Citation

Mutti, S., Hammond, D., Borland, R., Cummings, K.M., O’Connor, R.J., Fong, G.T. (2011). Beyond light and mild: Cigarette brand descriptors and perceptions of risk in the International Tobacco Control (ITC) Four Country Survey. Addiction, 106(6), 1166-1175.

Abstract

Aims: To examine perceptions of risk related to type of cigarette brand.

Design and setting: Cross-sectional findings from wave 5 of the ITC Four Country Survey, conducted with nationally representative samples of smokers in 2006.

Participants: A total of 8243 current and former adult (≥18 years) smokers from Canada (n = 2022), the United States (n = 2034), the United Kingdom (n = 2019) and Australia (n = 2168).

Measurements: Outcomes included beliefs about the relative risks of cigarettes, including perceptions of ‘own’ brand. Correlates included sociodemographic, smoking-related covariates and brand characteristics.

Findings: One-fifth of smokers believed incorrectly that ‘some cigarette brands could be less harmful’ than others. False beliefs were higher in both the United States and United Kingdom compared to Canada and Australia. Smokers of ‘light/mild’, ‘slim’ and 100 mm/120 mm cigarettes were more likely to believe that some cigarettes could be less harmful [odds ratio (OR) = 1.29, 95% confidence interval (CI) = 1.12–1.48 and that their own brand might be a little less harmful (OR = 2.61, 95% CI = 2.01–3.41). Smokers of ‘gold’, ‘silver’, ‘blue’ or ‘purple’ brands were more likely to believe that their ‘own brand might be a little less harmful’ compared to smokers of ‘red’ or ‘black’ brands (OR = 12.48, 95% CI = 1.45–107.31).

Conclusions: Despite current prohibitions on the words ‘light’ and ‘mild’, smokers in western countries continue to falsely believe that some cigarette brands may be less harmful than others. These beliefs are associated with descriptive words and elements of package design that have yet to be prohibited, including the names of colours and long, slim cigarettes.

Citation

Yong, H.H., Borland, R., Cummings, K.M., Hammond, D., O’Connor, R.J., Hastings, G., King, B. (2011). Impact of the removal of misleading terms on cigarette pack on smokers' beliefs about "light/mild" cigarettes: Cross-country comparisons. Addiction, 106(12), 2204-2213.

Abstract

Aim: This paper examines how smokers’ beliefs about “light/ mild” cigarettes in Australia, Canada and the UK were affected by the removal of misleading “light/mild” terms from packs.

Design, setting and participants: The data come from the first 7 waves (2002-2009) of the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey, an annual cohort telephone survey of adult smokers in Canada, United States, United Kingdom, and Australia (21,613 individual cases). “Light” and “mild” descriptors were removed in 2003 in the UK, in 2006 in Australia, and in 2007 in Canada. We compare beliefs about “light” cigarettes both before and after the bans, with those of smokers in the US serving as the control condition.

Findings: The proportions of respondents reporting misperceptions about light cigarettes declined between 2002 and 2009 in all four countries. There were marked temporary reductions in reported misperceptions in the UK and Australia but not in Canada following the removal of “light/mild” descriptors.

Conclusions: Removal of “light/mild” descriptors and tar, nicotine and carbon monoxide yield information from cigarette packs is insufficient to effectively eliminate false beliefs. The combination of alternative descriptors and design features that produce differences in taste strength and harshness, independent of actual intakes, are sufficient to produce or sustain the same misbeliefs.

Citation

Cooper, J., Borland, R., Yong, H.H., McNeill, A., Murray, R.L., O’Connor, R.J., Cummings, K.M. (2010). To what extent do smokers make spontaneous quit attempts and what are the implications for smoking cessation maintenance? Findings from the International Tobacco Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S51-57.

Abstract

Aim: To assess the extent to which quit attempts are spontaneous and to evaluate if this is a determinant of smoking cessation maintenance, with better control for memory effects.

Methods: We use data from 3,022 smokers who made quit attempts between Waves 4 and 5 and/or Waves 5 and 6 of the International Tobacco Control Four country survey. Outcomes (quitting for 6 months) were confirmed at the next wave for cases where the attempt began within the previous 6 months. We assessed the length of delay between the decision to quit and implementation and whether the attempt followed a “spur-of-the-moment” decision or some serious prior consideration. Outcomes were modeled using generalized estimating equations.

Results: Prior consideration of quitting was unrelated to the outcome, but there were complex relationships for the delay between choosing a quit day and implementation. Those who reported quitting on the day they decided and those who delayed for 1 week or more had comparable rates of 6-month abstinence. Delaying for 1–6 days was associated with a greater relapse rate than those who quit on the day, although this effect became non-significant in multivariate analyses.

Conclusions: Quitting is on most smokers’ minds regularly and most attempts are not preceded by a long lead in period following the decision to try. Neither prior consideration nor delay between the decision to quit and implementation was clearly related to outcomes. Previous findings of greater success for spontaneous quit attempts may be because they conflate setting a date in advance with planning and also perhaps some differential memory effects.

