Citation

Hall, P.A., Fong, G.T., Yong, H.H., Sansone, G.C., Borland, R., Siahpush, M. (2012). Do time perspective and sensation-seeking predict quitting activity among smokers? Findings from the International Tobacco Control (ITC) Four Country Survey. Addictive Behaviours, 37(12), 1307-1313.

Abstract

Personality factors such as time perspective and sensation-seeking have been shown to predict smoking uptake. However, little is known about the influences of these variables on quitting behavior, and no prior studies have examined the association cross-nationally in a large probability sample. In the current study it was hypothesized that future time perspective would enhance – while sensation-seeking would inhibit – quitting activity among smokers. It was anticipated that the effects would be similar across English speaking countries. Using a prospective cohort design, this cross-national study of adult smokers (N=8845) examined the associations among time perspective, sensation-seeking and quitting activity using the first three waves of data gathered from the International Tobacco Control Four Country Survey (ITC-4), a random digit dialed telephone survey of adult smokers from the United Kingdom, United States, Canada and Australia. Findings revealed that future time perspective (but not sensation-seeking) was a significant predictor of quitting attempts over the 8-month follow-up after adjusting for socio-demographic variables, factors known to inhibit quitting (e.g., perceived addiction, enjoyment of smoking, and perceived value of smoking), and factors known to enhance quitting (e.g., quit intention strength, perceived benefit of quitting, concerns about health effects of smoking). The latter, particularly intention, were significant mediators of the effect of time perspective on quitting activity. The effects of time perspective on quitting activity were similar across all four English speaking countries sampled. If these associations are causal in nature, it may be the case that interventions and health communications that enhance future-orientation may foster more quit attempts among current smokers.

Citation

Siahpush, M., Borland, R., Yong, H.H., Cummings, K.M., Fong, G.T. (2012). Tobacco expenditure, smoking-induced deprivation and financial stress: Results from the International Tobacco Control (ITC) Four-Country Survey. Drug and Alcohol Review, 31(5), 664-671.

Abstract

Introduction and Aims: While higher tobacco prices lead to a reduction in smoking prevalence, there is a concern that paying more for cigarettes can lead to excess financial burden. Our primary aim was to examine the association of daily cigarette expenditure with smoking-induced deprivation (SID) and financial stress (FS).

Design and Methods: We used data from wave 7 (2008–2009) of the International Tobacco Control (ITC) Four-Country Survey which is a survey of smokers in Canada, the USA, the UK and Australia (n = 5887). Logistic regressions were used to assess the association of daily cigarette expenditure with SID and FS.

Results: In multivariate analyses, a one standard deviation increase in daily cigarette expenditure was associated with an increase of 24% (P = 0.004) in the probability of experiencing SID. While we found no association between daily cigarette expenditure and FS, we found that SID is a strong predictor of FS (odds ratio 6.25; P < 0.001). This suggests that cigarette expenditure indirectly affects FS through SID. Results showed no evidence of an interaction between cigarette expenditure and income or education in their effect on SID or FS.

Conclusions: Our results imply that spending more on tobacco may result in SID but surprisingly has no direct effect on FS. While most smokers may be adjusting their incomes and consumption to minimise FS, some fail to do so occasionally as indexed by the SID measure. Future studies need to prospectively examine the effect of increased tobacco expenditure on financial burden of smokers.

Citation

Yong, H.H., Borland, R., Thrasher, J.F., Thompson, M.E. (2012). Stability of cigarette consumption over time among continuing smokers: A latent growth curve analysis. Nicotine & Tobacco Research, 14(5), 531-539.

Abstract

Objectives: This paper examined the stability over time of daily cigarette consumption of continuing smokers and explored factors that might account for the patterns of change in consumption using a latent growth curve (LGC) analytic approach.

Methods: Data come from the first 5 waves of the International Tobacco Control Four-Country Survey, conducted in Canada, the United States, the United Kingdom, and Australia where a cohort of over 2,000 smokers from each country were recruited and followed up annually with replenishment.

