Citation

Hammond, D., Wadsworth, E., Reid, J., Burkhalter, R. (2021). Prevalence and modes of cannabis use among youth in Canada, England, and the US, 2017 to 2019. Drug and Alcohol Dependence, 219, 108505.

Abstract

Objective: Cannabis markets are evolving in terms of greater diversity and potency of products. The current study examined changes in cannabis use and modes of consumption among 16- to 19-year-olds in three markets with different regulatory frameworks: England, Canada, and the United States (US).

Methods: Repeat cross-sectional online surveys were conducted in 2017, 2018, and 2019, with samples of 16- to 19-year-olds recruited from commercial panels in Canada (n = 11,779), England (n = 11,117), and the US (n = 11,869). Regression models examined changes in the prevalence of any cannabis use and use of seven modes of consumption, across the countries.

Results: Cannabis use among youth was more prevalent among respondents in Canada and the US than in England in all years and increased to a greater extent between 2017 and 2019 (p < .001 for all contrasts). Among past 30-day cannabis consumers, the prevalence of vaping oils/liquids and the use of cannabis extracts (oil, wax and shatter) increased in all countries, and was significantly higher in Canada and US. For example, the prevalence of vaping oils/liquids increased from 24.2 % in 2017 to 52.1 % in 2019 among past 30-day cannabis consumers in the US (AOR = 3.46, 95 %CI = 2.57-4.66).

Conclusion: Prevalence is increasing for the most potent categories of cannabis products, particularly among youth in Canada and the US. Future research should examine the potential risks of these products and whether shifts in modes of cannabis reflect recent permissive changes to cannabis policy.

Citation

Hammond, D., Reid, J., Rynard, V.L., O’Connor, R.J., Goniewicz, M., McNeill, A., Piper, M.E., Bansal-Travers, M. (2021). Indicators of dependence and efforts to quit vaping and smoking among youth in Canada, England, and the United States. Tobacco Control, [Published online February 1, doi: 10.1136/tobaccocontrol-2020-056269].

Abstract

Objective: The current study examined indicators of dependence among youth cigarette smokers and e-cigarette users in Canada, England and the USA, including changes between 2017 and 2019.

Methods: Data are from repeated cross-sectional online surveys conducted in 2017, 2018 and 2019 with national samples of youth aged 16-19 years, in Canada (n=12 018), England (n=11 362) and the USA (n=12 110). Measures included perceived addiction to cigarettes/e-cigarettes, frequency of experiencing strong urges to smoke/use an e-cigarette, plans to quit smoking/using e-cigarettes and past attempts to quit. Logistic regression models were fitted to examine differences between countries and changes over time.

Results: The proportion of ever-users who vaped frequently was significantly higher in 2019 compared with 2017 for all outcomes in each country. Between 2017 and 2019, the proportion of past 30-day vapers reporting strong urges to vape on most days or more often increased in each country (Canada: 35.3%, adjusted OR (AOR) 1.69, 95% CI 1.20 to 2.38; England: 32.8%, AOR 1.55, 1.08 to 2.23; USA: 46.1%, AOR 1.88, 1.41 to 2.50), along with perceptions of being 'a little' or 'very addicted' to e-cigarettes (Canada: 48.3%, AOR 1.99, 1.44 to 2.75; England: 40.1%, AOR 1.44, 1.03 to 2.01; USA: 53.1%, AOR 1.99, 1.50 to 2.63). Indicators of dependence among smokers were consistently greater than e-cigarette users, although differences had narrowed by 2019, particularly in Canada and the USA.

Conclusions: Prevalence of dependence symptoms among young e-cigarette users increased between 2017 and 2019, more so in Canada and the USA compared with England. Dependence symptom prevalence was lower for e-cigarettes than smoking; however, the gap has narrowed over time.

Citation

Levy, D., Sanchez-Romero, L.M., Douglas, C.E., Sweanor, D. (2021). An analysis of the Altria-Juul labs deal: Antitrust and public health implications. Journal of Competition Law and Economics, [Published online January 23, doi: doi.org/10.1093/joclec/ nhaa033].

Abstract

On December 19, 2018, Altria announced an offer of $12.8 billion for Juul Labs, combining the largest U.S. cigarette manufacturer with the largest U.S. e-cigarette company. This deal is currently being challenged by the Federal Trade Commission (FTC). We consider the antitrust implications. We also consider population health implications, which we argue are essential to a comprehensive analysis of the impact on consumers. Although the FTC antitrust investigation has focused on closed vaping systems, we argue that the relevant market is the broader nicotine delivery product market, which includes all vaping products along with tobacco products. With Altria having a large market share in the key nicotine delivery product submarkets and with important entry barriers, the merger potentially places Altria in a dominant position in the relevant market. In particular, competition in the vaping submarket is reduced, thereby likely to reduce the availability of less harmful alternatives to cigarettes.

Citation

Le Grande, M., Borland, R., Yong, H.H., Cummings, K.M., McNeill, A., Thompson, M.E., Fong, G.T. (2021). Predictive power of dependence measures for quitting smoking: Findings from the 2016-2018 ITC Four Country Smoking and Vaping Surveys. Nicotine and Tobacco Research, 23(2), 276-285.

Abstract

Objective: To test whether urges to smoke and perceived addiction to smoking, have independent predictive value for quit attempts and short-term quit success over and above the Heaviness of Smoking Index (HSI). Methods: Data were from the International Tobacco Control Four Country Smoking and Vaping Wave 1 (2016) and Wave 2 (2018) surveys. 3661 daily smokers (daily vapers excluded) provided data in both waves. A series of multivariable logistic regression models assessed the association of each dependence measure on odds of making a quit attempt and ≥1 month smoking abstinence.

Results: Of the 3661 participants, 1594 (43.5%) reported a quit attempt. Of those who reported a quit attempt, 546 (34.9%) reported short-term quit success. Fully adjusted models showed that making quit attempts was associated with lower HSI [adjusted odds ratio (aOR) = 0.81, 95% confidence interval (CI) = 0.73-0.90, P < 0.001), stronger urges to smoke (aOR = 1.08, 95% CI = 1.04-1.20, P = 0.002), and higher perceived addiction to smoking (aOR =0.52, 95% CI 0.32-0.84, P =0.008). Lower HSI (aOR = 0.57, 95% CI = 0.40–0.87, P < 0.001) weaker urges to smoke (aOR = 0.85, 95% CI = 0.76–0.95, P = 0.006), and lower perceived addiction to smoking (aOR = 0.55, 95% CI =0.32-0.91, P = 0.021) were associated with greater odds of short-term quit success. In both cases overall R2 was around 0.5.

