Citation

Smith, D.M., Miller, C., O’Connor, R.J., Kozlowski, L.T., Wadsworth, E., Fix, B.V., Collins, R.L., Wei, B., Goniewicz, M., Hyland, A., Hammond, D. (2021). Modes of delivery in concurrent nicotine and cannabis use ("co-use") among youth: Findings from the International Tobacco Control (ITC) Survey. Substance Abuse, 42(3), 339-347.

Abstract

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

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

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

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

Abstract

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

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

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

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

Citation

Li, L., Borland, R., O’Connor, R.J., Fong, G.T., McNeill, A., Driezen, P., Cummings, K.M. (2019). The association between smokers' self-reported health problems and quitting: Findings from ITC Four Country Smoking and Vaping Wave 1 Survey. Tobacco Prevention & Cessation, 5(December): 49.

Abstract

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

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

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

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

Citation

Levy, D.T., Warner, K.E., Cummings, K.M., Hammond, D., Kuo, C., Fong, G.T., Thrasher, J.F., Goniewicz, M.L., Borland, R. (2019). Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check. Tobacco Control, 28(6), 629-635.

Abstract

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

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

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

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

Citation

Fataar, F., Hammond, D. (2019). The prevalence of vaping and smoking as modes of delivery for nicotine and cannabis among youth in Canada, England and the United States. International Journal of Environmental Research and Public Health, 16(21), 4111. doi:10.3390/ijerph16214111

Abstract

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

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

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

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

Citation

Aleyan, S., East, K., McNeill, A., Cummings, K.M., Fong, G.T., Yong, H.H., Thrasher, J.F., Borland, R., Hitchman, S.C. (2019). Differences in norms towards the use of nicotine vaping products among adult smokers, former smokers and nicotine vaping product users: Cross-sectional findings from the 2016 ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 97-106.

Abstract

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

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

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

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

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

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

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

No abstract is available.

Citation

McNeill, A., Driezen, P., Hitchman, S.C., Cummings, K.M., Fong, G.T., Borland, R. (2019). Indicators of cigarette smoking dependence and relapse in former smokers who vape compared with those who do not: findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 49-60.

Abstract

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

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

Setting: United States, Canada, Australia and England.

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

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

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

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

Citation

O’Connor, R.J., Fix, B.V., McNeill, A., Goniewicz, M.L., Bansal-Travers-M., Heckman, B.W., Cummings, K.M., Hitchman, S., Borland, R., Hammond, D., Levy, D., Gravely, S., Fong, G.T. (2019). Characteristics of nicotine vaping products used by participants in the 2016 ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 15-23.

Abstract

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

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

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

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

Citation

Nahhas, G., Braak, D., Cummings, K.M., Heckman, B.W., Alberg, A.J., Yong, H.H., Fong, G.T., Boudreau, C., Hitchman, S.C., McNeill, A. (2019). Rules about smoking and vaping in the home: Findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 107-114.

Abstract

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

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

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

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

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

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

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, the United States, the United Kingdom, and Australia.

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

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

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

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

Abstract

Background: Despite restrictions on where and how cigarette companies can market their products, cigarettes remain a heavily advertised consumer product in America. Examining the brand preferences of smokers may provide clues to understanding how shifting consumer preferences and industry marketing strategies are influencing smoking related behaviors. This study presents estimates of cigarettes brand preferences of adolescents and adults in the United States. Objective: In this paper, we examine the brand preferences of smokers and how that relates to cigarette brand features in the Population Assessment of Tobacco and Health Survey Wave-1 (September 2013-December 2014).

Methods: There were 32,320 adult and 13,651 youth participants in the survey. Analyses were restricted to current smokers who reported purchasing cigarettes, 10,493 adults and 282 youth. Frequencies, weighted percentages, and chi-square tests were reported.

