Citation

Nagelhout, G.E., Hummel, K., Willemsen, M.C., Siahpush, M., Kunst, A. E., de Vries, H., Fong, G.T., van den Putte, B. (2014). Are there income differences in the impact of a national reimbursement policy for smoking cessation treatment and accompanying media attention? Findings from the International Tobacco Control (ITC) Netherlands Survey. Drug and Alcohol Dependence, 1(140), 183-190.

Abstract

Background: This study examined possible income differences in the impact of a national reimbursement policy for smoking cessation treatment and accompanying media attention in the Netherlands in 2011.

Methods: We used three waves of the International Tobacco Control (ITC) Netherlands Survey, a nationally representative longitudinal sample of smokers aged 15 years and older (n=1912). The main analyses tested trends and income differences in outcome measures (smokers' quit attempt rates, use of behavioral counseling, use of cessation medications, and quit success) and awareness variables (awareness of reimbursement possibilities, the media campaign, medications advertisements and other media attention) with generalized estimating equations analyses.

Results: In the first half of 2011, there was a significant increase in quit attempts (odds ratio (OR)=2.02, p<0.001) and quit success (OR=1.47, p<0.001). Use of counseling and medications remained stable at 3% of all smokers in this period. Awareness of reimbursement possibilities increased from 11% to 42% (OR=6.38, p<0.001). Only awareness of the media campaign was associated with more quit attempts at the follow-up survey (OR=1.95, p<0.001). Results were not different according to smokers' income level.

Conclusions: The Dutch reimbursement policy with accompanying media attention was followed by an increase in quit attempts and quit success, but use of cessation treatment remained stable. The impact of the policy and media attention did not seem to have decreased or increased socioeconomic inequalities in quit attempts, use of cessation treatment, or quit success.

Citation

Kasza, K.A., Bansal-Travers, M., O’Connor, R.J., Compton, W., Kettermann, A., Borek, N., Fong, G.T., Cummings, K.M., Hyland, A. (2014). Cigarette smokers’ use of unconventional tobacco products and associations with quitting activity: Findings from the ITC-4 U.S. Cohort. Nicotine & Tobacco Research, 16(6), 672-681.

Abstract

Introduction: The purpose of this study was to evaluate the prevalence and correlates of use of nicotinecontaining tobacco products such as cigars, pipe tobacco, cigarettes that promise less exposure to toxins, e-cigarettes, and smokeless tobacco products in a cohort of conventional cigarette smokers followed over the past decade, and to evaluate associations between use of such products and cigarette quitting.

Methods: Participants were 6,110 adult smokers in the United States, who were interviewed as part of the International Tobacco Control Four Country Survey between 2002 and 2011. Respondents reported their concurrent use of other smoked tobacco products (including cigars, pipe tobacco, and cigarillos), smokeless tobacco products (including chewing tobacco, snus, and snuff), unconventional cigarettes (including Omni, Accord, and Eclipse), and electronic cigarettes. Prevalence and correlates of use and associations between use and cigarette quitting were assessed using regression analyses via generalized estimating equations.

Results: Most cigarette smokers did not use unconventional tobacco products although use of any of these products started to rise at the end of the study period (2011). For each type of tobacco product evaluated, use was most prevalent among those aged 18–24 years. Smokers who did use unconventional tobacco products did not experience a clear cessation advantage.

Conclusions: Over the past decade, relatively few cigarette smokers reported also using other tobacco products. Those that did use such products were no more likely to stop using conventional cigarettes compared with those who did not use such products.

Citation

Mutti, S., Kennedy, R.D., Thompson, M.E., Fong, G.T. (2014). Prepaid monetary incentives - Predictors of taking the money and completing the survey: Results from the International Tobacco Control (ITC) Four-Country Survey. Sociological Methods & Research, 43(2), 338-355.

Abstract

Prepaid monetary incentives are used to address declining response rates in random-digit dial surveys. There is concern among researchers that some respondents will accept the prepayment but not complete the survey. There is little research to understand check cashing and survey completing behaviors among respondents who receive prepayment. Data from the International Tobacco Control Four-Country Study—a longitudinal survey of smokers in Canada, the United States, the United Kingdom, and Australia—were used to examine the impact of prepayment (in the form of checks, approximately US$10) on sample profile. Approximately 14 percent of respondents cashed their check, but did not complete the survey, while about 14 percent did not cash their checks, but completed the survey. Younger adults (Canada and United States), those of minority status (United States), and those who had been in the survey for only two waves or less (Canada and United States) were more likely to cash their checks and not complete the survey.

Citation

Bansal-Travers, M., Fong, G.T., Quah, A.C.K., Sansone, G.C., Pednekar, M.S., Gupta, P.C., Sinha, D.N. (2014). Awareness of pro-tobacco advertising and promotion and beliefs about tobacco use: Findings from the Tobacco Control Policy (TCP) India Pilot Survey. Journal of Epidemiology and Global Health, 4(4), 303-313.

