Citation

Hammond, D., Fong, G.T., Borland, R., Cummings, K.M., McNeill, A., Driezen, P. (2007). Communicating risk to smokers: The impact of health warnings on cigarette packages. American Journal of Preventive Medicine, 32(3), 202-209.

Abstract

Background: Health warnings on cigarette packages provide smokers with universal access to information on the risks of smoking. However, warnings vary considerably among countries, ranging from graphic depictions of disease on Canadian packages to obscure text warnings in the U.S. The current study examined the effectiveness of health warnings on cigarette packages in four countries.

Methods: Quasi-experimental design. Telephone surveys were conducted with representative cohorts of adult smokers (N= 14,975): Canada (n =3687); the U.S. (n =4273); the UK (n= 3634); and Australia (n =3381). Surveys were conducted between 2002 and 2005, before and at three time points following new warnings on UK packages.

Results: At Wave 1, Canadian smokers reported the highest levels of awareness and impact for health warnings among the four countries, followed by Australian smokers. Following the implementation of new UK warnings at Wave 2, UK smokers reported greater levels of awareness and impact, although Canadian smokers continued to report higher levels of impact after adjusting for the implementation date. U.S. smokers reported the lowest levels of effectiveness for almost every measure recorded at each survey wave.

Conclusions: Large, comprehensive warnings on cigarette packages are more likely to be noticed and rated as effective by smokers. Changes in health warnings are also associated with increased effectiveness. Health warnings on U.S. packages, which were last updated in 1984, were associated with the least effectiveness.

Citation

Young, D., Borland, R., Siahpush, M., Hastings, G., Fong, G.T., Cummings, K.M. (2007). Australian smokers support stronger regulatory controls on tobacco: Findings from the ITC Four-Country Survey. Australian and New Zealand Journal of Public Health, 31(2), 164-169.

Abstract

Objective: To examine Australian smokers’ attitudes towards regulation of the tobacco industry and to compare their attitudes with those of three similar countries – the United Kingdom (UK), the United States (US), and Canada

Method: A telephone survey of 2,056 adult Australian smokers and 6,166 Canadian, US, and UK smokers was conducted in 2004 as the third wave of the International Tobacco Control Policy Evaluation Four- Country Survey.

Results: Australian smokers display the strongest support for regulation. Only 16% believe that tobacco companies should be allowed to advertise/promote cigarettes as they please, 70% agree that tobacco products should be more tightly regulated, and 64% agree that governments should do more to tackle the harms of smoking. Smokers see government failure to do so in cynical terms – 77% agree that governments do not really care about smoking because of money from tobacco taxes. Opposition comes largely from smokers who hold self-exempting beliefs about smoking’s risks, have a positive attitude to smoking, do not accept that smoking is socially denormalised, and do not hold tobacco companies responsible for harms caused by smoking.

Conclusions and Implications: The majority of Australian smokers believe that the tobacco industry is partly responsible for the predicament they find themselves in and want governments to act more strongly in their real interests. The strong relationship between support for regulation and cynicism about government inaction should stimulate governments into action.

Citation

Cheong, Y., Yong, H.H., Borland, R. (2007). Does how you quit affect success? A comparison between abrupt and gradual methods using data from the International Tobacco Control Policy Evaluation Study. Nicotine & Tobacco Research, 9(8), 801-810.

Abstract

Two recommended quit methods in standard cessation programs involve either gradual reduction of smoking prior to complete abstinence ("cut down") or abrupt abstinence from cigarettes ("cold turkey"). This study examined the reported use, characteristics of users, and the impact of self-selected strategy choice on quitting success and relapse of adult smokers who reported quitting on their own. Data came from the first three waves of the International Tobacco Control Policy Evaluation 4-Country Survey (ITC-4). The ITC-4 is a random-digit-dialed telephone survey of a cohort of more than 8,000 adult smokers from the United Kingdom, the United States, Canada, and Australia, with a 75% follow-up rate. The results indicated that 68.5% of the smokers who had made a quit attempt between waves reported using the cold-turkey method. Of those who used the cold turkey method, 22% and 27% succeeded at Waves 2 and 3, respectively, compared with the 12% and 16%, respectively, who used the cut-down method. Multivariate analyses revealed that cold-turkey users were more likely to be aged 25-39 years, male, from the United Kingdom, and smoking heavily, and had lower perceived dependence. Controlling for sociodemographic and known predictors of quitting including use of medications, we found that smokers who used the cold-turkey method to quit were almost twice as likely to abstain for a month or more in their attempt. Overall, we cautiously conclude that cold turkey should be the recommended strategy for smokers who want to quit on their own.