Results: Respondents reported purchasing a total of 58 brands with many more brand name line extensions with a greater diversity of brands reported by adults compared to youth. Marlboro, Newport, Camel, and American Spirit accounted for >90% of the purchasing among youth, while accounting for about 70% among adults. Mentholated cigarettes were smoked by over 39% of youth and 38% of adults, particularly Hispanics and Blacks. Longer-length cigarette use was more commonly reported by females, and discounted brands were more commonly used by older and daily smokers.

Conclusions: Price discounting, cigarette length, use of menthol flavoring, age, and ethnicity were associated with cigarette brand preferences and purchases. Cigarette characteristics such as length, filtration, price, flavor, and general packaging could be regulated to limit the appeal of cigarettes to different sub-populations.

Citation

Cho, Y.J., Thrasher. J.F., Reid, J.L., Hitchman. S., Hammond, D. (2019). Youth self-reported exposure to and perceptions of vaping advertisements: Findings from the 2017 International Tobacco Control Youth Tobacco and Vaping Survey. Preventive Medicine, 126(2019), 105775. doi: 10.1016/j.ypmed.2019.105775

Abstract

Countries have adopted various regulations to limit youth exposure to vaping product advertising. This study aims to examine youth exposure to and perceptions of vaping ads in Canada, England, and the US, three countries with varying vaping product advertising regulations. Data were analyzed from the 2017 ITC Youth Tobacco and Vaping Survey, an online survey of youth aged 16 to 19 years from a consumer panel (n = 12,064). The survey assessed vaping product ad exposure in the prior month, including channels, perceived appeal, and perceived target audience. Most young people reported some vaping product ad exposure in the past 30 days (Canada = 74%, England = 83%, US = 81%). Among those exposed to vaping product ads, more than one-third found them appealing (Canada = 36%, England = 38%, US = 43%). Stores that sell cigarettes were the most common venue for vaping ad exposure, although it was less common in Canada (46%) than in England (60%) or the US (60%), both of which had less restrictive regulatory environments. Ad exposure through websites or social media did not differ by country (Canada = 38%, England = 40%, US = 41%). Compared to those who never smoked or used vaping products, youth who reported smoking and/or vaping were more likely to report ad exposure through most channels. More than one-third of youth perceived that vaping product ads target non-smokers (Canada = 47%, England = 36%, US = 48%). Our study suggests most youth are exposed to vaping product ads, which may promote product use. Except for online channels, cross-country differences in the channels of ad exposure may reflect contrasting regulatory environments.

Citation

Levy, D., Yuan, Z., Li, Y., Mays, D., Sanchez-Romero, L.M. (2019). An examination of the variation in estimates of e-cigarette prevalence among U.S. adults. International Journal of Environmental Research and Public Health, 16(17), 3164.

Abstract

Introduction: Accurate estimates of e-cigarette use are needed to gauge its impact on public health. We compared the results of online and traditional, large scale surveys and provide additional estimates from the Population Assessment of Tobacco and Health (PATH) survey, with the aim of assessing the extent of variation in prevalence estimates.

Materials and Methods: We searched the peer-reviewed literature for nationally representative estimates of U.S. adult e-cigarette prevalence, and developed our own estimates from waves one, two, and three of the PATH survey. We compared estimates by age, gender, cigarette smoking status, and e-cigarette use intensity both between online and traditional surveys and among the traditional surveys.

Results: For specific years, online surveys generally yielded higher adult use rates than most traditional surveys, but considerable variation was found among traditional surveys. E-cigarette prevalence was greater for less intensive than for more intensive use. Levels of use were higher among current and recent former cigarette smokers than among former smokers of longer quit duration and never smokers, and by those of younger ages.

Conclusions: Considerable variation in e-cigarette use estimates was observed even for a specific year. Further study is needed to uncover the source of variation in e-cigarette prevalence measures, with a view towards developing measures that best explain regular use and transitions between the use of e-cigarettes and other tobacco products.

