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.

Citation

Kasza, K.A., Hyland, A., Bansal-Travers, M., Vogl, L.M., Chen, J., Evans, S.E., Fong, G.T., Cummings, K.M., O’Connor, R.J. (2014). Switching between menthol and nonmenthol cigarettes: Findings from the U.S. Cohort of the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 16(9), 1255-1265.

Abstract

Introduction: This article examines trends in switching between menthol and nonmenthol cigarettes, smoker characteristics associated with switching, and associations among switching, indicators of nicotine dependence, and quitting activity.

Methods: Participants were 5,932 U.S. adult smokers who were interviewed annually as part of the International Tobacco Control Four Country Survey between 2002 and 2011. Generalized estimating equations (GEEs) were used to examine the prevalence of menthol cigarette use and switching between menthol and nonmenthol cigarettes (among 3,118 smokers who participated in at least 2 consecutive surveys). We also evaluated characteristics associated with menthol cigarette use and associations among switching, indicators of nicotine dependence, and quitting activity using GEEs.

Results: Across the entire study period, 27% of smokers smoked menthol cigarettes; prevalence was highest among Blacks (79%), young adults (36%), and females (30%). Prevalence of switching between menthol and nonmenthol cigarettes was low (3% switched to menthol and 8% switched to nonmenthol), and switchers tended to revert back to their previous type. Switching types was not associated with indicators of nicotine dependence or quit attempts. However, those who switched cigarette brands within cigarette types were more likely to attempt to quit smoking.

Conclusions: While overall switching rates were low, the percentage who switched from menthol to nonmenthol was significantly higher than the percentage who switched from nonmenthol to menthol. An asymmetry was seen in patterns of switching such that reverting back to menthol was more common than reverting back to nonmenthol, particularly among Black smokers.

Citation

Partos, T.R., Borland, R., Thrasher, J.F., Li, L., Yong, H.H., O’Connor, R.J., Siahpush, M. (2014). The predictive utility of micro indicators of concern about smoking: Data from the International Tobacco Control Four Country Survey. Addictive Behaviours, 39(8), 1235-1242.

Abstract

This study explored the association between six “micro indicators” of concern about smoking (1. stubbing out cigarettes before finishing; 2. forgoing cigarettes due to packet warning labels; thinking about… 3. the harms to oneself of smoking; 4. the harms to others of one's smoking; 5. the bad conduct of tobacco companies; and 6. money spent on cigarettes) and cessation outcomes (making quit attempts, and achieving at least six months of sustained abstinence) among adult smokers from Australia, Canada, the United Kingdom, and the United States of America. Participants were 12,049 individuals from five survey waves of the International Tobacco Control Four Country Survey (interviewed between 2002 and 2006, and followed-up approximately one year later). Generalized estimating equation logistic regression analysis was used, enabling us to control for within participant correlations due to possible multiple responses by the same individual over different survey waves. The frequency of micro indicators predicted making quit attempts, with premature stubbing out, forgoing, and thinking about the harms to oneself of smoking being particularly strong predictors. An interaction effect with expressed intention to quit was observed, such that stubbing out and thinking about the harms on oneself predicted quit attempts more strongly among smokers with no expressed plans to quit. In contrast, there was a negative association between some micro indicators and sustained abstinence, with more frequent stubbing out, forgoing, and thinking about money spent on cigarettes associated with a reduced likelihood of subsequently achieving sustained abstinence. In countries with long-established tobacco control programs, micro indicators index both high motivation by smokers to do something about their smoking at least partly independent of espoused intention and, especially those indicators not part of a direct pathway to quitting, reduced capacity to quit successfully.

Citation

Abdullah, A.S., Driezen, P., Sansone, G.C., Nargis, N., Hussain, A.K.M.G., Quah, A.C.K., Fong, G.T. (2014). Correlates of exposure to secondhand smoke (SHS) at home among non-smoking adults in Bangladesh: Findings from the International Tobacco Control (ITC) Bangladesh Survey. BioMed Central Pulmonary Medicine, 14, 117-127.

