Citation

El-Toukhy, S., Choi, K., Hitchman, S.C., Bansal-Travers, M., Thrasher, J.F., Yong, H.H., O’Connor, R.J., Shang, C. (2018). Banning tobacco price promotions, smoking-related beliefs, and behaviour: findings from the International Tobacco Control Four Country (ITC 4C) Survey. Tobacco Control, 27(3), 310-318.

Abstract

Background: Ecological models emphasise multilevel influences on health behaviours. While studies show that exposure to price promotions is associated with smoking behaviour and its antecedents, less is known about whether these associations differ by macro-level factors such as national price promotion policies.

Methods: Current and former smokers (N=4698) from the International Tobacco Control Policy Evaluation Project four-country cohort were included in weighted multivariate logistic regression models to examine individual-level associations between exposure to price promotions at waves 7 and 8 (conducted in 2008–2009 and 2010–2011) and beliefs (social and injunctive norms, functional value of smoking, misconceptions around smoking and beliefs of tobacco industry and its regulations) and behaviour at wave 8, stratified by whether countries allow (Australia and USA) or ban (Canada and UK) price promotions.

Results: Associations between exposure to price promotions and smoking-related beliefs and behaviour differed by national price promotion policies. In countries that allow price promotions, participants repeatedly exposed to price promotions at waves 7 and 8 were more likely to associate functional values to smoking (ie, calms down when stressed (adjusted OR (AOR) 1.83) and to be current smokers at wave 8 (AOR 1.94). In countries that ban price promotions, participants repeatedly exposed to price promotions were less likely to hold misconceptions around smoking (ie, harsher smoke is more dangerous).

Conclusions: Differential associations emerged between exposure to price promotions, smoking-related beliefs and behaviour across countries with and without a price promotions ban. Adopting price promotion bans could ameliorate the associations between exposure to price promotions and smoking beliefs and behaviours.

Citation

Cho, Y. J., Thrasher, J. F., Yong, H.-H., Szklo, A. S., O'Connor, R. J., Bansal-Travers, M., Hammond, D., Fong, G. T., Hardin, J., Borland, R. (2018). Path analysis of warning label effects on negative emotions and quit attempts: A longitudinal study of smokers in Australia, Canada, Mexico, and the US. Social Science & Medicine, 197, 226-234.

Abstract

Background: Cigarette pack health warning labels can elicit negative emotions among smokers, yet little is known about how these negative emotions influence behavior change.

Objective: Guided by psychological theories emphasizing the role of emotions on risk concern and behavior change, we investigated whether smokers who reported stronger negative emotional responses when viewing warnings reported stronger responses to warnings in daily life and were more likely to try to quit at follow-up.

Methods: We analyzed data from 5439 adult smokers from Australia, Canada, Mexico, and the US, who were surveyed every four months from September 2012 to September 2014. Participants were shown warnings already implemented on packs in their country and reported negative emotional responses (i.e., fear, disgust, worry), which were averaged (range = 1 to 9). Country-stratified logistic and linear generalized estimating equations were used to analyze the effect of negative emotional responses on self-reported responses to warnings in daily life (i.e., attention, risk concern, avoidance of warnings, forgoing planned cigarettes) and quit attempts at follow-up. Models were adjusted for socio-demographic and smoking-related characteristics, survey wave, and the number of prior surveys answered.

Results: Smokers who reported stronger negative emotions were more likely to make quit attempts at follow-up (Adjusted ORs ranged from 1.09 [95% CI 1.04 to 1.14] to 1.17 [95% CI 1.12 to 1.23]; p < .001) than those who reported lower negative emotions. This relationship was mediated through attention to warnings and behavioral responses to warnings. There was no significant interaction of negative emotions with self-efficacy or nicotine dependence.

Conclusion: Negative emotions elicited by warnings encourage behavior change, promoting attention to warnings and behavioral responses that positively predict quit attempts.

Citation

Meijer, E., Van den Putte, B., Gebhardt, W.A., Van Laar, C., Bakk, Z., Dijkstra, A., Fong, G.T., West, R., Willemsen, M.C. (2018). A longitudinal study into the reciprocal effects of identities and smoking behaviour: findings from the ITC Netherlands Survey. Social Science & Medicine, 200, 249-257.

Abstract

Objective: Although it has been found that identity constructs related to smoking are associated with changes in smoking behaviour, the direction of causal associations is as yet unclear. This study aims to clarify the nature and direction of these associations.

Methods: In this longitudinal study we examined the reciprocal relations between identity constructs (i.e., smoker self-identity, quitter self-identity and smoker group-identity), intention to quit and smoking and quitting behaviour among a sample of 1036 smokers and ex-smokers, using cross-lagged structural equation modelling. Moreover, we tested whether these relations differed by socio-economic status (SES).

Results: Identity and smoking behaviour were reciprocally related in that in intention to quit and smoking behaviour consistently predicted identity change, and identity predicted (changes in) intentions to quit and smoking behaviour. Behaviour appears more important for identity change than identity for behaviour change. Furthermore, quitter self-identity appears more important than smoker self- and group-identity. Relationships did not differ significantly between SES-groups. The findings were replicated using a crossvalidation sample.