Citation

O’Connor, R.J., McNeill, A., Borland, R., Hammond, D., King, B., Boudreau, C., Cummings, K.M. (2007). Smokers' beliefs about the relative safety of other tobacco products: Findings from the ITC collaboration.Nicotine & Tobacco Research, 9(10), 1033-1042.

Abstract

Most tobacco control efforts in western countries focus on the factory-made, mass-produced (FM) cigarette, whereas other tobacco products receive relatively little attention. Noncombusted tobacco products (i.e., referred to as smokeless tobacco), particularly Swedish-style snus, carry lower disease risks, compared with combusted tobacco products such as cigarettes. In this context, it is important to know what tobacco users believe about the relative harmfulness of various types of tobacco products. Data for this study came from random-digit-dialed telephone surveys of current smokers aged 18 or older in Australia, Canada, the United Kingdom, and the United States. Three waves of data, totaling 13,322 individuals, were assessed. Items assessed use of and beliefs about the relative harms of cigars, pipes, smokeless tobacco, and FM and roll-your-own cigarettes, as well as sociodemographics and smoking behaviors. Cigars (2.8%-12.7%) were the other tobacco products most commonly used by current cigarette smokers, followed by pipes (0.3%-2.1%) and smokeless tobacco (0.0%-2.3%). A significant minority of smokers (12%-21%) used roll-your-own cigarettes at least some of the time. About one-quarter of smokers believed that pipes, cigars, or roll-your-own cigarettes were safer than FM cigarettes, whereas only about 13% responded correctly that smokeless tobacco was less hazardous than cigarettes. Multivariate analyses showed that use of other tobacco products was most strongly related to beliefs about the reduced harm of these other products. Use of other tobacco products was low but may be growing among smokers in the four countries studied. Smokers are confused about the relative harms of tobacco products. Health education efforts are needed to correct smoker misperceptions.

Citation

Siahpush, M., Borland, R., Yong, H.H. (2007). Sociodemographic and psychosocial correlates of smoking-induced deprivation and its effect on quitting: Findings from the International Tobacco Control Policy Evaluation Survey. Tobacco Control, 16(2), 106-113.

Abstract

Aims: To determine the prevalence and characteristics of smokers who experience smoking-induced deprivation (SID), and to examine its effect on quit attempts, relapse and cessation.

Methods: Waves 2 and 3 (2003-5) of the International Tobacco Control Policy Evaluation Survey were used, which is a prospective study of a cohort of smokers in the US, Canada, UK and Australia. SID was measured with the question "In the last six months, have you spent money on cigarettes that you knew would be better spent on household essentials like food?" A total of 7802 smokers participated in the survey in wave 2, of whom 5408 were also interviewed in wave 3.

Findings: The proportion of smokers who reported SID was highest in Australia (33%) and lowest in the UK (20%). Younger age, minority status and low income were associated with a higher probability of SID. Some of the other factors related to a higher probability of SID were higher level of nicotine dependence, having an intention to quit, and smoking to help one socialise or control weight. The relationship between SID and quit attempt was mediated by having an intention to quit and worrying that smoking would damage health and reduce the quality of life. The relationship between SID and relapse was mediated by perceived stress. SID was not associated with successful cessation.

Conclusions: Many smokers experience deprivation that is the result of their smoking. Strategies to reduce the prevalence of smoking probably effect a general improvement in standards of living and reduction in deprivation.

Citation

O’Connor, R.J., Kozlowski, L.T., Borland, R., Hammond, D., McNeill, A. (2006). Relationship between constituent labelling and reporting of tar yields among smokers in four countries. Journal of Public Health, 28(4), 324-329.

Abstract

Countries have adopted different approaches to disseminating cigarette tar, nicotine, and carbon monoxide (CO) levels to consumers, with some (e.g. EU member states, Canada, Australia, but not the United States) requiring disclosure of results from the International Organization for Standardization (ISO) test method on packs. Cross-country comparisons can provide insight into how smokers use yields when information is presented differently. We examined whether smokers in four different countries could recall the tar yield of their brand of cigarettes, using data from the third wave of the International Tobacco Control Four Country Survey (ITC-4). Of current smokers in the United States, Canada, Australia and the United Kingdom, 33.6% gave a numeric response when asked to report the tar yield of their brand, whereas 66.4% responded ‘I don’t know.’ American participants (9.2%) were less likely than Canadian (28.0%), UK (36.5%) or Australian (68.2%) smokers to give an answer, even after controlling for sociodemographic and smoking behaviour factors. Constituent labelling policies can affect whether smokers report a tar yield for their cigarette brand. Pack labelling appears to be useful for conveying information about cigarettes to smokers; however, there is an urgent need to develop more meaningful information on toxic constituents of cigarette smoke.

