOR=0.41, p<0.001 and aOR=0.65, p=0.026, respectively) than males. There was no significant gender difference in use of flavoured e-liquids, with fruit being the most common flavour for both males (54.5%) and females (50.2%).

Conclusion:

There were some gender differences in reasons for vaping and characteristics of the product used. Monitoring of gender differences in patterns of EC use would be useful to inform outreach activities and interventions for EC use.

Implications:

Our findings provide some evidence of gender differences in reasons for vaping and characteristics of EC used. The most common reason for vaping reported by females was ‘less harmful to others’, which may reflect greater concern by female vapers about the adverse effects of second-hand smoke compared to male vapers. Gender differences might be considered when designing gender sensitive smoking cessation policies. Regarding characteristics of EC products used, we found gender differences in preferences for e-liquid nicotine strength and device capacity. Further studies should examine whether the observed gender differences in EC use reasons and product characteristics are predictive of smoking cessation. Furthermore, studies monitoring gender-based marketing of ECs may be considered.

Abstract

This descriptive study of smokers (smoked at least monthly) and recent ex-smokers (quit for ≤2 years) examined transitions over an 18 month period in their smoking and vaping behaviors. Data are from Waves 1 (W1: 2016) and 2 (W2: 2018) of the ITC Four Country Smoking and Vaping Survey, a cohort study of adult (≥18+) smokers, concurrent users (smoke and vape), and recent ex-smokers from Australia, Canada, England, and the United States (US). Respondents (N = 5016) were classified according to their smoking and vaping status, which resulted in eight subgroups: (1) exclusive daily smokers (2) exclusive non-daily smokers; (3–6) concurrent users (subdivided into four groups by each combination of daily/non-daily smoking and daily/non-daily vaping); (7) ex-smokers who vape; (8) ex-smokers not vaping. The analyses focused first on describing changes between groups from W1 to W2. Second, transition outcomes were assessed based on changes in smoking and vaping between W1 and W2. Transitions focused on smoking were: no change in smoking (continued smoking at the same frequency); decreased smoking; increased smoking; discontinued smoking; relapsed (ex-smokers at W1 who were smoking at W2). Transitions focused on vaping were: initiated vaping; switched from smoking to vaping. Overall, this study found that the vast majority of smokers were smoking 18 months later. Non-daily smokers were more likely than daily smokers to have discontinued smoking (p < 0.0001) and to have switched to exclusive vaping (p = 0.034). Exclusive non-daily smokers were more likely than exclusive daily smokers to have initiated vaping (p = 0.04). Among all W1 daily smokers, there were no differences in discontinued smoking between daily smokers who vaped (concurrent users) and exclusive daily smokers; however, concurrent users were more likely than exclusive daily smokers to have decreased to non-daily smoking (p < 0.001) or to have switched to vaping by W2 (p < 0.001). Among all W1 non-daily smokers, there were no significant differences in increased smoking or discontinued smoking between concurrent users or exclusive smokers. Most ex-smokers remained abstinent from smoking, and there was no difference in relapse back to smoking between those who vaped and those who did not.

Abstract

Background:

This study presents perceptions of the harmfulness of electronic cigarettes (e-cigarettes) relative to combustible cigarettes among smokers from six European Union (EU) countries, prior to the implementation of the EU Tobacco Products Directive (TPD), and 2 years post-TPD.

Methods:

Data were drawn from the EUREST-PLUS ITC Europe Surveys, a cohort study of adult smokers (≥18 years) from Germany, Greece, Hungary, Poland, Romania and Spain. Data were collected in 2016 (pre-TPD: N = 6011) and 2018 (post-TPD: N = 6027). Weighted generalized estimating equations were used to estimate perceptions of the harmfulness of e-cigarettes compared to combustible cigarettes (less harmful, equally harmful, more harmful or 'don't know').