Abstract

Tobacco companies are utilizing similar strategies to advertise and promote their products in developing countries as they have used successfully for over 50 years in developed countries. The present study describes how adult smokers, smokeless tobacco users, and non-users of tobacco from the Tobacco Control Project (TCP) India Pilot Survey, conducted in 2006, responded to questions regarding their perceptions and observations of pro-tobacco advertising and promotion and beliefs about tobacco use. Analyses found that 74% (n = 562) of respondents reported seeing some form of pro-tobacco advertising in the last six months, with no differences observed between smokers (74%), smokeless tobacco users (74%), and nonsmokers (73%). More than half of respondents reported seeing pro-tobacco advertising on store windows or inside shops. Overall, this study found that a significant percentage of tobacco users and non-users in India report seeing some form of pro-tobacco advertising and promotion messages. Additional analyses found that smokers were more likely to perceive tobacco use as harmful to their health compared with smokeless tobacco users and non-users (p < 0.01). The findings from this study reiterate the need for stronger legislation and strict enforcement of bans on direct and indirect advertising and promotion of tobacco products in India.

Citation

Abdullah, A.S., Driezen, P., Ruthbah, U.H., Nargis, N., Quah, A.C.K., Fong, G.T. (2014). Patterns and predictors of smokeless tobacco use among adults in Bangladesh: Findings from the International Tobacco Control (ITC) Bangladesh Survey. PLOS One, 9(7), 101934.

Abstract

Background: Although smokeless tobacco (SLT) use is prevalent in South Asian countries including Bangladesh, information about the pattern and correlates of SLT use is scarce. This study described the pattern and predictors of SLT use among Bangladeshi adults.

Methods: The data for this study were derived from the International Tobacco Control Policy Evaluation Bangladesh (ITC BD) Survey, a prospective cohort survey of a nationally representative sample of smokers and non-smokers, conducted during November 2011 and May 2012. The study included 5522 adults aged 15 or above. We used multiple logistic regression models to identify predictors of SLT use.

Results: Of the respondents (N = 5522), 20% were SLT users. In general, SLT use was significantly higher among women, the illiterate and residents of the Dhaka slums or non-tribal/non-border areas outside Dhaka; SLT use increased with age. Several attitudinal factors were also associated with SLT use. Multivariable logistic regression analyses revealed several predictors of SLT use: being female (OR = 1.96, 95% confidence interval, CI: 1.18– 3.24), an increasing age, being a resident of a Dhaka slum (OR = 5.86; 95% CI: 3.73–9.21) or nontribal/non-border areas outside Dhaka (OR = 3.42; 95% CI: 1.94–6.03), being illiterate (OR = 3.37; 95% CI: 1.99–5.71), holding positive opinion towards societal approval of SLT use (OR = 5.84; 95% CI: 3.38– 10.09), holding positive opinion towards SLT use by women (OR = 2.63; 95% CI: 1.53–4.54), believing that SLT is addictive (OR = 2.96; 95% CI: 1.51–5.81), and believing SLT is less harmful than bidi (OR = 2.22; 95% CI: 1.36–3.62).

Conclusion: The findings suggest that coordinated efforts of governmental and non-governmental organizations, targeting both smoked tobacco and SLT use reduction and cessation, could be modified to reach each level of population including those who are marginalized, female, less educated and elderly. As most tobacco control programs in Bangladesh target mainly cigarette or bidi smoking, coordinated programs are needed that will also include SLT use within the tobacco control policy and prevention strategies.

Citation

Richardson, S., McNeill, A., Langley, T., Sims, M., Gilmore, A., Szatkowski, L., Heath, R., Fong, G.T., Lewis, S. (2014). The impact of televised tobacco control advertising content and socioeconomic status on campaign recall: Evidence from the International Tobacco Control (ITC) United Kingdom Survey. BioMed Central Public Health, 14(1), 432.

Abstract

Background: Although there is some evidence to support an association between exposure to televised tobacco control campaigns and recall among youth, little research has been conducted among adults. In addition, no previous work has directly compared the impact of different types of emotive campaign content. The present study examined the impact of increased exposure to tobacco control advertising with different types of emotive content on rates and durations of self-reported recall.

Methods: Data on recall of televised campaigns from 1,968 adult smokers residing in England through four waves of the International Tobacco Control (ITC) United Kingdom Survey from 2005 to 2009 were merged with estimates of per capita exposure to government-run televised tobacco control advertising (measured in GRPs, or Gross Rating Points), which were categorised as either “positive” or “negative” according to their emotional content.

Results: Increased overall campaign exposure was found to significantly increase probability of recall. For every additional 1,000 GRPs of per capita exposure to negative emotive campaigns in the six months prior to survey, there was a 41% increase in likelihood of recall (OR = 1.41, 95% CI: 1.24-1.61), while positive campaigns had no significant effect. Increased exposure to negative campaigns in both the 1-3 months and 4-6 month periods before survey was positively associated with recall.

Conclusions: Increased per capita exposure to negative emotive campaigns had a greater effect on campaign recall than positive campaigns, and was positively associated with increased recall even when the exposure had occurred more than three months previously.

Citation

Hitchman, S.C., Fong, G.T., Zanna, M.P., Thrasher, J.F., Chung-Hall, J., Siahpush, M. (2014). Socioeconomic status and smokers' number of smoking friends: Findings from the International Tobacco Control (ITC) Four Country Survey. Drug and Alcohol Dependence, 143, 158-166.

Abstract

Background: Smoking rates are higher among low socioeconomic (SES) groups, and there is evidence that inequalities in smoking are widening over time in many countries. Low SES smokers may be more likely to smoke and less likely to quit because smoking is heavily concentrated in their social contexts. This study investigated whether low SES smokers (1) have more smoking friends, and (2) are more likely to gain and less likely to lose smoking friends over time. Correlates of having more smoking friends and gaining or losing smoking friends were also considered.