Conclusions: The two additional dependence measures were complementary to HSI adding explanatory power to smoking cessation models, but variance explained remains small.

Implications: Strength of urges to smoke and perceived addiction to smoking may significantly improve prediction of cessation attempts and short-term quit success over and above routinely assessed demographic variables and the HSI. Stratification of analyses by age group is recommended since the relationship between dependence measures and outcomes differ significantly for younger (age 18-39) compared to older (age over 40) participants. Even with the addition of these extra measures of dependence, the overall variance explained in predicting smoking cessation outcomes remains very low. These measures can only be thought of as assessing some aspects of dependence. Current understanding of the factors that ultimately determine quit success remains limited.

Citation

East, K., Hitchman, S.C., McNeill, A., Ferguson, S., Yong, H.H., Cummings, K.M., Fong, G.T., Borland, R. (2021). Trends in social norms towards smoking between 2002 and 2015 among daily smokers: Findings from the International Tobacco Control Four Country Survey (ITC 4C). Nicotine and Tobacco Research, 23(1), 203-211. doi: 10.1093/ntr/ntz179

Abstract

Objective: To assess trends in daily smokers’ social norms and opinions of smoking between 2002 and 2015 in Canada, US, UK and Australia.

Method: Data were from Waves-1 (2002) to -9 (2013-2015) of the longitudinal International Tobacco Control Four Country Survey (Canada, US, UK, Australia), involving 23,831 adult daily smokers. Generalised estimating equation logistic regression models, adjusted for demographics and survey design effects, assessed associations of Wave and country with outcomes: (i) over half of five closest friends smoke, (ii) agreeing that people important to you believe you should not smoke, (iii) agreeing that society disapproves of smoking, and (iv) negative opinion of smoking.

Results: Between 2002 and 2015, adjusting for covariates, (i) over half of five closest friends smoke did not change (56% vs. 55%; Adjusted Odds Ratio [AOR]=0.95[95% Confidence Interval=0.85-1.07]), (ii) agreeing that people important to you believe you should not smoke generally decreased (89% vs. 82%; AOR=0.54[0.46-0.64]) despite an increase around 2006-2007, (iii) agreeing that society disapproves of smoking increased between 2002 and 2006-2007 (83% vs. 87%; AOR=1.38[1.24-1.54]) then decreased until 2013-2015 (78%; AOR=0.74[0.63-0.88]), and (iv) negative opinion of smoking decreased between 2002 and 2010-2011 (54% vs. 49%; AOR=0.83[0.75-0.91]) despite an increase around 2005-2006 and at the final Wave (2013-2015). Except friend smoking, Canada had the greatest, and UK the lowest, anti-smoking social norms and opinions.

Conclusions: Except friend smoking and opinion of smoking, daily smokers’ social norms became less anti-smoking between 2002 and 2015 despite increases around 2006-2007. Several potential explanations are discussed yet remain undetermined.

Implications: Increasingly comprehensive tobacco control policies alongside decreasing smoking prevalence in Canada, the US, the UK, and Australia have led to the assumption that smoking has become increasingly denormalised in these countries. Absent from the literature is any formal assessment of social norms towards smoking over time. Contrary to our hypotheses, this study found that the injunctive social norms of daily smokers became less anti-smoking between 2002 and 2015, despite increases around 2006-2007. There was no change over time in the proportion of daily smokers who report that over half of their five closest friends smoke.

Citation

Callaghan, L., Yong, H., Borland, R., Cummings, K.M., Hitchman, S., Fong, G.T. (2021). What kind of smoking identity following quitting would elevate smokers relapse risk? Addictive Behaviors, 112(2021), 106654.

Abstract

Background: Research has suggested that smokers who quit smoking and continue to identify themselves as a smoker versus a non-smoker are at greater risk of relapse. This study examines the relationship between post-quit smoker identities and relapse risk of former smokers in Australia and the UK comparing those who still identified as a smoker with firm choice to no longer smoke versus those not expressing a firm choice. Cross-country differences were examined.

Methods: Data analysed came from 544 former smokers (quit 1 month or more) who participated in the Australian and UK Waves 9 (2013) and 10 (2014) of the International Tobacco Control (ITC) surveys. Post-quit smoker identities were assessed at baseline and smoking relapse at follow-up.

Results: Baseline self-reported smoker identity independently predicted smoking relapse at 12-month follow-up (p < .01). Compared with the subgroup who identified themselves as smokers trying to quit, those who identified themselves as smokers who had chosen to no longer smoke (OR = 0.01, 95% CI = 0.01-0.25, p < .001), ex-smokers (OR = 0.05, CI = 0.01-0.25, p < .001) or non-smokers (OR = 0.07, CI = 0.02-0.37, p < .001) were less likely to relapse at follow-up. No cross-country differences were found.

Conclusions: Following quitting, smokers who maintained a smoker identity with a firm choice to no longer smoke or adopted a non-smoker or ex-smoker identity were less likely to relapse than those who failed to do so, suggesting that a clear rule/commitment to not smoke and/or a shift to a non-smoking identity may be protective of relapse.

Citation

Cheng, K.-W., Shang, C., Lee, H.M., Chaloupka, F.J., Fong, G.T., Borland, R., Heckman, B.W., Hithchman, S.C., O’Connor, R.J., Levy, D.T., Cummings, K.M. (2021). Costs of vaping: Evidence from ITC Four Country Smoking and Vaping Survey. Tobacco Control, 30, 94-97.

Abstract

Study objectives: To compare the prices paid for nicotine vaping products (NVPs) and supplies among current NVP users to prices paid for cigarettes among current smokers.

Data: The 2016 International Tobacco Control Four Country Vaping and Smoking Survey (4CV1). Key measures included: (1) self-reported prices paid for reusable NVPs (eg, rechargeable devices with cartridges and tank system devices with e-liquids) in the 3-month period prior to the survey among current NVP users, (2) prices paid for disposable NVPs, cartridges and e-liquids purchased in the last 30 days among current NVP users and (3) self-reported prices paid for cigarettes among current smokers.

