Citation

Roberson, A., Cummings, K.M., Reid, J.L., Burkhalter, R., Gravely, S., East, K.A., Thrasher, J.F., Hammond, D. (2023). Trends in e cigarette and tobacco cigarette purchasing behaviors by youth in the United States, Canada, and England, 2017 2022. International Journal of Public Health , [Published online Nov 14, doi: 10.3389/ijph.2023.1606234].

Abstract

Objectives: This paper describes trends in youth e-cigarette (EC) and tobacco cigarette (TC) purchasing behaviors in Canada, England, and the United States (US) in relationship to changing minimum legal age (MLA)

Methods: Data are from eight cross-sectional online surveys among national samples of 16 to 19 year olds in Canada, England, and the US conducted from 2017 to 2022 (N = 104,467). Average wave percentage change in EC and TC purchasing prevalence and purchase locations were estimated using Joinpoint regressions.

Results: EC purchasing increased between 2017 and 2022, although the pattern of change differed by country. EC purchasing plateaued in 2019 for the US and in 2020 for Canada, while increasing through 2022 for England. TC purchasing declined sharply in the US, with purchasing from traditional retail locations declining, while purchasing from social sources increased. Vape shops were the most common location for EC purchasing, although declining in England and the US.

Conclusion: Trends in EC and TC purchasing trends in the US are consistent with the expected impact of the federal MLA law increasing the legal age to 21 years in December 2019.

Citation

Hammond, D., Reid, J.L. (2023). Trends in vaping and nicotine product use among youth in Canada, England and the USA between 2017 and 2022: evidence to inform policy. Tobacco Control, [Published online Nov 8, doi: 10.1136/tc-2023-058241].

Abstract

Background: Preventing uptake of nicotine products among youth remains a central objective of tobacco control policy. Comparing trends in the use of nicotine across countries provides an opportunity to identify emergent product trends and to evaluate ‘natural experiments’ in policies.

Methods: Repeat cross-sectional data were analysed from eight waves of the International Tobacco Control Youth Tobacco and Vaping Survey, conducted between 2017 and 2022. Non-probability samples of youth aged 16–19 years in Canada, England and the USA (N=104?473) completed online surveys including measures on vaping, smoking and use of other nicotine products. This paper summarises findings across the 5-year period of the study, as part of a comprehensive report on key indicators of youth vaping in the three countries.

Results: The youth nicotine market has rapidly evolved across the three countries, with different patterns of combustible and non-combustible product use in Canada, the USA and England. These changes are primarily attributable to trends in youth vaping: following declines during the initial COVID-19 pandemic period, by 2022, vaping prevalence neared pre-pandemic levels in the USA and Canada, and reached record highs in England. Notable shifts also occurred in the types of vaping products used by youth, including increased use of disposable, nicotine salt-based products. Additional findings are reported on a range of policy-relevant indicators, including for vaping products, promotions and purchasing.

Conclusions: Patterns of nicotine use among youth have rapidly evolved in recent years due to the proliferation of nicotine products, the COVID-19 pandemic and the emerging impact of policy measures.

Citation

Shimul S., Ghulam Hussain A.K.M., Nargis, N. (2023). Estimating own-price and cross-price elasticity of cigarette consumption by price tiers in Bangladesh. Tobacco Control. [Epub ahead of print: 30 October 2023]. doi: 10.1136/tc-2022-057679

Abstract

Objectives: The overall price elasticity of cigarette consumption in Bangladesh has been studied extensively. The estimates of price elasticity by price tiers are not available in the existing literature.

Methods: Using cohort data of nearly 6000 individuals from the International Tobacco Control Bangladesh survey, this study estimated the own-price and cross-price elasticity and income elasticity of cigarette demand by price tiers in Bangladesh. The elasticity was estimated in three stages of consumer decisions: whether to smoke, which brand to smoke and finally, how many cigarettes to smoke per day. The decision to smoke cigarettes and the choice of cigarette brands were modelled using instrumental variable probability regression. The cigarette consumption per day was modelled using seemingly unrelated regression.

Results: The price elasticity of cigarette smoking prevalence with respect to the price of low-price cigarettes is −0.0487. The total elasticity for low-price cigarette consumption with respect to its own price is −0.1678. The own-price elasticity of smoking intensity of high-priced brands is −0.2512. The cross-price elasticity of low-price cigarette consumption with respect to high-price brand prices is 0.2643. The income elasticity of smoking prevalence overall is 0.0564. The income elasticity of daily consumption of low-price cigarettes is −0.1934 and for high-price cigarettes, it is 1.4044. The total income elasticity is 1.4608 for high-price cigarettes.

Conclusion: A cigarette tax policy that raises the prices of both low-price and high-price brands—but increases prices in the low-price tier at a faster rate than in the high-price tier and increases prices of all brands at a pace faster than income growth—can effectively reduce cigarette consumption in Bangladesh.

Citation

King B, Borland R, Le Grande M, Diaz D, O’Connor R, et al. (2023) Associations between smokers’ knowledge of causes of smoking harm and related beliefs and behaviors: Findings from the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. PLOS ONE 18(10): e0292856. https://doi.org/10.1371/journal.pone.0292856

Abstract

Background: Most smokers know that smoking is harmful to health, but less is known about their understanding of what causes the harms. The primary aim was to examine smokers’ perceptions of the relative contributions to smoking-related morbidity from combustion products, nicotine, other substances present in unburned tobacco, and additives. A secondary aim was to evaluate the association of these perceptions with nicotine vaping product use intentions, and quitting motivation/intentions.

Methods: Participants were current smokers and recent ex-smokers from Australia, Canada, England and the United States (N = 12,904, including 8511 daily smokers), surveyed in the 2018 International Tobacco Control Four Country Smoking and Vaping Survey. Respondents reported on how much they thought combustion products, nicotine, chemicals in the tobacco and additives in cigarettes contribute to smoking-related morbidity (none/very little; some but less than half; around half; more than half; all or nearly all of it; don’t know).