Results:

In 2016, among respondents who were aware of e-cigarettes (72.2%), 28.6% reported that they perceived e-cigarettes to be less harmful than cigarettes (range 22.0% in Spain to 34.1% in Hungary). In 2018, 72.2% of respondents were aware of e-cigarettes, of whom 28.4% reported perceiving that e-cigarettes are less harmful. The majority of respondents perceived e-cigarettes to be equally or more harmful than cigarettes in both 2016 (58.5%) and 2018 (61.8%, P > 0.05). Overall, there were no significant changes in the perceptions that e-cigarettes are less, equally or more harmful than cigarettes, but 'don't know' responses significantly decreased from 12.9% to 9.8% (P = 0.036). The only significant change within countries was a decrease in 'don't know' responses in Spain (19.3-9.4%, P = .001).

Conclusions:

The majority of respondents in these six EU countries perceived e-cigarettes to be equally or more harmful than combustible cigarettes.

Abstract

Introduction: Although the United States has seen a rapid increase in tobacco minimum legal sales age (MLSA) laws set to age 21, there is wide variation across high-income countries and less is known about policy support outside of the United States. We examined the prevalence of support for tobacco MLSA 21 laws as well as associations by sociodemographic, smoking, and household characteristics among current and former adult smokers.

Methods: In this cross-sectional analysis, we used the 2018 International Tobacco Control Four Country Smoking and Vaping Survey to examine support for MLSA 21 laws among 12 904 respondents from Australia, Canada, England, and United States.

Results: Support for raising the legal age of purchasing cigarettes/tobacco to 21 ranged from 62.2% in the United States to 70.8% in Canada. Endorsement also varied by age, such that 40.6% of 18–20 years old supported the policy compared with 69.3% of those aged ≥60 years. In the adjusted regression model, there was also higher support among respondents who were female than male, non-white than white, those who did not allow smoking in the household than those that did, and those who had children in the household than those that did not. There were no differences by household income, education, or smoking status.

Conclusions: Most current and former smokers, including a sizable minority of those aged ≤20 years, support raising the legal age of purchasing cigarettes/tobacco to 21.

Implications: There was strong support for MLSA 21 laws among smokers and former smokers across Australia, Canada, England, and the United States, providing evidence for the increasing public support of the passage of these laws beyond the United States.

Abstract

This cohort study examines rates of vaping and smoking among youths aged 16 to 19 years in the United States, Canada, and England from 2017 to 2019

Abstract

Objectives: In this paper, we characterize physical design features of cigarette brands sold in the United States according to the delivery method of menthol that may affect sensory perception among users.

Methods: We used 12 cigarette brands, mentholated and non-mentholated, for analyses of the physical design characteristics, quantification of nicotine and menthol, and identification of flavor additives.

Results: Physical design characteristics did not differ significantly between the various cigarette brands. However, we found statistically significant differences in levels of menthol. Menthol levels were greatest in products that had dual delivery methods of menthol (6.7mg/cigarette; SE = 0.27) followed by products mentholated in a filter capsule only (5.7mg/cigarette; SE = 0.25), and those mentholated in the tobacco only (3.8mg/cigarette; SE = 0.12); products that were not mentholated had the least (0.38mg/cigarette; SE = 0.31). Finally, flavor additives with a mint flavor profile other than menthol were identified, such as pulegone and limonene, and differed between cigarette brands, which are likely contributing to the menthol flavor experience associated with use of these products.

Conclusions: The regulation of menthol delivery method, flavorings added to the capsule, and/or menthol concentration may be beneficial for the public health as these factors are likely creating unique sensory experiences.

Abstract

Introduction: JUUL has emerged as the leading brand in a rapidly evolving electronic cigarette (ecigarette) market. JUUL is distinctive for its novel nicotine delivery method that results in high nicotine concentrations, as well as its sleek, discreet design. This study examined national estimates of JUUL among youth in the United States, including whether JUUL users report different patterns of use compared to users of other e-cigarettes.

Methods: Data were analyzed from the US arm of the International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and E-cigarette Survey, an online survey conducted in July-August 2017 with youth aged 16-19 years recruited from consumer panels (n = 4086).

Results: Overall, 14.2% of respondents had used an e-cigarette in the past 30 days. JUUL was the second-most popular brand reported by past-30-day e-cigarette users (9.7%). Compared to e-cigarette users of other brands, JUUL users were significantly older (adjusted odds ratio [aOR] = 2.50, 95% confidence interval [CI] = 1.56 to 4.01) and reported a greater number of computers in the household (a socioeconomic status proxy; aOR = 1.55, 95% CI = 1.22 to 1.96), with no differences by sex, race/ethnicity, or student status. Controlling for sociodemographic variables, JUUL users were more likely than other e-cigarette users to have ever tried to quit e-cigarettes (aOR = 2.65, 95% CI = 1.12 to 6.30), with no differences observed by smoking status, frequency of e-cigarette use, urges to use e-cigarettes, or perceived addiction to e-cigarettes.

