Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

Abstract

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

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

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

Levy, D., Yuan, Z., Li, Y. (2017). The prevalence and characteristics of e-cigarette users in the U.S. International Journal of Environmental Research and Public Health, 14(10), 1200.

Abstract

Studies have examined the characteristics of individuals who use e-cigarettes, including sociodemographic and smoking characteristics, and the relationship of e-cigarette use to tobacco control policies. While most studies consider a subset of these characteristics with weak measures of regular e-cigarette use, this study uses a large, recent U.S. survey to simultaneously consider the association of each of these factors with different use measures. Data from the May 2014 Tobacco Use Supplement-Current Population Survey is supplemented with information on tobacco control policies. The prevalence of ever, current (at least 1 of the last 30 days), and regular (at least 20 of the last 30 days) e-cigarette use were 7.7%, 2.1% and 0.9%, implying that 27.0% of ever users were current users of which 45.3% were regular users. E-cigarette use varied by socio-demographic characteristics and by smoking status, and depended on the measure of use adopted. However, regardless of measures, e-cigarette use was higher among those smokers who smoked more cigarettes. The association with policies was generally weak, but we found more regular use by smokers in low tax and low tobacco control spending states. The results indicate that the user characteristics differ depending on the e-cigarette use measure. The measure of use should be carefully considered in analyzing how e-cigarette use affects cigarette use.

Citation

Levy, D., Borland, R., Lindblom, E., Goniewicz, M., Meza, R., Holford, T.R., Yuan, Z., Luo, Y., O’Connor, R.J., Niaura, R., Abrams, D.B. (2018). Potential deaths averted in USA by replacing cigarettes with e-cigarettes. Tobacco Control, 27(1), 18-25.

Abstract

Introduction: US tobacco control policies to reduce cigarette use have been effective, but their impact has been relatively slow. This study considers a strategy of switching cigarette smokers to e-cigarette use ('vaping') in the USA to accelerate tobacco control progress.

Methods: A Status Quo Scenario, developed to project smoking rates and health outcomes in the absence of vaping, is compared with Substitution models, whereby cigarette use is largely replaced by vaping over a 10-year period. We test an Optimistic and a Pessimistic Scenario, differing in terms of the relative harms of e-cigarettes compared with cigarettes and the impact on overall initiation, cessation and switching. Projected mortality outcomes by age and sex under the Status Quo and E-Cigarette Substitution Scenarios are compared from 2016 to 2100 to determine public health impacts.

Findings: Compared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. Under the Pessimistic Scenario, 1.6 million premature deaths are averted with 20.8 million fewer life years lost. The largest gains are among younger cohorts, with a 0.5 gain in average life expectancy projected for the age 15 years cohort in 2016.

Conclusions: The tobacco control community has been divided regarding the role of e-cigarettes in tobacco control. Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, even under pessimistic assumptions regarding cessation, initiation and relative harm

Citation

Thomas, D., Panaretto, K., Davey, M., Lyons, L., Borland, R. (2017). Response to ‘Let’s change the conversation’. Australian and New Zealand Journal of Public Health, 41(6), 650.

There is no abstract available for this publication.

Citation

Heckman, B.W., Cummings, K.M., Kasza, K.A., Borland, R., Burris, J.L., Fong, G.T., McNeill, A., Carpenter, M.J. (2017). Effectiveness of switching smoking cessation medications following relapse: A population-based study. American Journal of Preventive Medicine, 53(2), e63-e70.

Abstract

Introduction: Nicotine dependence is a chronic disorder often characterized by multiple failed quit attempts (QAs). Yet, little is known about the sequence of methods used across multiple QAs or how this may impact future ability to abstain from smoking. This prospective cohort study examines the effectiveness of switching smoking-cessation medications (SCMs) across multiple QAs.

Methods: Adult smokers (aged ≥18 years) participating in International Tobacco Control surveys in the United Kingdom, U.S., Canada, and Australia (N=795) who: (1) completed two consecutive surveys between 2006 and 2011; (2) initiated a QA at least 1 month before each survey; and (3) provided data for the primary predictor (SCM use during most recent QA), outcome (1-month point prevalence abstinence), and relevant covariates. Analyses were conducted in 2016.

