Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

Citation

Green, A., Driezen, P., Hammond, D., Soar, S., Fong, G.T. (2019). The impact of adding and removing warning label messages from cigarette packages on adult smokers’ awareness about the health harms of smoking: Findings from the ITC Canada Survey. Tobacco Control, 28(e1), 356-63.

Abstract

Introduction: Adding messages to cigarette health warning labels (HWLs) about the harms of smoking increases awareness of these health facts, but little is known about the impact of removing messages. This is the first study to directly investigate the impact of adding and removing messages from cigarette HWLs on smokers’ awareness of harms.

Methods: Data were drawn from nine waves of the International Tobacco Control (ITC) Canada Survey, a national representative cohort of adult smokers (n=5863) conducted nearly annually between 2002 and 2013–2014. Two analytical approaches were conducted: generalised estimating equation (GEE) regression models estimated adjusted percentages of correct smoking-related health statements at each wave and segmented regression analyses modelled temporal trends in awareness before and after the revisions by measuring the difference in slopes.

Results: Adding messages to HWLs significantly increased awareness that smoking causes blindness (OR=3.36 (95% CI 2.71 to 4.18); p<0.001; estimated increase of 1.01 million smokers in Canada) and bladder cancer (OR=2.14 (95% CI 1.71 to 2.66), p<0.001; estimated increase of 1.09 million smokers). Adding the warning that nicotine causes addiction did not significantly impact smokers’ awareness. Removing messages was shown to decrease awareness that cigarette smoke contains carbon monoxide (OR=0.53 (95% CI 0.41 to 0.70), p<0.001; estimated decrease of 342 000 smokers) and smoking causes impotence (p=0.007 for the difference in slopes; estimated decrease of 354 000 smokers).

Conclusions: Adding messages to HWLs increases smokers’ awareness of health facts, but removing messages decreases awareness. These findings demonstrate the importance of carefully considering the implications of adding and especially removing messages from HWLs and the importance of regularly revising warnings.

Citation

Chan, C.K.G., Morphett, K., Gartner, C., Leung, J., Yong, H.H., Hall, W., Borland, R. (2019). Predicting vaping uptake, vaping frequency and ongoing vaping among daily smokers using longitudinal data from the International Tobacco Control (ITC) Four Country Surveys. Addiction, 114(Suppl 1), 61-70.

Abstract

Aim: To assess (1) how far smoking patterns, depression and smoking‐related beliefs and intentions predict vaping uptake, current vaping and vaping frequency among daily smokers; and (2) how far the aforementioned predictors and baseline vaping frequency predict current vaping among those who reported ever vaped.

Design: Analysis of data from six waves of a longitudinal survey over 8 years. Longitudinal associations between predictors and outcomes were examined using multi‐level models.

Setting: United Kingdom, United States, Canada and Australia.

Participants: A total of 6296 daily smokers (53% females) who contributed data to at least two consecutive survey waves.

Measurements: The outcome variables were vaping uptake, vaping frequency and current vaping at follow‐up. The key predictor variables, measured in previous waves, were time to first cigarette, cigarettes smoked per day, depressive symptoms, intention to quit smoking, quitting self‐efficacy and worry about adverse health effects of smoking.

Findings: Number of cigarettes smoked daily was associated with (1) subsequent vaping uptake [odds ratio (OR) = 1.69, 95% confidence interval (CI) = 1.19, 2.39 for 30+ cigarette per day; reference category: 0–10 cigarettes] and (2) a higher frequency of current vaping (OR = 1.97, 95% CI = 1.36, 2.85 for 30+ cigarettes). Intention to quit was associated with a higher frequency of current vaping (OR = 1.48, 95% CI = 1.21, 1.82). Among those who reported ever vaped, higher baseline vaping frequency (OR = 11.98, 95% CI = 6.00, 23.93 for daily vaping at baseline; reference category: vaped less than monthly) predicted current vaping.

Conclusion: Among daily smokers, amount smoked and intention to quit smoking appear to predict subsequent vaping uptake. Vaping frequency at baseline appears to predict current vaping at follow‐up.

Citation

Zatoński, M., Herbec, A., Zatoński, W., Przewoźniak, K., Janik-Koncewicz, K., Mons, U., Fong, G.T., Demjén, T., Tountas, Y., Trofor, A., Fernández, E., McNeill, A., Willemsen, M.C., Hummel, K., Quah, A.C.K., Kyriakos, C.N., Vardavas, C. (2018). Characterising smokers of menthol and flavoured cigarettes, their attitudes towards tobacco regulation, and the anticipated impact of the Tobacco Products Directive on their smoking and quitting behaviours: The EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 34-46.

Abstract

Introduction: Little research exists on the sociodemographic characteristics of menthol and flavoured cigarette (MFC) smokers in Europe. This study assessed the proportion of MFC smokers in Europe, their sociodemographic characteristics, and their attitudes towards tobacco control measures.