Conclusions: JUUL was among the most popular e-cigarette brands among youth, and there were few differences in sociodemographic profile or patterns of use between users of JUUL and other e-cigarette brands. Implications: This study examined national estimates of JUUL e-cigarette use among youth in the United States, during the early phase of JUUL's popularity. JUUL was among the most popular ecigarette brands among youth, and there were few differences in sociodemographic profile or patterns of use between JUUL and other e-cigarette brands. The findings help to characterize the rapid rise of this new product category within the rapidly evolving e-cigarette market at a time when the US Food and Drug Administration and public health community are seeking to understand JUUL and its appeal among young people.

Abstract

Background: Although evidence shows that co-use of cigarettes and cannabis is common, there is little research examining if co-use patterns vary depending on the regulatory environment for cannabis. This study examined patterns of co-use and perceptions of relative harm among cigarette smokers in four countries with different histories, and at different stages of cannabis legalization.

Methods: Data are from the 2018 International Tobacco Control 4CV Survey and included 10035 adult cigarette smokers from Canada, United States (US), Australia, and England. At the time of the survey, Canada and the US had relatively more permissive cannabis regulations compared to Australia and England.

Results: Among this sample of 10035 cigarette smokers, Canada had the highest rate of cannabis co-use in the last 12 months (36.3%), followed by the US (29.1%), England (21.6%), and Australia (21.4%). Among past 12 month co-users (n = 3134), the US (40.2%) and Canada (35.2%) had the highest rates of daily cannabis use, followed by smokers in England (26.3%) and Australia (21.7%); Australian co-users had the highest rate of infrequent (<monthly) cannabis use. The highest proportion of co-users who smoked daily and used cannabis daily was in the US (34.8%), followed by Canada (30.6%), England (25.8%), and Australia (22.7%). More co-users in the US (78.3%) and Canada (73.6%) perceived smoked cannabis to be less harmful than cigarettes than in Australia (65.5%) and England (60.8%). The majority of co-users who used cannabis in the last 30 days had smoked it (92.3%), with those in England more likely to smoke cannabis (95.7%) compared to Canada (88.6%); there were no other differences between countries (US: 92.0%, Australia: 93.0%). Co-users in England (90.4%) and Australia (86.0%) were more likely to mix tobacco with cannabis than co-users in Canada (38.5%) and the US (22.3%).

Conclusion: Patterns of tobacco and cannabis co-use differed between countries. Smokers in Canada and the US had higher rates of co-use, daily cannabis use, dual-daily use of both cannabis and cigarettes, and were more likely to perceive smoked cannabis as less harmful than cigarettes compared to England and Australia.

Abstract

Background: Our study evaluated the short-term impact of introducing European Union’s tobacco pictorial health warnings (PHWs).

Methods: Longitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N = 3,487) and analyzed using Generalized Estimating Equations.

Results: Between both time-points, only Dutch smokers showed increases in noticing health warnings (β = 0.712, p < 0.001), self-reports of health warnings leading to a cognitive response such as thinking about smoking health-risks (SHRs) (OR = 1.834, p < 0.001), knowledge about SHRs (β = 0.369, p < 0.001), and avoiding health warnings (OR = 9.869, p < 0.001). However, Dutch smokers showed no changes in attitude towards smoking (β = 0.035, p = 0.518), intention to quit smoking (OR = 0.791, p = 0.157), self-efficacy to quit smoking (β=-0.072, p = 0.286), or reporting that health warnings helped them to resist having a cigarette (OR = 1.091, p = 0.714).

Conclusions: Results suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.

Abstract

Background: Cannabis use is more common among nicotine users than non-users. This study characterized concurrent use of nicotine and cannabis (co-use) among 12,064 youth aged 16-19 years residing in Canada, the United States, and England in 2017.