Results: Five SCM user classifications were identified: (1) non-users (43.5%); (2) early users (SCM used for initial, but not subsequent QA; 11.4%); (3) later users (SCM used for subsequent, but not initial QA; 18.4%); (4) repeaters (same SCM used for both QAs; 10.7%); and (5) switchers (different SCM used for each QA; 14.2%). Abstinence rates were lower for non-users (15.9%, OR=0.48, p=0.002), early users (16.6%, OR=0.27, p=0.03), and repeaters (12.4%, OR=0.36, p=0.004) relative to switchers (28.5%).

Conclusions: Findings suggest smokers will be more successful if they use a SCM in QAs and vary the SCM they use across time. That smokers can increase their odds of quitting by switching SCMs is an important message that could be communicated to smokers.

Citation

Partos, T.R., Gilmore, A., Hitchman, S.C., Hiscock, R., Branston, R., McNeill, A. (2018). Availability and use of cheap tobacco in the United Kingdom 2002-2014: findings from the International Tobacco Control Project. Nicotine and Tobacco Research, 20(6), 714-24.

Abstract

Introduction: Raising tobacco prices is the most effective population-level intervention for reducing smoking, but this is undermined by the availability of cheap tobacco. This study monitors trends in cheap tobacco use among adult smokers in the United Kingdom between 2002 and 2014 via changes in product type, purchase source, and prices paid.

Methods: Weighted data from 10 waves of the International Tobacco Control policy evaluation study were used. This is a longitudinal cohort study of adult smokers with replenishment; 6169 participants provided 15812 responses. Analyses contrasted (1) product type: roll-your-own (RYO) tobacco, factory-made packs (FM-P), and factory-made cartons (FM-C); (2) purchase source: UK store-based sources (e.g., supermarkets and convenience stores) with non-UK/nonstore sources representing tax avoidance/evasion (e.g., outside the UK, duty free, and informal sellers); and (3) prices paid (inflation-adjusted to 2014 values). Generalized estimating equations tested linear changes over time.

Results: (1) RYO use increased significantly over time as FM decreased. (2) UK store-based sources constituted approximately 80% of purchases over time, with no significant increases in tax avoidance/evasion. (3) Median RYO prices were less than half that of FM, with FM-C cheaper than FM-P. Non-UK/nonstore sources were cheapest. Price increases of all three product types from UK store-based sources from 2002 to 2014 were statistically significant but not substantial. Wide (and increasing for FM-P) price ranges meant each product type could be purchased in 2014 at prices below their 2002 medians from UK store-based sources.

Conclusions: Options exist driving UK smokers to minimize their tobacco expenditure; smokers do so largely by purchasing cheap tobacco products from UK stores.

Implications: The effectiveness of price increases as a deterrent to smoking is being undermined by the availability of cheap tobacco such as roll-your-own tobacco and cartons of packs of factory-made cigarettes. Wide price ranges allowed smokers in 2014 to easily obtain cigarettes at prices comparable to 12 years prior, without resorting to tax avoidance or evasion. UK store-based sources accounted for 80% or more of all tobacco purchases between 2002 and 2014, suggesting little change in tax avoidance or evasion over time. There was a widening price range between the cheapest and most expensive factory-made cigarettes.

Citation

Mutti-Packer, S., Reid, J.L., Thrasher, J.F., Romer, D., Fong, G.T., Gupta, P.C., Pednekar, M.S., Nargis, N., Hammond, D. (2017). The role of negative affect and message credibility in perceived effectiveness of smokeless tobacco health warning labels in Navi Mumbai, India and Dhaka, Bangladesh: A moderated-mediation analysis. Addictive Behaviours, 73, 22-29.

Abstract

Objective: There is strong evidence showing that pictorial health warnings are more effective than text-only warnings. However, much of this evidence comes from high-income countries and is limited to cigarette packaging. Moreover, few studies have identified mechanisms that might explain the impact of warnings.

Methods: The current study examined the potential mediating role of negative affect and the moderating influence of message credibility in perceived effectiveness of smokeless tobacco warnings in two low- and middle-income countries (LMICs). Field interviews were conducted in India and Bangladesh, with adult (19 + years) smokeless tobacco users (n = 1053), and youth (16–18 years) users (n = 304) and non-users (n = 687). Respondents were randomly assigned to view warnings in one of four conditions: (1) Text-only, (2) pictorial with symbolic imagery, (3) pictorial with graphic images of health effects, or (4) pictorial with personalized graphic images plus a personal testimonial.

