Scientific Journal Articles
Levy, D. T., Sweanor, D., Sanchez-Romero, L. M., O'Connor, R., Goniewicz, M. L., & Borland, R. (2020). Altria-Juul Labs deal: why did it occur and what does it mean for the US nicotine delivery product market. Tobacco control, 29(e1), e171-e174.
Showing 326-350 of 622 Results
Edwards. 2014. Roll your own cigarettes are less natural and at least as harmful as factory rolled tobacco [access full article]
Poorer smokers may favour “roll your own” and many falsely believe that use of loose tobacco is less dangerous than factory made cigarettes, writes Richard Edwards. Specific interventions may be needed to encourage such smokers to quit.[download PDF]
White, et al. 2014. The effect of cigarette prices on brand-switching in China: A longitudinal analysis of data from the ITC China Survey
Background: Recent studies have found that Chinese smokers are relatively unresponsive to cigarette prices. As the Chinese government contemplates higher tobacco taxes, it is important to understand the reasons for this low response. One possible explanation is that smokers buffer themselves from rising cigarette prices by switching to cheaper cigarette brands.
Objective: This study examines how cigarette prices influence consumers’ choices of cigarette brands in China.
Methods: This study uses panel data from the first three waves of the International Tobacco Control China Survey, drawn from six large cities in China and collected between 2006 and 2009. The study sample includes 3477 smokers who are present in at least two waves (8552 person-years). Cigarette brands are sorted by price into four tiers, using excise tax categories to determine the cut-off for each tier. The analysis relies on a conditional logit model to identify the relationship between price and brand choice.
Findings: Overall, 38% of smokers switched price tiers from one wave to the next. A ¥1 change in the price of cigarettes alters the tier choice of 4–7% of smokers. Restricting the sample to those who chose each given tier at baseline, a ¥1 increase in price in a given tier would decrease the share choosing that tier by 4% for Tier 1 and 1–2% for Tiers 2 and 3.
Conclusions: China's large price spread across cigarette brands appears to alter the brand selection of some consumers, especially smokers of cheaper brands. Tobacco pricing and tax policy can influence consumers’ incentives to switch brands. In particular, whereas ad valorem taxes in a tiered pricing system like China's encourage trading down, specific excise taxes discourage the practice.[download PDF]
This study examined whether awareness of tobacco control policies was associated with social unacceptability of smoking and whether social unacceptability had an effect on smoking cessation in three European countries. Representative samples (n = 3865) of adult smokers in France, the Netherlands and Germany were used from two survey waves of the longitudinal International Tobacco Control Europe Surveys. Associations were examined of aspects of social unacceptability of smoking (i.e. feeling uncomfortable, important people disapproval and societal disapproval) with tobacco policy awareness (i.e. awareness of warning labels, anti-tobacco information and smoking restrictions at work) and smoking cessation. Only the positive association of awareness of anti-tobacco information with feeling uncomfortable about smoking was significant in each of the three countries. Important people disapproval predicted whether smokers attempted to quit, although this did not reach significance in the French and German samples in multivariate analyses. Our findings suggest that anti-tobacco information campaigns about the dangers of second-hand smoke in France and about smoking cessation in the Netherlands and Germany might have reduced the social acceptability of smoking in these countries. However, campaigns that influence the perceived disapproval of smoking by important people may be needed to ultimately increase attempts to quit smoking.[download PDF]
Fix, et al. 2014. A novel approach to estimating the prevalence of untaxed cigarettes in the USA: Findings from the 2009 and 2010 International Tobacco Control Surveys
Background: Increases in tobacco taxes are effective in reducing tobacco consumption, but because of the addictive nature of cigarettes, smokers often seek out less expensive sources of cigarettes. The objective of this study is to estimate the prevalence of cigarette packs that are untaxed by the state in which the participant resides in a sample of US smokers at two time points.
Methods: Data for this study were taken from the 2009 and 2010 waves of the International Tobacco Control United States Survey. Members of this nationally representative cohort of smokers were invited to send us an unopened pack of their usual brand of cigarettes.
Results: In 2009, 318 packs were received from 401 eligible participants (79%). In 2010, 366 packs were received from 491 eligible participants (75%). In total, 20% of the packs in 2009 and 21% in 2010 were classified as untaxed by the participant's state of residence. The prevalence of untaxed cigarettes was higher in states with higher-excise taxes. Smokers who do not have a plan to quit were significantly more likely to have sent back a pack that was classified as untaxed by the participant's state of residence.
