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.

Citation

Fix, B.V., O’Connor, R., Benowitz, N.L., Heckman, B., Cummings, K.M., Fong, G.T., Thrasher, J.F. (2017). Nicotine Metabolite Ratio (NMR) prospectively predicts smoking relapse: longitudinal findings from ITC Surveys in five countries. Nicotine and Tobacco Research, 19(9), 1040-1047.

Abstract

Introduction: The ratio of trans 3’-hydroxycotinine (3HC) to cotinine (nicotine metabolite ratio, NMR) is a biomarker of the rate of nicotine metabolism, with higher NMR indicating faster metabolism. Higher NMR has been found to be associated with higher daily cigarette consumption and less success stopping smoking in cessation trials. This study examines differences in NMR among population-based samples of smokers in the 5 countries and explores the relationship between NMR and smoking abstinence.

Methods: Participants (N=874) provided saliva samples during International Tobacco Control (ITC) surveys in the US, UK, Mauritius, Mexico, and Thailand conducted in 2010/2011 with follow-up surveys in 2012/2013. When all samples were received, they were sent to a common laboratory for analysis using liquid chromatography and tandem mass spectroscopy.

Results: There was significant variation in NMR across countries (F=15.49, p<.001). Those who reported smoking at follow-up had a mean NMR of 0.32, compared to a mean NMR of 0.42 in participants who reported that they had stopped (F=8.93; p=0.003). Higher mean NMR values were also associated with longer quit duration (p=0.007). There was no substantial difference in NMR between current smokers who made a failed quit attempt and those who made no attempt – both had significantly lower NMR compared to those who quit and remained abstinent. Smokers with a higher NMR were more likely to report that they stopped smoking compared to those with a lower NMR (OR=2.67; 95%CI: 1.25-5.68).

Conclusions: These results suggest faster nicotine metabolizers may be less likely to relapse following a quit attempt. This finding differs from results of clinical trials testing stop smoking medications, where slower metabolizers have been found to be more likely to maintain abstinence from smoking.

Citation

Li, Z., Elton-Marshall, T., Fong, G.T., Quah, A.C.K., Feng, G., Jiang, Y., Hitchman, S.C. (2017). Noticing cigarette health warnings and support for new health warnings: findings from the ITC China. BioMed Central Public Health, 17(1), 476.

Abstract

Background: Health warnings labels (HWLs) have the potential to effectively communicate the health risks of smoking to smokers and non-smokers, and encourage smokers to quit. This study sought to examine whether non-smokers in China notice the current text-only HWLs and whether they support adding more health information and including pictures on HWLs.

Methods: Adult non-smokers (n = 1324) were drawn from Wave 4 (September 2011-November 2012) of the International Tobacco Control (ITC) China Survey. The proportion of non-smokers who noticed the HWLs, and supported adding more health information and pictures to the HWLs was examined. Additionally, the relation between non-smokers' demographic characteristics, including whether they had a smoking partner, their number of smoking friends, and noticing the HWLs and support for adding health information and pictures was examined. Because the HWLs changed during the survey period (April 2012), differences between non-smokers who completed the survey before and after the change were examined.

Results: 12.2% reported they noticed the HWLs often in the last month. The multivariate model, adjusting for demographics showed that respondents with a smoking partner (OR = 2.41, 95% CI 1.42- 4.13, p = 0.001) noticed the HWLs more often. 64.8% of respondents agreed that the HWLs should have more information, and 80.2% supported including pictures. The multivariate model showed that nonsmokers who completed the survey after the HWLs were implemented (OR = 0.63, 95% CI 0.40-0.99, p = 0.04) were less likely to support adding more health information. The multivariate model showed a significant relation between having a smoking partner and supporting pictorial HWLs (OR = 2.03, 95% CI 1.24-3.33, p = 0.005).

Conclusions: The findings indicate that the Chinese HWLs are noticed by a minority of non-smokers and that non-smokers strongly support strengthening the Chinese warning labels with more health information and pictures. Additionally, because the HWLs are noticed more often by non-smokers with a smoking spouse/partner, HWLs could be used to communicate the dangers of smoking and secondhand smoke exposure to non-smokers.

