Citation

Nicholson, A.K., Borland, R., Davey, M.E., Stevens, M., Thomas, D.P. (2015). Past quit attempts in a national sample of Aboriginal and Torres Strait Islander smokers. Medical Journal of Australia, 202(10), S20-25.

Abstract

Objectives: To describe past attempts to quit smoking in a national sample of Aboriginal and Torres Strait Islander people, and to compare their quitting activity with that in the general Australian population.

Design, setting and participants: The Talking About The Smokes (TATS) project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1643 smokers and 78 recent quitters between April 2012 and October 2013. Baseline results for daily smokers (n = 1392) are compared with results for daily smokers (n = 1655) from Waves 5 to 8.5 (2006–2012) of the Australian International Tobacco Control Policy Evaluation Project (ITC Project).

Main outcome measures: Ever having tried to quit, tried to quit in the past year, sustained a quit attempt for 1 month or more.

Results: Compared with the general population, a smaller proportion of Aboriginal and Torres Strait Islander daily smokers had ever tried to quit (TATS, 69% v ITC, 81.4%), but attempts to quit within the past year were similar (TATS, 48% v ITC, 45.7%). More Aboriginal and Torres Strait Islander daily smokers than those in the general population reported sustaining past quit attempts for short periods only. Aboriginal and Torres Strait Islander smokers whose local health services had tobacco control resources were more likely to have tried to quit, whereas men and people who perceived they had experienced racism in the past year were less likely. Younger smokers, those who had gone without essentials due to money spent on smoking, and those who were often unable to afford cigarettes were more likely to have tried to quit in the past year, but less likely to have ever sustained an attempt for 1 month or more. Smokers who were unemployed, those who had not completed Year 12 and those from remote areas were also less likely to sustain a quit attempt.

Conclusions: Existing comprehensive tobacco control programs appear to be motivating Aboriginal and Torres Strait Islander smokers to quit but do not appear to overcome challenges in sustaining quit attempts, especially for more disadvantaged smokers and those from remote areas.

Citation

Couzos, S., Nicholson, A.K., Hunt, J.M., Davey, M.E., May, J.K., Bennet, P.T., Westphal, D.W., Thomas, D.P. (2015). Talking About the Smokes: A large-scale, community-based participatory research project. Medical Journal of Australia, 202(10), S13-19.

Abstract

Objective: To describe the Talking About The Smokes (TATS) project according to the World Health Organization guiding principles for conducting community-based participatory research (PR) involving indigenous peoples, to assist others planning large-scale PR projects.

Design, setting and participants: The TATS project was initiated in Australia in 2010 as part of the International Tobacco Control Policy Evaluation Project, and surveyed a representative sample of 2522 Aboriginal and Torres Strait Islander adults to assess the impact of tobacco control policies. The PR process of the TATS project, which aimed to build partnerships to create equitable conditions for knowledge production, was mapped and summarised onto a framework adapted from the WHO principles.

Main outcome measures: Processes describing consultation and approval, partnerships and research agreements, communication, funding, ethics and consent, data and benefits of the research. Results: The TATS project involved baseline and follow-up surveys conducted in 34 Aboriginal community-controlled health services and one Torres Strait community. Consistent with the WHO PR principles, the TATS project built on community priorities and strengths through strategic partnerships from project inception, and demonstrated the value of research agreements and trusting relationships to foster shared decision making, capacity building and a commitment to Indigenous data ownership.

Conclusions: Community-based PR methodology, by definition, needs adaptation to local settings and priorities. The TATS project demonstrates that large-scale research can be participatory, with strong Indigenous community engagement and benefits.

Citation

Thomas, D.P., Panaretto, K.S., Stevens, M., Bennet, P.T., Borland, R. (2015). Smoke-free homes and workplaces of a national sample of Aboriginal and Torres Strait Islander people. Medical Journal of Australia, 202(10), S33-38.

Abstract

Objective: To examine Aboriginal and Torres Strait Islander people's protection from second-hand smoke at home and work.

Design, Setting and Participants: The Talking About The Smokes project surveyed 2522 Aboriginal and Torres Strait Islander people from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait, using quota sampling, from April 2012 to October 2013. We made comparisons with data from Australian smokers in the International Tobacco Control Policy Evaluation Project (ITC Project), collected from either July 2010 to May 2011 or September 2011 to February 2012. MAIN OUTCOME

Measures: Whether smoking was not allowed anywhere in the home, or not allowed in any indoor area at work.

Results: More than half (56%) of Aboriginal and Torres Strait Islander smokers and 80% of nonsmokers reported that smoking was never allowed anywhere in their home. Similar percentages of daily smokers in our sample and the Australian ITC Project data reported bans. Most employed Aboriginal and Torres Strait Islander daily smokers (88%) reported that smoking was not allowed in any indoor area at work, similar to the Australian ITC Project estimate. Smokers working in smoke-free workplaces were more likely to have smoke-free homes than those in workplaces where smoking was allowed indoors (odds ratio, 2.85; 95% CI, 1.67-4.87). Smokers who lived in smoke-free homes were more likely to have made a quit attempt in the past year, to want to quit, and to have made quit attempts of 1 month or longer.

Conclusion: Most Aboriginal and Torres Strait Islander people are protected from second-hand smoke at work, and similar proportions of Aboriginal and Torres Strait Islander smokers and other Australian smokers do not allow smoking inside their homes.

Citation

Thomas, D.P., Panaretto, K.S., Stevens, M., Borland, R. (2015). Dependence in a national sample of Aboriginal and Torres Strait Islander daily smokers. Medical Journal of Australia, 202(10), S39-44.

