Citation

Fix, B.V., Smith, D., O’Connor, R.J., Heckman, B., Willemsen, M.C., Cummings, K.M., Fong, G.T. (2019). Cannabis use among a nationally representative cross-sectional sample of smokers and non-smokers in The Netherlands: Results from the 2015 ITC Netherlands Gold Magic Survey. BMJ Open, 9(3), E024497.

Abstract

Objectives: Existing evidence shows that co-occurring use of tobacco and cannabis is widespread. Patterns of co-use of tobacco and cannabis may change as more jurisdictions legalise medicinal and/or recreational cannabis sales. This analysis examined predictors of current cannabis use and characterised methods of consumption among smokers and non-smokers in a context where cannabis use is legal.

Setting: The 2015 International Tobacco Control Netherlands—Gold Magic Survey conducted between July and August 2015.

Participants: Participants (n=1599; 1003 current smokers, 283 former smokers and 390 non-smokers) were asked to report their current (past 30-day) use of cigarettes and cannabis. Cigarette smokers reported whether they primarily used factory made of roll-your-own cigarettes. Those who reported any cannabis use in the last 30 days were asked about forms of cannabis used. X2and logistic regression analyses were used to assess relationships among combustible tobacco and cannabis use.

Results: Past 30-day cannabis use was somewhat higher among current tobacco (or cigarette) smokers (n=57/987=5.8%) than among former or never smokers (n=10/288=3.5% and n=6/316=1.9%, respectively). Joints were the most commonly used form of cannabis use for both current cigarette smokers (96.9%) and non-smokers (76.5%). Among those who smoked cannabis joints, 95% current smokers and 67% of non-smokers reported that they ‘always’ roll cannabis with tobacco.

Conclusions: In this Netherlands-based sample, most cannabis was reported to be consumed via smoking joints, most often mixed with tobacco. This behaviour may present unique health concerns for non-cigarette smoking cannabis users, since tobacco use could lead to nicotine dependence. Moreover, many non-cigarette smoking cannabis users appear to be misclassified as to their actual tobacco/nicotine exposure.

Citation

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

Abstract

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

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

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

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

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

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

Citation

Thomas, D.P., Lyons, L., Borland, R. (2019). Predictors and reasons for quitting smoking and sustaining abstinence in a national cohort of Aboriginal and Torres Strait Islander smokers. Drug and Alcohol Review, 38(3), 244-253.

Abstract

Introduction and Aims: The national prevalence of daily smoking among the Aboriginal and Torres Strait Islander population is 39% but falling. We explore factors associated with starting and sustaining quit attempts, and reasons given for quitting.

Design and Methods: We analysed data from the nationally representative quota sample of 759 Aboriginal and Torres Strait Islander adults who reported smoking at least weekly in the Talking About The Smokes baseline survey (April 2012–October 2013) who completed a follow‐up survey a year later (August 2013–August 2014).

Results: Having made more quit attempts, more recent quit attempts in the past, motivational attitudes, having been encouraged to quit by a health professional and having noticed tobacco advertising were associated with making a quit attempt between surveys. Having made longer quit attempts in the past, non‐daily smoking and quit self‐efficacy were associated with sustaining abstinence. But neither having made more quit attempts in the past nor dependence was associated with sustaining abstinence. Health concerns, price and setting an example to children were the most common reasons given by smokers and ex‐smokers for quitting.

Discussion and Conclusions: Different factors predict making and sustaining quit attempts among Aboriginal and Torres Strait Islander smokers. We need to rethink current messages that just encourage Aboriginal and Torres Strait Islander smokers to keep making quit attempts by increasing motivation to quit, as motivation and making more quit attempts does not predict eventual success. We could focus more on increasing smokers’ confidence that they can successfully quit.

Citation

Wadsworth, E., Hammond, D. (2019). International differences in patterns of cannabis use among youth: Prevalence, perceptions of harm, and driving under the influence in Canada, England & United states. Addictive Behaviors, 90, 171-175. https://doi.org/10.1016/j.addbeh.2018.10.050

Abstract

Introduction: Cannabis is the most widely used illicit substance in the world. An increasing number of jurisdictions have legalized medical and non-medical cannabis; comparisons across jurisdictions can help evaluate the impact of these policy innovations. The current study examined patterns of cannabis use among youth in Canada (CA), England (EN) and the United States (US). At the time of study, non-medical cannabis use was prohibited federally in all three countries; however, medical cannabis was accessible with varying restrictions in CA, EN and most US states, while non-medical cannabis was legal in four US states.

