Citation

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

Abstract

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

Citation

Kaai, S.C., Fong, G.T., Goma, F., Meng, G., Ikamari, L., Ong’ang’o, J.R., Elton-Marshall, T. (2019). Identifying factors associated with quit intentions among smokers from two nationally representative samples in Africa: Findings from the ITC Kenya and Zambia Surveys. Preventive Medicine Reports, 15(2019), 100951.

Abstract

It is well established that intentions to quit smoking is the strongest predictor of future quit attempts. However, most studies on quit intentions have been conducted in high-income countries with very few in low- and middle-income countries particularly in Africa. This is the first population-based study to compare factors associated with quit intentions among smokers in two African countries. Data were from the International Tobacco Control (ITC) Kenya and Zambia Surveys (2012), face-to-face surveys of nationally representative samples of 2291 adult smokers (Kenya = 1103; Zambia = 1188). Multivariate logistic regression analyses were conducted to identify predictors of quit intentions. Most Kenyan (65.1%) and Zambian (69.1%) smokers had quit intentions of which 54.8% planned to quit within the next 6 months. Five factors were significantly associated with quit intentions in both countries: being younger, having tried to quit previously, perceiving that quitting is beneficial to health, worrying about future health consequences of smoking, and being low in nicotine dependence. The predictive strength of these factors did not differ in the two countries. Four additional factors were significant predictors in Zambia only: having a quit attempt lasting six months or more, lower smoking enjoyment, having a negative opinion about smoking, and concern about cigarette expenses. The factors predicting quit intentions were similar to those in other ITC countries including Canada, US, UK, China and Mauritius. These findings highlight the need for stronger tobacco control policies in Kenya and Zambia including increased taxation, greater access to cessation services, and anti-smoking campaigns denormalizing tobacco use.

Citation

McKiernan, A., Stanley, J., Waa, A.M., Kaai, S.C., Quah, A.C.K., Fong, G.T., Edwards, R. (2019). Beliefs among adult smokers and quitters about nicotine and de-nicotinized cigarettes in the 2016-17 ITC New Zealand Survey. Tobacco Regulatory Science, 5(5), 400-409.

Abstract

Objectives: We sought to explore understanding of addiction and nicotine, as well as support and interest in low-nicotine cigarettes among New Zealand (NZ) smokers and recent quitters.

Methods: Data came from wave 1 (August 2016-April 2017) of the International Tobacco Control (ITC) NZ Survey, comprising 1090 smokers and recent quitters, including 363 identifying as Māori (the NZ indigenous population).

Results: Most participants (74%) were interested in trying low-nicotine or nicotine-free cigarettes and 80% supported introducing a law to reduce nicotine in cigarettes and tobacco if nicotine was available through alternative products. Support was similar among demographic groups, smokers, recent quitters, and daily and occasional smokers. Nearly all participants believed smoking is addictive and nicotine is the major cause of addiction. Almost half erroneously thought nicotine is the main cause of cancer from cigarettes.

Conclusions: Findings suggest that introducing mandated low-nicotine cigarettes could be feasible in NZ where alternative nicotine delivery products are widely available. However, implementation may need to be accompanied by public education to correct misperceptions about the harmfulness of nicotine and to encourage switching to alternative nicotine delivery products among smokers who cannot quit nicotine completely.

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

van Mourik, D.A., Nagelhout, G., can den Putte, B., Hummel, K., Willemsen, M.C., de Vries, H., (2019). Did e-cigarette users notice the new European Union’s e-cigarette legislation? Findings from the 2015–2017 International Tobacco Control (ITC) Netherlands Survey. International Journal of Environmental Research and Public Health, 16(16), 2917.

Abstract

This study examined to what extent e-cigarette users noticed the European Union’s new legislation regarding e-cigarettes, and whether this may have influenced perceptions regarding addictiveness and toxicity. Data were obtained from yearly surveys (2015–2017) of the International Tobacco Control (ITC) Netherlands Survey. Descriptive statistics and Generalized Estimating Equations were applied. About a third of the e-cigarette users noticed the text warning (28%) and the leaflet (32%). When compared to tobacco-only smokers, e-cigarette users showed greater increases in perceptions regarding addictiveness (β = 0.457, p = 0.045 vs. β = 0.135, p < 0.001) and toxicity (β = 0.246, p = 0.055 vs. β = 0.071, p = 0.010). In conclusion, the new legislation’s noticeability should be increased.