Abstract

Objectives: To examine indicators of nicotine dependence in a national sample of Aboriginal and Torres Strait Islander daily smokers and their association with sustaining a quit attempt for at least 1 month, and to make comparisons with a national sample of Australian daily smokers.

Design, Setting and Participants: The Talking About The Smokes project used a quota sampling design to recruit 1392 daily smokers from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait from April 2012 to October 2013. These were compared with 1010 daily smokers from the general Australian population surveyed by the International Tobacco Control Policy Evaluation Project from September 2011 to February 2012.

Main Outcome Measures: Cigarettes per day (CPD), time to first cigarette, Heaviness of Smoking Index (HSI), other indicators of dependence, and whether smokers had ever sustained a quit attempt for at least 1 month.

Results: There was little difference in the mean HSI scores for Aboriginal and Torres Strait Islander and other Australian daily smokers. A higher proportion of Aboriginal and Torres Strait Islander daily smokers smoked ≤ 10 CPD (40% v 33.4%), but more also smoked their first cigarette within 30 minutes of waking (75% v 64.6%). Lower proportions of Aboriginal and Torres Strait Islander smokers reported having strong urges to smoke at least several times a day (51% v 60.7%) or that it would be very hard to quit (39% v 47.9%). Most Aboriginal and Torres Strait Islander smokers reported experiencing difficulties during their most recent quit attempt. All indicators of dependence, except CPD and strong urges, were positively associated with not having made a sustained quit attempt. Reported difficulties during the most recent quit attempt were more strongly associated with being unable to sustain quit attempts than were traditional measures of dependence.

Conclusion: Aboriginal and Torres Strait Islander smokers' experiences of past attempts to quit may be more useful than conventional indicators of nicotine dependence in understanding their dependence.

Citation

Nicholson, A.K., Borland, R., Couzos, S., Stevens, M., Thomas, D.P. (2015). Smoking-related knowledge and health risk beliefs in a national sample of Aboriginal and Torres Strait Islander people. Medical Journal of Australia, 202(10), S45-50.

Abstract

Objectives: To describe general knowledge and perceived risk of the health consequences of smoking among Aboriginal and Torres Strait Islander people; and to assess whether knowledge varies among smokers and whether higher knowledge and perceived risk are associated with quitting.

Design, Setting and Participants: The Talking About The Smokes project used quota sampling to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. Baseline survey data were collected from 2522 Aboriginal and Torres Strait Islander adults from April 2012 to October 2013.

Main Outcome Measures: Knowledge of direct effects of smoking and harms of second-hand smoke (SHS), risk minimisation, health worry, and wanting and attempting to quit.

Results: Most Aboriginal and Torres Strait Islander participants who were daily smokers demonstrated knowledge that smoking causes lung cancer (94%), heart disease (89%) and low birthweight (82%), but fewer were aware that it makes diabetes worse (68%). Similarly, almost all daily smokers knew of the harms of SHS: that it is dangerous to non-smokers (90%) and children (95%) and that it causes asthma in children (91%). Levels of knowledge among daily smokers were lower than among non-daily smokers, ex-smokers and never-smokers. Among smokers, greater knowledge of SHS harms was associated with health worry, wanting to quit and having attempted to quit in the past year, but knowledge of direct harms of smoking was not.

Conclusion: Lack of basic knowledge about the health consequences of smoking is not an important barrier to trying to quit for Aboriginal and Torres Strait Islander smokers. Framing new messages about the negative health effects of smoking in ways that encompass the health of others is likely to contribute to goal setting and prioritising quitting among Aboriginal and Torres Strait Islander people.

Citation

Nicholson, A.K., Borland, R., Bennet, P.T., Van der Sterren, A.E., Stevens, M., Thomas, D.P. (2015). Personal attitudes towards smoking in a national sample of Aboriginal and Torres Strait Islander smokers and recent quitters. Medical Journal of Australia, 202(10), S51-56.

Abstract

Objectives: To describe attitudes towards smoking in a national sample of Aboriginal and Torres Strait Islander smokers and recent quitters and assess how they are associated with quitting, and to compare these attitudes with those of smokers in the general Australian population.

Design, Setting, and Participants: The Talking About The Smokes project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1392 daily smokers, 251 non-daily smokers and 78 recent quitters from April 2012 to October 2013.

Main Outcome Measures: Personal attitudes towards smoking and quitting, wanting to quit, and attempting to quit in the past year.

Results: Aboriginal and Torres Strait Islander daily smokers were less likely than daily smokers in the general Australian population to report enjoying smoking (65% v 81%) and more likely to disagree that smoking is an important part of their life (49% v 38%); other attitudes were similar between the two groups. In the Aboriginal and Torres Strait Islander sample, non-daily smokers generally held less positive attitudes towards smoking compared with daily smokers, and ex-smokers who had quit within the past year reported positive views about quitting. Among the daily smokers, 78% reported regretting starting to smoke and 81% reported spending too much money on cigarettes, both of which were positively associated with wanting and attempting to quit; 32% perceived smoking to be an important part of their life, which was negatively associated with both quit outcomes; and 83% agreed that smoking calms them down when stressed, which was not associated with the quitting outcomes.

Conclusions: Aboriginal and Torres Strait Islander smokers were less likely than those in the general population to report positive reasons to smoke and held similar views about the negative aspects, suggesting that factors other than personal attitudes may be responsible for the high continuing smoking rate in this population.