Methods: Data come from an international online survey conducted in July 2017 (n = 12,064). Youth, aged 16-19, were asked about cannabis consumption, perceived access to cannabis, perceptions of harm, and driving after cannabis use. All estimates represent weighted data.

Results: US youth were more likely to report more frequent cannabis consumption, easier access, lower perceptions of harm, and higher rates of driving after cannabis use than CA and EN youth. CA youth reported more frequent consumption, easier access, and higher rates of driving after cannabis use than EN youth.

Conclusion: CA and US youth had higher prevalence of use, easier access, lower perceived harm and higher driving rates after cannabis use in comparison to EN. These differences may reflect more permissive cannabis policies in CA and US, as well as pre-existing trends. Future waves of the international cannabis study will examine trends over time within the same countries after cannabis legalization in CA and additional US states.

Citation

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

Abstract

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

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

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

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

Citation

DeHart, WB, Mellis, AM, Kaplan, B.A., Pope, D.A., Bickel, W.K. (2019). The Experimental Tobacco Marketplace: Narratives engage cognitive biases to increase electronic cigarette substitution. Drug and Alcohol Dependence, 197, 203-211.

Abstract

Background

The Experimental Tobacco Marketplace (ETM) is a digital storefront in which participants can purchase tobacco products using an account balance that reflects their typical tobacco product purchasing. The ETM is also an ideal resource to investigate the harm-reduction potential of alternative nicotine products such as e-cigarettes. In a series of experiments, we explored the effects of harm-reduction narratives that encouraged e-cigarette substitution of conventional cigarettes in the ETM. These narratives incorporated different cognitive biases in order to determine which strategy is most effective.

Methods

In both experiments, participants, recruited from Amazon Mechanical Turk, read a narrative about a friend that either falls ill or faces financial difficulties and then made purchases in the ETM. Some of these narratives specifically incorporated different cognitive biases including trusting authority. Across ETM trials, the price of conventional cigarettes increased while the price of the alternative products, including e-cigarettes, remained constant.

Results

Across both experiments, a general pattern emerged supporting the effectiveness of narratives in increasing e-cigarette purchasing. Importantly, from a harm-reduction perspective, this increase in ecigarette substitution frequently corresponded with a decrease in conventional cigarette purchasing.

Conclusions

Narratives can decrease conventional cigarette and increase e-cigarette purchasing in an ETM that mimics real-world marketplaces. Invoking different cognitive biases may bolster this effect. Narratives can be a valuable harm-reduction tool because they are cost-effective, can be widely disseminated, and can be personalized to individuals.

Citation

Morphett, K., Weier, M., Borland, R., Yong, H.H., Gartner, C. (2019). Barriers and facilitators to switching from smoking to vaping: Advice from vapers. Drug and Alcohol Review, 38(3), 234-243.

Abstract

Introduction and Aims: Information available to consumers about nicotine vaping products varies according to the regulatory environment. A common information source in Australia, where nicotine vaping products are highly regulated, is advice from vapers. The aim of this study was to report on what advice current vapers would give to someone new to vaping.

Design and Methods: Australian vapers were recruited in 2016 via the International Tobacco Control Four‐Country Smoking and Vaping survey of smokers and ex‐smokers, as well as a separate recruitment process that targeted vapers. A total of 384 of 559 eligible participants responded to an open‐ended question about barriers to switching from smoking to vaping, and what advice they would give to new vapers.

Results: While some participants reported switching from smoking to vaping easily, others described an adjustment period. Difficulties included learning about technical aspects of nicotine vaping products, finding the ‘right’ combination of device and liquid, and accessing nicotine liquid given that it cannot legally be sold. Many accounts of satisfaction with quitting smoking and improved health were provided.

Discussion and Conclusions: Advice from current vapers is likely to be particularly influential in Australia, where information about vaping is not easily available from health organisations or official government sources. This research shows that advice to new vaper centres around experimentation with devices and flavours and finding trustworthy suppliers of nicotine liquid. It provides an insight into the initial challenges associated with switching from smoking to nicotine vaping products in environments where access to nicotine liquid is highly restricted.

