Citation

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

Abstract

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

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

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

Citation

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

Abstract

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

Citation

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

Abstract

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

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

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

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

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

Citation

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

Abstract

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

Citation

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

Abstract

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

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

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

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

Citation

Li, L., Borland, R., Yong, H.H., Fong, G.T., Jiang, Y., Li, Q., Hammond, D., Quah, A.C.K. (2014). Reported exposures to anti-smoking messages and their impact on Chinese smokers' subsequent quit attempts. International Journal of Behavioural Medicine, 21(4), 667-676.

Abstract

Background: It is important to monitor whether anti-smoking messages (if any) are noticed by the public in China and whether they have any impact on smokers' quitting behaviours over time

Purpose: This study aimed to examine Chinese smokers' exposure to anti-smoking messages in a range of channels and to determine if exposure was associated with subsequent quit attempts.

Method: A prospective cohort design was employed. Participants were 6,509 adult smokers who completed at least one of the first three waves (2006-2009) of the International Tobacco Control (ITC) China Survey sampled from six Chinese cities. The main measures were reported exposure to antismoking messages in a range of channels and smokers' subsequent quit attempts. Generalized Estimating Equations (GEE) modelling was used to combine respondents from all three waves while accounting for inherent within-person correlation.

Results: The overall exposure levels to anti-smoking messages were low and varied between cities and from one channel to another. Television was the medium with the greatest overall exposure (over 50 % in almost all the cities across all the waves). After controlling for a range of covariates, higher level of combined exposure were positively related to higher subsequent quit attempts (adjusted odds ratio = 1.03, 95 % CI 1.02 ~ 1.05, p < .001); among the individual channels, exposures in newspapers and on posters were significant in their own right.

Conclusion: The findings suggest that anti-smoking warning messages have the potential to stimulate Chinese smokers to make quit attempts, but they also indicate that the levels and strength of warning messages in China need to be increased. China should consider adopting proven international practices, including mandating pictorial health warnings on cigarette packages, adopting prominent point-of-sale warnings, and carrying out strong and ongoing mass media campaigns.

Citation

Saenz-de-Miera Juarez, B., Thrasher, J.F., Reynales, L.M., Hernández-Ávila, M., Chaloupka, F. (2014). Tax, price and cigarette brand preferences: A longitudinal study of adult smokers from the ITC Mexico Survey. Tobacco Control, 23(Suppl 1), i80-i85.

Abstract

Background: Recent tax increases in Mexico differed in structure and provided an opportunity to better understand tobacco industry pricing strategies, as well as smokers' responses to any resulting price changes.

Objectives: To assess if taxes were passed onto consumers of different cigarette brands, the extent of brand switching and predictors of preference for cheaper national brands.

Methods: Using data from three waves of the Mexican administration of the International Tobacco Control Survey, we analysed self-reported brand and price paid at last cigarette purchase. Generalised estimating equations were used to determine predictors of price and preference for national brands.

Results: The average price of premium/international brands increased each year from 2008 to 2011; however, the price for discount/national brands increased only from 2010 to 2011. The percentage of smokers who smoked national brands remained stable between 2008 and 2010 but dropped in 2011. Factors related to smoking national brands as opposed to international brands included being male and having relatively older age, lower education, lower income and higher consumption.

Conclusions: Tobacco industry pricing strategies in the wake of ad valorem taxes implemented in Mexico prior to 2011 had the impact of segmenting the market into discount national brands and premium international brands. The specific tax increase implemented in 2011 reduced the price gap between these two segments by raising the price of the national brands relative to the international brands. Evidence for trading up was found after the 2011 tax increase. These results provide further evidence for the relevance of tax policy as a tobacco control strategy; in particular, they illustrate the importance of how specific rather than ad valorem taxes can reduce the potential for downward brand switching in the face of decreasing cigarette affordability.

Citation

Cornelius, M.E., Driezen, P., Fong, G.T., Chaloupka, F., Hyland, A., Bansal-Travers, M., Carpenter, M.J., Cummings, K.M. (2014). Trends in the use of premium and discount cigarette brands: Findings from the ITC US Surveys (2002-2010). Tobacco Control, 23(Suppl 1), i48-53.

Abstract

Objective: The purpose of this paper was to examine trends in the use of premium and discount cigarette brands and determine correlates of type of brand used and brand switching.

Methods: Data from the International Tobacco Control (ITC) US adult smoker cohort survey were analysed. The total study sample included 6669 adult cigarette smokers recruited and followed from 2002 to 2011 over eight different survey waves. Each survey wave included an average of 1700 smokers per survey with replenishment of those lost to follow-up.