Citation

Park, E., Cho, S., Seo, H.G., Kim, Y., Jung, H.S., Fong, G.T., Quah, A.C.K. (2019). Attitudes of Korean smokers toward smoke-free public places: Findings from the longitudinal ITC Korea Survey, 2005-2010. BMJ Open, 9, e025298.

Abstract

Objective: Prior to December 2012, restaurants in South Korea were required to implement only partial smoking bans. This study documents the changes in Korean smokers' attitudes towards smoking bans between 2005 and 2010 and explores the effects of anti-smoking advertising as a correlate of support for total smoking bans in public places.

Design: Longitudinal cohort study of Korean adult smokers.

Settomg: The data were derived from three waves (2005, 2008 and 2010) of the International Tobacco Control (ITC) Korea Survey.

Participants: The ITC Korea Survey respondents were a probability-based, nationally representative sample of Korean smokers aged 19 and older. The current analysis includes 995 smokers who participated in Wave 1 (2005), 1737 smokers who participated in Wave 2 (2008) and 1560 smokers who participated in Wave 3 (2010).

Primary and Secondary Outcome Measures: Changes in respondents' awareness of secondhand smoke (SHS) harm, attitudes towards smoking bans and personal rules for smoking in private homes and/or vehicles were analysed. Correlates of support for smoking bans in public places were examined using generalised estimating equation regression models.

Results: More than 80% of Korean smokers are aware of the harms of SHS. The proportion of smokers who support smoke-free restaurants or smoke-free bars increased twofold between 2005 and 2010. Smokers who were aware of the dangers of SHS were more likely to support a total smoking ban in workplaces. Noticing anti-smoking advertising or information was not significantly associated with support for a total smoking ban in public places.

Conclusions: Korean smokers became more supportive of smoking bans in public places between 2005 and 2008. These results show that smokers' attitudes towards smoking bans can change with the implementation of smoke-free policies, even in a country that has a high prevalence of smokers.

Citation

Smith, T., Heckman, B.W., Wahlquist, A, Cummings, K.M., Carpenter, M.J. (2019). The impact of e-liquid propylene glycol and vegetable glycerin ratio on rating of subjective effects, reinforcements value, and use in current smokers. Nicotine and Tobacco Research, 22(5), 791-797.

Abstract

Introduction: Electronic nicotine delivery systems (ENDS) vary on a wide range of characteristics that may affect reinforcement value and use. One characteristic is the ratio of two solvents commonly used in most e-liquids: propylene glycol (PG) and vegetable glycerin (VG). The goal of this study was to understand how PG/VG ratio affects subjective effects, reinforcement value, and tobacco use patterns among current smokers who try using ENDS.

Aims and methods: Current smokers with minimal ENDS use history (n = 30) sampled, in a double-blind fashion, three different e-liquids that varied in PG/VG ratio (70/30, 50/50, 0/100) while holding constant other aspects of the e-liquid and ENDS. Participants tried each e-liquid before rating the subjective effects on a modified version of the Cigarette Evaluation Questionnaire. Reinforcement value was assessed using a preference task where participants chose between the three e-liquids. The impact of each e-liquid on cigarette reinforcement was assessed using a modified version of the Cigarette Purchase Task. Participants were randomly assigned to receive one e-liquid to take home for 1 week. Results: PG/VG ratio had minimal impact on most of the tested outcomes. Participants rated the highest PG concentration as having a stronger throat hit than the other two. There was no significant difference between the number of participants who preferred each of the PG/VG ratios in the preference assessment. PG/VG ratio did not affect cigarette or ENDS use during the sampling week.

Conclusions: These data suggest that PG/VG ratio has minimal impact on subjective effects and reinforcement value in ENDS naive current smokers. Implications: These data suggest that PG/VG ratio, within the range that is commonly used, has minimal impact on subjective effects, reinforcement value, or uptake in current smokers with minimal ENDS experience.