Methods: Cross-sectional data were collected in 2016 among 10760 adult current smokers from 8 European countries (ITC Europe Project and EUREST-PLUS). Smokers of menthol, other flavoured, unflavoured tobacco, or no usual brand were compared on sociodemographic characteristics, attitudes towards a range of tobacco control measures (e.g. ban on flavouring), and on intentions regarding their smoking behaviour following the ban on flavoured tobacco. Data were analysed in SPSS Complex Samples Package using univariate analyses.

Results: Among the respondents, 7.4% smoked menthol cigarettes and 2.9% other flavoured tobacco, but large differences existed between countries (e.g. 0.4% smokers smoked menthol cigarettes in Spain vs 12.4% in England). Compared to other groups, menthol cigarette smokers were younger, more likely to be female, better educated, had higher household income, and smoked fewer cigarettes (all p<0.001). A quarter of menthol smokers supported a ban on additives, compared with almost half of all other smokers (p<0.001). In case of a ban on flavourings, around a fifth of all MFC smokers intended to switch to another brand, and a third to reduce the amount they smoked or to quit smoking, but there was no consistent pattern across MFC smokers among the countries.

Conclusions: The ban on flavourings introduced by the EU Tobacco Products Directive (extended to 2020 for menthols) will affect one in ten smokers in the countries surveyed, which provides an opportunity for targeting these groups with cessation programmes. However, smokers of menthol and flavoured cigarettes in the different European countries are a heterogeneous group and may need different approaches.

Citation

Gravely, S., Thrasher, F.J., Cummings, K.M., Ouimet, J., McNeill, A., Meng, G., Lindblom, E.N., Loewen, R., O’Connor, R., Thompson, M.E., Hitchman, S., Hammond, D., Heckman, B.W., Borland, R., Yong, H.H., Elton-Marshall, T., Bansal-Travers, M., Gartner, C., Fong, G.T. (2019). Discussions between health professionals and smokers about nicotine vaping products: Results from the 2016 ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 71-85.

Abstract

Background and Aims: Debate exists about whether health professionals (HPs) should advise smokers to use nicotine vaping products (NVPs) to quit smoking. The objectives were to examine in four countries: (1) the prevalence of HP discussions and recommendations to use an NVP; (2) who initiated NVP discussions; (3) the type of HP advice received about NVPs; and (4) smoker's characteristics related to receiving advice about NVPs.

Design: Cross‐sectional study using multivariable logistic regression analyses on weighted data from the 2016 ITC Four Country Smoking and Vaping Survey (ITC 4CV1).

Setting: Four countries with varying regulations governing the sale and marketing of NVPs: ‘most restrictive’ (Australia), ‘restrictive’ (Canada) or ‘less restrictive’ (England and United States).

Participants: A total of 6615 adult smokers who reported having visited an HP in the last year (drawn from the total sample of 12 294 4CV1 respondents, of whom 9398 reported smoking cigarettes daily or weekly). Respondents were from the United States (n = 1518), England (n = 2116), Australia (n = 1046), and Canada (n = 1935).

Measurements: Participants’ survey responses indicated if they were current daily or weekly smokers and had visited an HP in the past year. Among those participants, further questions asked participants to report (1) whether NVPs were discussed, (2) who raised the topic, (3) advice received on use of NVPs and (4) advice received on quitting smoking.

Findings: Among the 6615 smokers who visited an HP in the last year, 6.8% reported discussing NVPs with an HP and 2.1% of smokers were encouraged to use an NVP (36.1% of those who had a discussion). Compared with Australia (4.3%), discussing NVPs with an HP was more likely in the United States [8.8%, odds ratio (OR) = 2.15, 95% confidence interval (CI) = 1.41–3.29] and Canada (7.8%, OR = 1.87, 95% CI = 1.26–2.78). Smokers in Australia were less likely to discuss NVPs than smokers in England (6.2%), although this was not statistically significant (OR = 1.47, 95% CI = 0.98–2.20). Overall, the prevalence of HPs recommending NVPs was three times more likely in the United States than in Australia (OR = 3.07, 95% CI = 1.45–6.47), and twice as likely in Canada (OR = 2.28, 95% CI = 1.06–4.87) than in Australia. Australia and England did not differ (OR = 1.76, 95% CI = 0.83–3.74). Just over half (54%) of respondents brought up NVPs themselves; there were no significant differences among countries.

Conclusions: Discussions in Australia, Canada, England, and the United States between smokers and health professionals about nicotine vaping products appear to be infrequent, regardless of the regulatory environment. A low percentage of health professionals recommended vaping products. This was particularly evident in Australia, which has the most restrictive regulatory environment of the four countries studied.

Citation

Thompson, M.E., Fong, G.T., Boudreau, C., Driezen, P., Li, G., Gravely, S., Cummings, K.M., Heckman, B.W., O’Connor, R.J., Thrasher, J.F., Nahhas, G., Borland, R., Yong, H.H., McNeill, A., Hitchman, S.C., Quah, A.C.K. (2019). Methods of the ITC Four Country Smoking and Vaping Survey, Wave 1 (2016). Addiction, 114(Suppl 1) 6-14.