Results: Disposable NVP price was higher than the price of a comparable unit for combustible cigarettes in England (EN), USA and Canada (CA). Prefilled cartridge price was higher than the price of a comparable unit of cigarettes in USA and CA, but lower in EN and Australia. E-liquid price was consistently lower than the price of a comparable unit of cigarettes across four countries. For start-up costs, price of a rechargeable device is approximately 3–5 times higher than a pack of cigarettes in four countries.

Conclusion: NVP prices were generally higher than prices of combustible cigarettes, especially the high upfront NVP devices. The high upfront costs of purchasing a reusable NVP may discourage some smokers from switching to vaping. However, the average lower costs of cartridges and e-liquids relative to a package of cigarettes make switching to a NVP an attractive alternative to smoking in the long term so long as smokers switch completely to vaping.

Citation

Yong, H.H., Karmakar, C., Kusmakar, S., Borland, R., Cummings, K.M., Fong, G.T., McNeill, A. (2021). Identifying factors that conjointly influence nicotine vaping product relative harm perception among smokers and recent ex-smokers: Findings from the 2016 ITC Four Country Smoking and Vaping Survey. Drug and Alcohol Dependence, 218, 108370.

Abstract

Background: Use of nicotine vaping products (NVPs) to replace smoking is often influenced by perceived harmfulness of these products relative to smoking. This study aimed to identify factors that conjointly influenced NVP relative harm perception among smokers and ex-smokers.

Methods: Data (n = 11,838) from adult smokers and ex-smokers (quit < 2 years) who participated in the 2016 ITC 4 Country Smoking and Vaping Surveys in Australia, Canada, England and the US were analyzed. Decision tree models were used to classify respondents into those who perceived vaping as less harmful than smoking (correct perception) versus otherwise (incorrect perception) based on their socio-demographic, smoking and vaping related variables.

Results: Decision tree analysis identified nicotine replacement therapy (NRT) harmfulness perceptions relative to smoking, perceived vaping portrayal in the media and other sources as positive, negative or balanced, recency of seeking online vaping information, and age as the key variables that interacted conjointly to classify respondents into those with correct versus incorrect harm perceptions of vaping relative to smoking (model performance accuracy = 0.70-0.74). In all countries, NRT relative harmfulness perception and vaping portrayal perception were consistently the two most important classifying variables, with other variables showing some country differences.

Conclusions: In all four countries, perception of NVP relative harmfulness among smokers and recent ex-smokers is strongly influenced by a combination of NRT relative harmfulness perception and vaping portrayal in the media and other sources. These conjoint factors can serve as useful markers for identifying subgroups more vulnerable to misperception about NVP relative harmfulness to benefit from corrective intervention.

Citation

Levy, D. T., Sweanor, D., Sanchez-Romero, L. M., O'Connor, R., Goniewicz, M. L., & Borland, R. (2020). Altria-Juul Labs deal: why did it occur and what does it mean for the US nicotine delivery product market. Tobacco control, 29(e1), e171-e174.

Citation

Meza, R., Jimenez-Mendoza, E, Levy, D. (2020). Trends in tobacco use among adolescents by grade, sex and race, 1991-2019. JAMA Network Open, 3(12), e2027465.

Abstract

Importance Use of e-cigarettes increased among adolescents between 2011 and 2019. However, whether these changes are affecting patterns of use of other tobacco products, especially cigarettes, remains unclear.

Objective To examine the long-term and recent trends in cigarette smoking and smokeless tobacco product use among US adolescents by grade (8th, 10th, and 12th), sex (male and female), and race (White and Black).

Design, Setting, and Participants In this cross-sectional study, joinpoint regression analyses were performed to characterize trends in tobacco product use for key sociodemographic groups, identifying change of trend years (joinpoints). Students in the 8th, 10th, and 12th grades at US secondary schools and high schools who participated in the nationally representative Monitoring the Future survey from January 7, 1991, to June 3, 2019, were evaluated.

Exposures Cigarette smoking and smokeless tobacco product use during the past 30 days.

Main Outcomes and Measures Past 30-day and daily prevalence of cigarette smoking and smokeless tobacco product use by year, grade, sex, and race. The prevalence trend segments, change of trend years (joinpoints), and annual percentage change (APC) in prevalence within each trend segment were estimated using joinpoint regression.

Results Since 1991, 487 335 8th-grade, 447 310 10th-grade, and 424 236 12th-grade students have completed the Monitoring the Future survey (including 663 663 girls and 632 698 boys [those who did not respond to the sex question in the survey were excluded from the sex analyses]). Past 30-day and daily smoking prevalence increased in all groups analyzed from 1991 until 1996 and 1997 and has been decreasing ever since, with more rapid reductions in recent years. For example, daily smoking among 12th-grade boys increased at an APC of 4.9% (95% CI, 3.5%-6.3%) from 1991 to 1998, decreased at an APC of −8.0% (95% CI, –9.3% to –6.7%) from 1998 to 2006, decreased at an APC of −1.6% (95% CI, –4.6% to 1.5%) from 2006 to 2012, and decreased at an APC of −17.4% (95% CI, –19.4% to –15.4%) from 2012 to 2019. Similar results were observed for boys in the 8th grade (5.0% [95% CI, 0.1%-10.2%] for 1991-1996, –8.8% [95% CI, –10.0% to –7.6%] for 1996-2011, and –17.3% [95% CI, –22.2% to –12.0%] for 2011-2019) and 10th grade (7.1% [95% CI, 3.7%-10.7%] for 1991-1997, –11.1% [95% CI, –13.9% to –8.2%] for 1997-2005,–0.7% [95% CI, –5.9% to 4.9%] for 2005-2011, and −17.9 [95%, –21.7% to –13.9%] for 2011-2019), for girls in 8th grade (10.9% [95% CI, 5.0%-17.2%] for 1991-1996 and –10.8% [95% CI, –11.7% to –10.0% for 1996-2019), 10th grade (7.2% [95% CI, 3.9%-10.7%] for 1991-1997, –9.5% [95% CI, –10.5% to –8.6%] for 1997-2012, and –16.3% [95% CI, –21.8% to –10.4%] for 2012-2019), and 12th grade (6.5% [95% CI, 3.6%-9.5%] for 1991-1997, –7.2% [95% CI, –8.1% to –6.3%] for 1997-2012, and –17.5% [95% CI, –21.2% to –13.6%] for 2012-2019). Results were similar, too, for Black adolescents (2015-2019 average annual percentage change: –8.6% [95% CI, –10.3% to –6.8%] for 8th graders; –17.7% [95% CI, –26.3% to –8.2%] for 10th graders; and –18.3% [95% CI, –23.9% to –12.2%] for 12th graders) and White adolescents (2015-2019 average annual percentage change: –17.3% [95% CI, –20.6% to –13.7%] for 8th graders; –16.9% [95% CI, –20.5% to –13.2%] for 10th graders; and –17.0% [95% CI, –20.5% to –13.2%] for 12th graders). Smokeless tobacco was used more variably through 2012, followed by consistent decreases in the past 5 years. For instance, smokeless tobacco use in the past 30 days in 10th-grade boys decreased at an APC of –6.5% (95% CI, –7.5% to –5.4%) from 1991 to 2004, increased at an APC of 3.1% (95% CI, –0.8% to 7.1%) from 2004 to 2012, and decreased at an APC of –11.6% (95% CI, –15.7% to –7.4%) from 2012 to 2019. Similarly, daily smokeless tobacco use in 12th-grade boys decreased at an APC of –3.8% (95% CI, –5.4% to –2.1%) from 1992 to 2005, increased at an APC of 3.1% (95% CI, –0.2% to 6.5%) from 2005 to 2015, and decreased at an APC of –23.0% (95% CI, –33.3% to –11.0%) from 2015 to 2019.

