Citation

van Mourik, D.J.A., Nagelhout, G.E., de Vries, H., van den Putte, B., Cummings, K.M., Borland, R., Fong, G.T., Willemsen, M.C. (2020). Quasi-experimentally examining the impact of introducing tobacco pictorial health warnings: Findings from the International Tobacco Control (ITC) 4C and Netherlands surveys in the Netherlands, Australia, Canada, United Kingdom, and the United States. Drug and Alcohol Dependence, 207, 107818.

Abstract

Background: Tobacco control policies and other denormalization strategies may reduce tobacco use by stigmatizing smoking. This raises an important question: Does perceived smoking-related stigma contribute to a smoker's decision to quit? The aim of this study was to evaluate if perceived smoking-related stigma was associated with smoking cessation outcomes among smokers in Mexico and Uruguay.

Methods: We analyzed prospective data from a panel of adult smokers who participated in the 2008-2012 administrations of the International Tobacco Control Policy Evaluation Surveys in Mexico and Uruguay. We defined two analytic samples of participants: the quit behavior sample (n=3896 Mexico; n=1525 Uruguay) and the relapse sample (n=596 Mexico). Generalized estimating equations were used to evaluate if different aspects of perceived stigma (i.e., discomfort, marginalization, and negative stereotype) at baseline were associated with smoking cessation outcomes at follow-up.

Results: We found that perceived smoking-related stigma was associated with a higher likelihood of making a quit attempt in Uruguay, but with a lower likelihood of successful quitting in Mexico.

Conclusions: This study suggests that perceived smoking-related stigma may be associated with more quit attempts, but less successful quitting among smokers. It is possible that once stigma is internalized by smokers, it may function as a damaging force. Future studies should evaluate the influence of internalized stigma on smoking behavior.

Implications: While perceived smoking-related stigma may prompt smokers to quit smoking, smoking stigma may also serve as a damaging force for some individuals, making quitting more difficult. This study found that perceived smoking-related stigma was associated with a higher likelihood of making a quit attempt in Uruguay, but with a lower likelihood of successful quitting in Mexico.

Citation

Nargis, N., Yong, H.H., Driezen, P., Mbulo, L., Zhao, L., Fong, G.T., Thompson, M.E., Borland, R., Palipudi, K.M., Giovino, G.A., Thrasher, J.F., Siahpush, M. (2019). Socioeconomic patterns of smoking cessation behavior in low and middle-income countries: Emerging evidence from the Global Adult Tobacco Surveys and International Tobacco Control Surveys. PLOS One, 14(9), e0220223.

Abstract

Introduction: Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs.

Methods: Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008–2011) and the International Tobacco Control Surveys (2009–2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country.

Results: Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10).

Conclusion: Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes.

Citation

Curti, D., Shang, C., Chaloupka, F.J., Fong, G.T. (2019). Tobacco taxation, illegal cigarette supply and geography: Findings from the ITC Uruguay Survey. Tobacco Control, 28(Suppl 1), S53-S60.

Abstract

Background: In Uruguay, real tobacco taxes increased significantly during 2005–2010 and 2014–2017 and decreased during 2010–2014. The effects of these tax changes on illegal and legal cigarette usage differed significantly when we compared cities in the middle and south of the country with cities on the border.

Objective: This paper analyses whether supply side factors such as geographical location, distribution networks and the effectiveness of tobacco control play a significant role in sales and use of illegal cigarettes when tobacco taxes change, particularly given the price gap between legal and lower-priced illegal cigarettes.

Methods: Using the International Tobacco Control Evaluation Project Uruguay Survey data (2008, 2010, 2012 and 2014), choices among illegal, legal and roll-your-own cigarettes are estimated as a function of smokers’ geographical location, an indicator of illegal cigarette supply, and controlling for socioeconomic and demographic variables. Smoking behaviours in Montevideo, Durazno and Maldonado were compared with those in two border cities, Salto and Rivera, where illegal cigarette prevalence may differ.