Citation

Reid, J., Hammond, D., Boudreau, C., Fong, G.T., Siahpush, M. (2010). Socioeconomic disparities in quit intentions, quit attempts, and smoking abstinence among smokers in four western countries: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S20-33.

Abstract

Introduction: Lower socioeconomic status (SES) groups have higher rates of tobacco use, are less likely to successfully quit, and may also be less likely to intend or attempt to quit. However, results are inconsistent for some outcomes, and little is known about how socioeconomic disparities vary across countries and over time.

Methods: This study examined the associations between SES and quitting-related behaviors among representative samples of smokers in Canada, the United States, the United Kingdom, and Australia, using data from the first five waves (2002–2006/2007) of the International Tobacco Control Four Country Survey (35,532 observations from 16,458 respondents). Generalized estimating equations modeling was used to examine whether education and income were related to intentions to quit, incidence of quit attempts, and smoking abstinence. Potential differences in the associations over time and across countries were also considered.

Results: Smokers with higher education were more likely to intend to quit, to make a quit attempt, and to be abstinent for at least 1 and 6 months; smokers with higher income were more likely to intend to quit and to be abstinent for at least 1 month. Some between-country differences were observed: U.K. and U.S. smokers were less likely to intend to quit than Australians and Canadians; and, although U.K. respondents were least likely to attempt to quit, those that did were more likely to be abstinent.

Discussion: The results suggest that socioeconomic disparities exist at multiple stages in the path to smoking cessation. Potential effects on socioeconomic disparities should be considered when implementing cessation interventions.

Citation

Gibson, J.E., Murray, R.L., Borland, R., Cummings, K.M., Fong, G.T., Hammond, D., McNeill, A. (2010). The impact of the United Kingdom's national smoking cessation strategy on quit attempts and use of cessation services: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S64-71.

Abstract

Introduction: The World Health Organization Framework Convention on Tobacco Control recommends that provision of cessation support should be included in national tobacco control strategies. This study examines the impact of the United Kingdom’s national smoking cessation strategy on quit attempts, use of treatment and short-term abstinence, relative to the United States, Canada, and Australia where less support is provided.

Methods: Data on quitting behavior and use of support were obtained for all smokers enrolled in the International Tobacco Control 4 Country Survey between 2002 and 2005. Generalized estimating equations were used to calculate the relative odds (adjusted by age, sex, and Heaviness of Smoking Index) that smokers in each country made quit attempts, used behavioral or pharmacological support, and to compare rates of short-term (28 days) abstinence between countries and users of different forms of support.

Results: U.K. smokers were less likely to have attempted to quit smoking than those in Australia (odds ratio [OR] = 1.25, 95% CI: 1.12–1.40), Canada (OR = 1.50, 95% CI: 1.34–1.67), and the United States (OR = 1.25, 95% CI: 1.11–1.40) but were more likely to use pharmacotherapy and/or support from a clinic, helpline, or health professional when attempting to quit than smokers in the other countries. U.K. smokers making quit attempts were significantly more likely to achieve 28-day abstinence than those in Australia (OR = 0.59, 95% CI: 0.49–0.71), Canada (OR = 0.72, 95% CI: 0.61–0.87), and the United States (OR = 0.51, 95% CI: 0.42–0.62).

Conclusions: U.K. smokers report fewer quit attempts but are more likely to use support when quitting and to achieve short-term abstinence.

Citation

Cooper, J., Borland, R., Yong, H.H., Hyland, A. (2010). Compliance and support for bans on smoking in licensed venues in Australia: Findings from the International Tobacco Control Four Country Survey. Australian and New Zealand Journal of Public Health, 34(4), 379-385.

Abstract

Objective: To examine attitudes towards and compliance with the recent Australian bans on smoking in licensed venues, and to explore effects on smoking behaviour.

Methods: Three Australian states (Queensland, Tasmania and Western Australia) implemented a total ban on smoking in all enclosed licensed premises in 2006, and two others (Victoria and New South Wales) did so in mid-2007. We used data from smokers residing in these states for each of the six waves of the ITC-4 country survey (2002-2007; average n=1,694).

Results: Consistent with the majority of international findings, observed compliance was reported by more than 90% of smokers from a pre-ban situation of indoor smoking being the norm. Attitudes became more positive in the year before the ban, but more than doubled in the year the bans were implemented. The associations found for the leading states were replicated by the lagging states a year later. We found no evidence for any increase in permitting smoking inside the home after the bans took effect. Further, we were unable to find any evidence of reductions in daily cigarette consumption or any increase in quitting activity due to the bans.

Implications: These results add to a growing body of international research that suggests that smokers are readily able to comply with, and increasingly support, smoke-free bars, though the bans may have limited effect on their smoking habits.

Citation

Hitchman, S.C., Fong, G.T., Borland, R., Hyland, A. (2010). Predictors of smoking in cars with nonsmokers: Findings from the 2007 Wave of the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(4), 374-380.

