Citation

Perez-Hernandez, R., Thrasher, J.F., Rodriquez-Bolanos, R., Barrientos-Gutierrez, I., Ibanez-Hernandez, N.A. (2012). Autorreporte de exposición a publicidad y promoción de tabaco en una cohorte de fumadores mexicanos [Self-reported exposure to tobacco advertising and promotion in a cohort of Mexican smokers]. Salud Publica de Mexico, 54(3), 204-212.

Abstract

Objective: To determine in a population-based sample of smokers the level exposure to tobacco industry marketing through different channels before and after their restriction through the General Tobacco Control Law of 2008.

Materials and Methods: Data were analyzed from a cohort of adult smokers from four Mexican cities who were surveyed in 2007 and 2008. GEE models were estimated for each indicator of advertising and promotion exposure.

Results: Increases were found in report of receiving free samples of tobacco (3.7-8.1%), branded clothing (3.6- 6.4%), noticing tobacco industry sponsored events (1.9-4.7%) and noticing ads in bars (21.4-28%). Noticing outdoor advertising decreased over this time (54.7 a 47.2%).

Conclusions: Our findings confirm tobacco industry shifting of marketing efforts when advertising and promotion bans are not comprehensive. There is a need to monitor compliance with marketing bans while working to make them comprehensive.

Citation

Thrasher, J.F., Arillo-Santillán, E., Villalobos, V., Perez-Hernandez, R., Hammond, D., Carter, J., Sebrie, E.M., Sansores, R., Regalado-Pineda, J. (2012). Can pictorial warning labels on cigarette packages address smoking-related health disparities? Field experiments in Mexico to assess pictorial warning label content. Cancer Causes Control, 23(Suppl 1), 69-80.

Abstract

Objective: The objective of this study was to determine the most effective content of pictorial health warning labels (HWLs) and whether educational attainment moderates these effects.

Methods: Field experiments were conducted with 529 adult smokers and 530 young adults (258 nonsmokers; 271 smokers). Participants reported responses to different pictorial HWLs printed on cigarette packages. One experiment involved manipulating textual form (testimonial narrative vs. didactic) and the other involved manipulating image type (diseased organs vs. human suffering).

Results: Tests of mean ratings and rankings indicated that pictorial HWLs with didactic textual forms had equivalent or significantly higher credibility, relevance, and impact than pictorial HWLs with testimonial forms. Results from mixed-effects models confirmed these results. However, responses differed by participant educational attainment: didactic forms were consistently rated higher than testimonials among participants with higher education, whereas the difference between didactic and testimonial narrative forms was weaker or not statistically significant among participants with lower education. In the second experiment, with textual content held constant, greater credibility, relevance, and impact was found for graphic imagery of diseased organs than imagery of human suffering.

Conclusions: Pictorial HWLs with didactic textual forms seem to work better than those with testimonial narratives. Future research should determine which pictorial HWL content has the greatest real-world impact among consumers from disadvantaged groups, including assessment of how HWL content should change to maintain its impact as tobacco control environments strengthen and consumer awareness of smoking-related risks increases.

Citation

Thrasher, J.F., Perez-Hernandez, R., Arillo-Santillán, E., Barrientos-Gutierrez, I. (2012). Hacia el consumo informado de tabaco en México: Efecto de las advertencias en población fumadora [Towards informed tobacco consumption in Mexico: Effects of pictorial warning labels among smokers]. Salud Publica de Mexico, 54(3), 242-253.

Abstract

Objective: Evaluate the effect of the first pictorial warning labels on cigarette packs in Mexican smokers.

Materials and Methods: A population-based representative cohort of smokers from seven Mexican cities was surveyed before (2010) and after (2011) the implementation of pictorial warning labels. To determine the change variables representing the cognitive and behavioral impact of pictorial warnings, bivariate and adjusted generalized estimating equations were estimated. Data from the second survey (2011) were analyzed to determine the factors associated with aided recall of specific pictorial warnings, as well as the factors associated with self-report of the impact that these warnings had.

Results: From 2010 to 2011, significant increases were found in smoker's knowledge about smoking risks, the toxic components of tobacco, and the quitline number for receiving cessation assistance. Recall and impact of specific pictorial warnings was generally broad and equally distributed across the smoker population. In comparison with recent ex-smokers interviewed in 2010, more recent ex-smokers in 2011 reported that pack warnings had influenced their decision to quit (RM=2.44, 95% IC 1.27-4.72).

Conclusion: The first pictorial warning labels on cigarette packages in Mexico have had a significant impact on knowledge and behavior.

Citation

Wilson, N., Gifford, H., Edwards, R., Thomson, G. (2012). Smokefree cars to protect children and denormalise smoking: a mini-review of New Zealand literature. New Zealand Medical Journal, 125 (1355), 81-86.

