Citation

Nagelhout, G.E., Willemsen, M.C., de Vries, H., Mons, U., Hitchman, S.C., Kunst, A. E., Guignard, R., Siahpush, M., Yong, H.H., van den Putte, B., Fong, G.T., Thrasher, J.F. (2016). Educational differences in the impact of pictorial cigarette warning labels on smokers: Findings from the International Tobacco Control (ITC) Europe Surveys. Tobacco Control, 25(3), 325-332.

Abstract

Objective: To examine (1) the impact of pictorial cigarette warning labels on changes in self-reported warning label responses: warning salience, cognitive responses, forgoing cigarettes and avoiding warnings, and (2) whether these changes differed by smokers’ educational level.

Methods: Longitudinal data of smokers from two survey waves of the International Tobacco Control (ITC) Europe Surveys were used. In France and the UK, pictorial warning labels were implemented on the back of cigarette packages between the two survey waves. In Germany and the Netherlands, the text warning labels did not change.

Findings: Warning salience decreased between the surveys in France (OR=0.81, p=0.046) and showed a non-significant increase in the UK (OR=1.30, p=0.058), cognitive responses increased in the UK (OR=1.34, p<0.001) and decreased in France (OR=0.70, p=0.002), forgoing cigarettes increased in the UK (OR=1.65, p<0.001) and decreased in France (OR=0.83, p=0.047), and avoiding warnings increased in France (OR=2.93, p<0.001) and the UK (OR=2.19, p<0.001). Warning salience and cognitive responses decreased in Germany and the Netherlands, forgoing did not change in these countries and avoidance increased in Germany. In general, these changes in warning label responses did not differ by education. However, in the UK, avoidance increased especially among low (OR=2.25, p=0.001) and moderate educated smokers (OR=3.21, p<0.001).

Conclusions: The warning labels implemented in France in 2010 and in the UK in 2008 with pictures on one side of the cigarette package did not succeed in increasing warning salience, but did increase avoidance. The labels did not increase educational inequalities among continuing smokers.

Citation

Cooper, J., Borland, R., Yong, H.H., Fotuhi, O. (2016). The impact of quitting smoking on depressive symptoms: Findings from the International Tobacco Control Four-Country Survey. Addiction, 111(8), 1448-1456.

Abstract

Aims: To determine whether abstinence or relapse on a quit attempt in the previous year is associated with current depressive symptoms.

Design: Prospective cohort with approximately annual waves. Mixed effect logistic regressions tested whether Time 2 (T2) quitting status was associated with reporting symptoms at T2, and whether Time 1 (T1) symptoms moderated this relationship.

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

Participants: 6978 smokers who participated in telephone surveys.

Measurements: T1 and T2 depressive symptoms in the last 4 weeks assessed with two screening items from the PRIME-MD questionnaire. Quitting status at T2: 1) No attempt since T1; 2) Attempted and relapsed; 3) Attempted and abstinent at T2.

Findings: Compared with no attempt, relapse was associated with reporting T2 symptoms (OR = 1.46, 95% CI:1.33,1.59). Associations between T2 quitting status and T2 symptoms were moderated by T1 symptoms. Relapse was positively associated with T2 symptoms for those without T1 symptoms (OR = 1.71, 95% CI:1.45,2.03) and those with T1 symptoms (OR = 1.45, 95% CI:1.23,1.70). Abstinence was positively associated for those without T1 symptoms (OR = 1.37, 95% CI:1.10,1.71) and negatively associated for those with T1 symptoms (OR = 0.74, 95% CI:0.59,0.94). Age significantly moderated these associations. Relapse did not predict T2 symptoms for those aged 18 to 39 irrespective of T1 symptoms. The negative effect of abstinence on T2 symptoms for those with T1 symptoms was significant only for those aged 18 to 39 (OR = 0.61, 95% CI = 0.40, 0.94) and 40 to 55 (OR = 0.58, 95% CI = 0.40, 0.84). The positive effect of abstinence on T2 symptoms for those without T1 symptoms was significant only for those aged over 55 (OR = 1.97, 95% CI = 1.35, 2.87).

Conclusions: Most people who stop smoking appear to be at no greater risk of developing symptoms of depression than if they had continued smoking. However, people over age 55 who stop smoking may be at greater risk of developing symptoms of depression than if they had continued smoking.

Citation

Zethof, D., Nagelhout, G.E., de Rooij, M., Driezen, P., Fong, G.T., van den Putte, B., Hummel, K., de Vries, H., Thompson, M.E., Willemsnen, M.C. (2016). Attrition analyzed in five yearly waves of a longitudinal survey of smokers: Findings from the ITC Netherlands Survey. European Journal of Public Health, 26(4), 693-699.

Abstract

Background: Attrition bias can affect the external validity of findings. This article analyses attrition bias and assesses the effectiveness of replenishment samples on demographic and smoking-related characteristics for the International Tobacco Control Netherlands Survey, a longitudinal survey among smokers.

Methods: Attrition analyses were conducted for the first five survey waves (2008–12). We assessed, including and excluding replenishment samples, whether the demographic composition of the samples changed between the first and fifth waves. Replenishment samples were tailored to ensure the sample remained representative of the smoking population. We also constructed a multivariable survival model of attrition that included all five waves with replenishment samples.