Results: Raw data revealed that continuing smokers showed a marked steep decline in cigarettes per day during the first 2 waves followed by a gentler linear decline in consumption over the remaining waves of the study period. This pattern of change in cigarette consumption was best modelled using a piecewise linear LGC model. Baseline consumption level was highest in Australia and lowest in the United Kingdom, although the rate of decline was similar across the 4 countries. Being older than 55 years and having made at least 1 quit attempt were related to greater rate of decline in consumption.

Conclusion: Continuing smokers who are unwilling or unable to quit smoking can and do attempt to reduce their daily cigarette consumption over time. Factors such as making a quit attempt even if unsuccessful and experiencing smoking bans at work and at homes can contribute to reduced smoking among this group, which suggests that interventions focusing in on these factors, along with providing cessation help, may greatly improve their chances of quitting smoking altogether.

Citation

Young, D., Yong, H.H., Borland, R., Shahab, L., Hammond, D., Cummings, K.M., Wilson, N. (2012). Trends in roll your own smoking: Findings from the ITC Four Country Survey (2002-2008). Journal of Environmental and Public Health, 2012, 1-7.

Abstract

Objective: To establish the trends in prevalence, and correlates, of roll-your-own (RYO) use in Canada, USA, UK and Australia, 2002–2008.

Methods: Participants were 19,456 cigarette smokers interviewed during the longitudinal International Tobacco Control (ITC) Four-Country Survey in Canada, USA, UK, and Australia.

Results: “Predominant” RYO use (i.e., >50% of cigarettes smoked) increased significantly in the UK and USA as a proportion of all cigarette use (both P < .001) and in all countries as a proportion of any RYO use (all P < .010). Younger, financially stressed smokers are disproportionately contributing to “some” use (i.e., ≤50% of cigarettes smoked). Relative cost was the major reason given for using RYO, and predominant RYO use is consistently and significantly associated with low income.

Conclusion: RYO market trends reflect the price advantages accruing to RYO (a product of favourable taxation regimes in some jurisdictions reinforced by the enhanced control over the amount of tobacco used), especially following the impact of the Global Financial Crisis; the availability of competing low-cost alternatives to RYO; accessibility of duty-free RYO tobacco; and tobacco industry niche marketing strategies. If policy makers want to ensure that the RYO option does not inhibit the fight to end the tobacco epidemic, especially amongst the disadvantaged, they need to reduce the price advantage, target additional health messages at (young) RYO users, and challenge niche marketing of RYO by the industry.

Citation

Li, L., Borland, R., Yong, H.H., Hitchman, S.C., Wakefield, M.A., Kasza, K.A., Fong, G.T. (2012). The association between exposure to point-of-sale anti-smoking warnings and smokers' interest in quitting and quit attempts: Findings from the International Tobacco Control Four Country Survey. Addiction, 107(2), 425-433.

Abstract

Aims: This study aimed to examine the associations between reported exposure to anti-smoking warnings at the point-of-sale (POS) and smokers’ interest in quitting and their subsequent quit attempts by comparing reactions in Australia where warnings are prominent to smokers in other countries.

Design: A prospective multi-country cohort design was employed.

Setting: Australia, Canada, the United Kingdom and the United States.

Participants: A total of 21 613 adult smokers who completed at least one of the seven waves (2002–08) of the International Tobacco Control Four Country Survey were included in the analysis.

Measurements: Reported exposure to POS anti-smoking warnings and smokers’ interest in quitting at the same wave and quit attempts over the following year.

Findings: Compared to smokers in Canada, the United Kingdom and the United States, Australian smokers reported higher levels of awareness of POS anti-smoking warnings, and this difference was consistent over the study period. Over waves in Australia (but not in the other three countries) there was a significantly positive association between reported exposure to POS anti-smoking warnings and interest in quitting [adjusted odds ratio = 1.139, 95% confidence interval (CI) 1.039–1.249, P < 0.01] and prospective quit attempts (adjusted odds ratio = 1.216, 95% CI 1.114–1.327, P < 0.001) when controlling for demographics, smoking characteristics, overall salience of anti-smoking information and awareness of anti-smoking material from channels other than POS.

Conclusions: Point-of-sale health warnings about tobacco are more prominent in Australia than the United Kingdom, the United States or Canada and appear to act as a prompt to quitting.