Abstract

The Associate Minister of Health (Hon Tariana Turia) has signalled interest in the New Zealand Government developing legislation to protect child health by limiting smoking in cars with children.1 Such a move would be part of an international trend that has seen such laws covering most Australian states, Canadian Provinces and some US States (including California).2 3 It would also be consistent with other actions to limit hazards and improve safety within cars: compulsory seat belts, compulsory car seats for infants, and bans on mobile phone use while driving (as recently enacted by the last National Party-led Government in New Zealand). Smokefree cars would help reduce the burden of child illness, given the evidence for the role of secondhand smoke (SHS) in “sudden infant death syndrome (SIDS), asthma, altered respiratory function, infection, cardiovascular effects, behaviour problems, sleep difficulties, increased cancer risk, and a higher likelihood of smoking initiation”.4 Reducing these impacts could in turn reduce both private and tax-payer funded health system costs (given international evidence on SHS impacts on health costs5–7). It is expected that the move would help reduce smoking uptake in children by providing positive smokefree modelling (given New Zealand evidence8 and international evidence4). To provide background and context to further policy-maker discussions on this topic, we tabulate the New Zealand literature relevant to smokefree car policies that we could identify on Medline and on health organisation websites in New Zealand (Table 1).

Citation

Wilson, N., Weerasekera, D., Peace, J., Edwards, R. (2011). Smokers have varying misperceptions about the harmfulness of menthol cigarettes: National survey data. Australian and New Zealand Journal of Public Health, 35(4), 364-367.

Abstract

Objective: To describe the prevalence of menthol use and perceptions of relative harmfulness among smokers in an ethnically diverse population where tobacco marketing is relatively constrained (New Zealand).

Methods: The New Zealand (NZ) arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) utilises the NZ Health Survey (a national sample). From this sample we surveyed adult smokers, with Wave 2 (n=923) covering beliefs around menthol cigarettes.

Results: Agreement with the statement that “menthol cigarettes are less harmful than regular cigarettes” was higher in smokers who were: older, Māori, Pacific, Asian, financially stressed and had higher levels of individual deprivation. Most of these associations were statistically significant in at least some of the logistic regression models (adjusting for socio-economic and smoking beliefs and behaviour). In the fully-adjusted model this belief was particularly elevated in Pacific smokers (adjusted odds ratio [aOR] = 7.36, 95% CI = 1.92 - 28.27) and also in menthol smokers (aOR = 4.58, 95% CI = 1.94-10.78). Most smokers in this study (56%), and especially menthol smokers (73%), believed that menthols are “smoother on your throat and chest”.

Conclusion: Various groups of smokers in this national sample had misperceptions around the relative harmfulness of menthols, which is consistent with most previous studies.

Implications: This evidence, along with a precautionary approach, supports arguments for enhanced regulation of tobacco marketing and tobacco ingredients such as menthol.

Citation

Siahpush, M., Borland, R., Fong, G.T., Elton-Marshall, T., Yong, H.H., Holumyong, C. (2011). Socioeconomic differences in the effectiveness of the removal of the light descriptor on cigarette packs: Findings from the International Tobacco Control (ITC) Thailand Survey. International Journal of Environmental Research and Public Health, 8(6), 2170-2180.

Abstract

Many smokers incorrectly believe that “light” cigarettes are less harmful than regular cigarettes. To address this problem, many countries have banned “light” or “mild” brand descriptors on cigarette packs. Our objective was to assess whether beliefs about “light” cigarettes changed following the 2007 removal of these brand descriptors in Thailand and, if a change occurred, the extent to which it differed by socioeconomic status. Data were from waves 2 (2006), 3 (2008), and 4 (2009) of the International Tobacco Control (ITC) Thailand Survey of adult smokers in Thailand. The results showed that, following the introduction of the ban, there was an overall decline in the two beliefs that “light” cigarettes are less harmful and smoother than regular cigarettes. The decline in the “less harmful” belief was considerably steeper in lower income and education groups. However, there was no evidence that the rate of decline in the “smoother” belief varied by income or education. Removing the “light” brand descriptor from cigarette packs should thus be viewed not only as a means to address the problem of smokers‘ incorrect beliefs about “light” cigarettes, but also as a factor that can potentially reduce socioeconomic disparities in smoking-related misconceptions.

Citation

Ross, H., Blecher, E., Yan, L., Cummings, K.M. (2011, February). Predictors of what smokers say they will do in response to future price increases: Findings from the ITC Four Country Study. Poster presentation at the Society for Research on Nicotine and Tobacco Annual Meeting, Toronto, Ontario, Canada.

Abstract

Introduction: Given the impact of higher tobacco prices on smoking cessation, we studied the role of future cigarette prices on forming expectation about smoking behavior.

Methods: Using a random sample of 9,058 adult cigarette smokers from the United States, Canada, Australia, and the United Kingdom collected in 2002, we examined predictors of what smokers say they will do in response to a hypothetical 50% increase in the price they paid for their last cigarette purchase. A series of regression analyses examined factors associated with intentions that have a positive impact on health, that is, intentions to quit and/or to consume fewer cigarettes.

Results: The quit and/or smoke less intentions were more pronounced among those who lived in areas with higher average cigarette prices and who paid higher prices for their brand of choice during the last purchase. The magnitude of the price increase is a more important predictor of an intention to quit/smoke less compared with the average cigarette price.

Conclusions: The availability of alternative (cheaper) cigarette sources may reduce but would not eliminate the impact of higher prices/taxes on smokers’ expected behavior that has been linked to actual quit intentions and quitting in follow-up surveys.