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

Braak, D., Cummings, K.M., Nahhas, G.J., Heckman, B.W., Borland, R., Fong, G.T., Hammond, D., Boudreau, C., McNeill, A., Levy, D.T., Shang, C. (2019). Where do vapers buy their vaping supplies? Findings from the International Tobacco Control (ITC) 4 Country Smoking and Vaping Survey. International Journal of Environmental Research and Public Health, 16(3), 338.

Abstract

Aim: This study examines where vapers purchase their vaping refills in countries having different regulations over such devices, Canada (CA), the United States (US), England (EN), and Australia (AU).

Methods: Data were available from 1899 current adult daily and weekly vapers who participated in the 2016 (Wave 1) International Tobacco Control Four Country Smoking and Vaping. The outcome was purchase location of vaping supplies (online, vape shop, other). Adjusted odds ratios and 95% confidence intervals were reported for between country comparisons.

Results: Overall, 41.4% of current vapers bought their vaping products from vape shops, 27.5% bought them online, and 31.1% from other retail locations. The vast majority of vapers (91.1%) reported using nicotine-containing e-liquids. In AU, vapers were more likely to buy online vs other locations compared to CA (OR = 6.4, 2.3–17.9), the US (OR = 4.1, 1.54–10.7), and EN (OR = 7.9, 2.9–21.8). In the US, they were more likely to buy from vape shops (OR = 3.3, 1.8–6.2) or online (OR = 1.9, 1.0–3.8) vs other retail locations when compared to those in EN. In CA, vapers were more likely to purchase at vape shops than at other retail locations when compared to vapers in EN (5.9, 3.2–10.9) and the US (1.87, 1.0–3.1).

Conclusions: The regulatory environment and enforcement of such regulations appear to influence the location where vapers buy their vaping products. In AU, banning the retail sale of nicotine vaping products has led vapers to rely mainly on online purchasing sources, whereas the lack of enforcement of the same regulation in CA has allowed specialty vape shops to flourish.

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

Nargis, N., Hussain, A.K.M.G., GoodChild, M., Quah, A.C.K., Fong, G.T. (2019). A decade of cigarette taxation in Bangladesh: lessons learnt for tobacco control policy and practice. Bulletin of the World Health Organization, 97(3), 221-229.

Abstract

Bangladesh has achieved a high share of tax in the price of cigarettes (greater than the 75% benchmark), but has not achieved the expected health benefits from reduction in cigarette consumption. In this paper we explore why cigarette taxation has not succeeded in reducing cigarette smoking in Bangladesh. Using government records over 2006–2017, we link trends in tax-paid cigarette sales to cigarette excise tax structure and changes in cigarette taxes and prices. We analysed data on smoking prevalence from Bangladesh Global Adult Tobacco Surveys to study consumption of different tobacco products in 2009 and 2017. Drawing on annual reports from tobacco manufacturers and other literature, we examine demand- and supply-side factors in the cigarette market. In addition to a growing affordability of cigarettes, three factors appear to have undermined the effectiveness of tax and price increases in reducing cigarette consumption in Bangladesh. First, the multitiered excise tax structure widened the price differential between brands and incentivized downward substitution by smokers from higher-price to lower-price cigarettes. Second, income growth and shifting preferences of smokers for better quality products encouraged upward substitution from hand-rolled local cigarettes (bidi) to machine-made low-price cigarettes. Third, the tobacco industry’s market expansion and differential pricing strategy changed the relative price to keep low-price cigarettes inexpensive. A high tax share alone may prove inadequate as a barometer of effective tobacco taxation in lower-middle income countries, particularly where the tobacco tax structure is complex, tobacco products prices are relatively low, and the affordability of tobacco products is increasing.

Citation

Thomas, D.P., Davey, M.E., van der Sterren, A.E., Lyons, L., Hunt, J.M., Bennet, P.T. (2019). Social networks and quitting in a national cohort of Australian Aboriginal and Torres Strait Islander smokers. Drug and Alcohol Review, 38(1), 82-91.