Citation

Heckman, B.W., Cummings, K.M., Hirsch, A.A., Quisenberry, A.J., Borland, R., O’Connor, R.J., Fong, G.T., Bickel, W.K. (2017). A novel method for evaluating the acceptability of substitutes for cigarettes: The experimental tobacco marketplace. Tobacco Regulatory Science, 3(3), 266-279.

Abstract

Objectives: We tested the substitutability of nicotine replacement therapy (NRT), electronic cigarettes (ECs), and very low nicotine cigarettes (VLNCs) in the context of an online experimental tobacco marketplace (ETM) that was designed to mimic the choices of smokers under 4 policy scenarios.

Methods: Dutch cigarette smokers (N = 840) completed an online survey in July 2015. The ETM was comprised of conventional cigarettes, VLNCs, ECs (disposable/cartridge/tank systems), and NRT (lozenges/patches/tabs). All participants completed a scenario in which conventional cigarettes were banned. To test additional policy scenarios participants were randomized to one of 3 experiments: (1) no VLNCs; (2) all products available; or (3) no ECs. Hypothetical weekly purchases were made when the cost for conventional cigarettes was one-half market price (MP), MP, 2x MP, and 4x MP. We measured substitutability by the change in estimated consumption as cigarette prices increased.

Results: Tank and cartridge ECs and VLNCs were stronger cigarette substitutes than disposable ECs and NRT products. Substitution of ECs and NRT for cigarettes was dampened when VLNCs were available.

Conclusions: The ETM offers a method to predict how smokers might respond to policies that alter the availability of potentially substitutable products available in the marketplace.

Citation

Meijer, E., van Laar, C., Gebhardt, W.A., Fokkema, M., van den Putte, B., Dijkstra, A., Fong, G.T., Willemsen, M.C. (2017). Identity change among smokers and ex-smokers: findings from the International Tobacco Control (ITC) Netherlands Survey. Psychology of Addictive Behaviours, 31(4) 465-478.

Abstract

Successful smoking cessation appears to be facilitated by identity change, that is, when quitting or nonsmoking becomes part of smokers’ and ex-smokers’ self-concepts. The current longitudinal study is the first to examine how identity changes over time among smokers and ex-smokers and whether this can be predicted by socioeconomic status (SES) and psychosocial factors (i.e., attitude, perceived health damage, social norms, stigma, acceptance, self-evaluative emotions, health worries, expected social support). We examined identification with smoking (i.e., smoker self-identity) and quitting (i.e., quitter selfidentity) among a large sample of smokers (n = 742) and ex-smokers (n = 201) in a cohort study with yearly measurements between 2009 and 2014. Latent growth curve modeling was used as an advanced statistical technique. As hypothesized, smokers perceived themselves more as smokers and less as quitters than do ex-smokers, and identification with smoking increased over time among smokers and decreased among ex-smokers. Furthermore, psychosocial factors predicted baseline identity and identity development. Socioeconomic status (SES) was particularly important. Specifically, lower SES smokers and lower SES ex-smokers identified more strongly with smoking, and smoker and quitter identities were more resistant to change among lower SES groups. Moreover, stronger proquitting social norms were associated with increasing quitter identities over time among smokers and ex-smokers and with decreasing smoker identities among ex-smokers. Predictors of identity differed between smokers and exsmokers. Results suggest that SES and proquitting social norms should be taken into account when developing ways to facilitate identity change and, thereby, successful smoking cessation.

Citation

Mendes, F., Szklo, A., Perez, C., Cavalcante, T.M., Fong, G.T. (2017). Perceived enforcement of anti-smoking laws in bars and restaurants of three Brazilian cities: data from the ITC Brazil Survey. Cadernos de Saude Publica, 33(Sup 3), e00140315.

Abstract

Passive smoking causes severe and lethal effects on health. Since 1996 Brazil has been moving forward in the implementation of anti-smoking legislation in enclosed public spaces. This article aims to evaluate the perceived enforcement of anti-smoking legislation in the cities of Porto Alegre (Rio Grande do Sul State), Rio de Janeiro and São Paulo, Brazil, based on the results of the ITCBrazil Survey (International Tobacco Control Policy Evaluation Project). The results of the survey showed a significant reduction in the proportion of people who saw individuals smoking in restaurants and bars between 2009 and 2013 in the three cities surveyed. Concurrently there was an increase in the proportion of smokers who mentioned having smoked in the outer areas of these facilities. These results likely reflect a successful implementation of anti-smoking laws. Of note is the fact that by decreasing passive smoking we further enhance smoking denormalization among the general population, decreasing smoking initiation and increasing its cessation.