Conclusion: Results imply that changing smoking behaviour may be a vehicle to change smoking-related identity. Moreover, strengthening identification with quitting is more crucial for quit success than decreasing smoker identities. The finding that behaviour may be more important for identity than vice versa, if replicated, may call for additions to identity theories.

Citation

Chen, M., Thompson, M.E., Wu, C. (2018). Empirical likelihood methods for complex surveys with data missing-by-design. Statistica Sinica, 28(4).

Abstract

We consider nonrandomized pretest-posttest designs with complex survey data for observational studies. We show that two-sample pseudo empirical likelihood methods provide efficient inferences on the treatment effect, with a missing-by-design feature used for forming the two samples and the baseline information incorporated through suitable constraints. The proposed maximum pseudo empirical likelihood estimators of the treatment effect are consistent and pseudo empirical likelihood ratio confidence intervals are constructed through bootstrap calibration methods. The proposed methods require estimation of propensity scores which depend on the underlying missing-by-design mechanism. A simulation study is conducted to examine finite sample performances of the proposed methods under different scenarios of nonignorable and ignorable missing patterns. An application to the International Tobacco Control Policy Evaluation Project Four Country Surveys is also presented to demonstrate the use of the proposed methods for examining the mode effect in survey data collection.

Citation

Choi, Y.J., Seo, H.G., Kim, Y., Fong, G.T., Yan, M., Driezen, P. (2018). Tobacco related knowledge is associated with heaviness of smoking index (HSI) and intention to quit among Korean smokers: findings from 2016 ITC Korea Survey. Journal of the Korean Society for Research on Nicotine and Tobacco, 9(Suppl 1), S31-S38.

Abstract

Background: International Tobacco Control project (ITC) was performed in South Korea for evaluation of the effects of smoking control policies in compliance with FCTC. We tested the association between the level of knowledge and heaviness of smoking index (HSI), and intention to quit smoking.

Methods: The study followed the same methodology by ITC policy evaluation project. Trained call center staffs interviewed 2000 current smokers (1800 men and 200 women, aged 19-65) on the phone. Tobacco-related knowledge was evaluated by asking participants the diseases related with smoking such as stroke, impotence, visual loss, peripheral vascular disease, bladder cancer, and breast cancer. Multivariate logistic regression was used for statistical analysis, which was adjusted by age, sex, education level, annual household income, alcohol consumption frequency, and heaviness of smoking index.

Results: High HSI score (3-6) was associated with low knowledge score (Odds ratio (OR) 0.80, 95% confidence interval (CI) 0.65-0.99). Smokers who had intention to quit smoking in any future were also more likely to be in a high knowledge score group (10-14 vs. 0-9 out of 14) (OR 1.50, 95% CI 1.19-1.89).

Conclusion: Smokers who had higher HSI or had no intention to quit tended to have lower level of knowledge regarding health risk of smoking. This implies that education and public awareness on health risk of tobacco could be more effective when targeted to these smokers.

Citation

Kim, E.Y., Kim, Y., Choi, Y.J., Seo, H.G., Yan, M., Driezen, P., Fong, G.T. (2018). Change of support for smoke-free area and perception of effectiveness of smoking ban policy among Korean smokers: findings from the 2010, 2016 International Tobacco Control Policy Evaluation Survey in Korea. Journal of the Korean Society for Research on Nicotine and Tobacco, 9(Suppl 1), S39-50.

Abstract

Background: Smoke-free policies have been reinforced in recent years in South Korea. We investigated factors that influenced support for smoke-free area (SSA) and perception of effectiveness of smoking ban policy (PESP) and examined whether SSA and PESP changed between 2010 and 2016.

Methods: We analyzed wave 3 (2010) and new wave 1 (2016) data from the International Tobacco Control (ITC) Survey in Korea. Telephone survey was conducted among Korean smokers aged ≥19 in 2010 (n=1,560) and 2016 (n=2,000). Differences between survey data in 2010 versus 2016 were evaluated by t-test. Multiple linear regression analysis was performed to analyze factors associated with SSA and PESP, and the changes of those factors over time.

Results: Smokers in 2016 had greater SSA and more positive PESP than in 2010. Respondents who were married, had plan to quit smoking within 6 months, initiated smoking later in their life, or had less nicotine dependency were more likely to present greater SSA and more positive PESP. Respondents had lesser SSA when they answered that smoking was allowed in bars and restaurants in their neighborhood, and workplace they belonged compared to those who experienced smoke-free policy in all three of the places. Older ages were associated with more positive PESP.

Conclusion: Smokers changed their SSA and PESP more positively in 2016 than 2010. Reinforced smoke-free policies would lead smokers to have more favorable SSA and PESP and possibly contribute to reduction in smoking rate.

Citation

Lee, C., Yong, H.H., Borland, R., McNeill, A., Hitchman, S.C. (2018). Acceptance and patterns of use of vaping in Australia and the United Kingdom: results from the International Tobacco Control Survey. Drug & Alcohol Dependence, 185, 142-48.

Abstract

Background: This study examined the prevalence and correlates of (1) perceived social acceptability of personal vaporizer (PV)/e-cigarette use, and (2) reported vaping in public and private places, in the UK and Australia with different regulatory environments for PVs.

Methods: Data analyzed come from 2849 smokers and recent ex-smokers in the UK and Australia who participated in the 2014 wave of the International Tobacco Control Survey.

