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 (≥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.

Citation

Yong, H.H., Borland, R., Cummings, K.M., Partos, T. (2018). Do predictors of smoking relapse change as a function of duration of abstinence? Findings from the United States, Canada, United Kingdom and Australia. Addiction, 113(7), 1295-1304.

Abstract

Aims: To estimate predictors of time to smoking relapse and test if prediction varied by quit duration.

Design: Longitudinal cohort data from the International Tobacco Control Four-Country survey with annual follow up collected between 2002 and 2015.

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

Participants: A total of 9171 eligible adult smokers who had made at least one quit attempt during the study period.

Measurements: Time to relapse was the main outcome. Predictor variables included pre-quit baseline measures of nicotine dependence, smoking and quitting-related motivations, quitting capacity and social influence, and also two post-quit measures, use of stop-smoking medications and quit duration (1–7 days, 8–14 days, 15–31 days, 1–3 months, 3–6 months, 6–12 months, 1–2 years and 2+ years), along with socio-demographics.

Findings: All factors were predictive of relapse within the first 6 months of quitting but only wanting to quit, quit intentions and number of friends who smoke were still predictive of relapse in the 6–12-month period of quitting [hazard ratios (HR) = 1.20, P < 0.05; 1.13, P < 0.05; and 1.21, P < 0.001, respectively]. Number of friends smoking was the only remaining predictor of relapse in the 1–2 years quit period (HR = 1.19, P = 0.001) with none predictive beyond the 2-year quit period. Use of stop-smoking medications during quit attempts was related negatively to relapse during the first 2 weeks of quitting (HR = 0.71–0.84), but related positively to relapse in the 1–6-month quit period (HR = 1.29–1.54). Predictive effects of all factors showed significant interaction with quit duration except for perceiving smoking as an important part of life, prematurely stubbing out a cigarette and wanting to quit.

Conclusions: Among adult smokers in the United States, Canada, United Kingdom and Australia, factors associated with smoking relapse differ between the early and later stages of a quit attempt, suggesting that the determinants of relapse change as a function of abstinence duration.

Citation

Ma, B., Yong, H.H., Borland, R., McNeill, A., Hitchman, S.C. (2018). Factors associated with future intentions to use personal vaporizers among those with some experience of vaping. Drug and Alcohol Review, 37(2), 216-225.

Abstract

Introduction and Aims: Personal vaporisers (PV), including e-cigarettes, may be a harm reduction strategy for tobacco control. This study aims to identify factors associated with future intentions to vape among smokers and ex-smokers in Australia and the UK.

Design and Methods: Cross-sectional data of smokers and ex-smokers (n = 1199, mean age = 45.3 years, 44.8% male), collected in 2014/2015 and divided into four subgroups: smoking past vapers (SPV), smoking vapers (SV), ex-smoking past vapers (ESPV) and ex-smoking vapers (ESV), from the International Tobacco Control Australia and UK surveys were analysed by using regression models.

Results: Higher vaping satisfaction increased vaping intentions for all groups except ESPV. Perceiving PVs as less harmful predicted intentions to vape for all groups except ESV. The importance of PVs for stopping smoking predicted lower intentions to continue vaping for SV, but higher intentions to initiate vaping for SPV. The importance of PVs for cutting down smoking was a positive predictor only for SPV. Among ex-smokers, importance for maintaining not smoking was a positive predictor for ESPV, but not for ESV. The importance of perceiving vapour being less harmful also depended on vaping status for ex-smokers. The only country interaction was that only in the UK was perceiving PVs as less harmful associated with intention among SPV.

Discussion and Conclusion: Factors influencing intentions vary by smoking and/or vaping status, with greater differences between the ex-smoker subgroups. This is consistent with PVs being seen as a way of managing smoking, rather than something that has intrinsic value, for all except the ex-smoking vapers.

Citation

Ma, B., Yong, H.H., Borland, R., McNeill, A., Hitchman, S.C. (2018). Factors associated with future intentions to use personal vaporizers among those with some experience of vaping. Drug and Alcohol Review, 37(2), 216-225.

Abstract

Introduction and Aims. Personal vaporisers (PV), including e‐cigarettes, may be a harm reduction strategy for tobacco control. This study aims to identify factors associated with future intentions to vape among smokers and ex‐smokers in Australia and the UK.

