Citation

East, K., Reid, J., Rynard, V.L., Hammond, D. (2021). Trends and patterns of tobacco and nicotine product use among youth in Canada, England, and the US from 2017-2019. Journal of Adolescent Health, 69(3), 447-456. doi: 10.1016/j.jadohealth.2021.02.011.

Abstract

Purpose: The tobacco and nicotine market is diversifying. Implications for public health will depend on trends in use, including overall use, and who is using these products. This study examined differences over time (2017–2019), across countries (Canada, England, the United States (US)), and by smoking and vaping, in use of other tobacco/nicotine products and overall use.

Methods: The study includes online repeat cross-sectional surveys of youth aged 16–19 years in Canada (N = 11,714), England (N = 11,170), US (N = 11,838) in 2017, 2018, and 2019. Past 30-day use of tobacco/nicotine products (any, cigarette, e-cigarette, other combusted [cigars/cigarillos/waterpipe], other non-combusted [smokeless tobacco/nicotine replacement therapies) were examined by country, year, and, for other combusted and non-combusted products, past 30-day cigarette smoking and vaping. Use of emerging products (IQOS, nicotine pouches) was explored in 2018–2019.

Results: From 2017 to 2019, use of any product increased in Canada (17.1%–23.2%, AOR = 1.07 [95% CI = 1.04–1.09]) and the US (18.0%–24.0%, AOR = 1.06 [1.04–1.09]) but not England (20.8%–21.7%, AOR = 1.01 [.99–1.03]). Use of other combusted products (cigars/cigarillos/waterpipe) showed little change (Canada: 8.1%–7.8%; England: 6.3%–7.3%; US: 8.6%–8.5%; p ≥ .151). Use of other non-combusted products (smokeless/nicotine replacement therapies) increased in all countries (Canada: 1.5%–3.2%, AOR = 1.02 [1.01–1.02]; England: 1.4%–2.6%, AOR = 1.02 [1.01–1.03]; US: 3.3%–4.9%, AOR = 1.02 [1.01–1.02]). Vaping increased in all countries (Canada: 8.4%–17.8%; England: 8.7%–12.6%; United States: 11.1%–18.5%; all p < .001). Smokers and vapers reported greater use of other combusted and non-combusted products than those who neither smoked/vaped (p < .001). Emerging product use was rare (≤1.5%).

Conclusions: Youth past 30-day tobacco and nicotine product use increased from 2017 to 2019 in Canada and the United States, largely due to increases in vaping and other non-combusted products. “Other” tobacco/nicotine products were used predominantly by youth who smoked cigarettes and/or vaped.

Citation

Gravely, S., Chung-Hall, J., Craig, L.V., Fong, G.T., Cummings, K.M., Borland, R., Yong, H.-H., Loewen, R., Martin, N., Quah, A.C.K., Hammond, D., Ouimet, J., Boudreau, C., Thompson, M.E., Driezen, P. (2021). Evaluating the impact of plain packaging among Canadian smokers: Findings from the 2018 and 2020 ITC Smoking and Vaping Surveys. Tobacco Control. Epub ahead of print: 21 09 2021. doi:10.1136/tobaccocontrol-2021-056635.

Related resources from the Health Canada Supported Dissemination Project (ITC Canada Survey Findings)

Mar 30, 2021 | Impact of Plain Packaging in Canada

Mar 30, 2021 | Incidence de l'emballage neutre au Canada

Sep 22, 2021 | Impact of Plain Packaging in Canada | Infographic | English

Sept 22, 2021 | Press Release from University of Waterloo: Plain packaging on cigarette packs in Canada advanced efforts for reducing smoking

Abstract

Background: In February 2020, Canada implemented plain packaging without any changes to the size and content of health warning labels (HWLs), which were last updated in 2012 (pictorial HWLs on 75% of the pack front and back). This pre-post evaluation study assessed the impact of plain packaging in Canada on: (1) pack appeal; (2) HWL effectiveness; and (3) support for plain packaging. Additionally, a quasi–experimental design was used to assess the Canadian results relative to two comparator countries: Australia, where plain packaging (with new larger HWLs) was implemented in 2012, and the United States (USA), where plain packaging has not been implemented and the same text warnings have appeared on cigarette packs since 1985.

Methods: Data are from adult smokers who participated in the 2018 and/or 2020 International Tobacco Control Smoking and Vaping Surveys in Canada (n=4600), Australia (n=1834) and the USA (n=3046). Online surveys were conducted before (February to July 2018) and after (February to June 2020) the implementation of plain packaging in Canada. Adjusted regression analyses were conducted on weighted data.

Results: Plain packaging was associated with a significant increase in the percentage of Canadian smokers who did not like the look of their cigarette pack (2018: 28.6% vs 2020: 44.7%, p<0.001), whereas no change in pack appeal was observed among smokers in Australia and the USA over the same period. Plain packaging was not associated with changes in HWL effectiveness in Canada. Support for plain packaging increased significantly among Canadian smokers (2018: 25.6% vs 2020: 33.7%, p><0.001).

Conclusions: Plain packaging in Canada substantially reduced pack appeal and increased support for the policy among adult smokers; however, there was no increase in the effectiveness of Canada’s 8-year-old HWLs. The impact of plain packaging on health warning effectiveness may depend on the design of the warnings and length of time since implementation.

Citation

Li, L., Borland, R., Cummings, K.M., Gravely, S., Quah, A.C.K., Fong, G.T., Miller, C.R., Goniewicz, M.L., Le Grande, M., McNeill, A. (2021). Patterns of non-cigarette tobacco and nicotine use among current cigarette smokers and recent quitters: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 23(9), 1611-1616. doi: https://doi.org/10.1093/ntr/ntab040.

Abstract

Introduction: This study explores patterns of use of non-cigarette tobacco and nicotine products among adult cigarette smokers and recent ex-smokers. Along with cigarette smoking status we explore differences as a function of countries with different product regulations, gender and age.