Citation

Sontag, J, Wackowski, O, Hammond, D. (2019). Baseline assessment of noticing e-cigarette health warnings among youth and young adults in the United States, Canada and England, and associations with harm perceptions, nicotine awareness and warning recall. Preventive Medicine Reports, 16, 100966. doi: 10.1016/j.pmedr.2019.100966

Abstract

Health warnings on tobacco products can inform users of potential risks. However, little is known about young people's exposure to health warnings on e-cigarette products. This baseline assessment of young people's noticing e-cigarette warnings uses nationally representative data from three countries. Data were collected under Wave 1 of the ITC Youth Tobacco and E-cigarette Survey, conducted in Canada, England, and the US. Online surveys were completed by 16-19-year-olds in July/August 2017 (n = 12,064), when warnings were either newly required (England) or voluntarily carried by some manufacturers (US, Canada). Analyses examined prevalence and correlates of noticing warnings and associations between noticing warnings and product perceptions, adjusting for country, sex, age, race/ethnicity, and cigarette/e-cigarette use status. About 12% reported noticing warnings on e-cigarette packaging in the past 30 days. Noticing warnings was significantly more likely among youth in England (AOR = 1.3, p < .01) and the US (AOR = 1.3, p < .01) versus Canada, and was most likely among dual ecigarette/cigarette users (AOR = 4.69, p < .001) versus nonusers. Unaided recall of the keyword nicotine was low among those who noticed warnings (7.5%). However, ever e-cigarette users who noticed warnings had higher odds of knowing whether e-cigarettes contained nicotine (AOR = 2.26, p < .001). Noticing warnings was significantly associated with higher odds of believing e-cigarettes cause at least some harm to users (AOR = 1.19), are as harmful as cigarettes (AOR = 1.45), and can be addictive (AOR = 1.43). Baseline assessment reveals that youth's noticing of e-cigarette warnings and recall of nicotineaddiction messages was low. Research should track exposure over time as warning requirements are implemented across different countries.

Citation

Driezen, P., Nargis, N., Thompson, M.E., Cummings, K.M., Fong, G.T., Chaloupka, F.J., Shang, C., Cheng, K-W. (2019). State-level affordability of factory-made cigarettes among current US smokers: Findings from the ITC US Survey, 2003-2015. International Journal of Environmental Research and Public Health, 16(13), 2439.

Abstract

Cigarette affordability measures the price smokers pay for cigarettes in relation to their incomes. Affordability can be measured using the relative income price of cigarettes (RIP), or the price smokers pay to purchase 100 packs of 20 cigarettes divided by their per capita household income. Using longitudinal data from 7046 smokers participating in the International Tobacco Control (ITC) US Survey, the purpose of this study was to test whether affordability significantly changed following the US federal tax increase implemented on 1 April 2009. This study also estimated temporal trends in affordability from 2003–2015 at state and national levels using small area estimation methods and segmented linear mixed effects regression models. RIP increased slightly during 2003–2008. This was followed by a 30% increase during 2008–2010, indicating cigarettes were less affordable after the federal tax increase. RIP continued to increase during 2010–2013 but decreased during 2013–2015, suggesting cigarettes have recently become more affordable for US smokers. State-level trends in RIP were consistent with overall national trends. Controlling for other factors, a $1 increase in the state excise tax was significantly associated with a 9% increase in RIP, indicating state taxes reduced affordability. Tax-induced price increases must keep pace with underlying economic conditions to ensure cigarettes do not become more affordable over time.

Citation

Sharma, A., Kasza, K., Hyland, A., Cummings, K.M., Bansal-Travers, M., Fong, G.T., O’Connor, R.J. (2019). Awareness and interest in lung cancer screening among current and former smokers: Findings from the ITC United States Survey. Cancer Causes & Control, 30(7), 733–745.

Abstract

Purpose: To examine the awareness of low-dose computed tomography (LDCT) lung cancer screening among a population of current and former smokers using a nationally representative sample from the United States.