Conclusions: One in five packs were untaxed with rates higher in states with higher-excise taxes. It is unclear whether these estimates differ from the actual prevalence of cigarettes that are untaxed by a smoker's state of residence. Harmonisation of excise tax rates across all 50 US states might be one method of reducing or eliminating the incentive to avoid or evade these taxes.[download PDF]
Li, et al. 2014. Reported exposures to anti-smoking messages and their impact on Chinese smoker's subsequent quit attempts
Background: It is important to monitor whether anti-smoking messages (if any) are noticed by the public in China and whether they have any impact on smokers' quitting behaviours over time
Purpose: This study aimed to examine Chinese smokers' exposure to anti-smoking messages in a range of channels and to determine if exposure was associated with subsequent quit attempts.
Method: A prospective cohort design was employed. Participants were 6,509 adult smokers who completed at least one of the first three waves (2006-2009) of the International Tobacco Control (ITC) China Survey sampled from six Chinese cities. The main measures were reported exposure to antismoking messages in a range of channels and smokers' subsequent quit attempts. Generalized Estimating Equations (GEE) modelling was used to combine respondents from all three waves while accounting for inherent within-person correlation.
Results: The overall exposure levels to anti-smoking messages were low and varied between cities and from one channel to another. Television was the medium with the greatest overall exposure (over 50 % in almost all the cities across all the waves). After controlling for a range of covariates, higher level of combined exposure were positively related to higher subsequent quit attempts (adjusted odds ratio = 1.03, 95 % CI 1.02 ~ 1.05, p < .001); among the individual channels, exposures in newspapers and on posters were significant in their own right.
Conclusion: The findings suggest that anti-smoking warning messages have the potential to stimulate Chinese smokers to make quit attempts, but they also indicate that the levels and strength of warning messages in China need to be increased. China should consider adopting proven international practices, including mandating pictorial health warnings on cigarette packages, adopting prominent point-of-sale warnings, and carrying out strong and ongoing mass media campaigns.[download PDF]
Saenz-de-Miera, et al. 2014. Tax, price and cigarette brand preferences: A longitudinal study of adult smokers from the ITC Mexico Survey
Background: Recent tax increases in Mexico differed in structure and provided an opportunity to better understand tobacco industry pricing strategies, as well as smokers' responses to any resulting price changes.
Objectives: To assess if taxes were passed onto consumers of different cigarette brands, the extent of brand switching and predictors of preference for cheaper national brands.
Methods: Using data from three waves of the Mexican administration of the International Tobacco Control Survey, we analysed self-reported brand and price paid at last cigarette purchase. Generalised estimating equations were used to determine predictors of price and preference for national brands.
Results: The average price of premium/international brands increased each year from 2008 to 2011; however, the price for discount/national brands increased only from 2010 to 2011. The percentage of smokers who smoked national brands remained stable between 2008 and 2010 but dropped in 2011. Factors related to smoking national brands as opposed to international brands included being male and having relatively older age, lower education, lower income and higher consumption.
Conclusions: Tobacco industry pricing strategies in the wake of ad valorem taxes implemented in Mexico prior to 2011 had the impact of segmenting the market into discount national brands and premium international brands. The specific tax increase implemented in 2011 reduced the price gap between these two segments by raising the price of the national brands relative to the international brands. Evidence for trading up was found after the 2011 tax increase. These results provide further evidence for the relevance of tax policy as a tobacco control strategy; in particular, they illustrate the importance of how specific rather than ad valorem taxes can reduce the potential for downward brand switching in the face of decreasing cigarette affordability.[download PDF]
Objective: The purpose of this paper was to examine trends in the use of premium and discount cigarette brands and determine correlates of type of brand used and brand switching.
Methods: Data from the International Tobacco Control (ITC) US adult smoker cohort survey were analysed. The total study sample included 6669 adult cigarette smokers recruited and followed from 2002 to 2011 over eight different survey waves. Each survey wave included an average of 1700 smokers per survey with replenishment of those lost to follow-up.
Results: Over the eight survey waves, a total of 260 different cigarette brands were reported by smokers, of which 17% were classified as premium and 83% as discount brands. Marlboro, Newport, and Camel were the most popular premium brands reported by smokers in our sample over all eight survey waves. The percentage of smokers using discount brands increased between 2002 and 2011, with a marked increase in brand switching from premium to discount cigarettes observed after 2009 corresponding to the $0.61 increase in the federal excise tax on cigarettes. Cigarette brand preferences varied by age group and income levels with younger, higher income smokers more likely to report smoking premium brand cigarettes, while older, middle and lower income, heavier smokers were more likely to report using discount brands.