Citation

Ross, H., Blecher, E., Yan, L., Cummings, K.M. (2011, February). Predictors of what smokers say they will do in response to future price increases: Findings from the ITC Four Country Study. Poster presentation at the Society for Research on Nicotine and Tobacco Annual Meeting, Toronto, Ontario, Canada.

Abstract

Introduction: Given the impact of higher tobacco prices on smoking cessation, we studied the role of future cigarette prices on forming expectation about smoking behavior.

Methods: Using a random sample of 9,058 adult cigarette smokers from the United States, Canada, Australia, and the United Kingdom collected in 2002, we examined predictors of what smokers say they will do in response to a hypothetical 50% increase in the price they paid for their last cigarette purchase. A series of regression analyses examined factors associated with intentions that have a positive impact on health, that is, intentions to quit and/or to consume fewer cigarettes.

Results: The quit and/or smoke less intentions were more pronounced among those who lived in areas with higher average cigarette prices and who paid higher prices for their brand of choice during the last purchase. The magnitude of the price increase is a more important predictor of an intention to quit/smoke less compared with the average cigarette price.

Conclusions: The availability of alternative (cheaper) cigarette sources may reduce but would not eliminate the impact of higher prices/taxes on smokers’ expected behavior that has been linked to actual quit intentions and quitting in follow-up surveys.

Citation

Licht, A.S., Hyland, A., O’Connor, R.J., Chaloupka, F., Borland, R., Fong, G.T., Nargis, N., Cummings, K.M. (2011). How do price minimizing behaviors impact smoking cessation? Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(5), 1671-1691.

Abstract

This paper examines how price minimizing behaviors impact efforts to stop smoking. Data on 4,988 participants from the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey who were smokers at baseline (wave 5) and interviewed at a 1 year follow-up were used. We examined whether price minimizing behaviors at baseline predicted: (1) cessation, (2) quit attempts, and (3) successful quit attempts at one year follow up using multivariate logistic regression modeling. A subset analysis included 3,387 participants who were current smokers at waves 5 and 6 and were followed through wave 7 to explore effects of changing purchase patterns on cessation. Statistical tests for interaction were performed to examine the joint effect of SES and price/tax avoidance behaviors on cessation outcomes. Smokers who engaged in any price/tax avoidance behaviors were 28% less likely to report cessation. Persons using low/untaxed sources were less likely to quit at follow up, those purchasing cartons were less likely to make quit attempts and quit, and those using discount cigarettes were less likely to succeed, conditional on making attempts. Respondents who utilized multiple behaviors simultaneously were less likely to make quit attempts and to succeed. SES did not modify the effects of price minimizing behaviors on cessation outcomes. The data from this paper indicate that the availability of lower priced cigarette alternatives may attenuate public health efforts aimed at to reduce reducing smoking prevalence through price and tax increases among all SES groups.

Citation

Ross, H., Blecher, E., Yan, L., Cummings, K.M. (2011). Do cigarette prices motivate smokers to quit? New evidence from the ITC Survey. Addiction, 106(3), 609-619.

Abstract

Aims: To examine the importance of cigarette prices in influencing smoking cessation and the motivation to quit.

Design: We use longitudinal data from three waves of the International Tobacco Control Policy Evaluation Survey (ITC). The study contrasts smoking cessation and motivation to quit among US and Canadian smokers and evaluates how this relationship is modified by cigarette prices, nicotine dependence and health knowledge. Different price measures are used to understand how the ability to purchase cheaper cigarettes may reduce the influence of prices. Our first model examines whether cigarette prices affect motivation to quit smoking using Generalized Estimating Equations to predict cessation stage and a least squares model to predict the change in cessation stage. The second model evaluates quitting behavior over time. The probability of quitting is estimated with Generalized Estimating Equations and a transition model to account for the ‘left-truncation’ of the data.

Settings: US and Canada. Participants 4352 smokers at Wave 1, 2000 smokers completing all three waves. Measurements Motivation to quit, cigarette prices, nicotine dependence and health knowledge. Findings Smokers living in areas with higher cigarette prices are significantly more motivated to quit. There is limited evidence to suggest that price increases over time may also increase quit motivation. Higher cigarette prices increase the likelihood of actual quitting, with the caveat that results are statistically significant in one out of two models. Access to cheaper cigarette sources does not impede cessation although smokers would respond more aggressively (in terms of cessation) to price increases if cheaper cigarette sources were not available.