Results: Of the original 1820 respondents recruited in 2008, 46% participated again in 2012. Demographic differences between waves due to attrition were generally small and replenishment samples tended to minimize them further. The multivariable survival analysis revealed that only two of the 10 variables analysed were significant predictors of attrition: a weak effect for gender (men dropped out more often) and weak to moderate effects for age (respondents aged 15–24 years dropped out more than aged 25–39 years, who dropped out more than those aged 40+ years).

Conclusions: Weak to moderate attrition effects were found for men and younger age groups. This information could be used to minimize respondent attrition. Our findings suggest that sampling weights and tailored replenishment samples can effectively compensate for attrition effects. This is already being done for the International Tobacco Control Netherlands Survey, including the categories that significantly predicted attrition in this study.

Citation

Caruso, R.V., Fix, B.V., Thrasher, J.F., Cummings, K.M., Fong, G.T., Stephens, W.E., O’Connor, R.J. (2016). Differences in cigarette design and metal content across five countries: results from the International Tobacco Control (ITC) Project. Tobacco Regulatory Science, 2(2), 166-175.

Abstract

Objectives: We examined physical cigarette design characteristics and tobacco metal content of cigarettes obtained from 5 countries to determine how these properties vary for cigarette brands, both within and across countries with different dominant manufacturers.

Methods: Cigarette packs were collected from International Tobacco Control Policy Evaluation Survey (ITC) participants in the United States (US), the United Kingdom (UK), Mauritius, Mexico, and Thailand. Cigarettes were assessed for physical and design properties (eg, ventilation, pressure drop, rod density, weight) by published methods, and for metal content (As, Cd, Ni, Pb) by X-ray fluorescence spectrometry.

Results: Statistically significant differences in cigarette design and toxic metal concentrations were observed among countries and among manufacturers within countries. Filter ventilation, which is strongly predictive of machinemeasured tar and nicotine levels, varied most widely across countries. Ni and Cd were highest in Thailand (2.23ug/g and 1.64ug/g, respectively); As was highest in Mexico (0.29ug/g) and Pb was highest in the UK. (0.43 ug/g).

Conclusions: Parties to the FCTC should consider the adoption of uniform product standards related to cigarette design, emissions, and tobacco content that would reduce population health risks.

Citation

Driezen, P., Abdullah, A.S., Nargis, N.N., Hussain, G.A.K.M., Fong, G.T., Thompson, M.E., Quah, A.C.K., Xu, S. (2016). Awareness of tobacco-related health harms among vulnerable populations in Bangladesh: Findings from the International Tobacco Control (ITC) Bangladesh Survey. International Journal of Environmental Research and Public Health, 13(9), 848-863.

Abstract

This study assessed the knowledge of the harmful effects of tobacco use among vulnerable populations in Bangladesh and whether vulnerability was associated with the presence of complete home smoking bans. Data came from Wave 3 (2011–2012) of the International Tobacco Control (ITC) Bangladesh Survey, a nationally-representative survey of 3131 tobacco users and 2147 non-users. Sociodemographic measures of disadvantage were used as proxy measures of vulnerability, including sex, residential location, education and income. Outcome measures were awareness of the harmful effects of (a) cigarette smoking and (b) smokeless tobacco use and (c) whether respondents had complete smoking bans in their homes. Logistic regression was used to examine whether the adjusted prevalence of each outcome differed by socio-demographic proxies of vulnerability. Smaller percentages of women, the illiterate, urban slum residents and low-income Bangladeshis were aware of the health harms of tobacco. These vulnerable groups generally had lower odds of awareness compared to the least disadvantaged groups. Incomplete knowledge of tobacco’s harms may prevent vulnerable groups from taking steps to protect their health. Development goals, such as increasing literacy rates and empowering women, can complement the goals of WHO’s Framework Convention on Tobacco Control.

Citation

Ray, C., Pednekar, M.S., Gupta, P.C., Bansal-Travers, M., Quah, A.C.K., Fong, G.T. (2016). Social impacts on adult use of tobacco: Findings from the International Tobacco Control Project India, Wave 1 Survey. WHO South-East Asia Journal of Public Health, 5(2), 123-132.

Abstract

Background: Social impacts on tobacco use have been reported but not well quantified. This study investigated how strongly the use of smoked and smokeless tobacco may be influenced by other users who are close to the respondents.

Methods: The International Tobacco Control Project (TCP), India, used stratified multistage cluster sampling to survey individuals aged ≥15 years in four areas of India about their tobacco use and that of their close associates. The present study used logistic regression to calculate odds ratios (ORs) for tobacco use for each type of close associate.

Results: Among the 9780 respondents, tobacco use was significantly associated with their close associates’ (father’s, mother’s, friends’, spouse’s) tobacco use in the same form. After adjusting for confounding variables, women smokers were nine times more likely to have a mother who ever smoked (OR: 9.0; 95% confidence interval [CI]: 3.3–24.7) and men smokers five times more likely (OR: 5.4; 95% CI: 2.1–14.1) than non-smokers. Men smokers were seven times more likely to have close friends who smoked (OR: 7.2; 95% CI: 5.6–9.3). Users of smokeless tobacco (SLT) were five times more likely to have friends who used SLT (OR: 5.3; 95% CI: 4.4–6.3 [men]; OR: 5.0; 95% CI: 4.3–5.9 [women]) and four times more likely to have a spouse who used SLT (OR: 4.1; 95% CI: 3.0–5.8 [men]; OR: 4.3; 95% CI: 3.6–5.3 [women]), than non-users. The ORs for the association of the individuals’ tobacco use, whether smoked or smokeless, increased with the number of close friends using it in the same form.