Methods: Data came from the ITC Four Country Smoking and Vaping Wave 3 Survey conducted between February-June 2020. The analytic sample consisted of 9112 current cigarette smokers (at least monthly) and 1184 recent ex-smokers (quit cigarettes ≤ 2 years) from Australia, Canada, England, and the US. Respondents were asked about their cigarette smoking and current use of the following non-cigarette products: combustible tobacco (cigars, cigarillos, pipe, waterpipe); non-combustible tobacco (smokeless tobacco, and heated tobacco products (HTPs)); and non-tobacco nicotine products (nicotine vaping products (NVPs), nicotine replacement therapy (NRT), and nicotine pouches)).

Results: Overall, NVPs (13.7%) and NRT (10.9%) were the most reported nicotine products used, followed by cigars (5.3%), cigarillos (4.2%), and HTPs (3.5%). More than 21% current and recent ex-smokers of cigarettes reported using a non-tobacco nicotine product and non-combustible product, with respondents in England reporting the highest levels of use (>26%). Males, younger respondents, and current non-daily cigarette smokers were more likely to use non-cigarette nicotine products. Notably, 11.6% of ex-cigarette smokers were using other combustible tobacco.

Conclusion: Considerable percentages of current cigarette smokers and ex-smokers use non-cigarette nicotine products, and there are unexpectedly high levels of use of other combustible products by those recent ex-smokers of cigarettes which is concerning and has important implications for definitions of smoking cessation.

Implications: The tobacco product market has evolved to include new products which add to existing non-cigarette tobacco products creating a much more diverse nicotine market. This brief report provides a snapshot of use of various combustible and non-combustible nicotine containing products among current cigarette smokers and recent ex-smokers in four western countries. Our results indicate that use of non-cigarette tobacco and nicotine products among these cigarette smokers and recent ex-smokers is not low, particularly among males, younger and non-daily cigarette smokers. Use of other combustible tobacco among respondents that recently quit cigarette smoking is concerning and has important implications for definitions of smoking cessation. Increased emphasis on researching non-cigarette nicotine product use is warranted in tobacco control generally and smoking cessation in particular.

Citation

Li, L., Borland, R., Cummings, K.M., Fong, G.T., Gravely, S., Smith, D.M., Goniewicz, M., O’Connor, R.J., Thompson, M.E., McNeill, A. (2021). How does the use of flavored nicotine vaping products relate to progression towards quitting smokers? Findings from the 2016 and 2018 ITC 4CV Surveys. Nicotine and Tobacco Research, 23(9), 1490-1497. doi: https://doi.org/10.1093/ntr/ntab033.

Abstract

Introduction: There is limited research on the role of flavors in nicotine vaping products (NVPs) in relation to smoking. We examined patterns of flavor use in NVPs in relation to progression towards quitting.

Methods: Data come from 886 concurrent users of NVPs (at least weekly) and cigarettes who were first surveyed in 2016 and then successfully recontacted in 2018 as part of the ITC 4CV Surveys conducted in Australia, Canada, England and the United States. Participants were asked about their main vaping flavor categorized as: 1) tobacco or unflavored, 2) menthol/mint flavored, and 3) “sweet” flavors (e.g., fruit/candy). We examined whether flavor was associated with progression towards quitting smoking between survey years.

Results: Overall, 11.1% of baseline concurrent users quit smoking by 2018. Compared to users of tobacco flavors, those vaping “sweet” flavors were more likely to quit smoking between surveys (13.8% vs. 9.6%; adjusted OR=1.61, 95% CI 1.01-2.58, p<0.05), but those using menthol flavors were no more likely to quit smoking (8.3% vs. 9.6%, aOR=0.87, 95% CI 0.43-1.47, p=0.69). Among those who had quit smoking in 2018, 52.0% were still vaping, which was lower than the 65.8% among continuing smokers (aOR=0.60, 95% CI 0.39-0.92, p=0.02). Sweet flavor users were no more likely to continue vaping compared to tobacco flavor users, either for those continuing smoking or those having quit smoking by 2018. There was a net shift away from tobacco flavor among those who continued to vape at follow-up.

Conclusions: Use of fruit and other sweet flavored e-liquids is positively related to smokers’ transition away from cigarettes.

Implications: With multiple jurisdictions considering limiting or banning the sale of flavored NVPs, it is important to consider how such policies may impact smokers using NVPs to transition away from cigarette smoking. Our results indicate that vapers who used sweet flavors were more likely to transition away from cigarette smoking and quit cigarette use, at least in the short term, compared to those who used tobacco or unflavored NVPs. Randomized clinical trials are needed to establish if the observed association between use of flavored e-liquids and smoking cessation is due to self-selection or is truly causal.

Citation

Felicione, N., Cummings, K.M., Gravely, S., Hammond, D., McNeill, A., Borland, R., Fong, G.T., O’Connor, R.J. (2021). “Don’t Know” responses for nicotine vaping product features among adult vapers: Findings from the 2018 and 2020 ITC Four Country Smoking and Vaping Surveys. International Journal of Environmental Research and Public Health, 18(15), 7928. doi: 10.3390/ijerph18157928.

Abstract

Nicotine vaping products (NVPs) have evolved rapidly, and some vapers have difficulty reporting about their NVP. NVP knowledge may be important for providing accurate survey data, understanding the potential risks of NVP use, and assessing legal and regulated products. This paper examines current vapers who responded “don’t know” (DK) regarding their NVP features. Data are from adult daily/weekly vapers in Waves Two (2018, n = 4192) and Three (2020, n = 3894) of the ITC Four Country Smoking and Vaping Survey. Analyses assessed DK responses for NVP features (e.g., type/appearance, nicotine) and consumption. A DK index score was computed based on the percent of all features with DK responses, which was tested for associations with demographics, smoking/vaping status, NVP features, purchase location, and knowledge of NVP relative risks. NVP description and appearance were easily identified, but DK was more common for features such as nicotine content (7.3–9.2%) and tank/cartridge volume capacity (26.6–30.0%). DK responses often differed by vaping/smoking status, NVP type/appearance, purchase location, and country. Vapers who are younger, use box-shaped NVPs, purchase online, and exclusive daily vapers were associated with lower DK index scores. Higher DK index scores were associated with poorer knowledge of relative health risks of NVP use. The diversity of the NVP market and wide variation in how products are used makes it challenging to capture information from users about device features, such as nicotine content and capacity, in population surveys.