Abstract

Aim: To describe the methods of the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey, conducted in 2016 in Australia (AU), Canada (CA), England (EN) and the United States (US).

Methods: The respondents were cigarette smokers, former smokers (quit within the previous 2 years), and at‐least‐weekly vapers, aged 18 years and older. Eligible cohort members from the ITC Four Country Survey (4C) were retained. New respondents were sampled by commercial firms from their panels. Where possible, ages 18–24 and vapers were oversampled. Data were collected online, and respondents were remunerated. Survey weights were calibrated to benchmarks from nationally representative surveys.

Results: Response rates by country for new recruits once invited ranged from 15.2 to 49.6%. Sample sizes for smokers/former smokers were 1504 in AU, 3006 in CA, 3773 in EN and 2239 in the US. Sample sizes for additional vapers were 727 in CA, 551 in EN and 494 in the US.

Conclusion: The International Tobacco Control Four Country Smoking and Vaping Survey design and data collection methods allow analyses to examine prospectively the use of cigarettes and nicotine vaping products in jurisdictions with different regulatory policies. The effects on the sampling designs and response quality of recruiting the respondents from commercial panels are mitigated by the use of demographic and geographic quotas in sampling; by quality control measures; and by the construction of survey weights taking into account smoking/vaping status, sex, age, education and geography.

Citation

Levy, D., Abrams, D.B., Yuan, Z., Lou, Y., Fong, G.T., Borland, R. (2019). A modeling approach to gauging the effects of nicotine vaping product use on cessation from cigarettes: What do we know, what do we need to know? Addiction, 114(Suppl 1), 86-96.

Abstract

Background and Aims: The long term population health impact of nicotine vaping products (NVPs) use among smokers is unknown and subject to a range of plausible assumptions about the use and health consequences of NVPs. While NVPs use may substitute for cigarette smoking and thereby aid in quitting cigarette use, it is also possible that smokers who would have otherwise quit would instead delay quitting cigarettes. We aimed to develop a cohort-specific simulation model of the impact of NVPs on smoking cessation by adult smokers and resulting premature deaths (PD) and life-years lost (LYL).

Design: A cohort-specific simulation model of the impact of NVPs on smoking cessation by adult smokers and resulting premature deaths (PD) and life-years lost (LYL) was developed by gender for two birth-cohorts, age 30 and age 50 in 2012. Extensive sensitivity analyses were conducted.

Setting: United States PARTICIPANTS: Smokers in two birth-cohorts, age 30 and age 50 in 2012 MEASUREMENTS: Data were from the 1965-2012 National Health Interview Surveys and the 2014/5 Tobacco Use Supplement of the Current Population Survey. The model incorporated a range of plausible assumptions from published literature about transition rates from regular smoking to exclusive NVP and dual use, from dual use to exclusive NVP use and from exclusive NVP use to no use.

Findings: Compared with the No-NVP scenario, the male (female) model projected 17.8% (19.3%) fewer PDs and 22.9% (26.6%) fewer LYL for the 1982 cohort and 5.4% (7.3%) fewer PDs and 7.9% (11.4%) fewer LYL for the 1962 cohort. These gains were sensitive to NVP use over time, age of initial NVP use, transitions from smoking to dual, exclusive NVP and no use, and relative NVP mortality risks.

Conclusions: Nicotine vaping product (NVP) use in the US is projected to have a net positive impact on population health over a wide range of plausible levels of NVP use, transitions to dual, exclusive NVP and no use, and NVP risks. However, net impact is sensitive to parameter estimates.

Citation

Branston, J.R., McNeill, A., Gilmore, A., Hiscock, R., Partos, T.R. (2018). Keeping smoking affordable in higher tax environments via smoking thinner roll-your-own cigarettes: Findings from the International Tobacco Control Four Country Survey 2006–15. Drug and Alcohol Dependence, 193, 110-116.

Abstract

Background: Roll-Your-Own tobacco (RYO) use is increasingly popular in many countries: it is generally cheaper than factory-made cigarettes (FM), and smokers can further reduce costs by adjusting the amount of tobacco in each cigarette. However, the level of risk of RYO compared with FM cigarettes is similar and does not meaningfully change with cigarette weight. We assessed the weight of tobacco in RYO cigarettes across jurisdictions with differing tobacco taxes/prices and over time.

Method: Six waves of the International Tobacco Control 4 Country longitudinal study of smokers and recent ex-smokers, providing 3176 observations from exclusive RYO users covering 2006-15, are used to calculate the weight of tobacco used in RYO cigarettes in the US, Canada, Australia, and the UK. Multilevel regression analyses were used to compare weights across countries, socio-demographic factors, and over time.