Methods: Data for this study come from Wave 9 of the International Tobacco Control (ITC) United States Survey, conducted between 2013 and 2015. Among respondents age ≥ 40 (n = 1145), a 50% random sample were asked a series of questions pertaining to lung cancer screening. This study examines awareness and screening behaviors in relationship to demographic characteristics of respondents, health beliefs, psychosocial behaviors, and smoking behaviors. Descriptive tables and χ2 tests were used to examine the association between those who were aware and unaware. Logistic regression analyses were conducted, stratified on respondents’ smoking status. Data were weighed to be representative of the current smoking population in the US.

Results: Overall, 52% of current and former smokers reported being aware of lung cancer screening. Among the group with no prior screening, 80.6% said they would take a lung cancer screening exam if recommended by their physician. In the multivariate models, former smokers had significantly greater awareness of lung cancer screening compared to current smokers [odds ratio 1.42 (95% confidence interval 1.03, 1.97)].

Conclusions: Awareness of LDCT lung cancer screening was lower among current smokers compared to former smokers. Most smokers who had not ever been screened said they would have lung cancer screening if it were recommended by their physician, demonstrating the need for healthcare providers to encourage those eligible for screening to

Citation

Hammond, D., Reid, J., Rynard, V.L., Fong, G.T., Cummings, K.M., McNeill, A., Hitchman, S.C., Thrasher, J.F., Goniewicz, M., Bansal-Travers, M., O’Connor, R.J., Levy, D., Borland, R., White, C. (2020). Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross-sectional surveys. BMJ, 370, m2579. doi: https://www.bmj.com/content/370/bmj.m2579

Abstract

Objective: To examine differences in vaping and smoking prevalence among adolescents in Canada, England, and the United States.

Design: Repeat cross sectional surveys.

Setting: Online surveys in Canada, England, and the US.

Participants: National samples of 16 to 19 year olds in 2017 and 2018, recruited from commercial panels in Canada (n=7891), England (n=7897), and the US (n=8140).

Main outcome measures: Prevalence of vaping and smoking was assessed for use ever, in the past 30 days, in the past week, and on 15 days or more in the past month. Use of JUUL (a nicotine salt based electronic cigarette with high nicotine concentration) and usual vaping brands were also assessed. Logistic regression models examined differences in vaping and smoking between countries and over time.

Results: The prevalence of vaping in the past 30 days, in the past week, and on 15 days or more in the past month increased in Canada and the US between 2017 and 2018 (P<0.001 for all), including among non-smokers and experimental smokers, with no changes in England. Smoking prevalence increased in Canada (P<0.001 for all measures), with modest increases in England, and no changes in the US. The percentage of ever vapers who reported more frequent vaping increased in Canada and the US (P<0.01 for all), but not in England. The use of JUUL increased in all countries, particularly the US and Canada—for example, the proportion of current vapers in the US citing JUUL as their usual brand increased threefold between 2017 and 2018.

Conclusions: Between 2017 and 2018, among 16 to 19 year olds the prevalence of vaping increased in Canada and the US, as did smoking in Canada, with little change in England. The rapidly evolving vaping market and emergence of nicotine salt based products warrant close monitoring.

Citation

Li, L., Borland, R., O’Connor, R., Fong, G.T., McNeill, A., Driezen, P., Cummings, K.M. (2019). How are self-reported physical and mental health conditions related to vaping activities among smokers and quitters: Findings from the ITC Four Country Smoking and Vaping Wave 1 Survey. International Journal of Environmental Research and Public Health, 16(8), e1412.