Results: UK respondents were more likely to think vaping is socially acceptable than Australians (56.4% vs. 27.9%; p < 0.001). Having quit smoking, observing vaping in smoke-free (SF) public places, and believing vaping is less harmful than smoking was all significantly associated with greater perceived social acceptability of vaping in both countries. However, vaping status and that of friends and family were more influential in Australia than in the UK. Vaping was reported as much more common in private, than public, settings in both countries. UK vapers were more likely to report vaping in SF public places (OR = 2.66; 95% CI = 1.5-4.7; p < 0.01) and at home (OR = 2.44; 95% CI = 1.5-3.9; p < 0.001), but not in their car when controlling for demographic factors and vaping and smoking status.

Conclusion: The acceptability of vaping was greater among those who were more exposed to vaping and not just among those with some personal experience of vaping, suggesting no strong social barriers to increased use. Vaping in SF public places was less common than in homes, and both were more common in the UK than in Australia, suggesting some social constraints on use, particularly in Australia.

Citation

van Mourik, D.J.A., Candel, M.J.J.M., Nagelhout, G.E., Willemsen, M.C., Fong, G.T., Hummel, K., van den Putte, B., de Vries, H. (2018). Support for a point-of-sale cigarette display ban among smokers: findings from the International Tobacco Control (ITC) Netherlands Survey. BMC Public Health, 18, 740.B

Abstract

Background: Displaying tobacco products at point-of-sale (PoS) has become an important marketing strategy for the tobacco industry. This study was designed to (1) examine how support for a PoS cigarette display ban changed among Dutch smokers between 2010 and 2015 and (2) identify the variables that predict support among smokers for a PoS cigarette display ban.

Methods: Longitudinal data from six annual survey waves (2010-2015) from the International Tobacco Control (ITC) Netherlands Survey were analyzed. The sample consisted of between 1279 and 1800 smokers per year. Smokers were asked whether they supported a complete ban on displays of cigarettes inside shops and stores.

Results: Support for a PoS cigarette display ban increased from 28.9% in 2010 to 42.5% in 2015 (OR = 1.40, p < 0.001). A multiple logistic regression analysis revealed that support for a PoS display ban of cigarettes was more likely among smokers who had more knowledge about the health risks of smoking (OR = 3.97, p < 0.001), believed smoking-related health risks to be severe (OR = 1.39, p < 0.001), had a more positive attitude towards quitting smoking (OR = 1.44, p = 0.006), reported stronger social norms to quit smoking (OR = 1.29, p = 0.035), had a higher self-efficacy for quitting smoking (OR = 1.31, p = 0.001), and had stronger intentions to quit smoking (OR = 1.23, p = 0.006).

Conclusions: This paper showed that support for a PoS display ban of cigarettes increased among smokers in the Netherlands over the years. To further increase support, educational campaigns about the dangers of smoking, and campaigns that encourage quitting may be needed.

Citation

Vardavas, C., Bécuwe, N., Demjén, T., Fernández, E., McNeill, A., Mons, U., Tountas, Y., Trofor, A., Tsatsakis, A., Rohde, G., Willemsen, M.C., Prezewozniak, K., Zatoński, W., Fong, G.T., on behalf of the EUREST-PLUS Consortium. (2018). Study protocol of European Regulatory Science on Tobacco (EUREST-PLUS): policy implementaton to reduce lung disease. Tobacco Induced Diseases, 16(Suppl 2), 3-10.

Abstract

Efforts to mitigate the devastation of tobacco-attributable morbidity and mortality in the European Union (EU) are founded on its newly adopted Tobacco Products Directive (TPD) along with the first-ever health treaty, the WHO Framework Convention on Tobacco Control (FCTC). The aim of this Horizon 2020 Project entitled European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Disease (EURESTPLUS) is to monitor and evaluate the impact of the implementation of the TPD across the EU, within the context of WHO FCTC ratification. To address this aim, EUREST-PLUS consists of four objectives: 1) To create a cohort study of 6000 adult smokers in six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) within a pre-TID vs post- TPD implementation study design; 2) To conduct secondary dataset analyses of the Special Eurobarometer on Tobacco Survey (SETS); 3) To document changes in e-cigarette product parameters (technical design, labelling/packaging and chemical composition) pre-TID vs post-TPD; and 4) To enhance innovative joint research collaborations on chronic non-communicable diseases. Through this methodological approach, EUREST-PLUS is designed to generate strong inferences about the effectiveness of tobacco control policies, as well as to elucidate the mechanisms and factors by which policy implementation translates to population impact. Findings from EUREST-PLUS have potential global implications for the implementation of innovative tobacco control policies and its impact on the prevention of lung diseases.

Abstract

Background: The Canadian government has committed to an endgame target of less than 5% tobacco use by 2035. The aims of this study were to assess baseline levels of support for potential endgame policies among Canadian smokers, by province/region, demographic characteristics and smoking-related correlates, and to identify predictors of support.

Methods: We analyzed data for 3215 adult (age ≥ 18 yr) smokers from the Canadian arm of the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. We estimated weighted percentages of support for endgame measures for 6 provinces/regions of the country. We used weighted logistic regression models to identify predictors of support for 14 endgame strategies.