Citation

Frietas-Lemos, R., Keith, D.R., Tegge, A.N., Stein, J.S., Cummings, K.M., Bickel, W.K. (2021). Estimating the impact of tobacco parity and harm reduction tax proposals using the Experimental Tobacco Marketplace. International Journal of Environmental Research and Public Health,18(15), 7835. doi: 10.3390/ijerph18157835.

Abstract

Taxes are a demonstrably effective method to suppress tobacco use. This study examined the effects of the tobacco parity (i.e., imposing taxes equally on all tobacco products) and the harm reduction (i.e., applying taxes in proportion to the products’ levels of harm) tax proposals on demand and substitution across products. A crowdsourced sample of cigarette smokers (n = 35) completed purchasing trials with increasing tax magnitudes across different tax tiers in the Experimental Tobacco Marketplace in a repeated-measures design. Products were placed in three tax tiers (high, medium, and no tax) according to each proposal’s goal. The results indicated that total nicotine (mg) purchased was not significantly different between the proposals, with higher taxes yielding lower demand. However, as taxes increased, the tobacco parity proposal decreased the purchasing of all tobacco products and increased the purchasing of medicinal nicotine (i.e., the no tax tier). Conversely, the harm reduction proposal resulted in greater purchases of electronic nicotine delivery systems and smokeless tobacco (i.e., the medium tax tier). These findings support tobacco taxation as a robust tool for suppressing purchasing and suggest that differential taxation in proportion to product risk would be an effective way to incentivize smokers to switch from smoked to unsmoked products. Further studies should investigate the unintended consequences of their implementation.

Citation

Levy, D., Sanchez-Romero, L.M., Douglas, C.E., Sweanor, D. (2021). An analysis of the Altria-Juul labs deal: Antitrust and public health implications. Journal of Competition Law and Economics, 17(2), 458-492. doi: 10.1093/joclec/nhaa033.

Abstract

On December 19, 2018, Altria announced an offer of $12.8 billion for Juul Labs, combining the largest U.S. cigarette manufacturer with the largest U.S. e-cigarette company. This deal is currently being challenged by the Federal Trade Commission (FTC). We consider the antitrust implications. We also consider population health implications, which we argue are essential to a comprehensive analysis of the impact on consumers. Although the FTC antitrust investigation has focused on closed vaping systems, we argue that the relevant market is the broader nicotine delivery product market, which includes all vaping products along with tobacco products. With Altria having a large market share in the key nicotine delivery product submarkets and with important entry barriers, the merger potentially places Altria in a dominant position in the relevant market. In particular, competition in the vaping submarket is reduced, thereby likely to reduce the availability of less harmful alternatives to cigarettes.

Citation

Gravely, S., Cummings, K.M., Hammond, D., Borland, R., McNeill, A., East, K., Loewen, R., Martin, N., Yong, H.H., Li, L., Liber, A., Levy, D.T., Quah, A.C.K., Ouimet, J., Hitchman, S.C., Thompson, M.E., Boudreau, C., Fong, G.T. (2021). Self-reported quit aids and assistance used by smokers at their most recent quit attempt: Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey. Nicotine & Tobacco Research, 23(10), 1699-1707. doi: 10.1093/ntr/ntab068.

Abstract

Introduction: This study retrospectively describes smoking cessation aids, cessation services, and other types of assistance used by current and ex-smokers at last quit attempt (LQA) in four high-income countries.

Methods: Data are from the Wave 3 (2020) International Tobacco Control Four Country Smoking and Vaping Survey in Australia, Canada, England, and the US. Eligible respondents were daily smokers or past-daily recent ex-smokers who made a quit attempt/quit smoking in the last 24-months, resulting in 3,614 respondents. Self-reported quit aids/assistance included: nicotine vaping products (NVPs), nicotine replacement therapy (NRT), other pharmacological therapies (OPT: varenicline/bupropion/cytisine), tobacco (non-combustible: heated tobacco product/smokeless tobacco), cessation services (quitline/counseling/doctor), other cessation support (e.g., mobile apps/website/pamphlets etc.), or no aid.

Results: Among all respondents, at LQA, 28.8% used NRT, 28.0% used an NVP, 12.0% used OPT, 7.8% used a cessation service, 1.7% used a tobacco product, 16.5% other cessation support, and 38.6% used no aid/assistance. Slightly more than half of all smokers and ex-smokers (57.2%) reported using any type of pharmacotherapy (NRT or OPT) and/or an NVP, half used NRT and/or an NVP (49.9%), and 38.4% used any type of pharmacotherapy (NRT and/or OPT). A quarter of smokers/ex-smokers used a combination of aids. NVPs and NRT were the most prevalent types of cessation aids used in all four countries; however, NRT was more commonly used in Australia, relative to NVPs, and in England, NVPs were more commonly used than NRT. The use of NVPs or NRT was more evenly distributed in Canada and the US.

Conclusions: It appears that many smokers are still trying to quit unassisted, rather than utilizing cessation aids or other forms of assistance. Of those who did use assistance, NRT and NVPs were the most common method, which appears to suggest that nicotine substitution is important for smokers when trying to quit smoking.

Citation

King, B., Borland, R., Le Grande, M., O’Connor, R.J., Fong, G.T., McNeill, A., Hatsukami, K., Cummings, K.M. (2021). Smokers’ awareness of filter ventilation, and how they believe it affects them: Findings from the ITC Four Country Smoking and Vaping Survey. Tobacco Control, [Published online June 15, doi: 10.1136/tobaccocontrol-2020-056134].