Abstract

This study examines whether having health conditions or concerns related to smoking is associated with use of vaping products. Data came from the 2016 wave of the International Tobacco Control Four Country Smoking and Vaping Survey. Smokers and recent quitters (n = 11,344) were asked whether they had a medical diagnosis for nine health conditions (i.e., depression, anxiety, alcohol problems, severe obesity, chronic pain, diabetes, heart disease, cancer, and chronic lung disease) and concerns about past and future health effects of smoking, and their vaping activities. Respondents with depression and alcohol problems were more likely to be current vapers both daily (Adjusted odds ratio, AOR = 1.42, 95% confidence interval, CI 1.09–1.85, p < 0.05 for depression; and AOR = 1.52, 95% CI 1.02–2.27, p < 0.05 for alcohol) and monthly (AOR = 1.32, 95% CI 1.11–1.57 for depression, p < 0.01; and AOR = 1.43, 95% CI 1.06–1.90, p < 0.05 for alcohol). Vaping was more likely at monthly level for those with severe obesity (AOR = 1.77, 95% CI 1.29–2.43, p < 0.001), cancer (AOR = 5.19, 95% CI 2.20–12.24, p < 0.001), and concerns about future effects of smoking (AOR = 1.83, 95% CI 1.47–2.28, p < 0.001). Positive associations were also found between chronic pain and concerns about past health effects of smoking and daily vaping. Only having heart disease was, in this case negatively, associated with use of vaping products on their last quit attempt (AOR = 0.72, 95% CI 0.43–0.91, p < 0.05). Self-reported health condition or reduced health associated with smoking is not systematically leading to increased vaping or increased likelihood of using vaping as a quitting strategy.

Citation

Ngo, A., Fong, G.T., Craig, L., Shang, C. (2019). Analysis of gender differences in the impact of taxation and taxation structure on cigarette consumption in 17 ITC countries. International Journal of Environmental Research and Public Health, 16(7), e1275.

Abstract

Although increasing taxes has been established as the most effective tobacco control policy, it is not clear whether these policies reduce cigarette consumption equally among women and men. In this study, we examine whether the association between taxation/taxation structure and cigarette consumption differs by gender. The data is from the International Tobacco Control Policy Evaluation (ITC) Projects in 17 countries. Cigarette consumption was measured by gender for each ITC country. Generalized estimating equations (GEE) were employed to investigate gender differences in the association between cigarette consumption and tax structures, while controlling for time-variant demographic characteristics such as unemployment rates, proportions of adults, and percent of female population. Tiered tax structures are associated with higher cigarette consumption among both males and females. Female smokers are more responsive to an average tax increase than male smokers. Among males, higher ad valorem share in excise taxes is associated with lower cigarette consumption, but it is not the case for females. Females may not be as responsive to the prices raised by ad valorem taxes, despite being responsive to average taxes, suggesting that smokers by gender may face different prices.

Citation

Wackowski, O, Sontag, J, Hammond, D. (2019). Youth and young adult exposure to and perceptions of news media coverage about e-cigarettes in the United States, Canada and England. Preventative Medicine, 121, 7-10. doi: 10.1016/j.ypmed.2019.01.013

Abstract

News media coverage has the potential to shape awareness and perceptions of e-cigarettes, but little is known about youth and young adult exposure to e-cigarette news. We analyzed news exposure measures on Wave 1 of the ITC Youth Tobacco and E-cigarette Survey, conducted in Canada, England, and the U.S. Web-based surveys were completed by 16-19-year-olds in July/August 2017 (n = 12,064). The prevalence of exposure to e-cigarette news and its perceived valence is provided. Logistic regression was used to model the odds of news exposure, and the association between news exposure and e-cigarette harm perceptions, susceptibility, and quitting intentions. Overall, 17.1% of young people reported hearing or seeing e-cigarette news at least 'sometimes' in the past 30 days. The majority of those exposed (n = 2052) perceived the content of the news stories to be mostly negative (35.7%) or mixed (34.8%) about e-cigarettes, versus mostly positive (19%). Perceived exposure to mostly negative e-cigarette stories was lower among past 30-day e-cigarette users and youth in England. Participants exposed to mostly negative e-cigarette news were more likely to perceive that e-cigarettes cause at least some harm and, among past 30 day users, have intentions to quit e-cigarettes in the next month. Exposure to mostly positive news was associated with higher odds of e-cigarette susceptibility among never triers. Young people report exposure to e-cigarette news with varied perceptions of its valence. E-cigarette news exposure may shape e-cigarette harm perceptions and use intentions, as well as reflect existing beliefs and product interest.