Conclusions and Relevance This cross-sectional study suggests that, despite the increase in the prevalence of e-cigarette use among adolescents between 2011 and 2019, the prevalence of cigarette and smokeless tobacco use has decreased more rapidly during the same period compared with earlier years.

Citation

Driezen, P., Fong, G.T., Hyland, A., Craig, L., Sansone, G., Hitchman, S.C., Cummings, K.M. (2020). Self-reported exposure to secondhand smoke and support for complete smoking bans in multiunit housing among smokers from the United States, Canada, and the United Kingdom. Preventing Chronic Disease, 17, E147

Abstract

Introduction

Involuntary exposure to secondhand smoke most frequently occurs at home, which is problematic for residents of multiunit housing (MUH). The primary objective of this study was to estimate the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their homes but lived in buildings where smoking is allowed.

Methods

We used data from Wave 9 of the International Tobacco Control Four Country Survey. We estimated 1) the prevalence of complete smoking bans among smokers living in single-family homes vs MUH in the United States (n = 3,208), Canada (n = 1,592), and the United Kingdom (n = 1,403) from 2013 to 2015; 2) the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their units but lived in buildings that allow smoking; and 3) MUH smokers’ preferences for complete smoking bans in MUH. Weighted multivariable logistic regression estimated the country-specific adjusted prevalence of all outcomes.

Results

Overall, 53.0% of smokers living in single-family homes completely banned smoking in their homes, compared with 44.8% of smokers in MUH. Across all 3 countries, only 27.8% of MUH smokers reported that smoking was completely prohibited in their building. A similar percentage of MUH smokers who banned smoking in their home but lived in buildings allowing smoking reported a secondhand smoke incursion into their home in the United States (29.9%; 95% CI, 20.4%–41.5%), Canada (38.4%; 95% CI, 26.7%–51.6%), and the United Kingdom (24.7%; 95% CI, 15.7%–36.7%). Across all 3 countries, 36.1% (95% CI, 33.4%–38.9%) of smokers in MUH reported they preferred a complete smoking ban in all building areas.

Conclusion

A need remains to educate MUH operators and residents about the benefits of comprehensive smoke-free policies.

Citation

Craig, L., Yoshimi, I., Fong, G.T., Meng, G., Yan, M., Mochizuki, Y., Tabuchi, T., Thrasher, J.F., Xu, S.S., Quah, A.C.K., Ouimet, J., Sansone, G., Chung-Hall, J. (2020). Awareness of marketing of heated tobacco products and cigarettes and support for tobacco marketing restrictions in Japan: Findings from the 2018 International Tobacco Control (ITC) Japan Survey. International Journal of Environmental Research and Public Health, 17(22), 8418.

Abstract

Japan is one of the world's largest cigarette markets and the top heated tobacco product (HTP) market. No forms of tobacco advertising, promotion, and sponsorship (TAPS) are banned under national law, although the industry has some voluntary TAPS restrictions. This study examines Japanese tobacco users' self-reported exposure to cigarette and HTP marketing through eight channels, as well as their support for TAPS bans. Data are from the 2018 ITC Japan Survey, a cohort survey of adult exclusive cigarette smokers (n = 3288), exclusive HTP users (n = 164), HTP-cigarette dual users (n = 549), and non-users (n = 614). Measures of overall average exposure to the eight channels of cigarette and HTP advertising were constructed to examine differences in exposure across user groups and products. Dual users reported the highest exposure to cigarette and HTP advertising. Tobacco users (those who used cigarettes, HTPs, or both) reported higher average exposure to HTP compared to cigarette advertising, however non-users reported higher average exposure to cigarette compared to HTP advertising. Retail stores where tobacco or HTPs are sold were the most prevalent channel for HTP and cigarette advertising, reported by 30-43% of non-users to 66-71% of dual users. Non-users reported similar exposure to cigarette advertising via television and newspapers/magazines as cigarette smokers and dual users; however, advertising via websites/social media was lower among non-users and HTP users than among cigarette smokers and dual users (p < 0.05). Most respondents supported a ban on cigarette (54%) and HTP (60%) product displays in stores, and cigarette advertising in stores (58%).

Citation

Cummings, K.M., Ballin, S., Sweanor, D. (2020). The past is not the future in tobacco control. Preventive Medicine, [Published online, doi:10.1016/j.ypmed.2020.106183].