Abstract

Background: Exposure to secondhand smoke (SHS) is a serious global public health problem. Understanding the correlates of SHS exposure could guide the development of evidence based SHS exposure reduction interventions. The purpose of this study is to describe the pattern of and factors associated with SHS exposure among non-smoking adults in Bangladesh.

Methods: Data come from adult non-smokers who participated in the second wave (2010) of the International Tobacco Control Policy (ITC) Evaluation Bangladesh Survey conducted in all six administrative divisions of Bangladesh. A structured questionnaire gathered information on participants' demographic characteristics, pattern of SHS exposure, SHS knowledge, and attitudes towards tobacco control. Exposure to SHS at home was defined as non-smokers who lived with at least one smoker in their household and who reported having no home smoking ban. The data were analyzed using chi-square tests and logistic regression procedures.

Results: The SHS exposure rate at home among the participants (N = 2813) was 43%. Several sociodemographic and attitudinal factors were associated with SHS exposure. Logistic regression analyses identified eight predictors of SHS exposure: being female (OR = 2.35), being aged 15-24 (OR = 2.17), being recruited from Dhaka slums (OR = 5.19) or non-tribal/non-border areas outside Dhaka (OR = 2.19) or tribal/border area (OR = 4.36), having lower education (1-8 years: OR = 2.45; illiterate: OR = 3.00, having higher monthly household income (5000 to <10,000 Taka: OR = 2.34; 10,000 Taka or more: OR = 2.28), having a father who smoked in the past or currently smokes (OR = 2.09), having lower concern about the harms of tobacco on children (unconcerned OR = 3.99; moderate concern OR = 2.26), and not knowing the fact that SHS causes lung cancer in non-smokers (OR = 2.04).

Conclusions: Almost half of non-smoking Bangladeshi adults are exposed to SHS at home. The findings suggest the need for comprehensive tobacco control measures that would improve public understanding about health hazards of SHS exposure at home and encourage educational initiatives to promote smoke-free homes. Interventions should deliver targeted messages to reach those in the low socioeconomic status group.

Citation

Hall, P.A., Fong, G.T., Meng, G. (2014). Time perspective as a determinant of smoking cessation in four countries: Direct and mediated effects from the International Tobacco Control (ITC) 4-Country Surveys. Addictive Behaviours, 39(7), 1183-1190.

Abstract

Background: Future oriented time perspective predicts a number of important health behaviors and outcomes, including smoking cessation. However, it is not known how future orientation exerts its effects on such outcomes, and no large scale cross-national studies have examined the question prospectively. The aim of the current investigation was to examine the relationship between time perspective and success in smoking cessation, and social cognitive mediators of the association.

Methods: The ITC-4 is a multi-wave, four country survey (Australia, Canada, United States, United Kingdom) of current smokers (N=9772); the survey includes baseline measurements of time perspective, intentions, quit attempts, and self-reported quit status at follow-up over 8years. We examined the predictive power of time perspective for smoking cessation, as mediated through strength of quit intentions and prior history of quit attempts.

Results: Findings indicated that those smokers with a stronger future orientation at baseline were more likely to have successfully quit at follow-up. This effect was partially explained by intention-mediated effects of future orientation on quit attempts. CONCLUSIONS: Future orientation predicts smoking cessation across four English-speaking countries; the cessation-facilitating effects of future orientation may be primarily due to future oriented individuals' motivated and sustained involvement in the quit cycle over time.

Citation

Hitchman, S.C., Fong, G.T., Zanna, M.P., Thrasher, J.F., Laux, F. (2014). The relation between number of smoking friends, and quit intentions, attempts, and success: Findings from the International Tobacco Control (ITC) Four Country Survey. Psychology of Addictive Behaviours, 28(4), 1144-1152.