Citation

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

Abstract

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

Citation

Passos, V.L., Crutzen, R., Feder, J., Willemsen, M.C., Lemmens, P., Hummel, K. (2019). Dynamic, data-driven typologies of long-term smoking, cessation and their correlates: Findings from the International Tobacco Control (ITC) Netherlands Survey. Social Science & Medicine, 235(2019), 112393.

Abstract

Rationale: Efforts towards tobacco control are numerous, but relapse rates for smoking cessations remain high. Behavioral changes necessary for continuous cessation appear complex, variable and subject to social, biological, psychological and environmental determinants. Currently, most cessation studies concentrate on short-to midterm behavioral changes. Besides, they use fixed typologies, thereby failing to capture the temporal changes in smoking/cessation behaviors, and its determinants.

Objective: To obtain long-term, data-driven longitudinal patterns or profiles of smoking, cessation, and related determinants in a cohort of adult smokers, and to investigate their dynamic links. Methods: The dataset originated from the International Tobacco Control (ITC) Netherlands Project, waves 2008 to 2016. Temporal dynamics of smoking/cessation, psychosocial constructs, and time-varying determinants of smoking were extracted with Group-Based Trajectory Modeling technique. Their associations were investigated via multiple regression models.

Results: Substantial heterogeneity of smoking and cessation behaviors was unveiled. Most respondents were classified as persistent smokers, albeit with distinct levels of consumption. For a minority, cessation could be sustained between 1 and 8 years, while others showed relapsing or fluctuating smoking behavior. Links between smoking/cessation trajectories with those of psychosocial and sociodemographic variables were diverse. Notably, changes in two variables were aligned to behavioral changes towards cessation: decreasing number of smoking peers and attaining a higher self-perceived control.

Conclusion: The unveiled heterogeneity of smoking behavior over time and the varied cross-dependencies between smoking data-driven typologies and those of underlying risk factors underscore the need of individually tailored approaches for motivational quitting.

Citation

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

Abstract

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

Design: Repeat cross sectional surveys.

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

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

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

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

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

Citation

Chung-Hall, J., Craig, L.V., Gravely, S., Sansone, N., Fong, G.T. (2019). Impact of the WHO FCTC over the first decade: a global evidence review prepared for the Impact Assessment Expert Group. Tobacco Control, 28(Suppl 2), S119-128.

Abstract

Objective: To present findings of a narrative review on the implementation and effectiveness of 17 Articles of the WHO Framework Convention on Tobacco Control (FCTC) during the Treaty’s first decade.

Data sources: Published reports on global FCTC implementation; searches of four databases through June 2016; hand-search of publications/online resources; tobacco control experts.

Study selection: WHO Convention Secretariat global progress reports (2010, 2012, 2014); 2015 WHO report on the global tobacco epidemic; studies of social, behavioural, health, economic and/or environmental impacts of FCTC policies.

Data extraction: Progress in the implementation of 17 FCTC Articles was categorised (higher/intermediate/lower) by consensus. 128 studies were independently selected by multiple authors in consultation with experts.

Data synthesis: Implementation was highest for smoke-free laws, health warnings and education campaigns, youth access laws, and reporting/information exchange, and lowest for measures to counter industry interference, regulate tobacco product contents, promote alternative livelihoods and protect health/environment. Price/tax increases, comprehensive smoking and marketing bans, health warnings, and cessation treatment are associated with decreased tobacco consumption/health risks and increased quitting. Mass media campaigns and youth access laws prevent smoking initiation, decrease prevalence and promote cessation. There were few studies on the effectiveness of policies in several domains, including measures to prevent industry interference and regulate tobacco product contents.

Conclusions: The FCTC has increased the implementation of measures across several policy domains, and these implementations have resulted in measurable impacts on tobacco consumption, prevalence and other outcomes. However, FCTC implementation must be accelerated, and Parties need to meet all their Treaty obligations and consider measures that exceed minimum requirements.

Citation

Lozano, P., Arillo-Santillán, E., Barrientos-Gutiérrez, I., Zavala-Arciniega, L., Reynales-Shigematsu, L. M., & Thrasher, J. F. (2019). E-cigarette use and its association with smoking reduction and cessation intentions among Mexican smokers. Salud Pública de México, 61(3), 276-285. doi: 10.21149/9797.

Abstract

Objective: Evaluate the patterns of e-cigarette use andtheir association with smoking behavior.