Abstract

In this paper we have attempted to identify missed opportunities to change the trajectory of smoking and smoking caused diseases in America over the past 100 years. Many of the missed opportunities identified are due to the actions of cigarette manufacturers who misled the public about the dangers of cigarette smoking, the addictiveness of nicotine, and the feasibility of providing lower risk alternative nicotine delivery products to addicted smokers. An important lesson learned from the past is that treating all tobacco/nicotine products as equivalently harmful is counterproductive to public health as it only serves to protect the most lethal nicotine product - cigarettes. Since 2000, the evolving marketplace of lower risk nicotine products combined with regulatory authority over tobacco products represents a new opportunity to dramatically transform the cigarette business in ways that were never imagined when the war on tobacco was raging decades ago. However, this requires embracing risk-proportionate regulation, taxation policies, and providing consumers with accurate public messaging on product relative risks. A regulatory framework based on sound science that encourages and rewards new or existing manufacturers to invest in consumer acceptable lower risk products to replace cigarettes needs to be encouraged. The past is indeed not the future in smoking control, but it may be difficult to escape the past unless a realignment of market forces and policies can be achieved.

Citation

Xu, S.S., Meng, G., Yan, M., Gravely, S., Quah, A.C.K., Ouimet, J., O’Connor, R.J., Sutanto, E., Yoshimi, I., Mochizuki, Y., Tabuchi, T., Fong, G.T. (2020). Reasons for regularly using heated tobacco products among adults current and former smokers in Japan: Findings from 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 17(21), 8030.

Abstract

The market growth of heated tobacco products (HTPs), such as IQOS, Ploom TECH, and glo, has increased dramatically in Japan since 2016. Little is known about the reasons why current and former smokers are using HTPs. The data for this cross-sectional study were from the 2018 (Wave 1) International Tobacco Control (ITC) Japan Survey, a national web-based survey of 4500 people, including 658 current HTP users, of whom 549 were concurrently smoking cigarettes and 109 were former smokers. The most common reasons for regularly using HTPs were: beliefs that HTP are less harmful than cigarettes to themselves (90.6%) or to others (86.7%), enjoyment (76.5%), and social acceptability (74.4%). About half of current smokers (55.1%) reported using HTPs because these products might help them quit smoking. However, a near-equal percentage (52.0%) of current smokers reported using HTPs to replace some of the cigarettes they smoked so that they did not have to give up smoking altogether. If smokers are using HTPs to complement rather than quit their smoking, then the harm reduction potential of HTPs suggested by the toxicity studies will be diminished.

Citation

Taylor, E., East, K., McNeill, A., Cummings, K.M., Thrasher, J.F., Fong, G.T., Quah, A.C.K., McDermott, M., Li, G., Borland, R., Hammond, D., Aleyan, S., Hitchman, S.C. (2020). Changes in responses to nicotine vaping product warnings and leaflets in England compared with Canada, the US, and Australia: Findings from the 2016-2018 ITC Four Country Smoking and Vaping Surveys. Tobacco Control, [Published online, doi:http://dx.doi.org/10.1136/tobaccocontrol-2020-055739].

Abstract

Background and aims:

In May 2017, black-and-white text nicotine addiction warning labels ('warnings') and health and safety leaflets ('leaflets') became mandatory for nicotine vaping products (NVPs) in England, in accordance with the European Union's Tobacco Products Directive. We compared changes over time in noticing warnings and leaflets, recall of warnings about nicotine and concerns about using NVP due to noticing warnings in England, compared with Canada, the US and Australia, where no warnings and leaflets were mandated.

Design:

19005 adult (aged 18+) NVP users, smokers and quitters of cigarettes and NVP from the 2016 and 2018 International Tobacco Control Four Country Smoking and Vaping Surveys in England, Canada, the US and Australia, recruited via probability and non-probability sampling.

Findings:

Noticing warnings increased in England from 4.9% (2016) to 9.4% (2018) (adjusted OR/AOR=1.64, 95% CI=1.15-2.36); this change was larger than changes in Canada (AOR=2.51, 95% CI=1.71-3.69) and the US (AOR=2.22, 95% CI=1.45-3.39). Recall of a nicotine warning increased in England from 86% (2016) to 94.9% (2018) (AOR=5.50, 95% CI=1.57-19.27) but not significantly elsewhere. Noticing leaflets increased in England from 14.6% (2016) to 19.1% (2018) (AOR=1.42, 95% CI=1.15-1.74); this change was larger than in Canada (AOR=1.42, 95% CI=1.12-1.79), the US (AOR=1.55, 95% CI=1.17-2.06) and Australia (AOR=1.51, 95% CI=1.02-2.22). Among those noticing warnings, concern about NVP use did not change significantly between 2016 and 2018 (all countries p>0.081).

Conclusions:

Introduction of mandatory NVP warnings and leaflets in England was associated with small increases in noticing them but not with changes in concerns about NVP use.

Citation

White, M., Edwards, R., Stanley, J., Hoek, J., Waa, A. M., Ouimet, J., Quah, A. CK., & Fong, G. T. (2020). Reasons for stopping e-cigarette use among smokers: findings from the 2018 ITC New Zealand Survey. The New Zealand Medical Journal (Online), 133(1523), 117-121.

No abstract available.

Citation

Gravely, S., Cummings, K.M., Hammond, D., Lindblom, E., Smith, D.M., Martin, N., Loewen, R., Borland, R., Hyland, A., Thompson, M.E., Boudreau, C., Kasza, K.A., Ouimet, J., Quah, A.C.K., O’Connor, R.J., Fong, G.T. (2020). The association of e-cigarette flavors with satisfaction, enjoyment, and trying to quit or stay abstinent from smoking among regular adult vapers from Canada and the United States: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 22(10), 1831-1841.

Abstract

Introduction: This study examined whether non-tobacco flavors are more commonly used by vapers (ecigarette users) compared to tobacco flavor, described which flavors are most popular, and tested whether flavors are associated with: vaping satisfaction relative to smoking, level of enjoyment with vaping, reasons for using e-cigarettes, and making an attempt to quit smoking by smokers.

Methods: This cross sectional study included 1,603 adults from Canada and the US who vaped at least weekly, and were either current smokers (concurrent users) or former smokers (exclusive vapers). Respondents were categorized into one of seven flavors they used most in the last month: tobacco, tobacco-menthol, unflavored, or one of the non-tobacco flavors: menthol/mint, fruit, candy, or ‘other’ (e.g. Coffee).