Citation

Licht, A.S., Hyland, A., O’Connor, R.J., Chaloupka, F., Borland, R., Fong, G.T., Nargis, N., Cummings, K.M. (2011). How do price minimizing behaviors impact smoking cessation? Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(5), 1671-1691.

Abstract

This paper examines how price minimizing behaviors impact efforts to stop smoking. Data on 4,988 participants from the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey who were smokers at baseline (wave 5) and interviewed at a 1 year follow-up were used. We examined whether price minimizing behaviors at baseline predicted: (1) cessation, (2) quit attempts, and (3) successful quit attempts at one year follow up using multivariate logistic regression modeling. A subset analysis included 3,387 participants who were current smokers at waves 5 and 6 and were followed through wave 7 to explore effects of changing purchase patterns on cessation. Statistical tests for interaction were performed to examine the joint effect of SES and price/tax avoidance behaviors on cessation outcomes. Smokers who engaged in any price/tax avoidance behaviors were 28% less likely to report cessation. Persons using low/untaxed sources were less likely to quit at follow up, those purchasing cartons were less likely to make quit attempts and quit, and those using discount cigarettes were less likely to succeed, conditional on making attempts. Respondents who utilized multiple behaviors simultaneously were less likely to make quit attempts and to succeed. SES did not modify the effects of price minimizing behaviors on cessation outcomes. The data from this paper indicate that the availability of lower priced cigarette alternatives may attenuate public health efforts aimed at to reduce reducing smoking prevalence through price and tax increases among all SES groups.

Citation

Nagelhout, G.E., Mons, U., Allwright, S., Guignard, R., Beck, F., Fong, G.T., de Vries, H., Willemsen, M.C. (2011). Prevalence and predictors of smoking in smoke-free bars: Findings from the International Tobacco Control (ITC) Europe Surveys. Social Science & Medicine, 72(10), 1643-1651.

Abstract

National level smoke-free legislation is implemented to protect the public from exposure to second-hand tobacco smoke (SHS). The first aim of this study was to investigate how successful the smoke-free hospitality industry legislation in Ireland (March 2004), France (January 2008), the Netherlands (July 2008), and Germany (between August 2007 and July 2008) was in reducing smoking in bars. The second aim was to assess individual smokers’ predictors of smoking in bars post-ban. The third aim was to examine country differences in predictors and the fourth aim was to examine differences between educational levels (as an indicator of socioeconomic status). This study used nationally representative samples of 3147 adult smokers from the International Tobacco Control (ITC) Europe Surveys who were surveyed pre- and post-ban. The results reveal that while the partial smoke-free legislation in the Netherlands and Germany was effective in reducing smoking in bars (from 88% to 34% and from 87% to 44%, respectively), the effectiveness was much lower than the comprehensive legislation in Ireland and France which almost completely eliminated smoking in bars (from 97% to 3% and from 84% to 3% respectively). Smokers who were more supportive of the ban, were more aware of the harm of SHS, and who had negative opinions of smoking were less likely to smoke in bars post-ban. Support for the ban was a stronger predictor in Germany. SHS harm awareness was a stronger predictor among less educated smokers in the Netherlands and Germany. The results indicate the need for strong comprehensive smoke-free legislation without exceptions. This should be accompanied by educational campaigns in which the public health rationale for the legislation is clearly explained.

Citation

Raute, L.J., Sansone, G.C., Pednekar, M.S., Fong, G.T., Gupta, P.C., Quah, A.C.K., Bansal-Travers, M., Sinha, D.N. (2011). Knowledge of health effects and intentions to quit among smokeless tobacco users in India: Findings from the International Tobacco Control Policy Evaluation (ITC) India Pilot Survey. Asian Pacific Journal of Cancer Prevention, 12(5), 1233-1238.

Abstract

Introduction and background: The prevalence of smokeless tobacco use in India is the highest in the world, with 26% of adults reporting being users of smokeless tobacco only. But to date, there are few of beliefs, knowledge, and other psychosocial measures relating to smokeless tobacco use in India. The aim of the present study was to use data from the ITC India Pilot Study conducted in 2006 to examine beliefs about the harms of smokeless tobacco use, knowledge of health effects, and intentions to quit among current smokeless tobacco users in two states, Maharashtra and Bihar.

Methods: Data from the ITC India Pilot Study, a face-to-face cross-sectional survey of 248 adults reporting exclusive current use of smokeless tobacco in Maharashtra and Bihar, were analyzed with respect to the knowledge of health effects, beliefs about harmfulness, and intentions to quit smokeless tobacco use.

Results: Around three quarters (36%) of smokeless tobacco users from Maharashtra and two thirds (62%) from Bihar had a ‘bad’ opinion about smokeless tobacco use. About 77% believed that smokeless tobacco use causes mouth cancer, followed by gum disease (66%) and difficulty in opening the mouth (56%). Significant differences were found in health knowledge between urban and rural smokeless tobacco users in both states. Only 38% of smokeless tobacco users reported having intentions to quit, and only 11% had intentions to quit within the next 6 months. Smokeless tobacco users who reported higher knowledge of the specific health effects from smokeless tobacco use were more likely to have intentions to quit.