Citation

Nicholson, A.K., Borland, R., Van der Sterren, A.E., Bennet, P.T., Stevens, M., Thomas, D.P. (2015). Social acceptability and desirability of smoking in a national sample of Aboriginal and Torres Strait Islander people. Medical Journal of Australia, 202(10), S57-62.

Abstract

Objectives: To describe social normative beliefs about smoking in a national sample of Aboriginal and Torres Strait Islander people, and to assess the relationship of these beliefs with quitting.

Design, setting and participants: The Talking About The Smokes project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1392 daily smokers, 251 nondaily smokers, 311 exsmokers and 568 never-smokers from April 2012 to October 2013.

Main outcome measures: Eight normative beliefs about smoking; wanting and attempting to quit.

Results: Compared with daily smokers in the general Australian population, Aboriginal and Torres Strait Islander daily smokers were less likely to report that mainstream society disapproves of smoking (78.5% v 62%). Among Aboriginal and Torres Strait Islander daily smokers, 40% agreed that Aboriginal and Torres Strait Islander community leaders where they live disapprove of smoking, 70% said there are increasingly fewer places they feel comfortable smoking, and most (90%) believed non-smokers set a good example to children. Support for the government to do more to tackle the harm caused by smoking was much higher than in the general Australian population (80% v 47.2%). These five normative beliefs were all associated with wanting to quit. Non-smokers reported low levels of pressure to take up smoking.

Conclusion: Tobacco control strategies that involve the leadership and participation of local Aboriginal and Torres Strait Islander community leaders, particularly strategies that emphasise protection of others, may be an important means of reinforcing beliefs that smoking is socially unacceptable, thus boosting motivation to quit.

Citation

Davey, M.E., Hunt, J.M., Foster, R., Couzos, S., Van der Sterren, A.E., Sarin, J., Thomas, D.P. (2015). Tobacco control policies and activities in Aboriginal community-controlled health services. Medical Journal of Australia, 202(10), S63-66.

Abstract

Objectives: To describe tobacco control policies and activities at a nationally representative sample of Aboriginal community-controlled health services (ACCHSs).

Design, Setting, and Participants: The Talking About The Smokes (TATS) project used a quota sampling design to recruit 34 ACCHSs around Australia. Between April 2012 and October 2013, a representative at each ACCHS completed a survey about the service's tobacco control policies and activities. Questions about support for smoke-free policies were also included in the TATS project survey of 2435 Aboriginal and Torres Strait Islander members of the communities served by the ACCHSs.

Main Outcome Measures: ACCHS tobacco control policies and activities.

Results: Thirty-two surveys were completed, covering 34 sites. Most ACCHSs (24/32) prioritised tobacco control “a great deal” or “a fair amount”, and all services had smoke-free workplace policies. Most had staff working on tobacco control and had provided tobacco control training within the past year. A range of quit-smoking information and activities had been provided for clients and the community, as well as extra smoking cessation support for staff. There was strong support for smoke-free ACCHSs from within the Aboriginal communities, with 87% of non-smokers, 85% of ex-smokers and 77% of daily smokers supporting a complete ban on smoking inside and around ACCHS buildings.

Conclusions: The high level of commitment and experience within ACCHSs provides a strong base to sustain further tobacco control measures to reduce the very high smoking prevalence in Aboriginal and Torres Strait Islander populations.

Citation

Nicholson, A.K., Borland, R., Sarin, J., Wallace, S., Van der Sterren, A.E., Stevens, M., Thomas, D.P. (2015). Recall of anti-tobacco advertising and information, warning labels and news stories in a national sample of Aboriginal and Torres Strait Islander smokers. Medical Journal of Australia, 202(10), S67-72.

Abstract

Objectives: To describe recall of anti-tobacco advertising (mainstream and targeted), pack warning labels, and news stories among a national sample of Aboriginal and Torres Strait Islander smokers, and to assess the association of these messages with attitudes that support quitting, including wanting to quit.

Design, Setting and Participants: A quota sampling design was used to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1643 Aboriginal and Torres Strait Islander smokers from April 2012 to October 2013.

Main Outcome Measures: Frequency of recall of advertising and information, warning labels and news stories; recall of targeted and local advertising; attitudes about smoking and wanting to quit.

Results: More smokers recalled often noticing warning labels in the past month (65%) than recalled advertising and information (45%) or news stories (24%) in the past 6 months. When prompted, most (82%) recalled seeing a television advertisement. Just under half (48%) recalled advertising that featured an Aboriginal or Torres Strait Islander person or artwork (targeted advertising), and 16% recalled targeted advertising from their community (local advertising). Frequent recall of warning labels, news stories and advertising was associated with worry about health and wanting to quit, but only frequent advertising recall was associated with believing that society disapproves of smoking. The magnitude of association with relevant attitudes and wanting to quit increased for targeted and local advertising.

Conclusions: Strategies to tackle Aboriginal and Torres Strait Islander smoking should sustain high levels of exposure to anti-tobacco advertising, news stories and warning labels. More targeted and local information may be particularly effective to influence relevant beliefs and subsequently increase quitting.

Citation

Thomas, D.P., Bennet, P.T., Briggs, V., Couzos, S., Hunt, J.M., Panaretto, K.S., Stevens, M., Borland, R. (2015). Smoking cessation advice and non-pharmacological support in a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers. Medical Journal of Australia, 202(10), S73-77.

Abstract

Objectives: To describe recall among a national sample of Aboriginal and Torres Strait Islander smokers and recent ex-smokers of having received advice to quit smoking and referral to nonpharmacological cessation support from health professionals, and their association with quit attempts.