Methods: Data were from the ITC Youth Tobacco & Vaping Survey (Wave 1). Seven modes of cannabis delivery (MOD) were characterized by country of residence and past 30-day use of combusted tobacco and electronic cigarettes. Weighted multivariable regression models were fitted to assess the correlates of co-use and each cannabis MOD.

Results: Seventy percent of cannabis users reported nicotine use. Co-users exhibited behavioral and demographic differences compared to exclusive users of either substance. Smoking cannabis without tobacco was the most popular form of use (78%). Use of nicotine-containing e-cigarettes was associated with using an e-cigarette to vape cannabis oil/liquid (aOR: 4.96, 95%CI: 2.23-11.06). Combustible tobacco use was associated with smoking cannabis with tobacco in a joint/blunt (aOR: 2.93, 95%CI: 1.894.56). Country-level differences were detected.

Conclusions: Nicotine use is substantial among cannabis users, and associations exist between modes of delivery for both drugs. Results underscore the importance of studying cannabis and nicotine use concurrently, and the need to address the use of both substances in developing interventions for youth users

Abstract

Background: Our study evaluated the short-term impact of introducing European Union’s tobacco pictorial health warnings (PHWs).

Methods: Longitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N = 3,487) and analyzed using Generalized Estimating Equations.

Results: Between both time-points, only Dutch smokers showed increases in noticing health warnings (β = 0.712, p < 0.001), self-reports of health warnings leading to a cognitive response such as thinking about smoking health-risks (SHRs) (OR = 1.834, p < 0.001), knowledge about SHRs (β = 0.369, p < 0.001), and avoiding health warnings (OR = 9.869, p < 0.001). However, Dutch smokers showed no changes in attitude towards smoking (β = 0.035, p = 0.518), intention to quit smoking (OR = 0.791, p = 0.157), self-efficacy to quit smoking (β=-0.072, p = 0.286), or reporting that health warnings helped them to resist having a cigarette (OR = 1.091, p = 0.714).

Conclusions: Results suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.

Abstract

Introduction: This study aimed to systematically examine whether having health conditions or concerns related to smoking are associated with quitting activities among smokers across four western countries.

Methods: Data came from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey conducted in Australia, Canada, England and US. We asked smokers and recent quitters (n=11838) whether they had a medical diagnosis for heart disease, cancer, chronic lung disease, depression, anxiety, alcohol problems, diabetes, severe obesity and chronic pain (nine conditions), and whether they believed smoking had harmed/would harm their health, along with questions on quitting activities.

Results: General concerns about smoking harming health and all specific health conditions, except for alcohol problems, were positively associated with quit attempts, but the relationships between health conditions and other quitting measures (being abstinent, planning to quit, use of quitting medications) were less consistent. Positive associations between conditions and use of quitting medications were only significant for depression, anxiety and chronic pain (adjusted odds ratios ranged from 1.4 to 1.5). There was a general tendency to report lower self-efficacy for quitting among those with the health conditions.

Conclusions: While those with smoking related conditions are somewhat more aware of the links to their smoking, and are largely taking more action, the extent of this is lower than one might reasonably expect. Enhanced awareness campaigns are needed and health professionals need to do more to use health conditions to motivate quit attempts and to ensure they are made with the most effective forms of help.

Abstract

Background: The 2018 National Academies of Sciences, Engineering, and Medicine Report found substantial evidence that electronic cigarette use (vaping) by youth is strongly associated with an increased risk of ever using cigarettes (smoking) and moderately associated with progressing to more established smoking. However, the Report also noted that recent increases in vaping have been associated with declining rates of youth smoking. This paper examines the temporal relationship between vaping and youth smoking using multiple data sets to explore the question of whether vaping promotes smoking initiation in the USA.

Methods: Using publicly available, nationally representative data on smoking and vaping among youth and young adults, we conducted a trend line analysis of deviations from long-term trends in smoking starting from when vaping became more prevalent.

Results: There was a substantial increase in youth vaping prevalence beginning in about 2014. Time trend analyses showed that the decline in past 30-day smoking prevalence accelerated by two to four times after 2014. Indicators of more established smoking rates, including the proportion of daily smokers among past 30-day smokers, also decreased more rapidly as vaping became more prevalent.

