Citation

Thompson, M.E., Fong, G.T., Hammond, D., Boudreau, C., Driezen, P., Hyland, A., Borland, R., Cummings, K.M., Hastings, G., Siahpush, M., MacKintosh, A.M., Laux, F. (2006). Methods of the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii12-iii18.

Abstract

This paper outlines the design features, data collection methods and analytic strategies of the International Tobacco Control (ITC) Four Country Survey, a prospective study of more than 2000 longitudinal respondents per country with yearly replenishments. This survey possesses unique features that sets it apart among surveys on tobacco use and cessation. One of these features is the use of theory-driven conceptual models. In this paper, however, the focus is on the two key statistical features of the survey: longitudinal and “quasi-experimental” designs. Although it is often possible to address the same scientific questions with a cross-sectional or a longitudinal study, the latter has the major advantage of being able to distinguish changes over time within individuals from differences among people at baseline (that is, differences between age and cohort effects). Furthermore, quasi-experiments, where countries not implementing a given new tobacco control policy act as the control group to which the country implementing such a policy will be compared, provide much stronger evidence than observational studies on the effects of national-level tobacco control policies. In summary, application of rigorous research methods enables this survey to be a rich data resource, not only to evaluate policies, but also to gain new insights into the natural history of smoking cessation, through longitudinal analyses of smoker behaviour.

Citation

Siahpush, M., McNeill, A., Hammond, D., Fong, G.T. (2006). Socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: Results from the 2002 International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii65-iii70.

Abstract

Background: Socioeconomic status is strongly associated with smoking prevalence and social class differences contribute substantially to social inequalities in mortality. This research investigated socioeconomic and country variations in smokers’ knowledge that smoking causes heart disease, stroke, impotence and lung cancer, that smoke contains cyanide, mercury, arsenic and carbon monoxide, and whether nicotine causes most of the cancer.

Methods: Data were from the International Tobacco Control (ITC) Four Country Survey, a cohort survey of over suppl_ adult smokers from four countries: the United States, Canada, the United Kingdom, and Australia. Data were collected via telephone interviews in 2002.

Results: Higher education and income were associated with higher awareness. For example, the odds of knowing that smoking causes heart disease, stroke and lung cancer were respectively 71%, 34% and 83% larger for respondents with high versus low income. The odds of knowing that smoke contains cyanide, mercury, arsenic and carbon monoxide were respectively 66%, 26%, 44% and 108% larger for respondents with a university degree than those with a high school diploma or lower level of education. Results also revealed that awareness of harms of smoking was generally the highest in Canada and the lowest in the UK.

Conclusions: Lower socioeconomic status was associated with lower awareness of the harms of smoking and misunderstanding around nicotine. There is a need to improve knowledge of the dangers of smoking among the disadvantaged segments of the population.

Citation

Borland, R., Yong, H.H., Cummings, K.M., Hyland, A., Anderson, S., Fong, G.T. (2006). Determinants and consequences of smoke-free homes: Findings from the International Tobacco Control (ITC) Four Country Survey.Tobacco Control, 15(Suppl 3), iii42-iii50.

Abstract

Objective: To report on prevalence, trends and determinants of smoke-free home policies in smokers’ homes in different countries and to estimate the effects of these policies on smoking cessation.

Design: Two waves of the International Tobacco Control (ITC) Four Country Survey (ITC-4), a cohort survey of smokers conducted by telephone. Wave 1 was conducted in October/December 2002 with broadly representative samples of over 2000 adult (⩾ 18 years) cigarette smokers in each of the following four countries: Canada, the United States, the United Kingdom, and Australia, 75% of whom were followed up at Wave 2 on average seven months later.

Key measures: Levels of smoking restrictions in homes (both waves).