Findings: An increase in taxes on manufactured legal and roll-your-own cigarettes increased the odds that smokers in cities near the borders and women switched down to illegal cigarettes. City geographical location, controls effectiveness and distribution networks may play a significant role in accessibility of illegal cigarettes. To improve the effectiveness of increased taxes and prices in reducing smoking, policymakers may consider specific policies intended to reduce access to illegal cigarettes, such as ratification and effective implementation of the Protocol to Eliminate Illicit Trade in Tobacco Products of WHO.

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

Gravely, S., Driezen, P., Ouimet, J., Quah, A.C.K., Cummings, K.M., Thompson, M.E., Boudreau, C., Hammond, D., McNeill, A., Borland, R., Thrasher, J.F., Edwards, R., Omar, M., Hitchman, S., Yong, H-H., Barrientos-Gutierrez, T., Willemsen, M.C., Bianco, E., Boado, M., Goma, F., Seo, H.G., Nargis, N., Jiang, Y., Perez, C., & Fong, G.T. (2019). Prevalence of awareness, ever-use, and current use of nicotine vaping products (NVPs) among adult current smokers and ex-smokers in 14 countries with differing regulations on sales and marketing of NVPs: Cross-sectional findings from the ITC Project. Addiction, 114(6), 1060-1073.

Abstract

Aims: This paper presents updated prevalence estimates of awareness, ever‐use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing.

Design, setting, participants and measurements: A cross‐sectional analysis of adult (≥18 years) current smokers and ex‐smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013 to 2017. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs): not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs): not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand (NZ); (3) less restrictive policies (LRPs): legal to be sold and marketed with regulations: England, Netherlands, Republic of Korea, United States (US); (4) no regulatory policies (NRPs): Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country‐specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily vs. non‐daily).

Findings: NVP awareness and use were lowest in NRP countries. Generally, ever‐ and current use of NVPs were lower in MRP countries [ever‐use: 7.1% to 48.9%; current use: 0.3% to 3.5%] relative to LRP countries [ever‐use: 38.9% to 66.6%; current use: 5.5% to 17.2%] and RP countries [ever‐use: 10.0% to 62.4%; current use: 1.4% to 15.5%]. NVP use was highest among high income countries, followed by upper‐middle income countries, and then by lower‐middle income countries.

Conclusions: With a few exceptions, awareness and use of nicotine vaping products (NVPs) varies by the strength of national regulations governing NVP sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in NVPs in these countries where smoking populations are predominantly poorer. The higher awareness and use of NVPs in high income countries with moderately (e.g., Canada, NZ) and less (e.g., England, US) restrictive policies, is likely due to the greater availability and affordability of NVPs.

Citation

Lozano, P., Thrasher, J.F., Forthofer, L., Hardin, J., Reynales-Shigematsu, L.M., Santillian, E., Fleischer, N.L. (2019). The role of social norms and socioeconomic status in smoking-related stigma among smokers in Mexico and Uruguay. Critical Public Health, 29(2), 215-27.

Abstract

Policies that promote the social unacceptability of smoking may also result in smoking-related stigma. The aim of this study is to evaluate how norms against smoking and socioeconomic status (SES) are associated with stigma among smokers. We used data from a panel of adult smokers who participated in the 2008–2012 administrations of the International Tobacco Control Policy Evaluation Survey in Mexico (n = 6670 observations) and Uruguay (n = 3296 observations). Generalized estimating equations were used to account for correlations in the outcomes over time within individuals. We evaluated if injunctive smoking norms (i.e. significant other norms and societal norms), descriptive smoking norms (i.e. number of smoking friends), and two markers of SES (i.e. education and income) were associated with different aspects of smoking-related stigma (i.e. feeling uncomfortable, negative stereotype of smokers, and perceived marginalization). We found that stronger anti-smoking injunctive norms were associated with higher levels of all indicators of perceived stigma in Mexico and Uruguay. Having fewer smoking friends was associated with feeling uncomfortable and perceived marginalization in Mexico. Higher income and education were associated with a stronger negative stereotype of smokers in Mexico. Lower income and education were associated with a stronger negative stereotype of smokers in Uruguay. Study results suggest that factors that drive the social unacceptability of tobacco may stigmatize smokers, although further research is needed to determine whether policy-promoted stigmatization produces undesirable outcomes (e.g. lower cessation rates).