Conclusions: Our data suggest that demographic and smoking trends favour the continued growth of low priced cigarette brands. From a tobacco control perspective, the findings from this study suggest that governments should consider enacting stronger minimum pricing laws in order to keep the base price of cigarettes high, since aggressive price marketing will likely continue to be used by manufacturers to compete for the shrinking pool of remaining smokers in the population.[download PDF]
Nargis, et al. 2014. The price sensitivity of cigarette consumption in Bangladesh: Evidence from the International Tobacco Control (ITC) Bangladesh Wave 1 (2009) and Wave 2 (2010) Surveys
Background: In Bangladesh, the average excise tax on cigarettes accounted for just 38% of the average retail price of cigarettes in 2009, and 45% in 2010. Both these rates are well below the WHO recommended share of 70% of the retail price at a minimum. There is thus ample room for raising taxes on cigarettes in Bangladesh. The objective of the present work was therefore to estimate the price elasticity of demand for cigarettes and the effect of tax increases on the consumption of cigarettes and on tax revenue in Bangladesh.
Methods: Based on data from Wave 1 (2009) and Wave 2 (2010) of the International Tobacco Control Bangladesh Survey, we estimated the overall impact of a price change on cigarette demand using a twopart model. The total price elasticity of cigarettes was measured by the sum of the elasticity of smoking prevalence and the elasticity of average daily consumption conditional on smoking participation. The price elasticity estimates were used in a simulation model to predict changes in cigarette consumption and tax revenue from tax and price increases.
Results: The total price elasticity of demand for cigarettes was estimated at −0.49. The elasticity of smoking prevalence accounted for 59% of the total price elasticity. The price elasticity of cigarette consumption is higher for people belonging to lower socioeconomic status. Increases in taxes would result in a significant reduction in cigarette consumption while increasing tax revenue.
Conclusions: Raising cigarette prices through increased taxation could lead to a win-win-win situation in Bangladesh: it would reduce cigarette consumption, increase tobacco tax revenue and potentially decrease socioeconomic inequities.[download PDF]
Yao, et al. 2014. Who purchases cigarettes from cheaper sources in China? Findings from the ITC China Survey
Objective: The availability of cigarettes from cheaper sources constitutes a major challenge to public health throughout the world, including China, because it may counteract price-based tobacco control policies. The goal of this study was to identify factors associated with purchasing cigarettes from cheaper sources among adult smokers in China.
Methods: Data were analysed from Waves 1 to 3 of the International Tobacco Control China Survey conducted in 2006–2009 among adult smokers in six cities in China (N=7980). One survey question asked, “In the last 6 months, have you purchased cheaper cigarettes than you can get from local stores for economic reasons?” We examined whether sociodemographic factors and smoking intensity were associated with purchasing cigarettes from cheaper sources using the general estimating equations model. Sociodemographic factors considered were gender, age, marital status, monthly household income, education, employment status and city of residence.
Results: 15.6% of smokers reported purchasing cigarettes from cheaper sources. After controlling for other covariates, the associations of the behaviour of purchasing cigarettes from cheaper sources with age (adjusted OR (AOR)=1.49, 95% CI 1.17 to 3.92 for age 18–24 compared with age 55+) and with income (AOR=2.93, 95% CI 2.27 to 3.79 for low income compared with high income) were statistically significant, but there was no statistically significant relationship with smoking intensity.
Conclusions: Our findings indicate that young and low-income smokers are more likely than older and high-income smokers to purchase cigarettes from cheaper sources in China. Tobacco control policies that reduce the availability of cigarettes from cheaper sources could have an impact on reducing cigarette consumption among young and low-income smokers in China.[download PDF]
Cowie, et al. 2014. Cigarette brand loyalty in Australia: Findings from the ITC Four Country Survey [access full article]
Background and aim: There is little academic research on tobacco brand loyalty and switching, and even less in restrictive marketing environments such as Australia. This paper examines tobacco brand family loyalty, reasons for choice of brand and the relation between these and sociodemographic variables over a period of 10 years in Australia.
Methods: Data from current Australian smokers from 9 waves of the International Tobacco Control Policy Evaluation 4-Country Survey covering the period from 2002 to early 2012. Key measures reported were having a regular brand, use for at least 1 year, brand stability (derived from same reported brand at successive waves), and reasons for choosing brands.
Results: Measures of brand loyalty showed little change across the period, with around 80% brand stability and 95% reporting a regular brand. Older adults were more brand-loyal than those under 25. Young people’s brand choice was influenced more by friends, whereas older adults were more concerned about health. Price was the most reported reason for brand switching. Those in the higher income tertiles showed more loyalty than those in the lowest. The least addicted smokers also showed less brand loyalty. We found no clear relationship between brand loyalty and policies that were implemented to affect tobacco use.