Citation

Cavalcante, T.M., Szklo, A.S., Perez, C., Thrasher, J.F., Szklo, M., Oiumet, J., Gravely, S., Fong, G.T., de Almeida, L.M. (2017). Electronic cigarette awareness, use, and perception of harmfulness in Brazil: findings from a country that has strict regulatory requirements. Cadernos de Saúde Pública, 33(3), e00074416.

Abstract

Given the uncertainties regarding electronic cigarettes’ (e-cigs) impact on health, in 2009 Brazil prohibited sales, importation or advertisements of these products until manufacturers are able to show they are safe and/or effective in smoking cessation. This study sought to analyze: (1) awareness of electronic cigarettes, ever-use and recent use; (2) perception of harmfulness of electronic cigarettes when compared with conventional cigarettes; and (3) correlates of awareness and perception of harmfulness. This is a cross-sectional study among Brazilian smokers (≥ 18 years) using the Wave 2 replenishment sample of the Brazilian International Tobacco Control Policy Evaluation Survey. Participants were recruited in three cities through a random-digit dialing sampling frame between October 2012 and February 2012. Among the 721 respondents, 37.4% (n = 249) of current smokers were aware of e-cigs, 9.3% (n = 48) reported having ever tried or used e-cigs and 4.6% (n = 24) reported having used them in the previous six months. Among those who were aware of e-cigs, 44.4% (n = 103) believed they were less harmful than regular cigarettes (low perception of harmfulness). “Low perception of harmfulness” was associated with a higher educational level and with having recently tried/used e-cigs. Despite restrictions to e-cigs in Brazil, 4.6% of sample smokers reported having recently used them. Health surveillance programs in Brazil and other countries should include questions on use and perceptions of e-cigs considering their respective regulatory environments.

Citation

Levy, D., Borland, R., Fong, G.T., Villanti, A.C., Niaura, R., Meza, R., Holford, T.R., Cummings, K.M., Abrams, D.B. (2017). Developing consistent and transparent models of e-cigarette use: Reply to Glantz and Soneji et al. Nicotine and Tobacco Research, 19(2), 268-270.

There is no abstract available for this publication.

Citation

Levy, D., Fong, G.T., Cummings, K.M., Borland, R., Abrams, D.B., Villanti, A.C., Niaura, R. (2017). The need for a comprehensive framework. Addiction, 112(1), 22-24.

Abstract

To facilitate individual and population-level behavior change, we need policies based on science. We must develop coherent policies that explicitly consider the benefits and risks of different classes of nicotine delivery products, rather than continuing the current ad-hoc approach which fails to adequately address the product itself.

Citation

Gravely, S., Fong, G.T., Driezen, P., Xu, S.S., Quah, A.C.K., Sansone, G.C., Gupta, P.C., Pednekar, M.S. (2016). An examination of the effectiveness of health warning labels on smokeless tobacco products in four states in India: Findings from the TCP India Cohort Survey. BMC Public Health, 16(1), 1246.

Abstract

Background: In 2009, after many delays and changes, India introduced a single pictorial health warning label (HWL) on smokeless tobacco (SLT) packing—a symbolic image of a scorpion covering 40% of the front surface. In 2011, the scorpion was replaced with 4 graphic images. This paper tested the effectiveness of SLT HWLs in India and whether the 2011 change from symbolic to graphic images increased their effectiveness.

Methods: Data were from a cohort of 4733 adult SLT users (age15+) of the Tobacco Control Project (TCP) India Survey from 4 states. The surveys included key indicators of health warning effectiveness, including warning salience, and cognitive, emotional, and behavioral responses to the warnings.

Results: The HWL change from symbolic to graphic did not result in significant increases on any of the HWL outcome indicators. A substantial minority of SLT users were unaware that SLT packages contained HWLs (27% at both waves). Noticing the warnings was also remarkably low at both waves (W1 = 34.3%, W2 = 28.1%). These effects carried over to the cognitive and behavioural measures, where among those who noticed HWLs, about one-third reported forgoing SLT at least once because of the HWLs, and fewer than 20% reported that HWLs made them think about SLT risks or about quitting SLT. Even fewer reported avoiding HWLs (8.1 to 11.6%). Among those who quit using SLT by post-policy, awareness that SLT packaging contained HWLs was significantly greater at post-policy (86.8%) compared to pre-policy (77.8%, p = 0.02). Quitters were also significantly more aware of the post-policy HWLs compared to those who continued to use SLT (p < 0.001).