Results: Among cigarette endgame policies, support was highest for reducing nicotine content (70.2%), raising the legal age for purchase (69.8%), increasing access to alternative nicotine products (65.8%) and banning marketing (58.5%). Among e-cigarette policies, there was majority support for restricting youth access (86.1%), restricting nicotine content (64.9%), prohibiting use in smokefree places (63.4%) and banning marketing (54.8%). The level of support for other endgame measures ranged from 28.9% to 45.2%. Support for cigarette and e-cigarette policies was generally higher among smokers with intentions to quit and those from Quebec. Support for e-cigarette policies was generally lower among smokers who also used e-cigarettes daily.

Interpretation: There is considerable support among Canadian smokers for endgame policies that go beyond current approaches to tobacco control. Our findings provide a baseline for evaluating future trends in smokers’ support for innovative measures to radically reduce smoking rates in Canada.

Citation

Levy, D. (2018). Communicating accurate and complete information. Addictive Behaviours, 76, 386-387.

Highlights:

• Consumers should be provided with the best information about the risks of different tobacco products to make informed choices.
• However, better information is needed about effectively communicating relative as well as absolute risks.
• In particular, studies are needed on communicating the risks of dual use.

Citation

Levy, D., Tam, J., Kuo, C., Fong, G.T., Chaloupka, F.J. (2018). The impact of implementing tobacco control policies: the 2017 tobacco control policy scorecard. Journal of Public Health Management and Practice, 24(5), 448-457.

Abstract

The Tobacco Control Scorecard, published in 2004, presented estimates of the effectiveness of different policies on smoking rates. Since its publication, new evidence has emerged. We update the Scorecard to include recent studies of demandreducing tobacco policies for high-income countries. We include cigarette taxes, smoke-free air laws, media campaigns, comprehensive tobacco control programs, marketing bans, health warnings, and cessation treatment policies. To update the 2004 Scorecard, a narrative review was conducted on reviews and studies published after 2000, with additional focus on 3 policies in which previous evidence was limited: tobacco control programs, graphic health warnings, and marketing bans. We consider evaluation studies that measured the effects of policies on smoking behaviors. Based on these findings, we derive estimates of short-term and long-term policy effect sizes. Cigarette taxes, smoke-free air laws, marketing restrictions, and comprehensive tobacco control programs are each found to play important roles in reducing smoking prevalence. Cessation treatment policies and graphic health warnings also reduce smoking and, when combined with policies that increase quit attempts, can improve quit success. The effect sizes are broadly consistent with those previously reported for the 2004 Scorecard but now reflect the larger evidence base evaluating the impact of health warnings and advertising restrictions.

No abstract is available.

Citation

Heckman, B., Fong, G.T., Borland, R., Hitchman, S.C., O’Connor, R.J., Bickel, W.K., Stein, J., Yong, H.H., Nahhas, G., Pope, D., Shang, C., Cheng, K.W., Levy, D., Cummings, K.M. (2019). The impact of vaping and regulatory environment on cigarette demand: Behavioral economic perspective across four countries. Addiction, 114(Suppl 1), 123-133.

Abstract

Background and Aims: Government regulations of nicotine vaping products (NVP) have evolved rapidly during the past decade. The impact of NVP regulatory environment and vaping on cigarette demand is unknown. The current study aims to investigate whether or not respondents’ reported cigarette demand, as measured by a hypothetical cigarette purchase task, varies with (1) smoking status, (2) vaping status or (3) NVP regulatory environment (country used as proxy).

Design: Cross‐sectional survey data from wave 1 of the International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey (2016).

Setting: Australia, Canada, England and the United States.

Participants: A total of 10 316 adult smokers.

Measurements: A hypothetical purchase task asked smokers to estimate how many cigarettes they would purchase for consumption in a single day across multiple cigarette prices. Responses were used to derive measures of cigarette demand. Overall sensitivity of cigarette consumption to price increases was quantified to index cigarette demand elasticity, whereas estimated consumption when cigarettes are free was used to index cigarette demand intensity.

Findings: A majority of the non‐daily smokers had previously smoked daily (72.3%); daily vapers were more likely to be former daily smokers (89.9%) compared to non‐daily vapers (70.1%) and non‐vapers (69.2%) (P < 0.001). The smoking status × vaping status interaction was significant for cigarette demand intensity (F = 4.93; P = 0.007) and elasticity (F = 7.30; P = 0.001): among non‐daily smokers, vapers reported greater intensity but lower elasticity (i.e. greater demand) relative to non‐vapers (Ps < 0.05). Among daily smokers, daily vapers reported greater intensity relative to non‐vapers (P = 0.005), but vaping status did not impact elasticity (Ps > 0.38). Intensity was higher in Australia compared with all other countries (Ps < 0.001), but elasticity did not vary by country (F = 2.15; P = 0.09).

Conclusions: In a hypothetical purchase task, non‐daily smokers showed lower price elasticity if they used e‐cigarettes than if they did not, while there was no clear difference in elasticity between e‐cigarette users and non‐users among daily smokers or according to regulatory environment of their country with regard to e‐cigarettes.

Citation

Braverman-Bronstein, A., Thrasher, J.F., Hernández-Ávila, M., Reynales-Shigematsu, L.M., Barrientos-Gutierrez, T. (2018). Concentrations of nicotine, nitrosamines, and humectants in legal and illegal cigarettes in Mexico. Harm Reduction Journal, 15(1), 50.