Citation

Hyland, A., Laux, F., Higbee, C., Hastings, G., Ross, H., Chaloupka, F., Fong, G.T., Cummings, K.M. (2006). Cigarette purchase patterns in four countries and the relationship with cessation: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii59-iii64.

Abstract

Background: Higher cigarette prices result in decreased cigarette consumption, but some smokers may seek lower-taxed cigarette sources. This price avoidance behaviour likely dampens the health impact of higher cigarette prices although it has not been thoroughly studied.

Objective: To describe the characteristics of smokers who purchase low/untaxed cigarettes and to examine how this behaviour is associated with subsequent changes in smoking behaviours.

Methods: Telephone survey data from 8930 smokers from the International Tobacco Control (ITC) Four Country Survey (ITC-4) were used to assess cigarette purchase patterns and smoking behaviours in Wave 1 conducted from October to December 2002 and subsequently followed seven months later in Wave 2. Respondents’ smoking status, attempts to quit, amount smoked, and cigarette purchase patterns were assessed in both waves.

Results: Rates of purchase from a low/untaxed source at the respondents’ last cigarette purchase differed notably between countries at Wave 1, from less than 1% in Australia to 15% in the United Kingdom. In the UK, but not the other countries, this increased significantly to 20% at Wave 2. Smokers who were older, white/English speakers, had higher incomes, and had higher levels of education were more likely to report purchasing cigarettes from a low/untaxed source on their last purchase. Those who reported purchasing from a low/untaxed source on their last purchase at Wave 1 were less likely to have tried to quit smoking quit smoking by Wave 2 (relative risk 0.70, p , 0.01), while no overall significant association with smoking cessation was observed.

Conclusion: Data from this study indicate that there are lower levels of making a quit attempt among purchasers of low/untaxed cigarettes compared to purchasers of full-priced cigarettes. The availability of low/untaxed cigarettes may mitigate the influence of increases in cigarette prices.

Citation

Borland, R., Yong, H.H., Siahpush, M., Hyland, A., Campbell, S., Hastings, G., Cummings, K.M., Fong, G.T. (2006). Support for and reported compliance with smoke-free restaurants and bars by smokers in four countries: Findings from the International Tobacco Control (ITC) Four Country Survey.Tobacco Control, 15(Suppl 3), iii34-iii41.

Abstract

Objective: To explore determinants of support for and reported compliance with smoke-free policies in restaurants and bars across the four countries of the International Tobacco Control (ITC) Four Country Survey.

Design: Separate telephone cross-sectional surveys conducted between October and December 2002 with broadly representative samples of over 2000 adult (⩾ 18 years) cigarette smokers in each of the following four countries: the United States, Canada, the United Kingdom, and Australia.

Outcome measures: Support for smoke-free policies in restaurants and pubs/bars and reported compliance with existing policies.

Results: Reported total bans on indoor smoking in restaurants varied from 62% in Australia to 5% in the UK. Smoking bans in bars were less common, with California in the USA being the only major part of any country with documented bans. Support for bans in both restaurants and bars was related to the existence of bans, beliefs about passive smoking being harmful, lower average cigarette consumption, and older age. Self-reported compliance with a smoking ban was generally high and was associated with greater support for the ban.

Conclusions: Among current cigarette smokers, support for smoking bans was associated with living in a place where the law prohibits smoking. Smokers adjust and both accept and comply with smoke-free laws. Associates of support and compliance are remarkably similar across countries given the notably different levels of smoke-free policies.

Citation

Borland, R., Yong, H.H., Cummings, K.M., Hyland, A., Anderson, S., Fong, G.T. (2006). Determinants and consequences of smoke-free homes: Findings from the International Tobacco Control (ITC) Four Country Survey.Tobacco Control, 15(Suppl 3), iii42-iii50.

Abstract

Objective: To report on prevalence, trends and determinants of smoke-free home policies in smokers’ homes in different countries and to estimate the effects of these policies on smoking cessation.