Conclusions: Levels of brand loyalty in Australia are quite high and consistent, and do not appear to have been influenced greatly by changes in tobacco control policies.[download PDF]
Huang, et al. 2014. Cigarette graphic warning labels and smoking prevalence in Canada: A critical examination and reformulation of the FDA regulatory impact analysis
Background: The estimated effect of cigarette graphic warning labels (GWL) on smoking rates is a key input to the Food and Drug Administration's (FDA) regulatory impact analysis (RIA), required by law as part of its rulemaking process. However, evidence on the impact of GWLs on smoking prevalence is scarce.
Objective: The goal of this paper is to critically analyse FDA's approach to estimating the impact of GWLs on smoking rates in its RIA, and to suggest a path forward to estimating the impact of the adoption of GWLs in Canada on Canadian national adult smoking prevalence.
Methods: A quasi-experimental methodology was employed to examine the impact of adoption of GWLs in Canada in 2000, using the USA as a control.
Findings: We found a statistically significant reduction in smoking rates after the adoption of GWLs in Canada in comparison with the USA. Our analyses show that implementation of GWLs in Canada reduced smoking rates by 2.87-4.68 percentage points, a relative reduction of 12.1-19.6%; 33-53 times larger than FDA's estimates of a 0.088 percentage point reduction. We also demonstrated that FDA's estimate of the impact was flawed because it is highly sensitive to the changes in variable selection, model specification, and the time period analysed.
Conclusions: Adopting GWLs on cigarette packages reduces smoking prevalence. Applying our analysis of the Canadian GWLs, we estimate that if the USA had adopted GWLs in 2012, the number of adult smokers in the USA would have decreased by 5.3-8.6 million in 2013. Our analysis demonstrates that FDA's approach to estimating the impact of GWLs on smoking rates is flawed. Rectifying these problems before this approach becomes the norm is critical for FDA's effective regulation of tobacco products.[download PDF]
Guindon, et al. 2014. Cigarette tax avoidance and evasion: Findings from the International Tobacco Control Policy Evaluation (ITC) Project
Background: Decades of research have produced overwhelming evidence that tobacco taxes reduce tobacco use and increase government tax revenue. The magnitude and effectiveness of taxes in reducing tobacco use provide an incentive for tobacco users, manufacturers and others, most notably criminal networks, to devise ways to avoid or evade tobacco taxes. Consequently, tobacco tax avoidance and tax evasion can reduce the public health and fiscal benefit of tobacco taxes.
Objectives: First, this study aims to document, using data from the International Tobacco Control Policy Evaluation Project (ITC), levels and trends in cigarette users’ tax avoidance and tax evasion behaviour in a sample of 16 low-, middle- and high-income countries. Second, this study explores factors associated with cigarette tax avoidance and evasion.
Methods: We used data from ITC surveys conducted in 16 countries to estimate the extent and type of cigarette tax avoidance/evasion between countries and across time. We used self-reported information about the source of a smoker’s last purchase of cigarettes or self-reported packaging information, or similar information gathered by the interviewers during face-to-face interviews to measure tax avoidance/evasion behaviours. We used generalised estimating equations to explore individual-level factors that may affect the likelihood of cigarette tax avoidance or evasion in Canada, the USA, the UK and France.
Findings: We found prevalence estimates of cigarette tax avoidance/evasion vary substantially between countries and across time. In Canada, France and the UK, more than 10% of smokers reported last purchasing cigarettes from low or untaxed sources, while in Malaysia some prevalence estimates suggested substantial cigarette tax avoidance/evasion. We also found important associations between household income and education and the likelihood to engage in tax avoidance/evasion. These associations, however, varied both in direction and magnitude across countries.[download PDF]
Nagelhout, et al. 2014. ‘Ik wed dat ik het kan!’ - Bereik en effecten van een entertainment-education strategie voor stoppen met roken bij laag-, middelbaar en hoogopgeleide rokers
Introduction: Smoking is in the Netherlands more prevalent among lower and moderate educated than among higher educated people. The entertainment-education television show ‘I bet I can do it!’ was specifically designed to stimulate smoking cessation among low and moderate educated smokers.
Methods: The effect of the television show was evaluated with longitudinal data of the International Tobacco Control Policy Evaluation Project. Dutch smokers (n = 1,743) aged 15 years and older filled in a survey before and after the seven episodes of ‘I bet I can do it!’ in 2008.