Results: Smokers in the UK and Australia, where tobacco is relatively expensive, show higher levels of exclusive RYO use (25.8% and 13.8% respectively) and lower mean weights of tobacco per RYO cigarette (0.51 g(sd 0.32 g) and 0.53 g(0.28 g)), compared with both Canada and especially the US (6.0% and 3.5%, and 0.76 g(0.45 g) and 1.07 g(0.51 g)). Smokers in the UK and Australia also exhibited a statistically significant year-on-year decrease in the mean weight of each RYO cigarette.

Conclusions: Taxation of RYO should increase considerably in the UK and Australia so that RYO and FM cigarettes are taxed equivalently to reduce RYO attractiveness and inequalities. Other measures to reduce the price differentials, including taxing RYO solely on weight, are also discussed.

Citation

Heckman, B.W., Cummings, K.M., Stoltman, J.J.K., Dahne, J., Borland, R., Fong, G.T., Carpenter, M.J. (2019). Longer duration of smoking abstinence is associated with waning cessation fatigue. Behaviour Research and Therapy, 115, 12-18.

Abstract

Background: Cessation fatigue, a construct theorized to reflect exhaustion of coping resources due to quitting smoking, has been found to predict relapse. This study examines the association between cessation fatigue and duration of abstinence among 1397 adult former smokers who participated in the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Wave 1 Survey (4CV). We hypothesized lower levels of cessation fatigue will be correlated with longer duration of abstinence.

Method: Data for this cross-sectional study were collected in a web-based survey which recruited national samples from Australia, Canada, England, and United States. Former smokers were abstinent up to five years.

Results: Lower cessation fatigue was associated with longer duration of smoking abstinence. Cessation fatigue was highest in former smokers that had been quit for up to six months, with lower cessation fatigue found in those quit for at least seven months and another drop-off in fatigue observed for those quit for at least two years.

Conclusions: Cessation fatigue is highest soon after quitting smoking but declines over time for those who remain abstinent. Understanding the mechanisms by which cessation fatigue is related to abstinence could potentially offer insights into ways to help individuals sustain quitting.

Citation

Shang, C., Chaloupka, F., Gupta, P.C., Pednekar, M.S., Fong, G.T. (2019). Association between tobacco prices and smoking onset: Evidence from the TCP India Survey. Tobacco Control, 28(Suppl1), S3-S8.

Abstract

Background: Tobacco use is prevalent among youth and adults in India. However, direct evidence on how increasing taxes or prices affect tobacco use onset is scarce.

Objective: To analyse the associations between cigarette and bidi prices and smoking onset in India, and how these associations differ by socioeconomic status.

Methodology: The Wave 1 of the Tobacco Control Policy Evaluation India Survey by the International Tobacco Control Project contains information on the age at smoking onset for cigarettes and bidis. Using this information, data were expanded to a yearly pseudo-panel dataset that tracked respondents at risk of smoking onset from 1998 to 2011. The associations between bidi prices and bidi smoking onset, between cigarette prices and cigarette smoking onset, and between bidi and cigarette prices and any smoking onset were examined using a discrete-time hazard model with a logit link function. Stratified analyses were conducted to examine the difference in these associations by rural versus urban division.

Results: We found that higher bidi prices were significantly associated with a lowered hazard of bidi smoking onset (OR 0.42, 95% CI 0.35 to 0.51). Higher cigarette prices were significantly (OR 0.87, 95% CI 0.83 to 0.92) associated with a lowered hazard of cigarette smoking onset among urban residents, but this association was non-significant when SEs were clustered at the state level. In addition, the association between increasing bidis prices and lowered hazards of bidi smoking onset was greater for urban residents than for rural ones (p<0.01).

Conclusions: Under the new regime of a central goods and service system, policymakers may need to raise the prices of tobacco products sufficiently to curb smoking onset.

Citation

Fu, M., Castellano, Y., Tigova, O., Kyriakos, C.N., Fong, G.T., Mons, U., Zatonzki, W.A., Agar, T., Quah, A.C.K., Trofor, A., Demjén, T., Przewoźniak, K., Tountas, Y., Vardavas, C., Fernández, E., on behalf of the EUREST-PLUS Consortium. (2018). Prevalence and correlates of different smoking bans in homes and cars among smokers in 6 countries of the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 85-97.

Abstract

Introduction: Second-hand smoke exposure has decreased in a number of countries due to widespread smoke-free legislation in public places, but exposure is still present in private settings like homes and cars. Our objective was to describe to what extent smokers implement smoking rules in these settings in six European Union (EU) Member States (MS).

Methods: A cross-sectional survey was conducted with a nationally representative sample of adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (ITC six European countries survey, part of the EUREST-PLUS Project). We analysed data from 6011 smokers regarding smoking rules in their homes and in cars with children (no rules, partial ban, total ban). We described the prevalence of smoking rules by EU MS and several sociodemographic and smoking characteristics using prevalence ratios (PR) and 95% confidence intervals (CI) derived from Poisson regression models.