Design: Two waves of the International Tobacco Control (ITC) Four Country Survey (ITC-4), a cohort survey of smokers conducted by telephone. Wave 1 was conducted in October/December 2002 with broadly representative samples of over 2000 adult (⩾ 18 years) cigarette smokers in each of the following four countries: Canada, the United States, the United Kingdom, and Australia, 75% of whom were followed up at Wave 2 on average seven months later.

Key measures: Levels of smoking restrictions in homes (both waves).

Results: Australian smokers were most likely to live in smoke-free homes and UK smokers least likely (34% v 15% at Wave 1). Levels of smoke-free homes increased between waves. Logistic regressions indicated that the main independent predictors of smokers reporting smoke-free homes or implementation of a smoke-free policy between waves included household factors such as having a child, particularly a young child, and having other non-smoking adults in the household. Positive attitudes to smoke-free public places and/or reported presence of smoke-free public places were independent predictors of having or implementing smoke-free homes, supporting a social diffusion model for smoking restrictions. Intentions to quit at Wave 1 and quitting activity between survey waves were associated with implementing bans between Waves 1 and 2. Presence of bans at Wave 1 was associated with significantly greater proportions of quit attempts, and success among those who tried at Wave 2. There was no significant interaction between the predictive models and country.

Conclusions: Smoke-free public places seem to stimulate adoption of smoke-free homes, a strategy associated with both increased frequency of quit attempts, and of the success of those attempts.

Citation

Thompson, M.E., Fong, G.T., Hammond, D., Boudreau, C., Driezen, P., Hyland, A., Borland, R., Cummings, K.M., Hastings, G., Siahpush, M., MacKintosh, A.M., Laux, F. (2006). Methods of the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii12-iii18.

Abstract

This paper outlines the design features, data collection methods and analytic strategies of the International Tobacco Control (ITC) Four Country Survey, a prospective study of more than 2000 longitudinal respondents per country with yearly replenishments. This survey possesses unique features that sets it apart among surveys on tobacco use and cessation. One of these features is the use of theory-driven conceptual models. In this paper, however, the focus is on the two key statistical features of the survey: longitudinal and “quasi-experimental” designs. Although it is often possible to address the same scientific questions with a cross-sectional or a longitudinal study, the latter has the major advantage of being able to distinguish changes over time within individuals from differences among people at baseline (that is, differences between age and cohort effects). Furthermore, quasi-experiments, where countries not implementing a given new tobacco control policy act as the control group to which the country implementing such a policy will be compared, provide much stronger evidence than observational studies on the effects of national-level tobacco control policies. In summary, application of rigorous research methods enables this survey to be a rich data resource, not only to evaluate policies, but also to gain new insights into the natural history of smoking cessation, through longitudinal analyses of smoker behaviour.

Citation

O’Connor, R.J., Giovino, G.A., Fix, B.V., Hyland, A., Hammond, D., Fong, G.T., Bauer, U., Cummings, K.M. (2006). Smokers' reactions to reduced ignition propensity cigarettes. Tobacco Control, 15(1), 45-49.

Abstract

Background: On 28 June 2004, New York State (NY) became the first jurisdiction to require cigarettes to meet a reduced ignition propensity (RIP) standard. This law resulted in cigarette manufacturers modifying nearly all of their brands sold in NY. However, the same cigarette brands sold in other states were not modified to meet the RIP standard.

Objectives: This paper examines relationships between the RIP law and smokers’ awareness of changes in the performance of their cigarettes (that is, going out more frequently, change in taste), and smoking behaviour.

Methods: Data for this analysis come from a nationwide survey of 2088 adult smokers (. 18 years of age) conducted in the USA between July and December 2004. 143 of the smokers included in the survey were residents of NY while the remainder were from other states (n = 1945). Survey participants were asked whether their cigarettes ‘‘ever go out between puffs’’ and whether they had noticed any change in the taste of their cigarettes in the past 12 months.

Results: NY smokers were three times more likely than smokers in other states to report that their cigarettes often went out between puffs (17.3% v 5.6%). However, NY smokers appeared no more likely to report noticing differences in cigarette taste, an intention to quit smoking, or to have made quit attempts.

Conclusions: A significant minority of smokers in NY reported noticing changes in the performance of their cigarettes following the RIP law, as would be expected. However, the RIP law appears to have had no impact on the smoking habits of New Yorkers, countering arguments made by cigarette manufacturers that the law would impact consumer acceptability.