Results: The findings provide support for the mediating influence of negative affect in perceived effectiveness, for adult and youth smokeless tobacco users who viewed pictorial warnings (vs. text-only), and graphic health warnings (vs. personal testimonials). Among adults, message credibility moderated the indirect effect; the association was stronger when credibility was high and weaker when it was low. Among youth users and non-users, message credibility did not moderate the indirect effect.

Conclusions: Consistent with research from high-income countries, these findings highlight the importance of selecting imagery that will elicit negative emotional reactions and be perceived as credible. Differential effects among adults and youth highlight the importance of pre-testing images.

Abstract

Smokers are exposed to advice about quitting from numerous sources. Within the 2013 ITC 4-Country Survey, 1211 Australian smokers or recent ex-smokers rated the perceived importance of eight sources of advice, categorized into evidence-based, non evidence-based, personal experience and vicarious experience (two items each), and also rated their intention to quit, nicotine dependence, use of quit medication, health concerns and harm beliefs. The eight items were all positively correlated. Respondents who placed greater importance on their experiences (either personal or vicarious) were more likely to agree that the evidence for smoking-related harm is exaggerated, and although not more likely to intend to quit overall, these responses were most strongly related to quit intention. Notably, of those responding that all sources were 'not at all important' (or don't know), only 3.2% reported any interest in quitting in the next 6 months (compared to 36.0% among those who endorsed any), 12.8% were often concerned about smoking's effect on their health (compared with 60.4%), and 73.7% agreed that 'smoking is no more risky than other things' (compared with 34.5%). There was no evidence that rejecting evidence-based sources (medical or governmental) in favour of other sources was associated with lower quit intentions or behaviour.

Citation

Heckman, B.W., Cummings, K.M., Kasza, K.A., Borland, R., Burris, J.L., Fong, G.T., McNeill, A., Carpenter, M.J. (2017). Effectiveness of switching smoking cessation medications following relapse: A population-based study. American Journal of Preventive Medicine, 53(2), e63-e70.

Abstract

Introduction: Nicotine dependence is a chronic disorder often characterized by multiple failed quit attempts (QAs). Yet, little is known about the sequence of methods used across multiple QAs or how this may impact future ability to abstain from smoking. This prospective cohort study examines the effectiveness of switching smoking-cessation medications (SCMs) across multiple QAs.

Methods: Adult smokers (aged ≥18 years) participating in International Tobacco Control surveys in the United Kingdom, U.S., Canada, and Australia (N=795) who: (1) completed two consecutive surveys between 2006 and 2011; (2) initiated a QA at least 1 month before each survey; and (3) provided data for the primary predictor (SCM use during most recent QA), outcome (1-month point prevalence abstinence), and relevant covariates. Analyses were conducted in 2016.

Results: Five SCM user classifications were identified: (1) non-users (43.5%); (2) early users (SCM used for initial, but not subsequent QA; 11.4%); (3) later users (SCM used for subsequent, but not initial QA; 18.4%); (4) repeaters (same SCM used for both QAs; 10.7%); and (5) switchers (different SCM used for each QA; 14.2%). Abstinence rates were lower for non-users (15.9%, OR=0.48, p=0.002), early users (16.6%, OR=0.27, p=0.03), and repeaters (12.4%, OR=0.36, p=0.004) relative to switchers (28.5%).

Conclusions: Findings suggest smokers will be more successful if they use a SCM in QAs and vary the SCM they use across time. That smokers can increase their odds of quitting by switching SCMs is an important message that could be communicated to smokers.

Citation

Nicholson, A., Borland, R., Sarin, J., Bennet, P., Davey, M., Van der Sterren, A., Stevens, M., Thomas, D. (2017). Associations between advertising recall and quitting in a national cohort of Aboriginal and Torres Strait Islander smokers. Australian and New Zealand Journal of Public Health, 41(4), 444-45.

There is no abstract available for this publication.

Citation

Yong, H.H., Borland, R., Balmford, J., Hitchman, S.C., Cummings, K.M., Driezen, P., Thompson, M.E. (2017). Prevalence and correlates of the belief that electronic cigarettes are a lot less harmful than conventional cigarettes under the different regulatory environments of Australia and the United Kingdom. Nicotine & Tobacco Research, 19(2), 258-263.