Results: Australian smokers were most likely to live in smoke-free homes and UK smokers least likely (34% v 15% at Wave 1). Levels of smoke-free homes increased between waves. Logistic regressions indicated that the main independent predictors of smokers reporting smoke-free homes or implementation of a smoke-free policy between waves included household factors such as having a child, particularly a young child, and having other non-smoking adults in the household. Positive attitudes to smoke-free public places and/or reported presence of smoke-free public places were independent predictors of having or implementing smoke-free homes, supporting a social diffusion model for smoking restrictions. Intentions to quit at Wave 1 and quitting activity between survey waves were associated with implementing bans between Waves 1 and 2. Presence of bans at Wave 1 was associated with significantly greater proportions of quit attempts, and success among those who tried at Wave 2. There was no significant interaction between the predictive models and country.

Conclusions: Smoke-free public places seem to stimulate adoption of smoke-free homes, a strategy associated with both increased frequency of quit attempts, and of the success of those attempts.

Citation

Young, D., Borland, R., Hammond, D., Cummings, K.M., Devlin, E., Yong, H.H., O’Connor, R.J. (2006). Prevalence and attributes of roll-your-own smokers in the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii76-iii82.

Abstract

Background: Roll-your-own (RYO) cigarettes are often substantially less expensive than factory made (FM) cigarettes, and appear to be increasing in popularity—perhaps because smokers seek out less expensive options to maintain their nicotine addiction. There is surprisingly little research available on the actual prevalence of RYO cigarette usage, and even less on the attributes of those who smoke RYO cigarettes.

Objectives: This study has two objectives: (1) to compare the prevalence of RYO versus FM cigarette usage among adult smokers in Australia, Canada, the United Kingdom, and the United States; and (2) to compare the attributes of exclusive FM smokers, exclusive RYO smokers, and those who report “mixed” RYO and FM use.

Design: The data were collected from the International Tobacco Control (ITC) Four Country Survey (ITC-4), a random digit dialed telephone survey of representative samples of over 9046 adult smokers from the following four countries: Australia (n  =  2301), Canada (n  =  2,206), the UK (n  =  2400), and the USA (n  =  2,139), surveyed between October and December 2002, and on 6075 smokers followed-up, on average, seven months later.

Results: The prevalence of RYO cigarette usage varied widely across the four countries, with a low of 6.7% in the USA, to 28.4% in the UK. Exclusive use of RYO cigarettes was more common in the UK than in the other three countries. The use of RYO cigarettes was associated with having a lower annual income, male sex, younger average age, higher level of nicotine addiction, a stronger belief that RYO tobacco is less harmful compared to other forms of tobacco, and a more positive perception of tobacco use. Prevalence of RYO use was relatively stable within each of the four countries between the baseline and follow-up survey. RYO use was unrelated to quitting activity at follow-up, although mixed RYO users who had made a quit attempt were more likely to relapse than either exclusive FM or exclusive RYO smokers.

Conclusions: Patterns of RYO use vary considerably across Australia, Canada, the USA, and the UK. RYO smokers are a heterogeneous group; however, the factors associated with RYO use appear to be the same across the four countries studied.

Citation

Harris, F., MacKintosh, A.M., Anderson, S., Hastings, G., Borland, R., Fong, G.T., Hammond, D., Cummings, K.M. (2006). Effects of the 2003 advertising/promotion ban in the United Kingdom on awareness of tobacco marketing: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii26-iii33.

Abstract

Background: In February 2003, a comprehensive ban on tobacco promotion came into effect in the United Kingdom, which prohibited tobacco marketing through print and broadcast media, billboards, the internet, direct mail, product placement, promotions, free gifts, coupons and sponsorships.

Objective: To investigate the impact of the UK’s comprehensive ban on tobacco promotion on adult smokers’ awareness of tobacco marketing in the UK relative to Canada, the United States and Australia.

Design: A total of 6762 adult smokers participated in two waves of a random digit dialled telephone survey across the four countries. Wave 1 was conducted before the UK ban (October–December 2002) and Wave 2 was conducted after the UK ban (May–September 2003).

Key measures: Awareness of a range of forms of tobacco marketing.