Conclusions: The inverse relationship between vaping and smoking was robust across different data sets for both youth and young adults and for current and more established smoking. While trying electronic cigarettes may causally increase smoking among some youth, the aggregate effect at the population level appears to be negligible given the reduction in smoking initiation during the period of vaping’s ascendance.

Abstract

Background: Vaping has become an increasingly common mode of administration for both nicotine and cannabis, with overlap among users, devices, as well as nicotine and cannabis companies. There is a need to understand patterns of use among youth, including the way nicotine and cannabis are administered.

Methods: Data are from Wave 2 of the ITC Youth Tobacco and Vaping survey, an online survey conducted in 2018 among 16-19 year-olds recruited from commercial panels in Canada (n = 3757), England (n = 3819), and the U.S. (n = 3961). The prevalence of past 30-day vaping nicotine, nonnicotine and cannabis substances, as well as cannabis modes of use was examined. Logistic regression models examined between country differences in prevalence.

Results: Past 30-day cannabis use was highest among Canadian youth (16.6%), followed by youth in the U.S. (13.8%) and England (9.0%). Vaping e-cigarettes was substantially more prevalent than vaping cannabis in all three countries. All forms of cannabis use were higher among Canadian and U.S. youth compared to England (p < 0.001 for all). Past 30-day cannabis users in the U.S. were more likely to report vaping cannabis oil (30.1%), and consuming solid concentrates such as wax and shatter (30.2%), compared to cannabis users in Canada (18.6% and 22.9%) and England (14.3% and 11.0%; p < 0.001 for all).

Conclusions: Youth are administering cannabis and nicotine using a wide diversity of modes. Cannabis users in the U.S.-where an increasing number of states have legalized medical and non-medical cannabis-reported notably higher use of more potent cannabis products, including cannabis oils and extracts.

Abstract

Aims: To examine whether norms towards nicotine vaping product (NVP) use varied between Australia, Canada, England and the United States and by socio‐demographics, smoking and NVP status.

Design: Cross‐sectional data from the 2016 ITC Four Country Smoking and Vaping Survey.

Setting: Four countries with distinct regulatory policies relating to the sale and advertising of NVPs: Australia (most restrictive), Canada (restrictive), England and the United States (least restrictive).

Participants: A total of 10900 adult (age 18+) current smokers, former smokers, or at least weekly NVP users. Respondents were from Australia (n = 1366), Canada (n = 3309), England (n = 3835) and the United States (n = 2390).

Measurements: Questions permitted the categorization of respondents as current smokers, former smokers, NVP users and socio‐demographic categories (sex, age, country, ethnicity, income and education). Further questions were asked regarding the frequency of exposure to NVPs in public, whether they had a partner or close friends who vaped and whether they believed society or those considered important to them approved of NVPs.

Findings: Adjusting for relevant covariates, compared with Australian respondents, those in England, Canada and the United States were more likely to report frequent exposure to NVPs in public (83.1%, 57.3% and 48.3%, respectively, compared to 19.8% in Australia; P < 0.0001), having a partner who vaped (13.8%, 7.1% and 7.7%, respectively, compared to 2.1% in Australia; P < 0.0001) and having close friend(s) who vaped (31.7%, 25.3%, 20.9%, respectively, compared to 10.0% in Australia; P < 0.0001). Compared with Australian respondents, respondents from England were more likely to report that society (27.6% compared to 12.3% in Australia; P < 0.0001) and people important to them approved of NVP use (28.9% compared to 14.3% in Australia; P < 0.0001).

Conclusions: Norms towards nicotine vaping product (NVP) use appear to vary among countries with different regulatory contexts regarding sales and advertising.

No abstract is available.

Abstract

Background and Aims: The regulatory environment for nicotine vaping products (NVPs) varies widely across countries and this will probably affect the devices used, nicotine content and usage, and hence the ability of NVPs to substitute for cigarettes. We aimed to describe the types of NVPs used by current vapers in four countries with varying regulatory and enforcement approaches toward the marketing and sale of NVPs.