Abstract

Background: Filter ventilation creates sensations of ‘lightness’ or ‘smoothness’ and is also highly effective for controlling machine-tested yields of tar, nicotine and carbon monoxide. Nearly all factory-made cigarettes (FMC) now have filter ventilation in countries such as Australia, Canada, the UK and the USA. Research conducted before ‘light’ and ‘mild’ labelling was banned found low smoker awareness of filter ventilation and its effects. This study explores current levels of awareness of filter ventilation and current understanding of its effects in these four countries.

Methods: We used data from the 2018 wave of the ITC Four Country Smoking and Vaping Survey with samples from USA, England, Canada and Australia. Analyses were conducted initially on a weighted sample of 11 844, and subsequently on 7541 daily FMC smokers.

Findings: Only 40.3% of all respondents reported being aware of filter ventilation. Among daily FMC smokers, only 9.4% believed their cigarettes had filter ventilation. Believing that their usual cigarettes are smoother was positively associated with believing they are also less harmful. Both these beliefs independently predict believing their cigarettes are ventilated (smoother OR=1.97 (95% CI 1.50 to 2.59) and less harmful OR=2.41 (95% CI 1.66 to 3.49) in relation to those believing each characteristic is average.

Interpretation: Awareness of filter ventilation is currently low, despite decades of public ‘education efforts around the misleading nature of ‘light’ and ‘mild” descriptors. Few smokers realise that their cigarettes almost certainly are vented. Smokers who believed their cigarettes have filter ventilation were more likely to believe they were both smoother and less harmful. Awareness of the technology appears to be insufficient to prevent smokers being deceived by it. Filter ventilation is inherently misleading to smokers and it is time to ban it.

Citation

Driezen, P., Gravely, S., Wadsworth, E., Smith, D.M., Loewen, R., Hammond, D., Li, L., Abramovici, H., McNeill, A., Borland, R., Cummings, K.M., Thompson, M.E., Fong, G.T. (2021). Increasing cannabis use is associated with poorer cigarette smoking cessation outcomes: Findings from the ITC Four Country Smoking and Vaping Surveys, 2016-2018. Nicotine and Tobacco Research, [Published online June 10, doi: 10.1093/ntr/ntab122].

Abstract

Introduction: Concurrent use (co-use) of tobacco and cannabis may impede successful cigarette smoking cessation. This study examined whether changes in cannabis use frequency were associated with smoking cessation.

Methods: Nationally representative samples of adult cigarette smokers from Canada (n=1455), the United States (n=892), England (n=1416), and Australia (n=717) were surveyed in 2016 and 2018. In each year, smokers reported how often they used cannabis in the previous 12 months. Reports were compared to determine whether cannabis use increased, remained unchanged, or decreased. Smoking cessation outcomes, measured in 2018, were (1) any attempt to quit in the previous year, (2) currently quit, and (3) currently quit for at least 6 months. Weighted multivariable logistic regression estimated the association between changes in cannabis use and cessation outcomes.

Results: Cigarette smokers who increased their frequency of cannabis use were significantly less likely to be currently quit than non-cannabis using smokers (adjusted odds ratio (aOR) = 0.52, 95% CI: 0.31, 0.86); they were also less likely to have quit for at least 6 months (aOR = 0.30; 95% CI: 0.15, 0.62).

Conclusions: Smokers who increase their frequency of cannabis use have poorer smoking cessation outcomes compared to non-cannabis using smokers. It will be important to monitor the impact of cannabis legalization on patterns of cannabis use, and whether this influences cigarette smoking cessation rates.

Citation

Hammond, D., Reid, J., Burkhalter, R., O’Connor, R.J., Goniewicz, M., Wackowski, O., Thrasher, J.F., Hitchman, S.C. (2021). Trends in e-cigarette brands, devices and nicotine levels used by youth in England, Canada, and the United States: 2017 to 2019. Tobacco Control, [Published online June 7, doi: 10.1136/tobaccocontrol-2020-056371].

Abstract

Background: The e-cigarette market has rapidly evolved, with a shift towards higher nicotine concentration and salt-based products, such as JUUL; however, the implications for youth vaping remain unclear.

Methods: Repeat cross-sectional online surveys were conducted in 2017, 2018 and 2019, with national samples of youth aged 16–19 years recruited from commercial panels in Canada (n=12 018), England (n=11 362) and the USA (n=12 110). Regression models examined differences between countries and over time in the types of e-cigarette products used (design and nicotine content), reasons for using brands and differences in patterns of use, sociodemographics and dependence symptoms by brand/nicotine content.

Results: In 2019, the use of pod- or cartridge-style e-cigarettes was greater in Canada and the USA than England, with Smok and JUUL the leading brands in all countries. In 2019, youth vapers in England were less likely to report using e-cigarettes with ≥2% nicotine (12.8%) compared with Canada (40.5%; adjusted OR (AOR)=4.96; 95% CI 3.51 to 7.01) and the USA (37.0%; AOR=3.99, 95% CI 2.79 to 5.71) and less likely to report using nicotine salt-based products (12.3%) compared with Canada (27.1%; AOR=2.77, 95% CI 1.93 to 3.99) and the USA (21.9%; AOR=2.00, 95% CI 1.36 to 2.95). In 2019, self-reported use of products with higher nicotine concentration was associated with significantly greater frequency of vaping, urges to vape and perceived vaping addiction (p<0.05 for all).

Conclusions: The use of high-nicotine salt-based products is associated with greater symptoms of dependence, including JUUL and other higher-nicotine brands. Greater use of high-nicotine salt-based products may account for recent increases in the frequency of vaping among youth in Canada and the USA.

Citation

Gravely, S., Craig, L., Cummings, K.M., Ouimet, J., Loewen, R., Martin, N., Chung-Hall, J., Driezen, P., Hitchman, S.C., McNeill, A., Hyland, A., Quah, A.C.K., O’Connor, R.J., Borland, R., Thompson, M.E., Boudreau, C., Fong, G.T. (2021). Smokers’ cognitive and behavioural reactions during the early phase of the COVID-19 pandemic: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. PLoS One, 16(6), e0252427. doi: 10.1371/journal.pone.0252427.