Design, Setting and Participants: The Talking About The Smokes project used a quota sampling design to recruit 1721 smokers and exsmokers who had quit ≤ 12 months previously from communities served by 34 Aboriginal communitycontrolled health services and one community in the Torres Strait. Baseline surveys were conducted from April 2012 to October 2013. Results for daily smokers were compared with 1412 Australian daily smokers surveyed by the International Tobacco Control Policy Evaluation Project between 2006 and 2011.

Main Outcome Measures: Participants' recall of having been: seen by a health professional in the past year, asked if they smoke, advised to quit, and referred to other cessation support services; and having made a quit attempt in the past year.

Results: Compared with other Australian daily smokers, higher proportions of Aboriginal and Torres Strait Islander daily smokers saw a health professional in the past year (76% v 68.1%) and were advised to quit smoking (75% v 56.2% of those seen). Most Aboriginal and Torres Strait daily smokers who saw a health professional recalled being asked if they smoke (93%). Aboriginal and Torres Strait Islander daily smokers who had been advised to quit were more likely to have made a quit attempt in the past year than those who had not (odds ratio, 2.00; 95% CI, 1.58-2.52). Among all Aboriginal and Torres Strait Islander smokers and recent ex-smokers who had been advised to quit, 49% were given a pamphlet or brochure on how to quit, but fewer were referred to the telephone Quitline (28%), a quit-smoking website (27%) or a local quit course, group or clinic (16%).

Conclusion: Most Aboriginal and Torres Strait Islander daily smokers recalled being recently advised by a health professional to quit, which was associated with making a quit attempt.

Citation

Thomas, D.P., Briggs, V., Couzos, S., Panaretto, K.S., Van der Sterren, A.E., Stevens, M., Borland, R. (2015). Use of nicotine replacement therapy and stop-smoking medicines in a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers. Medical Journal of Australia, 202(10), S78-84.

Abstract

Objective: To examine the use of nicotine replacement therapy (NRT) and the stop-smoking medicines (SSMs) varenicline and bupropion in a national sample of Aboriginal and Torres Strait Islander smokers and recent ex-smokers.

Design, Setting and Participants: The Talking About The Smokes (TATS) project used a quota sampling design to recruit a nationally representative sample of 1721 smokers and ex-smokers who had quit ≤ 12 months before from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. Baseline surveys were conducted from April 2012 to October 2013. These were compared with 1017 daily smokers from the general Australian population surveyed by the International Tobacco Control Policy Evaluation Project (ITC Project) from July 2010 to May 2011.

Main Outcome Measures: Past and intended use of NRT and SSMs, duration of use, and whether participants thought NRT and SSMs help smokers to quit.

Results: Compared with other daily Australian smokers, lower proportions of Aboriginal and Torres Strait Islander daily smokers had ever used any NRT or SSMs (TATS, 37% v ITC, 58.5%) or used them in the past year (TATS, 23% v ITC, 42.1%). Nicotine patches were most commonly used by Aboriginal and Torres Strait Islander smokers and recent ex-smokers (24%), followed by varenicline (11%) and nicotine gum (10%); most (74%) had got their last NRT at no cost. Among dependent Aboriginal and Torres Strait Islander daily smokers, those who were more socioeconomically advantaged were more likely than the disadvantaged to have used NRT or SSMs. Similar proportions of Aboriginal and Torres Strait Islander daily smokers and other Australian daily smokers said that NRT or SSMs help smokers to quit (TATS, 70% v ITC, 74.2%). Dependent Aboriginal and Torres Strait Islander smokers who had previously used NRT or SSMs were more likely to believe they help in quitting and to intend to use them in the future.

Conclusion: Aboriginal and Torres Strait Islander daily smokers, particularly those who are most disadvantaged, are less likely to have used NRT or SSMs than other Australian daily smokers. Some of the barriers to use, including cost, are being overcome, but further improvements are possible.

Citation

Thomas, D.P., Davey, M.E., Panaretto, K.S., Hunt, J.M., Stevens, M., Van der Sterren, A.E. (2015). Smoking among a national sample of Aboriginal and Torres Strait Islander health service staff. Medical Journal of Australia, 202(10), S85-89.

Abstract

Objective: To examine smoking among Aboriginal and Torres Strait Islander staff of Aboriginal community-controlled health services (ACCHSs).

Design, Setting and Participants: The Talking About The Smokes (TATS) project surveyed 374 Aboriginal and Torres Strait Islander staff at a national sample of 31 ACCHSs, from April 2012 to October 2013. We made comparisons with adult participants in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) and with 1643 smokers in a community sample of 2522 Aboriginal and Torres Strait Islander people also surveyed in the TATS project.

Main Outcome Measures: Smoking status, smoking behaviour at work, quitting behaviour, attitudes and beliefs about smoking and quitting.

Results: Aboriginal and Torres Strait Islander ACCHS staff had a lower smoking prevalence than among all Aboriginal and Torres Strait Islander adults surveyed in the NATSISS (38% v 49.8%), but this difference was smaller when compared with only employed adults (38% v 44.8%). Staff smokers had higher odds than smokers in their communities of ever trying to quit (odds ratio [OR], 2.1; 95% CI, 1.1- 3.7), of having often noticed anti-smoking advertising (OR, 2.8; 95% CI, 1.4-5.6), and of having used stop-smoking medications (OR, 3.0; 95% CI, 1.6-5.7), often with the support of their ACCHS. There was a significant association (P < 0.001) between the smoking status of Aboriginal and Torres Strait Islander staff and their confidence in talking to others about smoking and quitting; ex-smokers were most likely to report being confident. Most Aboriginal and Torres Strait Islander staff who smoked (74%) agreed that being a non-smoker sets a good example to patients at their health service, and most did not smoke with patients or at work where patients could see them.