Method: Respondents included 6321 adult current smokers (at recruitment) from Wave 1 (2002) and Wave 2 (2003) of the International Tobacco Control Project (ITC) Four Country Survey, a nationally representative longitudinal cohort survey of smokers in Australia, Canada, UK, and US.

Results: Low SES smokers reported more smoking friends than moderate and high SES smokers. Low SES smokers were also more likely to gain smoking friends over time compared with high SES smokers. Smokers who were male, younger, and lived with other smokers reported more smoking friends, and were also more likely to gain and less likely to lose smoking friends. Smoking behaviours, such as higher nicotine dependence were related to reporting more smoking friends, but not to losing or gain smoking friends.

Conclusions: Smoking is highly concentrated in the social networks of lower SES smokers and this concentration may be increasing over time. Cessation interventions should consider how the structure of low SES smokers' social networks affects quitting.

Citation

Balmford, J., Swift, E., Borland, R. (2014). Reported planning before and after quitting and quit success: Retrospective data from the ITC 4-Country Survey. Psychology of Addictive Behaviours, 28(3), 899-906

Abstract

Planning before quitting smoking is widely believed to be beneficial and is usually recommended in cessation counseling, but there is little evidence on the efficacy of specific planning activities. Using data from 1140 respondents who reported quit attempts at Wave 8 of the ITC 4-Country Survey, we analyzed use of 8 specific planning strategies before (5) and after (3) implementation of a quit attempt, in relation to cessation outcomes, delay in implementation of the attempt, and recent quitting history. Most participants reported some planning both before and after quitting, even among those reporting quitting ‘spontaneously.’ Younger smokers, those who cut down before quitting, and users of stop-smoking medication were more likely to report planning. Those who planned prequit were also more likely to plan postquit. Unexpectedly, we found no clear benefit of planning on short-term (1 month) cessation outcomes, whereas one prequit strategy (practicing not smoking) was negatively related to outcome. There was evidence for a predicted moderating effect of recent quitting experience on planning for the prequit task ‘practice replacement strategies.’ This predicted quit success among those with multiple quit attempts in the past year, but failure among those without. This finding suggests that the quality of planning may be critical. More research, particularly on the moderating effect of quit experience, and where measures of planning are collected before outcomes become evident, is needed before clear recommendations can be made on the utility of various forms of planning for the success of quit attempts.

Citation

Yong, H.H., Thompson, M.E., Thrasher, J.F., Borland, R., Fong, G.T., Hammond, D., Cummings, K.M., Nagelhout, G.E., Meng, G., McNeill, A. (2014). Mediational pathways of the impact of cigarette warning labels on quit attempts. Health Psychology, 33(11), 1410-1420.

Abstract

Objective: To test and develop, using structural equation modeling, a robust model of the mediational pathways through which health warning labels exert their influence on smokers' subsequent quitting behavior.

Method: Data come from the International Tobacco Control Four-Country Survey, a longitudinal cohort study conducted in Australia, Canada, the United Kingdom, and the United States. Waves 5-6 data (n = 4,988) were used to calibrate the hypothesized model of warning label impact on subsequent quit attempts via a set of policy-specific and general psychosocial mediators. The finalized model was validated using Waves 6-7 data (n = 5065).

Results: As hypothesized, warning label salience was positively associated with thoughts about risks of smoking stimulated by the warnings (β = .58, p < .001), which in turn were positively related to increased worry about negative outcomes of smoking (β = .52, p < .001); increased worry in turn predicted stronger intention to quit (β = .39, p < .001), which was a strong predictor of subsequent quit attempts (β = .39, p < .001). This calibrated model was successfully replicated using Waves 6-7 data.

Conclusion: Health warning labels seem to influence future quitting attempts primarily through their ability to stimulate thoughts about the risks of smoking, which in turn help to raise smoking-related health concerns, which lead to stronger intentions to quit, a known key predictor of future quit attempts for smokers. By making warning labels more salient and engaging, they should have a greater chance to change behavior.

Citation

Gravely, S., Fong, G.T., Cummings, K.M., Yan, M., Quah, A.C.K., Borland, R., Yong, H.H., Hitchman, S.C., McNeill, A., Hammond, D., Thrasher, J.F., Willemsen, M.C., Seo, H.G., Jiang, Y., Cavalcante, T.M., Perez, C., Omar, M., Hummel, K. (2015). Awareness, trial, and current use of electronic cigarettes in 10 countries: findings from the ITC Project. International Journal of Environmental Research and Public Health, 12(5), 4631-4637.

Abstract

Background: In recent years, electronic cigarettes (e-cigarettes) have generated considerable interest and debate on the implications for tobacco control and public health. Although the rapid growth of e-cigarettes is global, at present, little is known about awareness and use. This paper presents self-reported awareness, trial and current use of e-cigarettes in 10 countries surveyed between 2009 and 2013; for six of these countries, we present the first data on e-cigarettes from probability samples of adult smokers.

Methods: A cross-sectional analysis of probability samples of adult (≥ 18 years) current and former smokers participating in the International Tobacco Control (ITC) surveys from 10 countries. Surveys were administered either via phone, face-to-face interviews, or the web. Survey questions included sociodemographic and smoking-related variables, and questions about e-cigarette awareness, trial and current use.