Conclusion: The influence of family members and friends on tobacco use needs to be appropriately addressed in tobacco-control interventions.

Citation

Lozano, P., Fleischer, N.L., Thrasher, J.F., Arillo-Santillán, E., Reynales-Shigematsu, L.M. (2016). Does neighborhood social cohesion modify the relationship between neighborhood social norms and smoking behaviors in Mexico? Health & Place, 40, 145–152.

Abstract

The aim of this study was to examine the separate and combined relationships of neighborhood social norms and neighborhood social cohesion with smoking behavior in a cohort of adult Mexican smokers. Neighborhood anti-smoking norms were measured as the proportion of residents in each neighborhood who believed that society disapproves of smoking. Perceived social cohesion was measured using a 5- item cohesion scale and aggregated to the neighborhood level. Higher neighborhood anti-smoking norms were associated with less successful quitting. Neighborhood social cohesion modified the relationship between neighborhood social norms and two smoking behaviors: smoking intensity and quit attempts. Residents of neighborhoods with weaker anti-smoking norms and higher social cohesion had lower smoking intensity and more quit attempts than residents living in other areas. Social cohesion may help buffer smoking behavior in areas with weak social norms.

Citation

Guindon, E., Burkhalter, R., Brown, S.K. (2016). Levels and trends in cigarette contraband in Canada. Tobacco Control, 26(5), 518-525.

Abstract

Background: There is overwhelming evidence that increases in tobacco taxes reduce tobacco use, save lives and increase government tax revenue. High taxes, however, create an incentive to devise ways to avoid or evade tobacco taxes through contraband tobacco. The associated consequences are significant and call for an accurate measurement of contraband's magnitude. However, its illegal nature makes the levels and trends in contraband intrinsically difficult to measure accurately.

Objective: To examine levels and trends in cigarette contraband in Canada.

Methods: We employed 2 approaches: first, we contrasted estimates of tax-paid cigarettes sales with consumption estimates based on survey data; second, we used data from several individual-level surveys that examined smokers' purchasing and use behaviours. We placed a particular emphasis on the provinces of Québec and Ontario because existing research suggests that cigarette contraband levels are far higher than in any other province.

Results: The estimates presented show a clear upward trend from the early 2000s in cigarette contraband in Québec and Ontario followed by, on the whole, a decreasing trend from about 2007 to 2009. None of the data presented provide support to the narrative that cigarette contraband has been increasing in recent years. Of note are Québec estimates which suggest relatively low levels of cigarette contraband since 2010, at levels no higher than in the early 2000s.

Conclusions: The data presented suggest that policies to tackle cigarette contraband introduced from the mid-2000s to late 2000s, at both federal and provincial levels, may have dampened the demand for contraband cigarettes.

Citation

Kaai, S.C., Fong, G.T., Green, A., Goma, F., Meng, G., Quah, A.C.K., Borland, R., Phiri, M.M., Elton-Marshall, T. (2016). Misperceptions about "light" cigarettes among smokers in Zambia: Findings from the International Tobacco Control (ITC) Zambia Survey. Tobacco Prevention & Cessation Journal, 2, 65-75.

Abstract

Little is known about beliefs about “light” cigarettes (“lights”) in African countries where both tobacco industry activity and tobacco control efforts are intensifying. This study in Zambia is the first to examine the prevalence and beliefs about “lights” among smokers in Africa. Data are from 1,214 smokers participating in the International Tobacco Control (ITC) Zambia Wave 1 Survey (2012), a multi-stage clustered sampling design, face-to-face nationally representative probability sample of tobacco users and non-users aged 15 years and older. 17.0% of respondents’ usual brand of cigarettes was “lights”. 36.5% of smokers believed that “lights” are less harmful; beliefs differed by brand type (42.1% “lights” vs. 38.2% “non-lights”). 42.0% of smokers believed that “lights” are smoother on the throat and chest than regular cigarettes with beliefs differing by brand type. Among smokers who believed that “lights” are smoother, 81.0% believed that these cigarettes are less harmful, much higher than the 4.1% of smokers who did not believe that “lights” are smoother. Smoothness beliefs about “lights” was the strongest predictor of the belief that “lights” are less harmful (p<0.001, OR=131.13, 95% CI 59.4 to 289.5). Zambian smokers incorrectly believe that “lights” are less harmful. The highly strong association between the belief that “lights” are smoother and the belief that “lights” are less harmful suggests that tobacco control policies need to use a multi-pronged approach including product regulation, banning misleading descriptors and menthol, and implementing sustained long-term public education campaigns to combat sensory beliefs and misperceptions about “lights”.

Citation

Kaai, S.C., Chung-Hall, J., Chan, S., Burhoo, P., Moussa, B., Yan, M., Ramasawmy, D., Quah, A.C.K., Fong, G.T. (2016). Predictors of quit intentions among adult smokers in Mauritius: Findings from the ITC Mauritius Survey. Tobacco Prevention & Cessation, 2, 69-77.

Abstract

Introduction: Mauritius has one of the highest rates of smoking in Africa. Smoking cessation is a priority for preventing tobacco-related morbidity and mortality. The purpose of this study is to identify the predictors of quit intentions among smokers in Mauritius in order to strengthen tobacco control policies and inform the development and delivery of services that may increase the likelihood of successful quitting.

Methods: Data were drawn from one wave (2009) of the International Tobacco Control (ITC) Mauritius Survey, a face-to-face cohort survey of a nationally representative sample of 598 adult smokers who were randomly selected from nine geographic districts in Mauritius using a multistage sampling procedure.