July 14, 2021 | Press Release from University of Waterloo: Unlike other global crises, COVID-19 pandemic did not spark more smoking in its initial stage

Abstract

Introduction: COVID-19 is primarily a respiratory illness, and smoking adversely impacts the respiratory and immune systems; this confluence may therefore incentivize smokers to quit. The present study, conducted in four high-income countries during the first global wave of COVID-19, examined the association between COVID-19 and: (1) thoughts about quitting smoking; (2) changes in smoking (quit attempt, reduced or increased smoking, or no change); and (3) factors related to a positive change (making a quit attempt or reducing smoking) based on an adapted framework of the Health Belief Model.

Methods: This cross-sectional study included 6,870 adult smokers participating in the Wave 3 (2020) ITC Four Country Smoking and Vaping Survey conducted in Australia, Canada, England, and United States (US). These four countries had varying responses to the pandemic by governments and public health, ranging from advising voluntary social distancing to implementing national and subnational staged lockdowns. Considering these varying responses, and the differences in the number of confirmed cases and deaths (greatest in England and the US and lowest in Australia), smoking behaviours related to COVID-19 may have differed between countries. Other factors that may be related to changes in smoking because of COVID-19 were also explored (e.g., sociodemographics, nicotine dependence, perceptions about personal and general risks of smoking on COVID-19). Regression analyses were conducted on weighted data.

Results: Overall, 46.7% of smokers reported thinking about quitting because of COVID-19, which differed by country (p<0.001): England highest (50.9%) and Australia lowest (37.6%). Thinking about quitting smoking because of COVID-19 was more frequent among: females, ethnic minorities, those with financial stress, current vapers, less dependent smokers (non-daily and fewer cigarettes smoked/day), those with greater concern about personal susceptibility of infection, and those who believe COVID-19 is more severe for smokers. Smoking behaviour changes due to COVID-19 were: 1.1% attempted to quit, 14.2% reduced smoking, and 14.6% increased smoking (70.2% reported no change). Positive behaviour change (tried to quit/reduced smoking) was reported by 15.5% of smokers, which differed by country (p = 0.02), where Australia had significantly lower rates than the other three countries. A positive behavioural smoking change was more likely among smokers with: lower dependence, greater concern about personal susceptibility to infection, and believing that COVID-19 is more severe for smokers.

Conclusions: Though nearly half of smokers reported thinking about quitting because of COVID-19, the vast majority did not change their smoking behaviour. Smokers were more likely to try and quit or reduce their smoking if they had greater concern about susceptibility and severity of COVID-19 related to smoking. Smokers in Australia were least likely to reduce or try to quit smoking, which could be related to the significantly lower impact of COVID-19 during the early phase of the pandemic, relative to the other countries.

Citation

Fix, B.V., O’Connor, R.J., Goniewicz, M.L., Leigh, N.L., Cummings, K.M., Hitchman, S.C., Fong, G.T., el Nahas, G., Hammond, D., McNeill, A., Borland, R., King, B., Palumbo, M.N. (2021). Characterization of vaping liquids used in vaping devices across four countries: Results from an analysis of selected vaping liquids reported by users in the 2016 ITC Four Country Smoking and Vaping Survey. Tobacco Control, [Published online May 21, doi: 10.1136/tobaccocontrol-2020-056338].

Abstract

Objectives: This study presents an analysis of vaping products (VPs) purchased in the USA, Canada, England and Australia and assesses whether differences in regulations were associated with differences in the chemical composition of the VPs.

Methods: April-September 2017, a total of 234 VP refill liquids and prefilled cartridges were purchased in convenience samples of retail locations in each country. Products were chosen from brands and styles most commonly reported by current VP users in the 2016 ITC Four Country Smoking and Vaping Survey. All products were tested for nicotine, tobacco-specific nitrosamines (TSNAs), minor tobacco alkaloids, organic acids and flavouring chemicals.

Results: Consistent with the laws in Canada and Australia at the time of product purchase, nicotine was not detected in any of the VPs (n=10 in Canada; n=15 in Australia). US liquids (n=54) had a mean nicotine concentration of 16.2 mg/mL, (range=0.0-58.6) and English liquids (n=166) had a mean concentration of 11.9 mg/mL ((range=0.0-31.2) F(3244)=12.32, p<0.001). About 5% of English samples exceeded the UK's 20 mg/mL nicotine limit. Substantial country differences were observed in levels ofTSNAs, with the USA being higher than elsewhere. Of all products tested, 18.8% contained at least one organic acid. Liquids purchased in England contained far more identifiable flavouring chemicals than those in the other countries.

Conclusions: VP composition, particularly with respect to nicotine and flavouring, varies by country, likely reflecting both marketplace preferences and country-specific regulations. There are differences between nicotine levels claimed on the package and actual levels, particularly in England.

Citation

Freitas Lemos, R., Stein, J.S., Tegge, A.N., Kaplan, B.A., Heckman, B.W., Cummings, K.M., Bickel, W.K. (2021). The Illegal Experimental Tobacco Marketplace I: Effects of vaping product bans. Nicotine and Tobacco Research, [Published online, doi:https://doi.org/10.1093/ntr/ntab088].

Abstract

Objectives: Banning vaping products may have unintended outcomes, such as increased demand for illegal products. This study experimentally examined the effects of a vaping ban and a flavored vaping ban on the probability of purchasing illicit vaping products, and factors affecting purchasing from a hypothetical illegal marketplace.

Methods: A crowdsourced sample of exclusive cigarette smokers, exclusive e-cigarette users, and frequent dual users (n=150) completed hypothetical purchasing trials in an Experimental Tobacco Marketplace under three conditions (no ban, vaping ban, flavored vaping ban). Participants chose to purchase in a hypothetical legal experimental tobacco marketplace (LETM) or illegal experimental tobacco marketplace (IETM). Vaping products were available in each marketplace depending on the condition. Other tobacco products were always available in the LETM. A hypothetical illicit purchase task with five fine amounts assessed the effect of monetary penalties.