Citation

Thrasher, J.F., Chaloupka, F., Hammond, D., Fong, G.T., Borland, R., Hastings, G., Cummings, K.M. (2006). Evaluación de las políticas contra el tabaquismo en paises Latino Americanos en la era del Convenio Marco para el Control del Tabaco [Evaluating tobacco control policy in Latin American countries during the era of the Framework Convention on Tobacco Control]. Salud Publica de Mexico, 48(Suppl 1), S155-S166.

Abstract

Objective: The Framework Convention on Tobacco Control (FCTC) aims to coordinate tobacco control policies around the world that reduce tobacco consumption. The FCTC's recommended policies are likely to be effective in low- and middle-income countries. Nevertheless, policy evaluation studies are needed to determine policy impact and potential synergies across policies.

Materials and methods: The International Tobacco Control Policy Evaluation Project (ITC) is an international collaboration to assess the psychosocial and behavioral impact of the FCTC's policies among adult smokers in nine countries. The ITC evaluation framework utilizes multiple country controls, a longitudinal design, and a theory-driven conceptual model to test hypotheses about the anticipated effects of given policies.

Results: ITC Project results generally confirm previous studies that form the evidence base for FCTC policy recommendations, in particular: the use of graphic warning labels; banning of "light" and "mild" descriptors; smoking bans; increasing tax and price; banning advertising; and using new cigarette product testing methods.

Conclusions: Initial findings from the ITC Project suggest that Latin American countries could use similar methods to monitor and evaluate their own tobacco control policies while contributing to the evidence base for policy interventions in other countries.

Citations

Siahpush, M., McNeill, A., Borland, R., Fong, G.T. (2006). Socioeconomic variations in nicotine dependence, self-efficacy, and intention to quit across four countries: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii71-iii75.

Abstract

Objective: To examine the effect of socioeconomic status (SES) on nicotine dependence, self-efficacy, and intention to quit.

Design setting and participants: Data were from the first wave (2002) of the International Tobacco Control (ITC) Four Country Survey (ITC-4), a panel study of over 2000 adult smokers from each of four countries: the United States, Canada, the United Kingdom, and Australia. Data were collected via telephone interviews.

Main outcome measures: Nicotine dependence, intention to quit, and self-efficacy to quit smoking were the main outcome measures used in this study.

Results: Lower levels of education were associated with higher nicotine dependence. The effect of lower income on higher heaviness of smoking index (HIS) scores was significant in Canada, the UK, and Australia. Respondents with low education had 35% larger odds of low self-efficacy than those with high education. Respondents with low education had 40% larger odds of having no intention to quit than those with high education. Respondents with low income had 23% larger odds of having no intention to quit than those with high income. Country was not a moderator of the association of SES with self-efficacy and intention to quit.

Conclusion: To the extent that lower SES smokers are more addicted, they are likely to need more intensive support if they are to be successful in their attempts to quit. Given their lower incomes, this places a special responsibility on government to provide or subsidise such services. This should include access to the widest possible range of effective pharmacotherapies complemented with evidence based counselling and support.

Citation

Hyland, A., Borland, R., Li, Q., Yong, H.H., McNeill, A., Fong, G.T., O’Connor, R.J., Cummings, K.M. (2006). Individual-level predictors of cessation behaviours among participants in the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii83-iii94.

Abstract

Background: The International Tobacco Control (ITC) Four Country Survey (ITC-4) is a prospective cohort study designed to evaluate the psychosocial and behavioural impact of national-level tobacco control policies enacted in the Australia, Canada, the UK, and the USA. Wave 1 of ITC-4 survey was conducted between October 2002 and December 2002. Wave 2 survey was conducted between May 2003 and August 2003.

Objective: To test for individual-level predictors of smoking cessation behaviours (that is, quit attempts and smoking cessation) among cigarette smokers in the ITC Four Country Study measured between Wave 1 and Wave 2. This set of predictors will serve as the base for evaluating the added effect of tobacco control policies and other factors.

Methods: Respondents included in this study are 6682 adult current smokers in the Wave 1 main survey who completed the Wave 2 follow-up (1665 were in Canada, 1329 were in the USA, 1837 were in the UK and 1851 were in Australia).

Results: Factors predictive of making a quit attempt included intention to quit, making a quit attempt in the previous year, longer duration of past quit attempts, less nicotine dependence, more negative attitudes about smoking, and younger age. Lower levels of nicotine dependence were the main factor that predicted future cessation among those that made a quit attempt.