Results: Levels of tobacco promotion awareness declined significantly among smokers in the UK after implementation of the advertising ban. Declines in awareness were greater in those channels regulated by the new law and change in awareness of tobacco promotions was much greater in the UK than the other three countries not affected by the ban. At least in the short term, there was no evidence that the law resulted in greater exposure to tobacco promotions in the few media channels not covered by the law. Notwithstanding the apparent success of the UK advertising ban and the controls in other countries, 9–22% of smokers in the four countries still reported noticing things that promoted smoking ‘‘often or very often’’ at Wave 2.

Conclusions: The UK policy to ban tobacco advertising and promotion has significantly reduced exposure to pro-tobacco marketing influences. These findings support the effectiveness of comprehensive bans on advertising and promotion, as included in the Framework Convention on Tobacco Control.

Citation

Borland, R., Yong, H.H., Siahpush, M., Hyland, A., Campbell, S., Hastings, G., Cummings, K.M., Fong, G.T. (2006). Support for and reported compliance with smoke-free restaurants and bars by smokers in four countries: Findings from the International Tobacco Control (ITC) Four Country Survey.Tobacco Control, 15(Suppl 3), iii34-iii41.

Abstract

Objective: To explore determinants of support for and reported compliance with smoke-free policies in restaurants and bars across the four countries of the International Tobacco Control (ITC) Four Country Survey.

Design: Separate telephone cross-sectional surveys conducted between October and December 2002 with broadly representative samples of over 2000 adult (⩾ 18 years) cigarette smokers in each of the following four countries: the United States, Canada, the United Kingdom, and Australia.

Outcome measures: Support for smoke-free policies in restaurants and pubs/bars and reported compliance with existing policies.

Results: Reported total bans on indoor smoking in restaurants varied from 62% in Australia to 5% in the UK. Smoking bans in bars were less common, with California in the USA being the only major part of any country with documented bans. Support for bans in both restaurants and bars was related to the existence of bans, beliefs about passive smoking being harmful, lower average cigarette consumption, and older age. Self-reported compliance with a smoking ban was generally high and was associated with greater support for the ban.

Conclusions: Among current cigarette smokers, support for smoking bans was associated with living in a place where the law prohibits smoking. Smokers adjust and both accept and comply with smoke-free laws. Associates of support and compliance are remarkably similar across countries given the notably different levels of smoke-free policies.

Citation

Fong, G.T., Hyland, A., Borland, R., Hammond, D., Hastings, G., McNeill, A., Anderson, S., Cummings, K.M., Allwright, S., Mulcahy, M., Clancy, L., Thompson, M.E., Connolly, G.N., Driezen, P. (2006). Reductions in tobacco smoke pollution and increases in support for smoke-free public places following the implementation of comprehensive smoke-free workplace legislation in the Republic of Ireland: Findings from the ITC Ireland/UK Survey.Tobacco Control, 15(Suppl 3), iii51-iii58.

Abstract

Objective: To evaluate the psychosocial and behavioural impact of the first ever national level comprehensive workplace smoke-free law, implemented in Ireland in March 2004.

Design: Quasi-experimental prospective cohort survey: parallel cohort telephone surveys of national representative samples of adult smokers in Ireland (n = 769) and the UK (n = 416), surveyed before the law (December 2003 to January 2004) and 8-9 months after the law (December 2004 to January 2005).

Main outcome measures: Respondents' reports of smoking in key public venues, support for total bans in those key venues, and behavioural changes due to the law.

Results: The Irish law led to dramatic declines in reported smoking in all venues, including workplaces (62% to 14%), restaurants (85% to 3%), and bars/pubs (98% to 5%). Support for total bans among Irish smokers increased in all venues, including workplaces (43% to 67%), restaurants (45% to 77%), and bars/pubs (13% to 46%). Overall, 83% of Irish smokers reported that the smoke-free law was a "good" or "very good" thing. The proportion of Irish homes with smoking bans also increased. Approximately 46% of Irish smokers reported that the law had made them more likely to quit. Among Irish smokers who had quit at post-legislation, 80% reported that the law had helped them quit and 88% reported that the law helped them stay quit.