Materials and methods: We analyzed data from a population-based representative cohort of adult smokers who participated in the International Tobacco Control Policy Evaluation Surveys in Mexico. The analytic sample (n=760) was restricted to participants who were followed up from wave 6 (2012) to wave 7 (2014-2015). GEE models regressed e-cigarette use at follow-up and changes in cigarettes per day (CPD) between waves, on baseline sociodemographic variables, smoking status (daily, non-daily, quit), e-cigarette trial, and quit intentions.

Results: Smokers who were younger, had a higher income, and had tried e-cigarettes at baseline were more likely to be current e-cigarette users at follow-up. Ecigarette use at follow-up was not associated with a change in CPD over time.

Conclusions: E-cigarette use does not appear to have promoted smoking cessation or reduction in this sample of Mexican smokers.

Citation

Craig, L., Fong, G.T., Chung-Hall, J., Puska, P. (2019). The impact of the WHO FCTC on tobacco control: Perspectives from stakeholders in 12 countries. Tobacco Control, 28(Suppl 2),S129-135.

Abstract

Background: The WHO Framework Convention on Tobacco Control (WHO FCTC), the first WHO treaty, entered into force in 2005. In April 2015, a seven-member independent expert group (EG) was established by a decision of the FCTC Conference of the Parties to assess the impact of the Treaty in its first decade. One component of the EG’s methodology was to gather evidence on WHO FCTC impact from Parties themselves. This paper presents findings from 12 country missions on how the FCTC impacted progress on tobacco control.

Methods: Between November 2015 and May 2016, EG members conducted missions in 12 countries representing each of the six WHO regions and the four World Bank economic development levels. In each country, the EG interviewed a broad range of stakeholders to assess the extent to which the FCTC had contributed to tobacco control. The primary objective was to assess whether tobacco control measures would have been developed or passed, or implemented at all, or as quickly, if there had been no FCTC. Through this counterfactual inquiry, the EG sought to determine the FCTC’s causal role.

Conclusion: The FCTC was reported to have made contributions along the entire policy/regulation process: the development of a measure, building legislative and political support for a measure and its implementation. These stakeholder perspectives support the conclusion that the FCTC has played a pivotal role in accelerating and strengthening the implementation of tobacco control measures, although tobacco industry interference continues to be a significant obstacle to further advancement.

Citation

Heckman, B.W., Cummings, K.M., El Nahas, G., Willemsen, M.C., O’Connor, R.J., Borland, R., Hirsch, A.A., Bickel, W.K., Carpenter, C.M. (2019). Behavioral economic purchase tasks to estimate demand for novel nicotine/tobacco products and prospectively predict future use: Evidence from the Netherlands. Nicotine and Tobacco Research, 21(6), 784-791.

Abstract

Introduction: The demand for alternative nicotine/tobacco products is not well established. This paper uses a behavioral economic approach to test whether smokers have differential demand for conventional factory-made, electronic, and very low nicotine content cigarettes (FMCs/ECs/VLNCs) and uses the prospective cohort design to test the predictive validity of demand indices on subsequent use of commercially available FMCs and Ecs.

Methods: Daily smokers (≥16 years) from the Netherlands completed an online survey in April 2014 (N = 1215). Purchase tasks were completed for FMCs, ECs, and VLNCs. Participants indicated the number of cigarettes they would consume in 24 h, across a range of prices (0-30 euro). The relationship between consumption and price was quantified into four indices of demand (intensity, Pmax, breakpoint, and essential value). A follow-up survey in July 2015 measured FMC and EC use. Results: At baseline, greater demand was observed for FMCs relative to ECs and VLNCs across all demand indices, with no difference between ECs and VLNCs. At follow-up, greater baseline FMC demand (intensity, essential value) was associated with lower quit rates and higher relapse. EC demand (Pmax, breakpoint, essential value) was positively associated with any EC use between survey waves, past 30 day EC use, and EC purchase between waves.

Conclusions: Smokers valued FMCs more than ECs or VLNCs, and FMCs were less sensitive to price increases. Demand indices predicted use of commercially available products over a 15 month period. To serve as viable substitutes for FMCs, ECs and VLNCs will need to be priced lower than FMCs.