Citation

Levy, D., Lindblom, E., Sweanor, D, Chaloupka, F.J., O’Connor, R.J., Shang, C., Palley, T, Fong, G.T., Cummings, K.M., Goniewicz, M., Borland, R. (2019). An economic analysis of the pre-deeming US market for nicotine vaping products. Tobacco Regulatory Science, 5(2), 169-181.

Abstract

Objectives: Public health policies are often enacted without adequate consideration of the existing market structure or their impacts on that market structure. This paper provides context for the potential impact of regulations on nicotine vaping products (NVP) use by providing a structural analysis of competition in the US NVP market before FDA regulation.

Methods: A literature review was conducted with the aim of providing a framework for analysis that: 1) defines the market; 2) evaluates market concentration; 3) identifies entry barriers; and 4) examines firm conduct.

Results: The NVP market includes retail, internet sellers and vape shops. Although conventional retail became more concentrated after the major cigarette companies entered the NVP market, the vape shop and internet sectors remain substantially less concentrated, producing an overall low market concentration, with few entry barriers and competitive behavior.

Conclusions: The largely unregulated US NVP market has been highly competitive, with a high degree of innovation. However, new FDA deeming regulations as applied to NVPs could make it difficult for smaller companies to remain in the market and could discourage new companies and new product innovations from entering the market.

Citation

Yong, H.H., Borland, R., Cummings, K.M., Gravely, S., Thrasher, J., McNeill, A., Hitchman, S.C., Greenhalgh, B., Thompson, M.E., Fong, G.T. (2019). Reasons for regular vaping and for its discontinuation among smokers and recent ex-smokers: findings from the 2016 ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 35-48.

Abstract

Aims: To examine current and ex‐ smokers’ reasons for continuing or discontinuing regular use of nicotine vaping products (NVPs).

Design and participants: Cross‐sectional study of 2,722 current daily/weekly, and 921 ex‐daily/weekly, adult vapers who were either current or ex‐cigarette smokers when surveyed.

Setting: 2016 ITC Four Country Smoking and Vaping Wave 1 (4CV1) surveys conducted in the United States (n=1159), England (n=1269), Canada (n=964), and Australia (n=251).

Measurements: Current vapers were asked about the following reasons for regular NVP use: less harmful to others, social acceptance, enjoyment, use in smoke‐free areas, affordability, and managing smoking behaviour. Ex‐vapers were asked about the following reasons for discontinuing regular NVP use: addiction concerns, affordability, negative experiences, perceived social unacceptability, safety concerns, product dissatisfaction, inconvenience, unhelpfulness for quitting, unhelpfulness for managing cravings, and not needed for smoking relapse prevention. Possible correlates of NVP use and discontinuation, including smoking status, smoking/vaping frequency, quit duration (ex‐smokers only), country, age, and type of NVP device used, were examined using multivariate logistic regression models.

Findings: For current smokers, the top three reasons for current regular NVP use were: helpful for cutting down smoking (86%), less harmful to others (78%), and helpful for quitting smoking (77%). The top three reasons for discontinuing vaping were: not being satisfying (78%), unhelpfulness for cravings (63%), and unhelpfulness for quitting smoking (52%). For ex‐smokers, the top three reasons for current vaping were: enjoyment (91%), less harmful to others (90%) and affordability (90%); and for discontinuing were: not needed to stay quit (77%), not being satisfying (50%) and safety concerns (44%). Reported reasons varied by user characteristics, including age, country and NVP device‐type.

Conclusions: Regular use of nicotine vaping products is mainly motivated by its perceived benefits, especially for reducing or quitting smoking, whereas its discontinuation is motivated by perceived lack of such benefits, with some variation by user characteristics.

Citation

Borland, R., Murray, K., Gravely, S., Fong, G.T., Thompson, M.E., McNeill, A., O’Connor, R.J., Goniewicz, M., Yong, H.H., Levy, D., Heckman, B., Cummings, K.M. (2019). A new classification system for describing concurrent use of nicotine vaping products alongside cigarettes (so-called "dual use"): Findings from the ITC 4-Country Smoking and Vaping Wave 1 Survey. Addiction, 114(Suppl 1), 24-34.