Results: Overall, 4% of participants provided estimates for all four component causes that fell within the ranges classified correct, with younger respondents and those from England most likely to be correct. Respondents who rated combustion as clearly more important than nicotine in causing harm (25%) were the least likely to be smoking daily and more likely to have quit and/or to be vaping. Among daily smokers, all four cause estimates were independently related to overall health worry and extent of wanting to quit, but the relative rating of combustion compared to nicotine did not add to prediction. Those who answered ‘don’t know’ to the sources of harm questions and those suggesting very little harm were consistently least interested in quitting.

Conclusions: Most smokers’ knowledge of specific causes of harm is currently inadequate and could impact their informed decision-making ability.

Citation

Nguyen, T.N.P., Love, J., Hunsberger, M., Tran, T.P.T., Nguyen, T.L., Phan, T.H., Luong, N.K., Minh, H.V., Ng, N. (2023). Individual-, social- and policy- factors associated with smoking cessation among adult male cigarette smokers in Hanoi, Vietnam: a longitudinal study. BMC Public Health, 23, 1883. doi: 10.1186/s12889-023-16781-7.

Abstract

Background: Nearly one-in-two Vietnamese men smoke cigarettes placing them among the highest tobacco consumers in the world. Despite the need for smoking cessation to curb the burden of tobacco-related diseases in Vietnam, this rate remains at less than 30%. Therefore, this study examines individual-, social- and policy factors associated with smoking cessation among adult male smokers in Vietnam.

Methods: We established a longitudinal International Tobacco Control study of male smokers in Hanoi, Vietnam, in September 2018. This paper analyses 1525 men who participated in baseline and one-year follow-up. We applied a weighted multivariable logistic regression to examine the association between smoking cessation and individual-, social- and policy predictors.

Results: At follow-up, 14.8% of participants had quit smoking for at least 30 consecutive days during the last year. Among the persistent smokers, 56.6% expressed intention to quit smoking. Factors associated with smoking cessation included a lower number of cigarettes smoked per day (aOR?=?0.96, 95% CI: 0.94, 0.99) and having several attempts to quit smoking (aOR?=?2.16, 95% CI 1.13, 4.12). Intention to quit smoking was associated with multiple quit attempts, a chronic condition diagnosis, more tobacco-related knowledge, greater self-efficacy, and more worries about their future health. The perceived impact of smoke-free policy and health warning labels were positively associated with intention to quit at any stage.

Conclusions: Interventions aimed at increasing smoking cessation should focus on all aspects of individual, social, and policy factors. Persistent smokers are more motivated to quit if they have made multiple quit attempts, more self-efficacy of quitting and worried about their future health, indicating that increasing smokers’ beliefs and knowledge may be important for behavioural change. Health warning labels and tobacco taxation policies should be maintained and promoted as they are perceived to be particularly useful for persistent smokers’ intention to quit.

Citation

Goulette, M. R., Gravely, S., Xu, S. S., Meng, G., Quah, A. C., Lee, S. Cho, S., Kim, Y., Lim, S., Bansal-Travers, M., Hyland, A., Fong, G.T., & Seo, H.G. (2023). Perceptions of harmfulness of heated tobacco and nicotine vaping products compared to cigarettes, and the association of advertising exposure on harm perceptions among adults who smoke in South Korea: Cross-sectional findings from the 2020 ITC Korea Survey. Tobacco Induced Diseases, 21(September), 121. doi: 10.18332/tid/170252.

Abstract

Introduction: Heated tobacco products (HTPs) and nicotine vaping products (NVPs) both are legal consumer products in the Republic of Korea. Little is known about perceptions of harmfulness of HTPs and NVPs relative to cigarettes in South Korea among adults who smoke, and how exposure to marketing may be associated with harmfulness perceptions.

Methods: This study used data from the 2020 International Tobacco Control (ITC) Korea Survey, and included 3713 adult (aged 19 years) cigarette smokers who were: 1) exclusive smokers (n=1845); 2) dual HTP + cigarette consumers (n=1130); 3) dual NVP + cigarette consumers (n=224); and 4) triple consumers (all three products, n=514). Weighted multinomial regression models were conducted to estimate smokers’ perceptions of harmfulness of HTPs and NVPs compared to cigarettes, NVPs to HTPs, and self-reported exposure to HTP/NVP advertising. Analyses compared the perceptions of harmfulness between the four different consumer groups, and tested whether exposure to HTP/NVP advertising was associated with perceptions of lower relative harm.

Results: Among all respondents, 27.5% believe that HTPs are less harmful than cigarettes and 23.4% believe that NVPs are less harmful than cigarettes. Exclusive cigarettes smokers were significantly less likely to perceive that HTPs and NVPs are less harmful than cigarettes compared to dual HTP + cigarette consumers, dual NVP + cigarette consumers, and triple consumers (all p<0.001). Half of respondents perceive NVPs as equally harmful as HTPs (14.1% perceive NVPs as more harmful than HTPs). Exposure to HTP/NVP advertising was associated with perceiving these products as less harmful than cigarettes.

Conclusions: About one-quarter of Korean cigarette smokers perceive HTPs and NVPs as less harmful than cigarettes. Further investigation is required to understand how harm perceptions and HTP/NVP advertising are related to changes in product use, such as switching between products, using multiple products, or discontinuing all product use.

Citation

Kyriakos, C.N., Chung-Hall, J., Craig, L.V., Fong, G.T. (in press). Optimizing a product standard for banning menthol and other flavors in tobacco products: Implications for the United States and other countries. in press, Tobacco Control.

Abstract

In this paper, we highlight key issues that policymakers should consider when developing a product standard banning menthol and other flavors in tobacco products based on research evidence and experiences learned from other countries. A flavor product standard may be optimized by (1) having a clear and comprehensive definition of flavor that includes a complete ban on additives that have flavor properties and/or evoke sensory/cooling effects (i.e., menthol analogues and synthetic coolants that stimulate the cooling receptor of the brain) rather than only as a “characterizing flavor”, and (2) applying the standard to all tobacco product categories as well as all components or parts of the tobacco product (i.e., the tobacco, filter, wrapper, or paper), including separate flavorings that can be added to the product.