Results: There was considerable cross-country variation by year of data collection and for awareness of e-cigarettes (Netherlands (2013: 88%), Republic of Korea (2010: 79%), United States (2010: 73%), Australia (2013: 66%), Malaysia (2011: 62%), United Kingdom (2010: 54%), Canada (2010: 40%), Brazil (2013: 35%), Mexico (2012: 34%), and China (2009: 31%)), in self-reports of ever having tried e-cigarettes (Australia, (20%), Malaysia (19%), Netherlands (18%), United States (15%), Republic of Korea (11%), United Kingdom (10%), Mexico (4%), Canada (4%), Brazil (3%), and China (2%)), and in current use (Malaysia (14%), Republic of Korea (7%), Australia (7%), United States (6%), United Kingdom (4%), Netherlands (3%), Canada (1%), and China (0.05%)).

Conclusions: The cross-country variability in awareness, trial, and current use of e-cigarettes is likely due to a confluence of country-specific market factors, tobacco control policies and regulations (e.g., the legal status of e-cigarettes and nicotine), and the survey timing along the trajectory of e-cigarette awareness and trial/use in each country. These ITC results constitute an important snapshot of an early stage of what appears to be a rapid progression of global e-cigarette use.

Citation

Nargis, N., Hussain, A.K.M.G., Fong, G.T. (2014). Smokeless tobacco product prices and taxation in Bangladesh: Findings from the ITC Survey. Indian Journal of Cancer, 51(Suppl 1), S33-38.

Abstract

Smokeless tobacco use occupies a significant portion of overall tobacco consumption in Bangladesh. Yet very little is known about the effectiveness of tax and price policy in controlling the use of smokeless tobacco use in the country.

Methods: The paper examines the price distribution of various smoked (cigarette, bidi) and smokeless tobacco products (zarda, gul) using the univariate Epanechnikov kernel density function. It estimates the own and cross price elasticity of demand for the most widely used smokeless tobacco product zarda using two-step regression analysis. The analysis is based on data from the ITC Bangladesh Wave 3 Survey which is a nationally representative cohort survey of tobacco users and nonusers conducted in in Bangladesh during 2011-12. Results: The price elasticity of lower price brands of zarda is estimated at −0.64 and of higher priced brands at −0.39, and the cross price elasticity of zarda with respect to cigarette price at 0.35. The tax increase on smokeless tobacco needs to be greater than the tax increase on smoked tobacco to bridge the wide price differential between the two types of products that currently encourages downward substitution from smoked to smokeless tobacco and discourages quitting behavior.

Conclusions: This paper argues that increasing tax on smokeless tobacco simultaneously with the tax increase on smoked tobacco can have significant negative impact on the prevalence of smokeless tobacco use in Bangladesh. Finally, a specific excise system replacing the existing ad valorem excise tax can substantially contribute to the revenue collection performance from smokeless tobacco products.

Citation

Pawar, P.S, Pednekar, M.S., Gupta, P.C., Shang, C., Quah, A.C.K., Fong, G.T. (2014). The relation between price and daily consumption of cigarettes and bidis: Findings from TCP India Wave 1 Survey. Indian Journal of Cancer, 51(Suppl 1), S83-87.

Abstract

Context: In India, 14% of the population use smoked tobacco products. Increasing prices of these products is one of the measures to curb their consumption. AIMS: This study analyzes “unit price” and “daily consumption” of cigarettes and bidis and investigates their relation with each other.

Settings and Design: A cross‑sectional survey was conducted in four states of India (Bihar, West Bengal, Madhya Pradesh and Maharashtra) as a part of the International Tobacco Control Policy (TCP) Evaluation Project (the TCP India Project) during 2010–2011.

Methods: Information was collected from adult (aged ≥15) daily exclusive smokers of cigarette/bidi regarding (a) last purchase (purchase in pack/loose, brand and price) and (b) daily consumption. Average unit price and daily consumption was calculated for different brands and states. Regression model was used to assess the impact of price on daily consumption.

Results: Bidis were much less expensive (₹0.39) than cigarettes (₹3.1). The daily consumption was higher (14) among bidi smokers than cigarette smokers (8). The prices and daily consumption of bidis (₹0.33–0.43; 12–15) and cigarettes (₹2.9–3.6; 5–9) varied across the four states. The unit prices of bidis and cigarettes did not influence their daily consumption. Smokers purchasing bidis in packs paid substantially less per unit and purchase of bidis and cigarettes in packs influenced their consumption positively.

Conclusions: Cigarettes although more expensive than bidis, seem very cheap if compared internationally. Hence, prices of both cigarettes and bidis do not influence their consumption. Recommended

Citation

Dhumal, G.G., Pednekar, M.S., Gupta, P.C., Sansone, G.C., Quah, A.C.K., Bansal-Travers, M., Fong, G.T. (2014). Quit history, intentions to quit, and reasons for considering quitting among tobacco users in India: Findings from the Tobacco Control Policy Evaluation India Wave 1 Survey. Indian Journal of Cancer, 51(Suppl 1), S39-45.

Abstract

Background: Global Adult Tobacco Survey India 2009-2010 revealed that more than one-third (35%) of adults in India use tobacco in some form: 21% use smokeless tobacco, 9% smoke, and 5% are mixed users (they smoke and use smokeless tobacco), and the quit rate is very low. In an effort to decrease prevalence of tobacco use, it is thus important to understand the factors that are related to intention to quit among Indian tobacco users. Research has shown consistently that intention to quit is a strong predictor of future quitting. The present study reports the factors encouraging quitting tobacco products in India.