Citation

Shang, C., Myung Lee, H., Chaloupka, F., Fong, G.T., Thompson, M.E., O’Connor, R.J. (2019). Association between tax structure and cigarette consumption: findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 28(Suppl 1), S31-S36.

Abstract

Background: Recent studies show that greater price variability and more opportunities for tax avoidance are associated with tax structures that depart from a specific uniform one. These findings indicate that tax structures other than a specific uniform one may lead to more cigarette consumption.

Objective: This paper aims to examine how cigarette tax structure is associated with cigarette consumption.

Methods: We used survey data taken from the International Tobacco Control Policy Evaluation Project in 17 countries to conduct the analysis. Self-reported cigarette consumption was aggregated to average measures for each surveyed country and wave. The effect of tax structures on cigarette consumption was estimated using generalised estimating equations after adjusting for sociodemographic characteristics, average taxes and year fixed effects.

Findings: Our study provides important empirical evidence of a relationship between tax structure and cigarette consumption. We find that a change from a specific to an ad valorem structure is associated with a 6%–11% higher cigarette consumption. In addition, a change from uniform to tiered structure is associated with a 34%–65% higher cigarette consumption. The results are consistent with existing evidence and suggest that a uniform and specific tax structure is the most effective tax structure for reducing tobacco consumption.

Citation

Gravely, S., Fong, G.T., Driezen, P., McNally, M., Thrasher, J.F., Thompson, M.E., Boado, M., Bianco, E., Borland, R., Hammond, D. (2016). The impact of the 2009/2010 enhancement of cigarette health warning labels in Uruguay: Longitudinal findings from the International Tobacco Control (ITC) Uruguay Survey. Tobacco Control, 25, 89-95.

Abstract

Background: Framework Convention on Tobacco Control (FCTC) Article 11 Guidelines recommend that health warning labels (HWLs) should occupy at least 50% of the package, but the tobacco industry claims that increasing the size would not lead to further benefits. This article reports the first population study to examine the impact of increasing HWL size above 50%. We tested the hypothesis that the 2009/2010 enhancement of the HWLs in Uruguay would be associated with higher levels of effectiveness.

Methods: Data were drawn from a cohort of adult smokers (≥18 years) participating in the International Tobacco Control (ITC) Uruguay Survey. The probability sample cohort was representative of adult smokers in five cities. The surveys included key indicators of HWL effectiveness. Data were collected in 2008/09 (prepolicy: wave 2) and 2010/11 (postpolicy: wave 3).

Results: Overall, 1746 smokers participated in the study at wave 2 (n=1379) and wave 3 (n=1411). Following the 2009/2010 HWL changes in Uruguay (from 50% to 80% in size), all indicators of HWL effectiveness increased significantly (noticing HWLs: OR=1.44, p=0.015; reading HWLs: OR=1.42, p=0.002; impact of HWLs on thinking about risks of smoking: OR=1.66, p<0.001; HWLs increasing thinking about quitting: OR=1.76, p<0.001; avoiding looking at the HWLs: OR=2.35, p<0.001; and reports that HWLs stopped smokers from having a cigarette ‘many times’: OR=3.42, p<0.001).

Conclusions: The 2009/2010 changes to HWLs in Uruguay, including a substantial increment in size, led to increases of key HWL indicators, thus supporting the conclusion that enhancing HWLs beyond minimum guideline recommendations can lead to even higher levels of effectiveness.