Citation

Chung-Hall, J., Craig, L.V., Kyriakos, C.N., Fong, G.T. (2023). U.S. Food and Drug Administration must ban menthol cigarettes without delay: Lessons from other countries. American Journal of Preventive Medicine , [Published online Aug 7, doi: 10.1016/j.amepre.2023.08.001]

Abstract

No abstract.

Citation

Naznin, E., George, J., Driezen, P., Palazzi, K., Faulkner, J., Wynne, O., Nargis, N., Fong, G.T., Bonevski, B. (2023). Trend over time on knowledge of the health effects of cigarette smoking and smokeless tobacco use in Bangladesh: Findings from the International Tobacco Control Policy Evaluation Bangladesh Surveys. Drug and Alcohol Review, [Published online 11 August, 2023, doi:10.1111/dar.13735].

Abstract

Introduction: Cigarette smoking and smokeless tobacco (ST) use are prevalent in Bangladesh. This longitudinal study examined how knowledge of the health effects of smoking and ST use in Bangladesh has changed overtime with the country's acceleration of tobacco control efforts.

Methods: Data were analysed from the International Tobacco Control Survey, a nationally representative longitudinal study of users and non-users of tobacco (aged 15 and older) in Bangladesh, across four waves conducted in 2009 (n = 4378), 2010 (n = 4359), 2012 (n = 4223) and 2015 (n = 4242). Generalised estimating equations assessed the level of knowledge about harms of tobacco use across four waves. Multivariable logistic regressions assessed whether knowledge of health effects from cigarette smoking and ST use in 2015 differed by user group.

Results: In 2015 survey, most tobacco users were aware that cigarette smoking causes stroke (92%), lung cancer (97%), pulmonary tuberculosis (97%) and ST use causes mouth cancer (97%) and difficulty in opening mouth (80%). There were significant increases in the total knowledge score of smoking related health harm from 2010 to 2012 (mean difference = 0.640; 95% confidence interval [CI] 0.537, 0.742) and 2012 to 2015 (mean difference = 0.555; 95% CI 0.465, 0.645). Participants had greater odds of awareness for ST health effects from 2010 to 2015.

Discussion and Conclusions: The results suggest that increasing efforts of awareness policy interventions is having a positive effect on tobacco-related knowledge in Bangladesh. These policy initiatives should be continued to identify optimal methods to facilitate behaviour change and improve cessation of smoking and ST use.

Citation

Simonavicius, E., East, K.A., Taylor, E., Nottage, M., Reid, J.R., Arnott, D., Bunce, , McNeill, A., Hammond, D. (2023). Impact of e-liquid packaging on vaping product perceptions among youth in England, Canada, and the United States: a randomised online experiment. Nicotine and Tobacco Research, [Published online, doi:10.1093/ntr/ntad144].

Abstract

Introduction: Vaping is not risk-free but can help those who smoke to reduce harm to health and stop smoking. However, packaging of vaping products, including e-liquids, appeals to youth and might facilitate vaping among nicotine-naïve people. Standardised packaging of vaping products could moderate the appeal of vaping among youth. This study assessed how youth interest in trying and perceived health harms of using eliquids are associated with branded or standardised (white or olive) e-liquid packaging with different nicotine levels displayed.

Methods: A between-subject experiment with 3 packaging and 2 nicotine level conditions included youth (n=13801) aged 16 to 19 from England, Canada and the United States as a part of a crosssectional online survey in August-September 2021. Participants' interest in trying and perceived harm of e-liquids were analysed using logistic and multinomial regressions adjusted for age, sex, race/ethnicity, country, vaping and smoking status.

Results: Compared with branded e-liquid packs, more youth reported no interest in trying eliquids in white (aOR=1.48, 95% CI=1.34-1.64) or olive (aOR=1.62, 95% CI: 1.47-1.80) standardised packs. Compared with branded eliquid packs, more youth inaccurately perceived eliquids in white (aOR=1.22, 95% CI: 1.11-1.34) or olive (aOR=1.29, 95% CI: 1.18-1.41) standardised packs as equally or more harmful than smoking. E-liquid nicotine levels displayed on packs were not associated with youth interest in trying or harm perceptions of using eliquids.

Conclusion: Among 16- to 19-year-old youth from England, Canada and the US, standardised packaging of e-liquids was associated with lower interest in trying and higher health risk perceptions.

Implications: Branded packaging of vaping products appeals to youth and might prompt nicotine use among those who had never smoked. This study suggests that restricting branding elements on e-liquid packaging is associated with youth lower interest in trying e-liquids and higher misperceptions that vaping is equally or more harmful than smoking. Standardised packaging might reduce appeal of vaping among youth, but its potential to discourage vaping for harm reduction should also be considered.

Citation

Levy, D.T., Cadham, C., Yuan, Z., Li, Y., Gravely, S., Cummings, K.M. (2023). Comparison of smoking prevalence i n Canada before and after nicotine vaping product access using the SimSmoke model. Canadian Journal of Public Health, 114(6), 992-1005. doi: 10.17269/s41997-023-00792-3.

Abstract

Objectives: The public health impact of nicotine vaping products (NVPs) is subject to complex transitions between NVP and cigarette use. To circumvent the data limitations and parameter instability challenges in modeling transitions, we indirectly estimate NVPs impact on smoking prevalence and resulting smoking attributable deaths using the SimSmoke simulation model.

Methods: Canada SimSmoke uses age and sex specific data on Canadian population, smoking prevalence and tobacco control policies. The model incorporates the impact of cigarette oriented policies on smoking prevalence but not the explicit contribution of NVPs. Th e model was calibrated from 1999 to 2012, thereby projecting smoking prevalence before NVPs were widely used in Canada. The NVP impact on smoking prevalence is inferred by comparing projected 2012 2020 smoking trends absent NVPs to corresponding trends fro m two Canadian national surveys. We further distinguish impacts before and after NVPs became regulated in 2018 and more available.