Results: Low educated (OR = 1.55, p = 0.048) and moderate educated respondents (OR = 1.99, p < 0.001) had seen the television show significantly more often than high educated respondents. The show was not significantly associated with self efficacy, quit intention, and quit success, but it was significantly associated with more quit attempts among moderate educated respondents (OR = 2.36, p < 0.001).
Conclusion: The reach of ‘I bet I can do it!’ and the effect on quit attempts was larger among moderate educated smokers. The entertainment-education strategy for smoking cessation television programs should be further refined. This can possible lead to a program that has positive effects on the quit intention, self efficacy, quit attempts and the quit success of low and moderate educated smokers.[download PDF]
Yong, et al. 2014. Heaviness of Smoking Index only predicts smoking abstinence in the first month of a quit attempt: Findings from the International Tobacco Control Four Country Survey [access full article]
Introduction: The Heaviness of Smoking Index (HSI) is the measure of dependence most strongly predictive of relapse. However, recent research suggests it may not be predictive of longer term relapse. Our aim was to examine its predictive power over the first 2 years after quitting and explore whether use of stop-smoking medications is a moderator.
Methods: Data (n = 7,093) came from the first 7 waves (2002-2009) of the International Tobacco Control Four-Country Survey, an annual cohort survey of smokers in Canada, United States, United Kingdom, and Australia. HSI and its 2 components (cigarettes per day [CPD] and time to first cigarette [TTFC]) were used to predict smoking relapse risk in the 2 years after the start of a quit attempt.
Results: Scores on HSI and its components all strongly predicted relapse, but there was an interaction with time (p < .001). These measures were strong predictors of relapse within the first week of quitting (hazard ratios [HR] = 1.17, 1.24, and 1.30 for HSI, CPD, and TTFC, respectively, all p < .001), less predictive of relapse occurring between 1 week and 1 month, and not clearly predictive beyond 1 month. Among those using medication to quit, hazard ratio for HSI (HR = 1.11, p < .001) was significantly lower than for those not using (HR = 1.24, p < .001) in the first week, but not beyond.
Conclusions: HSI and its 2 components are strong predictors of short-term smoking relapse, but they rapidly lose predictive power over the first weeks of an attempt, becoming marginally significant at around 1 month, and not clearly predictive beyond that.[download PDF]
Tauras, et al. 2014. The economics of tobacco control: Evidence from the International Tobacco Control (ITC) Policy Evaluation Project
Over the past few decades, the importance of economic research in advancing tobacco control policies has become increasingly clear. Extensive research has demonstrated that increasing tobacco taxes and prices is the single most cost-effective tobacco control measure. The research contained in this supplement adds to this evidence and provides new insights into how smokers respond to tax and price changes using the rich data on purchase behaviours, brand choices, tax avoidance and evasion, and tobacco use collected systematically and consistently across countries and over time by the International Tobacco Control (ITC) Project. The findings from this research will help inform policymakers, public health professionals, advocates, and others seeking to maximise the public health and economic benefits from higher taxes.[download PDF]
Nagelhout, et al. 2014. Are there income differences in the impact of a national reimbursement policy for smoking cessation treatment and accompanying media attention? Findings from the International Tobacco Control (ITC) Netherlands Survey
Background: This study examined possible income differences in the impact of a national reimbursement policy for smoking cessation treatment and accompanying media attention in the Netherlands in 2011.
Methods: We used three waves of the International Tobacco Control (ITC) Netherlands Survey, a nationally representative longitudinal sample of smokers aged 15 years and older (n=1912). The main analyses tested trends and income differences in outcome measures (smokers' quit attempt rates, use of behavioral counseling, use of cessation medications, and quit success) and awareness variables (awareness of reimbursement possibilities, the media campaign, medications advertisements and other media attention) with generalized estimating equations analyses.
Results: In the first half of 2011, there was a significant increase in quit attempts (odds ratio (OR)=2.02, p<0.001) and quit success (OR=1.47, p<0.001). Use of counseling and medications remained stable at 3% of all smokers in this period. Awareness of reimbursement possibilities increased from 11% to 42% (OR=6.38, p<0.001). Only awareness of the media campaign was associated with more quit attempts at the follow-up survey (OR=1.95, p<0.001). Results were not different according to smokers' income level.
Conclusions: The Dutch reimbursement policy with accompanying media attention was followed by an increase in quit attempts and quit success, but use of cessation treatment remained stable. The impact of the policy and media attention did not seem to have decreased or increased socioeconomic inequalities in quit attempts, use of cessation treatment, or quit success.[download PDF]
Kasza, et al. 2014. Cigarette smokers' use of unconventional tobacco products and associations with quitting activity: Findings from the ITC-4 U.S. Cohort
Introduction: The purpose of this study was to evaluate the prevalence and correlates of use of nicotinecontaining tobacco products such as cigars, pipe tobacco, cigarettes that promise less exposure to toxins, e-cigarettes, and smokeless tobacco products in a cohort of conventional cigarette smokers followed over the past decade, and to evaluate associations between use of such products and cigarette quitting.