Abstract

Objective: This study examines the proportion and characteristics of smokers who smoke in cars with nonsmokers across four countries and the potentially modifiable correlates of this behavior.

Methods: Respondents included a total of 6,786 current adult smokers from Wave 6 (September 2007– February 2008) of the International Tobacco Control Four Country Survey, a random digit-dial telephone survey of nationally representative samples of adult smokers in Australia, the United Kingdom, Canada, and the United States.

Results: Reports of smoking in cars with nonsmokers ranged from a low of 29% in Australia and the United Kingdom, to 34% in Canada, and to a high of 44% in the United States. Daily smokers who were from the United States, male, and younger were the most likely to smoke in cars with nonsmokers. Several potentially modifiable factors were also found to be related to this behavior, including smoke-free homes and beliefs about the dangers of cigarette smoke exposure to nonsmokers.

Conclusions: A considerable proportion of smokers continue to smoke in cars with nonsmokers across the four countries, particularly in the United States. Public health campaigns should educate smokers about the hazards of cigarette smoke exposure and promote the need for smoke-free cars. These findings provide a foundation of evidence relevant for jurisdictions

Citation

Yong, H.H., Borland, R., Cooper, J., Cummings, K.M. (2010). Postquitting experiences and expectations of adult smokers and their association with subsequent relapse: Findings from the International Tobacco Control (ITC) Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S12-19.

Abstract

Introduction: This paper explores postquitting experiences and expectations of adult ex-smokers and their utility as predictors of smoking relapse after prolonged abstinence.

Methods: Data are from 1,449 ex-smokers (providing 2,234 observations) recruited as smokers as part of the International Tobacco Control (ITC) Four Country Survey (Australia, Canada, the United Kingdom, and the United States) but surveyed after they had quit. Controlling for length of time quit, reported postquitting experiences, and expectations assessed at one of three waves were used as predictors. Smoking status (whether they had relapsed) at the next wave was used as the outcome of interest.

Results: Postquitting experiences and expectations, such as capacity to enjoy life’s simple pleasures, ability to cope with stress, ability to control negative emotions, and health concerns, changed systematically over time but at different rates. The trajectory of change for life enjoyment and health concerns followed a rapidly asymptoting logarithmic function, while that of stress and negative affect coping followed a slower asymptoting square root function. After controlling for sociodemographic and abstinence duration, only reported decline in capacity to control negative affect since quitting was associated with increased relapse risk.

Discussion: The varying patterns of change in postquitting experiences suggest that psychological gains over time following smoking cessation do not all occur at the same rate. The relative importance of each factor in maintaining abstinence is also not the same with deficits in perceived control of negative emotions being the only one predictive of subsequent relapse. Strategies to improve impulse control over negative emotions postquitting may help to reduce relapse risk.

Citation

Borland, R., Yong, H.H., Balmford, J., Cooper, J., Cummings, K.M., O’Connor, R.J., McNeill, A., Zanna, M.P., Fong, G.T. (2010). Motivational factors predict quit attempts but not maintenance of smoking cessation: Findings from the International Tobacco Control Four Country Project. Nicotine & Tobacco Research, 12(Suppl 1), S4-11.

Abstract

Aim: To explore whether measures of motivation to quit smoking have different predictive relationships with making quit attempts and the maintenance of those attempts.

Methods: Data are from three wave-to-wave transitions of the International Tobacco Control Four (ITC-4) country project. Smokers' responses at one wave were used to predict the likelihood of making an attempt and among those trying the likelihood of maintaining an attempt for at least a month at the next wave. For both outcomes, hierarchical logistic regressions were used to explore the predictive capacity of seven measures of motivation to quit smoking, controlling for a range of other known or possible predictors.

Results: Bivariate analyses indicate that measures of motivation to quit are predictive of making quit attempts, but they predict relapse among those making attempts. Multivariate analyses identified wanting to quit and frequency of prematurely butting out cigarettes as the main positive predictors of making attempts, but this was reduced by intention and recency of last attempt. For maintenance, premature butting out was the main motivation variable predicting relapse and was essentially unaffected by other measures.

Discussion: The findings show that it is wrong to suggest that all one needs to quit is to be motivated to do so. The reality is that one needs to be motivated to prompt action to stop smoking, but this is not sufficient in and of itself to ensure that cessation is maintained. These findings call attention to the importance of understanding the differential roles that prequit and postquit experiences play in smoking cessation and of providing help to smokers to stay off cigarettes.

Citation

Borland, R., Yong, H.H., O’Connor, R.J., Hyland, A., Thompson, M.E. (2010). The reliability and predictive validity of the Heaviness of Smoking Index and its two components: Findings from the International Tobacco Control Four Country Study. Nicotine & Tobacco Research, 12(Suppl 1), S45-50.

Abstract

Background: There is increasing recognition that the two measures in the Heaviness of Smoking Index (HSI), time to first cigarette of the day (TTFC) and daily consumption (cigarettes per day [CPD]), are strong predictors of quitting behavior.