Design and Methods. Cross‐sectional data of smokers and ex‐smokers (n = 1199, mean age = 45.3 years, 44.8% male), collected in 2014/2015 and divided into four subgroups: smoking past vapers (SPV), smoking vapers (SV), ex‐smoking past vapers (ESPV) and ex‐smoking vapers (ESV), from the International Tobacco Control Australia and UK surveys were analysed by using regression models.

Results. Higher vaping satisfaction increased vaping intentions for all groups except ESPV. Perceiving PVs as less harmful predicted intentions to vape for all groups except ESV. The importance of PVs for stopping smoking predicted lower intentions to continue vaping for SV, but higher intentions to initiate vaping for SPV. The importance of PVs for cutting down smoking was a positive predictor only for SPV. Among ex‐smokers, importance for maintaining not smoking was a positive predictor for ESPV, but not for ESV. The importance of perceiving vapour being less harmful also depended on vaping status for ex‐smokers. The only country interaction was that only in the UK was perceiving PVs as less harmful associated with intention among SPV.

Discussion and Conclusion. Factors influencing intentions vary by smoking and/or vaping status, with greater differences between the ex‐smoker subgroups. This is consistent with PVs being seen as a way of managing smoking, rather than something that has intrinsic value, for all except the ex‐smoking vapers.

Citation

Seo, H.G., Kim, Y., Xu, S.S., Quah, A.C.K., Boudreau, C., Yan, M., Thompson, M.E., Fong, G.T. (2018). Tobacco control policies in the Republic of Korea and the methods of the ITC Korea Surveys. Journal of the Korean Society for Research on Nicotine and Tobacco, 9(Suppl 1), S1-10.

Abstract

Policies that promote the social unacceptability of smoking may also result in smoking-related stigma. The aim of this study is to evaluate how norms against smoking and socioeconomic status (SES) are associated with stigma among smokers. We used data from a panel of adult smokers who participated in the 2008–2012 administrations of the International Tobacco Control Policy Evaluation Survey in Mexico (n = 6670 observations) and Uruguay (n = 3296 observations).

Generalized estimating equations were used to account for correlations in the outcomes over time within individuals. We evaluated if injunctive smoking norms (i.e. significant other norms and societal norms), descriptive smoking norms (i.e. number of smoking friends), and two markers of SES (i.e. education and income) were associated with different aspects of smoking-related stigma (i.e. feeling uncomfortable, negative stereotype of smokers, and perceived marginalization). We found that stronger anti-smoking injunctive norms were associated with higher levels of all indicators of perceived stigma in Mexico and Uruguay. Having fewer smoking friends was associated with feeling uncomfortable and perceived marginalization in Mexico. Higher income and education were associated with a stronger negative stereotype of smokers in Mexico.

Lower income and education were associated with a stronger negative stereotype of smokers in Uruguay. Study results suggest that factors that drive the social unacceptability of tobacco may stigmatize smokers, although further research is needed to determine whether policy-promoted stigmatization produces undesirable outcomes (e.g. lower cessation rates).

Citation

Lee, E.S., Seo, H.G., Fong, G.T., Yan, M., Driezen, P. (2018). Awareness of Korean adult smokers about national smoking cessation programs in Korea: findings from the 2016 International Tobacco Control Policy Evaluation Korea Survey. Journal of the Korean Society for Research on Nicotine and Tobacco, 9(Suppl 1), S22-30.