Citation

Curti, D., Shang, C., Ridgeway, W., Chaloupka, F., Fong, G.T. (2015). The use of legal, illegal, and roll-your-own cigarettes to increasing tobacco excise taxes and comprehensive tobacco control policies: Findings from the ITC Uruguay Survey. Tobacco Control, 24(Suppl 3), iii17-iii24

Abstract

Background: Little research has been done to examine whether smokers switch to illegal or roll-yourown (RYO) cigarettes in response to a change in their relative price.

Objective: This paper explores how relative prices between three cigarette forms (manufactured legal, manufactured illegal and RYO cigarettes) are associated with the choice of one form over another after controlling for covariates, including sociodemographic characteristics, smokers' exposure to antismoking messaging, health warning labels and tobacco marketing.

Methods: Generalised estimating equations were employed to analyse the association between the price ratio of two different cigarette forms and the usage of one form over the other.

Findings: A 10% increase in the relative price ratio of legal to RYO cigarettes is associated with a 4.6% increase in the probability of consuming RYO cigarettes over manufactured legal cigarettes (p≤0.05). In addition, more exposure to antismoking messaging is associated with a lower odds of choosing RYO cigarettes over manufactured legal cigarettes (p≤0.05). Non-significant associations exist between the manufactured illegal to legal cigarette price ratios and choosing manufactured illegal cigarettes, suggesting that smokers do not switch to manufactured illegal cigarettes as prices of legal ones increase. However, these non-significant findings may be due to lack of variation in the price ratio measures. To improve the effectiveness of increased taxes and prices in reducing smoking, policymakers need to narrow price variability in the tobacco market. Moreover, increasing antismoking messaging reduces tax avoidance in the form of switching to cheaper RYO cigarettes in Uruguay.

Citation

Boado Martinez, M., Rodriguez Sendoya, D., Fong, G.T., Bianco, E. (2014). Impacto de las políticas de control del tabaco en los fumadores de Uruguay. Tendencias en Medicina, XXII(45), 43-52.

Abstract

This research presents the conceptual framework and the results of ITC PES (International Tobacco Control Project Evaluation Survey) evaluations. The project conducts surveys in 22 countires, and has been evalutating the impact of tobacco control policies in Uruguay since 2006 (n=887 to 1411) on beliefs, propensity to stop smoking and quitting smoking.

Citation

Shang, C., Chaloupka, F., Zahra, N., Fong, G.T. (2014). The distribution of cigarette prices under different tax structures: Findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 23(Suppl 1), i23-i29.

Abstract

Background: The distribution of cigarette prices has rarely been studied and compared under different tax structures. Descriptive evidence on price distributions by countries can shed light on opportunities for tax avoidance and brand switching under different tobacco tax structures, which could impact the effectiveness of increased taxation in reducing smoking.

Objective: This paper aims to describe the distribution of cigarette prices by countries and to compare these distributions based on the tobacco tax structure in these countries.

Methods: We employed data for 16 countries taken from the International Tobacco Control Policy Evaluation Project to construct survey-derived cigarette prices for each country. Self-reported prices were weighted by cigarette consumption and described using a comprehensive set of statistics. We then compared these statistics for cigarette prices under different tax structures. In particular, countries of similar income levels and countries that impose similar total excise taxes using different tax structures were paired and compared in mean and variance using a two-sample comparison test.

Findings: Our investigation illustrates that, compared with specific uniform taxation, other tax structures, such as ad valorem uniform taxation, mixed (a tax system using ad valorem and specific taxes) uniform taxation, and tiered tax structures of specific, ad valorem and mixed taxation tend to have price distributions with greater variability. Countries that rely heavily on ad valorem and tiered taxes also tend to have greater price variability around the median. Among mixed taxation systems, countries that rely more heavily on the ad valorem component tend to have greater price variability than countries that rely more heavily on the specific component. In countries with tiered tax systems, cigarette prices are skewed more towards lower prices than are prices under uniform tax systems. The analyses presented here demonstrate that more opportunities exist for tax avoidance and brand switching when the tax structure departs from a uniform specific tax.