Methods: Use of Waves 1-4 of International Tobacco Control cohort with around 8,000 respondents per wave and 6,000 for prediction of quit outcomes at the next wave. We measured TTFC and CPD at each wave and quit outcomes at the next wave. We also looked at the relative utility of the standard categorical scoring compared with a continuous score using the square root of CPD minus the natural log of TTFC in minutes.

Results: We found considerable consistency of the measures across years with a small decrease as duration between measurements increased. For a 3-year gap, the correlations were .72 and .70 for the continuous and categorical composite HSI measures, respectively, and were at least .63 for the individual components. Both TTFC and CPD independently predicted maintenance of quit attempts (for at least 1 month) in each of the three wave-to-wave replications, and these effects were maintained when controlling for demographic factors. CPD also predicted making attempts consistently, but the results for TTFC was not consistently significant.

Discussion: Both TTFC and CPD are fairly reliable over time and are important predictors of quitting. There are only small effects of mode of computing the scores, and the two items can be used either individually or combined as the HSI.

Citation

Fix, B.V., O’Connor, R.J., Hammond, D., King, B., McNeill, A., Thrasher, J.F., Boado Martinez, M., Cummings, K.M., Yong, H.H., Thompson, M.E., Hyland, A. (2010). ITC spit and butts pilot study: The feasibility of collecting saliva and cigarette butt samples from smokers to evaluate policy. Nicotine & Tobacco Research, 12(3), 185-190.

Abstract

Introduction: Large-scale epidemiological surveys have frequently relied upon clinic-based sample collection to incorporate biological data, which can be costly and result in non-representative data. Collecting samples in a nonclinical setting (i.e., through postal mail or at the subject’s home) offers an alternative option that is minimally invasive and can be incorporated into large population-based studies.

Objectives: (a) To assess the feasibility of collecting biological data from a cohort of smokers in the International Tobacco Control (ITC) study, through the mail and in the home; (b) to examine whether participants are representative of the population under consideration; and (c) to evaluate how the added burden of providing biomarker samples might impact subsequent participation in a follow-up survey.

Methods: Participants were asked to provide a saliva sample and five cigarette butts from cigarettes smoked on a single day, using standardized procedures. Sample collection kits were mailed to a random sample of 400 daily cigarette smokers who were involved in the 2006 annual ITC Four Country (United Kingdom, United States, Canada, and Australia) telephone survey and agreed to participate in sample collection. A random sample of 179 daily smokers who participated in a face-to-face ITC survey in Mexico and Uruguay and agreed to participate in sample collection were also asked to provide samples.

Results: Samples were collected from 96% of invited participants in the face-to-face surveys and 52% of participants in the telephone survey. The added burden of the sample collection did not reduce survey retention rates. Participants who initially agreed to participate in the sample collection were more likely to participate in the subsequent survey than participants who were not asked or declined to participate (odds ratio [OR] = 1.28; 95% CI = 1.01–1.62, p = .021). Further, those who provided samples were also more likely to participate in the subsequent survey than those who did not (OR = 2.78; 95% CI = 1.71–4.52, p < .001).

Discussion: Collecting saliva and cigarette butt samples from a group of smokers is feasible, yields a representative sample, and the added participant burden does not reduce subsequent survey response rates.

Citation

Kahler, C.W., Borland, R., Hyland, A., McKee, S., O’Connor, R.J., Fong, G.T., Cummings, K.M. (2010). Quitting smoking and change in alcohol consumption in the International Tobacco Control (ITC) Four Country Survey. Drug and Alcohol Dependence, 110(1-2), 101-107.

Abstract

Although frequent heavy drinking has been associated with decreased odds of quitting smoking, the extent to which smoking cessation is associated with decreased alcohol consumption is less clear. The present study examined over a 2-year period whether individuals who quit smoking for at least 6 months, compared to those making a quit attempt but continuing to smoke and to those not making any attempt to quit smoking, showed greater reductions in drinking frequency, average weekly quantity of alcohol consumption, and frequency of heavy drinking. Data were drawn from the International Tobacco Control Four Country Survey, a prospective cohort study of smokers in Australia, Canada, the UK, and the US. A total of 3614 participants provided alcohol data at one study wave and were re-interviewed 2 years later regarding smoking and alcohol use. Consistent with prior studies, individuals who drank heavily (4+/5+ drinks for women and men, respectively) more than once a week had especially low rates of quitting smoking. There was little evidence, however, that those who achieved sustained smoking cessation made greater reductions in drinking compared to those who continued to smoke. These results were consistent across countries and sexes and did not differ significantly by heaviness of smoking. Results indicate that quitting smoking, in and of itself, does not lead to meaningful changes in alcohol use. Therefore, interventions and policies directed towards increasing smoking cessation are unlikely to affect rates of hazardous drinking unless they include specific elements that address alcohol consumption.