Abstract

Smokers who inhabit social contexts with a greater number of smokers may be exposed to more positive norms toward smoking and more cues to smoke. This study examines the relation between number of smoking friends and changes in number of smoking friends, and smoking cessation outcomes. Data were drawn from Wave 1 (2002) and Wave 2 (2003) of the International Tobacco Control (ITC) Project Four Country Survey, a longitudinal cohort survey of nationally representative samples of adult smokers in Australia, Canada, United Kingdom, and United States (N = 6,321). Smokers with fewer smoking friends at Wave 1 were more likely to intend to quit at Wave 1 and were more likely to succeed in their attempts to quit at Wave 2. Compared with smokers who experienced no change in their number of smoking friends, smokers who lost smoking friends were more likely to intend to quit at Wave 2, attempt to quit between Wave 1 and Wave 2, and succeed in their quit attempts at Wave 2. Smokers who inhabit social contexts with a greater number of smokers may be less likely to successfully quit. Quitting may be particularly unlikely among smokers who do not experience a loss in the number of smokers in their social context.

Citation

Green, A., Kaai, S.C., Fong, G.T., Driezen, P., Quah, A.C.K., Burhoo, P. (2014). Investigating the effectiveness of graphic health warnings in Mauritius: Findings from the International Tobacco Control (ITC) Mauritius Survey. Nicotine & Tobacco Research, 16(9), 1240-1247.

Abstract

Introduction: Health warnings on tobacco packages are an effective strategy to inform the public about the harms associated with tobacco use. Most studies investigating the effectiveness of pictorial health warnings (PHWs) on cigarette packages are from high-income countries. This study evaluated the impact of PHWs on smokers’ perceptions and behavior in Mauritius, the first country in the World Health Organization African region to implement PHWs.

Methods: Data were drawn from 3 waves of a nationally representative cohort of adult smokers from the International Tobacco Control (ITC) Mauritius Survey (n = 668). Wave 1 was conducted in 2009, six months prior to the implementation of PHWs. Waves 2 and 3 were conducted 10–12 months and 20–21 months, respectively, post implementation. Six established indicators of warning effectiveness were used to evaluate the effect of PHWs on smokers’ perceptions and behavior.

Results: All indicators of warning effectiveness (salience, cognitive, and behavioral reactions) and the Label Impact Index, a weighted combination of 4 indicators, increased significantly between Waves 1 and 2. However, between Waves 2 and 3, there was a significant decline in the proportion of smokers reporting “avoiding looking” at labels.

Conclusions: This study found that implementation of PHWs in Mauritius significantly enhanced the effectiveness of warnings, illustrating their value for other countries, particularly in Africa, at an early stage in tobacco control. The study also demonstrates the importance of revising PHWs to counteract wearout. The introduction of PHWs in Mauritius clearly demonstrates the benefits of employing an evidence-based approach to strengthen tobacco control policies.

Citation

Huang, J., Zheng, R., Chaloupka, F., Fong, G.T., Li, Q., Jiang, Y. (2014). Chinese smokers' cigarette purchase behaviours, cigarette prices and consumption: Findings from the ITC China Survey. Tobacco Control, 23(Suppl 1), i67-i72.

Abstract

Background: While cigarette purchasing behaviour has been shown to be linked with certain tobacco use outcomes such as quit intentions and quit attempts, there have been very few studies examining cigarette purchasing behaviours and their impact on cigarette price and consumption in China, the world's largest cigarette consumer.

Objective: The aim of the present study was to examine the extent and determinants of cost/price-related purchase behaviours, and estimate the impact of these behaviours on cigarette prices paid by Chinese smokers. It also assesses the socioeconomic differences in compensatory purchase behaviours, and examines how they influence the relationship between purchase behaviours, cigarette prices and cigarette consumption.

Methods: Multivariate analyses using the general estimating equations method were conducted using data from the International Tobacco Control China Survey (the ITC China Survey), a longitudinal survey of adult smokers in seven cities in China: Beijing, Changsha, Guangzhou, Kunming, Shanghai, Shenyang and Yinchuan. In each city, about 800 smokers were surveyed in each wave. The first three waves-wave 1 (conducted between March to December 2006), wave 2 (November 2007 to March 2008) and wave 3 (May to October 2009 and February to March 2010)-of the ITC China Survey data were used in this analysis. Various aspects of smokers' self-reported price/cost-related cigarette purchasing behaviours were analysed.