Abstract

Aims: To determine whether a simple combination of level of smoking and level of vaping results in a useful typology for characterising smoking and vaping behaviours.

Methods: Cross‐sectional data from adults (≥18 years) in the 2016 Wave 1 ITC Four Country Smoking and Vaping Survey in the United States (n=2291), England (n=3591), Australia (n=1376), and Canada (n=2784) were used. Participants who either smoked, vaped or concurrently used both at least monthly were included and divided into 8 groups based on use frequency of each product (daily, non‐daily, no current use). This resulted in 4 concurrent use groups (predominant smokers, dual daily users, predominant vapers and concurrent non‐daily users). These groups were compared with each other and with the 4 exclusive use groups, on socio‐demographics, nicotine dependence, beliefs and attitudes about both products, and quit‐related measures using data weighted to reference population surveys in each country.

Results: 10.8% of the sample were concurrent users, with daily smokers vaping non‐daily (predominant smokers) constituting 51.6% of this group. All 8 categories differed from other categories on at least some measures. Concurrent daily nicotine users reported higher levels of indicators of nicotine dependence, and generally more positive attitudes toward both smoking and vaping than concurrent non‐daily users. Among daily nicotine users, compared with exclusive daily smokers, reports of interest in quitting were higher in all concurrent use groups. Dual daily users had the most positive attitudes about smoking overall, and saw it as the least denormalised, and at the same time were equally interested in quitting as other concurrent users and were most likely to report intending to continue vaping.

Conclusions: In Australia, Canada, England and the United States in 2016, daily nicotine users differed considerably from non‐daily nicotine users. Among daily nicotine users, dual daily users (those who smoke and vape concurrently) should be treated as a distinct grouping when studying relationships between smoking and vaping. The 8 level typology characterising concurrent and exclusive use of smoking and vaping should be considered when studying both products.

Citation

Cheng, K.-W., Chaloupka, F.J., Shang, C., Ngo, A., Fong, G.T., Borland, R., Heckman, B.W., Levy, D.T., Cummings, K.M. (2019). Prices, use restrictions and electronic cigarette use—evidence from Wave 1 (2016) US data of the ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 115-122.

Abstract

Aims: To determine if there are associations between changes in the explicit (i.e., price) and implicit (i.e., use restrictions in public places) costs of cigarettes and nicotine vaping products (NVPs) and their use patterns in the United States.

Methods: Data came from the Wave 1 (2016) US data of the ITC Four Country Smoking and Vaping Survey (ITC US 4CV1) and Nielsen Scanner Track database. A multiple logistic regression model was applied to estimate the likelihoods of NVP use (vaping at least monthly), cigarette/NVP concurrent use (vaping and smoking at least monthly), and switch from cigarettes to NVPs (had quit smoking < 24 months and currently vape) among ever smokers, conditioning upon cigarette/NVP prices, use restrictions and socio‐demographics.

Results: Living in places where vaping is allowed in smoke‐free areas was significantly associated with an increase in the likelihood of vaping (Marginal Effect, M.E. = 0.17; p<0.05) and the concurrent use of cigarettes and NVPs (M.E. = 0.11; p<0.05). Higher NVP prices were associated with decreased likelihood of NVP use, concurrent use, and complete switch (P>0.05). Higher cigarette prices were associated with greater likelihood of cigarette and NVP concurrent use (P>0.05). Working in places where vaping is banned is associated with lower likelihood of vaping and NVP and cigarette concurrent use (P>0.05).

Conclusions: Higher prices for nicotine vaping products (NVPs) and vaping restrictions in public places are associated with less NVP use and less concurrent use of vaping and smoking. Public policies that increase prices for vaping devices and supplies (i.e., regulations, taxes) and restrict where vaping is allowed are likely to suppress vaping.