Results: In homes, 26.5% had a total smoking ban (from 13.1% in Spain to 35.5% in Hungary), 44.7% had a partial ban (from 41.3% in Spain to 49.9% in Greece), and 28.8% had no-smoking rules (from 20.2% in Romania to 45.6% in Spain). Prevalence of no-smoking rules in cars with children was 16.2% (from 11.2% in Germany to 20.4% in Spain). The correlates of not restricting smoking in homes and cars included: low education (PR=1.51; 95%CI: 1.20-1.90 and PR=1.55; 95%CI: 1.09-2.20), smoking >30 cigarettes daily (PR=1.53; 95%CI: 1.10-2.14 and PR=2.66; 95%CI: 1.40-5.05) and no attempts to quit ever (PR=1.18; 95%CI: 1.06-1.31 and PR=1.28; 95%CI: 1.06-1.54).

Conclusions: Among smokers in six EU MS, no-smoking rules were more prevalent in homes than in cars with children. Whilst awareness about the health effects of exposure to tobacco smoke on children seemed to be high, more research is needed to better understand the factors that promote private smoke-free environments.

Citation

Shang, C., Chaloupka, F., Fong, G.T., Gupta, P.C., Pednekar, M.S. (2018). The association between state value-added taxes in tobacco use in India: evidence from GATS and TCP India Survey. Nicotine & Tobacco Research, 20(11), 1344-1352.

Abstract

Introduction: State value-added taxes (VAT) on tobacco products have been increased significantly in recent years in India. Evidence on how these VATs were associated with smoking is highly needed.

Methods: State bidi and cigarette VAT rates were linked to Global Adult Tobacco Survey (GATS) India 2009–2010 and Tobacco Control Policy (TCP) India Survey waves 1 (2010–2011) and 2 (2012–2013), respectively. These linked data were used to analyze the associations between bidi VAT rates and bidi smoking, between cigarette VAT rates and cigarette smoking, and between the two VAT rates and dual use of bidis and cigarettes. Weighted logistic regressions were employed to examine GATS cross-sectional data, whereas Generalized Estimating Equations (GEE) were employed to examine longitudinal TCP data. We further stratified the analyses by gender.

Results: A 10% increase in cigarette VAT rates was associated with a 6.5% (p<0.001) decrease in dual use of cigarettes and bidis among adults and a 0.9% decrease (p<0.05) in cigarette smoking among males in TCP; and with a 21.6% decrease (p<0.05) in dual use among adults and a 17.2% decrease (p<0.001) in cigarette smoking among males in GATS. TCP analyses controlling for state fixed effects are less likely to be biased and indicate a cigarette price elasticity of – 0.44. As female smoking prevalence was extremely low, these associations were non-significant for females.

Conclusions: Higher state cigarette VAT rates in India were significantly associated with lower cigarette smoking and lower dual use of cigarettes and bidis. Increasing state VAT rates may significantly reduce smoking in India.

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

Stein, J., Heckman, B.W., Pope, D.A., Perry, E.S., Fong, G.T., Cummings, K.M., Bickel, W.K. (2018). Delay discounting and e-cigarette use: an investigation in current, former, and never cigarette smokers. Drug and Alcohol Dependence, 191, 165-173.

Abstract

Background: Cigarette smokers show greater delay discounting (devaluation of delayed consequences) than non-smokers, suggesting that rapid devaluation of the future contributes to tobacco use through a mechanism in which tobacco-related health consequences are too delayed to discourage smoking. However, little work has quantified delay discounting in relation to electronic cigarette (EC) use, a tobacco product that many users believe to pose fewer negative health consequences than cigarettes.

Methods: We assessed discounting of delayed monetary rewards in a web-based sample of 976 participants, stratified by both EC use (current and never) and cigarette use (current, former, and never).

Results: Controlling for demographic variance, current EC users generally showed greater discounting than never EC users (p = .019). Current cigarette smokers also showed greater discounting than former and never smokers (p < .001). However, the between-group difference for EC use was much smaller (ηp2 = .006) than for cigarette use (ηp2 = .026). Moreover, differences in discounting in relation to EC use were not statistically apparent in most pairwise comparisons. Most notably, the difference between former smokers who achieved smoking cessation by transitioning to ECs (i.e., exclusive EC users) and those who have never used ECs or cigarettes was nonsignificant and small (ηp2 = .010).

Conclusions: The smaller effect size for the association between delay discounting and current EC use, relative to current cigarette use, suggests that public perception of ECs as a safer alternative to cigarettes attenuates the role of delay discounting in decisions to use ECs.

Citation

Kyriakos, C.N., Filippidis, F., Hitchman, S.C., Girvalaki, C., Tzavara, C.K., Demjén, T., Fernández, E., Mons, U., Trofor, A., Tountas, Y., Zatoński, M., Zatoński, W., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2018). Characteristics and correlates of electronic cigarette product attributes and undesirable events during e-cigarette use in six countries of the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 21-33

Abstract

Introduction: This study assessed characteristics and correlates associated with e-cigarette product attributes and identified correlates of experiencing undesirable events during e-cigarette use among adult smokers across six European Union (EU) Members States (MS) prior to the implementation of the Tobacco Products Directive (TPD) in 2016.