Results: The vast majority of smokers (77.8%) had plans to quit smoking. Longer duration of past quit attempts (6 months or less), perceiving benefits of quitting, worrying about smoking damaging health in the future, and enjoyment of smoking were significantly associated with quit intentions. However, sociodemographic characteristics, past quit attempts, overall attitude about smoking, and Heaviness of Smoking Index (HSI) were not associated with quit intentions.

Conclusions: The predictors of quit intentions among Mauritian smokers were generally similar to those found among smokers in other high- and middle-income countries. However, in contrast to findings in those other countries, nicotine dependence as measured by the HSI was not a significant predictor of quit intentions among Mauritian smokers. These findings highlight the need to consider the predictors of quit intentions when developing and delivering smoking cessation support services in Mauritius.

Citation

Gravely, S., Fong, G.T., Driezen, P., McNally, M., Thrasher, J.F., Thompson, M.E., Boado, M., Bianco, E., Borland, R., Hammond, D. (2016). The impact of the 2009/2010 enhancement of cigarette health warning labels in Uruguay: Longitudinal findings from the International Tobacco Control (ITC) Uruguay Survey. Tobacco Control, 25, 89-95.

Abstract

Background: Framework Convention on Tobacco Control (FCTC) Article 11 Guidelines recommend that health warning labels (HWLs) should occupy at least 50% of the package, but the tobacco industry claims that increasing the size would not lead to further benefits. This article reports the first population study to examine the impact of increasing HWL size above 50%. We tested the hypothesis that the 2009/2010 enhancement of the HWLs in Uruguay would be associated with higher levels of effectiveness.

Methods: Data were drawn from a cohort of adult smokers (≥18 years) participating in the International Tobacco Control (ITC) Uruguay Survey. The probability sample cohort was representative of adult smokers in five cities. The surveys included key indicators of HWL effectiveness. Data were collected in 2008/09 (prepolicy: wave 2) and 2010/11 (postpolicy: wave 3).

Results: Overall, 1746 smokers participated in the study at wave 2 (n=1379) and wave 3 (n=1411). Following the 2009/2010 HWL changes in Uruguay (from 50% to 80% in size), all indicators of HWL effectiveness increased significantly (noticing HWLs: OR=1.44, p=0.015; reading HWLs: OR=1.42, p=0.002; impact of HWLs on thinking about risks of smoking: OR=1.66, p<0.001; HWLs increasing thinking about quitting: OR=1.76, p<0.001; avoiding looking at the HWLs: OR=2.35, p<0.001; and reports that HWLs stopped smokers from having a cigarette ‘many times’: OR=3.42, p<0.001).

Conclusions: The 2009/2010 changes to HWLs in Uruguay, including a substantial increment in size, led to increases of key HWL indicators, thus supporting the conclusion that enhancing HWLs beyond minimum guideline recommendations can lead to even higher levels of effectiveness.

Citation

Quisenberry, A.J., Koffarnus, M.N., Hatz, L. E., Epstein, L.H., Bickel, W.K. (2016). The experimental tobacco marketplace I: Substitutability as a function of the price of conventional cigarettes. Nicotine and Tobacco Research, 18(7), 1642-8.

Abstract

Introduction: Behavioral economic studies of nicotine product consumption have traditionally examined substitution between two products and rarely examined substitution with more products. Increasing numbers of tobacco products available for commercial sale leads to more possible cross-product interactions, indicating a need to examine substitution in more complex arrangements that closely mirror the tobacco marketplace.

Methods: The experimental tobacco marketplace (ETM) is an experimental online store that displays pictures, information, and prices for several tobacco products. Smokers were endowed with an account balance based on their weekly tobacco purchases. Participants then made potentially real purchases for seven (Experiment 1) or six (Experiment 2) tobacco/nicotine products under four price conditions for conventional cigarettes while prices for other products remained constant. Smokers returned 1 week later to report tobacco/nicotine use and return unused products for a refund.

Results: In Experiment 1 (n = 22), cigarette purchasing decreased as a function of price. Substitution was greatest for electronic cigarettes and cigarillos and significant for electronic cigarettes. Experiment 2 (n = 34) was a replication of Experiment 1, but with cigarillos unavailable in the ETM. In Experiment 2, cigarette purchases decreased as a function of price. Substitution was robust and significant for electronic cigarettes and Camel Snus.

Conclusions: The ETM is a novel, practical assay that mimics the real-world marketplace, and functions as a simple research tool for both researchers and participants. Across the two experiments the product mix in the ETM altered which products functioned as substitutes suggesting complex interactions between purchasing and product availability.

Citation

Yong, H.H., Borland, R., Balmford, J., McNeill, A., Hitchman, S.C., Driezen, P., Thompson, M.E., Fong, G.T., Cummings, K.M. (2015). Trends in e-cigarette awareness, trial, and use under the different regulatory environments of Australia and the UK. Nicotine & Tobacco Research, 17(10), 1203-1211.

Abstract

Introduction: E-cigarettes (ECs) have gained significant attention in recent years. They have been introduced in jurisdictions with divergent existing laws that affect their legality. This provides the opportunity for natural experiments to assess effects of such laws in some cases independent of any formulated government policy. We compare patterns of EC awareness and use over a three year period in Australia where laws severely restrict EC availability, with awareness and use in the UK where ECs are readily available.