Abstract

Introduction and Aims: Health behaviours, such as smoking and quitting, spread person-to-person through social networks. We explore how social networks are associated with making and sustaining quit attempts for at least 1 month among Aboriginal and Torres Strait Islander smokers.

Design and Methods: We analysed data from the nationally representative quota sample of 759 Aboriginal and Torres Strait Islander adults who reported smoking at least weekly in Talking About The Smokes baseline survey (April 2012-October 2013) who completed a follow-up survey a year later (August 2013-August 2014).

Results: At baseline, 41% of smokers reported that all of their five closest family or friends smoked, but 62% reported that family or friends had provided encouragement to quit. Fewer smokers with other adult smokers in their household at baseline made a quit attempt between surveys (OR 0.63, 95% CI 0.45- 0.87). Fewer smokers who had made an attempt between surveys sustained abstinence for at least 1 month if all of their five closest friends smoked (OR 0.60, 95% CI 0.37-0.97). Perceived support to quit in your social network was associated with making and sustaining a quit attempt.

Discussion and Conclusions: Exposure to smoking in the social networks of Aboriginal and Torres Strait Islander smokers is an obstacle to quitting, but there is also considerable support for quitting from within these same social networks. Health staff could consider encouraging smokers to draw on the few non-smokers within their social networks as role models to increase their confidence in quitting.

Citation

McDermott, M., Li, G., McNeill, A., Hammond, D., Thrasher, J.F., O’Connor, R.J., Cummings, K.M., Borland, R., Fong, G.T., Hitchman, S.C. (2019). Exposure to and perceptions of health warning labels on nicotine vaping products: Findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 134-143.

Abstract

Background and Aims: The presence and content of health warning labels (HWLs) on nicotine vaping products (NVPs), such as electronic cigarettes, varies by country and manufacturer. We compared proportions of people who report (i) noticing HWLs on NVPs and (ii) feeling concerned having noticed HWLs, by country and by smoking or vaping status. We also examined recall of HWL content and whether this varies by country.

Design: Cross‐sectional survey

Setting: Australia (AU), Canada (CA), England (EN), and the United States (US). At the time of data collection, HWLs on NVPs were only mandatory in EN.

Participants: A total of 11561 respondents from the following samples in the 2016 International Tobacco Control 4‐Country Project: (1) re‐contacted smokers and quitters who had participated in the previous wave of the project; (2) newly recruited current smokers and recent quitters, and (3) newly recruited current vapers from CA, EN and US.

Measurements: Outcomes included: 1) having noticed HWLs on NVPs, 2) feeling concerned having noticed HWLs, and 3) recall of HWL message content.

Findings: Compared with respondents in EN, respondents in CA were more likely to report having noticed HWLs (OR=1.58, p=0.02) whereas respondents in AU (OR=0.76, p=1.00) and the US (OR=1.54, p=0.09) were not significantly more or less likely to report having noticed HWLs. Compared with concurrent smokers and vapers, daily smokers, non‐daily smokers, and quitters were less likely to report having noticed HWLs, (ORs=0.21, 0.33 and 0.19 respectively, all p<0.001). There were no significant differences in reports of noticing HWLs when comparing concurrent smokers and vapers with daily (OR=1.62, p=0.91) or non‐daily (OR=1.15, p=1.00) vapers. There were no significant differences by country in reporting that HWLs made them concerned about using NVPs. Daily vapers were less likely to report feeling concerned than concurrent users (OR=0.11, p=0.017). Among those who reported reading HWLs (n=688), there was little evidence of differences in recall of the HWL content.

Conclusions: Respondents in England, where health warning labels on nicotine vaping products are not mandatory, were not significantly more likely to report having noticed such warnings than those in Australia, Canada and the US where warnings are not mandatory.

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

Fleischer, N.L., Lozano, P., Wu, Y.H., Hardin, J.W., Meng, G., Liese, A.D., Fong, G.T., Thrasher, J.F. (2019). Disentangling the roles of point-of-sale bans, tobacco retailer density and proximity on cessation and relapse among a cohort of smokers: findings from ITC Canada Survey. Tobacco Control, 28(1), 81-87.

Abstract

Objective: To examine how point-of-sale (POS) display bans, tobacco retailer density and tobacco retailer proximity were associated with smoking cessation and relapse in a cohort of smokers in Canada, where provincial POS bans were implemented differentially over time from 2004 to 2010.