Results: Over the eight survey waves, a total of 260 different cigarette brands were reported by smokers, of which 17% were classified as premium and 83% as discount brands. Marlboro, Newport, and Camel were the most popular premium brands reported by smokers in our sample over all eight survey waves. The percentage of smokers using discount brands increased between 2002 and 2011, with a marked increase in brand switching from premium to discount cigarettes observed after 2009 corresponding to the $0.61 increase in the federal excise tax on cigarettes. Cigarette brand preferences varied by age group and income levels with younger, higher income smokers more likely to report smoking premium brand cigarettes, while older, middle and lower income, heavier smokers were more likely to report using discount brands.

Conclusions: Our data suggest that demographic and smoking trends favour the continued growth of low priced cigarette brands. From a tobacco control perspective, the findings from this study suggest that governments should consider enacting stronger minimum pricing laws in order to keep the base price of cigarettes high, since aggressive price marketing will likely continue to be used by manufacturers to compete for the shrinking pool of remaining smokers in the population.

Citation

Nargis, N., Ashiquzzaman, S.M., Huq, I., Fong, G.T., Hussain, A.K.M.G., Ruthbah, U.H. (2014). The price sensitivity of cigarette consumption in Bangladesh: Evidence from the International Tobacco Control (ITC) Bangladesh Wave 1 (2009) and Wave 2 (2010) Surveys. Tobacco Control, 23(Suppl 1), i39-i47.

Abstract

Background: In Bangladesh, the average excise tax on cigarettes accounted for just 38% of the average retail price of cigarettes in 2009, and 45% in 2010. Both these rates are well below the WHO recommended share of 70% of the retail price at a minimum. There is thus ample room for raising taxes on cigarettes in Bangladesh. The objective of the present work was therefore to estimate the price elasticity of demand for cigarettes and the effect of tax increases on the consumption of cigarettes and on tax revenue in Bangladesh.

Methods: Based on data from Wave 1 (2009) and Wave 2 (2010) of the International Tobacco Control Bangladesh Survey, we estimated the overall impact of a price change on cigarette demand using a twopart model. The total price elasticity of cigarettes was measured by the sum of the elasticity of smoking prevalence and the elasticity of average daily consumption conditional on smoking participation. The price elasticity estimates were used in a simulation model to predict changes in cigarette consumption and tax revenue from tax and price increases.

Results: The total price elasticity of demand for cigarettes was estimated at −0.49. The elasticity of smoking prevalence accounted for 59% of the total price elasticity. The price elasticity of cigarette consumption is higher for people belonging to lower socioeconomic status. Increases in taxes would result in a significant reduction in cigarette consumption while increasing tax revenue.

Conclusions: Raising cigarette prices through increased taxation could lead to a win-win-win situation in Bangladesh: it would reduce cigarette consumption, increase tobacco tax revenue and potentially decrease socioeconomic inequities.

Citation

Yao, T., Huang, J., Sung, H.Y., Ong, M., Mao, Z., Jiang, Y., Fong, G.T., Max, W. (2014). Who purchases cigarettes from cheaper sources in China? Findings from the ITC China Survey. Tobacco Control, 23(Suppl 1), i97-i101.

Abstract

Objective: The availability of cigarettes from cheaper sources constitutes a major challenge to public health throughout the world, including China, because it may counteract price-based tobacco control policies. The goal of this study was to identify factors associated with purchasing cigarettes from cheaper sources among adult smokers in China.

Methods: Data were analysed from Waves 1 to 3 of the International Tobacco Control China Survey conducted in 2006–2009 among adult smokers in six cities in China (N=7980). One survey question asked, “In the last 6 months, have you purchased cheaper cigarettes than you can get from local stores for economic reasons?” We examined whether sociodemographic factors and smoking intensity were associated with purchasing cigarettes from cheaper sources using the general estimating equations model. Sociodemographic factors considered were gender, age, marital status, monthly household income, education, employment status and city of residence.

Results: 15.6% of smokers reported purchasing cigarettes from cheaper sources. After controlling for other covariates, the associations of the behaviour of purchasing cigarettes from cheaper sources with age (adjusted OR (AOR)=1.49, 95% CI 1.17 to 3.92 for age 18–24 compared with age 55+) and with income (AOR=2.93, 95% CI 2.27 to 3.79 for low income compared with high income) were statistically significant, but there was no statistically significant relationship with smoking intensity.

Conclusions: Our findings indicate that young and low-income smokers are more likely than older and high-income smokers to purchase cigarettes from cheaper sources in China. Tobacco control policies that reduce the availability of cigarettes from cheaper sources could have an impact on reducing cigarette consumption among young and low-income smokers in China.