Abstract

Introduction: The rapid rise in electronic cigarettes (ECs) globally has stimulated much debate about the relative risk and public health impact of this new emerging product category as compared to conventional cigarettes. The sale and marketing of ECs containing nicotine are banned in many countries (eg, Australia) but are allowed in others (eg, United Kingdom). This study examined prevalence and correlates of the belief that ECs are a lot less harmful than conventional cigarettes under the different regulatory environments in Australia (ie, more restrictive) and the United Kingdom (ie, less restrictive).

Methods: Australian and UK data from the 2013 survey of the International Tobacco Control Four-Country project were analyzed.

Results: More UK than Australian respondents (58.5% vs. 35.2%) believed that ECs are a lot less harmful than conventional cigarettes but more respondents in Australia than in the United Kingdom selected “Don’t Know” (36.5% vs. 17.1%). The proportion that responded “A little less, equally or more harmful” did not differ between countries. Correlates of the belief that ECs are “A lot less harmful” differed between countries, while correlates of “Don’t Know” response did not differ.

Conclusions: Consistent with the less restrictive regulatory environment affecting the sale and marketing of ECs, smokers and recent ex-smokers in the United Kingdom were more likely to believe ECs were less harmful relative to conventional cigarettes compared to those in Australia.

Implications: What this study adds: Among smokers and ex-smokers, this study found that the belief that ECs are (a lot) less harmful than conventional cigarettes was considerably higher in the United Kingdom than in Australia in 2013. The finding is consistent with the less restrictive regulatory environment for ECs in the United Kingdom, suggesting that the regulatory framework for ECs adopted by a country can affect smokers’ perceptions about the relative harmfulness of ECs, the group that stands to gain the most from having an accurate belief about the relative harms of ECs.

Citation

Levy, D.T., Borland, R., Villanti, A.C., Niaura, R., Yuan, Z., Zhang, Y., Meza, R., Holford, T.R., Fong, G.T., Cummings, K.M., Abrams, D. B. (2017). The application of a decision-theoretic model to estimate the public health impact of vaporized nicotine product initiation in the United States. Nicotine & Tobacco Research, 19(2), 149-159.

Abstract

Introduction: The public health impact of vaporized nicotine products (VNPs) such as e-cigarettes is unknown at this time. VNP uptake may encourage or deflect progression to cigarette smoking in those who would not have otherwise smoked, thereby undermining or accelerating reductions in smoking prevalence seen in recent years.

Methods: The public health impact of VNP use are modeled in terms of how it alters smoking patterns among those who would have otherwise smoked cigarettes and among those who would not have otherwise smoked cigarettes in the absence of VNPs. The model incorporates transitions from trial to established VNP use, transitions to exclusive VNP and dual use, and the effects of cessation at later ages. Public health impact on deaths and life years lost is estimated for a recent birth cohort incorporating evidence-informed parameter estimates.

Results: Based on current use patterns and conservative assumptions, we project a reduction of 21% in smoking-attributable deaths and of 20% in life years lost as a result of VNP use by the 1997 US birth cohort compared to a scenario without VNPs. In sensitivity analysis, health gains from VNP use are especially sensitive to VNP risks and VNP use rates among those likely to smoke cigarettes.

Conclusions: Under most plausible scenarios, VNP use generally has a positive public health impact. However, very high VNP use rates could result in net harms. More accurate projections of VNP impacts will require better longitudinal measures of transitions into and out of VNP, cigarette and dual use.

Implications: Previous models of VNP use do not incorporate whether youth and young adults initiating VNP would have been likely to have been a smoker in the absence of VNPs. This study provides a decision-theoretic model of VNP use in a young cohort that incorporates tendencies toward smoking and shows that, under most plausible scenarios, VNP use yields public health gains. The model makes explicit the type of surveillance information needed to better estimate the effect of new products and thereby inform public policy.

Citation

Thomas, D.P., Panaretto, K.S., Davey, M.E., Briggs, V., Borland, R. (2017). The social determinants, starting, and sustaining quit attempts in a national sample of Aboriginal and Torres Strait Islander smokers. Australian and New Zealand Journal of Public Health, 41(3), 230-236.

Abstract

Objective: To assess whether social, economic and demographic measures are associated with initiating and sustaining quit attempts in a national sample of Aboriginal and Torres Strait Islander smokers.