Methods: Data from the 2005 to 2011 administrations of the International Tobacco Control (ITC) Canada Survey, a nationally representative cohort of adult smokers, were linked via residential geocoding with tobacco retailer data to derive for each smoker a measure of retailer density and proximity. An indicator variable identified whether the smoker’s province banned POS displays at the time of the interview. Outcomes included cessation for at least 1 month at follow-up among smokers from the previous wave and relapse at follow-up among smokers who had quit at the previous wave. Logistic generalised estimating equation models were used to determine the relationship between living in a province with a POS display ban, tobacco retailer density and tobacco retailer proximity with cessation (n=4388) and relapse (n=866).

Results: Provincial POS display bans were not associated with cessation. In adjusted models, POS display bans were associated with lower odds of relapse which strengthened after adjusting for retailer density and proximity, although results were not statistically significant (OR 0.66, 95% CI 0.41 to 1.07, p=0.089). Neither tobacco retailer density nor proximity was associated with cessation or relapse.

Conclusions: Banning POS retail displays shows promise as an additional tool to prevent relapse, although these results need to be confirmed in larger longitudinal studies.

Citation

Huq, I., Nargis, N., Lkhagvasuren, D., Hussain, A.K.M.G., Fong, G.T. (2019). The impact of income and taxation in a price-tiered cigarette market: Findings from the ITC Bangladesh Surveys. Tobacco Control, 28(Suppl 1), S37-S44.

Abstract

Background: Taxing tobacco is among the most effective measures of tobacco control. However, in a tiered market structure where multiple tiers of taxes coexist, the anticipated impact of tobacco taxes on consumption is complex. This paper investigates changing smoking behaviour in lieu of changing prices and changing income. The objective of the paper is to evaluate the effectiveness of change in prices (through taxes) and change in income in a price-tiered cigarette market.

Method: A panel dataset from the International Tobacco Control Bangladesh surveys is used for analysis. For preliminary analysis transition matrices are developed. Next, probit and multinomial logit regression models are used to identify the effects of changes in prices and changes in income along with other control variables.

Findings: Transition matrices show significant movement of smokers across price tiers from one wave to another. Regression results show that higher income raises the probability to up-trade and decreases the probability to down-trade. Results also show that higher prices raises the probability to up-trade and reduces the probability to down-trade. Although not significant, there exists a negative relationship between the probability to down-trade and the probability to intend to quit.

Conclusion: It is evident from the results that a price-tiered market provides smokers more opportunities to accommodate their smoking behaviour when faced with price and income change. Therefore, tiered structure of the tax system should be replaced with uniform taxes. Moreover, overall cigarette taxes need to be raised to an extent so that it off-sets any positive effects of income growth.

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

Chyderiotis, S., Beck, F., Andler, R., Hitchman, S.C., Benmarhnia, T. (2019). How to reduce biases coming from a before and after design: the impact of the 2007-2008 French smoking ban policy. European Journal of Public Health, 29(2), 372-377.

Abstract

Background: Smoke-free laws aim at protecting against second-hand smoke and at contributing to change smoking behaviors. Impact evaluation studies can help understand to what extent they reach their goals. Simple before and after designs are often used but cannot isolate the effect of the policy of interest.

Methods: The short-term impact of the French smoking ban (2007-08) on smoking behavior outcomes was evaluated among smokers with data from the ITC project. We first conducted a before and after design on the French sample. Second, we added the UK (excluding Scotland) as a control group and finally used external pre-policy data from national surveys to control for bias arising from pre-policy trends.

Results: After one year post-implementation, the smoking ban led to a decrease in seeing people smoking in bars, restaurants and workplaces [estimated risk ratios (RR) of 8.81 IC95% (5.34-14.71), 2.02 (1.79-2.31) and 1.24 (1.16-1.33), respectively], as well as an increase in support for the smoke-free policy, but only in bars and restaurants [RR of 1.35 (1.15-1.61) and 1.25 (1.16-1.35)], respectively. No impact was found on smoking behaviors and on having a strict no smoking policy at home. The simple before and after design systematically overestimated the smoking ban's impact [e.g. RR of 29.9 (20.06- 44.56) for observed smoking in bar, compared to 13.21 (7.78-22.42) with the control group, and 8.81 (5.34-14.71) with the correction from external data].