Citation

Cowie, G.A., Fong, G.T., Chaloupka, F., Borland, R., Swift, E. (2014). Cigarette brand loyalty in Australia: Findings from the ITC Four Country Survey. Tobacco Control, 23(Suppl 1), i73-i79.

Abstract

Background and aim: There is little academic research on tobacco brand loyalty and switching, and even less in restrictive marketing environments such as Australia. This paper examines tobacco brand family loyalty, reasons for choice of brand and the relation between these and sociodemographic variables over a period of 10 years in Australia.

Methods: Data from current Australian smokers from 9 waves of the International Tobacco Control Policy Evaluation 4-Country Survey covering the period from 2002 to early 2012. Key measures reported were having a regular brand, use for at least 1 year, brand stability (derived from same reported brand at successive waves), and reasons for choosing brands.

Results: Measures of brand loyalty showed little change across the period, with around 80% brand stability and 95% reporting a regular brand. Older adults were more brand-loyal than those under 25. Young people’s brand choice was influenced more by friends, whereas older adults were more concerned about health. Price was the most reported reason for brand switching. Those in the higher income tertiles showed more loyalty than those in the lowest. The least addicted smokers also showed less brand loyalty. We found no clear relationship between brand loyalty and policies that were implemented to affect tobacco use.

Conclusions: Levels of brand loyalty in Australia are quite high and consistent, and do not appear to have been influenced greatly by changes in tobacco control policies.

Citation

Huang, J., Chaloupka, F., Fong, G.T. (2014). Cigarette graphic warning labels and smoking preference in Canada: A critical examination and reformulation of the FDA regulatory impact analysis. Tobacco Control, 23(Suppl 1), i7-i12.

Abstract

Background: The estimated effect of cigarette graphic warning labels (GWL) on smoking rates is a key input to the Food and Drug Administration's (FDA) regulatory impact analysis (RIA), required by law as part of its rulemaking process. However, evidence on the impact of GWLs on smoking prevalence is scarce.

Objective: The goal of this paper is to critically analyse FDA's approach to estimating the impact of GWLs on smoking rates in its RIA, and to suggest a path forward to estimating the impact of the adoption of GWLs in Canada on Canadian national adult smoking prevalence.

Methods: A quasi-experimental methodology was employed to examine the impact of adoption of GWLs in Canada in 2000, using the USA as a control.

Findings: We found a statistically significant reduction in smoking rates after the adoption of GWLs in Canada in comparison with the USA. Our analyses show that implementation of GWLs in Canada reduced smoking rates by 2.87-4.68 percentage points, a relative reduction of 12.1-19.6%; 33-53 times larger than FDA's estimates of a 0.088 percentage point reduction. We also demonstrated that FDA's estimate of the impact was flawed because it is highly sensitive to the changes in variable selection, model specification, and the time period analysed.

Conclusions: Adopting GWLs on cigarette packages reduces smoking prevalence. Applying our analysis of the Canadian GWLs, we estimate that if the USA had adopted GWLs in 2012, the number of adult smokers in the USA would have decreased by 5.3-8.6 million in 2013. Our analysis demonstrates that FDA's approach to estimating the impact of GWLs on smoking rates is flawed. Rectifying these problems before this approach becomes the norm is critical for FDA's effective regulation of tobacco products.

Citation

Guindon, E., Driezen, P., Chaloupka, F., Fong, G.T. (2014). Cigarette tax avoidance and evasion: Findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 23(Suppl 1), i13-i22.

Abstract

Background: Decades of research have produced overwhelming evidence that tobacco taxes reduce tobacco use and increase government tax revenue. The magnitude and effectiveness of taxes in reducing tobacco use provide an incentive for tobacco users, manufacturers and others, most notably criminal networks, to devise ways to avoid or evade tobacco taxes. Consequently, tobacco tax avoidance and tax evasion can reduce the public health and fiscal benefit of tobacco taxes.

Objectives: First, this study aims to document, using data from the International Tobacco Control Policy Evaluation Project (ITC), levels and trends in cigarette users’ tax avoidance and tax evasion behaviour in a sample of 16 low-, middle- and high-income countries. Second, this study explores factors associated with cigarette tax avoidance and evasion.

Methods: We used data from ITC surveys conducted in 16 countries to estimate the extent and type of cigarette tax avoidance/evasion between countries and across time. We used self-reported information about the source of a smoker’s last purchase of cigarettes or self-reported packaging information, or similar information gathered by the interviewers during face-to-face interviews to measure tax avoidance/evasion behaviours. We used generalised estimating equations to explore individual-level factors that may affect the likelihood of cigarette tax avoidance or evasion in Canada, the USA, the UK and France.