Results: Participants from all groups were more likely to purchase from the IETM when product availability in the LETM was more restricted, with e-cigarette users being most affected. The likelihood of purchasing illegal products was systematically decreased as monetary penalties associated with the IETM increased, with e-cigarette users showing greater persistence in defending their illicit purchases.

Conclusions: Restricting vaping products from the marketplace may shift preference towards purchasing vaping products in the illegal marketplace. Nevertheless, penalties imposed on consumer's behavior might be effective in preventing illicit trade. The IETM is a methodological extension that supports the utility and flexibility of the ETM as a framework for understanding the impact of different tobacco regulatory policies.

Citation

Levy, D.T., Sánchez-Romero, L.M., Travis, N., Yuan, Z., Li, Y., Skolnick, S., Jeon, J., Tam, J., Meza, R. (2021). US nicotine vaping product SimSmoke Simulation Model: The effect of vaping and tobacco control policies on smoking prevalence and smoking-attributable deaths. International Journal of Environmental Research and Public Health, 18(9), 4876. doi:10.3390/ijerph18094876.

Abstract

The public health impact of nicotine vaping products (NVPs) is subject to a complex set of uncertain transitions between NVP and cigarette use. Instead, we apply an indirect method to gauge the impact of NVP use on smoking prevalence and smoking-attributable deaths (SADs) using the well-established SimSmoke tobacco control policy simulation model. Upon validating the model before NVPs were more widely used, we project a No-NVP (i.e., in the absence of NVPs) while controlling for the impact of cigarette-oriented policies. The net impact of NVPs on smoking prevalence is inferred by comparing the projected No-NVP smoking trends to corresponding trends from two US national surveys. Using the TUS-CPS estimates for the period 2012–2018, we estimate that adult smoking prevalence declined in relative terms by 9.7% (95% CI: 7.5–11.7%) for males and 10.7% (95% CI: 9.1–13.0%) for females. Compared to NHIS, smoking prevalence declined by 10.7% (95% CI: 6.8–14.6%) for males and 11.3% (95% CI: 7.4–15.6%) for females. These impacts were confined mainly to ages 18–44. Vaping-related reductions in smoking prevalence were projected to avert nearly 0.4 million SADs between 2012 and 2052. Our analysis indicates that NVP use is associated with substantial reductions in US smoking prevalence among younger adults.

Citation

Smith, T., Nahhas, G., Borland, R., Cho, Y., Chung-Hall, J., Fairman, R.T., Fong, G.T., McNeill, A., Popova, L., Thrasher, J.F., Cummings, K.M. (2021). Which tobacco control policies do smokers support? Findings from the International Tobacco Control Smoking and Vaping Survey. Preventive Medicine, [Published online May 3, doi: https://doi.org/10.1016/j.ypmed.2021.106600].

Abstract

As governments consider policy action to reduce smoking, a key factor in creating political will is the level of public support, particularly among smokers who are most affected by the policies. The goal of this paper is to assess and compare the level of support in Canada, the United States, England, and Australia for five smoking control policies: 1) banning menthol in cigarettes, 2) banning cigarette additives, 3) reducing nicotine in cigarettes to make them less addictive, 4) raising the minimum age to purchase cigarettes to 21 years and older, and 5) requiring pictorial warning labels on cigarette packs (examined in the US only). Data for these analyses come from 8165 daily cigarette smokers who responded to the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. In all countries, the highest level of support was for raising the legal age for purchase to 21 years and older (62-70%) and reducing the nicotine content of cigarettes to make them less addictive (57-70%). Smokers who were less dependent on cigarettes and those expressing interest in quitting were more likely to support all policies. When asked how they would respond to a nicotine reduction policy, the most common response given was to try the non-nicotine cigarettes to see how they liked them (42-48%), with the next most common response being to quit smoking entirely (16-24%). The high level of support for these proposed policies among daily smokers provides important evidence for policymakers to counteract claims that such policies would be unpopular.

Citation

Yimsaard, P., McNeill, A., Yong, H.H., Cummings, K.M., Chung-Hall, J., Hawkins, S., Quah, A.C.K., Fong, G.T., O’Connor, R.J., Hitchman, S.C. (2021). Gender differences in reasons for using electronic cigarettes and product characteristics: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 23(4), 678-686.

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 3,938 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.

Citation

Levy, D., Tam, J., Sanchez-Romero, L.M., Li, Y., Yuan, Z., Travis, N, Jeon, J, Meza, R. (2021). Public health implications of vaping in the US: The smoking and vaping simulation model. Population Health Metrics, 19(1), 19. doi: 10.1186/s12963-021-00250-7.

Abstract

Background: Nicotine vaping products (NVPs) are increasingly popular worldwide. They may provide public health benefits if used as a substitute for smoking, but may create public health harms if used as a gateway to smoking or to discourage smoking cessation. This paper presents the Smoking and Vaping Model (SAVM), a user-friendly model which estimates the public health implications of NVPs in the USA.

Methods: SAVM adopts a cohort approach. We derive public health implications by comparing smoking- and NVP-attributable deaths and life-years lost under a No-NVP and an NVP Scenario. The No-NVP Scenario projects current, former, and never smoking rates via smoking initiation and cessation rates, with their respective mortality rates. The NVP Scenario allows for smoking- and NVP-specific mortality rates, switching from cigarette to NVP use, separate NVP and smoking initiation rates, and separate NVP and smoking cessation rates. After validating the model against recent US survey data, we present the base model with extensive sensitivity analyses.

Results: The SAVM projects that under current patterns of US NVP use and substitution, NVP use will translate into 1.8 million premature smoking- and vaping-attributable deaths avoided and 38.9 million life-years gained between 2013 and 2060. When the NVP relative risk is set to 5%, the results are sensitive to the level of switching and smoking cessation rates and to a lesser extent smoking initiation rates. When the NVP relative risk is raised to 40%, the public health gains in terms of averted deaths and LYL are reduced by 42% in the base case, and the results become much more sensitive to variations in the base case parameters.