Implications: Purchase tasks can be adapted for novel nicotine/tobacco products as a means to efficiently quantify demand and predict use. Among current daily smokers, the demand for ECs and VLNCs is lower than FMCs.

Citation

Thompson, M.E. (2019). Combining data from new and traditional sources in population surveys. International Statistical Review, 87(S1), S79-89.

Abstract

This paper is a review of some applications of the combination of data sets, such as combining census or administrative data and survey data, constructing expanded data sets through linkage, combining largescale commercial databases with survey data and harnessing designed data collection to be able to make use of non-probability samples. It is aimed to highlight their commonalities and differences and to formulate some general principles for data set combination.

Citation

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

Abstract

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

Citation

Stoklosa, M., Goma, F., Nargis, N., Drope, J., Chelwa, C., Chisha, Z., Fong, G.T. (2019). Price, tax and tobacco product substitution in Zambia: Findings from the ITC Zambia Survey. Tobacco Control, 28(Suppl 1), S45-S52.

Abstract

Background: In Zambia, the number of cigarette users is growing, and the lack of strong tax policies is likely an important cause. When adjusted for inflation, levels of tobacco tax have not changed since 2007. Moreover, roll-your-own (RYO) tobacco, a less-costly alternative to factory-made (FM) cigarettes, is highly prevalent.

Data and methods: We modelled the probability of FM and RYO cigarette smoking using individual-level data obtained from the 2012 and 2014 waves of the International Tobacco Control (ITC) Zambia Survey. We used two estimation methods: the standard estimation method involving separate random effects probit models and a method involving a system of equations (incorporating bivariate seemingly unrelated random effects probit) to estimate price elasticities of FM and RYO cigarettes and their cross-price elasticities.

Results: The estimated price elasticities of smoking prevalence are −0.20 and −0.03 for FM and RYO cigarettes, respectively. FM and RYO are substitutes; that is, when the price of one of the products goes up, some smokers switch to the other product. The effects are stronger for substitution from FM to RYO than vice versa.

Conclusions: This study affirms that increasing cigarette tax with corresponding price increases could significantly reduce cigarette use in Zambia. Furthermore, reducing between-product price differences would reduce substitution from FM to RYO. Since RYO use is associated with lower socioeconomic status, efforts to decrease RYO use, including through tax/price approaches and cessation assistance, would decrease health inequalities in Zambian society and reduce the negative economic consequences of tobacco use experienced by the poor.

Citation

Nargis, N., Stoklosa, M., Drope, J., Fong, G.T., Quah, A.C.K., Driezen, P., Chaloupka, F.J., Shang, C. (2019). Trend in the affordability of tobacco products in Bangladesh: Findings from the International Tobacco Control Bangladesh Survey. Tobacco Control, 28(Suppl1), S20-S30.

Abstract

Background: The price of tobacco products in relation to the income of tobacco users—affordability—is recognised as a key determinant of tobacco use behaviour. The effectiveness of a price increase as a deterrent to tobacco use depends on how much price increases in relation to the income of the potential users. The aim of this paper is to examine the distribution of and trends in the affordability of tobacco products in Bangladesh.

Method: Using four waves of International Tobacco Control Survey data on Bangladesh, this study measures affordability of tobacco products at the individual level as the ratio of self-reported price and self-reported income. The trends in affordability by brand categories of cigarettes and of bidi and smokeless tobacco are estimated using multivariate linear regression analysis.

Results: Despite significant increase in price, the affordability of cigarettes increased between 2009 and 2014–2015 due to income growth outpacing price increase. The increase was disproportionately larger for more expensive brands. The affordability of bidis increased over this period as well. The affordability of smokeless tobacco products remained unchanged between 2011–2012 and 2014–2015.

Conclusion: The tax increases that were implemented during 2009–2015 were not enough to increase tobacco product prices sufficiently to outweigh the effect of income growth, and to reduce tobacco consumption. The findings from this research inform policymakers that in countries experiencing rapid economic growth, significant tax increases are needed to counteract the effect of income growth, in order for the tax increases to be effective in reducing tobacco use.