Abstract

Background: There are effective intervention program for smoking cessation such as clinics at public health centres, quitlines, residential cessation program, and insurance program in South Korea. The purpose of this study is to investigate awareness and utilization of smoking cessation program in current smokers.
Methods: We analyzed data from the ITC Korea Survey, a telephone survey of a nationally representative sample of 2,000 adult smokers, conducted from June 2015 to June 2016. Frequency of awareness, intention to use, and utilization about smoking cessation program were reported in current smokers. To evaluate influence of smoking related factors like nicotine dependence on awareness, intention to use, and use about smoking cessation program of current smokers, logistic regression was used. All analyses were performed with use of STATA version 11.
Results: In case of the insurance program to help quit, current smokers have an awareness about it (36.9%) and an interest in using it (50.3%). The proportion of current smoker utilizing quit program was 32.3% for public clinic, 0.9% for residential program, 7.4% for insurance program to help quit, and 3.0% for Quitlines. Higher utilization was observed current smokers over 40 years of age, married, with daily smoking amount (above 10/d), with quit attempt in the last 1 year (OR 1.32, 95% CI 1.04-1.68), and with smoking cessation plan (OR 2.47, 95% CI 1.85-3.29).
Conclusion: A small percentage of current smokers participated the government providing smoking cessation program in Korea, even though their awareness is relatively good. Further strategy is necessary to encourage current smoker to participate smoking cessation program.

Abstract

Background: This paper aimed to present proportion of awareness and use of e-cigarettes and vaping behaviors among adult smokers in South Korea.

Methods: We used data of current adult smokers participating in the International Tobacco Control (ITC) survey Korea in 2016. The frequency analysis and cross analysis were used to present the proportion of awareness, experience, current use, reasons for use and vaping behaviors of e-cigarettes, and logistic regression analysis was used to present factors associated with awareness, experience, and current e-cigarette use. All data were submitted to complex sample survey data analysis using SPSS version 23.0 (SPSS Inc., Chicago, IL, USA) and weighted to represent the Korean population.

Results: Out of 2000 adult smokers, the proportion of awareness, experience, and current use e-cigarettes were 93.8%, 33.8%, and 5.5%, respectively. In multivariable logistic regression analysis, younger age groups were associated with increased odds ratios (ORs) for awareness, higher consumption of tobacco and no past quit attempt were associated with increased ORs for experience, and higher income groups were associated with increased ORs for current use of e-cigarettes. The common reasons for using e-cigarettes were because of thinking that using e-cigarettes were more acceptable than smoking and less harmful to other people, and makes it easier to cut down on smoking. Most e-cigarette users vaped nicotine-contained e-cigarettes and bought them at e-cigarettes shop.

Conclusion: E-cigarette awareness and use increased among Korean smokers especially among higher income groups. Careful monitoring of behavior of using e-cigarettes is needed.

Citation

Hummel, K., Candel, M.J.J.M., Nagelhout, G.E., Brown, J., van den Putte, B., Kotz, D., Willemsen, M.C., Fong, G.T., West, R., de Vries, H. (2018). Construct and predictive validity of three measures of intention to quit smoking: Findings from the International Tobacco Control (ITC) Netherlands Survey. Nicotine and Tobacco Research, 20(9), 1101-1108.

Abstract

Introduction: The aim of the study was to compare the construct validity and the predictive validity of three instruments to measure intention to quit smoking: a Stages of Change measure, the Motivation To Stop Scale (MTSS) and a Likert scale. We used the Theory of Planned Behaviour as theoretical framework.

Methods: We used data from the International Tobacco Control (ITC) Netherlands Survey. We included smokers who participated in three consecutive survey waves (n=980). We measured attitude, subjective norm, and perceived behavioural control in 2012, intention to quit with three instruments in 2013, and having made a quit attempt in the last year in 2014. We conducted Structural Equation Modelling with three models for the instruments of intention separately, and with one model that included the three instruments simultaneously.

Results: All three instruments of intention were significantly and positively related to attitude and perceived behavioural control but none was related to subjective norm. All three instruments were significantly and positively related to making a quit attempt. The relation of the Likert scale with making a quit attempt (β=0.38) was somewhat stronger than that of the Stages of Change measure (β=0.35) and the MTSS (β=0.22). When entering the three instruments together into one model, only the Likert scale was significantly related to making a quit attempt.

Conclusions: All three instruments showed reasonable construct validity and comparable predictive validity. Under the studied conditions, the Likert scale performed slightly better than the Stages of Change measure and the MTSS.

Implications: An assessment of the Stages of Change, the Motivation To Stop Scale (MTSS) and a Likert scale showed comparable predictive and construct validity as measures for intention to quit smoking. All three instruments can be used in future research; however, under the studied theoretical framework, i.e. the Theory of Planned Behaviour, the Likert scale performed slightly better than the other two instruments.

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

Abstract

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

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

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

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