Discussion: Policymakers, researchers, and other public health stakeholders can apply the SAVM to estimate the potential public health impact of NVPs in their country or region using their own data sources. In developing new simulation models involving NVPs, it will be important to conduct extensive sensitivity analysis and continually update and validate with new data.

Conclusion: The SAVM indicates the potential benefits of NVP use. However, given the uncertainty surrounding model parameters, extensive sensitivity analysis becomes particularly important.

Citation

Tercyak, K.P., Phan, L., Gallegos-Carrillo, K., Mays, D., Audrain-McGovern, J., Tehberg, K., Li, Y., Cartujano-Barrera, F., Cupertino, A.P. (2021). Prevalence and correlates of lifetime e-cigarette use among adolescents attending public school in a low income community in the US. Addictive Behaviours, 114, 106738.

Abstract

Introduction: The prevalence of e-cigarette use among US adolescents is increasing. However, there is limited research on the prevalence and correlates of e-cigarette use among adolescents in low income and under resourced communities. We report on their e-cigarette susceptibility and use behaviors, and perceived risks of harm and addiction.

Methods: Students in grades 7, 9, and 11 from a Title I school district in the northeastern US completed an online survey during a class period. Lifetime e-cigarette use and its correlates were tested in bivariate and logistic regression models.

Results: Most students were of Latino ethnicity (66%), and 36% identified as Black/African American. Overall, 55% of the full sample were considered 'susceptible' to e-cigarette use: 19% were lifetime e-cigarette users while 6% were lifetime smokers. Students in 11th grade were more likely (OR = 2.5) to have ever used e-cigarettes compared to students in 7th grade. Those that were more curious (OR = 11.8), intended to use e-cigarettes in the next 12 months (OR = 2.8), and would use the product if it was offered by a friend (OR = 2.4) had greater odds of lifetime e-cigarette use. By contrast, students who perceived at least moderate risks of health harm (OR = 0.44) were less likely to have used e-cigarettes.

Conclusions: Adolescents from marginalized communities are susceptible to and are using e-cigarettes. Prevention efforts targeting underserved areas may benefit from e-cigarette health education messages that reduce curiosity, interrupt social aspects of initiation, and emphasize health harms.

Citation

Freitas Lemos, R, Stein, J.S., Pope, D.A., Brown, J., Feinstein, M, Stamborski, KM, Tegge, A.N., Heckman, B.W., Bickel, W.K. (2021). E-liquid purchase as a function of workplace restriction in the Experimental Tobacco Marketplace. Experimental and Clinical Psychopharmacology, [Published online February 25, doi: http://dx.doi.org/10.1037/pha0000444].

Abstract

E-cigarette use is prohibited in most smoke-free environments. The effect of this policy on tobacco consumption could be examined using the Experimental Tobacco Marketplace (ETM). The ETM allows observation of policy on smokers’ purchasing behavior under conditions that simulate “real-world” circumstances. A within-subject design was used to evaluate the effect of workplace policy (Vaping Allowed vs. Not Allowed) and nicotine concentration (24 mg/mL vs. 0 mg/mL) on tobacco product consumption. Participants (n = 31) completed one sampling and two ETM/workplace sessions per week for 2 weeks. During the sampling session, participants were given an e-cigarette with a 2-day supply of a commercially available e-liquid of their preferred flavor. Before purchasing, participants were informed whether e-cigarette use was permitted. During the four ETM sessions, participants purchased for the following 24 hr, including the 4-hr work shift that started immediately after buying products in the ETM. The workplace session consisted of data entry tasks in a mock office environment. Participants could use any purchased tobacco products during two 15-min breaks. Condition order was counterbalanced. The results show that permitting E-cigarette use in the workplace increased e-liquid purchase on average, but nicotine concentration had no effect on e-liquid demand. Cigarette demand was unaltered across conditions. The present study suggests that allowing e-cigarette use in the workplace would increase demand for e-liquid regardless of nicotine strength. However, it would not change conventional cigarette demand.

Citation

Hammond, D., Wadsworth, E., Reid, J., Burkhalter, R. (2021). Prevalence and modes of cannabis use among youth in Canada, England, and the US, 2017 to 2019. Drug and Alcohol Dependence, 219, 108505.

Abstract

Objective: Cannabis markets are evolving in terms of greater diversity and potency of products. The current study examined changes in cannabis use and modes of consumption among 16- to 19-year-olds in three markets with different regulatory frameworks: England, Canada, and the United States (US).

Methods: Repeat cross-sectional online surveys were conducted in 2017, 2018, and 2019, with samples of 16- to 19-year-olds recruited from commercial panels in Canada (n = 11,779), England (n = 11,117), and the US (n = 11,869). Regression models examined changes in the prevalence of any cannabis use and use of seven modes of consumption, across the countries.

Results: Cannabis use among youth was more prevalent among respondents in Canada and the US than in England in all years and increased to a greater extent between 2017 and 2019 (p < .001 for all contrasts). Among past 30-day cannabis consumers, the prevalence of vaping oils/liquids and the use of cannabis extracts (oil, wax and shatter) increased in all countries, and was significantly higher in Canada and US. For example, the prevalence of vaping oils/liquids increased from 24.2 % in 2017 to 52.1 % in 2019 among past 30-day cannabis consumers in the US (AOR = 3.46, 95 %CI = 2.57-4.66).

Conclusion: Prevalence is increasing for the most potent categories of cannabis products, particularly among youth in Canada and the US. Future research should examine the potential risks of these products and whether shifts in modes of cannabis reflect recent permissive changes to cannabis policy.

Citation

Le Grande, M., Borland, R., Yong, H.H., Cummings, K.M., McNeill, A., Thompson, M.E., Fong, G.T. (2021). Predictive power of dependence measures for quitting smoking: Findings from the 2016-2018 ITC Four Country Smoking and Vaping Surveys. Nicotine and Tobacco Research, 23(2), 276-285.