Results: Vapers use a wide range of flavors, with 63.1% using a non-tobacco flavor. The most common flavor categories were fruit (29.4%) and tobacco (28.7%), followed by mint/menthol (14.4%) and candy (13.5%). Vapers using candy (41.0%, p<0.0001) or fruit flavors (26.0%, p=0.01) found vaping more satisfying (compared to smoking) than vapers using tobacco flavor (15.5%) and rated vaping as very/extremely enjoyable (fruit: 50.9%; candy: 60.9%) than those using tobacco flavor (39.4%). Among concurrent users, those using fruit (74.6%, p=0.04) or candy flavors (81.1%, p=0.003) were more likely than tobacco flavor users (63.5%) to vape in order to quit smoking. Flavor category was not associated with the likelihood of a quit attempt (p=0.46). Among exclusive vapers, tobacco and non-tobacco flavors were popular; however, those using tobacco (99.0%) were more likely than those using candy (72.8%, p=0.002) or unflavored (42.5%, p=0.005) to vape in order to stay quit.

Conclusions: A majority of regular vapers in Canada and the US use non-tobacco flavors. Greater satisfaction and enjoyment with vaping is higher among fruit and candy flavor users. While it does not appear that certain flavors are associated with a greater propensity to attempt to quit smoking among concurrent users, non-tobacco flavors are popular among former smokers who are exclusively vaping. Future research should determine the likely impact of flavor bans on those who are vaping to quit smoking or to stay quit.

Implications: Recent concerns about the attractiveness of e-cigarette flavors among youth have resulted in flavor restrictions in some jurisdictions of the United States and Canada. However, little is known about

the possible consequences for current and former smokers if they no longer have access to their preferred flavors. This study shows that a variety of nontobacco flavors, especially fruit, are popular among adult vapers, particularly among those who have quit smoking and are now exclusively vaping. Limiting access to flavors may therefore reduce the appeal of e-cigarettes among adults who are trying to quit smoking or stay quit.

Citation

Li, L., Borland, R., Cummings, K.M., McNeill, A., Heckman, B.W., Fong, G.T., O’Connor, R.J., Driezen, P. (2020). Are health conditions and concerns about health effects of smoking predictive of quitting? Findings from the ITC 4CV Survey (2016-2018). Tobacco Prevention & Cessation, 6(October), 60.

Abstract

Introduction:

Limited research has investigated the relationship between multiple health conditions and subsequent quitting activities at the population level. This study examines whether nine health conditions and concerns related to smoking are predictive of quit attempts and success among those who tried.

Methods:

Data came from the International Tobacco Control Four Country Smoking and Vaping Survey conducted in Australia, Canada, England and the US. A total of 3998 daily smokers were surveyed in 2016 and recontacted in 2018. Respondents were asked in 2016 whether they had a medical diagnosis for depression, anxiety, alcohol problems, obesity, chronic pain, diabetes, heart disease, cancer, and chronic lung disease, and whether they had concerns about past/future health effects of smoking. Outcomes were quit attempts and success (having been abstinent for at least one month between surveys).

Results:

Across all four countries, 44.4% of smokers tried to quit between the two survey years, and of these 36.8% were successful. Concerns about past (adjusted odds ratio, AOR=1.66, 95% CI: 1.32–2.08, p<0.001) and future effects of smoking (AOR=2.17, 95% CI: 1.62–2.91, p<0.001) and most health conditions predicted quit attempts, but were mostly unrelated to quit success, with concerns about future effects (AOR=0.59, 95% CI: 0.35–0.99, p<0.05), chronic lung conditions (AOR=0.56, 95% CI: 0.37–0.86, p<0.01) and chronic pain (with a trend) being associated with lower success.

Conclusions:

Having a major chronic health condition does, generally, motivate making quit attempts, but in some cases it is associated with failure among those who try. More effective cessation support is required for these high priority groups.

Citation

Miller, C., Sutanto, E., Smith, D.M., Hitchman, S.C., Gravely, S., Yong, H.H., Borland, R., O’Connor, R.J., Cummings, K.M., Fong, G.T., Hyland, A., Quah, A.C.K., Goniewicz, M. (2020). Awareness, trial, and use of heated tobacco products among adult cigarette smokers and e-cigarettes users: Findings from the 2018 ITC Four Country Smoking & Vaping Survey. Tobacco Control, [Published online, doi:10.1136/tobaccocontrol-2020-055985].

Abstract

Objective:

To evaluate heated tobacco product (HTP) awareness, trial and current use among adult cigarette smokers and vaping product users in four countries with varying regulations governing HTP sales.

Design:

Data came from Wave 2 of the ITC Four Country Smoking and Vaping Survey, collected from February to July 2018. Respondents were current and former smokers and/or users of vaping products (18 years or older) from Canada (CA; n=3778), England (EN; n=4848), the USA (US; n=2846) and Australia (AU; n=1515). At the time of the survey, only Canada and England permitted the sale of contemporary HTPs (eg, IQOS).

Results:

Overall, 30.2% of respondents reported being aware of HTPs (CA=30.4%; EN=31.0%; US=30.2%; AU=27.4%; p=0.346), 2.4% had ever tried HTPs (CA=3.3%; EN=2.4%; US=2.0%; AU=0.9%; p=0.001) and 0.9% currently used HTPs at least monthly (CA=0.8%; EN=1.2%; US=0.7%; AU=0.2%; p<0.001). Trial and current use were higher among those who concurrently smoked and vaped (at least monthly) versus other nicotine use categories (trial: 10.9% v. 1.2%-2.0%, p><0.001; current use: 8.4% v. 0.1%-1.0%, p><0.001). In multivariable analyses, HTP awareness did not differ across countries, whereas odds of trial and current use were lower where HTPs were unavailable. Odds of HTP trial did not differ by regulatory environment when restricting analysis to HTP-aware concurrent smokers-vapers.

Conclusion:

Approximately one third of respondents were aware of HTPs, even in the USA and Australia, where contemporary HTPs were not yet on the market. Trial and use were uncommon, except among concurrent smokers-vapers. Restrictions on availability may have limited HTP use generally, but less so for concurrent smokers-vapers.

Citation

Gravely, S., Meng, G., Cummings, K.M., Hyland, A., Borland, R., Hammond, D., O’Connor, R.J., Goniewicz, M., Kasza, K.A., McNeill, A., Thompson, M.E., Hitchman, S.C., Levy, D., Thrasher, J.F., Quah, A.C.K., Martin, N., Ouimet, J., Boudreau, C., Fong, G.T. (2020). Changes in smoking and vaping over 18 months among smokers and recent ex-smokers: Longitudinal findings from the 2016 and 2018 ITC Four Country Smoking and Vaping Surveys. International Journal of Environmental Research and Public Health, 17(19), E7084.