Conclusion: Despite the fairly high levels of awareness of health effects from smokeless tobacco use in Maharashtra and Bihar, the majority of smokeless users had no intentions to quit. Increased educational efforts about the detrimental health effects from smokeless tobacco use may result in higher levels of knowledge about the harms of smokeless tobacco and this in turn could increase quit intentions and subsequent quitting among users.

Citation

Abdullah, A.S., Hitchman, S.C., Driezen, P., Nargis, N., Quah, A.C.K., Fong, G.T. (2011). Socioeconomic differences in exposure to tobacco smoke pollution (TSP) in Bangladeshi households with children: Findings from the International Tobacco Control (ITC) Bangladesh Survey. International Journal of Environmental Research and Public Health, 8(3), 842-860.

Abstract

This study assessed the pattern of exposure to tobacco smoke pollution (TSP; also known as, secondhand smoke) in Bangladeshi households with children and examined the variations in household smoking restrictions and perception of risk for children‘s exposure to TSP by socioeconomic status. We interviewed 1,947 respondents from Bangladeshi households with children from the first wave (2009) of the International Tobacco Control (ITC) Bangladesh Survey. 43.5% of the complete smoking restrictions at home and 39.7% were very or extremely concerned about TSP risk to children‘s health. Participants with lower level of education were significantly less likely to be concerned about the risk of TSP exposure to children‘s health and less likely to adopt complete smoking restrictions at home. Logistic regression revealed that the predictors of concern for TSP exposure risk were educational attainment of 1 to 8 years (OR = 1.94) or 9 years or more (OR = 4.07) and being a smoker (OR = 0.24). The predictors of having complete household smoking restrictions were: urban residence (OR = 1.64), attaining education of 9 years or more (OR = 1.94), being a smoker (OR = 0.40) and being concerned about TSP exposure risk to children (OR = 3.25). The findings show that a high proportion of adults with children at home smoke tobacco at home and their perceptions of risk about TSP exposure to children‘s health were low. These behaviours were more prevalent among rural smokers who were illiterate. There is a need for targeted intervention, customized for low educated public, on TSP risk to children‘s health and tobacco control policy with specific focus on smoke-free home.

Citation

Ross, H., Blecher, E., Yan, L., Cummings, K.M. (2011). Do cigarette prices motivate smokers to quit? New evidence from the ITC Survey. Addiction, 106(3), 609-619.

Abstract

Aims: To examine the importance of cigarette prices in influencing smoking cessation and the motivation to quit.

Design: We use longitudinal data from three waves of the International Tobacco Control Policy Evaluation Survey (ITC). The study contrasts smoking cessation and motivation to quit among US and Canadian smokers and evaluates how this relationship is modified by cigarette prices, nicotine dependence and health knowledge. Different price measures are used to understand how the ability to purchase cheaper cigarettes may reduce the influence of prices. Our first model examines whether cigarette prices affect motivation to quit smoking using Generalized Estimating Equations to predict cessation stage and a least squares model to predict the change in cessation stage. The second model evaluates quitting behavior over time. The probability of quitting is estimated with Generalized Estimating Equations and a transition model to account for the ‘left-truncation’ of the data.

Settings: US and Canada. Participants 4352 smokers at Wave 1, 2000 smokers completing all three waves. Measurements Motivation to quit, cigarette prices, nicotine dependence and health knowledge. Findings Smokers living in areas with higher cigarette prices are significantly more motivated to quit. There is limited evidence to suggest that price increases over time may also increase quit motivation. Higher cigarette prices increase the likelihood of actual quitting, with the caveat that results are statistically significant in one out of two models. Access to cheaper cigarette sources does not impede cessation although smokers would respond more aggressively (in terms of cessation) to price increases if cheaper cigarette sources were not available.

Conclusions: This research provides a unique opportunity to study smoking cessation among adult smokers and their response to cigarette prices in a market where they are able to avoid tax increases by purchasing cigarettes from cheaper sources. Higher cigarette prices appear to be associated with greater motivation to stop smoking, an effect which does not appear to be mitigated by cheaper cigarette sources. The paper supports the use of higher prices as a means of encouraging smoking cessation and motivation to quit.

Citation

Yang, J., Hammond, D., Driezen, P., O’Connor, R.J., Li, Q., Yong, H.H., Fong, G.T., Jiang, Y. (2011). The use of cessation assistance among smokers from China: Findings from the ITC China Survey. BioMed Central Public Health, 11, 75.

Abstract

Background: Stop smoking medications significantly increase the likelihood of smoking cessation. However, there are no population-based studies of stop-smoking medication use in China, the largest tobacco market in the world. This study examined stop-smoking medication use and its association with quitting behavior among a population based sample of Chinese smokers.

Methods: Face-to-face interviews were conducted with 4,627 smokers from six cities in the ITC China cohort survey. Longitudinal analyses were conducted using Wave 1 (April to August, 2006) and Wave 2 (November 2007 to January 2008).