Conclusions: This research provides a unique opportunity to study smoking cessation among adult smokers and their response to cigarette prices in a market where they are able to avoid tax increases by purchasing cigarettes from cheaper sources. Higher cigarette prices appear to be associated with greater motivation to stop smoking, an effect which does not appear to be mitigated by cheaper cigarette sources. The paper supports the use of higher prices as a means of encouraging smoking cessation and motivation to quit.

Citation

Kasza, K.A., Hyland, A., Brown, A., Siahpush, M., Yong, H.H., McNeill, A., Li, L., Cummings, K.M. (2011). The effectiveness of tobacco marketing regulations on reducing smokers' exposure to advertising and promotion: Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(2), 321-340.

Abstract

Exposure to tobacco product marketing promotes the initiation, continuation, and reuptake of cigarette smoking and as a result the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) has called upon member Parties to enact comprehensive bans on tobacco advertising and promotion. This study examines the immediate and long term effectiveness of advertising restrictions enacted in different countries on exposure to different forms of product marketing, and examines differences in exposure across different socioeconomic status (SES) groups. Nationally representative data from the United Kingdom, Canada, Australia, and the United States, collected from adult smokers between 2002 and 2008 using the International Tobacco Control Four Country Survey (ITC-4), were used in this study (N = 21,615). In light of the specific marketing regulation changes that occurred during the course of this study period, changes in awareness of tobacco marketing via various channels were assessed for each country, and for different SES groups within countries. Tobacco marketing regulations, once implemented, were associated with significant reductions in smokers’ reported awareness of prosmoking cues, and the observed reductions were greatest immediately following the enactment of regulations. Changes in reported awareness were generally the same across different SES groups, although some exceptions were noted. While tobacco marketing regulations have been effective in reducing exposure to certain types of product marketing there still remain gaps, especially with regard to in-store marketing and price promotions.

Citation

Licht, A.S., Hyland, A., O’Connor, R.J., Chaloupka, F., Borland, R., Fong, G.T., Nargis, N., Cummings, K.M. (2011). Socio-economic variation in price minimizing behaviors: Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(1), 234-252.

Abstract

This paper examines how socio-economic status (SES) modifies how smokers adjust to changes in the price of tobacco products through utilization of multiple price minimizing techniques. Data come from the International Tobacco Control Policy Evaluation (ITC) Four Country Survey, nationally representative samples of adult smokers and includes respondents from Canada, the United States, the United Kingdom and Australia. Cross-sectional analyses were completed among 8,243 respondents (7,038 current smokers) from the survey wave conducted between October 2006 and February 2007. Analyses examined predictors of purchasing from low/untaxed sources, using discount cigarettes or roll-your-own (RYO) tobacco, purchasing cigarettes in cartons, and engaging in high levels of price and tax avoidance at last purchase. All analyses tested for interactions with SES and were weighted to account for changing and under-represented demographics. Relatively high levels of price and tax avoidance behaviors were present; 8% reported buying from low or untaxed source; 36% used discount or generic brands, 13.5% used RYO tobacco, 29% reported purchasing cartons, and 63% reported using at least one of these high price avoidance behaviors. Respondents categorized as having low SES were approximately 26% less likely to report using low or untaxed sources and 43% less likely to purchase tobacco by the carton. However, respondents with low SES were 85% more likely to report using discount brands/RYO compared to participants with higher SES. Overall, lower SES smokers were 25% more likely to engage in at least one or more tax avoidance behaviors compared to their higher SES counterparts. Price and tax avoidance behaviors are relatively common among smokers of all SES strata, but strategies differed with higher SES groups more likely to report traveling to a low-tax location to avoid paying higher prices, purchase duty free tobacco, and purchase by cartons instead of packs all of which were less commonly reported by low SES smokers. Because of the strategies lower SES respondents are more likely to use, reducing price differentials between discount and premium brands may have a greater impact on them, potentially increasing the likelihood of quitting.