Conclusion: When data are lacking to conduct quasi-experimental designs for impact evaluation, the use of external data could help understand and correct pre-policy trends.

Citation

Tigova, O., Amalia, B., Castellano, Y., Fu, M., Nogueira, S.O., Kyriakos, C.N., Mons, U., Trofor, A., Zatoński, W.A., Przewoźniak, K., Demjén, T., Tountas, Y., Quah, A.C.K., Fong, G.T., Fernández, E., Vardavas, C.I., on behalf of the EUREST-PLUS Consortium. (2019). Secondhand exposure to e-cigarette aerosols among smokers: a cross-sectional study in six European countries of the EUREST-PLUS ITC Survey. Tobacco Induced Disease, 16(Suppl 2), 124-134.

Abstract

Introduction: Electronic cigarette (e-cigarette) use has grown significantly in some European Union (EU) Member States (MS). A better understanding of the exposure to secondhand e-cigarette aerosols (SHA) is necessary to develop and implement comprehensive regulations on e-cigarette use in public places. This study aims to assess the observation of e-cigarette use in public places, the self-reported exposure to SHA, and the level of users’ comfort using e-cigarettes in the presence of others.

Methods: This is a cross-sectional study of the Wave 1 International Tobacco Control 6 European Countries Survey recruiting adult smokers (n=6011) across six EU MS: Germany, Greece, Hungary, Poland, Romania, and Spain, within the EURESTPLUS Project. A descriptive analysis was conducted to estimate the prevalence (%) of observed e-cigarette use in different places, frequency of self-reported exposure to SHA, and level of comfort using e-cigarettes in the presence of others.

Results: In all, 31.0% of smokers observed others using e-cigarette in public places, 19.7% in indoor places where smoking is banned, and 14.5% indoors at work. Almost 37% of smokers reported to be ever exposed to SHA, ranging from 17.7% in Spain to 63.3% in Greece. The higher prevalence of observed ecigarette use and passive exposure to SHA was reported by smokers of younger age, of higher educational level and those being current or former e-cigarette users. Part (8.8%) of the smokers who were also e-cigarette users reported feeling uncomfortable using e-cigarettes in the presence of others.

Conclusions: A third of smokers from six EU MS reported being exposed to SHA. Prevalence differences were observed among the countries. In the context of scarce evidence on long-term health effects of exposure to SHA, precautionary regulations protecting bystanders from involuntary exposure should be developed.

Citation

Nogueira, S., Tigova, O., Castellano, Y., Mons, U., Kyriakos, C.N., McNeill, A., Trofor, A., Zatoński, W.A., Przwozniak, K., Demjén, T., Tountas, Y., Quah, A.C.K., Fong, G.T., Fu, M., Vardavas, C.I., Fernández, E., on behalf of the EUREST-PLUS Consortium. (2019). Cigarette brand loyalty among smokers in six European countries: findings from the EUREST-PLUS ITC Survey. Tobacco Induced Diseases, 16(Suppl 2), 135-144.

Abstract

Introduction: This study aims to describe the degree of smokers’ loyalty to a specific brand of tobacco products and the variables related to choosing a specific brand among smokers in six European countries.

Methods: A cross-sectional analysis was conducted for a representative sample of adult smokers from Germany, Greece, Hungary, Poland, Romania, and Spain (approximately 1000 smokers per country). The prevalence of smokers’ having a usual brand of cigarettes smoked (factory-made or roll-yourown cigarettes), the brand of choice, the factors for choosing a specific brand and the degree of loyalty to that brand (not at all, a little, somewhat and a lot) were assessed by country, sociodemographics and smoking-related variables.

Results: In total, 86.6% of the smokers reported having a usual brand. In three out of the six countries, one brand holds the loyalty of between 17.8% and 24.5% of the smokers that reported having a usual brand for factory-made cigarettes. Most participants reported being loyal ‘a lot’ to their brand of choice (44.4%). The reasons most reported for choosing a cigarette brand were the taste (83.2%) and the price (51.7%).

Conclusions: Brand loyalty is high among factory-made and roll-your-own cigarette smokers in six European countries. Future research on longitudinal trends of brand loyalty to evaluate the effect of tobacco control policies in these European countries is warranted.