Results: Approximately 26% of smokers had attempted to quit between Waves 1 and 2, and 6% were abstinent at 18-month follow-up. Only 5.8% of those attempting to quit reported NRT use and NRT was associated with lower odds of abstinence at Wave 2 (OR = 0.11; 95%CI = 0.03-0.46). Visiting a doctor/health professional was associated with greater attempts to quit smoking (OR = 1.60 and 2.78; 95%CI = 1.22-2.10 and 2.21-3.49 respectively) and being abstinent (OR = 1.77 and 1.85; 95%CI = 1.18- 2.66 and 1.13-3.04 respectively) at 18-month follow-up relative to the smokers who did not visit doctor/health professional.

Conclusions: The use of formal help for smoking cessation is low in China. There is an urgent need to explore the use and effectiveness of stop-smoking medications in China and in other non-Western markets.

Citation

Thomson, G., Wilson, N., Weerasekera, D., Edwards, R. (2011). Strong smoker interest in 'setting example to children' by quitting: National survey data. Australian and New Zealand Journal of Public Health, 35(1), 81-84.

Abstract

Objective: To further explore smoker views on reasons to quit.

Methods: As part of the multi-country ITC Project, a national sample of 1,376 New Zealand adult (18+ years) smokers was surveyed in 2007/08. This sample included boosted sampling of Māori, Pacific and Asian New Zealanders.

Results: 'Setting an example to children' was given as 'very much' a reason to quit by 51%, compared to 45% giving personal health concerns. However, the 'very much' and 'somewhat' responses (combined) were greater for personal health (81%) than 'setting an example to children' (74%). Price was the third ranked reason (67%). In a multivariate analysis, women were significantly more likely to state that 'setting an example to children' was 'very much' or 'somewhat' a reason to quit; as were Māori, or Pacific compared to European; and those suffering financial stress.

Conclusion: The relatively high importance of 'example to children' as a reason to quit is an unusual finding, and may have arisen as a result of social marketing campaigns encouraging cessation to protect families in New Zealand.

Implications: The policy implications could include a need for a greater emphasis on social reasons (e.g. 'example to children'), in pack warnings, and in social marketing for smoking cessation.

Citation

Kasza, K.A., Hyland, A., Brown, A., Siahpush, M., Yong, H.H., McNeill, A., Li, L., Cummings, K.M. (2011). The effectiveness of tobacco marketing regulations on reducing smokers' exposure to advertising and promotion: Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(2), 321-340.

Abstract

Exposure to tobacco product marketing promotes the initiation, continuation, and reuptake of cigarette smoking and as a result the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) has called upon member Parties to enact comprehensive bans on tobacco advertising and promotion. This study examines the immediate and long term effectiveness of advertising restrictions enacted in different countries on exposure to different forms of product marketing, and examines differences in exposure across different socioeconomic status (SES) groups. Nationally representative data from the United Kingdom, Canada, Australia, and the United States, collected from adult smokers between 2002 and 2008 using the International Tobacco Control Four Country Survey (ITC-4), were used in this study (N = 21,615). In light of the specific marketing regulation changes that occurred during the course of this study period, changes in awareness of tobacco marketing via various channels were assessed for each country, and for different SES groups within countries. Tobacco marketing regulations, once implemented, were associated with significant reductions in smokers’ reported awareness of prosmoking cues, and the observed reductions were greatest immediately following the enactment of regulations. Changes in reported awareness were generally the same across different SES groups, although some exceptions were noted. While tobacco marketing regulations have been effective in reducing exposure to certain types of product marketing there still remain gaps, especially with regard to in-store marketing and price promotions.

Citation

Licht, A.S., Hyland, A., O’Connor, R.J., Chaloupka, F., Borland, R., Fong, G.T., Nargis, N., Cummings, K.M. (2011). Socio-economic variation in price minimizing behaviors: Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(1), 234-252.

Abstract

This paper examines how socio-economic status (SES) modifies how smokers adjust to changes in the price of tobacco products through utilization of multiple price minimizing techniques. Data come from the International Tobacco Control Policy Evaluation (ITC) Four Country Survey, nationally representative samples of adult smokers and includes respondents from Canada, the United States, the United Kingdom and Australia. Cross-sectional analyses were completed among 8,243 respondents (7,038 current smokers) from the survey wave conducted between October 2006 and February 2007. Analyses examined predictors of purchasing from low/untaxed sources, using discount cigarettes or roll-your-own (RYO) tobacco, purchasing cigarettes in cartons, and engaging in high levels of price and tax avoidance at last purchase. All analyses tested for interactions with SES and were weighted to account for changing and under-represented demographics. Relatively high levels of price and tax avoidance behaviors were present; 8% reported buying from low or untaxed source; 36% used discount or generic brands, 13.5% used RYO tobacco, 29% reported purchasing cartons, and 63% reported using at least one of these high price avoidance behaviors. Respondents categorized as having low SES were approximately 26% less likely to report using low or untaxed sources and 43% less likely to purchase tobacco by the carton. However, respondents with low SES were 85% more likely to report using discount brands/RYO compared to participants with higher SES. Overall, lower SES smokers were 25% more likely to engage in at least one or more tax avoidance behaviors compared to their higher SES counterparts. Price and tax avoidance behaviors are relatively common among smokers of all SES strata, but strategies differed with higher SES groups more likely to report traveling to a low-tax location to avoid paying higher prices, purchase duty free tobacco, and purchase by cartons instead of packs all of which were less commonly reported by low SES smokers. Because of the strategies lower SES respondents are more likely to use, reducing price differentials between discount and premium brands may have a greater impact on them, potentially increasing the likelihood of quitting.