Abstract

Background: Article 10 of the World Health Organization Framework Convention on Tobacco Control states the need for industry disclosure of tobacco contents and emissions. Currently, the profiles of key tobacco compounds in legal and illegal cigarettes are largely unknown. We aimed to analyze and compare concentrations of nicotine, nitrosamines, and humectants in legal and illegal cigarettes collected from a representative sample of smokers.

Methods: Participants of the International Tobacco Control cohort provided a cigarette pack of the brand they smoked during the 2014 wave. Brands were classified as legal or illegal according to the Mexican legislation. Nicotine, nitrosamines, glycerol, propylene glycol, and pH were quantified in seven randomly selected packs of each brand. All analyses were done blinded to legality status. Average concentrations per brand and global averages for legal and illegal brands were calculated. Comparisons between legal and illegal brands were conducted using t tests.

Results: Participants provided 76 different brands, from which 6.8% were illegal. Legal brands had higher nicotine (15.05 ± 1.89 mg/g vs 12.09 ± 2.69 mg/g; p < 0001), glycerol (12.98 ± 8.03 vs 2.93 ± 1.96 mg/g; p < 0.001), and N-nitrosanatabine (NAT) (1087.5 ± 127.0 vs 738.5 ± 338 ng/g; p = 0.006) concentrations compared to illegal brands. For all other compounds, legal and illegal brands had similar concentrations.

Conclusion: Compared to illegal cigarettes, legal brands seem to have higher concentrations of nicotine, NAT, and glycerol. Efforts must be made to implement and enforce Article 10 of the Framework Convention on Tobacco Control to provide transparent information to consumers, regulators, and policymakers; and to limit cigarette engineering from the tobacco industry.

Citation

Hummel, K., Nagelhout, G.E., Fong, G.T., Vardavas, C., Papadakis, S., Herbec, A., Mons, U., van den Putte, B., Borland, R., Fernández, E., de Vries, H., McNeill, A., Gravely, S., Przewoźniak, K., Kovacs, P., Trofor, A., Willemsen, M.C., on behalf of the EUREST-PLUS Consortium. (2018). Quitting activity and use of cessation assistance reported by smokers in eight European countries: Findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 57-73.

Abstract

Introduction: There is clear evidence that the use of cessation aids significantly increases the likelihood of successful smoking cessation. The aim of this study was to examine quitting activity and use of cessation aids among smokers from various European countries. Subgroup differences were also examined for sex, income, education, and age in each country.

Methods: Cross-sectional data were collected in 2016 from 10683 smokers in eight European countries participating in the ITC Project: England (n=3536), Germany (n=1003), Greece (n=1000), Hungary (n=1000), the Netherlands (n=1136), Poland (n=1006), Romania (n=1001), and Spain (n=1001). We measured quitting activity, including quit attempts in the previous 12 months and intention to quit, use of cessation aids (i.e. medication, quitlines, internet, local services, e-cigarettes), and whether respondents had received advice from health professionals about quitting and e-cigarettes.

Results: Quit attempts were most common in England (46.3%) and least common in Hungary (10.4%). Quit intention was highest in England and lowest in Greece. Use of e-cigarettes to quit was highest in England (51.6%) and lowest in Spain (5.0%). Use of cessation aids was generally low across all countries; in particular this was true for quitlines, internet based support, and local services. Receiving health professional advice to quit was highest in Romania (56.5%), and lowest in Poland (20.8%); few smokers received advice about e-cigarettes from health professionals. No clear differences were found for sex and income groups. Across countries, smokers with lower education reported less quitting activity.

Conclusions: Quitting activity and use of cessation methods were low in most countries. Greater quit attempts and use of cessation aids were found in England, where large investments in tobacco control and smoking cessation have been made. Health professionals are important for motivating smokers to quit and promoting the effectiveness of various methods, but overall, few smokers get advice to quit.

Citation

Kahnert, S., Demjén, T., Tountas, Y., Trofor, A., Przewoźniak, K., Zatónski, W.A., Fernández, E., McNeill, A., Willemsen, M.C., Kyriakos, C.N., Fong, G.T., Vardavas, C. Mons, U., on behalf of the EUREST-PLUS Consortium. (2018). Extent and correlates of self-reported exposure to tobacco advertising, promotion, and sponsorship in smokers: findings from the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 74-84.

Abstract

Introduction: Tobacco advertising, promotion and sponsorship (TAPS) are known to promote tobacco consumption and to discourage smoking cessation. Consequently, comprehensive TAPS bans are effective measures to reduce smoking. The objective of this study was to investigate to what extent smokers are exposed to TAPS in general, and in various media and localities, in different European countries.

Methods: A cross-sectional analysis of national representative samples of adult smokers in 2016 from Germany, Greece, Hungary, Poland, Romania, and Spain (EUREST-PLUS Project, n=6011), as well as England (n=3503) and the Netherlands (n=1213) (ITC Europe Surveys) was conducted. Prevalence of self-reported TAPS exposure is reported by country, and socioeconomic correlates were investigated using logistic regression models.

Results: Self-reported exposure to TAPS varied widely among the countries, from 15.4 % in Hungary to 69.2 % in the Netherlands. In most countries, tobacco advertising was most commonly seen at the point of sale, and rarely noticed in mass media. The multivariate analysis revealed some variation in exposure to TAPS by sociodemographic factors. Age showed the greatest consistency across countries with younger smokers (18–24 years) being more likely to notice TAPS than older smokers.