Methods: We conducted a cross-sectional survey with a nationally representative sample of adult cigarette smokers from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) reporting e-cigarette use; randomly selected through a multistage cluster sampling design from June to September 2016. Stepwise logistic regressions were used to identify factors associated with use of flavors, noticing health warnings, mixing e-liquids, experiencing ‘dry puff’, e-liquid leaking during use and e-liquid spilling during refill.

Results: Current daily or weekly prevalence of e-cigarette use among this sample of adult smokers was 7.5%. The most common attributes of e-cigarettes used included those that are flavored, contain nicotine, and are of tank style. Noticing health warnings on e-cigarette packaging and leaflets, respectively, was low (10.2% and 28%, respectively). Use of e-liquid refill nozzle caps, described as easy for a child to open, was associated with spilling during refill (OR=6.73; 95% CI: 2.02–22.37). Participants who adjusted occasionally or regularly the power (voltage) or temperature of their e-cigarette had greater odds of ever experiencing a ‘dry puff’ (OR=6.01; 95% CI: 2.68–13.46). Mixing different e-liquids was associated with leaking during use (OR=7.78; 95% CI: 2.45–24.73) and spilling during refill (OR=8.54; 95% CI: 2.29–31.88).

Conclusions: Ongoing evaluation of factors associated with e-cigarette attributes and of the correlates of experiencing e-cigarette undesirable events during use, related to product design, is crucial to monitoring the impact of the implementing Acts of the EU TPD.

Citation

Levy, D., Yuan, Z., Abrams, D.B. (2018). The relationship of e-cigarette use to cigarette quit attempts and cessation: insights from a large, nationally representative U.S. Survey. Nicotine and Tobacco Research, 20(8), 931-939.

Abstract

Objectives: While cessation from cigarettes is a top priority for public health, controversy surrounds the role of e-cigarettes for quitting cigarettes. This study examines the role of e-cigarettes in quit attempts and 3-month cigarette abstinence using a large, recent nationally representative US sample.

Methods: Data from the 2014/15 Tobacco Use Supplement-Current Population Survey (TUS-CPS) on cigarette and e-cigarette use and individual characteristics were supplemented with information on state tobacco control policies. We estimated frequencies and multivariate logistic equations for making a quit attempt among those who smoked 1 year earlier and for remaining abstinent at least 3 months among those making a quit attempt. These two outcomes were related to demographic characteristics, tobacco control policies and different frequency measures of e-cigarette use (ever, at least 1, 5, 20 of the last 30 days, a continuous measure of days use).

Results: Having made a quit attempt was more likely among smokers using e-cigarettes than non-users. Among those making at least one quit attempt, quit success was lower among ever users, but higher among those with at least 5 days use of e-cigarettes in the last month. Both quit attempts and quit success were linearly related to the frequency of e-cigarette use.

Conclusions: Consistent with randomized trials and those observational studies that measure frequency of e-cigarette use, both quit attempts and quit success were positively associated with increased frequency of e-cigarette use. Frequency of e-cigarette use was important in gauging the nature of these relationships.

Implications: Previous studies have obtained mixed results regarding the relationship of e-cigarette use to cigarette smoking cessation. This study provides a more precise methodology for considering the relationship of e-cigarette use to quit attempts and to quit success, and finds that quit attempts and quit success increase with the number of days use in the past month.

Citation

Partos, T.R., Branston, J.R., Hiscock, R., Gilmore, A., McNeill, A. (2019). Individualised tobacco affordability in the UK 2002-2014: Findings from the International Tobacco Control Policy Evaluation Project. Tobacco Control, 28(Suppl 1), S9-S19.

Abstract

Objective: The existing measures of tobacco affordability (smokers' purchasing power for tobacco) use national estimates of income and average cigarette prices, and exclude roll-your-own (RYO) tobacco. This study developed an individualised measure of tobacco affordability using smokers' own incomes and factory-made (FM) or RYO tobacco purchase prices, and explored how it was impacted by taxation changes, individual characteristics and purchase patterns.

Design: Cross-sectional survey data collated from 10 waves of a longitudinal cohort study.

Data Sources: Adult smokers (n=4062) from the International Tobacco Control Policy Evaluation Project United Kingdom (UK), surveyed between 2002 and 2014, providing 8943 observations over 10 surveys.

Analysis: Affordability was calculated as the percentage of annual income remaining with the individuals after their annual tobacco expenditure. Multilevel linear regression models were used with affordability as the outcome using time, sex, age, geographical region, ethnicity, education, nicotine dependence and tobacco purchase source as the predictor variables.