Citation

O’Connor, R.J., Norton, K.J., Bansal-Travers, M., Mahoney, M.C., Cummings, K.M., Borland, R. (2011). US smokers' reactions to a brief trial of oral nicotine products. Harm Reduction Journal, 8(1), 1.

Abstract

Background: It has been suggested that cigarette smokers will switch to alternative oral nicotine delivery products to reduce their health risks if informed of the relative risk difference. However, it is important to assess how smokers are likely to use cigarette alternatives before making predictions about their potential to promote individual or population harm reduction.

Objectives: This study examines smokers’ interest in using a smokeless tobacco or a nicotine replacement product as a substitute for their cigarettes.

Methods: The study included 67 adult cigarette smokers, not currently interested in quitting, who were given an opportunity to sample four alternative oral nicotine products: 1) Camel Snus, 2) Marlboro Snus, 3) Stonewall dissolvable tobacco tablets, and 4) Commit nicotine lozenges. At visit 1, subjects were presented information about the relative benefits/risks of oral nicotine delivery compared to cigarettes. At visit 2, subjects were given a supply of each of the four products to sample at home for a week. At visit 3, subjects received a one-week supply of their preferred product to see if using such products reduced or eliminated cigarette use.

Results: After multiple product sampling, participants preferred the Commit lozenges over the three smokeless tobacco products (p = 0.011). Following the one week single-product trial experience, GEE models controlling for gender, age, level of education, baseline cigarettes use, and alternative product chosen, indicated a significant decline in cigarettes smoked per day across one week of single-product sampling (p < 0.01, from 11.8 to 8.7 cigarettes per day), but no change in alternative product use (approximately 4.5 units per day). Biomarkers of exposure showed no change in cotinine, but a 19% reduction in exhaled CO (p < 0.001).

Conclusions: Findings from this study show that smokers, who are currently unwilling to make a quit attempt, may be willing to use alternative products in the short term as a temporary substitute for smoking. However, this use is more likely to be for partial substitution (i.e. they will continue to smoke, albeit at a lower rate) rather than complete substitution. Of the various substitutes offered, smokers were more willing to use a nicotine replacement product over a tobacco-based product.

Citation

Hitchman, S.C., Fong, G.T., Zanna, M.P., Hyland, A., Bansal-Travers, M. (2011). Support and correlates of support for banning smoking in cars with children: Findings from the ITC Four Country Survey. European Journal of Public Health, 21(3), 360-365.

Abstract

Background: Since 2006, banning smoking in cars with children has become a rapidly growing tobacco control policy. However, to date, there have been few studies examining support and correlates of support for car smoking bans, and none of the existing studies have been international in nature. We conducted such a study among smokers in four countries.

Methods: 6716 adult current smokers from the 2007 Wave of the International Tobacco Control Four Country Survey, a nationally representative, longitudinal cohort telephone survey of smokers in the USA, Canada, UK and Australia. Controlling for demographics, heaviness of smoking, smoking health knowledge/beliefs and quit intentions, we compared support and correlates of support for banning smoking in cars with children across the four countries.

Results: The majority of smokers supported banning smoking in cars with children. Support was highest in Australia (83%), followed by the UK (75%) and Canada (74%); support was lower—but still high—in the USA (60%). Support was highest among smokers who: had stronger quit intentions, were lighter smokers, had lower education, had no children in the home, believed that cigarette smoke is dangerous to non-smokers and could cause asthma in children, and were concerned about modelling smoking to children.

Conclusions: These findings indicate that a majority of smokers in the four countries support banning smoking in cars with children, and lend support to banning smoking in cars with children. Additionally, they suggest that support may be increased by educating smokers about the dangers of cigarette smoke exposure.

Citation

Balmford, J., Borland, R., Hammond, D., Cummings, K.M. (2011). Adherence to and reasons for premature discontinuation from stop-smoking medications: Data from the ITC Four-Country Survey. Nicotine & Tobacco Research, 13(2), 94-102.

Abstract

Introduction: Nicotine replacement therapies (NRTs) have been demonstrated to be effective in clinical trials but may have lower efficacy when purchased over-the-counter (OTC). Premature discontinuation and insufficient dosing have been offered as possible explanations. The aims are to (a) investigate the prevalence of and reasons for premature discontinuation of stop-smoking medications (including prescription only) and (b) how these differ by type, duration of use, and source (prescription or OTC).

Methods: The sample includes 1,219 smokers or recent quitters who had used medication in the last year (80.5% NRT, 19.5% prescription only). Data were from Waves 5 and 6 of the International Tobacco Control (ITC) Four-Country Survey.