Conclusion: Intention to quit and other cognitive variables were associated with quit attempts, but not cessation. Behavioural variables related to task difficulty, including measures of dependence, predicted both making attempts and their success. Predictors of making quit attempts and cessation were similar for each of the four countries, but there were some differences in predictors of success.

Citation

Siahpush, M., McNeill, A., Hammond, D., Fong, G.T. (2006). Socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: Results from the 2002 International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii65-iii70.

Abstract

Background: Socioeconomic status is strongly associated with smoking prevalence and social class differences contribute substantially to social inequalities in mortality. This research investigated socioeconomic and country variations in smokers’ knowledge that smoking causes heart disease, stroke, impotence and lung cancer, that smoke contains cyanide, mercury, arsenic and carbon monoxide, and whether nicotine causes most of the cancer.

Methods: Data were from the International Tobacco Control (ITC) Four Country Survey, a cohort survey of over suppl_ adult smokers from four countries: the United States, Canada, the United Kingdom, and Australia. Data were collected via telephone interviews in 2002.

Results: Higher education and income were associated with higher awareness. For example, the odds of knowing that smoking causes heart disease, stroke and lung cancer were respectively 71%, 34% and 83% larger for respondents with high versus low income. The odds of knowing that smoke contains cyanide, mercury, arsenic and carbon monoxide were respectively 66%, 26%, 44% and 108% larger for respondents with a university degree than those with a high school diploma or lower level of education. Results also revealed that awareness of harms of smoking was generally the highest in Canada and the lowest in the UK.

Conclusions: Lower socioeconomic status was associated with lower awareness of the harms of smoking and misunderstanding around nicotine. There is a need to improve knowledge of the dangers of smoking among the disadvantaged segments of the population.

Citation

Hammond, D., Fong, G.T., Zanna, M.P., Thrasher, J.F., Borland, R. (2006). Tobacco denormalization and industry beliefs among smokers from four countries. American Journal of Preventive Medicine, 31(3), 225-232.

Abstract

Background: Tobacco denormalization is an important concept for understanding smoking behavior. The present study sought to assess beliefs about the tobacco industry and the social acceptability of smoking among nationally representative samples of adult smokers from four countries, and to assess the relationship of these measures to cessation behavior and tobacco-control policy.

Design: A longitudinal survey of 9058 adult smokers from Canada (n = 2214), the United States (n = 2138), the United Kingdom (n = 2401), and Australia (n = 2305), was conducted in October-December 2002 and again in June and August 2003 (75% follow-up rate). The analyses were conducted in 2005.

Results: The findings indicate that few smokers perceive approval for their smoking, and most hold relatively antagonistic beliefs toward the tobacco industry. For example, 80% of smokers reported that society disapproves of smoking, and more than three quarters reported that tobacco companies cannot be trusted to tell the truth. Social and industry denormalization were independently associated with intentions to quit smoking. Baseline levels of social denormalization were associated with abstinence at the 8-month follow-up, as were changes in industry denormalization beliefs between baseline and follow-up. Anti-industry beliefs at baseline did not predict abstinence at follow-up. A similar pattern of findings was observed across all four countries. In addition, social denormalization and anti-industry beliefs were significantly associated with tobacco-control policies, such as noticing health warnings on packages and greater workplace smoking restrictions.

Conclusions: Tobacco denormalization constructs were independently linked to cessation-related outcomes among adults from four countries. Tobacco-industry denormalization themes in mass media campaigns may help to reduce tobacco use above and beyond more traditional communications that target social norms.

Citation

Young, D., Borland, R., Hammond, D., Cummings, K.M., Devlin, E., Yong, H.H., O’Connor, R.J. (2006). Prevalence and attributes of roll-your-own smokers in the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii76-iii82.

Abstract

Background: Roll-your-own (RYO) cigarettes are often substantially less expensive than factory made (FM) cigarettes, and appear to be increasing in popularity—perhaps because smokers seek out less expensive options to maintain their nicotine addiction. There is surprisingly little research available on the actual prevalence of RYO cigarette usage, and even less on the attributes of those who smoke RYO cigarettes.

Objectives: This study has two objectives: (1) to compare the prevalence of RYO versus FM cigarette usage among adult smokers in Australia, Canada, the United Kingdom, and the United States; and (2) to compare the attributes of exclusive FM smokers, exclusive RYO smokers, and those who report “mixed” RYO and FM use.