Conclusion: Smoking prevalence among Aboriginal and Torres Strait Islander ACCHS staff is only modestly lower than among other employed Aboriginal and Torres Strait Islander people. Given that exsmokers feel more confident to help others quit than any other group, smoking cessation in ACCHS staff is a useful contributor to reducing community smoking rates.

Citation

Fleischer, N.L., Lozano, P., Arillo-Santillán, E., Reynales-Shigematsu, L.M., Thrasher, J.F. (2015). The impact of neighbourhood violence and social cohesion on smoking behaviours among a cohort of smokers in Mexico. Journal of Epidemiology and Community Health, 69(11), 1083-1090.

Abstract

Background: Recent increases in violent crime may impact a variety of health outcomes in Mexico. We examined relationships between neighbourhood-level violence and smoking behaviours in a cohort of Mexican smokers from 2011 to 2012, and whether neighbourhood-level social cohesion modified these relationships.

Methods: Data were analysed from adult smokers and recent ex-smokers who participated in waves 5 and 6 of the International Tobacco Control Mexico survey. Self-reported neighbourhood violence and social cohesion were asked of wave 6 survey participants (n=2129 current and former smokers, n=150 neighbourhoods). Neighbourhood-level averages for violence and social cohesion (ranges 4–14 and 10– 25, respectively) were assigned to individuals. We used generalised estimating equations to determine associations between neighbourhood indicators and individual-level smoking intensity, quit behaviours and relapse.

Results: Higher neighbourhood violence was associated with higher smoking intensity (risk ratio (RR)=1.17, 95% CI 1.02 to 1.33), and fewer quit attempts (RR=0.72, 95% CI 0.61 to 0.85). Neighbourhood violence was not associated with successful quitting or relapse. Higher neighbourhood social cohesion was associated with more quit attempts and more successful quitting. Neighbourhood social cohesion modified the association between neighbourhood violence and smoking intensity: in neighbourhoods with higher social cohesion, as violence increased, smoking intensity decreased and in neighbourhoods with lower social cohesion, as violence increased, so did smoking intensity.

Conclusions: In the context of recent increased violence in Mexico, smokers living in neighbourhoods with more violence may smoke more cigarettes per day and make fewer quit attempts than their counterparts in less violent neighbourhoods. Neighbourhood social cohesion may buffer the impact of violence on smoking intensity.

Citation

Lee, W.B., Fong, G.T., Dewhirst, T., Kennedy, R.D., Yong, H.H., Borland, R., Awang, R., Omar, M. (2015). Social marketing in Malaysia: Cognitive, affective, and normative mediators of the TAK NAK antismoking advertising campaign. Journal of Health Communication, 20(10), 1166-1176.

Abstract

Antismoking mass media campaigns are known to be effective as part of comprehensive tobacco control programs in high-income countries, but such campaigns are relatively new in low- and middle-income countries and there is a need for strong evaluation studies from these regions. This study examines Malaysia's first national antismoking campaign, TAK NAK. The data are from the International Tobacco Control Malaysia Survey, which is an ongoing cohort survey of a nationally representative sample of adult smokers (18 years and older; N = 2,006). The outcome variable was quit intentions of adult smokers, and the authors assessed the extent to which quit intentions may have been strengthened by exposure to the antismoking campaign. The authors also tested whether the impact of the campaign on quit intentions was related to cognitive mechanisms (increasing thoughts about the harm of smoking), affective mechanisms (increasing fear from the campaign), and perceived social norms (increasing perceived social disapproval about smoking). Mediational regression analyses revealed that thoughts about the harm of smoking, fear arousal, and social norms against smoking mediated the relation between TAK NAK impact and quit intentions. Effective campaigns should prompt smokers to engage in both cognitive and affective processes and encourage consideration of social norms about smoking in their society.

Citation

Park, E., Park, S., Cho, S., Kim, Y., Seo, H.G., Driezen, P., Quah, A.C.K., Fong, G.T. (2015). What cigarette price is required for smokers to attempt to quit smoking? Findings from the ITC Korea Waves 2 and 3 Survey. Tobacco Control, 24(Suppl 3), iii48-iii55.

Abstract

Objectives: We assess the cigarette price that would motivate smokers to quit. We also explore the factors associated with the required price, including exposures to non-tax tobacco control policies.

Methods: Cross-sectional analysis was conducted on data from 1257 male smokers, who participated in either Wave 2 or 3 of the ITC Korea Survey. Information was obtained on what cigarette price per pack would make them try to quit (‘price to quit’). Tobit regression on log-transformed price and logistic regression on non-quitting were conducted to identify associated factors.

Results: The median price to quit was KRW5854 (US$5.31)/pack, given the current price of KRW2500 (US$2.27)/pack. Younger age, higher education, lack of concern about the health effects of smoking, lack of quit attempts and more cigarettes consumed per day were related to a higher price needed for a quit attempt. Exposures to combinations of non-tax policies were significantly associated with lower price levels to be motivated to quit.

Conclusions: Considering the large price increase required for quit attempts, tax policy needs to be combined with other policies, particularly for certain groups, such as heavy smokers. Strengthening nontax policies is likely to facilitate greater responsiveness to tax policy.