Methods: Data analysed come from Waves 8 and 9 (collected in 2010 and 2013, respectively) of the International Tobacco Control (ITC) surveys in Australia and the UK (approximately 1500 respondents per wave per country).

Results: Across both waves, EC awareness, trial, and use among current and former smokers was significantly greater in the UK than in Australia, but all three of these measures increased significantly between 2010 and 2013 in both countries, and the rate of increase was equivalent between countries. 73% of UK respondents reported that their current brands contained nicotine as did 43% in Australia even though sale, possession and/or use of nicotine-containing ECs without a permit is illegal in Australia. EC use was greater among smokers in both countries, at least in part due to less uptake by ex-smokers.

Conclusions: EC awareness and use have risen rapidly between 2010 and 2013 among current and former smokers in both Australia and the UK despite different EC regulatory environments. Substantial numbers in both countries are using ECs that contain nicotine.

Citation

Hummel, K., Nagelhout, G.E., Willemsen, M.C., Driezen, P., Springvloet, L., Mons, U., Kunst, A.E., Guignard, R., Allwright, S., van den Putte, B., Hoving, C., Fong, G.T., McNeill, A., Siahpush, M., de Vries, H. (2015). Trends and socioeconomic differences in policy triggers for thinking about quitting smoking: Findings from the International Tobacco Control (ITC) Europe Surveys. Drug and Alcohol Dependence, 155, 154-162.

Abstract

Introduction: The aim of the current study is to investigate trends and socioeconomic differences in policy triggers for thinking about quitting in six European countries.

Methods: Data were derived from all available survey waves of the International Tobacco Control (ITC) Europe Surveys (2003-2013). France conducted three survey waves (n=1420-1735), Germany three waves (n=515-1515), The Netherlands seven waves (n=1420-1668), Ireland three waves (n=582-1071), Scotland two waves (n=461-507), and the rest of the United Kingdom conducted seven survey waves (n=861-1737). Smokers were asked whether four different policies (cigarette price, smoking restrictions in public places, free or lower cost medication, and warning labels on cigarette packs) influenced them to think about quitting. Generalized Estimating Equation (GEE) models were estimated for each country.

Results: Cigarette price was mentioned most often in all countries and across all waves as trigger for thinking about quitting. Mentioning cigarette price and warning labels increased after the implementation of price increases and warning labels in some countries, while mentioning smoking restrictions decreased after their implementation in four countries. All studied policy triggers were mentioned more often by smokers with low and/or moderate education and income than smokers with high education and income. The education and income differences did not change significantly over time for most policies and in most countries.

Conclusions: Tobacco control policies work as a trigger to increase thoughts about quitting, particularly in smokers with low education and low income and therefore have the potential to reduce health inequalities in smoking.

Citation

Jampaklay, A., Borland, R., Yong, H.H., Sirirassamee, B., Fotuhi, O., Fong, G.T. (2015). Predictors of successful quitting among Thai adult smokers: Evidence from ITC-SEA (Thailand) Survey. International Journal of Environmental Research and Public Health, 12(10), 12095-12109.

Abstract

This study uses longitudinal data from the International Tobacco Control Southeast Asia (ITC-SEA Thailand) survey to explore patterns and predictors of successful quitting among Thai adult smokers as a function of time quit. A cohort of a representative sample of 2000 smokers was surveyed four times from 2005 to 2009. A sample of 1533 individuals provided data for at least one of the reported analyses. Over the four years of follow-up, 97% made attempts to quit. Outcomes were successful quitting/relapse: (a) quit attempts of at least one month (short-term relapse, 43%) (57% remaining quit); (b) surviving at least six months (medium-term) (31%); (c) relapse between one and six months (45%); (d) having continuously quit between Waves 3 and 4 (sustained abstinence) (14%); and (e) relapse from six months on (44%) compared to those who continuously quit between Waves 3 and 4 (56%). Predictors for early relapse (<1 month) differ from longer-term relapse. Age was associated with reduced relapse over all three periods, and was much stronger for longer periods of abstinence. Cigarette consumption predicted relapse for short and medium terms. Self-assessed addiction was predictive of early relapse, but reversed to predict abstinence beyond six months. Previous quit history of more than one week was predictive of early abstinence, but became unrelated subsequently. Self-efficacy was strongly predictive of abstinence in the first month but was associated with relapse thereafter. Some determinants of relapse change with time quit, but this may be in somewhat different to patterns found in the West.

Citation

Li, L, Borland, R., Yong, H.H., Sirirassamee, B., Hamann, S.L., Omar, M, Quah, A.C.K. (2015). Impact of point-of-sale tobacco display bans in Thailand: Findings from the International Tobacco Control (ITC) Southeast Asia Survey. International Journal of Environmental Research and Public Health, 12(8), 9508-9522.

Abstract

In September 2005 Thailand became the first Asian country to implement a complete ban on the display of cigarettes and other tobacco products at point-of-sale (POS). This paper examined the impact of the POS tobacco display ban in Thailand, with Malaysia (which did not impose bans) serving as a comparison. The data came from the International Tobacco Control Southeast Asia Survey (2005–2011), a prospective cohort survey designed to evaluate the psychosocial and behavioral impacts of tobacco control policies. Main measures included smokers’ reported awareness of tobacco displays and advertising at POS. At the first post-ban survey wave over 90% of smokers in Thailand were aware of the display ban policy and supported it, and about three quarters thought the ban was effective. Noticing tobacco displays in stores was lowest (16.9%) at the first post-ban survey wave, but increased at later survey waves; however, the levels were consistently lower than those in Malaysia. Similarly, exposure to POS tobacco advertising was lower in Thailand. The display ban has reduced exposure to tobacco marketing at POS. The trend toward increased noticing is likely at least in part due to some increase in violations of the display bans and/or strategies to circumvent them.