Subjects and Methods: Cross-sectional data from Wave 1 of the International Tobacco Control Policy Evaluation India Survey conducted in four cities and surrounding rural areas (i.e. Mumbai [Maharashtra], Patna [Bihar], Indore [Madhya Pradesh], and Kolkata [West Bengal]) between August 2010 and December 2011 were analyzed. A total of 8051 tobacco users (15+ years) were randomly sampled from 8586 households: 1255 smokers, 5991 smokeless users, and 805 mixed (smoke and smokeless) users. Validated, standardized questions were asked about current tobacco use, intention to quit, and factors encouraging quitting.

Results: Overall, 19.6% of tobacco users intended to quit. Smokers had less intention to quit as compared to smokeless tobacco users whereas mixed users had more intention to quit (odds ratio [OR] =1.48, 95% confidence interval [CI] =1.12-1.97) compared to smokeless tobacco users. Highly educated people were more likely to report intention to quit (OR = 1.82, 95% CI = 1.09-3.02) compared to less educated. Advice by doctors to quit tobacco had a strong impact on intention to quit (OR = 1.68, CI = 1.29-2.15). Tobacco users who were exposed to antitobacco messages at work places (OR = 1.74, CI = 1.23-2.46), at restaurants (OR = 1.65, CI = 1.12-2.43), bars (OR = 1.81, CI = 1.07-3.06), on public transportation (OR = 2.14, CI = 1.49-3.08) and on tobacco packages (OR = 1.77, CI = 1.29-2.14) also expressed greater intention to quit tobacco use.

Conclusion: Around one-fifth of tobacco users in India intended to quit tobacco use. Higher education, doctor's advice, and antitobacco messages were positively associated with users' intention to quit tobacco.

Citation

Thompson, M.E., Huang, C., Boudreau, C., Fong, G.T., van den Putte, B., Nagelhout, G.E., Willemsen, M.C. (2014). Accounting for the effects of data collection method: Application to the International Tobacco Control Netherlands Survey. Population, 68(3), 447-471.

Abstract

Qualitative surveys employ an ever wider range of data collection methods. The development of telephone surveys in the 1900s offered a cheaper alternative to face-to-face interviews (Riandey and Firdion, 1993). Later, as the number of cell phone owners increased, technical advances made it possible to conduct detailed interviews and to directly select random samples of adults by means of cell phone numbers. More recently, the spread of the Internet has made it possible to conduct surveys with minimal data collection costs on “spontaneous” samples of volunteers or on representative samples of respondents recruited by phone. These innovations raise questions of sample representativeness and of the effect of data collection mode on the responses obtained. Analysing the Dutch version of an international survey on tobacco control, Mary Thompson and her colleagues compare the results obtained on two subsamples, on that responded via the web, and the other by phone. They highlight differences linked to the respondents' characteristics and other attributable to the data collection mode, and present a method or estimating the results that would have been obtained using a single collection method, i.e. that used in the other countries.

Citation

Caruso, R., O’Connor, R.J., Stephens, W.E., Cummings, K.M., Fong, G.T. (2013). Toxic metal concentrations in cigarettes obtained from U.S. smokers in 2009: Results from the International Tobacco Control (ITC) United States Survey Cohort. International Journal of Environmental Research and Public Health, 11(1), 202-217.

Abstract

Smoking-related diseases can be attributed to the inhalation of many different toxins, including heavy metals, which have a host of detrimental health effects. The current study reports the levels of arsenic (As), cadmium (Cd), chromium (Cr), nickel (Ni), and lead (Pb) in cigarettes obtained from adult smokers participating in the 2009 wave of the ITC United States Survey (N = 320). The mean As, Cd, Cr, Ni, and Pb levels were 0.17, 0.86, 2.35, 2.21, and 0.44 μg/g, respectively. There were some differences in metal concentrations of cigarette brands produced by different manufacturers, suggesting differences in the source of tobaccos used by different companies. For Ni, there were significant pairwise differences between Philip Morris U.S. (PMUSA) and R.J. Reynolds (RJR) brands (PMUSA higher; p < 0.001), PMUSA and other manufacturer (OM) brands (PMUSA higher; p < 0.001), and RJR and OM brands (RJR higher; p = 0.006). For Cr, RJR brands had higher levels than did OM brands (p = 0.02). Levels of As, Cd, and Pb did not differ significantly across manufacturer groups (p > 0.10). Because of the variety of toxic heavy metals in cigarette tobacco, and their numerous negative health effects, metal content in cigarette tobacco should be reduced.

Citation

Hitchman, S.C., Driezen, P., Logel, C., Hammond, D., Fong, G.T. (2014). Changes in effectiveness of cigarette health warnings over time in Canada and the United States, 2002 - 2011. Nicotine & Tobacco Research, 16(5), 536-543.

Abstract

Introduction: Article 11 of the World Health Organization's Framework Convention on Tobacco Control (FCTC) requires countries to implement health warnings on tobacco products. The Article 11 Guidelines advise countries to periodically rotate warnings to prevent “wearout” of the health warnings. This study investigates potential wearout of cigarette health warnings over a period of 9 years in 2 countries: Canada, where larger pictorial warnings were implemented approximately 1 year prior to the study, and in the United States, where small text-only warnings were in place for 17 years at the beginning of the study.

Methods: Data were drawn from national samples of smokers from the International Tobacco Control (ITC) Surveys in Canada (N = 5,309), and the United States (N = 6,412) recruited originally by telephone using random digit dialing. Changes in 4 measures of health warning effectiveness and in a composite Labels Impact Index were examined over 8 waves of survey data (2002-2011). Analyses were conducted in 2012.