Methods: Data are from wave 1 (July–November 2016) of the ITC Four Country Smoking and Vaping Survey (4CV1), conducted among a cohort of current and former smokers, and current NVP users (n = 5147 adults; ≥ 18 years) in Australia (AU), Canada (CA), England (EN) and the United States (US) reporting either current daily, weekly or occasional NVP use. Devices were described by type, brand, voltage variability and refill capacity. Refill solutions were described by flavour and nicotine content. Descriptive statistics and bivariate analyses were conducted on the overall sample and stratified by country. A multinomial logistic regression examined factors associated with device preference across the whole sample.

Results: The types of NVPs used differed by pattern of use and country. Exclusive, daily vapers were more likely to use refillable pen‐shaped devices [odds ratio (OR) = 10.0] or refillable box‐shaped devices (OR = 5.4) than disposable cigalike devices, when compared with other (non‐daily/dual) users. Nearly all respondents reported using flavoured NVPs, fruit (28.3%) being the most common flavour. Refillable devices were the most popular: refillable box‐shaped devices were more commonly reported by vapers in AU (36.8%) and US (31.4%), whereas in EN (47.4%) and CA (29.7%), vapers more often reported using refillable pen‐style devices. Most users also reported that their products contained nicotine, even in CA (87.8%) and AU (91.2%), where vaping products containing nicotine were technically illegal.

Conclusions: In Australia, Canada, England and the United States in 2016, refillable nicotine vaping products were the most common type of nicotine vaping products used by daily vapers. Most daily vapers reported using flavoured e‐liquids/refills (with variance across countries) and most reported using products that contain nicotine, even where vaping products with nicotine were banned.

Abstract

Background and Aims: It has been proposed that many smokers switch to vaping because their nicotine addiction makes this their only viable route out of smoking. We compared indicators of prior and current cigarette smoking dependence and of relapse in former smokers who were daily users of nicotine vaping products (‘vapers’) or who were not vaping at the time of survey (‘non‐vapers’).

Design: Cross‐sectional survey‐based comparison between vaping and non‐vaping former smokers, including a weighted logistic regression of vaping status onto predictor variables, adjusting for covariates specified below.

Setting: United States, Canada, Australia and England.

Participants: A total of 1070 people aged 18+ years from the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Wave 1 Survey who reported having ever been daily smokers but who stopped less than 2 years ago and who were currently vapers or non‐vapers.

Measurements: Dependent variable was current vaping status. Predictor variables were self‐reported: (1) smoking within 5 minutes of waking and usual daily cigarette consumption, both assessed retrospectively; (2) current perceived addiction to smoking, urges to smoke and confidence in staying quit. Covariates: country, sample sources, sex, age group, ethnicity, income, education, current nicotine replacement therapy use and time since quitting.

Findings: Vapers were more likely than non‐vapers to report: (1) having smoked within 5 minutes of waking [34.3 versus 15.9%, adjusted odds ratio (aOR) = 3.74, 95% confidence interval (CI) = 1.99, 7.03), χ2 = 16.92, P < 0.001]; having smoked > 10 cigarettes/day (74.4 versus 47.2%, aOR = 4.39, 95% CI = 2.22, 8.68), χ2 = 18.18, P < 0.001); (2) perceiving themselves to be still very addicted to smoking (41.3 versus 26.2%, aOR = 2.89, 95% CI = 1.58, 5.30, χ2 = 11.87, P < 0.001) and feeling extremely confident about staying quit (62.1 versus 36.6%, aOR = 3.22, 95% CI = 1.86, 5.59, χ2 = 17.36, P < 0.001). Vapers were not more likely to report any urges to smoke than non‐vapers (27.7 versus 38.8%, aOR = 0.86, 95% CI = 0.44, 1.65, χ2 = 0.21, P = 0.643).

Conclusions: While former smokers who currently vape nicotine daily report higher levels of cigarette smoking dependence pre‐ and post‐cessation compared with former smokers who are current non‐vapers, they report greater confidence in staying quit and similar strength of urges to smoke.

Abstract

Aims: To examine rules about smoking and vaping in the home in relation to beliefs about the relative harm of second-hand vapor (SHV) compared with second-hand smoke (SHS) in four countries: Canada, United States, England and Australia.

Design: Data were available from 12 294 adults (18+) who participated in the 2016 (wave 1) International Tobacco Control Four Country Smoking and Vaping (ITC 4CV1) Survey.