Citation

Thomas, D.P., Briggs, V., Couzos, S., Dvey, M., Hunt, J.M., Panaretto, K.S., Van der Sterren, A.E., Stevens, M., Nicholson, A.K., Borland, R. (2015). Research methods of 'Talking about the Smokes': An International Tobacco Control (ITC) Policy Evaluation Project with Aboriginal and Torres Strait Islander Australians. Medical Journal of Australia, 202(10), S5-12.

Abstract

Objective: To describe the research methods and baseline sample of the Talking About The Smokes (TATS) project.

Design: The TATS project is a collaboration between research institutions and Aboriginal community-controlled health services (ACCHSs) and their state and national representative bodies. It is one of the studies within the International Tobacco Control Policy Evaluation Project, enabling national and international comparisons. It includes a prospective longitudinal study of Aboriginal and Torres Strait Islander smokers and recent ex-smokers; a survey of non-smokers; repeated cross-sectional surveys of ACCHS staff; and descriptions of the tobacco policies and practices at the ACCHSs. Community members completed face-to-face surveys; staff completed surveys on paper or online. We compared potential biases and the distribution of variables common to the main community baseline sample and unweighted and weighted results of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). The baseline survey (Wave 1) was conducted between April 2012 and October 2013.

Setting and participants: 2522 Aboriginal and Torres Strait Islander people in 35 locations (the communities served by 34 ACCHSs and one community in the Torres Strait), and 645 staff in the ACCHSs.

Main outcome measures: Sociodemographic and general health indicators, smoking status, number of cigarettes smoked per day and quit attempts.

Results: The main community baseline sample closely matched the distribution of the Aboriginal and Torres Strait Islander population in the weighted NATSISS by age, sex, jurisdiction and remoteness. There were inconsistent differences in some sociodemographic factors between our sample and the NATSISS: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas. In both surveys, similar percentages of smokers reported having attempted to quit in the past year, and daily smokers reported similar numbers of cigarettes smoked per day.

Conclusion: The TATS project provides a detailed and nationally representative description of Aboriginal and Torres Strait Islander smoking behaviour, attitudes, knowledge and exposure to tobacco control activities and policies, and their association with quitting.

Citation

Smith, P.H., Kasza, K.A., Hyland, A., Fong, G.T., Borland, R., McNeill, A., Brady, K., Carpenter, M.J., Hartwell, K., Prohmmo, A., McKee, S. (2015). Gender differences in medication use and cigarette smoking cessation: Results from the ITC Four Country Survey. Nicotine & Tobacco Research, 17(4), 463-472

Abstract

Introduction: There is conflicting evidence for gender differences in smoking cessation, and there has been little research on gender differences in smoking cessation medication (SCM) use and effectiveness. Using longitudinal data from the International Tobacco Control Four Country Surveys (ITC-4) conducted in the United Kingdom, the United States, Canada, and Australia, we examined gender differences in the incidence of quit attempts, reasons for quitting, use of SCMs, reasons for discontinuing use of SCMs, and rates of smoking cessation.

Methods: Data were analyzed from adult smokers participating in the ITC-4, annual waves 2006-2011 (n = 7,825), as well as a subsample of smokers (n = 1,079) who made quit attempts within 2 months of survey. Adjusted modeling utilized generalized estimating equations.

Results: There were no gender differences in the likelihood of desire to quit, plans to quit, or quit attempts between survey waves. Among quit attempters, women had 31% lower odds of successfully quitting (OR = 0.69; 95% CI = 0.51, 0.94). Stratified by medication use, quit success was lower among women who did not use any SCMs (OR = 0.59; 95% CI = 0.39, 0.90), and it was no different from men when medications were used (OR = 0.73; 95% CI = 0.46, 1.16). In particular, self-selected use of nicotine patch and varenicline contributed to successful quitting among women.

Conclusions: Women may have more difficulty quitting than men, and SCMs use may help attenuate this difference.

Citation

Brown, A., Nagelhout, G.E., van den Putte, B., Willemsen, M.C., Mons, U., Guignard, R., Thompson, M.E. (2015). Trends and socioeconomic differences in roll-your-own tobacco use: Findings from the ITC Europe Surveys.Tobacco Control, 24(Suppl 3), iii11-iii16.

Abstract

Objectives: To examine if exclusive Roll-Your-Own (RYO) tobacco use relative to factory-made (FM) cigarette use has been rising over time, to determine the extent to which economic motives and perceptions that RYO cigarettes are less harmful act as primary motivations for use, and to examine the association of income and education with the level of RYO tobacco use among smokers in four European countries.

Methods: Data were obtained from the International Tobacco Control (ITC) Europe Surveys, and a cohort sample of 7070 smokers from the Netherlands, Germany, France and UK were interviewed between June 2006 and December 2012. Generalised estimating equations (GEE) were used to assess trends in RYO use, and whether RYO consumption varied by socioeconomic variables.