Results: Most of the sample (69.1%) discontinued medication use prematurely. This was more common among NRT users (71.4%) than in users of bupropion and varenicline (59.6%). OTC NRT users were particularly likely to discontinue (76.3%). Relapse back to smoking was the most common reason for discontinuation of medication reported by 41.6% of respondents. Side effects (18.3%) and believing that the medication was no longer needed (17.1%) were also commonly reported. Of those who completed treatment, 37.9% achieved 6-month continuous abstinence compared with 15.6% who discontinued prematurely. Notably, 65.6% who discontinued because they believed the medication had worked were abstinent.

Conclusions: Premature discontinuation of stop-smoking medications is common but is not a plausible reason for poorer quit outcomes for most people. Encouraging persistence of medication use after relapse or in the face of minor side effects may help increase long-term cessation outcomes.

Citation

Borland, R., Cooper, J., McNeill, A., O’Connor, R.J., Cummings, K.M. (2011). Trends in beliefs about the harmfulness and use of stop-smoking medications and smokeless tobacco products among cigarettes smokers: Findings from the ITC Four-Country Survey. Harm Reduction Journal, 8(1), 21-31.

Abstract

Background: Evidence shows that smokers are generally misinformed about the relative harmfulness of nicotine, and smokeless forms of nicotine delivery in relation to smoked tobacco. This study explores changing trends in the beliefs about the harmfulness and use of stop smoking medications and smokeless tobacco in adult smokers in four countries where public education and access to alternative forms of nicotine is varied (Canada, the US, the UK and Australia).

Methods: Data are from seven waves of the ITC-4 country study conducted between 2002 and 2009 with adult smokers from Canada, the US, the UK and Australia. For the purposes of this study, data were collected from 21,207 current smokers. Using generalised estimating equations to control for multiple response sets, multivariate models were tested to look for main effects of country, and trends across time, controlling for demographic variables.

Results: Knowledge remained low in all countries, although UK smokers tended to be better informed. There was a small but significant improvement across time in the UK, but mixed effects in the other three countries. At the final wave, between 37.5% (US) and 61.4% (UK) reported that NRT is a lot less harmful than cigarettes. In Canada and the US, where smokeless tobacco is marketed, only around one in six believed some smokeless tobacco products could be less harmful than cigarettes.

Conclusions: Many smokers continue to be misinformed about the relative safety of nicotine and alternatives to smoked tobacco, especially in the US and Canada. Concerted efforts to educate UK smokers have probably improved their knowledge. Further research is required to assess whether misinformation deters smokers from appropriate use of alternative forms of nicotine.

Citation

Cooper, J., Borland, R., Yong, H.H. (2011). Australian smokers increasingly use help to quit, but number of attempts remains stable: Findings from the International Tobacco Control Study 2002-09. Australian and New Zealand Journal of Public Health, 35(4), 368-376.

Abstract

Objective: To assess interest in quitting smoking and quitting activity, and the use of pharmacotherapy and behavioural cessation support, among Australian smokers between 2002 and 2009.

Methods: Data were taken from 3303 daily smokers taking part in a minimum of two consecutive waves of the International Tobacco Control Four Country Survey. Using weighted data to control for sampling and attrition, we explored any effects due to age, sex, whether living in a metropolitan or regional area, and nicotine dependence.

Results: Around 40% of smokers reported trying to quit and, of these, about 23% remained abstinent for at least one month when surveyed. Low socioeconomic smokers were less likely to be interested in quitting and less likely to make a quit attempt. Reported use of prescription medication to quit smoking rose sharply at the last wave with the addition of varenicline to the pharmaceutical benefits scheme. Among those who tried, use of help rose gradually from 37% in 2002 to almost 59% in 2009 (including 52% using pharmacotherapy and 15% using behavioural forms of support).

Implications: Use of help to quit is now the norm, especially among more dependent smokers. This may reflect a realization among smokers that quitting unassisted is more likely to fail than quitting with help, as well as the cumulative effect of promoting the use of help. Given the continuing high levels of failed quit attempts, services need to be able to expand to meet this increasing demand.

Citation

Li, L., Feng, G., Jiang, Y., Yong, H.H., Borland, R., Fong, G.T. (2011). Prospective predictors of quitting behaviours among adult smokers in six cities in China: Findings from the International Tobacco Control (ITC) China Survey. Addiction, 106(7), 1335-1345.

Abstract

Aims: To examine predictors of quitting behaviours among adult smokers in China, in light of existing knowledge from previous research in four western countries and two southeast Asian countries.

Design: Face-to-face interviews were carried out with smokers in 2006 using the International Tobacco Control (ITC) China Survey, with follow-up about 16 months later. A stratified multi-stage cluster sampling design was employed.

Setting: Beijing and five other cities in China.

Participants: A total of 4732 smokers were first surveyed in 2006. Of these, 3863 were re-contacted in 2007, with a retention rate of 81.6%.

Measurements: Baseline measures of socio-demographics, dependence and interest in quitting were used prospectively to predict both making quit attempts and staying quit among those who attempted.

Findings: Overall, 25.3% Chinese smokers reported having made at least one quit attempt between waves 1 and 2; of these, 21.7% were still stopped at wave 2. Independent predictors of making quit attempts included having higher quitting self-efficacy, previous quit attempts, more immediate intentions to quit, longer time to first cigarette upon waking, negative opinion of smoking and having smoking restrictions at home. Independent predictors of staying quit were being older, having longer previous abstinence from smoking and having more immediate quitting intentions.