Citation

O’Connor, R.J., Norton, K.J., Bansal-Travers, M., Mahoney, M.C., Cummings, K.M., Borland, R. (2011). US smokers' reactions to a brief trial of oral nicotine products. Harm Reduction Journal, 8(1), 1.

Abstract

Background: It has been suggested that cigarette smokers will switch to alternative oral nicotine delivery products to reduce their health risks if informed of the relative risk difference. However, it is important to assess how smokers are likely to use cigarette alternatives before making predictions about their potential to promote individual or population harm reduction.

Objectives: This study examines smokers’ interest in using a smokeless tobacco or a nicotine replacement product as a substitute for their cigarettes.

Methods: The study included 67 adult cigarette smokers, not currently interested in quitting, who were given an opportunity to sample four alternative oral nicotine products: 1) Camel Snus, 2) Marlboro Snus, 3) Stonewall dissolvable tobacco tablets, and 4) Commit nicotine lozenges. At visit 1, subjects were presented information about the relative benefits/risks of oral nicotine delivery compared to cigarettes. At visit 2, subjects were given a supply of each of the four products to sample at home for a week. At visit 3, subjects received a one-week supply of their preferred product to see if using such products reduced or eliminated cigarette use.

Results: After multiple product sampling, participants preferred the Commit lozenges over the three smokeless tobacco products (p = 0.011). Following the one week single-product trial experience, GEE models controlling for gender, age, level of education, baseline cigarettes use, and alternative product chosen, indicated a significant decline in cigarettes smoked per day across one week of single-product sampling (p < 0.01, from 11.8 to 8.7 cigarettes per day), but no change in alternative product use (approximately 4.5 units per day). Biomarkers of exposure showed no change in cotinine, but a 19% reduction in exhaled CO (p < 0.001).

Conclusions: Findings from this study show that smokers, who are currently unwilling to make a quit attempt, may be willing to use alternative products in the short term as a temporary substitute for smoking. However, this use is more likely to be for partial substitution (i.e. they will continue to smoke, albeit at a lower rate) rather than complete substitution. Of the various substitutes offered, smokers were more willing to use a nicotine replacement product over a tobacco-based product.

Citation

Balmford, J., Borland, R., Hammond, D., Cummings, K.M. (2011). Adherence to and reasons for premature discontinuation from stop-smoking medications: Data from the ITC Four-Country Survey. Nicotine & Tobacco Research, 13(2), 94-102.

Abstract

Introduction: Nicotine replacement therapies (NRTs) have been demonstrated to be effective in clinical trials but may have lower efficacy when purchased over-the-counter (OTC). Premature discontinuation and insufficient dosing have been offered as possible explanations. The aims are to (a) investigate the prevalence of and reasons for premature discontinuation of stop-smoking medications (including prescription only) and (b) how these differ by type, duration of use, and source (prescription or OTC).

Methods: The sample includes 1,219 smokers or recent quitters who had used medication in the last year (80.5% NRT, 19.5% prescription only). Data were from Waves 5 and 6 of the International Tobacco Control (ITC) Four-Country Survey.

Results: Most of the sample (69.1%) discontinued medication use prematurely. This was more common among NRT users (71.4%) than in users of bupropion and varenicline (59.6%). OTC NRT users were particularly likely to discontinue (76.3%). Relapse back to smoking was the most common reason for discontinuation of medication reported by 41.6% of respondents. Side effects (18.3%) and believing that the medication was no longer needed (17.1%) were also commonly reported. Of those who completed treatment, 37.9% achieved 6-month continuous abstinence compared with 15.6% who discontinued prematurely. Notably, 65.6% who discontinued because they believed the medication had worked were abstinent.

Conclusions: Premature discontinuation of stop-smoking medications is common but is not a plausible reason for poorer quit outcomes for most people. Encouraging persistence of medication use after relapse or in the face of minor side effects may help increase long-term cessation outcomes.

Citation

Borland, R., Cooper, J., McNeill, A., O’Connor, R.J., Cummings, K.M. (2011). Trends in beliefs about the harmfulness and use of stop-smoking medications and smokeless tobacco products among cigarettes smokers: Findings from the ITC Four-Country Survey. Harm Reduction Journal, 8(1), 21-31.