Citation

Siahpush, M., Yong, H.H., Borland, R., Reid, J. (2010). Socioeconomic position and abrupt versus gradual method of quitting smoking: Findings from the International Tobacco Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S58-63.

Abstract

Introduction: Our aim was to investigate the association between socioeconomic position (income and education) and abrupt versus gradual method of smoking cessation.

Methods: The analysis used data (n = 5,629) from Waves 1 through 6 (2002–2008) of the International Tobacco Control Four-Country Survey, a prospective study of a cohort of smokers in the United States, Canada, the United Kingdom, and Australia.

Results: Logistic regression analyses using generalized estimating equations showed that higher income (p < .001) and higher education (p = .011) were associated with a higher probability of abrupt versus gradual quitting. The odds of adopting abrupt versus gradual quitting were about 40% higher among respondents with high income ($60,000 and more in the United States/Canada/Australia and £30,000 and more in the United Kingdom) compared with those with low income (less than $30,000 in the United States/Canada/Australia; £15,000 and less in the United Kingdom). Similarly, the odds of abrupt versus gradual quitting were about 30% higher among respondents with a high level of education (university degree) compared with those with a low level of education (high school diploma or lower).

Discussion: Higher socioeconomic position is associated with a higher probability of quitting abruptly rather than gradually reducing smoking before quitting.

Citation

Siahpush, M., Yong, H.H., Borland, R., Reid, J., Hammond, D. (2009). Smokers with financial stress are more likely to want to quit but less likely to try or succeed: Findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 104(8), 1382-1390.

Abstract

Objective: To examine the association of financial stress with interest in quitting smoking, making a quit attempt and quit success.

Design and participants: The analysis used data from 4984 smokers who participated in waves 4 and 5 (2005–07) of the International Tobacco Control (ITC) Four Country Survey, a prospective study of a cohort of smokers in the United States, Canada, the United Kingdom and Australia.

Measurement: The outcomes were interest in quitting at wave 4, making a quit attempt and quit success at wave 5. The main predictor was financial stress at wave 4: ‘. . . because of a shortage of money, were you unable to pay any important bills on time, such as electricity, telephone or rent bills?’. Additional socio-demographic and smoking-related covariates were also examined.

Findings: Smokers with financial stress were more likely than others to have an interest in quitting at baseline [odds ratio (OR): 1.63; 95% confidence interval (CI): 1.22–2.19], but were less likely to have made a quit attempt at follow-up (OR: 0.74; 95% CI: 0.57–0.96). Among those who made a quit attempt, financial stress was associated with a lower probability of abstinence at follow-up (OR: 0.53; 95% CI: 0.33–0.87).

Conclusions: Cessation treatment efforts should consider assessing routinely the financial stress of their clients and providing additional counseling and resources for smokers who experience financial stress. Social policies that provide a safety net for people who might otherwise face severe financial problems, such as not being able to pay for rent or food, may have a favorable impact on cessation rates.

Citation

Hyland, A., Higbee, C., Borland, R., Travers, M.J., Hastings, G., Fong, G.T., Cummings, K.M. (2009). Attitudes and beliefs about secondhand smoke and smoke-free policies in four countries: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 11(6), 642-649.

Abstract

Introduction: This paper describes the varying levels of smoking policies in nationally representative samples of smokers in four countries and examines how these policies are associated with changes in attitudes and beliefs about secondhand smoke over time.

Methods: We report data on 5,788 respondents to Wave 1 of the International Tobacco Control Four Country Survey who were employed at the time of the survey. A cohort of these respondents was followed up with two additional survey waves approximately 12 months apart. Respondents ’ attitudes and beliefs about secondhand smoke as well as self-reported policies in their workplace and in bars and restaurants in their community were assessed at all waves.

Results: The level of comprehensive smoke-free policies in workplaces, restaurants, and bars increased over the study period for all countries combined and was highest in Canada (30%) and lowest in the United Kingdom (0%) in 2004. In both crosssectional and longitudinal analyses, stronger secondhand smoke policies were associated with more favorable attitudes and support for comprehensive regulations. The associations were the strongest for smokers who reported comprehensive policies in restaurants, bars, and their workplace for all three survey waves.

Discussion: Comprehensive smoke-free policies are increasing over time, and stronger policies and the public education opportunities surrounding their passage are associated with more favorable attitudes toward secondhand smoke regulations. The implication for policy makers is that, although the initial debate over smoke-free policies may be tumultuous, once people understand the rationale for implementing smoke-free policies and experience their benefits, public support increases even among smokers, and compliance with smoke-free regulations increases over time.

Citation

Li, L., Yong, H.H., Borland, R., Fong, G.T., Thompson, M.E., Jiang, Y., Yang, Y., Sirirassamee, B., Hastings, G., Harris, F. (2009). Reported awareness of tobacco advertising and promotion in China compared to Thailand, Australia and the USA. Tobacco Control, 18(3), 222-227.