Conclusion: The Ireland smoke-free law stands as a positive example of how a population-level policy intervention can achieve its public health goals while achieving a high level of acceptance among smokers. These findings support initiatives in many countries toward implementing smoke-free legislation, particularly those who have ratified the Framework Convention on Tobacco Control, which calls for legislation to reduce tobacco smoke pollution.

Citation

Hammond, D., Fong, G.T., Zanna, M.P., Thrasher, J.F., Borland, R. (2006). Tobacco denormalization and industry beliefs among smokers from four countries. American Journal of Preventive Medicine, 31(3), 225-232.

Abstract

Background: Tobacco denormalization is an important concept for understanding smoking behavior. The present study sought to assess beliefs about the tobacco industry and the social acceptability of smoking among nationally representative samples of adult smokers from four countries, and to assess the relationship of these measures to cessation behavior and tobacco-control policy.

Design: A longitudinal survey of 9058 adult smokers from Canada (n = 2214), the United States (n = 2138), the United Kingdom (n = 2401), and Australia (n = 2305), was conducted in October-December 2002 and again in June and August 2003 (75% follow-up rate). The analyses were conducted in 2005.

Results: The findings indicate that few smokers perceive approval for their smoking, and most hold relatively antagonistic beliefs toward the tobacco industry. For example, 80% of smokers reported that society disapproves of smoking, and more than three quarters reported that tobacco companies cannot be trusted to tell the truth. Social and industry denormalization were independently associated with intentions to quit smoking. Baseline levels of social denormalization were associated with abstinence at the 8-month follow-up, as were changes in industry denormalization beliefs between baseline and follow-up. Anti-industry beliefs at baseline did not predict abstinence at follow-up. A similar pattern of findings was observed across all four countries. In addition, social denormalization and anti-industry beliefs were significantly associated with tobacco-control policies, such as noticing health warnings on packages and greater workplace smoking restrictions.

Conclusions: Tobacco denormalization constructs were independently linked to cessation-related outcomes among adults from four countries. Tobacco-industry denormalization themes in mass media campaigns may help to reduce tobacco use above and beyond more traditional communications that target social norms.

Citation

Haw, S.J., Gruer, L., Amos, A., Currie, C., Fischbacher, C., Fong, G.T., Hastings, G., Malam, S., Scott, C., Semple, S. (2006). Legislation on smoking in enclosed public places in Scotland: How will we evaluate the impact? Journal of Public Health, 28(1), 24-30.

Abstract

Background: From 26 March 2006, smoking will be prohibited in wholly and substantially enclosed public places in Scotland, and it will be an offence to permit smoking or to smoke in no-smoking premises. We anticipate that implementation of the smoke-free legislation will result in significant health gains associated with reductions in exposure to both environmental tobacco smoke (ETS) and personal tobacco consumption as well as other social and economic impacts.

Methods: Health Scotland in conjunction with the Information Services Division (ISD) Scotland and the Scottish Executive have developed a comprehensive evaluation strategy to assess the expected short-term, intermediate and long-term outcomes. Using routine health, behavioural and economic data and commissioned research, we will assess the impact of the smoke-free legislation in eight key outcome areas – knowledge and attitudes, ETS exposure, compliance, culture, smoking prevalence and tobacco consumption, tobacco-related morbidity and mortality, economic impacts on the hospitality sector and health inequalities.

Conclusion: The findings from this evaluation will make a significant contribution to the international understanding of the health effects of exposure to ETS and the broader social, cultural and economic impacts of smoke-free legislation.

Citation

Yong, H.H., Borland, R., Siahpush, M. (2005). Quitting-related beliefs, intentions, and motivations of older smokers in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Addictive Behaviours, 30(4), 777-788.