Abstract

Background: Evidence shows that smokers are generally misinformed about the relative harmfulness of nicotine, and smokeless forms of nicotine delivery in relation to smoked tobacco. This study explores changing trends in the beliefs about the harmfulness and use of stop smoking medications and smokeless tobacco in adult smokers in four countries where public education and access to alternative forms of nicotine is varied (Canada, the US, the UK and Australia).

Methods: Data are from seven waves of the ITC-4 country study conducted between 2002 and 2009 with adult smokers from Canada, the US, the UK and Australia. For the purposes of this study, data were collected from 21,207 current smokers. Using generalised estimating equations to control for multiple response sets, multivariate models were tested to look for main effects of country, and trends across time, controlling for demographic variables.

Results: Knowledge remained low in all countries, although UK smokers tended to be better informed. There was a small but significant improvement across time in the UK, but mixed effects in the other three countries. At the final wave, between 37.5% (US) and 61.4% (UK) reported that NRT is a lot less harmful than cigarettes. In Canada and the US, where smokeless tobacco is marketed, only around one in six believed some smokeless tobacco products could be less harmful than cigarettes.

Conclusions: Many smokers continue to be misinformed about the relative safety of nicotine and alternatives to smoked tobacco, especially in the US and Canada. Concerted efforts to educate UK smokers have probably improved their knowledge. Further research is required to assess whether misinformation deters smokers from appropriate use of alternative forms of nicotine.

Citation

Fix, B.V., O’Connor, R.J., Fong, G.T., Borland, R., Cummings, K.M., Hyland, A. (2011). Smokers' reactions to FDA regulation of tobacco products: Findings from the 2009 ITC United States Survey. BioMed Central Public Health, 11, 941-947.

Abstract

Background: On June 22, 2009, the US FDA was granted the authority to regulate tobacco products through the Family Smoking Prevention and Tobacco Control Act (FSPTCA). The intent is to improve public health through regulations on tobacco product marketing and tobacco products themselves. This manuscript reports baseline data on smokers’ attitudes and beliefs on specific issues relevant to the FSPTCA.

Method: Between November 2009 and January 2010, a telephone survey among a nationally representative sample of n = 678 smokers in the US was performed as part of the International Tobacco Control (ITC) United States Survey. Participants answered a battery of questions on their attitudes and beliefs about aspects of the FSPTCA.

Results: Most smokers were unaware of the new FDA tobacco regulations. Smokers indicated support for banning cigarette promotion and nearly a quarter supported requiring tobacco companies to sell cigarettes in plain packaging. Seventy two percent of smokers supported reducing nicotine levels to make cigarettes less addictive if nicotine was made easily available in non-cigarette form.

Conclusion: Most smokers were limited in their understanding of efforts to regulate tobacco products in general. Smokers were supportive of efforts to better inform the public about health risks, restrict advertising, and make tobacco products less addictive.

Citation

King, B., Hyland, A., Borland, R., McNeill, A., Cummings, K.M. (2011). Socioeconomic variation in the prevalence, introduction, retention, and removal of smoke-free policies among smokers: Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(2), 411-434.

Abstract

Introduction: Exposure to secondhand smoke causes premature death and disease in non-smokers and indoor smoke-free policies have become increasingly prevalent worldwide. Although socioeconomic disparities have been documented in tobacco use and cessation, the association between socioeconomic status (SES) and smoke-free policies is less well studied.

Methods: Data were obtained from the 2006 and 2007 Waves of the International Tobacco Control Four Country Survey (ITC-4), a prospective study of nationally representative samples of smokers in Canada, the United States, the United Kingdom, and Australia. Telephone interviews were administered to 8,245 current and former adult smokers from October 2006 to February 2007. Between September 2007 and February 2008, 5,866 respondents were re-interviewed. Self-reported education and annual household income were used to create SES tertiles. Outcomes included the presence, introduction, and removal of smoke-free policies in homes, worksites, bars, and restaurants.