Citation

East, K., Hitchman, S.C., McDermott, M., McNeill, A., Herbeć, A., Tountas, Y., Bécuwe, N., Demjén, T., Fu, M., Fernández, E., Mons, U., Trofor, A., Zatoński, W., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2019). Social norms towards smoking and electronic cigarettes among adult smokers in seven European Countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 172-183.

Abstract

Introduction: This study explores whether current smokers’ social norms towards smoking and electronic cigarettes (e-cigarettes) vary across seven European countries alongside smoking and e-cigarette prevalence rates. At the time of surveying, England had the lowest current smoking prevalence and Greece the highest. Hungary, Romania and Spain had the lowest prevalence of any e-cigarette use and England the highest.

Methods: Respondents were adult (≥18 years) current smokers from the 2016 EUREST-PLUS ITC (Romania, Spain, Hungary, Poland, Greece, Germany) and ITC 4CV England Surveys (N=7779). Using logistic regression, associations between country and (a) smoking norms and (b) e-cigarette norms were assessed, adjusting for age, sex, income, education, smoking status, heaviness of smoking, and ecigarette status.

Results: Compared with England, smoking norms were higher in all countries: reporting that at least three of five closest friends smoke (19% vs 65–84% [AOR=6.9–24.0; Hungary–Greece]), perceiving that people important to them approve of smoking (8% vs 14–57% [1.9–51.1; Spain–Hungary]), perceiving that the public approves of smoking (5% vs 6–37% [1.7–15.8; Spain–Hungary]), disagreeing that smokers are marginalised (9% vs 16–50% [2.3–12.3; Poland–Greece]) except in Hungary. Compared with England: reporting that at least one of five closest friends uses e-cigarettes was higher in Poland (28% vs 36% [2.7]) but lower in Spain and Romania (28% vs 6–14% [0.3–0.6]), perceiving that the public approves of e-cigarettes was higher in Poland, Hungary and Greece (32% vs 36–40% [1.5–1.6]) but lower in Spain and Romania in unadjusted analyses only (32% vs 24–26%), reporting seeing e-cigarette use in public at least some days was lower in all countries (81% vs 12–55% [0.1–0.4]; Spain–Greece).

Conclusions: Smokers from England had the least pro-smoking norms. Smokers from Spain had the least pro-e-cigarette norms. Friend smoking and disagreeing that smokers are marginalised broadly aligned with country-level current smoking rates. Seeing e-cigarette use in public broadly aligned with countrylevel any e-cigarette use. Generally, no other norms aligned with product prevalence.

Citation

Fu, M., Castellano, Y., Tigova, O., Mons, U., Agar, T., Kyriakos, C.N., Quah, A.C.K., Fong, G.T., Trofor, A.C., Przewoźniak, K., Zatoński, W.A., Demjén, T., Tountas, Y., Vardavas, C.I., Fernández, E., on behalf of the EUREST-PLUS Consortium. (2019). Correlates of the support for smoke-free policies among smokers: A cross-sectional study in six European countries of the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 193-202.

Abstract

Introduction: This report describes the support for smoke-free policies in different settings among smokers in six European countries and the relationship between their opinions about the places where smoking should be banned and their beliefs about the harms of secondhand smoke to non-smokers.

Methods: A cross-sectional survey (the ITC 6 European Country Survey, part of the EUREST-PLUS Project) was conducted using nationally representative samples of adult smokers in Germany, Greece, Hungary, Poland, Romania and Spain (n=6011). We describe the prevalence of agreement and support for smoke-free policies in different settings according to sociodemographics, smoking characteristics and beliefs about the danger of secondhand smoke to non-smokers.

Results: There was high agreement with smoking regulations in cars with preschool children and in schoolyards of primary/secondary schools (>90% overall) and low agreement with banning smoking in outdoor terraces of bars/pubs (8.6%; 95%CI: 7.5%-9.8%) and restaurants (10.1%; 95%CI: 8.9%-11.4%). The highest support for complete smoking bans inside public places came from smokers in Poland, among women, people aged ≥25 years, who had low nicotine dependence, and who tried to quit smoking in the last 12 months. About 78% of participants agreed that tobacco smoke is dangerous to nonsmokers, ranging from 63.1% in Hungary to 88.3% in Romania; the highest agreement was noted among women, the 25-54 age groups, those with higher education, low cigarette dependence, and those who tried to quit in the last 12 months. The support for complete smoking bans in public places was consistently higher among smokers who agreed that secondhand smoke is dangerous to non-smokers.