Results: Exclusive RYO use over the study period has increased significantly in the UK from 26.4% in 2007 to 32.7% in 2010 (p<0.001); France from 12.2% in 2006 to 19.1% in 2012 (p<0.001); and Germany from 12.7% in 2007 to 18.6% in 2011 (p=0.031), with increased borderline significantly in the Netherlands (31.7% to 34.3%, p=0.052), from 2008 to 2010. Over three-quarters of users in each of the study countries indicated that lower price was a reason why they smoked RYO. Just over a fourth of smokers in the UK, less than a fifth in France, and around a tenth in Germany and the Netherlands believed that RYO is healthier. Compared with exclusive FM users, exclusive RYO users were more likely to have lower incomes and lower education.

Conclusions: Effective tobacco tax regulation is needed in the European Union and elsewhere to eliminate or reduce the price advantage of RYO tobacco. Additional health messages are also required to correct the misperception that RYO tobacco is healthier than FM cigarettes.

Citation

Nicholson, A.K., Borland, R., Davey, M.E., Stevens, M., Thomas, D.P. (2015). Predictors of wanting to quit in a national sample of Aboriginal and Torres Strait Islander smokers. Medical Journal of Australia, 202(10), S26-32.

Abstract

Objective: To describe factors that predict wanting to quit smoking in a national sample of Aboriginal and Torres Strait Islander people.

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. Baseline survey data were collected from 1643 current smokers between April 2012 and October 2013.

Main Outcome Measure: Wanting to quit smoking.

Results: More than two-thirds of smokers (70%) said they want to quit. Many factors were associated with wanting to quit, including past quitting activity. Interest in quitting was lower among men and smokers from economically disadvantaged areas, but there was no difference by age, remoteness or other measures of economic disadvantage. Attitudes and beliefs negatively associated with wanting to quit included enjoying smoking and believing quitting to be very difficult, and those positively associated included regretting ever starting to smoke, perceiving that local Aboriginal and Torres Strait Islander community leaders disapprove of smoking, believing non-smokers set a good example to children, worrying about future smoking-related health effects and believing quitting to be beneficial. Reporting support from family and friends was predictive of wanting to quit, but factors related to smoking in the social network were not. Associations with health and wellbeing were mixed. While most tobacco control policy exposure variables were positively associated with wanting to quit, two - receiving advice to quit from a health professional, and recall of targeted anti-tobacco advertising - appeared to have an effect that extended beyond influencing relevant attitudes and beliefs.

Conclusion: Interest in quitting among Aboriginal and Torres Strait Islander smokers appears to be influenced by a broad range of factors, highlighting the importance of taking a comprehensive approach to tobacco control. Advice from health professionals and targeted advertising appear to be important intervention strategies.

Citation

Im, P.K., McNeill, A., Thompson, M.E., Fong, G.T., Xu, S.S., Quah, A.C.K., Jiang, Y., Shahab, L. (2015). Individual and interpersonal triggers to quit smoking in China: A cross-sectional analysis. Tobacco Control, 24(Suppl 4), iv40-iv47.

Abstract

Aims: To determine the most prominent individual and interpersonal triggers to quit smoking in China and their associations with sociodemographic characteristics.

Methods: Data come from Waves 1-3 (2006-2009) of the International Tobacco Control (ITC) China Survey, analysed cross-sectionally as person-waves (N=14 358). Measures included sociodemographic and smoking characteristics. Those who quit between waves (4.3%) were asked about triggers that 'very much' led them to stop smoking, and continuing smokers about triggers that 'very much' made them think about quitting. Triggers covered individual (personal health concerns, cigarette price, smoking restrictions, advertisements, warning labels) and interpersonal factors (family/societal disapproval of smoking, setting an example to children, concerns about secondhand smoke).

Results: Over a third of respondents (34.9%) endorsed at least one trigger strongly; quitters were more likely than smokers to mention any trigger. While similar proportions of smokers endorsed individual (24.4%) and interpersonal triggers (24.0%), quitters endorsed more individual (61.1%) than interpersonal (48.3%) triggers. However, the most common triggers (personal health concerns; setting an example to children) were the same, endorsed by two-thirds of quitters and a quarter of smokers, as were the least common triggers (warning labels; cigarette price), endorsed by 1 in 10 quitters and 1 in 20 smokers. Lower dependence among smokers and greater education among all respondents were associated with endorsing any trigger.

Conclusions: Individual rather than interpersonal triggers appear more important for quitters. Major opportunities to motivate quit attempts are missed in China, particularly with regard to taxation and risk communication. Interventions need to focus on more dependent and less-educated smokers.

Citation

Li, J., White, J.S., Hu, T.W., Fong, G.T., Jiang, Y. (2015). The heterogeneous effects of cigarette prices on brand choice in China: Implications for tobacco control policy. Tobacco Control, 24(Suppl 3), iii25-iii32.

Abstract

Background: China has long kept its tobacco taxes below international standards. The Chinese government has cited two rationales against raising tobacco tax, namely, the unfair burden it places on low-income smokers and the ability of consumers to switch to cheaper brands.

Objective: This study examines how different socioeconomic subgroups of Chinese smokers switch brands in response to cigarette price changes.

Methods: We model smokers' choice of cigarette tier as a function of tier-specific prices. We examine heterogeneous responses to prices by estimating mixed logit models for different income and education subgroups that allow for random variation in smokers' preferences. We use data from three waves of the longitudinal International Tobacco Control China Survey, collected in six large Chinese cities between 2006 and 2009.