Findings: We found prevalence estimates of cigarette tax avoidance/evasion vary substantially between countries and across time. In Canada, France and the UK, more than 10% of smokers reported last purchasing cigarettes from low or untaxed sources, while in Malaysia some prevalence estimates suggested substantial cigarette tax avoidance/evasion. We also found important associations between household income and education and the likelihood to engage in tax avoidance/evasion. These associations, however, varied both in direction and magnitude across countries.

Citation

Nagelhout, G.E., Wiebing, M.A., van den Putte, B., de Vries, H., Crone, M.R., Bot, S.M., Willemsen, M.C. (2014). ‘Ik wed dat ik het kan!’ - Bereik en effecten van een entertainment-education strategie voor stoppen met roken bij laag-, middelbaar en hoogopgeleide rokers [‘I bet I can do it!’ – Reach and effects of an entertainment education strategy for smoking cessation among low, moderate and high educated smokers]. Tijdschrift voor Gezondheidswetenschappen, 92, 84-92.

Abstract

Introduction: Smoking is in the Netherlands more prevalent among lower and moderate educated than among higher educated people. The entertainment-education television show ‘I bet I can do it!’ was specifically designed to stimulate smoking cessation among low and moderate educated smokers.

Methods: The effect of the television show was evaluated with longitudinal data of the International Tobacco Control Policy Evaluation Project. Dutch smokers (n = 1,743) aged 15 years and older filled in a survey before and after the seven episodes of ‘I bet I can do it!’ in 2008.

Results: Low educated (OR = 1.55, p = 0.048) and moderate educated respondents (OR = 1.99, p < 0.001) had seen the television show significantly more often than high educated respondents. The show was not significantly associated with self efficacy, quit intention, and quit success, but it was significantly associated with more quit attempts among moderate educated respondents (OR = 2.36, p < 0.001).

Conclusion: The reach of ‘I bet I can do it!’ and the effect on quit attempts was larger among moderate educated smokers. The entertainment-education strategy for smoking cessation television programs should be further refined. This can possible lead to a program that has positive effects on the quit intention, self efficacy, quit attempts and the quit success of low and moderate educated smokers.

Abstract

Introduction: The Heaviness of Smoking Index (HSI) is the measure of dependence most strongly predictive of relapse. However, recent research suggests it may not be predictive of longer term relapse. Our aim was to examine its predictive power over the first 2 years after quitting and explore whether use of stop-smoking medications is a moderator.

Methods: Data (n = 7,093) came from the first 7 waves (2002-2009) of the International Tobacco Control Four-Country Survey, an annual cohort survey of smokers in Canada, United States, United Kingdom, and Australia. HSI and its 2 components (cigarettes per day [CPD] and time to first cigarette [TTFC]) were used to predict smoking relapse risk in the 2 years after the start of a quit attempt.

Results: Scores on HSI and its components all strongly predicted relapse, but there was an interaction with time (p < .001). These measures were strong predictors of relapse within the first week of quitting (hazard ratios [HR] = 1.17, 1.24, and 1.30 for HSI, CPD, and TTFC, respectively, all p < .001), less predictive of relapse occurring between 1 week and 1 month, and not clearly predictive beyond 1 month. Among those using medication to quit, hazard ratio for HSI (HR = 1.11, p < .001) was significantly lower than for those not using (HR = 1.24, p < .001) in the first week, but not beyond.

Conclusions: HSI and its 2 components are strong predictors of short-term smoking relapse, but they rapidly lose predictive power over the first weeks of an attempt, becoming marginally significant at around 1 month, and not clearly predictive beyond that.

Citation

Tauras, J.A., Chaloupka, F., Fong, G.T., Quah, A.C.K. (2014). The economics of tobacco control: Evidence from the International Tobacco Control (ITC) Policy Evaluation Project. Tobacco Control, 23(Suppl 1), i1-i3.

Abstract

Over the past few decades, the importance of economic research in advancing tobacco control policies has become increasingly clear. Extensive research has demonstrated that increasing tobacco taxes and prices is the single most cost-effective tobacco control measure. The research contained in this supplement adds to this evidence and provides new insights into how smokers respond to tax and price changes using the rich data on purchase behaviours, brand choices, tax avoidance and evasion, and tobacco use collected systematically and consistently across countries and over time by the International Tobacco Control (ITC) Project. The findings from this research will help inform policymakers, public health professionals, advocates, and others seeking to maximise the public health and economic benefits from higher taxes.

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.