Conclusions: Health warnings on SLT packages in India are low in effectiveness, and the change from the symbolic warning (pre-policy) to graphic HWLs (post-policy) did not lead to significant increases of effectiveness on any of the HWL indicators among those who continued to use SLT products, thus suggesting that changing an image alone is not enough to have an impact. There is a critical need to implement SLT HWLs in India that are more salient (large in size and on the front and back of the package) and impactful, which following from studies of HWLs on cigarette packaging, would have strong potential to increase awareness of the harms of SLT and to motivate quitting.

Citation

Driezen, P., Abdullah, A.S., Quah, A.C.K., Nargis, N., Fong, G.T. (2016). Determinants of intentions to quit smoking among adult smokers in Bangladesh: Findings from the International Tobacco Control (ITC) Bangladesh Wave 2 Survey. Global Health Research and Policy, 1, 11-22.

Abstract

Background: With about 22 million adult smokers, Bangladesh needs strong measures that would promote smoking cessation. Using data from Wave 2 of the International Tobacco Control (ITC) Survey, this study examined the factors associated with intention to quit smoking among Bangladeshi smokers.

Methods: Data from Wave 2 of the International Tobacco Control (ITC) Survey in Bangladesh, a face to face survey of adult smokers, were analysed. In the ITC survey, households were sampled using a stratified multistage design and interviewed using a structured questionnaire.

Results: Of the respondents (N = 2982), most were male (96 %), married (80 %), and Muslim (83 %); 33 % were illiterate and 54 % were aged below 40. Almost two-thirds were from areas outside Dhaka, 78 % smoked cigarettes exclusively; and 36 % had an intention to quit smoking in the future. This study identified several predictors, comparable to other international studies, of intention to quit smoking: area of residence, number of cigarettes smoked daily, previous quit attempt, visiting a doctor in the past, having child aged 5 or below at home, perceived benefit from quitting, being worried about own health, knowledge of SHS, not enjoying smoking and workplace smoking policy.

Conclusions: These findings suggest that the prevalence of intention to quit smoking is lower among Bangladeshi smokers than those among smokers in developed countries. However, the factors relating to quit intentions among Bangladeshi smokers are comparable to those found in Western countries. Population based tobacco control programs and policies should consider these predictors in the design of interventions to increase quitting among smokers in Bangladesh.

Citation

Thrasher, J.F., Abad-Vivero, E.N., Moodie, C., Hammond, D., Cummings, K.M., Yong, H.H., Salloum, R.G., Czoli, C., Reynales-Shigematsu, L.M. (2016). Cigarette brands with flavor capsules in the filter: Trends in the use and brand perceptions among smokers in the United States, Mexico, and Australia, 2012-2014. Tobacco Control, 25(3), 275-283.

Abstract

Objective: To describe trends, correlates of use and consumer perceptions related to the product design innovation of flavour capsules in cigarette filters.

Methods: Quarterly surveys from 2012 to 2014 were analysed from an online consumer panel of adult smokers aged 18–64, living in the USA (n=6865 observations; 4154 individuals); Mexico (n=5723 observations; 3366 individuals); and Australia (n=5864 observations; 2710 individuals). Preferred brand varieties were classified by price (ie, premium; discount) and flavour (ie, regular; flavoured without capsule; flavoured with capsule). Participants reported their preferred brand variety's appeal (ie, satisfaction; stylishness), taste (ie, smoothness, intensity), and harm relative to other brands and varieties. GEE models were used to determine time trends and correlates of flavour capsule use, as well as associations between preferred brand characteristics (ie, price stratum, flavour) and perceptions of relative appeal, taste and harm.

Results: Preference for flavour capsules increased significantly in Mexico (6% to 14%) and Australia (1% to 3%), but not in the USA (4% to 5%). 18–24 year olds were most likely to prefer capsules in the USA (10%) and Australia (4%), but not Mexico. When compared to smokers who preferred regular brands, smokers who preferred brands with capsules viewed their variety of cigarettes as having more positive appeal (all countries), better taste (all countries), and lesser risk (Mexico, USA) than other brand varieties.