Results: Comparing 2012-2020 survey data of post NVP to SimSmoke projected smoking prevalence trends, one survey indicated a n NVP related relative reduction of 15% (15%) for males (females) age 15+, but 32% (52%) for those ages 15 24. The other survey indicated a 14% (19%) NVP related smoking reduction for ages 18+, but 42% (53%) for persons ages 18 24. Much of the gain occurre d since Canada relaxed NVP restrictions. NVP related 2012 2020 smoking reductions yielded 100,000 smoking attributable deaths averted from 2012 to 2060. Conclusion: Smoking prevalence in Canada, especially among younger adults, declined more rapidly once NVPs became readily available. The emergence of NVPs into the Canadian marketplace has not slowed the decline in smoking.

Conclusion: Smoking prevalence in Canada, especially among younger adults, declined more rapidly once NVPs became readily available. The emergence of NVPs into the Canadian marketplace has not slowed the decline in smoking.

Citation

Levy, D.T., Warner, K., Liber, A.C., Travis, N., Sweanor, D.T., Meza, R., Cummings, K.M. (2023). Potential implications for tobacco industry transformation of the acquisition of Swedish Match by Philip Morris International. Nicotine and Tobacco Research, 25(12), 1899-1903. doi: 10.1093/ntr/ntad138.

Abstract

Philip Morris International’s recent purchase of Swedish Match may prove to be a vital tobacco industry development. We focus on PMIs potential progress in moving from primarily selling cigarettes toward primarily selling noncombustible nicotine delivery products (NCNDPs). We also consider the potential contribution of the acquisition to industry transformation whereby other cigarette firms may potentially move toward primarily selling NCNDPs. We examine the potential impact on noncombustible nicotine delivery product use, including nicotine pouches (a major Swedish Match product), e-cigarettes, heated tobacco products, and, most importantly, on sales of the industry’s staple, combustible cigarettes. We focus on the United States as a special case, where PMI is limited from entering the cigarette market.

Implications: Philip Morris International’s purchase of Swedish Match and policies regarding nicotine pouches (NPs) have been overlooked in the tobacco control literature. The acquisition indicates the importance of the NP market to the largest nonstate-owned tobacco company. The acquisition has the potential through pricing and marketing tactics to either encourage or discourage the use of NPs, e-cigarettes, heated tobacco products, and most importantly cigarettes. Due to its inability to sell cigarettes in the United States, PMI will have incentives to use its alternative nicotine delivery products, including its newly acquired NPs, to reduce the sale of cigarettes by other companies. However, the potential effects in other countries, where PMI does sell cigarettes, are less clear. Monitoring and analyzing tobacco company acquisitions is essential to studying future transitions in using different kinds of tobacco products, especially from cigarettes to lower-risk alternative nicotine delivery products.

Citation

Tildy, B., McNeill, A., East, K.A., Gravely, S., Fong, G.T., Cummings, K.M., Borland, R., Chan, C.K.G., Lim, C., Gartner, C., Yong, H.H., Brose, L.S. (2023). Self-reported depression and anxiety and healthcare professional interactions regarding smoking cessations and nicotine vaping: Findings from 2018 International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. Tobacco Prevention & Cessation, 9(August), 26. doi: 10.18332/tpc/168288.

Abstract

Introduction: People with mental health conditions are disproportionately affected by smoking-related diseases and death. The aim of this study was to assess whether health professional (HP) interactions regarding smoking cessation and nicotine vaping products (NVPs) differ by mental health condition.

Methods: The cross-sectional 2018 International Tobacco Control Four Country (Australia, Canada, England, United States) Smoking and Vaping Survey data included 11040 adults currently smoking or recently quit. Adjusted weighted logistic regressions examined associations between mental health (self-reported current depression and/or anxiety) and visiting a HP in last 18 months; receiving advice to quit smoking; discussing NVPs with a HP; and receiving a recommendation to use NVPs.

Results: Overall, 16.1% self-reported depression and anxiety, 7.6% depression only, and 6.6% anxiety only. Compared with respondents with no depression/anxiety, those with depression (84.7%, AOR=2.65; 95% CI: 2.17–3.27), anxiety (82.2%, AOR=2.08; 95% CI: 1.70–2.57), and depression and anxiety (87.6%, AOR=3.74; 95% CI: 3.19–4.40) were more likely to have visited a HP. Among those who had visited a HP, 47.9% received advice to quit smoking, which was more likely among respondents with depression (AOR=1.58; 95% CI: 1.34–1.86), and NVP discussions were more likely among those with depression and anxiety (AOR=1.63; 95% CI: 1.29–2.06). Of the 6.1% who discussed NVPs, 33.5% received a recommendation to use them, with no difference by mental health.

Conclusions: People with anxiety and/or depression who smoke were more likely to visit a HP than those without, but only those with depression were more likely to receive cessation advice, and only those with depression and anxiety were more likely to discuss NVPs. There are missed opportunities for HPs to deliver cessation advice. NVP discussions and receiving a positive recommendation to use them were rare overall.

Citation

Liu, C., Yong, H.H., Gravely, S., East, K.A., Kasza, K., Gartner, C., Cummings, K.M., Fong, G.T. (2023). Gender differences in cigarette smoking cessation attempts among adults who smoke and drink alcohol at high levels: Findings from the 2018-2020 International Tobacco Control Four Country Smoking and Vaping Surveys. Addictive Behaviours, 147 [Published online 28 July 2023, doi: 10.1016/j.addbeh.2023.107817].

Abstract

Background: This study examined the association between alcohol consumption and smoking cessation behaviour of adults who smoke in four countries.

Methods: Data came from 4275 adults (≥18 years) who smoked tobacco ≥ monthly and participated in the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping Surveys (Australia: n = 720; Canada: n = 1250; US: n = 1011; England: n = 1294). The 2018 Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) survey data coded into three levels ('never/low', 'moderate' or 'heavy' consumption) were analysed using multivariable logistic regression models to predict any smoking cessation attempts and successful cessation by 2020 survey, and whether this differed by gender and country.