Design: The data were collected from the International Tobacco Control (ITC) Four Country Survey (ITC-4), a random digit dialed telephone survey of representative samples of over 9046 adult smokers from the following four countries: Australia (n  =  2301), Canada (n  =  2,206), the UK (n  =  2400), and the USA (n  =  2,139), surveyed between October and December 2002, and on 6075 smokers followed-up, on average, seven months later.

Results: The prevalence of RYO cigarette usage varied widely across the four countries, with a low of 6.7% in the USA, to 28.4% in the UK. Exclusive use of RYO cigarettes was more common in the UK than in the other three countries. The use of RYO cigarettes was associated with having a lower annual income, male sex, younger average age, higher level of nicotine addiction, a stronger belief that RYO tobacco is less harmful compared to other forms of tobacco, and a more positive perception of tobacco use. Prevalence of RYO use was relatively stable within each of the four countries between the baseline and follow-up survey. RYO use was unrelated to quitting activity at follow-up, although mixed RYO users who had made a quit attempt were more likely to relapse than either exclusive FM or exclusive RYO smokers.

Conclusions: Patterns of RYO use vary considerably across Australia, Canada, the USA, and the UK. RYO smokers are a heterogeneous group; however, the factors associated with RYO use appear to be the same across the four countries studied.

Citation

Hammond, D., Fong, G.T., McNeill, A., Borland, R., Cummings, K.M. (2006). Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii19-iii25.

Abstract

Background: Health warnings on cigarette packages are among the most common means of communicating the health risks of smoking. However, few studies have evaluated the impact of package warnings on consumer knowledge about tobacco risks.

Objective: The aim of the current study was to use nationally representative samples of adult smokers from the United States (USA), the United Kingdom (UK), Canada (CAN), and Australia (AUS) from the International Tobacco Control Four Country Survey (ITC-4) to examine variations in smokers’ knowledge about tobacco risks and the impact of package warnings.

Methods: A telephone survey was conducted with 9058 adult smokers from the following countries: USA (n  =  2138), UK (n  =  2401), CAN (n  =  2214) and AUS (n  =  2305). Respondents were asked to state whether they believed smoking caused heart disease, stroke, impotence, lung cancer in smokers, and lung cancer in non-smokers. Respondents were also asked whether the following chemicals are found in cigarette smoke: cyanide, arsenic and carbon monoxide.

Findings: Smokers in the four countries exhibited significant gaps in their knowledge of the risks of smoking. Smokers who noticed the warnings were significantly more likely to endorse health risks, including lung cancer and heart disease. In each instance where labelling policies differed between countries, smokers living in countries with government mandated warnings reported greater health knowledge. For example, in Canada, where package warnings include information about the risks of impotence, smokers were 2.68 (2.41–2.97) times more likely to agree that smoking causes impotence compared to smokers from the other three countries.

Conclusion: Smokers are not fully informed about the risks of smoking. Warnings that are graphic, larger, and more comprehensive in content are more effective in communicating the health risks of smoking.

Citation

Harris, F., MacKintosh, A.M., Anderson, S., Hastings, G., Borland, R., Fong, G.T., Hammond, D., Cummings, K.M. (2006). Effects of the 2003 advertising/promotion ban in the United Kingdom on awareness of tobacco marketing: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii26-iii33.

Abstract

Background: In February 2003, a comprehensive ban on tobacco promotion came into effect in the United Kingdom, which prohibited tobacco marketing through print and broadcast media, billboards, the internet, direct mail, product placement, promotions, free gifts, coupons and sponsorships.

Objective: To investigate the impact of the UK’s comprehensive ban on tobacco promotion on adult smokers’ awareness of tobacco marketing in the UK relative to Canada, the United States and Australia.

Design: A total of 6762 adult smokers participated in two waves of a random digit dialled telephone survey across the four countries. Wave 1 was conducted before the UK ban (October–December 2002) and Wave 2 was conducted after the UK ban (May–September 2003).

Key measures: Awareness of a range of forms of tobacco marketing.

Results: Levels of tobacco promotion awareness declined significantly among smokers in the UK after implementation of the advertising ban. Declines in awareness were greater in those channels regulated by the new law and change in awareness of tobacco promotions was much greater in the UK than the other three countries not affected by the ban. At least in the short term, there was no evidence that the law resulted in greater exposure to tobacco promotions in the few media channels not covered by the law. Notwithstanding the apparent success of the UK advertising ban and the controls in other countries, 9–22% of smokers in the four countries still reported noticing things that promoted smoking ‘‘often or very often’’ at Wave 2.