Citation

Sansone, N., Yong, H.H., Li, L., Jiang, Y., Fong, G.T. (2015). Perceived acceptability of female smoking in China: Findings from Waves 1 to 3 of the ITC China Survey. Tobacco Control, 24(Suppl 4), iv48-iv54.

Abstract

Background: Female smoking prevalence in China is very low but may rise with increased tobacco marketing towards women and changing norms. However, little is known about current perceptions of women smoking in China.

Objective: This study sought to examine smokers’ and non-smokers’ perceived acceptability of female smoking and how it changed over time in China.

Methods: Data come from waves 1 to 3 (2006–2009) of the International Tobacco Control China Survey, a face-to-face cohort survey of approximately 800 adult smokers and 200 non-smokers in each of seven cities in mainland China.

Results: At wave 3 (2009), about 38% of smokers and 9% of non-smokers agreed that female smoking is acceptable with women being almost twice as likely to do so as men (67% vs 36% and 11% vs 6%, respectively). In addition to women, smokers who were younger and had more positive perceptions of smoking in general were more likely to say that female smoking is acceptable. This perception significantly increased from wave 1 (2006) to wave 3 (2009), as did the perception that smoking is a sign of sophistication, but other general perceptions of smoking did not significantly change between 2006 and 2009.

Conclusions: Norms against female smoking appear to remain strong in China, but female smoking may be becoming more acceptable. It is important to monitor these perceptions to prevent a rise in female smoking prevalence along with an increase in tobacco-related death and disease among women in China.

Citation

Abdullah, A.S., Driezen, P., Quah, A.C.K., Nargis, N., Fong, G.T. (2015). Predictors of smoking cessation behavior among Bangladeshi adults: Findings from ITC Bangladesh Survey. Tobacco Induced Diseases, 13(1), 23.

Abstract

Background: Research findings on the predictors of smoking cessation behavior identified in Western countries may not be generalizable to smokers in the Southeast Asian countries (i.e., Bangladesh). This study examined the factors associated with smoking cessation behavior (quit attempts and smoking cessation) among a representative sample of Bangladeshi adults.

Methods: Data from Wave 1 (2009) and Wave 2 (2010) of the International Tobacco Control (ITC) Survey in Bangladesh, a face-to-face survey of adult smokers, were analysed. Households were sampled using a stratified multistage design and interviewed using a structured questionnaire. Respondents included in the study are 1,861 adult daily smokers (cigarette only or dual use of cigarette and bidi) in the Wave 1 survey who completed the Wave 2 follow up.

Results: Of the smokers (N = 1,861), 98 % were male, 18 % illiterate, 78 % married and 42 % were aged 40 or above; 89 % were cigarette smokers and 11 % were dual users (cigarette & bidi). Overall, 21.8 % of the baseline smokers made quit attempts (that is, making at least one quit attempt that lasted for at least 24 hours) during the 11- to 12-month interval between Waves 1 and 2 with only 4.1 % quitting successfully (that is, smokers who had stopped smoking for at least 6 months at the time of the Wave 2 survey). Significant predictors of attempts to quit included: residing areas outside Dhaka (OR = 3.41), being aged 40 or older (OR = 1.53), having a monthly income of above BDT10,000 (US$126) versus below BDT 5,000 (US$63) (OR = 1.57), intending to quit sometime in the future (OR = 1.73). Respondents not working indoors/outside the home were less likely to have made a quit attempt than those with no workplace restrictions on smoking (OR = 0.62). Predictors of successful smoking cessation included: being aged 40 or older (OR = 3.11), perceiving self-rated health as good or excellent (OR = 2.40), and an increased level of self-efficacy (OR = 1.75). Smokers who made a quit attempt not so recently (6 months ago or earlier) were less likely to quit than those who made a more recent (in last 6 months) quit attempt (OR = 0.23).

Conclusion: Among Bangladeshi smokers, different factors were associated with quit attempt or successful cessation. Population based smoking cessation programs should take these factors into consideration in the design of smoking cessation interventions. At the same time, measures are necessary to encourage more smokers to make quit attempts.

Citation

Springvloet, L., Willemsen, M.C., Mons, U., van den Putte, B., Kunst, A.E., Guignard, R., Hummel, K., Allwright, S., Siahpush, M., de Vries, H., Nagelhout, G.E. (2015). Educational differences in associations of noticing anti-tobacco information with smoking-related attitudes and quit intentions: Findings from the International Tobacco Control (ITC) Europe Surveys. Health Education Research, 30(5), 719-730.

Abstract

This study examined educational differences in associations of noticing anti-tobacco information with smoking-related attitudes and quit intentions among adult smokers. Longitudinal data (N = 7571) from two waves of six countries of the International Tobacco Control (ITC) Europe Surveys were included. Generalized estimating equation analyses and multiple linear and logistic regression analyses were conducted. Higher educated smokers noticed anti-tobacco information slightly more often than lower educated smokers (F(2) = 25.78, P < 0.001). Noticing anti-tobacco information was associated with more negative smoking-related attitudes (β = 0.05, P < 0.001) and more quit intentions (OR = 1.08, P < 0.001). Among smokers without a quit intention at baseline, a positive association was found for noticing antitobacco information at baseline with follow-up quit intention (OR = 1.14, P = 0.003). No other longitudinal associations were found. No educational differences were found in the association of noticing antitobacco information with smoking-related attitudes but associations with quit intentions were found only among low (OR = 1.12, P = 0.001) and high educated respondents (OR = 1.11, P < 0.001) and not among moderate educated respondents (OR = 1.02, P = 0.43). Noticing anti-tobacco information may positively influence quit intentions and possibly smoking-related attitudes. Lower educated smokers were as likely to be influenced by anti-tobacco information as higher educated smokers but noticed antitobacco information less often; increasing reach of anti-tobacco information may increase impact in this group.