Results: Compared to never/low alcohol consumers, only those who drink heavily were less likely to have made a quit smoking attempt (40.4 % vs. 43.8 %; AOR = 0.69, 95 % CI = 0.57-0.83, p < .001). The association differed by gender and country (3-way interaction, p < .001), with females who drink heavily being less likely to attempt to quit smoking in England (AOR = 0.27, 95 % CI = 0.15-0.49, p < .001) and Australia (AOR = 0.38, 95 % CI = 0.19-0.77, p = .008), but for males, those who drink moderately (AOR = 2.18, 95 % CI = 1.17-4.06, p = .014) or heavily (AOR = 2.61, 95 % CI = 1.45-4.68, p = .001) were more likely to make a quit attempt in England only. Alcohol consumption did not predict quit success.

Conclusion: Heavy alcohol use among adults who smoke appears to only undermine the likelihood of trying to quit smoking with some variation by gender and country of residence, but not their chances of succeeding if they tried.

Citation

Lemos, M.K., Taylor, E., Wadsworth, E., Reid, J.L., Hammond, D., East, K.A. (2023). Perceptions of cannabis use risk to mental health among youth in Canada, England, and the United States from 2017 to 2021. Drug and Alcohol Dependence, 250, 110904. doi: 10.1016/j.drugalcdep.2023.110904.

Abstract

Background: There is little research examining perceptions of cannabis use risk to mental health in countries with differing cannabis regulations. This study therefore examines such perceptions among youth between 2017 and 2021 in Canada (non-medical cannabis legalized in October 2018), England (highly-restricted medical cannabis legalized November 2018), and the US (non-medical cannabis legal in some states).

Methods: Seven repeat cross-sectional online surveys were conducted between July 2017 to August 2021 among youth aged 16-19 in Canada (N=29,420), England (N=28,155), and the US (N=32,974). Logistic regression models, stratified by country, were used to examine perceptions of cannabis use risk to mental health over time, adjusting for age group, sex, race/ethnicity, cannabis use and, for the US only, state-level cannabis legalization.

Results: Perceptions that cannabis use posed “no risk” to mental health decreased between July 2017 and August 2021 in Canada (6.1% to 4.4%; AOR=0.64, 95% CI=0.52-0.78) and the US (14.0% to 11.3%; AOR=0.74, 0.65-0.84) but not England (3.7% to 4.5%; AOR=1.21, 0.97-1.52). No significant changes were observed from immediately before (August 2018) to after (August 2019) legalization of non-medical cannabis in Canada (AOR=0.99, 0.83-1.20) or highly-restricted medical cannabis in England (AOR=0.90, 0.70-1.17). In the US, perceptions of “no risk” were more likely in states where cannabis use was illegal (15.0%) compared with legal non-medical (12.2%) (AOR=0.68, 0.63-0.74).

Conclusion: There were modest decreases in perceptions that cannabis use poses no risk to mental health in Canada and the US between 2017 and 2021 but no clear association with cannabis legalization status.

Citation

Gravely, S., Meng, G., Hammond, D., Driezen, P., Thrasher, J.F., Fong, G.T., Craig, L.V., Chung-Hall, J., Quah, A.C.K., Ouimet, J., Bansal-Travers, M., Cummings, K.M. (2023). Support for pictorial health warning labels on cigarette packages in the United States among adults who currently smoke or quit smoking: Findings from the ITC US Smoking and Vaping Surveys. Tobacco Induced Diseases, 21(June), 84. doi: 10.18332/tid/166001.

Abstract

Introduction: In March 2020, the US Food and Drug Administration (FDA) finalized new pictorial health warnings (PHWs), covering 50% of the front and back of the pack; however, legal challenges from cigarette manufacturers have prevented the new warnings from being implemented. About 70% of adults in the general US population support PHWs. This study assessed support for PHWs in 2016, 2018 and 2020 among US adults (aged ≥18 years) who currently smoke or formerly smoked cigarettes. We also assessed factors related to support.

Methods: Respondents included adults who currently or formerly smoked cigarettes and participated in at least one wave of the US ITC Smoking and Vaping Surveys: Wave 1 (2016, n=2557); Wave 2 (2018, n=2685); and Wave 3 (2020, n=1112). We assessed changes in support for PHWs between 2016 and 2020, and assessed factors related to support (support vs oppose/don’t know). Analyses were conducted on weighted data.

Results: Overall, 38.0% of respondents supported PHWs in 2016, with a significant increase to 44.7% in 2018 (p<0.001), and leveling off to 45.0% in 2020 (2018 vs 2020, p=0.91). Support was highest among former smokers and lowest among daily smokers in all three survey years. Support for PHWs at all survey years was significantly higher among those who formerly smoked, were younger (aged 18–39 vs ≥40 years), those who identified as Black (vs White), and planned to quit smoking (vs not planning to quit). There were no differences by income level, education level, or sex.

Conclusions: Nearly half of US adults who smoke cigarettes or quit smoking supported PHWs in 2020, with support being higher among younger adults, ethnic minorities, and those who formerly smoked. Support increased between 2016 and 2018, but not between 2018 and 2020. Similar to other studies, fewer current and former smokers supported PHWs compared to the US adult general population.

Citation

Mechili, E.A., Przewoźniak, K., Driezen, P., Kyriakos, C.N., Girvalaki, C., Mons, U., Quah, A.C.K., Fernández, E., Trofor, A.C., Demjén, T., Katsaounou, P.A., Zatoński, W.A., Fong, G.T., Vardavas, C.I. (2023). Smokers' support for the ban on sale of slim cigarettes in six European countries: Findings from the EUREST PLUS ITC Europe Surveys. Open Research Europe, 1(52). [Published online Jun 19, doi: 10.12688/openreseurope.13405.4].

Abstract

Background: Efforts to regulate tobacco products and reduce consumption in the European Union (EU) include the European Tobacco Products Directive (TPD), which went into force in May 2016. Despite the initial discussion to include a ban on sale of slim cigarettes, it was excluded in the final TPD. The main goal of this study was to examine support for a ban on slim cigarettes among smokers in six European Countries.