Results: Nearly three-quarters (72%) of smokers surveyed indicated that a major reason they chose their most-used cigarette brand was its low cost/price. Almost half (50.6%) of smokers reported buying in cartons in their most recent cigarette purchase. Smokers with lower income and/or low levels of education were more likely to choose a brand because of its low cost/price. However, those with higher income and/or high levels of education were more likely to buy cartons. Gender and age were also related to type of purchase behaviours. Those behaviours led to reductions in purchase prices. The price savings ranged from ¥0.54 to ¥1.01 per pack of cigarettes, depending on the behaviour examined, representing a price reduction of 8% to 15%.

Conclusions: A significant portion of Chinese urban adult smokers engaged in cost/price-reducing purchase behaviours. Such behaviours reduce cigarette purchase prices and are associated with increased cigarette consumption. Smokers of different socioeconomic status engaged in different purchase behaviours to mitigate the impact of higher cigarette prices. Reducing tobacco use through raising tobacco taxes/prices in China needs to take into account these cost/price-reducing behaviours.

Citation

Shang, C., Chaloupka, F., Zahra, N., Fong, G.T. (2014). The distribution of cigarette prices under different tax structures: Findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 23(Suppl 1), i23-i29.

Abstract

Background: The distribution of cigarette prices has rarely been studied and compared under different tax structures. Descriptive evidence on price distributions by countries can shed light on opportunities for tax avoidance and brand switching under different tobacco tax structures, which could impact the effectiveness of increased taxation in reducing smoking.

Objective: This paper aims to describe the distribution of cigarette prices by countries and to compare these distributions based on the tobacco tax structure in these countries.

Methods: We employed data for 16 countries taken from the International Tobacco Control Policy Evaluation Project to construct survey-derived cigarette prices for each country. Self-reported prices were weighted by cigarette consumption and described using a comprehensive set of statistics. We then compared these statistics for cigarette prices under different tax structures. In particular, countries of similar income levels and countries that impose similar total excise taxes using different tax structures were paired and compared in mean and variance using a two-sample comparison test.

Findings: Our investigation illustrates that, compared with specific uniform taxation, other tax structures, such as ad valorem uniform taxation, mixed (a tax system using ad valorem and specific taxes) uniform taxation, and tiered tax structures of specific, ad valorem and mixed taxation tend to have price distributions with greater variability. Countries that rely heavily on ad valorem and tiered taxes also tend to have greater price variability around the median. Among mixed taxation systems, countries that rely more heavily on the ad valorem component tend to have greater price variability than countries that rely more heavily on the specific component. In countries with tiered tax systems, cigarette prices are skewed more towards lower prices than are prices under uniform tax systems. The analyses presented here demonstrate that more opportunities exist for tax avoidance and brand switching when the tax structure departs from a uniform specific tax.

Citation

Edwards, R. (2014). Roll your own cigarettes are less natural and at least as harmful as factory rolled tobacco. British Medical Journal, 348, 7616.

Abstract

Poorer smokers may favour “roll your own” and many falsely believe that use of loose tobacco is less dangerous than factory made cigarettes, writes Richard Edwards. Specific interventions may be needed to encourage such smokers to quit.

Citation

White, J.S., Li, J., Hu, T.W., Fong, G.T., Jiang, Y. (2014). The effect of cigarette prices on brand-switching in China: A longitudinal analysis of data from the ITC China Survey. Tobacco Control, 23(Suppl 1), i54-i60.

Abstract

Background: Recent studies have found that Chinese smokers are relatively unresponsive to cigarette prices. As the Chinese government contemplates higher tobacco taxes, it is important to understand the reasons for this low response. One possible explanation is that smokers buffer themselves from rising cigarette prices by switching to cheaper cigarette brands.

Objective: This study examines how cigarette prices influence consumers’ choices of cigarette brands in China.