Citation

Thrasher, J.F., Naveli Abad-Vivero, E., Sebrie, E.M., Barrientos-Gutierrez, I., Boado Martinez, M., Yong, H.H., Arillo-Santillán, E., Bianco, E. (2013). Tobacco smoke exposure in public places and workplaces after smoke-free policy implementation: A longitudinal analysis of smoker cohorts in Mexico and Uruguay. Health & Policy Planning, 28(8), 789-798.

Abstract

Objective: To determine the prevalence, correlates and changes in secondhand smoke (SHS) exposure over the period after comprehensive smoke-free policy implementation in two Latin American countries.

Methods: Data were analysed from population-based representative samples of adult smokers and recent quitters from the 2008 and 2010 waves of the International Tobacco Control Policy Evaluation Survey in Mexico (n = 1766 and 1840, respectively) and Uruguay (n = 1379 and 1411, respectively). Prevalence of SHS exposure was estimated for regulated venues, and generalized estimating equations were used to determine correlates of SHS exposure.

Results: Workplace SHS exposure in the last month was similar within and across countries (range: Mexico 20–25%; Uruguay 14–29%). At the most recent restaurant visit, SHS exposure was lower where comprehensive smoke-free policies were implemented (range: Uruguay 6–9%; Mexico City 5–7%) compared with Mexican cities with weaker policies, where exposure remained higher but decreased over time (32–17%). At the most recent bar visit, SHS exposure was common (range: Uruguay 8–36%; Mexico City 23–31%), although highest in jurisdictions with weaker policies (range in other Mexican cities: 74–86%). In Uruguay, males were more likely than females to be exposed to SHS across venues, as were younger compared with older smokers in Mexico.

Conclusions: Comprehensive smoke-free policies are more effective than weaker policies, although compliance in Mexico and Uruguay is not as high as desired.

Citation

Borland, R., Li, L., Driezen, P., Wilson, N., Hammond, D., Thompson, M.E., Fong, G.T., Mons, U., Willemsen, M.C., McNeill, A., Thrasher, J.F., Cummings, K.M. (2012). Cessation assistance reported by smokers in 15 countries participating in the International Tobacco Control (ITC) Policy Evaluation Survey. Addiction, 107(1), 197-205.

Abstract

Aims: To describe some of the variability across the world in levels of quit smoking attempts and use of various forms of cessation support.

Design: Use of the International Tobacco Control Policy Evaluation Project surveys of smokers, using the 2007 survey wave (or later, where necessary).

Settings: Australia, Canada, China, France, Germany, Ireland, Malaysia, Mexico, the Netherlands, New Zealand, South Korea, Thailand, United Kingdom, Uruguay and United States.

Participants: Samples of smokers from 15 countries.

Measurements: Self-report on use of cessation aids and on visits to health professionals and provision of cessation advice during the visits.

Findings: Prevalence of quit attempts in the last year varied from less than 20% to more than 50% across countries. Similarly, smokers varied greatly in reporting visiting health professionals in the last year (<20% to over 70%), and among those who did, provision of advice to quit also varied greatly. There was also marked variability in the levels and types of help reported. Use of medication was generally more common than use of behavioural support, except where medications are not readily available.

Conclusions: There is wide variation across countries in rates of attempts to stop smoking and use of assistance with higher overall use of medication than behavioural support. There is also wide variation in the provision of brief advice to stop by health professionals.

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

Thrasher, J.F., Villalobos, V., Szklo, A.S., Fong, G.T., Perez, C., Sebrie, E.M., Sansone, N., Figueiredo, V., Boado Martinez, M., Arillo-Santillán, E., Bianco, E. (2010). Assessing the impact of cigarette package health warning labels: A cross-country comparison in Brazil, Uruguay and Mexico. Salud Publica de Mexico, 52(Suppl 2), S206-215.