Abstract

Objective: To test whether urges to smoke and perceived addiction to smoking, have independent predictive value for quit attempts and short-term quit success over and above the Heaviness of Smoking Index (HSI). Methods: Data were from the International Tobacco Control Four Country Smoking and Vaping Wave 1 (2016) and Wave 2 (2018) surveys. 3661 daily smokers (daily vapers excluded) provided data in both waves. A series of multivariable logistic regression models assessed the association of each dependence measure on odds of making a quit attempt and ≥1 month smoking abstinence.

Results: Of the 3661 participants, 1594 (43.5%) reported a quit attempt. Of those who reported a quit attempt, 546 (34.9%) reported short-term quit success. Fully adjusted models showed that making quit attempts was associated with lower HSI [adjusted odds ratio (aOR) = 0.81, 95% confidence interval (CI) = 0.73-0.90, P < 0.001), stronger urges to smoke (aOR = 1.08, 95% CI = 1.04-1.20, P = 0.002), and higher perceived addiction to smoking (aOR =0.52, 95% CI 0.32-0.84, P =0.008). Lower HSI (aOR = 0.57, 95% CI = 0.40–0.87, P < 0.001) weaker urges to smoke (aOR = 0.85, 95% CI = 0.76–0.95, P = 0.006), and lower perceived addiction to smoking (aOR = 0.55, 95% CI =0.32-0.91, P = 0.021) were associated with greater odds of short-term quit success. In both cases overall R2 was around 0.5.

Conclusions: The two additional dependence measures were complementary to HSI adding explanatory power to smoking cessation models, but variance explained remains small.

Implications: Strength of urges to smoke and perceived addiction to smoking may significantly improve prediction of cessation attempts and short-term quit success over and above routinely assessed demographic variables and the HSI. Stratification of analyses by age group is recommended since the relationship between dependence measures and outcomes differ significantly for younger (age 18-39) compared to older (age over 40) participants. Even with the addition of these extra measures of dependence, the overall variance explained in predicting smoking cessation outcomes remains very low. These measures can only be thought of as assessing some aspects of dependence. Current understanding of the factors that ultimately determine quit success remains limited.

Citation

East, K., Hitchman, S.C., McNeill, A., Ferguson, S., Yong, H.H., Cummings, K.M., Fong, G.T., Borland, R. (2021). Trends in social norms towards smoking between 2002 and 2015 among daily smokers: Findings from the International Tobacco Control Four Country Survey (ITC 4C). Nicotine and Tobacco Research, 23(1), 203-211. doi: 10.1093/ntr/ntz179

Abstract

Objective: To assess trends in daily smokers’ social norms and opinions of smoking between 2002 and 2015 in Canada, US, UK and Australia.

Method: Data were from Waves-1 (2002) to -9 (2013-2015) of the longitudinal International Tobacco Control Four Country Survey (Canada, US, UK, Australia), involving 23,831 adult daily smokers. Generalised estimating equation logistic regression models, adjusted for demographics and survey design effects, assessed associations of Wave and country with outcomes: (i) over half of five closest friends smoke, (ii) agreeing that people important to you believe you should not smoke, (iii) agreeing that society disapproves of smoking, and (iv) negative opinion of smoking.

Results: Between 2002 and 2015, adjusting for covariates, (i) 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]), (ii) 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, (iii) 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 (iv) 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 UK the lowest, anti-smoking social norms and opinions.

Conclusions: Except friend smoking and opinion of smoking, daily smokers’ social norms became less anti-smoking 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 US, the UK, and Australia have led to the assumption that smoking has become increasingly denormalised 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 anti-smoking 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.

Citation

Yong, H.H., Karmakar, C., Kusmakar, S., Borland, R., Cummings, K.M., Fong, G.T., McNeill, A. (2021). Identifying factors that conjointly influence nicotine vaping product relative harm perception among smokers and recent ex-smokers: Findings from the 2016 ITC Four Country Smoking and Vaping Survey. Drug and Alcohol Dependence, 218, 108370.

Abstract

Background: Use of nicotine vaping products (NVPs) to replace smoking is often influenced by perceived harmfulness of these products relative to smoking. This study aimed to identify factors that conjointly influenced NVP relative harm perception among smokers and ex-smokers.

Methods: Data (n = 11,838) from adult smokers and ex-smokers (quit < 2 years) who participated in the 2016 ITC 4 Country Smoking and Vaping Surveys in Australia, Canada, England and the US were analyzed. Decision tree models were used to classify respondents into those who perceived vaping as less harmful than smoking (correct perception) versus otherwise (incorrect perception) based on their socio-demographic, smoking and vaping related variables.

Results: Decision tree analysis identified nicotine replacement therapy (NRT) harmfulness perceptions relative to smoking, perceived vaping portrayal in the media and other sources as positive, negative or balanced, recency of seeking online vaping information, and age as the key variables that interacted conjointly to classify respondents into those with correct versus incorrect harm perceptions of vaping relative to smoking (model performance accuracy = 0.70-0.74). In all countries, NRT relative harmfulness perception and vaping portrayal perception were consistently the two most important classifying variables, with other variables showing some country differences.

Conclusions: In all four countries, perception of NVP relative harmfulness among smokers and recent ex-smokers is strongly influenced by a combination of NRT relative harmfulness perception and vaping portrayal in the media and other sources. These conjoint factors can serve as useful markers for identifying subgroups more vulnerable to misperception about NVP relative harmfulness to benefit from corrective intervention.

Citation

Cheng, K.-W., Shang, C., Lee, H.M., Chaloupka, F.J., Fong, G.T., Borland, R., Heckman, B.W., Hithchman, S.C., O’Connor, R.J., Levy, D.T., Cummings, K.M. (2021). Costs of vaping: Evidence from ITC Four Country Smoking and Vaping Survey. Tobacco Control, 30, 94-97.

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.