Conclusions: TAPS exposure tended to be higher in countries with less restrictive regulation but was also reported in countries with more comprehensive bans, although at lower levels. The findings indicate the need for a comprehensive ban on TAPS to avoid a shift of marketing efforts to less regulated channels, and for stronger enforcement of existing bans.

Citation

Nogueira, S., McNeill, A., Fu, M., Kyriakos, C.N., Mons, U., Fernández, E., Zatoński, W., Trofor, A., Demjén, T., Tountas, Y., Przwozniak, K., Quah, A.C.K., Fong, G.T., Hitchman, S.C., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2018). Impact of anti-smoking advertising on health-risk knowledge and quit attempts across 6 European countries from the EUREST-PLUS ITC Europe Survey. Tobacco Induced Diseases, 16(Suppl 2), 47-56.

Abstract

Introduction: Exposure to anti-smoking advertising and its effects differ across countries. This study examines the reported exposure to anti-smoking advertising among smokers and its relation to knowledge of smoking harms and quit attempts in six European countries.

Methods: Data come from Wave 1 of the International Tobacco Control (ITC) 6 European Country (6E) Survey (Germany, Greece, Hungary, Poland, Romania, Spain) carried out among smokers between June and September 2016 (n=6011). Key measures included whether participants had noticed anti-smoking advertising in the last six months in 6 different channels, their knowledge of 13 adverse smoking/second-hand smoking health effects and if they had made at least one quit attempt in the last 12 months. Multivariate logistic regression models were used in the analysis.

Results: Across the six countries, only 35.2% of smokers reported being exposed to any anti-smoking advertising. Television was the most common channel identified (25.7%), followed by newspapers and magazines (13.8%), while social media were the least reported (9.5%). Participants 18–24 years old were significantly more likely to have noticed advertisements on the Internet than participants >55 years old (24.3% vs 4.9%; OR=5.15). Participants exposed to anti-smoking advertising in all six channels were twice more likely to have a higher knowledge of smoking risks than those not exposed (2.4% vs 97.6%, respectively; OR=2.49). The likelihood of making a quit attempt was increased by 10% for each additional channel through which smokers were exposed to anti-smoking advertising.

Conclusions: Knowledge of health risks of smoking tended to be higher in countries that aired a campaign in recent years. Exposure to anti-smoking advertising, in the six channels combined, was related to higher smoking knowledge of risks and to more quit attempts. Future anti-smoking mass media campaigns should consider advertising in all dissemination channels to increase the awareness of the dangers of smoking.

Citation

Petroulia, I., Kyriakos, C.N., Papadakis, S., Tzavara, C.K., Filippidis, F., Girvalaki, C., Peleki, T., Katsaounou, P., McNeill, A., Mons, U., Fernández, E., Demjén, T., Trofor, A., Herbec, A., Zatoński, W., Tountas, Y., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2018). Patterns of tobacco use, quit attempts, readiness to quit and self-efficacy among smokers with anxiety or depression: Findings among six European Union Member States. Tobacco Induced Diseases, 16(Suppl 2), 98-110.

Abstract

Introduction: We compared smoking behaviors, past quit attempts, readiness to quit and beliefs about quitting among current cigarette smokers with probable anxiety or depression (PAD) to those without PAD, from six European Union (EU) Member States (MS).

Methods: A nationally representative cross-sectional sample of 6011 adult cigarette smokers from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) was randomly selected through a multistage cluster sampling design in 2016. Respondents were classified as having PAD based on self-reported current diagnosis or treatment for anxiety or depression, or a positive screen for major depression, according to a validated two-item instrument. Sociodemographic characteristics, patterns of tobacco use, past quitting, readiness to quit, self-efficacy and beliefs about quitting were assessed for patients with and without PAD. Logistic regression was used to examine predictors of PAD. All analyses were conducted using the complex samples package of SPSS.

Results: Among smokers sampled, 21.0% (95% CI: 19.3–22.9) were identified as having PAD. Logistic regression analyses controlling for socioeconomic variables and cigarettes smoked per day found smokers with PAD were more likely to have made an attempt to quit smoking in the past (AOR=1.48; 95% CI: 1.25–1.74), made a quit attempt in the last 12 months (AOR=1.75; 95% CI: 1.45–2.11), and report lower self-efficacy with quitting (AOR=1.83; 95% CI: 1.44–2.32) compared to smokers without PAD. Additionally, it was found that individuals with PAD were more likely to report having received advice to quit from a doctor or health professional and having used quitline support as part of their last quit attempt.

Conclusions: Smokers with PAD report a greater interest in quitting in the future and more frequent failed quit attempts than smokers without PAD; however, the high rates of untreated anxiety or depression, nicotine dependence, low confidence in the ability to quit, infrequent use of cessation methods, as well as socioeconomic factors may make quitting difficult.

Citation

Swayampakala, K., Fleisher, N.L., Hardin, J., Liu, J., Fong, G.T., Thrasher, J.F. (2015, June). Factors associated with changing cigarette consumption patterns among low-intensity smokers: Results from the ITC Mexico Survey. Oral presentation at the 48th Annual Society for Epidemiologic Research Meeting, Denver, Colorado, United States.