Abstract

This descriptive study of smokers (smoked at least monthly) and recent ex-smokers (quit for ≤2 years) examined transitions over an 18 month period in their smoking and vaping behaviors. Data are from Waves 1 (W1: 2016) and 2 (W2: 2018) of the ITC Four Country Smoking and Vaping Survey, a cohort study of adult (≥18+) smokers, concurrent users (smoke and vape), and recent ex-smokers from Australia, Canada, England, and the United States (US). Respondents (N = 5016) were classified according to their smoking and vaping status, which resulted in eight subgroups: (1) exclusive daily smokers (2) exclusive non-daily smokers; (3–6) concurrent users (subdivided into four groups by each combination of daily/non-daily smoking and daily/non-daily vaping); (7) ex-smokers who vape; (8) ex-smokers not vaping. The analyses focused first on describing changes between groups from W1 to W2. Second, transition outcomes were assessed based on changes in smoking and vaping between W1 and W2. Transitions focused on smoking were: no change in smoking (continued smoking at the same frequency); decreased smoking; increased smoking; discontinued smoking; relapsed (ex-smokers at W1 who were smoking at W2). Transitions focused on vaping were: initiated vaping; switched from smoking to vaping. Overall, this study found that the vast majority of smokers were smoking 18 months later. Non-daily smokers were more likely than daily smokers to have discontinued smoking (p < 0.0001) and to have switched to exclusive vaping (p = 0.034). Exclusive non-daily smokers were more likely than exclusive daily smokers to have initiated vaping (p = 0.04). Among all W1 daily smokers, there were no differences in discontinued smoking between daily smokers who vaped (concurrent users) and exclusive daily smokers; however, concurrent users were more likely than exclusive daily smokers to have decreased to non-daily smoking (p < 0.001) or to have switched to vaping by W2 (p < 0.001). Among all W1 non-daily smokers, there were no significant differences in increased smoking or discontinued smoking between concurrent users or exclusive smokers. Most ex-smokers remained abstinent from smoking, and there was no difference in relapse back to smoking between those who vaped and those who did not.

Citation

Sutanto, E., Miller, C., Smith, D.M., O’Connor, R.J., Gravely, S., Hammond, D., Hyland, A., Cummings, K.M., Quah, A.C.K., Fong, G.T., Agar, T.K., Goniewicz, M. (2020). Perceived relative harm of heated tobacco products (IQOS), e-cigarettes, and cigarettes among adults in Canada: Findings from the ITC Project. Tobacco Induced Diseases, 18(September), 81.

Abstract

Introduction:

Tobacco companies have introduced heated tobacco products (HTPs), such as IQOS, which may compete with e-cigarettes among smokers interested in switching to potentially reduced-risk products. Non-smokers may also start using IQOS if they believe this product is less harmful than other nicotine products. Smokers' and non-smokers' decisions may be driven by relative harm perceptions of emerging nicotine products. We aimed to examine relative harm perceptions between IQOS, e-cigarettes, and cigarettes, among nicotine product users and non-users.

Methods:

We conducted a web survey with Canadian respondents (aged >/ 20 years; n=268) in September-October 2018. Perceptions about relative harm between IQOS (available for sale since 2017 and subject to the same comprehensive marketing restrictions as cigarettes in Canada), e-cigarettes, and cigarettes, were assessed among nonusers (n=79), exclusive smokers (n=78), exclusive e-cigarette users (n=32), and dual users (n=79). Multiple logistic regression explored the association between relative harm perceptions and nicotine-use status, adjusting for sociodemographic variables.

Results:

Over half of respondents perceived IQOS as equally or more harmful than e-cigarettes (53.7%), while almost a quarter either reported IQOS as less harmful than e-cigarettes or were uncertain (22.7% and 23.5%, respectively). Two-thirds of respondents (65.7%) perceived e-cigarettes as less harmful than cigarettes, yet only half (48.1%) perceived IQOS as less harmful than cigarettes. Both exclusive and dual e-cigarette users, but not exclusive smokers, had higher odds of perceiving IQOS as more harmful than e-cigarettes and less harmful than cigarettes compared to non-users.

Conclusions:

Most nicotine users and non-users perceive differential health risk across IQOS, e-cigarettes, and cigarettes. Although e-cigarettes are generally viewed as less harmful than cigarettes, the perceived harm of IQOS was unclear.

Citation

Aleyan, S., Driezen, P., McNeill, A., McDermott, M., Kahnert, S., Kyriakos, C.N., Mons, U., Fernández, E., Trofor, A.C., Zatoński, M., Demjén, T., Katsaounou, P.A., Przewoźniak, K., Balmford, J., Filippidis, F.T., Fong, G.T., Vardavas, C.I., Hitchman, S.C. (2020). Evaluating the impact of introducing standardized packaging with larger health warning labels in England: Findings from adult smokers within the EURESTPLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl 3), iii91-iii97.

Abstract

Introduction: The European (EU) Tobacco Product Directive (TPD) was implemented in May 2016 to regulate the design and labelling of cigarettes and roll-your-own tobacco. At the same time, the UK introduced standardized packaging measures, whereas Germany, Greece, Hungary, Poland, Romania and Spain did not. This study examines the impact of introducing standardized packaging in England using a quasi-experimental design.

Material and Methods: Data from adult smokers in Waves 1 (2016; N=9547) and 2 (2018; N=9724) from the International Tobacco Control Policy Evaluation surveys (England) and EUREST-PLUS surveys (Germany, Greece, Hungary, Poland, Romania and Spain) were used. Generalized estimating equations were used to estimate changes in pack/brand appeal, salience of health-warning labels (HWLs) and perceived relative harm of different brands in England (where larger HWLs and standardized packaging were implemented), vs. each EU country (where only larger HWLs were implemented).

Results: There was an increase in the percentage of respondents from Germany, Hungary and Poland reporting they did not like the look of the pack (4.7%, 9.6%, and 14.2%, respectively), but the largest increase was in England (41.0%). Moreover, there was a statistically significant increase in the salience of HWLs in Hungary, Poland and Romania (17.0%, 13.9%, and 15.3%, respectively), but the largest increase was in England (27.6%). Few differences were observed in cross-country comparisons of the perceived relative harm of different brands.