Results: The health warning effectiveness measures and the Labels Impact Index indicated that the effectiveness of both the Canadian, and the U.S. warnings declined significantly over time. The Canadian warnings showed greater declines in effectiveness than the U.S. warnings, likely due to the initial novelty of the Canadian warnings. Despite the greater decline in Canada, the Canadian pictorial warnings were significantly more effective than the U.S. text-only warnings throughout the study.

Conclusions: Health warnings decline in effectiveness over time. Health warnings on tobacco products should be changed periodically to maintain effectiveness.

Citation

Thrasher, J.F., Naveli Abad-Vivero, E., Sebrie, E.M., Barrientos-Gutierrez, I., Boado Martinez, M., Yong, H.H., Arillo-Santillán, E., Bianco, E. (2013). Tobacco smoke exposure in public places and workplaces after smoke-free policy implementation: A longitudinal analysis of smoker cohorts in Mexico and Uruguay. Health & Policy Planning, 28(8), 789-798.

Abstract

Objective: To determine the prevalence, correlates and changes in secondhand smoke (SHS) exposure over the period after comprehensive smoke-free policy implementation in two Latin American countries.

Methods: Data were analysed from population-based representative samples of adult smokers and recent quitters from the 2008 and 2010 waves of the International Tobacco Control Policy Evaluation Survey in Mexico (n = 1766 and 1840, respectively) and Uruguay (n = 1379 and 1411, respectively). Prevalence of SHS exposure was estimated for regulated venues, and generalized estimating equations were used to determine correlates of SHS exposure.

Results: Workplace SHS exposure in the last month was similar within and across countries (range: Mexico 20–25%; Uruguay 14–29%). At the most recent restaurant visit, SHS exposure was lower where comprehensive smoke-free policies were implemented (range: Uruguay 6–9%; Mexico City 5–7%) compared with Mexican cities with weaker policies, where exposure remained higher but decreased over time (32–17%). At the most recent bar visit, SHS exposure was common (range: Uruguay 8–36%; Mexico City 23–31%), although highest in jurisdictions with weaker policies (range in other Mexican cities: 74–86%). In Uruguay, males were more likely than females to be exposed to SHS across venues, as were younger compared with older smokers in Mexico.

Conclusions: Comprehensive smoke-free policies are more effective than weaker policies, although compliance in Mexico and Uruguay is not as high as desired.

Citation

Li, L., Borland, R., Fong, G.T., Thrasher, J.F., Hammond, D., Cummings, K.M. (2013). Impact of point-of-sale tobacco display bans: Findings from the International Tobacco Control Four Country Survey. Health Education Research, 28(5), 898-910.

Abstract

This study examined the impact of point-of-sale (POS) tobacco marketing restrictions in Australia and Canada, in relation to the United Kingdom and the United States where there were no such restrictions during the study period (2006–10). The data came from the International Tobacco Control Four Country Survey, a prospective multi-country cohort survey of adult smokers. In jurisdictions where POS display bans were implemented, smokers’ reported exposure to tobacco marketing declined markedly. From 2006 to 2010, in Canada, the percentages noticing POS tobacco displays declined from 74.1 to 6.1% [adjusted odds ratio (OR)¼0.26, P<0.001]; and reported exposure to POS tobacco advertising decreased from 40.3 to 14.1% (adjusted OR¼0.61, P<0.001). Similarly, in Australia, noticing of POS displays decreased from 73.9 to 42.9%. In contrast, exposure to POS marketing in the United States and United Kingdom remained high during this period. In parallel, there were declines in reported exposures to other forms of advertising/promotion in Canada and Australia, but again, not in the United States or United Kingdom. Impulse purchasing of cigarettes was lower in places that enacted POS display bans. These findings indicate that implementing POS tobacco display bans does result in lower exposure to tobacco marketing and less frequent impulse purchasing of cigarettes.

Citation

Nargis, N., Fong, G.T., Chaloupka, F., Li, Q. (2014). The choice of discount brand cigarettes: A comparative analysis of International Tobacco Control Surveys in Canada and the United States (2002-05). Tobacco Control, 23(Suppl 1), i86-i96.

Abstract

Background: Increasing tobacco taxes to increase price is a proven tobacco control measure. This article investigates how smokers respond to tax and price increases in their choice of discount brand cigarettes versus premium brands.

Objective: To estimate how increase in the tax rate can affect smokers' choice of discount brands versus premium brands.

Methods: Using data from International Tobacco Control surveys in Canada and the USA, a logit model was constructed to estimate the probability of choosing discount brand cigarettes in response to its price changes relative to premium brands, controlling for individual-specific demographic and socioeconomic characteristics and regional effects. The self-reported price of an individual smoker is used in a random-effects regression model to impute price and to construct the price ratio for discount and premium brands for each smoker, which is used in the logit model.

Findings: An increase in the ratio of price of discount brand cigarettes to the price of premium brands by 0.1 is associated with a decrease in the probability of choosing discount brands by 0.08 in Canada. No significant effect is observed in case of the USA.

Conclusions: The results of the model explain two phenomena: (1) the widened price differential between premium and discount brand cigarettes contributed to the increased share of discount brand cigarettes in Canada in contrast to a relatively steady share in the USA during 2002-2005 and (2) increasing the price ratio of discount brands to premium brands-which occurs with an increase in specific excise tax-may lead to upward shifting from discount to premium brands rather than to downward shifting. These results underscore the significance of studying the effectiveness of tax increases in reducing overall tobacco consumption, particularly for specific excise taxes.