Conclusions: Results indicate that use of cigarettes with flavour capsules is growing, is associated with misperceptions of relative harm, and differentiates brands in ways that justify regulatory action.

Citation

Yong, H.H., Borland, R., Cummings, K.M., Lindblom, E., Li, L., Bansal-Travers, M., O’Connor, R., Elton-Marshall, T., Thrasher, J., Hammond, D., Thompson, M.E., Partos, T. (2016). US smokers’ beliefs, experiences, and perceptions of different cigarette variants before and after the FSPTCA ban on misleading descriptors such as ‘light’, ‘mild’, or ‘low’. Nicotine and Tobacco Research, 18(11), 2115-2123.

Abstract

Introduction: In December 2008, the Federal Trade Commission (FTC) took action that prompted the removal of nicotine and tar listings from cigarette packs and ads. As of June 2010, the U.S. Family Smoking Prevention and Tobacco Control Act prohibited the use of explicit or implicit descriptors on tobacco packaging or in advertising that convey messages of reduced risk or exposure, specifically including terms like 'light', 'mild' and 'low' and similar descriptors. This study evaluates the effect of these two policy changes on smokers' beliefs, experiences and perceptions of different cigarettes.

Methods: Using generalized estimating equations models, this study analysed survey data collected between 2002 and 2013 by the International Tobacco Control Policy Evaluation Study regarding U.S. smokers' beliefs, experiences, and perceptions of different cigarettes.

Results: Between 2002 and 2013, smoker misperceptions about 'light' cigarettes being less harmful did not change significantly and remained substantial, especially among those who reported using lower-strength cigarettes. After the two policy changes, reported reliance on pack colours, colour terms, and other product descriptors like 'smooth' to determine cigarette strength style trended upward.

Conclusions: Policies implemented to reduce smoker misperceptions that some cigarettes are safer than others appear to have had little impact. Because of pack colours, colour terms, descriptors such as “smooth,” cigarette taste or feel, and possibly other characteristics, millions of smokers continue to believe, inaccurately, that they can reduce their harms and risks by smoking one cigarette brand or sub-brand instead of another, which may be delaying or reducing smoking cessation.

Citation

Kulak, J., Cornelius, M.E., Fong, G.T., Giovino, G.A. (2016). Differences in quit attempts and cigarette smoking abstinence between Whites and African Americans in the United States: Literature review and results from the ITC United States Survey. Nicotine and Tobacco Research, 18(Suppl 1), S79-S87.

Abstract

Introduction: While cigarette smoking prevalence is declining among US adults, quit rates may differ between white and African American smokers. Here, we summarize the literature on smoking cessation behaviors in whites and African Americans across four study designs and report the findings of new analyses of International Tobacco Control (ITC) US Survey cohort data.

Methods: We reviewed 32 publications containing 39 relevant analyses that compared quit attempts and abstinence between US whites and African Americans. Two additional longitudinal analyses were conducted on 821 white and 76 African American cigarette smokers from Waves 7 and 8 of the ITC US Survey (mean follow-up = 19 months).

Results: Of 17 total analyses of quit attempts, nine (including the ITC US Survey) observed that African American smokers were more likely than whites to attempt to quit during a given year; seven found no differences. Whites were more likely than African Americans to be abstinent in five of six retrospective cohort analyses and in two of five considered community- and population-based cohort studies. Four of these 11 analyses, including one from the ITC US Survey, found no differences.

Conclusions: Of 11 population- or community-based analyses, all seven that found significant differences indicated that whites were more likely to quit than African Americans. These findings, combined with the similar results from population-based birth cohort analyses, support the conclusion that white smokers are more likely to quit than African American smokers. Efforts to encourage and support quitting among all tobacco users remain a priority.

Implications: This article provides a review of the literature on smoking cessation among African American and white smokers, and adds new analyses that compare quit attempts and abstinence between US African Americans and whites. Results demonstrate a clear distinction between the findings of cross-sectional and retrospective cohort studies with those of cohort studies. Reasons for these differences merit further study.

Citation

Yong, H.H., Borland, R., Hammond, D., Thrasher, J.F., Cummings, K.M., Fong, G.T. (2016). Smokers’ reactions to the new larger health warning labels on plain cigarette packs in Australia: Findings from the ITC Australia Project. Tobacco Control, 25(2), 181-187.