Conclusions: Smokers in six European countries declared strong support for smoke-free policies in indoor settings and in settings with minors but low support in outdoor settings, particularly leisure facilities. More education is needed to increase the awareness about the potential exposure to secondhand smoke in specific outdoor areas.

Citation

Fu, M., Castellano, Y., Tigova, O., Mons, U., Agar, T., Kyriakos, C.N., Trofor, A.C., Quah, A.C.K., Fong, G.T., Przewoźniak, K., Zatoński, W.A., Demjén, T., Tountas, Y., Vardavas, C.I., Fernández, E., on behalf of the EUREST-PLUS Consortium. (2019). Smoking in public places in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 203-209.

Abstract

Introduction: Surveillance of tobacco consumption in public places is an important measure to evaluate the impact of tobacco control interventions over time. The objective of this study was to estimate the prevalence of smoking as seen by smokers and their smoking behaviour in public places, in six European countries.

Methods: We used baseline data of the International Tobacco Control Six European countries (ITC 6E) Survey, part of the EUREST-PLUS Project, conducted in 2016 in national representative samples of about 1000 adult smokers aged 18 years and older in Germany, Greece, Hungary, Poland, Romania and Spain. For each setting (workplaces, restaurants, bars/pubs and discos) participants were asked whether they had seen someone smoking during their last visit there and whether they too had smoked there. We report the overall and by-country weighted prevalence of seeing someone smoking and the smokers’ own smoking behaviour at each setting. We also assess the relationship between seeing someone smoking and smoking themselves at these settings.

Results: The prevalence of smoking as seen by smokers was 18.8% at workplaces, with high variability among countries (from 4.7% in Hungary to 40.8% in Greece). Among smokers visiting leisure facilities in the last year, during their last visit 22.7% had seen someone smoking inside restaurants and 12.2% had smoked themselves there, while for bars/pubs the corresponding prevalences were 33.9% and 20.4%, and inside discos 44.8% and 34.8%.

Conclusions: Smoking is still prevalent at leisure facilities, particularly at discos in Europe, with high variability among countries. More extensive awareness campaigns and stricter enforcement are needed to increase the compliance of smokefree regulations, especially in leisure facilities.

Citation

Nargis, N., Zheng, R., Xu, S.S., Fong, G.T., Feng, G., Jiang, Y., Wang, Y., Hu, X. (2019). Cigarette affordability in China, 2006-2015: Findings from the ITC China Survey. International Journal of Environmental Research and Public Health, 16(7), 1205.

Abstract

China is world’s largest market of machine-made cigarettes. In 2015, more than 315 million or around 26.9% of the adult population in China were smokers—50.6% among men and 2.2% among women. Growing affordability of cigarettes led to increased cigarette consumption in China to the detriment of public health. This study investigated whether the level and growth in cigarette affordability in China was equally shared by smokers from all demographic and socio-economic statuses (SES) and across all price tiers of cigarette brands. The data came from the urban smoker sample (≥18 years) of the International Tobacco Control China Surveys conducted in five waves over 2006–2015. Cigarette affordability was measured by Relative Income Price—percentage of per capita household income needed to purchase 100 cigarette packs of the last purchased brand. Overall and group-specific trends in affordability by age, gender, SES (e.g., income, education, and employment status), and price tiers were analyzed using generalized estimating equations method. Cigarette affordability was higher among older, female, and higher-SES smokers, and for cheaper brands. It increased overall and across all groups over time. The increase was significantly larger among younger and lower-SES smokers, a trend that poses an added challenge to tobacco control and health equity. To reduce cigarette affordability and consumption among these vulnerable groups, a uniform specific excise system should be introduced in place of the existing tiered ad valorem excise. The specific excise should be periodically adjusted to inflation and per capita income growth observed among younger and lower-SES people, who can potentially experience faster income growth than the national average. The excise tax policy can also be complimented with minimum price regulations and restrictions on price promotions.