Abstract

Older smokers represent an important subgroup that has been shown to benefit considerably from quitting smoking. However, to date little is known about relevant beliefs, intentions, and motivations. This study examined factors associated with older smokers' (aged 60 years and above) intention to quit smoking using data gathered via the International Tobacco Control Policy Evaluation Survey (ITCPES), a random digit dialed telephone survey of over 9000 adult smokers from United Kingdom, United States, Canada, and Australia. Having smoked for a long time and having survived, it was hypothesized that older smokers would perceive themselves as being less vulnerable to the harm of smoking (self-exempting beliefs); be less concerned about the health effects of smoking; be less confident about being able to quit successfully (self-efficacy); not perceive any health benefit of quitting, and hence be less willing to want to quit. Controlling for possible confounders, the hypotheses were all confirmed. Further analysis into reported considerations for quitting revealed that price of cigarettes, health professional advice, cheap quitting medication, and information on health risks were important predictors of quitting intention, with cigarette price and cheap medication also associated with recent quit attempts. Together, these findings have important implications for developing strategies for encouraging older smokers to give up smoking.

Citation

Borland, R., Yong, H.H., King, B., Cummings, K.M., Fong, G.T., Elton-Marshall, T., Hammond, D., McNeill, A. (2004). Use of and beliefs about light cigarettes in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Nicotine & Tobacco Research, 6(Suppl 3), S311-321.

Abstract

This study examined reported use of, and beliefs about, so-called light cigarettes among adult smokers in four countries: Australia (Aus), Canada (Can), the United Kingdom (U.K.) and the United States (U.S.). The method used was parallel telephone surveys among 9,046 smokers across the four countries. The results indicated that more than half of all smokers in each country except the U.K. reported smoking light cigarette brands. A majority of smokers surveyed in each country except Canada continue to believe that light cigarettes offer some health benefit compared to regular cigarettes (Canada 43%, U.S. 51%, Australia 55%, U.K. 70%). A majority of smokers in all four countries believed that light cigarettes are smoother on the throat and chest than regular cigarettes. Predictors of use of light cigarettes and beliefs about possible benefits were very similar in the four countries. These results demonstrate an ongoing need for public education about why light cigarettes do not reduce harm and do not make quitting easier. The results provide further evidence for the need for regulatory measures in all four countries to prohibit the use of misleading light and mild descriptors including package imagery in product marketing (as prescribed in Article 11 of the Framework Convention on Tobacco Control), abandon the use of standard FTC/ISO tar and nicotine yields as consumer information, and adopt policies to regulate deceptive design features of cigarettes, such as ventilated filters.

Citation

Fong, G.T., Hammond, D., Laux, F., Zanna, M.P., Cummings, K.M., Borland, R., Ross, H. (2004). The near-universal experience of regret among smokers in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Nicotine & Tobacco Research, 6(Suppl 3), S341-351.

Abstract

Regret may be a key variable in understanding the experience of smokers, the vast majority of whom continue to smoke while desiring to quit. We present data from the baseline wave (October-December 2002) of the International Tobacco Control Policy Evaluation Survey, a random-digit-dialed telephone survey of a cohort of over 8,000 adult smokers across four countries--Canada, the United States, the United Kingdom, and Australia--to estimate the prevalence of regret and to identify its predictors. The proportion of smokers who agreed or agreed strongly with the statement "If you had to do it over again, you would not have started smoking" was extremely high--about 90%--and nearly identical across the four countries. Regret was more likely to be experienced by older smokers, women, those who had tried to quit more often, those who perceived quitting as conferring benefits, those with higher levels of perceived addiction, those who worried about future damage to health, those who perceived smoking as lowering their quality of life, those who perceived higher monetary costs of smoking, and those who believed that smoking is not socially acceptable. This predictive model was the same in all four countries. Regret is thus a near-universal experience among smokers in all four countries, and the factors that predict regret are universal across these four countries. Among other implications for cessation treatment and smoking prevention, this near universality of regret casts doubt on the view of some policy analysts and economists that the decisions to take up and continue smoking are welfare-maximizing for the consumer.