Abstract

Objectives: This study examined whether larger sized Australian cigarette health warning labels (HWLs) with plain packaging (PP) were associated with increased desirable reactions towards the HWLs postimplementation.

Methods: Data were from the International Tobacco Control (ITC) longitudinal cohort survey assessing Australian smokers one wave prior to the policy change in 2011 (n=1104) and another wave after the policy change in 2013 (n=1093). We assessed initial attentional orientation (AO) to or away from warnings, plus other reactions, including cognitive reactions towards the HWLs and quit intentions.

Results: As expected, AO towards the HWLs and reported frequency of noticing warnings increased significantly after the policy change, but not more reading. Smokers also thought more about the harms of smoking and avoided the HWLs more after the policy change, but frequency of forgoing cigarettes did not change. The subgroup that switched from initially focusing away to focusing on the HWLs following the policy change noticed and read the HWLs more, and also thought more about the harmful effects of smoking, whereas the subgroup (5.4%) that changed to focusing away from the HWLs showed opposite effects. We tested the mediational model of Yong et al and confirmed it for predicting quit intentions, with larger effects post-policy.

Conclusions: Increasing the size of HWLs and introducing them on PP in Australia appears to have led to an overall increase in desired levels and strength of some reactions, but evidence of reactance was among a small minority.

Citation

Nagelhout, G.E., Heijndijk, S.M., Cummings, K.M., Willemsen, M.C., van den Putte, B., Heckman, B., Hummel, K., de Vries, H., Hammond, D., Borland, R. (2016). E-cigarette advertisements, and associations with the use of e-cigarettes and disapproval or quitting smoking: Findings from the International Tobacco Control (ITC) Netherlands Survey. Journal of Drug Policy, 29, 73-79.

Abstract

Background: Much attention has been directed towards the possible effects of e-cigarette advertisements on adolescent never smokers. However, e-cigarette advertising may also influence perceptions and behaviors of adult smokers. The aim of our study was to examine whether noticing e-cigarette advertisements is associated with current use of e-cigarettes, disapproval of smoking, quit smoking attempts, and quit smoking success.

Methods: We used longitudinal data from two survey waves of the ITC Netherlands Survey among smokers aged 16 years and older (n = 1198). Respondents were asked whether they noticed e-cigarettes being advertised on television, on the radio, and in newspapers or magazines in the previous 6 months.

Results: There was a significant increase in noticing e-cigarette advertisements between 2013 (13.3%) and 2014 (36.0%), across all media. The largest increase was for television advertisements. There was also a substantial increase in current use of e-cigarettes (from 3.1% to 13.3%), but this was not related to noticing advertisements in traditional media (OR = 0.99, p = 0.937). Noticing advertisements was bivariately associated with more disapproval of smoking (Beta = 0.05, p = 0.019) and with a higher likelihood of attempting to quit smoking (OR = 1.37, p = 0.038), but these associations did not reach significance in multivariate analyses. There was no significant association between noticing advertisements and quit smoking success in either the bivariate or multivariate regression analysis (OR = 0.92, p = 0.807).

Conclusion: Noticing e-cigarette advertisements increased sharply in the Netherlands between 2013 and 2014 along with increased e-cigarette use, but the two appear unrelated. The advertisements did not seem to have adverse effects on disapproval of smoking and smoking cessation.

Citation

Cooper, J., Borland, R., McKee, S., Yong, H.H., Dugué, P.A. (2016). Depression motivates quit attempts but predicts relapse: Differential findings for gender from the International Tobacco Control Study. Addiction, 111(8), 1438-47.

Abstract

Aims: To determine whether signs of current depression predict attempts to quit smoking, and short-term abstinence among those who try, and to test moderating effects of gender and cessation support (pharmacological and behavioural).

Design: Prospective cohort with approximately annual waves. Among smokers at one wave we assessed outcomes at the next wave using mixed-effects logistic regressions.

Setting: Waves 5-8 of the Four Country International Tobacco Control Study: a quasi-experimental cohort study of smokers from Canada, USA, UK and Australia.

Participants: A total of 6811 tobacco smokers who participated in telephone surveys.