Methods: Participants were 6,110 adult smokers in the United States, who were interviewed as part of the International Tobacco Control Four Country Survey between 2002 and 2011. Respondents reported their concurrent use of other smoked tobacco products (including cigars, pipe tobacco, and cigarillos), smokeless tobacco products (including chewing tobacco, snus, and snuff), unconventional cigarettes (including Omni, Accord, and Eclipse), and electronic cigarettes. Prevalence and correlates of use and associations between use and cigarette quitting were assessed using regression analyses via generalized estimating equations.
Results: Most cigarette smokers did not use unconventional tobacco products although use of any of these products started to rise at the end of the study period (2011). For each type of tobacco product evaluated, use was most prevalent among those aged 18–24 years. Smokers who did use unconventional tobacco products did not experience a clear cessation advantage.
Conclusions: Over the past decade, relatively few cigarette smokers reported also using other tobacco products. Those that did use such products were no more likely to stop using conventional cigarettes compared with those who did not use such products.[download PDF]
Mutti, et al. 2014. Prepaid monetary incentives—Predictors of taking the money and completing the survey: Results from the International Tobacco Control (ITC) Four-Country Survey [access full article]
Prepaid monetary incentives are used to address declining response rates in random-digit dial surveys. There is concern among researchers that some respondents will accept the prepayment but not complete the survey. There is little research to understand check cashing and survey completing behaviors among respondents who receive prepayment. Data from the International Tobacco Control Four-Country Study—a longitudinal survey of smokers in Canada, the United States, the United Kingdom, and Australia—were used to examine the impact of prepayment (in the form of checks, approximately US$10) on sample profile. Approximately 14 percent of respondents cashed their check, but did not complete the survey, while about 14 percent did not cash their checks, but completed the survey. Younger adults (Canada and United States), those of minority status (United States), and those who had been in the survey for only two waves or less (Canada and United States) were more likely to cash their checks and not complete the survey.[download PDF]
Bansal-Travers, et al. 2014. Awareness of pro-tobacco advertising and promotion and beliefs about tobacco use: Findings from the Tobacco Control Policy (TCP) India Pilot Survey
Tobacco companies are utilizing similar strategies to advertise and promote their products in developing countries as they have used successfully for over 50 years in developed countries. The present study describes how adult smokers, smokeless tobacco users, and non-users of tobacco from the Tobacco Control Project (TCP) India Pilot Survey, conducted in 2006, responded to questions regarding their perceptions and observations of pro-tobacco advertising and promotion and beliefs about tobacco use. Analyses found that 74% (n = 562) of respondents reported seeing some form of pro-tobacco advertising in the last six months, with no differences observed between smokers (74%), smokeless tobacco users (74%), and nonsmokers (73%). More than half of respondents reported seeing pro-tobacco advertising on store windows or inside shops. Overall, this study found that a significant percentage of tobacco users and non-users in India report seeing some form of pro-tobacco advertising and promotion messages. Additional analyses found that smokers were more likely to perceive tobacco use as harmful to their health compared with smokeless tobacco users and non-users (p < 0.01). The findings from this study reiterate the need for stronger legislation and strict enforcement of bans on direct and indirect advertising and promotion of tobacco products in India.[download PDF]
Abdullah, et al. 2014. Patterns and predictors of smokeless tobacco use among adults in Bangladesh: Findings from the International Tobacco Control (ITC) Bangladesh Survey
Background: Although smokeless tobacco (SLT) use is prevalent in South Asian countries including Bangladesh, information about the pattern and correlates of SLT use is scarce. This study described the pattern and predictors of SLT use among Bangladeshi adults.
Methods: The data for this study were derived from the International Tobacco Control Policy Evaluation Bangladesh (ITC BD) Survey, a prospective cohort survey of a nationally representative sample of smokers and non-smokers, conducted during November 2011 and May 2012. The study included 5522 adults aged 15 or above. We used multiple logistic regression models to identify predictors of SLT use.