Citation

van den Brand, F., Nagelhout, G.E., Hummel, K., Willemsen, M.C., McNeill, A., van Schayck, O. (2019). Does free or lower cost smoking cessation medication stimulate quitting? Findings from the International Tobacco Control (ITC) Netherlands and United Kingdom Surveys. Tobacco Control, 28(Suppl 1), S61-S67.

Abstract

Objective: To investigate whether mentioning free or lower cost smoking cessation medication as a trigger for thinking about quitting is related to higher medication use, more quit attempts and quit success, and whether these associations are modified by education and income.

Methods: Data were derived from the 2013 and 2014 surveys of the International Tobacco Control Netherlands (n=1164) and UK (n=768) cohort. Logistic regression analyses were used to assess associations between mentioning in 2013 that free/lower cost smoking cessation medication was a trigger for thinking about quitting smoking and the use of medication, quit attempts and smoking cessation in 2014.

Results: 37.0% of smokers in the UK and 24.9% of smokers in the Netherlands mentioned free/lower cost medication as a trigger for thinking about quitting. Smokers who mentioned this trigger were more likely to have used cessation medication during a quit attempt both in the UK (OR=4.19, p<0.001) and in the Netherlands (OR=2.14, p=0.033). The association between mentioning free/lower cost medication as a trigger for thinking about quitting and actual quit attempts was significant in the UK (OR=1.45, p=0.030), but not in the Netherlands (OR=1.10, p=0.587). There was no significant association with quit success. Associations did not differ across income and education groups.

Conclusion: Free/lower cost smoking cessation medication may increase the use of cessation medication and stimulate quit attempts among smokers with low, moderate and high education and income.

Citation

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

Abstract

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

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

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

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

Citation

Xu, S.S., Gravely, S., Meng, G., Elton-Marshall, T., O’Connor, R.J., Quah, A.C.K., Feng, G., Jiang, Y., Hu, G., Fong, G.T. (2019). Impact of China National Tobacco Company’s ‘premiumization’ strategy: Longitudinal findings from the ITC China Project (2006-2015). Tobacco Control, 28(Suppl 1), S68-S76.

Abstract

Background: In 2009, the China National Tobacco Company (CNTC) began their Premiumization Strategy, designed to encourage smokers to trade up to more expensive brands, mainly by promoting the concept that higher class cigarettes are better quality and less harmful. This study is the first evaluation of the strategy’s impact on: (1) prevalence of premium brand cigarettes (PBC), mid-priced brand cigarettes (MBC) and discount brand cigarettes (DBC) over 9 years, from 3 years pre-strategy (2006) to 6 years post-strategy (2015); and (2) changes in reasons for choosing PBCs, MBCs and DBCs.

Methods: A representative cohort of adult Chinese smokers (n=9047) in seven cities who participated in five waves of the International Tobacco Control (ITC) China Survey: pre-implementation (Wave 1 (2006; n=3452), Wave 2 (2007–2008; n=3586)); mid-implementation (Wave 3 (2009; n=4172)); and post-implementation (Wave 4 (2011–2012; n=4070), Wave 5 (2013–2015; n=2775)). Generalised estimating equations were conducted to examine changes in prevalence of PBCs, MBCs and DBCs, and reasons for brand choice from pre-implementation to post-implementation.

Results: From pre-implementation to post-implementation, there was an increase in prevalence of PBCs (5.4% to 23.2%, p<0.001) and MBCs (40.0% to 50.4%, p<0.001), and a decrease in DBCs (54.6% to 26.5%, p<0.001). There was an increase in smokers who chose their current brand because they believed it to be less harmful, both for MBC smokers (+13.0%, p=0.001) and PBC smokers (+9.0%, p=0.06). There was an increase for smokers in all brand classes for choosing their current brand because they were ‘higher in quality’ and because of affordable price, but the greatest increase was among PBC smokers (+18.6%, p<0.001 and +34.9%, p<0.001, respectively).

Conclusions: Our findings demonstrate that the rising trend in Chinese smokers’ choice of ‘less harmful’, ‘higher quality’ and ‘affordable’ cigarettes, particularly PBCs, is likely due to CNTC’s aggressive marketing strategies. Strong tobacco control policies that prohibit CNTC’s marketing activities are critical in order to dispel erroneous beliefs that sustain continued smoking in China, where the global tobacco epidemic is exerting its greatest toll.

Citation

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

Abstract

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