Results: Smokers with high SES had increased odds of both having [OR: 1.54, 95% CI: 1.27–2.87] and introducing [OR: 1.49, 95% CI: 1.04–2.13] a total ban on smoking in the home compared to low SES smokers. Continuing smokers with high SES also had decreased odds of removing a total ban [OR: 0.44, 95% CI: 0.26–0.73]. No consistent association was observed between SES and the presence or introduction of bans in worksites, bars, or restaurants.

Conclusions: The presence, introduction, and retention of smoke-free homes increases with increasing SES, but no consistent socioeconomic variation exists in the presence or introduction of total smoking bans in worksites, bars, or restaurants. Opportunities exist to reduce SES disparities in smoke-free homes, while the lack of socioeconomic differences in public workplace, bar, and restaurant smoke-free policies suggest these measures are now equitably distributed in these four countries.

Citation

Hitchman, S.C., Fong, G.T., Zanna, M.P., Hyland, A., Bansal-Travers, M. (2011). Support and correlates of support for banning smoking in cars with children: Findings from the ITC Four Country Survey. European Journal of Public Health, 21(3), 360-365.

Abstract

Background: Since 2006, banning smoking in cars with children has become a rapidly growing tobacco control policy. However, to date, there have been few studies examining support and correlates of support for car smoking bans, and none of the existing studies have been international in nature. We conducted such a study among smokers in four countries.

Methods: 6716 adult current smokers from the 2007 Wave of the International Tobacco Control Four Country Survey, a nationally representative, longitudinal cohort telephone survey of smokers in the USA, Canada, UK and Australia. Controlling for demographics, heaviness of smoking, smoking health knowledge/beliefs and quit intentions, we compared support and correlates of support for banning smoking in cars with children across the four countries.

Results: The majority of smokers supported banning smoking in cars with children. Support was highest in Australia (83%), followed by the UK (75%) and Canada (74%); support was lower—but still high—in the USA (60%). Support was highest among smokers who: had stronger quit intentions, were lighter smokers, had lower education, had no children in the home, believed that cigarette smoke is dangerous to non-smokers and could cause asthma in children, and were concerned about modelling smoking to children.

Conclusions: These findings indicate that a majority of smokers in the four countries support banning smoking in cars with children, and lend support to banning smoking in cars with children. Additionally, they suggest that support may be increased by educating smokers about the dangers of cigarette smoke exposure.

Citation

Kennedy, R.D., Spafford, M., Parkinson, C., Fong, G.T. (2011). Knowledge about the relationship between smoking and blindness in Canada, the United States, the United Kingdom, and Australia: Results from the International Tobacco Control Four-Country Project. Optometry, 82(5), 310-317.

Abstract

Purpose: Smoking is causally associated with certain prevalent visually impairing eye diseases, including age-related macular degeneration and cataract. Studies have found that people are afraid of ‘‘going blind’’ and may be motivated to quit smoking if they know that vision loss is associated with smoking behavior.

Methods: A random-digit dialed telephone survey was used to measure health knowledge of adult smokers in Canada (n=2,765), the United States (n=3,178), the United Kingdom (n=2,767), and Australia (n=2,623) as part of the International Tobacco Control Four-Country Project.

Results: A low proportion of smokers from Canada (13.0%), the United States (9.5%), and the United Kingdom (9.7%) believed that smoking can cause blindness. In contrast, 47.2% of Australian smokers believed that smoking causes blindness. Australia was the only country during the sampling period to have national awareness campaigns about smoking and its effects on eye health.

Conclusion: These findings point to the need across countries to educate the public on this important consequence of smoking. There is an opportunity for the public health and eye health communities to work to educate the public about the impacts smoking has on eye health to improve quit rates and help discourage people from starting to smoke.

Citation

Seidenberg, A.B., Rees, V.W., Alpert, H.R., O’Connor, R.J., Connolly, G.N. (2011). Ignition strength of 25 international cigarette brands. Tobacco Control, 20(1), 77-80.

Abstract

Background: Cigarette-ignited fires are a leading cause of fire death and injury throughout the world and remain a global public health and safety problem. To reduce this harm, a small number of countries now require cigarettes to have reduced ignition propensity (RIP). It is not known if cigarette manufacturers are voluntarily introducing RIP cigarettes in other countries to help save lives.