Methods: Data from the 2018 (Wave 2) International Tobacco Control Policy Evaluation Project 6 European Country (ITC 6E) EUREST PLUS project survey, a cross sectional study of adult smokers (n=5592) fro m Germany, Greece, Hungary, Poland, Romania, and Spain, was analysed. Descriptive statistics were used to estimate support for a ban on slim cigarettes by sociodemographic characteristics and smoking behaviors. Logistic regression analysis was used to examine factors associated with support for a ban on slim cigarettes and perceptions of harm.

Results: Support for a ban on slims varied across countries, with highest support in Romania (33.8%), and lowest in Greece (18.0%). Female smokers (OR=0.78; 95%CI=0. 67 0.91, daily smokers (OR=0.68; 95%CI=0.47 0.97), menthol smokers (OR=0.55; 95%CI=0.36 0.86), and smokers who did not have plans to quit within next six months (OR=0.45; 95%CI=0.36 0.56) had significantly lower odds of supporting a ban on slim cigarettes. Overall, 21% of smokers perceived slim cigarettes as less harmful than regular cigarettes.

Conclusions: Support for a ban of slim cigarettes was relatively low among smokers, while misperceptions that slim cigarettes are less harmful is high, particularly among countries where slim cigarette use is more revalent. Findings support a ban on slim cigarettes to reduce misperceptions around slim cigarettes being less harmful.

Citation

Gravely, S., Driezen, P., McClure, E., Smith, D.M., Fong, G.T. (2023). Prevalence of depressive symptoms and cannabis use among adult cigarette smokers in Canada: cross-sectional findings from the 2020 International Tobacco Control Policy Evaluation Project Canada Smoking and Vaping Survey. Canadian Medical Association Journal Open, 11(3), E516-E526. doi: 10.9778/cmajo.20220081.

Abstract

Background: Tobacco smoking and cannabis use are independently associated with depression, and evidence suggests that people who use both tobacco and cannabis (co-consumers) are more likely to report mental health problems, greater nicotine dependence and alcohol misuse than those who use either product exclusively. We examined prevalence of cannabis use and depressive symptoms among Canadian adults who smoke cigarettes and tested whether co-consumers of cannabis and tobacco were more likely to report depressive symptoms than cigarette-only smokers; we also tested whether cigarette-only smokers and co-consumers differed on cigarette dependence measures, motivation to quit smoking and risky alcohol use by the presence or absence of depressive symptoms.

Methods: We analyzed cross-sectional data from adult (age ≥ 18 yr) current (≥ monthly) cigarette smokers from the Canadian arm of the 2020 International Tobacco Control Policy Evaluation Project Four Country Smoking and Vaping Survey. Canadian respondents were recruited from Leger’s online probability panel across all 10 provinces. We estimated weighted percentages for depressive symptoms and cannabis use among all respondents and tested whether co-consumers (≥ monthly use of cannabis and cigarettes) were more likely to report depressive symptoms than cigarette-only smokers. Weighted multivariable regression models were used to identify differences between co-consumers and cigarette-only smokers with and without depressive symptoms.

Results: A total of 2843 current smokers were included in the study. The prevalence of past-year, past-30-day and daily cannabis use was 44.0%, 33.2% and 16.1%, respectively (30.4% reported using cannabis at least monthly). Among all respondents, 30.0% screened positive for depressive symptoms, with co-consumers being more likely to report depressive symptoms (36.5%) than those who did not report current cannabis use (27.4%, p < 0.001). Depressive symptoms were associated with planning to quit smoking (p = 0.01), having made multiple attempts to quit smoking (p < 0.001), the perception of being very addicted to cigarettes (p < 0.001) and strong urges to smoke (p = 0.001), whereas cannabis use was not (all p ≥ 0.05). Cannabis use was associated with high-risk alcohol consumption (p < 0.001), whereas depressive symptoms were not (p = 0.1).

Interpretation: Co-consumers were more likely to report depressive symptoms and high-risk alcohol consumption; however, only depression, and not cannabis use, was associated with greater motivation to quit smoking and greater perceived dependence on cigarettes. A deeper understanding of how cannabis, alcohol use and depression interact among people who smoke cigarettes is needed, as well as how these factors affect cessation activity over time.

Citation

Gravely, S., Yong, H.H., Reid, J.L., East, K.A., Liber, A.C., Cummings, K.M., Quah, A.C.K., Fong, G.T., Hammond, D. (2023). An examination of quitting smoking as a reason for vaping by the type of nicotine vaping device used most often among adults who smoke and vape: Findings from the Canada, England and the United States 2020 ITC Smoking and Vaping Survey. Preventive Medicine Reports, 33, 102201. doi: 10.1016/j.pmedr.2023.102201.

Abstract

Several nicotine vaping product (NVP) device types are available to consumers, and many people who smoke report vaping to help them quit. This study included data from the Wave 3 (2020) ITC Smoking and Vaping Survey in the US, Canada, and England and included 2324 adults who were smoking cigarettes and vaping at least weekly. Device types currently used most often (disposables, cartridges/pods, or tank systems) were assessed using weighted descriptive statistics. Multivariable regression analyses were used to compare differences between respondents who reported vaping to quit smoking (‘yes’ vs. ‘no/don’t know’) by device type, overall and by country. Overall, 71.3% of respondents reported vaping to help them quit smoking, with no country differences (p = 0.12). Those using tanks (78.7%, p < 0.001) and cartridges/pods (69.5%, p = 0.02) were more likely to report this reason for vaping than those using disposables (59.3%); respondents using tanks were also more likely than those using cartridges/pods (p = 0.001) to report this reason. By country, respondents in England using cartridges/pods or tanks (vs. disposables) were more likely to report vaping to quit smoking (with no difference between cartridges/pods and tanks). In Canada, respondents using tanks were more likely to report vaping to quit smoking than those using cartridges/pods or disposables (no difference between disposables and cartridges/pods). No significant differences by device type were found in the US. In conclusion, most adult respondents who smoked and vaped reported using either cartridges/pods or tanks, which were associated with greater odds of vaping for the purpose of quitting smoking versus disposables, with some country variations.