Conclusions: Findings suggest that standardized packaging reduces pack appeal and enhances the salience of HWLs over and above the effects of larger HWLs. Findings provide additional evidence and support for incorporating standardized packaging into the EU TPD.

Citation

Papadakis, S., Katsaounou, P.A., Kyriakos, C.N., Balmford, J., Tzavara, C.K., Girvalaki, C., Driezen, P., Filippidis, F.T., Herbec, A., Hummel, K., McNeill, A., Mons, U., Fernández, E., Fu, M., Trofor, A.C., Demjén, T., Zatoński, W.A., Willemsen, M.C., Fong, G.T., Vardavas, C.I. (2020). Quitting behaviours and cessation methods used in eight European Countries in 2018: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Supplement_3), iii26-iii33

Abstract

Background:

We examined quit attempts, use of cessation assistance, quitting beliefs and intentions among smokers who participated in the 2018 International Tobacco Control (ITC) Europe Surveys in eight European Union Member States (England, Germany, Greece, Hungary, the Netherlands, Poland, Romania and Spain).

Methods:

Cross-sectional data from 11 543 smokers were collected from Wave 2 of the ITC Six European Country (6E) Survey (Germany, Greece, Hungary, Poland, Romania and Spain—2018), the ITC Netherlands Survey (the Netherlands—late 2017) and the Four Countries Smoking and Vaping (4CV1) Survey (England—2018). Logistic regression was used to examine associations between smokers’ characteristics and recent quit attempts.

Results:

Quit attempts in the past 12 months were more frequently reported by respondents in the Netherlands (33.0%) and England (29.3%) and least frequently in Hungary (11.5%), Greece (14.7%), Poland (16.7%) and Germany (16.7%). With the exception of England (35.9%), the majority (56–84%) of recent quit attempts was unaided. Making a quit attempt was associated with younger age, higher education and income, having a smoking-related illness and living in England. In all countries, the majority of continuing smokers did not intend to quit in the next 6 months, had moderate to high levels of nicotine dependence and perceived quitting to be difficult.

Conclusions:

Apart from England and the Netherlands, smokers made few quit attempts in the past year and had low intentions to quit in the near future. The use of cessation assistance was sub-optimal. There is a need to examine approaches to supporting quitting among the significant proportion of tobacco users in Europe and increase the use of cessation support as part of quit attempts

Citation

Chung-Hall, J., Fong, G.T., Vardavas, C.I., Meng, G., Craig, L., McNeill, A., Hitchman, S.C., Fernández, E., Mons, U., Trofor, A.C., Przewoźniak, K., Zatoński, W.A., Demjén, T., Katsaounou, P.A., Kyriakos, C.N. (2020). Support for e-cigarette policies among smokers in seven European countries: Longitudinal findings from the 2016–18 EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl 3), iii68-iii77.

Abstract

Background:

The 2016 European Tobacco Products Directive (TPD) required Member States (MS) to implement new regulations for electronic cigarettes (ECs). We conducted a longitudinal study to assess changes over 2 years in smokers’ support for EC policies and identify predictors of support in seven European countries after TPD implementation.

Methods:

Prospective cohort surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, Spain and England in 2016 (n = 9547; just after TPD) and 2018 (n = 10 287; 2 years after TPD). Multivariable logistic regression models employing generalized estimating equations assessed changes in support for four EC policies, and tested for country differences and strength of key predictors of support.

Results:

Banning EC use in smoke-free places was supported by 53.1% in 2016 and 54.6% in 2018 with a significant increase in Greece (51.7–66.0%) and a decrease in Spain (60.1–48.6%). Restricting EC/e-liquid nicotine content was supported by 52.2 and 47.4% in 2016 and 2018, respectively, with a significant decrease in England (54.2–46.5%) and Romania (52.5–41.0%). An EC promotion ban was supported by 41.1 and 40.2%. A flavour ban was supported by 33.3% and 32.3% with a significant increase in Hungary (34.3–43.3%). Support was generally higher in Poland, Hungary and Greece vs. England. Support was lower among dual and EC-only users, and low-income smokers.

Conclusions:

Smokers in all countries strongly supported banning EC use in smoke-free places and restricting nicotine content after TPD implementation, with no clear trends for changes in policy support.

Citation

Gravely, S., Driezen, P., Kyriakos, C.N., Thompson, M.E., Balmford, J., Demjén, T., Fernández, E., Mons, U., Tountas, Y., Janik-Koncewicz, K., Zatoński, W.A., Trofor, A.C., Vardavas, C.I., Fong, G.T. (2020). European adult smokers’ perceptions of the harmfulness of e-cigarettes relative to combustible cigarettes: Cohort findings from the 2016 and 2018 EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii26-iii33.

Abstract

Background:

This study presents perceptions of the harmfulness of electronic cigarettes (e-cigarettes) relative to combustible cigarettes among smokers from six European Union (EU) countries, prior to the implementation of the EU Tobacco Products Directive (TPD), and 2 years post-TPD.

Methods:

Data were drawn from the EUREST-PLUS ITC Europe Surveys, a cohort study of adult smokers (≥18 years) from Germany, Greece, Hungary, Poland, Romania and Spain. Data were collected in 2016 (pre-TPD: N = 6011) and 2018 (post-TPD: N = 6027). Weighted generalized estimating equations were used to estimate perceptions of the harmfulness of e-cigarettes compared to combustible cigarettes (less harmful, equally harmful, more harmful or 'don't know').

Results:

In 2016, among respondents who were aware of e-cigarettes (72.2%), 28.6% reported that they perceived e-cigarettes to be less harmful than cigarettes (range 22.0% in Spain to 34.1% in Hungary). In 2018, 72.2% of respondents were aware of e-cigarettes, of whom 28.4% reported perceiving that e-cigarettes are less harmful. The majority of respondents perceived e-cigarettes to be equally or more harmful than cigarettes in both 2016 (58.5%) and 2018 (61.8%, P > 0.05). Overall, there were no significant changes in the perceptions that e-cigarettes are less, equally or more harmful than cigarettes, but 'don't know' responses significantly decreased from 12.9% to 9.8% (P = 0.036). The only significant change within countries was a decrease in 'don't know' responses in Spain (19.3-9.4%, P = .001).

Conclusions:

The majority of respondents in these six EU countries perceived e-cigarettes to be equally or more harmful than combustible cigarettes.