Conclusions: The UK policy to ban tobacco advertising and promotion has significantly reduced exposure to pro-tobacco marketing influences. These findings support the effectiveness of comprehensive bans on advertising and promotion, as included in the Framework Convention on Tobacco Control.

Citation

Yong, H.H., Borland, R., Siahpush, M. (2005). Quitting-related beliefs, intentions, and motivations of older smokers in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Addictive Behaviours, 30(4), 777-788.

Abstract

Older smokers represent an important subgroup that has been shown to benefit considerably from quitting smoking. However, to date little is known about relevant beliefs, intentions, and motivations. This study examined factors associated with older smokers' (aged 60 years and above) intention to quit smoking using data gathered via the International Tobacco Control Policy Evaluation Survey (ITCPES), a random digit dialed telephone survey of over 9000 adult smokers from United Kingdom, United States, Canada, and Australia. Having smoked for a long time and having survived, it was hypothesized that older smokers would perceive themselves as being less vulnerable to the harm of smoking (self-exempting beliefs); be less concerned about the health effects of smoking; be less confident about being able to quit successfully (self-efficacy); not perceive any health benefit of quitting, and hence be less willing to want to quit. Controlling for possible confounders, the hypotheses were all confirmed. Further analysis into reported considerations for quitting revealed that price of cigarettes, health professional advice, cheap quitting medication, and information on health risks were important predictors of quitting intention, with cigarette price and cheap medication also associated with recent quit attempts. Together, these findings have important implications for developing strategies for encouraging older smokers to give up smoking.

Citation

Fong, G.T., Hammond, D., Laux, F., Zanna, M.P., Cummings, K.M., Borland, R., Ross, H. (2004). The near-universal experience of regret among smokers in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Nicotine & Tobacco Research, 6(Suppl 3), S341-351.

Abstract

Regret may be a key variable in understanding the experience of smokers, the vast majority of whom continue to smoke while desiring to quit. We present data from the baseline wave (October-December 2002) of the International Tobacco Control Policy Evaluation Survey, a random-digit-dialed telephone survey of a cohort of over 8,000 adult smokers across four countries--Canada, the United States, the United Kingdom, and Australia--to estimate the prevalence of regret and to identify its predictors. The proportion of smokers who agreed or agreed strongly with the statement "If you had to do it over again, you would not have started smoking" was extremely high--about 90%--and nearly identical across the four countries. Regret was more likely to be experienced by older smokers, women, those who had tried to quit more often, those who perceived quitting as conferring benefits, those with higher levels of perceived addiction, those who worried about future damage to health, those who perceived smoking as lowering their quality of life, those who perceived higher monetary costs of smoking, and those who believed that smoking is not socially acceptable. This predictive model was the same in all four countries. Regret is thus a near-universal experience among smokers in all four countries, and the factors that predict regret are universal across these four countries. Among other implications for cessation treatment and smoking prevention, this near universality of regret casts doubt on the view of some policy analysts and economists that the decisions to take up and continue smoking are welfare-maximizing for the consumer.

Citation

Borland, R., Yong, H.H., King, B., Cummings, K.M., Fong, G.T., Elton-Marshall, T., Hammond, D., McNeill, A. (2004). Use of and beliefs about light cigarettes in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Nicotine & Tobacco Research, 6(Suppl 3), S311-321.

Abstract

This study examined reported use of, and beliefs about, so-called light cigarettes among adult smokers in four countries: Australia (Aus), Canada (Can), the United Kingdom (U.K.) and the United States (U.S.). The method used was parallel telephone surveys among 9,046 smokers across the four countries. The results indicated that more than half of all smokers in each country except the U.K. reported smoking light cigarette brands. A majority of smokers surveyed in each country except Canada continue to believe that light cigarettes offer some health benefit compared to regular cigarettes (Canada 43%, U.S. 51%, Australia 55%, U.K. 70%). A majority of smokers in all four countries believed that light cigarettes are smoother on the throat and chest than regular cigarettes. Predictors of use of light cigarettes and beliefs about possible benefits were very similar in the four countries. These results demonstrate an ongoing need for public education about why light cigarettes do not reduce harm and do not make quitting easier. The results provide further evidence for the need for regulatory measures in all four countries to prohibit the use of misleading light and mild descriptors including package imagery in product marketing (as prescribed in Article 11 of the Framework Convention on Tobacco Control), abandon the use of standard FTC/ISO tar and nicotine yields as consumer information, and adopt policies to regulate deceptive design features of cigarettes, such as ventilated filters.