Citation

Yong, H.H., Karmakar, C., Motin, M. A., Borland, R., Cummings, K.M., Gravely, S., Fong, G.T. (2023). Individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies relative to combustible cigarettes among people who smoke: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 25(9), 1594-1602. doi: 10.1093/ntr/ntad075.

Abstract

Introduction: This study examined individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies (NRTs) relative to combustible cigarettes (CCs).

Methods: Data analyzed came from 8,642 adults (18+ years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n=1213), Canada (n=2633), England (n=3057), and United States (US, n=1739). Respondents were asked: Compared to smoking cigarettes, how harmful do you think nicotine replacement products are? Responses were dichotomised into much less vs. otherwise for analysis using multivariable logistic regression models, complemented by decision-tree analysis to identify conjoint factors.

Results: Percentages believing that NRTs are much less harmful than CCs were 29.7% (95% CI:26.2-33.5%) in Australia, 27.4% (95% CI=25.1-29.8%) in England, 26.4% (95% CI=24.4-28.4%) in Canada and 21.7% (95% CI=19.2-24.3%) in the US. Across all countries, believing nicotine is not at all/slightly harmful to health (aOR=1.53-2.27), endorsing nicotine vaping products as less harmful than CCs (much less harmful: aOR=7.24-14.27; somewhat less harmful: aOR=1.97-3.23), and possessing higher knowledge of smoking harms (aOR=1.23-1.88) were individual factors associated with increased odds of believing NRTs are much less harmful than CCs. With some country variations, these nicotine-related measures also interacted with each other and socio-demographic variables to serve as conjoint factors associated with the likelihood of accurate NRT relative harm belief.

Conclusions: Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors.

Implications: This study demonstrates that despite past efforts to educate people who smoke about the harms of NRTs relative to CCs, misperceptions around the relative harmfulness of NRTs remain substantial. In all four studied countries, subgroups of people who smoke regularly who are misinformed about the relative harmfulness of NRTs, and who may be reluctant to use NRTs for smoking cessation can be reliably identified for corrective interventions based o n their understanding of the harms related to nicotine, NVPs and smoking along with sociodemographic markers. The identified subgroup information can be used to prioritize and inform the development of effective interventions to specifically address the gaps in knowledge and understanding of the various subgroups identified. Our results suggest these may need to be tailored for each country.

Citation

Taylor, E., East, K.A., Reid, J., Hammond, D. (2023). Awareness and use of short-fill e-liquids by youth in England in 2021: Findings from the ITC Youth Survey. Tobacco Control, [Published online May 2, doi:10.1136/tc-2022-057871].

Abstract

Background: Refillable e-cigarettes were popular among youth in England in 2021. The UK Tobacco and Related Products Regulations (TRPR) limits e-liquids to 20 mg/mL of nicotine in a 10 mL bottle. Short-fill e-liquids, which are not covered by TRPR regulations, are typically nicotine-free and come in larger, underfilled bottles allowing customisation with the addition of ‘nicotine shots’. This paper investigates awareness, use, and reasons for use of short-fill e-liquids among youth in England.

Methods: Data are from the online 2021 International Tobacco Control Youth Survey, comprising 4224 youth (aged 16–19 years) in England. Weighted logistic regression models investigated associations between awareness and past 30-day use of short-fills by smoking status, vaping status, nicotine strength vaped and participant demographics. Reasons for use were also reported.

Results: Approximately one-quarter (23.0%) of youth in England reported awareness of short-fill e-liquids. Among youth who had vaped in the past 30 days, 22.1% had used short-fills in the past 30 days; use was most prevalent among those who were also smoking (43.2%) and those who reported usually vaping nicotine concentrations of 2.1% (21 mg/mL) or more (40.8%). ‘Convenience of a bigger bottle’ was the most selected reason for use (45.0%), followed by ‘less expensive than regular e-liquids’ (37.6%).

Conclusions: Awareness of short-fills was common among youth in 2021, including among those who had never vaped or smoked. Among youth who vaped in the past 30 days, short-fill use was more prevalent among those who also smoked and those who vaped nicotine-containing e-liquids. Integration of short-fill products into existing e-cigarette regulations should be considered.

Citation

Reid, J., Burkhalter, R., Kasza, K.A., Seo, Y., East, K.A., Hyland, A., Hammond, D. (2023). Minimum legal age laws and perceived access to cigarettes, e-cigarettes, and other substances among youth in Canada, England, and the United States: 2017-2021. International Journal of Drug Policy, 115, 104003. doi: 10.1016/j.drugpo.2023.104003.

Abstract

Background: Minimum legal age (MLA) restrictions are a core policy to reduce youth use of tobacco, e-cigarettes, and other substances. We examined trends in perceived ease of access to tobacco and other substances across three countries with differing MLA policies, including the United States (US), which increased the federal MLA for tobacco products from 18 to 21 in 2019.

Methods: Repeat cross-sectional data were analyzed from seven waves of the International Tobacco Control (ITC) Youth Tobacco and Vaping Survey conducted between 2017 and 2021. Online surveys were conducted with non-probability samples of 91,647 youth aged 16-19 in Canada, England, and the US. Regression models were used to examine differences in perceived ease of accessing each of 7 substances (analyzed as "very easy" or "fairly easy" versus else), and differences between countries and over time (including before and after any MLA changes) for cigarettes, e-cigarettes, cannabis, and alcohol; additional models examined sub-national variation in MLA.

Results: Perceived access varied by substance and across countries: in August/September 2021, perceived ease of accessing cigarettes and e-cigarettes was greater in Canada where MLA was 18-19 (61.7% cigarettes, 66.4% e-cigarettes) and England where MLA was 18 (66.9%, 69.6%), compared to the US where MLA was 21 (48.0%, 60.9%; p < 0.001 for all). Perceived ease of accessing cannabis was greatest in Canada (53.3%), followed by the US (44.1%) and England (34.0%; p < 0.001 for all). Following the federal MLA increase for tobacco products in the US, perceived ease of access decreased significantly for cigarettes (65.1% in 2019Aug to 59.7% in 2020Feb; aOR=0.80 (95%CI=0.71-0.89)) and e-cigarettes (72.4% in 2019Aug to 69.4% in 2020Feb; aOR=0.87 (95%CI=0.77-0.98)).