Methods: This study uses panel data from the first three waves of the International Tobacco Control China Survey, drawn from six large cities in China and collected between 2006 and 2009. The study sample includes 3477 smokers who are present in at least two waves (8552 person-years). Cigarette brands are sorted by price into four tiers, using excise tax categories to determine the cut-off for each tier. The analysis relies on a conditional logit model to identify the relationship between price and brand choice.

Findings: Overall, 38% of smokers switched price tiers from one wave to the next. A ¥1 change in the price of cigarettes alters the tier choice of 4–7% of smokers. Restricting the sample to those who chose each given tier at baseline, a ¥1 increase in price in a given tier would decrease the share choosing that tier by 4% for Tier 1 and 1–2% for Tiers 2 and 3.

Conclusions: China's large price spread across cigarette brands appears to alter the brand selection of some consumers, especially smokers of cheaper brands. Tobacco pricing and tax policy can influence consumers’ incentives to switch brands. In particular, whereas ad valorem taxes in a tiered pricing system like China's encourage trading down, specific excise taxes discourage the practice.

Citation

Rennen, E., Nagelhout, G.E., van den Putte, B., Janssen, E., Mons, U., Guignard, R., Beck, F., de Vries, H., Thrasher, J.F., Willemsen, M.C. (2014). Associations between tobacco control policy awareness, social acceptability of smoking and smoking cessation: findings from the International Tobacco Control (ITC) Europe Surveys. Health Education Research, 29(1), 72-82.

Abstract

This study examined whether awareness of tobacco control policies was associated with social unacceptability of smoking and whether social unacceptability had an effect on smoking cessation in three European countries. Representative samples (n = 3865) of adult smokers in France, the Netherlands and Germany were used from two survey waves of the longitudinal International Tobacco Control Europe Surveys. Associations were examined of aspects of social unacceptability of smoking (i.e. feeling uncomfortable, important people disapproval and societal disapproval) with tobacco policy awareness (i.e. awareness of warning labels, anti-tobacco information and smoking restrictions at work) and smoking cessation. Only the positive association of awareness of anti-tobacco information with feeling uncomfortable about smoking was significant in each of the three countries. Important people disapproval predicted whether smokers attempted to quit, although this did not reach significance in the French and German samples in multivariate analyses. Our findings suggest that anti-tobacco information campaigns about the dangers of second-hand smoke in France and about smoking cessation in the Netherlands and Germany might have reduced the social acceptability of smoking in these countries. However, campaigns that influence the perceived disapproval of smoking by important people may be needed to ultimately increase attempts to quit smoking.

Citation

Fix, B.V., Hyland, A., O’Connor, R.J., Cummings, K.M., Fong, G.T., Chaloupka, F., Licht, A.S. (2014). A novel approach to estimating the prevalence of untaxed cigarettes in the USA: Findings from the 2009 and 2010 International Tobacco Control Surveys. Tobacco Control, 23(Suppl 1), i61-i66.

Abstract

Background: Increases in tobacco taxes are effective in reducing tobacco consumption, but because of the addictive nature of cigarettes, smokers often seek out less expensive sources of cigarettes. The objective of this study is to estimate the prevalence of cigarette packs that are untaxed by the state in which the participant resides in a sample of US smokers at two time points.

Methods: Data for this study were taken from the 2009 and 2010 waves of the International Tobacco Control United States Survey. Members of this nationally representative cohort of smokers were invited to send us an unopened pack of their usual brand of cigarettes.

Results: In 2009, 318 packs were received from 401 eligible participants (79%). In 2010, 366 packs were received from 491 eligible participants (75%). In total, 20% of the packs in 2009 and 21% in 2010 were classified as untaxed by the participant's state of residence. The prevalence of untaxed cigarettes was higher in states with higher-excise taxes. Smokers who do not have a plan to quit were significantly more likely to have sent back a pack that was classified as untaxed by the participant's state of residence.

Conclusions: One in five packs were untaxed with rates higher in states with higher-excise taxes. It is unclear whether these estimates differ from the actual prevalence of cigarettes that are untaxed by a smoker's state of residence. Harmonisation of excise tax rates across all 50 US states might be one method of reducing or eliminating the incentive to avoid or evade these taxes.