Abstract

Objective: To assess the impact of different health warning labels (HWL).

Material and Methods: Data from the International Tobacco Control Survey (ITC Survey) were analyzed from adult smokers in Brazil, Uruguay and Mexico, each of which used a different HWL strategy (pictures of human suffering and diseased organs; abstract pictorial representations of risk; and text-only messages, respectively). Main outcomes were HWL salience and cognitive impact.

Results: HWLs in Uruguay (which was the only country with a HWL on the front of the package) had higher salience than either Brazilian or Mexican packs. People at higher levels of educational attainment in Mexico were more likely to read the text-only HWLs whereas education was unassociated with salience in Brazil or Uruguay. Brazilian HWLs had greater cognitive impacts than HWLs in either Uruguay or Mexico. HWLs in Uruguay generated lower cognitive impacts than the text-only HWLs in Mexico. In Brazil, cognitive impacts were strongest among smokers with low educational attainment.

Conclusions: This study suggests that HWLs have the most impact when they are prominent (i.e., front and back of the package) and include emotionally engaging imagery that illustrates negative bodily impacts or human suffering due to smoking.

Citation

Thrasher, J.F., Boado Martinez, M., Sebrie, E.M., Bianco, E. (2009). Smoke-free policies and the social acceptability of smoking in Uruguay and Mexico: Findings from the International Tobacco Control Policy Evaluation Project. Nicotine & Tobacco Research, 11(6), 591-599.

Abstract

Introduction: Little research has been conducted to determine the psychosocial and behavioral impacts of smoke-free policies in middle-income countries.

Methods: Cross-sectional data were analyzed from the 2006 waves of the International Tobacco Control Policy Evaluation. Survey comparing adult smokers in Mexico (n = 1,080), where smoke-free legislation at that time was weak, and Uruguay (n = 1,002), where comprehensive smoke-free legislation was implemented. Analyses aimed to determine whether exposure to smoke-free policies and perceived antismoking social norms were associated with smokers' receiving cues about the bothersome nature of secondhand smoke (SHS), with smokers' reactance against such cues, and with smokers' level of support for smoke-free policies in different venues.

Results: In bivariate analyses, Uruguayan smokers were more likely than Mexican smokers to experience verbal anti-SHS cues, lower reactance against anti-SHS cues, stronger antismoking societal norms, and stronger support for 100% smoke-free policies in enclosed workplaces, restaurants, and bars. In multivariate models for both countries, the strength of voluntary smoke-free policies at home was independently associated with support for smoke-free policies across all venues queried, except for in bars among Uruguayans. Perceived strength of familial antismoking norms was consistently associated with all indicators of the social acceptability of smoking in Uruguay but only with the frequency of receiving anti-SHS verbal cues in Mexico.

Discussion: These results are generally consistent with previous research indicating that comprehensive smoke-free policies are likely to increase the social unacceptability of smoking and that resistance against such policies is likely to diminish once such policies are in place.

Citation

Fong, G.T., Hammond, D., Hitchman, S.C. (2009). The impact of pictures on the effectiveness of tobacco warnings. Bulletin of the World Health Organization, 87(8), 640-643.

Abstract

Cigarette packages in most countries carry a health warning; however, the position, size and general strength of these warnings vary considerably across jurisdictions.1 Article 11 of the WHO Framework Convention on Tobacco Control (FCTC) and the Article 11 Guidelines adopted at the Third Conference of the Parties in November 2008 have put the spotlight on the inclusion of pictures on tobacco package health warnings. Beginning with Canada in 2001, 28 countries have introduced pictorial warnings and many other countries are in the process of drafting regulations for pictorial warnings (Box 1 and Box 2). This paper presents a brief review of the research studies that support pictorial warnings, reviewed in greater depth by Hammond and by the International Tobacco Control (ITC) Policy Evaluation Project.