Abstract

Background: Light and intermittent smoking has become increasingly prevalent as smokers shift to lower consumption in response to tobacco control policies. We examined changes in cigarette consumption patterns over a four-year period and determined which factors were associated with smoking transitions.

Methods: We used data from a cohort of smokers from the 2008–2012 ITC Mexico Survey administrations to investigate transitions from non-daily (ND; n = 669), daily light (DL; ≤5 cigarettes per day (cpd); n = 643), and daily heavy (DH; >5 cpd; n = 761) smoking patterns. To identify which factors (i.e., sociodemographic measures, perceived addiction, quit behavior, social norms) were associated with smoking transitions, we stratified on smoking status at time t (ND, DL, DH) and used multinomial (ND, DL) and binomial (DH) logistic regression to examine transitions (quitting/reducing or increasing versus same level for ND and DL, quitting/reducing versus same level for DH).

Results: ND smokers were more likely to quit at follow-up than DL or DH smokers. DH smokers who reduced their consumption to ND were more likely to quit eventually compared to those who continued as DH. Smokers who perceived themselves as addicted had lower odds of quitting/reducing smoking consumption at follow-up compared to smokers who did not, regardless of smoking status at the prior survey. Quit attempts and quit intentions were also associated with quitting/reducing consumption.

Conclusions: Reducing consumption may eventually lead to cessation, even for heavier smokers. The findings that perceived addiction and quit behavior were important predictors of changing consumption for all groups may offer insights into potential interventions.

Citation

Trofor, A., Papadakis, S., Lotrean, L.M., Radu-Loghin, C., Eremia, M., Mihaltan, F., Driezen, P., Kyriakos, C.N., Mons, U., Demjén, T., Nogueira, S.O., Fernández, E., Tountas, Y., Przewoźniak, K., McNeill, A., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2018). Knowledge of the health risks of smoking and impact of cigarette warning labels among tobacco users in six European countries. Tobacco Induced Diseases, 16(Suppl 2), 111-123.

Abstract

Introduction: The aim of this study was to examine knowledge of health effects of smoking and the impact of cigarette package warnings among tobacco users from six European Union (EU) Member States (MS) immediately prior to the introduction of the EU Tobacco Products Directive (TPD) in 2016 and to explore the interrelationship between these two factors.

Methods: Cross-sectional data were collected via face-to-face interviews with adult smokers (n=6011) from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) between June–September 2016. Sociodemographic variables and knowledge of health risks of smoking (KHR) were assessed. Warning salience, thoughts of harm, thoughts of quitting and foregoing of cigarettes as a result of health warnings were assessed. The Label Impact Index (LII) was used as a composite measure of warning effects. Linear and logistic regression analyses were used to examine sociodemographic predictors of KHR and LII and the inter-relationship between knowledge and LII scores.

Results: The KHR index was highest in Romania and Greece and lowest in Hungary and Germany. While the majority of smokers knew that smoking increases the risk for heart diseases, lung and throat cancer, there was lower awareness that tobacco use caused mouth cancer, pulmonary diseases, stroke, and there were very low levels of knowledge that it was also associated with impotence and blindness, in all six countries. Knowledge regarding the health risks of passive smoking was moderate in most countries. The LII was highest in Romania and Poland, followed by Spain and Greece, and lowest in Germany and Hungary. In almost all countries, there was a positive association between LII scores and higher KHR scores after controlling for sociodemographic variables. Several sociodemographic factors were associated with KHR and LII, with differences in these associations documented across countries.

Conclusions: These data provide evidence to support the need for stronger educational efforts and policies that can enhance the effectiveness of health warnings in communicating health risks and promoting quit attempts. Data will serve as a baseline for examining the impact of the TPD.

Citation

Fong, G.T., Thompson, M.E., Boudreau, C., Bécuwe, N., Driezen, P., Agar, T.K., Quah, A.C.K., Zatoński, W., Przewoźniak, K., Mons, U., Demjén, T., Tountas, Y., Trofor, A., Fernández, E., McNeill, A., Willemsen, M., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2018). The conceptual model and methods of Wave 1 (2016) of the EUREST-PLUS ITC 6 European Countries Survey. Tobacco Induced Diseases, 16(Suppl 2), 11-20.

Abstract

Population-level interventions represent the only real approach for combatting the tobacco epidemic. There is thus great importance in conducting rigorous evaluation studies of tobacco control policies and regulations such as those arising from the WHO Framework Convention on Tobacco Control (FCTC) and the European Union’s 2014 Tobacco Products Directive (TPD). The ITC 6 European Countries Survey, a component of the Horizon 2020 Project entitled European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Disease (EUREST-PLUS), was created to evaluate and impact of the TPD in six EU Member States: Germany, Greece, Hungary, Poland, Romania, and Spain. In each country, a cohort survey of a representative national sample of 1000 smokers was conducted. This paper describes the conceptual model, methodology, and initial survey statistics of Wave 1 of the ITC 6E Survey, which was conducted June–September 2016. The ITC 6E Survey’s conceptual model, methodology, and survey instrument, were based on the broader 29-country ITC Project cohort studies, which have been conducted since 2002. The commonality of methods and measures allow a strong potential for cross-country comparisons between the 6 EU countries of the ITC 6E Project and 3 other EU countries (England, France, The Netherlands) in the ITC Project, as well as the broader set of ITC countries outside the EU.