Methods: We analysed data from 759 adults who reported smoking at least weekly in the Talking About The Smokes baseline survey (April 2012 - October 2013) and completed a follow up survey a year later (August 2013 - August 2014).

Results: Almost none of the standard baseline socioeconomic indicators predicted making or sustaining quit attempts. However, becoming employed was associated with making quit attempts (OR 1.88) and both becoming employed (OR 3.03) and moving to purchase a home (OR 2.34) were both positively associated with sustaining abstinence of one month or more. More smokers who had insufficient money for food or essentials because of money spent on cigarettes had made a quit attempt (OR 1.47) and sustained abstinence of one month or more (OR 1.74).

Conclusions and Implications: Disadvantage does not seem to have pervasive negative effects on quitting. We should be more optimistic in our tobacco control activities with the most disadvantaged among Aboriginal and Torres Strait Islander smokers. Increasing personal empowerment (e.g. getting a job) may lead to at least short-term improvements in quitting.

Citation

Hummel, K., Brown, J., Willemsen, M.C., West, R., Kotz, D. (2017). External validation of the Motivation to Stop Scale (MTSS) and comparison with the Stages of Change: Findings from the International Tobacco Control (ITC) Netherlands Survey. European Journal of Public Health, 27(1), 129-134.

Abstract

Background: The Motivation To Stop Scale (MTSS) is a single-item instrument which has been shown to predict quit attempts in the next 6 months in a previous validation study conducted in England. The aim of the current study was to determine the external validity of the MTSS among Dutch smokers in predicting quit attempts in the next 12 months. A secondary aim was to compare the discriminative accuracy of the MTSS with that of a Stages of Change assessment.

Methods: We analysed data from three consecutive waves of the International Tobacco Control (ITC) Netherlands Survey (n = 1272). We conducted logistic regression analyses with the baseline score of the MTSS (measured in 2012 or 2013) predicting a quit attempt in the next 12 months (measured in 2013 or 2014). We furthermore compared the area under the Receiver Operating Characteristics (ROCAUC) curves of the MTSS and a Stages of Change measure.

Results: A total of 450 smokers (35.4%) made a quit attempt between baseline and 12-month follow-up. The regression analysis showed a positive relationship between scoring on the MTSS and quit attempts (odds ratio = 18.15, 95% confidence interval = 8.12–40.58 for the most vs. least motivated group). The discriminative accuracy of the MTSS (ROCAUC = 0.68) was marginally higher than that of a Stages of Change assessment (ROCAUC = 0.65), but not statistically significant (P = 0.21).

Conclusion: The MTSS is an externally valid instrument to predict quit attempts in the next 12 months.

Citation

Levy, D., Cummings, K.M., Villanti, A.C., Niaura, R., Abrams, D.B., Fong, G.T., Borland, R. (2017). A framework for evaluating the public health impact of e-cigarettes and other vaporized nicotine products. Addiction, 112(1), 8-17.

Abstract

The use of vaporized nicotine products (VNPs), especially e-cigarettes and, to a lesser extent, pressurized aerosol nicotine products and heat-not-burn tobacco products, are being adopted increasingly as an alternative to smoking combusted products, primarily cigarettes. Considerable controversy has accompanied their marketing and use. We propose a framework that describes and incorporates patterns of VNP and combustible cigarette use in determining the total amount of toxic exposure effects on population health. We begin by considering toxicity and the outcomes relevant to population health. We then present the framework and define different measures of VNP use; namely, trial and long-term use for exclusive cigarette smokers, exclusive VNP and dual (cigarette and VNP) use. Using a systems thinking framework and decision theory we considered potential pathways for current, former and never users of VNPs. We then consider the evidence to date and the probable impacts of VNP use on public health, the potential effects of different policy approaches and the possible influence of the tobacco industry on VNP and cigarette use.

Citation

Nicholson, A.K., Borland, R., Bennet, P.T., Davey, M.E., Van der Sterren, A., Stevens, M., Thomas, D. (2017). The effect of pack warning labels on quitting and related thoughts and behaviours in a national cohort of Aboriginal and Torres Strait Islander smokers. Nicotine & Tobacco Research, 19(10), 1163-71.