Citation

Fong, G.T., Sansone, G., Yan, M., Craig, L., Quah, A.C.K, Jiang, Y. (2015). Evaluation of smoke-free policies in seven cities in China: Longitudinal findings from the ITC China Project (2007-2012). Tobacco Control, 24(Suppl 4), iv14-iv20.

Abstract

Background: China is the world's largest consumer of tobacco, with hundreds of millions of people exposed daily to secondhand smoke (SHS). Comprehensive smoke-free policies are the only effective way to protect the population from the harms of SHS. China does not have a comprehensive national smoke-free law but some local-level regulations have been implemented.

Objective: To evaluate local level smoke-free regulations across 7 cities in China by measuring the prevalence of smoking in public places (workplaces, restaurants and bars), and support for smoke-free policies over time.

Methods: Data were from waves 2 to 4 of the International Tobacco Control (ITC) China Survey (2007- 2012), a face-to-face cohort survey of approximately 800 smokers in each of 7 cities in mainland China. Multivariate logistic regression models estimated with generalised estimating equations were used to test the changes in variables over time.

Results: As of 2012, over three-quarters of respondents were exposed to smoking in bars; more than two-thirds were exposed to smoking in restaurants and more than half were exposed to smoking in indoor workplaces. Small decreases in the prevalence of smoking were found overall from waves 2 to 4 for indoor workplaces, restaurants and bars, although the decline was minimal for bars. Support for complete smoking bans increased over time for each venue, although it was lowest for bars.

Conclusions: Existing partial smoking bans across China have had minimal impact on reducing smoking in public places. A strongly enforced, comprehensive national smoke-free law is urgently needed in order to achieve greater public health gains

Citation

Elton-Marshall, T., Xu, S.S., Meng, G., Quah, A.C.K., Sansone, G.C., Feng, G., Jiang, Y., Driezen, P., Maizurah, O., Awang, R., Fong, G.T. (2015). The lower effectiveness of text-only health warnings in China compared to pictorial warnings in Malaysia: Findings from the ITC Project. Tobacco Control, 24(Suppl 4), iv6-iv13.

Abstract

Background: In 2009, China changed its health warnings on cigarette packs from side-only text warnings to two text-only warnings on 30% of the bottom of the front and back of the pack. Also in 2009, Malaysia changed from similar text warnings to pictorial health warnings consistent with Framework Convention on Tobacco Control (FCTC) Article 11 Guidelines.

Objective: To measure the impact of the change in health warnings in China and to compare the text-only health warnings to the impact of the pictorial warnings introduced in Malaysia.

Methods: We measured changes in key indicators of warning effectiveness among a longitudinal cohort sample of smokers from Waves 1 to 3 (2006–2009) of the International Tobacco Control (ITC) China Survey and from Waves 3 to 4 (2008–2009) of the ITC Malaysia Survey. Each cohort consisted of representative samples of adult (≥18 years) smokers from six cities in China (n=6575) and from a national sample in Malaysia (n=2883). Generalised Estimating Equations (GEE) were used to examine the impact of the health warnings on subsequent changes in salience of warnings, cognitive and behavioural outcomes.

Findings: Compared to Malaysia, the weak text-only warning labels in China led to a significant change in only two of six key indicators of health warning effectiveness: forgoing cigarettes and reading the warning labels. The change to pictorial warnings in Malaysia led to significant and substantial increases in five of six indicators (noticing, reading, forgoing, avoiding, thinking about quitting).

Conclusions: The delay in implementing pictorial warnings in China constitutes a lost opportunity for increasing knowledge and awareness of the harms of cigarettes, and for motivating smokers to quit

Citation

Green, A., Fong, G.T., Borland, R., Quah, A.C.K., Seo, H.G., Kim, Y., Elton-Marshall, T. (2015). The importance of the belief that "light" cigarettes are smoother in misperceptions of the harmfulness of "light" cigarettes in the Republic of Korea: A cohort study. BioMed Central Public Health, 15(1), 1108.

Abstract

Background: A number of countries have banned misleading cigarette descriptors such as “light” and “low-tar” as called for by the WHO Framework Convention on Tobacco Control. These laws, however, do not address the underlying cigarette design elements that contribute to misperceptions about harm. This is the first study to examine beliefs about “light” cigarettes among Korean smokers, and the first to identify factors related to cigarette design that are associated with the belief that “light” cigarettes are less harmful.

Methods: We analysed data from Wave 3 of the ITC Korea Survey, a telephone survey of a nationally representative sample of 1,753 adult smokers, conducted October - December 2010. A multinomial logistic regression was used to examine which factors were associated with the belief that “light” cigarettes are less harmful than regular cigarettes.

Results: One quarter (25.0 %) of smokers believed that “light” cigarettes are less harmful than regular cigarettes, 25.8 % believed that smokers of “light” brands take in less tar, and 15.5 % held both of these beliefs. By far the strongest predictor of the erroneous belief that “light” cigarettes are less harmful was the belief that “light” cigarettes are smoother on the throat and chest (p < 0.001, OR = 44.8, 95 % CI 23.6- 84.9).