Participants: All participants were current or recent former adult smokers.

Measurements: Data were analyzed by weighted logistic regression on rules about smoking and vaping in the home; odds ratios and 95% confidence intervals were reported, adjusted for demographic and behavioral variables.

Findings: Of all respondents, 37.4% allowed smoking inside their home. Among a subset who were current vapers (n = 6135), 60.4% allowed vaping in their homes. After controlling for demographic and behavioral characteristics, beliefs about the harm of SHV compared with SHS was not associated with allowing smoking in the home, but was associated with allowing vaping in the home [odds ratio (OR) = 2.86 in Canada, OR = 1.82 in the United States and OR = 1.68 in England]. Characteristics that were associated with rules about vaping inside the home included daily vaping (OR = 2.95, 2.04-4.26; OR = 7.00, 4.12-11.87; OR = 5.50, 3.40-8.88; OR = 7.78, 1.90-31.80), living with a spouse who vapes (OR = 2.48, 1.54-3.98; OR = 2.69, 1.42-5.11; OR = 4.67, 2.74-7.95; OR = 21.82, 2.16-220.9) and living with children aged under 18 years (OR = 0.50, 0.37-0.68; OR = 0.89, 0.48-1.65; OR = 0.76, 0.53-1.09; OR = 0.26, = 0.11-0.61) in Canada, the United States, England and Australia, respectively. Similar characteristics were associated with rules about smoking inside the home.

Conclusions: Among current and former smokers in 2016 in Canada, the United States, England and Australia, 37.4% allowed smoking in the home; 60.4% of current vapers allowed vaping. Both concurrent users and exclusive vapers were more likely to allow vaping than smoking inside the home. Allowing vaping inside the home was correlated with the belief that second-hand vapor is less harmful than second-hand smoke.

Abstract

Objective: To assess trends in daily smokers' social norms and opinions of smoking between 2002 and 2015 in Canada, the United States, the United Kingdom, and Australia.

Method: Data were from wave 1 (2002) to wave 9 (2013–2015) of the longitudinal International Tobacco Control Four Country Survey (Canada, the United States, the United Kingdom, Australia), involving 23 831 adult daily smokers. Generalized estimating equation logistic regression models, adjusted for demographics and survey design effects, assessed associations of wave and country with outcomes: (A) over half of five closest friends smoke, (B) agreeing that people important to you believe you should not smoke, (C) agreeing that society disapproves of smoking, and (D) negative opinion of smoking.

Results: Between 2002 and 2015, adjusting for covariates, (A) over half of five closest friends smoke did not change (56% vs. 55%; adjusted odds ratio [AOR] = 0.95 [95% Confidence Interval = 0.85–1.07]), (B) agreeing that people important to you believe you should not smoke generally decreased (89% vs. 82%; AOR = 0.54 [0.46–0.64]) despite an increase around 2006–2007, (C) agreeing that society disapproves of smoking increased between 2002 and 2006–2007 (83% vs. 87%; AOR = 1.38 [1.24–1.54]) then decreased until 2013–2015 (78%; AOR = 0.74 [0.63–0.88]), and (D) negative opinion of smoking decreased between 2002 and 2010–2011 (54% vs. 49%; AOR = 0.83 [0.75–0.91]) despite an increase around 2005–2006 and at the final wave (2013–2015). Except friend smoking, Canada had the greatest, and the United Kingdom the lowest, antismoking social norms and opinions.

Conclusions: Except friend smoking and opinion of smoking, daily smokers' social norms became less antismoking between 2002 and 2015 despite increases around 2006–2007. Several potential explanations are discussed yet remain undetermined.

Implications: Increasingly comprehensive tobacco control policies alongside decreasing smoking prevalence in Canada, the United States, the United Kingdom, and Australia have led to the assumption that smoking has become denormalized in these countries. Absent from the literature is any formal assessment of social norms towards smoking over time. Contrary to our hypotheses, this study found that the injunctive social norms of daily smokers became less antismoking between 2002 and 2015, despite increases around 2006–2007. There was no change over time in the proportion of daily smokers who report that over half of their five closest friends smoke.

No abstract is available.