Citation

Fong, G.T., Craig, L., Guignard, R., Nagelhout, G.E., Tait, M., Driezen, P., Kennedy, R.D., Boudreau, C., Wilquin, J.L., Deutsch, A., Beck, F. (2013). Evaluating the effectiveness of France's indoor smoke-free law 1 year and 5 years after implementation: Findings from the ITC France Survey. PLOS One, 8(6), 66692.

Abstract

France implemented a comprehensive smoke-free law in two phases: Phase 1 (February 2007) banned smoking in workplaces, shopping centres, airports, train stations, hospitals, and schools; Phase 2 (January 2008) banned smoking in hospitality venues (bars, restaurants, hotels, casinos, nightclubs). This paper evaluates France’s smoke-free law based on the International Tobacco Control Policy Evaluation Project in France (the ITC France Project), which conducted a cohort survey of approximately 1,500 smokers and 500 non-smokers before the implementation of the laws (Wave 1) and two waves after the implementation (Waves 2 and 3). Results show that the smoke-free law led to a very significant and near-total elimination of observed smoking in key venues such as bars (from 94–97% to 4%) and restaurants (from 60–71% to 2–3%) at Wave 2, which was sustained four years later (6–8% in bars; 1–2% in restaurants). The reduction in self-reported smoking by smoking respondents was nearly identical to the effects shown in observed smoking. Observed smoking in workplaces declined significantly after the law (from 41–48% to 18–20%), which continued to decline at Wave 3 (to 14–15%). Support for the smoke-free laws increased significantly after their implementation and continued to increase at Wave 3 (p,.001 among smokers for bars and restaurants; p,.001 among smokers and p = .003 for non-smokers for workplaces). The findings demonstrate that smoke-free policies that are implemented in ways consistent with the Guidelines for Article 8 of the WHO Framework Convention on Tobacco Control (WHO FCTC) lead to substantial and sustained reductions in indoor smoking while also leading to high levels of support by the public. Moreover, contrary to arguments by opponents of smoke-free laws, smoking in the home did not increase after the law was implemented and prevalence of smoke-free homes among smokers increased from 23.2% before the law to 37.2% 5 years after the law.

Citation

Sirirassamee, T., Sirirassamee, B. (2013). Trends in tobacco use among Thai adolescents. Journal of the Medical Association of Thailand, 96(1), 78-84.

Abstract

Background: Tobacco use continues to be the leading global cause of preventable death. Understanding the trends in prevalence of cigarette smoking and smoking behaviors among adolescents enables physicians to target prevention resources more effectively.

Objective: The objectives of this study were to monitor the prevalence of smoking, to compare the prevalence of smoking in subgroups of region, gender and age, and to explore smoking behavior among adolescent smokers.

Material and Method: The International Tobacco Control Survey-Thailand is a population-based, national representative, longitudinal survey conducted among adolescents between the ages of 13-17. Adolescents were sampled from Bangkok and 4 regions of Thailand using stratified multistage sampling. Three surveys were conducted during January 2005 to March 2008. Respondents were asked to complete self-administered questionnaires. Data was analyzed using descriptive statistics.

Results: Overall, smoking prevalence has increased from 12.0% in wave 1 to 14.3% in wave 2 and 18.3% in wave 3. Smoking prevalence in males was more than 10 times higher than females. Manufactured cigarettes were most frequently used by adolescents. More than 70% of smokers reported that they smoked manufactured cigarettes. Total amount of tobacco use per day increased from wave 1 to wave 3. The proportion of smokers who reported that they bought cigarettes by themselves increased during the follow-up waves (38.3%, 60.9%, 68.2% respectively). More than 20% of smokers reported that they never plan to quit smoking.

Conclusion: Smoking prevalence among thai adolescents was apparently increased.

Citation

Nagelhout, G.E., van den Putte, B., Allwright, S., Mons, U., McNeill, A., Guignard, R., Beck, F., Siahpush, M., Joossens, L., Fong, G.T., de Vries, H., Willemsen, M.C. (2014). Socioeconomic and country variations in cross-border cigarette purchasing as tobacco tax avoidance strategy: Findings from the ITC Europe Surveys. Tobacco Control, 23(Suppl 1), i30-i38.

Abstract

Background: Legal tobacco tax avoidance strategies such as cross-border cigarette purchasing may attenuate the impact of tax increases on tobacco consumption. Little is known about socioeconomic and country variations in cross-border purchasing.

Objective: To describe socioeconomic and country variations in cross-border cigarette purchasing in six European countries.

Methods: Cross-sectional data from adult smokers (n=7873) from the International Tobacco Control (ITC) Surveys in France (2006/2007), Germany (2007), Ireland (2006), The Netherlands (2008), Scotland (2006) and the rest of the UK (2007/2008) were used. Respondents were asked whether they had bought cigarettes outside their country in the last 6 months and how often.

Findings: In French and German provinces/states bordering countries with lower cigarette prices, 24% and 13% of smokers, respectively, reported purchasing cigarettes frequently outside their country. In non-border regions of France and Germany, and in Ireland, Scotland, the rest of the UK and The Netherlands, frequent purchasing of cigarettes outside the country was reported by 2-7% of smokers. Smokers with higher levels of education or income, younger smokers, daily smokers, heavier smokers and smokers not planning to quit smoking were more likely to purchase cigarettes outside their country.

Conclusions: Cross-border cigarette purchasing is more common in European regions bordering countries with lower cigarette prices and is more often reported by smokers with higher education and income. Increasing taxes in countries with lower cigarette prices, and reducing the number of cigarettes that can be legally imported across borders could help to avoid cross-border purchasing.