Methods: Using the ASTM E2187-04 test method, per cent full length burn (%FLB) was measured for three popular brands from each of seven countries that did not have RIP legislation at the time of purchase. Results were compared with %FLB measurements from four popular US brands purchased in a jurisdiction (Vermont) with an RIP law. SRM 1082 reference cigarette was also tested to assure laboratory quality control.

Results: All cigarette brands purchased in countries not requiring fire safety standards for cigarettes exceeded 75% FLB. In contrast, none of the cigarette brands from the USA exceeded 10% FLB. The SRM 1082 reference cigarette demonstrated 5% FLB.

Conclusion: Cigarette ignition propensity can be greatly reduced through legislation that requires cigarette fire safety standards. RIP cigarettes have the potential to significantly decrease the number of fire deaths, injuries and destruction of property caused by cigarette-ignited fires. Appropriate standards should be applied in cigarette markets globally.

Citation

Thrasher, J.F., Quah, A.C.K., Dominick, G., Borland, R., Driezen, P., Awang, R., Omar, M., Hosking, W., Sirirassamee, B., Boado Martinez, M. (2011). Using cognitive interviewing and behavioral coding to determine measurement equivalence across linguistic and cultural groups: An example from the International Tobacco Control Policy Evaluation Project. Field Methods, 23(4), 439-460.

Abstract

This study examined and compared results from two questionnaire pretesting methods (i.e., behavioral coding and cognitive interviewing [CI]) to assess systematic measurement bias in survey questions for adult smokers across six countries (United States, Australia, Uruguay, Mexico, Malaysia, and Thailand). Protocol development and translation involved multiple bilingual partners in each linguistic/cultural group. The study was conducted with convenience samples of 20 adult smokers in each country. Behavioral coding and CI methods produced similar conclusions regarding measurement bias for some questions; however, CI was more likely to identify potential response errors than behavioral coding. Coordinated qualitative pretesting of survey questions (or postsurvey evaluation) is feasible across cultural groups and can provide important information on comprehension and comparability. The CI appears to be a more robust technique than behavioral coding, although combinations of the two might be even better.

Citation

Fix, B.V., Hyland, A., Rivard, C., McNeill, A., Fong, G.T., Borland, R., Hammond, D., Cummings, K.M. (2011). Usage patterns of stop smoking medications in Australia, Canada, the United Kingdom, and the United States: Findings from the 2006-2008 International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(1), 222-233.

Abstract

Varenicline is a new prescription stop smoking medication (SSM) that has been available in the United States since August 1, 2006, in the United Kingdom and other European Union countries since December 5, 2006, in Canada since April 12, 2007, and in Australia since January 1, 2008. There are few population-based studies that have examined use rates of varenicline and other stop smoking medications. We report data from the ITC Four Country survey conducted with smokers in the US, UK, Canada, and Australia who reported an attempt to quit smoking in past year in the 2006 survey (n = 4,022 participants), 2007 (n = 3,790 participants), and 2008 surveys (n = 2,735 participants) Respondents reported use of various stop smoking medications to quit smoking at each survey wave, along with demographic and smoker characteristics. The self-reported use of any stop smoking medication has increased significantly over the 3 year period in all 4 countries, with the sharpest increase occurring in the United States. Varenicline has become the second most used stop smoking medication, behind NRT, in all 4 countries since being introduced. Between 2006 and 2008, varenicline use rates increased from 0.4% to 21.7% in the US, 0.0% to 14.8% in Canada, 0.0% to 14.5% in Australia, and 0.0% to 4.4% in the UK. In contrast, use of NRT and bupropion remained constant in each country. Males and non-whites were significantly less likely to report using any SSM, while more educated smokers were significantly more likely to use any SSM, including varenicline. Our findings suggest that the introduction of varenicline led to an increase in the number of smokers who used evidence-based treatment during their quit attempts, rather than simply gaining market share at the expense of other medications. From a public health perspective, messages regarding increased success rates among medication users and the relative safety of stop smoking medications should be disseminated widely so as to reach all smokers of all socioeconomic classifications equally.

Citation

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

Abstract

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

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

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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