Conclusions: Predictors of Chinese smokers' quitting behaviours are somewhat different to those found in previous research from other countries. Nicotine dependence and self-efficacy seem to be more important for attempts than for staying quit in China, and quitting intentions are related to both attempts and staying quit.

Citation

Fix, B.V., O’Connor, R.J., Fong, G.T., Borland, R., Cummings, K.M., Hyland, A. (2011). Smokers' reactions to FDA regulation of tobacco products: Findings from the 2009 ITC United States Survey. BioMed Central Public Health, 11, 941-947.

Abstract

Background: On June 22, 2009, the US FDA was granted the authority to regulate tobacco products through the Family Smoking Prevention and Tobacco Control Act (FSPTCA). The intent is to improve public health through regulations on tobacco product marketing and tobacco products themselves. This manuscript reports baseline data on smokers’ attitudes and beliefs on specific issues relevant to the FSPTCA.

Method: Between November 2009 and January 2010, a telephone survey among a nationally representative sample of n = 678 smokers in the US was performed as part of the International Tobacco Control (ITC) United States Survey. Participants answered a battery of questions on their attitudes and beliefs about aspects of the FSPTCA.

Results: Most smokers were unaware of the new FDA tobacco regulations. Smokers indicated support for banning cigarette promotion and nearly a quarter supported requiring tobacco companies to sell cigarettes in plain packaging. Seventy two percent of smokers supported reducing nicotine levels to make cigarettes less addictive if nicotine was made easily available in non-cigarette form.

Conclusion: Most smokers were limited in their understanding of efforts to regulate tobacco products in general. Smokers were supportive of efforts to better inform the public about health risks, restrict advertising, and make tobacco products less addictive.

Citation

Fix, B.V., Hyland, A., Rivard, C., McNeill, A., Fong, G.T., Borland, R., Hammond, D., Cummings, K.M. (2011). Usage patterns of stop smoking medications in Australia, Canada, the United Kingdom, and the United States: Findings from the 2006-2008 International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(1), 222-233.

Abstract

Varenicline is a new prescription stop smoking medication (SSM) that has been available in the United States since August 1, 2006, in the United Kingdom and other European Union countries since December 5, 2006, in Canada since April 12, 2007, and in Australia since January 1, 2008. There are few population-based studies that have examined use rates of varenicline and other stop smoking medications. We report data from the ITC Four Country survey conducted with smokers in the US, UK, Canada, and Australia who reported an attempt to quit smoking in past year in the 2006 survey (n = 4,022 participants), 2007 (n = 3,790 participants), and 2008 surveys (n = 2,735 participants) Respondents reported use of various stop smoking medications to quit smoking at each survey wave, along with demographic and smoker characteristics. The self-reported use of any stop smoking medication has increased significantly over the 3 year period in all 4 countries, with the sharpest increase occurring in the United States. Varenicline has become the second most used stop smoking medication, behind NRT, in all 4 countries since being introduced. Between 2006 and 2008, varenicline use rates increased from 0.4% to 21.7% in the US, 0.0% to 14.8% in Canada, 0.0% to 14.5% in Australia, and 0.0% to 4.4% in the UK. In contrast, use of NRT and bupropion remained constant in each country. Males and non-whites were significantly less likely to report using any SSM, while more educated smokers were significantly more likely to use any SSM, including varenicline. Our findings suggest that the introduction of varenicline led to an increase in the number of smokers who used evidence-based treatment during their quit attempts, rather than simply gaining market share at the expense of other medications. From a public health perspective, messages regarding increased success rates among medication users and the relative safety of stop smoking medications should be disseminated widely so as to reach all smokers of all socioeconomic classifications equally.

Citation

Kennedy, R.D., Spafford, M., Parkinson, C., Fong, G.T. (2011). Knowledge about the relationship between smoking and blindness in Canada, the United States, the United Kingdom, and Australia: Results from the International Tobacco Control Four-Country Project. Optometry, 82(5), 310-317.

Abstract

Purpose: Smoking is causally associated with certain prevalent visually impairing eye diseases, including age-related macular degeneration and cataract. Studies have found that people are afraid of ‘‘going blind’’ and may be motivated to quit smoking if they know that vision loss is associated with smoking behavior.

Methods: A random-digit dialed telephone survey was used to measure health knowledge of adult smokers in Canada (n=2,765), the United States (n=3,178), the United Kingdom (n=2,767), and Australia (n=2,623) as part of the International Tobacco Control Four-Country Project.

Results: A low proportion of smokers from Canada (13.0%), the United States (9.5%), and the United Kingdom (9.7%) believed that smoking can cause blindness. In contrast, 47.2% of Australian smokers believed that smoking causes blindness. Australia was the only country during the sampling period to have national awareness campaigns about smoking and its effects on eye health.

Conclusion: These findings point to the need across countries to educate the public on this important consequence of smoking. There is an opportunity for the public health and eye health communities to work to educate the public about the impacts smoking has on eye health to improve quit rates and help discourage people from starting to smoke.