Citation

Partos, T.R., Borland, R., Yong, H.H., Thrasher, J.F., Hammond, D. (2013). Cigarette packet warning labels can prevent relapse: Findings from the International Tobacco Control 4-Country Policy Evaluation Cohort Study. Tobacco Control, 22(1), 43-50.

Abstract

Objectives: To investigate the links between health warning labels (WLs) on cigarette packets and relapse among recently quit smokers.

Design: Prospective longitudinal cohort survey.

Setting: Australia, Canada, the UK and the USA.

Participants: 1936 recent ex-smokers (44.4% male) from one of the first six waves (2002–2007) of the International Tobacco Control 4-Country policy evaluation survey, who were followed up in the next wave.

Main outcome measures: Whether participants had relapsed at follow-up (approximately 1 year later).

Results: In multivariate analysis, very frequent noticing of WLs among ex-smokers was associated with greater relapse 1 year later (OR: 1.52, 95% CI 1.11 to 2.09, p<0.01), but this effect disappeared after controlling for urges to smoke and self-efficacy (OR: 1.29, 95% CI 0.92 to 1.80, p=0.135). In contrast, reporting that WLs make staying quit ‘a lot’ more likely (compared with ‘not at all’ likely) was associated with a lower likelihood of relapse 1 year later (OR: 0.65, 95% CI 0.49 to 0.86, p<0.01) and this effect remained robust across all models tested, increasing in some.

Conclusions: This study provides the first longitudinal evidence that health warnings can help ex-smokers stay quit. Once the authors control for greater exposure to cigarettes, which is understandably predictive of relapse, WL effects are positive. However, it may be that ex-smokers need to actively use the health consequences that WLs highlight to remind them of their reasons for quitting, rather than it being something that happens automatically. Ex-smokers should be encouraged to use pack warnings to counter urges to resume smoking. Novel warnings may be more likely to facilitate this.

Citation

Cooper, J., Borland, R., Yong, H.H., Hyland, A., Cummings, K.M. (2013). Variations in daily cigarette consumption on work days compared with nonwork days and associations with quitting: Findings from the International Tobacco Control Four-Country Survey. Nicotine & Tobacco Research, 15(1), 192-198.

Abstract

Introduction: We explore whether reported daily cigarette consumption differs between work days and nonwork days and whether variation in consumption between work days and nonwork days influences quitting and abstinence from smoking. We also explore whether effects are independent of measures of addiction and smoking restrictions at work and home.

Methods: Data were from 5,732 respondents from the first five waves of the International Tobacco Control FourCountry Survey, occurring between 2002 and 2006. Respondents were current smokers employed outside the home. Variation in daily cigarette consumption on work days compared with nonwork days at one wave was used to predict the likelihood of making an attempt and the likelihood of maintaining a quit attempt for at least a month at the next wave. Generalized estimating equations were used to combine data for multiple waves.

Results: Just under half reported smoking more on a nonwork day, a little over a third reported no difference, and around one fifth reported smoking more on a work day. Controlling for possible confounding factors, smoking more on a work day was associated with making quit attempts. Among people who made a quit attempt, variation in consumption did not consistently predict one month's abstinence, being positive in Australia, but negative in the United Kingdom.

Conclusion: Those who smoke more on work days try to quit more. Country differences for success may be related to the extent of bans on smoking, with those smoking more on work days more likely to succeed where bans in workplaces and public places were more prevalent, such as Australia at the time.

Citation

Zawahir, S., Omar, M., Awang, R., Yong, H.H., Borland, R., Sirirassamee, B., Fong, G.T., Hammond, D. (2013). Effectiveness of antismoking media messages and education among adolescents in Malaysia and Thailand: Findings from the International Tobacco Control Southeast Asia (ITC-SEA) Project. Nicotine & Tobacco Research, 15(2), 482-491.

Abstract

Introduction: Finding ways to discourage adolescents from taking up smoking is important because those who begin smoking at an earlier age are more likely to become addicted and have greater difficulty in quitting. This article examined whether anti smoking messages and education could help to reduce smoking susceptibility among adolescents in two Southeast Asian countries and to explore the possible moderating effect of country and gender.

Methods: Data came from Wave 1 of the International Tobacco Control Southeast Asia Project (ITC-SEA) survey conducted in Malaysia (n = 1,008) and Thailand (n = 1,000) where adolescents were asked about receiving antismoking advice from nurses or doctors, being taught at schools about the danger of smoking, noticing antismoking messages, knowledge of health effects of smoking, beliefs about the health risks of smoking, smoking susceptibility, and demographic information. Data were analyzed using chi-square tests and logistic regression models.

Results: Overall, significantly more Thai adolescents reported receiving advice from their nurses or doctors about the danger of smoking (p < .001), but no country difference was observed for reported antismoking education in schools and exposure to antismoking messages. Multivariate analyses revealed that only provision of antismoking education at schools was significantly associated with reduced susceptibility to smoking among female Malaysian adolescents (OR = 0.26). Higher knowledge of smoking harm and higher perceived health risk of smoking were associated with reduced smoking susceptibility among Thai female (OR = 0.52) and Malaysian male adolescents (OR = 0.63), respectively.

Conclusions: Educating adolescents about the dangers of smoking in schools appears to be the most effective means of reducing adolescents’ smoking susceptibility in both countries, although different prevention strategies may be necessary to ensure effectiveness for male and female adolescents.