Abstract

Introduction: To date, no studies have explored how different regulatory environments may influence the effectiveness of ECs as a smoking cessation aid.

Objective: This study compares the real-world effectiveness of adult smokers using ECs for quitting compared with quitting unassisted or quitting with NRT and/or prescription medications in two countries with restrictive policies towards ECs (i.e., Canada and Australia) versus two countries with less restrictive policies (i.e., US and UK).

Methods: Data were drawn from the International Tobacco Control Four Country surveys, from the US and Canada (2 waves, n=318 and 380, respectively), the UK (3 waves, n=439) and Australia (4 waves, n=662), collected 2010-2014. Smokers at baseline wave who reported making a quit attempt at follow-up were included. The primary outcome was self-reported abstinence for at least 30 days regardless of smoking status at follow-up assessment. Data across waves were combined and analysed using generalised estimating equations.

Results: Compared to unassisted quitting (i.e. no medications or ECs), smokers who used ECs for quitting from countries with less restrictive EC policy environments were more likely (OR=1.95, 95%CI=1.19-3.20, p<0.01), whereas smokers who used ECs for quitting from countries with more restrictive EC policies were less likely (OR=0.36, 95%CI=0.18-0.72, p<0.01), to report sustained abstinence for at least 30 days.

Conclusion: Use of ECs in the real world during a quit attempt appears only effective for sustaining smoking abstinence in a less restrictive EC environment suggesting that the benefits of ECs for smoking cessation are likely highly dependent on the regulatory environment.

Implications: What this study adds: This is the first study to examine the impact of regulatory environment for electronic cigarettes (ECs) on their real-world effectiveness for smoking cessation. This study shows that in a less restrictive EC regulatory environment, use of ECs during a quit attempt facilitates, but in a more restrictive environment, it inhibits, short-term sustained abstinence. The findings underscore the need for careful consideration on how best to regulate this emerging product so that EC benefits for smoking cessation are maximised and its risks to public health are minimised.

Citation

Kasza, K.A., Hyland, A., Cummings, K.M., Carpenter, M.J., Fong, G.T., Borland, R., McNeill, A. (2017). A cross-country comparison of smokers’ reasons for thinking about quitting over time: Findings from the International Tobacco Control Four Country Survey (ITC-4C), 2002-2015. Tobacco Control, 26(6), 641-48.

Abstract

Objective: To explore between-country differences and within-country trends over time in smokers' reasons for thinking about quitting and the relationship between reasons and making a quit attempt.

Methods: Participants were nationally representative samples of adult smokers from the UK (N=4717), Canada (N=4884), the USA (N=6703) and Australia (N=4482), surveyed as part of the International Tobacco Control Four Country Survey between 2002 and 2015. Generalised estimating equations were used to evaluate differences among countries in smokers' reasons for thinking about quitting and their association with making a quit attempt at follow-up wave.

Results: Smokers' concern for personal health was consistently the most frequently endorsed reason for thinking about quitting in each country and across waves, and was most strongly associated with making a quit attempt. UK smokers were less likely than their counterparts to endorse health concerns, but were more likely to endorse medication and quitline availability reasons. Canadian smokers endorsed the most reasons, and smokers in the USA and Australia increased in number of reasons endorsed over the course of the study period. Endorsement of health warnings, and perhaps price, appears to peak in the year or so after the change is introduced, whereas other responses were not immediately linked to policy changes.

Conclusions: Differences in reasons for thinking about quitting exist among smokers in countries with different histories of tobacco control policies. Health concern is consistently the most common reason for quitting and the strongest predictor of future attempts.

Citation

Kasza, K.A., Hyland, A., Borland, R., McNeill, A., Fong, G.T., Carpenter, M.J., Partos, T.R., Cummings, K.M. (2017). Cross-country comparison of smokers’ reasons for thinking about quitting over time: Findings from the International Tobacco Control Four Country Survey (ITC-4C), 2002-2015. Tobacco Control, 26(6), 641-648.

Abstract

Objective: To explore between-country differences and within-country trends over time in smokers' reasons for thinking about quitting and the relationship between reasons and making a quit attempt.

Methods: Participants were nationally representative samples of adult smokers from the UK (N=4717), Canada (N=4884), the USA (N=6703) and Australia (N=4482), surveyed as part of the International Tobacco Control Four Country Survey between 2002 and 2015. Generalised estimating equations were used to evaluate differences among countries in smokers' reasons for thinking about quitting and their association with making a quit attempt at follow-up wave.

Results: Smokers' concern for personal health was consistently the most frequently endorsed reason for thinking about quitting in each country and across waves, and was most strongly associated with making a quit attempt. UK smokers were less likely than their counterparts to endorse health concerns, but were more likely to endorse medication and quitline availability reasons. Canadian smokers endorsed the most reasons, and smokers in the USA and Australia increased in number of reasons endorsed over the course of the study period. Endorsement of health warnings, and perhaps price, appears to peak in the year or so after the change is introduced, whereas other responses were not immediately linked to policy changes.

Conclusions: Differences in reasons for thinking about quitting exist among smokers in countries with different histories of tobacco control policies. Health concern is consistently the most common reason for quitting and the strongest predictor of future attempts.