Conclusions: The strong association between the belief that “light” cigarettes are smoother on the throat and chest and the belief that “light” cigarettes are less harmful, which is consistent with previous research, provides further evidence of the need to not only ban “light” descriptors, but also prohibit cigarette design and packaging features that contribute to the perception of smoothness.

Citation

Nargis, N., Thompson, M.E., Fong, G.T., Driezen, P., Hussain, A.K., Ruthbah, U.H., Quah, A.C., Abdullah, A.S. (2015). Prevalence and patterns of tobacco use in Bangladesh from 2009 to 2012: Evidence from International Tobacco Control Study. PLOS One, 10(11), e0141135.

Abstract

Background: Smoking and passive smoking are collectively the biggest preventable cause of death in Bangladesh, with major public health burden of morbidity, disability, mortality and community costs. The available studies of tobacco use in Bangladesh, however, do not necessarily employ nationally representative samples needed to monitor the problem at a national scale. This paper examines the prevalence and patterns of tobacco use among adults in Bangladesh and the changes over time using large nationally representative comparable surveys.

Methods: Using data from two enumerations of the International Tobacco Control (ITC) Bangladesh Project conducted in 2009 and 2012, prevalence estimates are obtained for all tobacco products by socioeconomic determinants and sample types of over 90,000 individuals drawn from over 30,000 households. Household level sample weights are used to obtain nationally representative prevalence estimates and standard errors. Statistical tests of difference in the estimates between two time periods are based on a logistic regression model that accounts for the complex sampling design. Using a multinomial logit model, the time trend in tobacco use status is identified to capture the effects of macro level determinants including changes in tobacco control policies.

Results: Between 2009 and 2012, overall tobacco use went down from 42.4% to 36.3%. The decline is more pronounced with respect to smokeless tobacco use than smoking. The prevalence of exclusive cigarette smoking went up from 7.2% to 10.6%; exclusive bidi smoking remained stable at around 2%; while smoking both cigarette and bidi went down from 4.6% to 1.8%; exclusive smokeless tobacco use went down from 20.2% to 16.9%; and both smokeless tobacco use and smoking went down from 8.4% to 5.1%. In general, the prevalence of tobacco use is higher among men, increases from younger to older age groups, and is higher among poorer people. Smoking prevalence is the highest among the slum population, followed by the tribal population, the national population and the border area population, suggesting greater burden of tobacco use among the disadvantaged groups.

Conclusions: The overall decline in tobacco use can be viewed as a structural shift in the tobacco market in Bangladesh from low value products such as bidi and smokeless tobacco to high value cigarettes, which is expected with the growth in income and purchasing power of the general population. Despite the reduction in overall tobacco use, the male smoking prevalence in Bangladesh is still high at 37%. The world average of daily smoking among men is 31.1%. The Tobacco Control Act 2005 and the Amendment have yet to make a significant impact in curbing tobacco usage in Bangladesh. The findings in this paper further suggest that the tobacco control policies in Bangladesh need to include targeted interventions to restrain the use of particular types of tobacco products among specific demographic and socio-economic groups of the population, such as smoked tobacco among men, smokeless tobacco among women, and both smoked and smokeless tobacco among those living in rural areas, those in low socio-economic status and those belonging to the tribal and the slum population.

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

Boado Martinez, M., Rodriguez Sendoya, D., Fong, G.T., Bianco, E. (2014). Impacto de las políticas de control del tabaco en los fumadores de Uruguay. Tendencias en Medicina, XXII(45), 43-52.

Abstract

This research presents the conceptual framework and the results of ITC PES (International Tobacco Control Project Evaluation Survey) evaluations. The project conducts surveys in 22 countires, and has been evalutating the impact of tobacco control policies in Uruguay since 2006 (n=887 to 1411) on beliefs, propensity to stop smoking and quitting smoking.

Citation

O’Connor, R.J., Schneller, L., Caruso, R., Stephens, W.E., Li, Q., Jiang, Y., Fong, G.T. (2015). Toxic metal and nicotine content of cigarettes sold in China, 2009 and 2012. Tobacco Control, 24(Suppl 4), iv55-iv59.

Abstract

Background: Metals of primary health concern can accumulate in the tobacco plant and contribute to smokers’ exposures to carcinogens, a significant cause of the millions of smoking-related deaths in China each year. These exposures are due to the smoker's addiction to nicotine.

Objective: This study sought to explore toxic heavy metal and nicotine concentrations in the tobacco of Chinese cigarette brands purchased in 2009 and 2012, as well as its regional variation.

Methods: Cigarette packs for this study were purchased from seven Chinese cities in 2009 and 2012, and 91 pairs of cigarettes were matched based on UPC for comparison. Ten cigarette sticks were randomly selected from each pack and tested using polarised energy dispersive X-ray fluorescence (XRF) for arsenic (As), cadmium (Cd), chromium (Cr), nickel (Ni) and lead (Pb) concentrations. Nicotine analysis was conducted following Coresta's Recommended Method N°62. Data analysis was conducted using SPSS, encompassing descriptive statistics, correlations and generalised estimating equations to observe changes in brand varieties overtime.

Findings: On average, from 2009 to 2012, As, Cd, Cr and Pb concentrations have decreased in Chinese tobacco. Of the seven cities where the cigarette brands were purchased, only four cities showed significant differences of the selected metals from 2009 to 2012. However, there was no significant change in the tobacco nicotine content from 2009 to 2012.

Conclusions: Tobacco in Chinese cigarettes purchased in seven geographically disbursed cities contains consistently high levels of metals, including carcinogens like Cd. One source may be the improper use of fertilisers. These numbers should be monitored more carefully and regulated by health officials.