Findings: Low-income and less educated smokers are considerably more likely to switch tiers (including both up-trading and down-trading) than are their high-socioeconomic status (SES) counterparts. For those in the second-to-lowest tier, a ¥1 ($0.16, or roughly 25%) rise in prices increases the likelihood of switching tiers by 5.6% points for low-income smokers and 7.2% points for less educated smokers, compared to 1.6% and 3.0% points for the corresponding high-SES groups. Low-income and less educated groups are also more likely to trade down compared to their high-SES counterparts.

Conclusions: Only a small percentage of low-income and less educated Chinese smokers switched to cheaper brands in response to price increases. Hence, the concern of the Chinese government that a cigarette tax increase will lead to large-scale brand switching is not supported by this study.

Citation

Cowie, G.A., Swift, E., Partos, T.R., Borland, R. (2015). Quitting activity and tobacco brand switching: Findings from the ITC-4 Country Survey. Australian and New Zealand Journal of Public Health, 39(2), 109-113.

Abstract

Objective: Among Australian smokers, to examine associations between cigarette brand switching, quitting activity and possible causal directions by lagging the relationships in different directions.

Methods: Current smokers from nine waves (2002 to early 2012) of the ITC-4 Country Survey Australian dataset were surveyed. Measures were brand switching, both brand family and product type (roll-your-own versus factory-made cigarettes) reported in adjacent waves, interest in quitting, recent quit attempts, and one month sustained abstinence.

Results: Switching at one interval was unrelated to concurrent quit interest. Quit interest predicted switching at the following interval, but the effect disappeared once subsequent quit attempts were controlled for. Recent quit attempts more strongly predicted switching at concurrent (OR 1.34, 95%CI=1.18-1.52, p<0.001) and subsequent intervals (OR 1.31, 95%CI=1.12-1.53, p=0.001) than switching predicted quit attempts, with greater asymmetry when both types of switching were combined. One month sustained abstinence and switching were unrelated in the same interval; however, after controlling for concurrent switching and excluding type switchers, sustained abstinence predicted lower chance of switching at the following interval (OR=0.66, 95%CI=0.47-0.93, p=0.016).

Conclusions: The asymmetry suggests brand switching does not affect subsequent quitting.

Implications: Brand switching does not appear to interfere with quitting.

Citation

Thrasher, J.F., Osman, A., Moodie, C., Hammond, D., Bansal-Travers, M., Cummings, K.M., Borland, R., Yong, H.H., Hardin, J. (2015). Promoting cessation resources through cigarette package warning labels: A longitudinal survey with adult smokers in Canada, Australia and Mexico. Tobacco Control, 24 (e1), 23-31.

Abstract

Introduction: Health warning labels (HWLs) on tobacco packaging can be used to provide smoking cessation information, but the impact of this information is not well understood.

Methods: Online consumer panels of adult smokers from Canada, Australia and Mexico were surveyed in September 2012, January 2013 and May 2013; replenishment was used to maintain sample sizes of 1000 participants in each country at each wave. Country-stratified logistic Generalised Estimating Equation (GEE) models were estimated to assess correlates of citing HWLs as a source of information on quitlines and cessation websites. GEE models also regressed having called the quitline, and having visited a cessation website, on awareness of these resources because of HWLs.

Results: At baseline, citing HWLs as a source of information about quitlines was highest in Canada, followed by Australia and Mexico (33%, 19% and 16%, respectively). Significant increases over time were only evident in Australia and Mexico. In all countries, citing HWLs as a source of quitline information was significantly associated with self-report of having called a quitline. At baseline, citing HWLs as a source of information about cessation websites was higher in Canada than in Australia (14% and 6%, respectively; Mexico was excluded because HWLs do not include website information), but no significant changes over time were found for either country. Citing HWLs as a source of information about cessation websites was significantly associated with having visited a website in both Canada and Australia.

Conclusions: HWLs are an important source of cessation information.

Citation

Salloum, R., Thrasher, J.F., Kaai, S., Fong, G.T., Quah, A.C.K., Zulu, R., Goma, F., Chelwa, G. (2015, March). Cigarette price and brand loyalty in Zambia: Findings from the ITC Zambia Survey. Poster presentation at the 16th World Conference on Tobacco or Health, Abu Dhabi, United Arab Emirates.

Abstract

Objectives: Little is known about cigarette pricing and brand loyalty in sub-Saharan Africa. This study examines these issues in Zambia, analysing data from the International Tobacco Control (ITC) Zambia Survey.

Methods: Data from Wave 1 of the ITC Zambia Survey (2012) were analysed for current smokers of factory-made (FM) cigarettes compared with those who smoked both FM and roll-your-own (RYO) cigarettes, using multivariate logistic regression models to identify the predictors of brand loyalty and reasons for brand choice.

Results: 75% of FM-only smokers and 64% of FM+RYO smokers reported having a regular brand. Compared with FM-only smokers, FM+RYO smokers were, on average, older (28% vs 20% ≥40 years), low income (64% vs 43%) and had lower education (76% vs 44% < secondary). Mean price across FM brands was ZMW0.50 (US$0.08) per stick. Smokers were significantly less likely to be brand loyal (>1 year) if they were aged 15–17 years (vs 40–54 years) and if they had moderate (vs low) income. Brand choice was predicted mostly by friends, taste and brand popularity. Price was more likely to be a reason for brand loyalty among FM+RYO smokers, among ≥55-year-old smokers and among those who reported being more addicted to cigarettes.

Conclusions: These results in Zambia document the high levels of brand loyalty in a market where price variation is fairly small across cigarette brands. Future research is needed on longitudinal trends to evaluate the effect of tobacco control policies in Zambia.