Abstract

Introduction: The high prevalence of smoking among Aboriginal and Torres Strait Islander people in Australia (39%) contributes substantially to health inequalities. This study assesses the impact of warning labels on quitting and related thoughts and behaviours for Aboriginal and Torres Strait Islander smokers.

Methods: Participants were recruited from communities served by 34 Aboriginal Community Controlled Health Services and communities in the Torres Strait, Australia, using quota sampling. A cohort of 642 daily/weekly smokers completed relevant questions at baseline (April 2012-October 2013) and follow up (August 2013-August 2014).

Results: We considered three baseline predictor variables: noticing warning labels, forgoing cigarettes due to warning labels ('forgoing') and perceiving labels to be effective. Forgoing increased significantly between surveys only for those first surveyed prior to the introduction of plain packs (19% vs. 34%), however there were no significant interactions between forgoing cigarettes and the introduction of new and enlarged graphic warning labels on plain packaging in any model. Forgoing cigarettes predicted attempting to quit (AOR: 1.45, 95% CI: 1.02-2.06) and, among those who did not want to quit at baseline, wanting to quit at follow-up (AOR: 3.19, 95% CI: 1.06-9.63). Among those less worried about future health effects, all three variables predicted being very worried at follow-up. Often noticing warning labels predicted correct responses to questions about health effects that had featured on warning labels (AOR: 1.84, 95% CI: 1.20-2.82) but not for those not featured.

Conclusions: Graphic warning labels appear to have a positive impact on the understanding, concerns and motivations of Aboriginal and Torres Strait Islander smokers and, through these, their quit attempts.

Implications: Graphic warning labels are likely to be effective for Aboriginal and Torres Strait Islander smokers as they are for the broader Australian population.

Citation

Gravely, S., Giovino, G.A., Craig, L.V., Commar, A., d'Espaignet, E.T., Schotte, K., Fong, G.T. (2017). Implementation of key demand-reduction measures of the WHO Framework Convention on Tobacco Control and change in smoking prevalence in 126 countries: an association study. Lancet Public Health, 2(4), e166-174.

Abstract

Background: The WHO Framework Convention on Tobacco Control (WHO FCTC) has mobilised efforts among 180 parties to combat the global tobacco epidemic. This study examined the association between highest-level implementation of key tobacco control demand-reduction measures of the WHO FCTC and smoking prevalence over the treaty's first decade.

Methods: We used WHO data from 126 countries to examine the association between the number of highest-level implementations of key demand-reduction measures (WHO FCTC articles 6, 8, 11, 13, and 14) between 2007 and 2014 and smoking prevalence estimates between 2005 and 2015. McNemar tests were done to test differences in the proportion of countries that had implemented each of the measures at the highest level between 2007 and 2014. Four linear regression models were computed to examine the association between the predictor variable (the change between 2007 and 2014 in the number of key measures implemented at the highest level), and the outcome variable (the percentage point change in tobacco smoking prevalence between 2005 and 2015).

Findings: Between 2007 and 2014, there was a significant global increase in highest-level implementation of all key demand-reduction measures. The mean smoking prevalence for all 126 countries was 24·73% (SD 10·32) in 2005 and 22·18% (SD 8·87) in 2015, an average decrease in prevalence of 2·55 percentage points (SD 5·08; relative reduction 10·31%). Unadjusted linear regression showed that increases in highest-level implementations of key measures between 2007 and 2014 were significantly associated with a decrease in smoking prevalence between 2005 and 2015). Each additional measure implemented at the highest level was associated with an average decrease in smoking prevalence of 1·57 percentage points (95% CI −2·51 to −0·63, p=0·001) and an average relative decrease of 7·09% (−12·55 to −1·63, p=0·011). Controlling for geographical subregion, income level, and WHO FCTC party status, the per-measure decrease in prevalence was 0·94 percentage points (−1·76 to −0·13, p=0·023) and an average relative decrease of 3·18% (−6·75 to 0·38, p=0·079). This association was consistent across all three control variables.

Interpretation: Implementation of key WHO FCTC demand-reduction measures is significantly associated with lower smoking prevalence, with anticipated future reductions in tobacco-related morbidity and mortality. These findings validate the call for strong implementation of the WHO FCTC in the WHO's Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013–2020, and in advancing the UN's Sustainable Development Goal 3, setting a global target of reducing tobacco use and premature mortality from non-communicable diseases by a third by 2030.