Results: Of the respondents (N = 5522), 20% were SLT users. In general, SLT use was significantly higher among women, the illiterate and residents of the Dhaka slums or non-tribal/non-border areas outside Dhaka; SLT use increased with age. Several attitudinal factors were also associated with SLT use. Multivariable logistic regression analyses revealed several predictors of SLT use: being female (OR = 1.96, 95% confidence interval, CI: 1.18– 3.24), an increasing age, being a resident of a Dhaka slum (OR = 5.86; 95% CI: 3.73–9.21) or nontribal/non-border areas outside Dhaka (OR = 3.42; 95% CI: 1.94–6.03), being illiterate (OR = 3.37; 95% CI: 1.99–5.71), holding positive opinion towards societal approval of SLT use (OR = 5.84; 95% CI: 3.38– 10.09), holding positive opinion towards SLT use by women (OR = 2.63; 95% CI: 1.53–4.54), believing that SLT is addictive (OR = 2.96; 95% CI: 1.51–5.81), and believing SLT is less harmful than bidi (OR = 2.22; 95% CI: 1.36–3.62).
Conclusion: The findings suggest that coordinated efforts of governmental and non-governmental organizations, targeting both smoked tobacco and SLT use reduction and cessation, could be modified to reach each level of population including those who are marginalized, female, less educated and elderly. As most tobacco control programs in Bangladesh target mainly cigarette or bidi smoking, coordinated programs are needed that will also include SLT use within the tobacco control policy and prevention strategies.[download PDF]
Richardson, et al. 2014. The impact of televised tobacco control advertising content and socioeconomic status on campaign recall: Evidence from the International Tobacco Control (ITC) United Kingdom Survey
Background: Although there is some evidence to support an association between exposure to televised tobacco control campaigns and recall among youth, little research has been conducted among adults. In addition, no previous work has directly compared the impact of different types of emotive campaign content. The present study examined the impact of increased exposure to tobacco control advertising with different types of emotive content on rates and durations of self-reported recall.
Methods: Data on recall of televised campaigns from 1,968 adult smokers residing in England through four waves of the International Tobacco Control (ITC) United Kingdom Survey from 2005 to 2009 were merged with estimates of per capita exposure to government-run televised tobacco control advertising (measured in GRPs, or Gross Rating Points), which were categorised as either “positive” or “negative” according to their emotional content.
Results: Increased overall campaign exposure was found to significantly increase probability of recall. For every additional 1,000 GRPs of per capita exposure to negative emotive campaigns in the six months prior to survey, there was a 41% increase in likelihood of recall (OR = 1.41, 95% CI: 1.24-1.61), while positive campaigns had no significant effect. Increased exposure to negative campaigns in both the 1-3 months and 4-6 month periods before survey was positively associated with recall.
Conclusions: Increased per capita exposure to negative emotive campaigns had a greater effect on campaign recall than positive campaigns, and was positively associated with increased recall even when the exposure had occurred more than three months previously.[download PDF]
Hitchman, et al. 2014. Socioeconomic status and smokers' number of smoking friends: Findings from the International Tobacco Control (ITC) Four Country Survey [access full article]
Background: Smoking rates are higher among low socioeconomic (SES) groups, and there is evidence that inequalities in smoking are widening over time in many countries. Low SES smokers may be more likely to smoke and less likely to quit because smoking is heavily concentrated in their social contexts. This study investigated whether low SES smokers (1) have more smoking friends, and (2) are more likely to gain and less likely to lose smoking friends over time. Correlates of having more smoking friends and gaining or losing smoking friends were also considered.
Method: Respondents included 6321 adult current smokers (at recruitment) from Wave 1 (2002) and Wave 2 (2003) of the International Tobacco Control Project (ITC) Four Country Survey, a nationally representative longitudinal cohort survey of smokers in Australia, Canada, UK, and US.
Results: Low SES smokers reported more smoking friends than moderate and high SES smokers. Low SES smokers were also more likely to gain smoking friends over time compared with high SES smokers. Smokers who were male, younger, and lived with other smokers reported more smoking friends, and were also more likely to gain and less likely to lose smoking friends. Smoking behaviours, such as higher nicotine dependence were related to reporting more smoking friends, but not to losing or gain smoking friends.