Conclusions: Higher MLA was strongly associated with fewer youth perceiving easy access to substances: perceived access varied between countries with differing MLA, as well as within-country before and after changes to MLA.

Citation

Fu, M., Castellano, Y., Tigova, O., Driezen, P., Thompson, M.E., Kaai, S.C., Quah, A.C.K., Fong, G.T., Vardavas, C.I., Fern á ndez, E. (2023). ITC EUREST PLUS España: protocolo de un estudio longitudinal de fumadores en España [ITC EUREST PLUS Spain: Protocol of a longitudinal study of smokers in Spain]. Gaceta Sanitaria, 37, 102307. doi: 10.1016/j.gaceta.2023.102307.

Abstract

Objective: The ITC EUREST-PLUS Spain Survey is a longitudinal study of a representative sample of Spanish adult (≥18 years old) smokers. This protocol describes the methods of the 2021 follow-up survey.

Method:The ITC EUREST-PLUS Survey, a prospective cohort study of a representative sample of smokers in six European countries, was conducted in 2016 (baseline) and 2018 (waves 1 and 2). The 2021 ITC EUREST-PLUS Spain Survey is a continuation of the Spanish cohort with a new interview in 2021 (wave 3). Lost participants were replaced with new smokers recruited using the same multi-stage sampling design. This latest follow-up aims to examine current patterns and transitions of tobacco use and to evaluate the impact of new tobacco-related policies.

Citation

Yimsaard, P., Gravely, S., Meng, G., Fong, G.T., Cummings, K.M., Hyland, A., Borland, R., Hammond, D., Kasza, K.A., Li, L., Quah, A.C.K. (2023). Differences in smoking cessation behaviours and vaping status among adult daily smokers with or without depression, anxiety, hazardous alcohol use: Findings from the 2018 and 2020 ITC Four Country Smoking and Vaping Survey. International Journal of Mental Health and Addiction, [Published online, doi:10.1007/s11469-023-01058].

Abstract

This study examined differences in quit attempts, 1-month quit success, and vaping status at follow-up among a cohort of 3709 daily smokers with and without depression, anxiety, and regular alcohol use who participated in both the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys. At baseline, a survey with validated screening tools was used to classify respondents as having no, or one or more of the following: 1) depression, 2) anxiety, and 3) regular alcohol use. Multivariable adjusted regression analyses were used to examine whether baseline (2018) self-report conditions were associated with quit attempts; quit success; and vaping status by follow-up (2020). Results showed that respondents who reported depressive symptoms were more likely than those without to have made a quit attempt (aOR = 1.32, 95% CI:1.03–1.70, p = 0.03), but were less likely to have quit (aOR = 0.55, 95% CI:0.34–0.89, p = 0.01). There were no differences in quit attempts or quit success between those with and without self-reported anxiety diagnoses or regular alcohol use. Among successful quitters, respondents with baseline depressive symptoms and self-reported anxiety diagnoses were more likely than those without to report vaping at follow-up (aOR = 2.58, 95% CI:1.16–5.74, p = 0.02, and aOR = 3.35 95% CI:1.14–9.87, p = 0.03). In summary, it appears that smokers with depression are motivated to quit smoking but were less likely to manage to stay quit, and more likely to be vaping if successfully quit. As smoking rates are higher among people with mental health conditions, it is crucial for healthcare professionals to identify these vulnerable groups and offer tailored smoking cessation support and continued support during their quit attempt.

Citation

Geboers, C., Candel, M.J.J.M., Nagelhout, G.E., de Vries, H., van den Putte, B., Fong, G.T., Willemsen, M.C. (2023). Smokers’ strategies to reduce tobacco spending: self-reported use and differences across subgroups. Findings from the International Tobacco Control (ITC) Netherlands Survey. BMC Public Health, 23(1), 738. doi:10.1186/s12889-023-15678-9.

Abstract

Background: The cost of tobacco is one of the most reported reasons for smoking cessation. Rather than quitting, smokers can use also strategies to reduce tobacco expenditure while continuing smoking, such as smoking less or using price-minimising strategies. The Netherlands announced to increase the price of a pack cigarettes from seven (2018) to ten euros (2023), to reduce tobacco prevalence and consumption. This study explores the self-reported strategies to reduce tobacco spending among Dutch smokers, and whether this differed per age, income, and education. Additionally, we analysed among quitters in these subgroups whether price played a role in their decision to quit.

Methods: Cross-sectional survey data from the International Tobacco Control (ITC) Netherlands Wave 2 (September-November 2020, N = 1915) was used. Strategies to reduce spending among smokers (N = 1790) were: reducing consumption, bulk buying, switching to cheaper products or buying from low-taxed sources. These were collapsed into: reducing consumption (solely or in combination with other behaviours), solely price-minimising behaviours (such as buying cheaper brands), or no strategies to reduce spending. Associations between strategies and characteristics were analysed through multinomial and binary logistic regression models. Second, we explored which subgroups were more likely to report that price played a role in their decision to quit among quitters (N = 125).

Results: The majority of smokers used strategies to reduce tobacco spending: 35.6% reduced consumption and 19.3% used solely price-minimising strategies. 82.1% of quitters reported that price played a role in their decision to quit. Low-income individuals were more likely to report price as a reason for quitting and reduce consumption, but also to buy cheaper products. Highly nicotine dependent smokers were more likely to use price-minimising behaviours, and less likely to reduce consumption.

Conclusions: The majority reported using strategies to reduce spending or that price played a role in their decision to quit. Reducing consumption was the most reported strategy. Low-income smokers were more likely to reportedly reduce consumption, buy cheaper products, or quit. Price policies have the potential to reduce socioeconomic inequalities in smoking. To discourage price-minimising behaviours, such as switching to cheaper products, reducing price differences between products should be prioritized.