Results: Affordability of FM cigarettes decreased significantly from 91.5% (±95% CI: 91.0% to 91.9%) in 2002 to 87.8% (87.0% to 88.5%) in 2014; and RYO from 96.3% (95.7% to 96.9%) in 2006 to 93.7% (93.0% to 94.4%) in 2014. Affordability was significantly lower for FM than RYO. Year-on-year decreases were not statistically significant. Tobacco was more affordable for males, those with higher education, less dependent smokers and those purchasing from non-store (potentially illicit) or non-UK sources.

Conclusions: An individualised measure of tobacco affordability provided useful insights on the impact of tobacco taxes, social inequalities and purchase patterns in the UK. Although tobacco became less affordable, the annual rate of decline was low, suggesting annual tax rises were not large enough.

Citation

Fong, G.T., Chung-Hall, J., Craig, L.V., for the WHO FCTC Impact Assessment Expert Group. (2019). Impact assessment of the WHO FCTC over its first decade: Methodology of the Expert Group. Tobacco Control, 28(Suppl 2), S84-88.

Abstract

Background: At its sixth meeting (Moscow, November 2014), the Conference of the Parties (COP) adopted decision FCTC/COP6(13) that called for an impact assessment to 'examine the impact of the WHO Framework Convention on Tobacco Control (FCTC) on the implementation of tobacco control measures and on the effectiveness of its implementation' after its first 10 years. An independent expert group (EG) was established to conduct the impact assessment, and report their findings at COP7 (Delhi, November 2016). This article describes the methodology used by the EG to conduct the first comprehensive multi-method assessment of the possible causal impact of the FCTC on global tobacco control over the past decade.

Methods: The EG developed and followed a four-stage process model to conduct the impact assessment: (1) desk review of literature on FCTC impact; (2) collection and analysis of interview data from 12 country missions; (3) data synthesis and interpretation; and (4) preparation of a final report.

Conclusions: The EG developed and engaged in a transparent and systematic process to conduct the FCTC impact assessment. The methods employed were rigorous, and explicitly guided by concerns about the difficulty of ascribing cause-and-effect relations. The EG's report and supporting documents represent important sources of the positive impact of the Convention over its first decade. As development of the FCTC increasingly shifts to mechanisms for accelerating global implementation, the EG's process model can be used as a methodology to assist Parties in carrying out their own assessments of the impact of the Treaty.

Citation

Thomas, D., Davey, M.E., Panaretto, K.S., van der Sterren, A.E. (2018). Cannabis use among two national samples of Aboriginal and Torres Strait Islander tobacco smokers. Drug and Alcohol Review, 37(Suppl 1), S394-S403.

Abstract

Introduction and Aims: There is a concern that cannabis use is an important barrier to reducing Aboriginal and Torres Strait Islander smoking. We investigate the associations of cannabis use and tobacco smoking and quitting in two large national samples.

Design and Methods: The 2012–2013 National Aboriginal and Torres Strait Islander Health Survey was a national stratified random household survey conducted between April 2012 and February 2013, and included 2580 adult Aboriginal and Torres Strait Islander smokers. The Talking About The Smokes Project interviewed a national quota sample of 1301 Aboriginal and Torres Strait Islander adult smokers between August 2013 and August 2014. Both surveys asked about tobacco smoking and quitting, cannabis use and socio‐demographic factors.

Results: Both surveys estimated that cannabis use is common among Aboriginal and Torres Strait Islander smokers (National Aboriginal and Torres Strait Islander Health Survey: 32%, Talking About The Smokes: 24%). Both surveys found a higher prevalence of cannabis use among smokers who were male, younger, unemployed or who more frequently consumed five or more alcoholic drinks in a day. However, the two surveys provided inconsistent evidence about whether cannabis use is associated with not quitting smoking tobacco.

Discussion and Conclusions: We did not find consistent evidence in this setting that cannabis use is an obstacle to quitting tobacco smoking. Nevertheless, we would still recommend that clinicians counselling Aboriginal and Torres Strait Islander tobacco smokers about quitting talk about cannabis use because its use is common and almost all mix it with tobacco.

Citation

Wadsworth, E., McNeill, A., Li, L., Hammond, D., Thrasher, J.F., Yong, H.H., Cummings, K.M., Fong, G.T., Hitchman, S.C. (2018). Reported exposure to e-cigarette advertising and promotion in different regulatory environments: findings from the International Tobacco Control Four Country (ITC-4C) Survey. Preventive Medicine, 112, 130-37.

Abstract

Electronic cigarette (e-cigarette) advertising regulations differ across countries. This study examines how differences in e-cigarette advertising regulations influence exposure to e-cigarette advertising, and perceptions about what participants had seen and read about e-cigarettes. Data come from the ITC Four Country Survey (Canada [CA], United States [US], Australia [AU] and United Kingdom [UK]) carried out between August 2013 and March 2015 (n = 3460). In 2014, AU and CA had laws prohibiting the retail sale of e-cigarettes containing nicotine while the US and UK had no restrictions, although a voluntary agreement restricting advertising in the UK was introduced during fieldwork. Smokers and ex-smokers were asked whether in the last six months they had noticed e-cigarettes advertisements and received free samples/special offers (promotion), and about their perceptions (positive or otherwise) of what they had seen or read about e-cigarettes. Data were analyzed in 2017. US and UK participants were more likely to report that they had noticed e-cigarette advertisements and received promotions compared to CA or AU participants. For TV and radio advertisements, reported exposure was higher in US compared to UK. For all types of advertisements, reported exposure was higher in CA than AU. Overall, nearly half of AU (44.0%) and UK (47.8%) participants perceived everything they had seen and read about e-cigarettes to be positive, with no significant differences between AU and UK. Participants in countries with permissive e-cigarette advertising restrictions and less restrictive e-cigarette regulations were more likely to notice advertisements than participants in countries with more restrictive e-cigarette regulations.