Abstract

Background: China currently does not have comprehensive laws or regulations on tobacco advertising and promotion, although it ratified the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in October 2005 and promised to ban all tobacco advertising by January 2011. Much effort is needed to monitor the current situation of tobacco advertising and promotion in China.

Objective: This study aims to examine levels of awareness of tobacco advertising and promotion among smokers in China as compared to other countries with different levels of restrictions.

Methods: One developing country (Thailand) and two developed countries (Australia and the USA) were selected for comparison. All four countries are part of the International Tobacco Control (ITC) Policy Evaluation Survey project. Between 2005 and 2006, parallel ITC surveys were conducted among adult smokers (at least smoked weekly) in China (n=4763), Thailand (n=2000), Australia (n=1767) and the USA (n=1780). Unprompted and prompted recall of noticing tobacco advertising and promotion were measured.

Results: Chinese respondents reported noticing tobacco advertisements in a range of channels and venues, with highest exposure levels on television (34.5%), billboards (33.4%) and in stores (29.2%). A quarter of respondents noticed tobacco sponsorships, and a high level of awareness of promotion was reported. Cross-country comparison reveals that overall reported awareness was significantly higher in China than in Thailand (particularly) and Australia, but lower than in the USA.

Conclusions: There is a big gap between China and the better-performing countries such as Thailand and Australia regarding tobacco promotion restrictions. China needs to do more, including enhanced policy and more robust enforcement.

Citation

Thomson, G., Wilson, N. (2009). Public attitudes to laws for smoke-free private vehicles: A brief review. Tobacco Control, 18(4), 256-261.

Abstract

As smoke-free car policy is a frontier domain for tobacco control, attitudes to smoke-free private car laws are briefly reviewed. Medline and Google Scholar searches for the period up to midNovember 2008, from English language sources, were undertaken. Studies were included that contained data from national and subnational populations (eg, in states and provinces), but not for smaller administrative units, eg, cities or councils. Jurisdiction, sample size and survey questions were assessed. One reviewer conducted the data extraction and both authors conducted assessments. A total of 15 relevant studies (from 1988) were identified, set in North America, the UK and Australasia. The available data indicates that, for the jurisdictions with data, there is majority public support for laws requiring cars that contain children to be smoke free. There appears to be an increase over time in this support. In five surveys in 2005 or since (in California, New Zealand and Australia), the support from smokers was 77% or more. The high levels of public (and smoker) support for smokefree car laws found in the studies to date suggest that this can be a relatively non-controversial tobacco control intervention. Survey series on attitudes to such laws are needed, and surveys in jurisdictions where the issue has not been investigated to date.

Citation

Borland, R., Wilson, N., Fong, G.T., Hammond, D., Cummings, K.M., Yong, H.H., Hosking, W., Hastings, G., Thrasher, J.F., McNeill, A. (2009). Impact of graphic and text warnings on cigarette packs: Findings from four countries over five years. Tobacco Control, 18(5), 358-364.

Abstract

Objectives: To examine the impact of health warnings on smokers by comparing the short-term impact of new graphic (2006) Australian warnings with: (i) earlier (2003) United Kingdom larger text-based warnings; (ii) and Canadian graphic warnings (late 2000); and also to extend our understanding of warning wear-out.

Methods: The International Tobacco Control Policy Evaluation Survey (ITC Project) follows prospective cohorts (with replenishment) of adult smokers annually (five waves: 2002–2006), in Canada, United States, UK and Australia (around 2000 per country per wave; total n=17 773). Measures were of pack warning salience (reading and noticing); cognitive responses (thoughts of harm and quitting); and two behavioural responses: forgoing cigarettes and avoiding the warnings.

Results: All four indicators of impact increased markedly among Australian smokers following the introduction of graphic warnings. Controlling for date of introduction, they stimulated more cognitive responses than the UK (textonly) changes, and were avoided more, did not significantly increase forgoing cigarettes, but were read and noticed less. The findings also extend previous work showing partial wear-out of both graphic and text-only warnings, but the Canadian warnings have more sustained effects than UK ones.

Conclusions: Australia’s new health warnings increased reactions that are prospectively predictive of cessation activity. Warning size increases warning effectiveness and graphic warnings may be superior to text-based warnings. While there is partial wear-out in the initial impact associated with all warnings, stronger warnings tend to sustain their effects for longer. These findings support arguments for governments to exceed minimum FCTC requirements on warnings.

Citation

Shahab, L., Cummings, K.M., Hammond, D., Borland, R., West, R., McNeill, A. (2009). The impact of changing nicotine replacement therapy licensing laws in the United Kingdom: Findings from the International Tobacco Control Four Country Survey. Addiction, 104(8), 1420-1427.

Abstract

Aim: To evaluate the impact of a new licence for some nicotine replacement therapy products (NRT) for cutting down to stop (CDTS) on changes in the pattern of NRT use.

Design: Quasi-experimental design comparing changes in NRT use across two waves of a population-based, replenished-panel, telephone survey conducted before and after the introduction of new licensing laws in the United Kingdom with changes in NRT use in three comparison countries (Australia, Canada and United States) without a licensing change.