Measurements: Three-level depression index: (1) neither low positive affect (LPA) nor negative affect (NA) in the last 4 weeks; (2) LPA and/or NA but not diagnosed with depression in the last 12 months; and (3) diagnosed with depression. Outcomes were quit attempts and 1-month abstinence among attempters.

Findings: Depression positively predicted quit attempts, but not after controlling for quitting history and motivational variables. Controlling for all covariates, depression consistently negatively predicted abstinence. Cessation support did not moderate this effect. There was a significant interaction with gender for quit attempts (P = 0.018) and abstinence (P = 0.049) after controlling for demographics, but not after all covariates. Depression did not predict abstinence among men. Among women, depressive symptoms [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.49-0.81] and diagnosis (OR = 0.46, 95% CI = 0.34-0.63) negatively predicted abstinence.

Conclusions: Smokers with depressive symptoms or diagnosis make more quit attempts than their non-depressed counterparts, which may be explained by higher motivation to quit, but they are also more likely to relapse in the first month. These findings are stronger in women than men.

Citation

Li, L., Fathelrahman, A.I., Borland, R., Omar, M., Fong, G.T., Quah, A.C.K., Sirirassamee, B., Yong, H.H. (2016). Impact of graphic pack warnings on adult smokers’ quitting activities: Findings from the ITC Southeast Asia Survey (2005-2014). Journal of Smoking Cessation, 11(2), 124-34.

Abstract

Malaysia introduced graphic health warning labels (GHWLs) on all tobacco packages in 2009. We aimed to examine if implementing GHWLs led to stronger warning reactions (e.g., thinking about the health risks of smoking) and an increase in subsequent quitting activities; and to examine how reactions changed over time since the implementation of the GHWLs in Malaysia and Thailand where GHWL size increased from 50–55% in 2010. Data came from six waves (2005–2014) of the International Tobacco Control Southeast Asia Survey. Between 3,706 and 4,422 smokers were interviewed across these two countries at each survey wave. Measures included salience of warnings, cognitive responses (i.e., thinking about the health risks and being more likely to quit smoking), forgoing cigarettes, and avoiding warnings. The main outcome was subsequent quit attempts. Following the implementation of GHWLs in Malaysia, reactions increased, in some cases to levels similar to the larger Thai warnings, but declined over time. In Thailand, reactions increased following implementation, with no decline for several years, and no clear effect of the small increase in warning size. Reactions, mainly cognitive responses, were consistently predictive of quit attempts in Thailand, but this was only consistently so in Malaysia after the change to GHWLs. In conclusion, GHWLs are responded to more frequently, and generate more quit attempts, but warning wear-out is not consistent in these two countries, perhaps due to differences in other tobacco control efforts.

Citation

Balmford, J., Borland, R., Yong, H.H. (2016). Impact of the introduction of standardised packaging on smokers' brand awareness and identification in Australia. Drug and Alcohol Review, 35, 102-109.

Abstract

Introduction and Aims: The introduction of standardised packaging (SP) in Australia in December 2012 has heightened interest in how image and branding might affect smoking. This paper tests the hypothesis that brand awareness and identification among smokers will decline after the introduction of SP.

Design and Methods: Longitudinal study of three waves of smokers in Australia, conducted between October 2011–February 2012 (pre-SP) (n = 1104), February–May 2013 (post-SP1) (n = 1093) and August–December 2014 (post-SP2) (n = 1090). We explored the extent of changes in two variables, brand awareness (noticing others with the brand of cigarettes you smoke) and brand identification (perceiving something in common among smokers of your brand), and examined change in a number of other measures of brand appeal, brand characteristics and determinants of brand choice.

Results: Brand awareness 'at least sometimes’ reduced from 45.3% pre-SP to 26.9% at post-SP2 [odds ratio (OR) 0.35 (0.27–0.45)]. Brand identification also decreased from 18.2% to 12.7% [OR 0.62 (0.42–0.91)]. Significant decline was also found in measures of perceived brand prestige [OR 0.51 (0.39–0.66)] and choice of brand for health reasons [OR 0.45 (0.32–0.63)]. Liking the look of the pack was strongly associated with brand identification, but only post-SP (P = 0.02 for interaction across the three waves).

Discussion and Conclusions: The introduction of SP of tobacco products in Australia has been associated with reductions in brand awareness and identification, and changes in related measures. The findings support the notion that SP has reduced the capacity for smokers to use pack branding to create and communicate a desired identity.