Citation

Casado, L., Thrasher, J.F., de Abreu Perez, C., Thuler, L.C.S., Fong, G.T. (2018). Factors associated with quit attempts and smoking cessation in Brazil: Findings from the International Tobacco Control Brazil Survey. Tobacco Induced Diseases, 16(Suppl 1), A343.

Abstract

Background: In Brazil, the treatment of tobacco dependence is available at no cost. This study aimed to identify factors associated with attempting to quit and of successful smoking cessation in a population-based sample of Brazilian smokers.

Methods: Data came from the first two waves of the International Tobacco Control (ITC) Brazil Survey, conducted in 2009 and 2012/2013 in three cities: Rio de Janeiro, São Paulo, and Porto Alegre. Prospective cohort data were collected from 488 adults (&#8805;18 years) who smoked at Wave 1 who were resurveyed at Wave 2. Crude and adjusted relative risks (RR) for two outcomes (making a quit attempt between Wave 1 and Wave 2 and successfully quitting by Wave 2) were estimated. Multivariable multilevel logistic regression models were used, whereby variables were added to the models in a series of blocks.

Results: Nearly two-thirds (65.6%) of smokers attempted to quit between waves, and 23.4% had quit at Wave 2. Intention to quit smoking at Wave 1 was the only variable associated with attempt to quit by Wave 2 (OR=2.85; 95%CI 1.64-4.94; p< 0.001). Smokers of higher socioeconomic status (ORhigh versus low=1.80; 95%CI 1.05-3.10; p=0.03) and lower nicotine dependence (ORlow HSI versus high HSI=1.94; 95%CI 1.10-3.43; p=0.02) were more likely to successfully quit. The presence of another adult smoker at home was negatively related to successful quitting (OR=0.50; 95%CI 0.26-0.94; p= 0.03).

Conclusions: These results are generally consistent with prior research and have potential to inform governmental interventions to promote tobacco cessation, particularly among disadvantaged groups.

Citation

Puntambekar, N., Pednekar, M., Adhikari, K., Quah, A.C.K., Fong, G.T., Driezen, P.*, Gupta, P. C. (2018). Awareness of tobacco advertising, promotion and sponsorship in four states: findings from TCP India Survey - Wave 1 and Wave 2. Tobacco Induced Diseases, 16(Suppl1), A191.

Abstract

Background: India's Cigarette and Other Tobacco Products Act (COTPA) of 2003 prescribes a complete ban on all forms of tobacco advertisements, promotions and sponsorships (TAPS) of events by tobacco companies across India. We examined the level of variation and predictors of awareness of TAPS in four Indian states.

Methods: We used data from the International Tobacco Control Policy (TCP) Survey India from Wave1 (Aug 2010- Dec 2011) and Wave2 (Aug 2012-Dec 2013) consisting of 10,585 and 10,501 respondents, respectively, surveyed from Madhya Pradesh (MP), Bihar (BR), Maharashtra (MH) and West Bengal (WB). Bivariate analysis and multivariable logistic regression was used to investigate associations between sociodemographic factors, states and TAPS awareness. All analyses were performed using SPSS V. 20.0

Results: Noticing tobacco advertisements was highest in MH (78.5%) and lowest in WB (50.1%) in Wave 1, while in Wave 2, it was highest in MP (83.5%) and lowest in WB (32.6%). Noticing tobacco promotions and sponsorships was highest in MP (promotions: 35.7%, sponsorships: 14.4%) in Wave 1, while in Wave 2, it was highest in WB (promotions:15.0%, sponsorships:10.8%). Across waves, education was a predictor of noticing tobacco advertisements, promotions and sponsorships. In Wave 1, but not Wave 2, noticing tobacco advertisements (OR:2.11) and promotions (OR:2.02) was highest among the youngest age group (15-17yrs) compared to corresponding oldest age group (55yrs+). Noticing advertisements and sponsorships remained consistent in urban areas across both waves. In Wave 1 tobacco promotions were observed twice as frequently among rural population as compared urban population but the association was reversed in Wave 2.

Conclusions: Awareness of tobacco marketing varied across the four states of India to observe a greater impact of the tobacco control legislation. This study suggests that even though policies are the same in all states, a coordinated effort is required to implement the law on TAPS ban consistently.