Participants: A total of 7386 and 7013 smokers and recent ex-smokers participating in the 2004 and/or 2006/7 survey.

Measurements: Data were collected on demographic and smoking characteristics as well as NRT use and access. In order to account for interdependence resulting from some participants being present in both waves, generalized estimation equations with an exchangeable correlation matrix were used to assess within-country changes and linear and logistic regressions to assess betweencountry differences in adjusted analyses.

Findings: NRT use was more prevalent in the United Kingdom and increased across waves in all countries but nowave x country interaction was observed. There was no evidence that the licensing change increased the prevalence of CDTS or the use of NRT (irrespective of how it was accessed) for CDTS in the United Kingdom relative to comparison countries. There was also no evidence for a change in concurrent smoking and NRT use among smokers not attempting to stop in the United Kingdom relative to comparison countries.

Conclusion: The addition of the CDTS licence for some NRT products in the United Kingdom appears to have had very limited, if any, impact on NRT use in the first year after the licence change.

Citation

Kahler, C.W., Borland, R., Hyland, A., McKee, S., Thompson, M.E., Cummings, K.M. (2009). Alcohol consumption and quitting smoking in the International Tobacco Control (ITC) Four Country Survey. Drug and Alcohol Dependence, 100(3), 214-220.

Abstract

Although greater alcohol consumption has been associated with decreased odds of quitting smoking in prospective studies, the aspects of drinking most strongly associated with quitting have not been fully explored and examination of potential confounder variables has been limited. Further studies are needed to inform efforts to enhance smoking cessation among the substantial portion of smokers who drink alcohol. The present study examines (a) drinking frequency, average weekly quantity of alcohol consumption, and frequency of heavy drinking as prospective predictors of quit smoking behaviors, (b) difference across countries in this prediction, and (c) third variables that might account for the association between alcohol consumption and quitting smoking. Data were drawn from the International Tobacco Control Four Country Survey, a prospective cohort study of smokers in Australia, Canada, the UK, and the US. A total of 4,831 participants provided alcohol data at one study wave and were re-interviewed 1 year later. Individuals who drank heavily (4+/5+ drinks for women and men, respectively) more than once a week had significantly lower rates of quitting smoking than all other participants, in part due to the fact that a significantly lower proportion of those making a quit attempt remained quit for more than one month at follow-up. The role of frequent heavy drinking did not differ by country or sex and was not accounted for by demographics, smoking dependence, or attitudes regarding quitting smoking. Neither drinking frequency nor weekly quantity of consumption showed robust associations with quitting behaviors. Results indicate further study of interventions to address heavy drinking among smokers is warranted.

Citation

Hyland, A., Higbee, C., Travers, M. J., Van Deusen, A., Bansal-Travers, M., King, B., & Cummings, K. M. (2009). Smoke-free homes and smoking cessation and relapse in a longitudinal population of adults. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 11(6), 614–618. https://doi.org/10.1093/ntr/ntp022

Abstract

Introduction: The present study reports on the prevalence of smoke-free homes, the characteristics of participants who adopted a smoke-free home policy, and the association between smoke-free homes and subsequent predictors of smoking cessation.

Methods: Data are reported on 4,963 individuals who originally participated in the Community Intervention Trial for Smoking Cessation between 1988 and 1993 and completed follow-up surveys in 2001 and 2005. The relationship between home smoking policy and smoking behavior was examined with a multivariate regression model.

Results: Among those who were smokers at the 2001 followup, the percentage reporting that no smoking was allowed in their home increased from 29% in 2001 to 38% in 2005. Smokers most likely to adopt smoke-free home policies between 2001 and 2005 were males, former smokers, and those who had lower levels of daily cigarette consumption (among those who continued to smoke), those with higher annual household incomes, and those with no other smokers in the household. Some 28% of smokers with smoke-free homes in 2001 reported that they had quit smoking by 2005 compared with 16% of those who allowed smoking in their homes (odds ratio [ OR ] = 1.7, 95% CI = 1.4 – 2.2), and baseline quitters with smoke-free homes also were less likely to relapse ( OR = 0.6,95% CI = 0.4 – 0.8).

Discussion: Smoke-free homes are becoming more prevalent, and they are a powerful tool not only to help smokers stop smoking but also to help keep those who quit from relapsing back to smoking.

Citation

Borland, R., Yong, H.H., Wilson, N., Fong, G.T., Hammond, D., Cummings, K.M., Hosking, W., McNeill, A. (2009). How reactions to cigarette packet health warnings influence quitting: Findings from the ITC Four Country Survey. Addiction, 104(4), 669-675.

Abstract

Objectives: To examine prospectively the impact of health warnings on quitting activity.

Design: Five waves (2002–06) of a cohort survey where reactions to health warnings at one survey wave are used to predict cessation activity at the next wave, controlling for country (proxy for warning differences) and other factors. These analyses were replicated on four wave-to-wave transitions.