Conclusions: Smoking is highly concentrated in the social networks of lower SES smokers and this concentration may be increasing over time. Cessation interventions should consider how the structure of low SES smokers' social networks affects quitting.[download PDF]
Balmford, et al. 2014. Reported planning before and after quitting and quit success: Retrospective data from the ITC 4-Country Survey [access full article]
Planning before quitting smoking is widely believed to be beneficial and is usually recommended in cessation counseling, but there is little evidence on the efficacy of specific planning activities. Using data from 1140 respondents who reported quit attempts at Wave 8 of the ITC 4-Country Survey, we analyzed use of 8 specific planning strategies before (5) and after (3) implementation of a quit attempt, in relation to cessation outcomes, delay in implementation of the attempt, and recent quitting history. Most participants reported some planning both before and after quitting, even among those reporting quitting ‘spontaneously.’ Younger smokers, those who cut down before quitting, and users of stop-smoking medication were more likely to report planning. Those who planned prequit were also more likely to plan postquit. Unexpectedly, we found no clear benefit of planning on short-term (1 month) cessation outcomes, whereas one prequit strategy (practicing not smoking) was negatively related to outcome. There was evidence for a predicted moderating effect of recent quitting experience on planning for the prequit task ‘practice replacement strategies.’ This predicted quit success among those with multiple quit attempts in the past year, but failure among those without. This finding suggests that the quality of planning may be critical. More research, particularly on the moderating effect of quit experience, and where measures of planning are collected before outcomes become evident, is needed before clear recommendations can be made on the utility of various forms of planning for the success of quit attempts.[download PDF]
Yong, et al. 2014. Mediational pathways of cigarette warning labels' impact on smoking cessation attempts in four countries: An application of the International Tobacco Control (ITC) Conceptual Model [access full article]
Objective: To test and develop, using structural equation modeling, a robust model of the mediational pathways through which health warning labels exert their influence on smokers' subsequent quitting behavior.
Method: Data come from the International Tobacco Control Four-Country Survey, a longitudinal cohort study conducted in Australia, Canada, the United Kingdom, and the United States. Waves 5-6 data (n = 4,988) were used to calibrate the hypothesized model of warning label impact on subsequent quit attempts via a set of policy-specific and general psychosocial mediators. The finalized model was validated using Waves 6-7 data (n = 5065).
Results: As hypothesized, warning label salience was positively associated with thoughts about risks of smoking stimulated by the warnings (β = .58, p < .001), which in turn were positively related to increased worry about negative outcomes of smoking (β = .52, p < .001); increased worry in turn predicted stronger intention to quit (β = .39, p < .001), which was a strong predictor of subsequent quit attempts (β = .39, p < .001). This calibrated model was successfully replicated using Waves 6-7 data.
Conclusion: Health warning labels seem to influence future quitting attempts primarily through their ability to stimulate thoughts about the risks of smoking, which in turn help to raise smoking-related health concerns, which lead to stronger intentions to quit, a known key predictor of future quit attempts for smokers. By making warning labels more salient and engaging, they should have a greater chance to change behavior.[download PDF]
Gravely, et al. 2014. Awareness, trial, and current use of electronic cigarettes in 10 countries: Findings from the ITC Project [access full article]
Background: In recent years, electronic cigarettes (e-cigarettes) have generated considerable interest and debate on the implications for tobacco control and public health. Although the rapid growth of e-cigarettes is global, at present, little is known about awareness and use. This paper presents self-reported awareness, trial and current use of e-cigarettes in 10 countries surveyed between 2009 and 2013; for six of these countries, we present the first data on e-cigarettes from probability samples of adult smokers.
Methods: A cross-sectional analysis of probability samples of adult (≥ 18 years) current and former smokers participating in the International Tobacco Control (ITC) surveys from 10 countries. Surveys were administered either via phone, face-to-face interviews, or the web. Survey questions included sociodemographic and smoking-related variables, and questions about e-cigarette awareness, trial and current use.
Results: There was considerable cross-country variation by year of data collection and for awareness of e-cigarettes (Netherlands (2013: 88%), Republic of Korea (2010: 79%), United States (2010: 73%), Australia (2013: 66%), Malaysia (2011: 62%), United Kingdom (2010: 54%), Canada (2010: 40%), Brazil (2013: 35%), Mexico (2012: 34%), and China (2009: 31%)), in self-reports of ever having tried e-cigarettes (Australia, (20%), Malaysia (19%), Netherlands (18%), United States (15%), Republic of Korea (11%), United Kingdom (10%), Mexico (4%), Canada (4%), Brazil (3%), and China (2%)), and in current use (Malaysia (14%), Republic of Korea (7%), Australia (7%), United States (6%), United Kingdom (4%), Netherlands (3%), Canada (1%), and China (0.05%)).
Conclusions: The cross-country variability in awareness, trial, and current use of e-cigarettes is likely due to a confluence of country-specific market factors, tobacco control policies and regulations (e.g., the legal status of e-cigarettes and nicotine), and the survey timing along the trajectory of e-cigarette awareness and trial/use in each country. These ITC results constitute an important snapshot of an early stage of what appears to be a rapid progression of global e-cigarette use.[download PDF]