Setting and participants: Smokers from Australia, Canada, the United Kingdom and the United States. Samples were waves 1–2: n = 6525; waves 2–3: n = 5257; waves 3–4: n = 4439; and waves 4–5: n = 3993.

Measures: Warning salience, cognitive responses (thoughts of harm and of quitting), forgoing of cigarettes and avoidance of warnings were examined as predictors of quit attempts, and of quitting success among those who tried (1 month sustained abstinence), replicated across four wave-to-wave transitions.

Results: All four responses to warnings were independently predictive of quitting activity in bivariate analyses. In multivariate analyses, both forgoing cigarettes and cognitive responses to the warnings predicted prospectively making quit attempts in all replications. However, avoiding warnings did not add predictive value consistently, and there was no consistent pattern for warning salience. There were no interactions by country. Some, but not all, the effects were mediated by quitting intentions. There were no consistent effects on quit success.

Conclusions: This study adds to the evidence that forgoing cigarettes as a result of noticing warnings and quit-related cognitive reactions to warnings are consistent prospective predictors of making quit attempts. This work strengthens the evidence base for governments to go beyond the Framework Convention on Tobacco Control to mandate health warnings on tobacco products that stimulate the highest possible levels of these reactions.

Citation

Borland, R., Yong, H.H., Balmford, J., Fong, G.T., Zanna, M.P., Hastings, G. (2009). Do risk-minimizing beliefs about smoking inhibit quitting? Findings from the International Tobacco Control (ITC) Four Country Survey. Preventive Medicine, 19(2-3), 219-223.

Abstract

Objective: To replicate findings that risk-minimizing and self-exempting beliefs lower quit intentions, and to extend this by testing their capacity to prospectively predict smoking cessation.

Method: 13,324 adult (≥ 18 years) cigarette smokers from the USA, Canada, UK, and Australia from one of the first three waves (2002-2004) of the International Tobacco Control 4-Country survey were employed for the predictive analysis where beliefs measured in one wave (1-3) of a cohort were used to predict cessation outcomes in the next wave (2-4).

Results: Both types of belief were negatively associated with both intention to quit in the same wave and making a quit attempt at the next wave. When taken together and controlling for demographic factors, the risk-minimizing beliefs continued to be predictive, but the self-exempting belief was not. Some of the effects of risk-minimizing beliefs on quit attempts seem to be independent of intentions, but not consistently independent of other known predictors. There were no consistent predictive effects on sustained cessation among those who made attempts to quit for either measure.

Conclusions: Countering risk-minimizing beliefs may facilitate increased quitting, but this may not be so important for self-exempting beliefs.

Citation

Herd, N., Borland, R. (2009). The natural history of quitting smoking: Findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 104 (12), 2075-2087.

Abstract

Aims: To describe the long-term natural history of a range of potential determinants of relapse from quitting smoking.

Design setting and participants: A survey of 2502 ex-smokers of varying lengths of time quit recruited as part of the International Tobacco Control (ITC) Four Country Survey (Australia, Canada, United Kingdom, United States) across five annual waves of surveying.

Measurements: Quitters were interviewed by telephone at varying durations of abstinence, ranging from 1 to 1472 days (about 4 years) post-quitting. Smoking-related beliefs and experiences (i.e. urges to smoke; outcome expectancies of smoking and quitting; and abstinence self-efficacy) were included in the survey.

Findings: Most theorized determinants of relapse changed over time in a manner theoretically associated with reduced risk of relapse, except most notably the belief that smoking controls weight, which strengthened. Change in these determinants changed at different rates: from a rapidly asymptoting log function to a less rapidly asymptoting square-root function.

Conclusions: Variation in patterns of change across time suggests that the relative importance of each factor to maintaining abstinence may similarly vary.

Citation

Herd, N., Borland, R., Hyland, A. (2009). Predictors of smoking relapse by duration of abstinence: Findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 104(12), 2088-2099.

Abstract

Aim: To explore predictors of smoking relapse and how predictors vary according to duration of abstinence.

Design, setting and participants: A longitudinal survey of 1296 ex-smokers recruited as part of the International Tobacco Control (ITC) Four Country Survey (Australia, Canada, United Kingdom and United States).

Measurements: Quitters were interviewed by telephone at varying durations of abstinence (from 1 day to approximately 3 years) and then followed-up approximately 1 year later. Theorized predictors of relapse (i.e. urges to smoke; outcome expectancies of smoking and quitting; and abstinence self-efficacy) and nicotine dependence were measured in the survey.

Findings: Relapse was associated with lower abstinence self-efficacy and a higher frequency of urges to smoke, but only after the first month or so of quitting. Both these measures mediated relationships between perceived benefits of smoking and relapse. Perceived costs of smoking and benefits of quitting were unrelated to relapse.

Conclusions: Challenging perceived benefits of smoking may be an effective way to increase abstinence self-efficacy and reduce frequency of urges to smoke (particularly after the initial weeks of quitting), in order to reduce subsequent relapse risk.