Citation

Fathelrahman, A., Li, L., Borland, R., Yong, H.H., Omar, M., Awang, R., Sirirassamee, B., Fong, G.T., Hammond, D. (2013). Stronger pack warnings predict quitting more than weaker ones: Findings from the ITC Malaysia and Thailand Surveys. Tobacco Induced Diseases, 11(1), 20-27.

Abstract

Background: We examined the impact of cigarette pack warning labels on interest in quitting and subsequent quit attempts among adult smokers in Malaysia and Thailand.

Methods: Two overlapping cohorts of adults who reported smoking factory- made cigarettes from Malaysia and Thailand were interviewed face-to-face (3189 were surveyed at baseline and 1781 recontacted at Wave 2; 2361 current smokers were surveyed at Wave 2 and 1586 re-contacted at Wave 3). In Thailand at baseline, large text only warnings were assessed, while at Wave 2 new large graphic warnings were assessed. In Malaysia, during both waves small text only warnings were in effect. Reactions were used to predict interest in quitting, and to predict making quit attempts over the following inter-wave interval.

Results: Multivariate predictors of “interest in quitting” were comparable across countries, but predictors of quit attempts varied. In both countries, cognitive reactions to warnings (adjusted ORs; 1.57 & 1.69 for Malaysia at wave 1 and wave 2 respectively and 1.29 & 1.19 for Thailand at wave 1 and wave 2 respectively), forgoing a cigarette (except Wave 2 in Malaysia) (adjusted ORs; 1.77 for Malaysia at wave 1 and 1.54 & 2.32 for Thailand at wave 1 and wave 2 respectively), and baseline knowledge (except wave 2 in both countries) (adjusted ORs; 1.71 & 1.51 for Malaysia and Thailand respectively) were positively associated with interest in quitting at that wave. In Thailand only, “cognitive reactions to warnings” (adjusted ORs; 1.12 & 1.23 at wave 1 and wave 2 respectively), “forgoing a cigarette” (adjusted OR = 1.55 at wave 2 only) and “an interest in quitting” (adjusted ORs; 1.61 & 2.85 at wave 1 and wave 2 respectively) were positively associated with quit attempts over the following inter-wave interval. Salience was negatively associated with subsequent quit attempts in both Malaysia and Thailand, but at Wave 2 only (adjusted ORs; 0.89 & 0.88 for Malaysia and Thailand respectively).

Conclusion: Warnings appear to have common mechanisms for influencing quitting regardless of warning strength. The larger and more informative Thai warnings were associated with higher levels of reactions predictive of quitting and stronger associations with subsequent quitting, demonstrating their greater potency.

Citation

O’Connor, R.J., Caruso, R., Borland, R., Cummings, K.M., Bansal-Travers, M., Fix, B.V., King, B., Hammond, D., Fong, G.T. (2013). Relationship of cigarette-related perceptions to cigarette design features: Findings from the 2009 ITC U.S. Survey. Nicotine & Tobacco Research, 15(11), 1943-1947.

Abstract

Introduction: Many governments around the world have banned the use of misleading cigarette descriptors such as “light” and “mild” because the cigarettes so labeled were found not to reduce smokers' health risks. However, underlying cigarette design features, which are retained in many brands, likely contribute to ongoing belief that these cigarettes are less harmful by producing perceptions of lightness/smoothness through lighter taste and reduced harshness and irritation.

Methods: Participants (N = 320) were recruited from the International Tobacco Control U.S. Survey conducted in 2009 and 2010, when they answered questions about smoking behavior, attitudes and beliefs about tobacco products, and key mediators and moderators of tobacco use behaviors. Participants also submitted an unopened pack of their usual brand of cigarettes for analysis using established methods.

Results: Own-brand filter ventilation level (M 29%, range 0%-71%) was consistently associated with perceived lightness (p < .001) and smoothness (p = .005) of own brand. Those whose brand bore a light/mild label (55% of participants) were more likely to report their cigarettes were lighter [71.9% vs. 41.9%; χ(2)(2) = 38.1, p < .001] and smoother than other brands [75.5% vs. 68.7%; χ(2)(2) = 7.8, p = .020].

Conclusion: Product design features, particularly filter ventilation, influence smokers' beliefs about product attributes such as lightness and smoothness, independent of package labels. Regulation of cigarette design features such as filter ventilation should be considered as a complement to removal of misleading terms in order to reduce smokers' misperceptions regarding product risks.

Citation

Nagelhout, G.E., Crone, M.R., van den Putte, B., Willemsen, M.C., Fong, G.T., de Vries, H. (2013). Age and educational inequalities in smoking cessation due to three population-level tobacco control interventions: Findings from the International Tobacco Control (ITC) Netherlands Survey. Health Education Research, 28(1), 83-91.

Abstract

This study aimed to examine age and educational inequalities in smoking cessation due to the implementation of a tobacco tax increase, smoke-free legislation and a cessation campaign. Longitudinal data from 962 smokers aged 15 years and older were used from three survey waves of the International Tobacco Control (ITC) Netherlands Survey. The 2008 survey was performed before the implementation of the interventions and the 2009 and 2010 surveys were performed after the implementation. No significant age and educational differences in successful smoking cessation were found after the implementation of the three tobacco control interventions, although smokers aged 15–39 years were more likely to attempt to quit. Of the three population-level tobacco control interventions that were implemented simultaneously in the Netherlands, only the smoke-free legislation seemed to have increased quit attempts. The price increase of cigarettes may have been only effective in stimulating smoking cessation among younger smokers. Larger tax increases, stronger smoke-free legislation and media campaigns about the dangers of (second-hand) smoking are needed in the Netherlands.

Citation

Yong, H.H., Fong, G.T., Driezen, P., Borland, R., Quah, A.C.K., Sirirassamee, B., Hamann, S.L., Omar, M. (2013). Adult smokers’ reactions to pictorial health warning labels on cigarette packs in Thailand and moderating effects of type of cigarette smoked: Findings from the International Tobacco Control Southeast Asia Survey. Nicotine & Tobacco Research, 15(8), 1339-1347.

Abstract

Introduction: In this study, we aimed to examine, in Thailand, the impact on smokers’ reported awareness of and their cognitive and behavioral reactions following the change from text-only to pictorial warnings printed on cigarette packs. We also sought to explore differences by type of cigarette smoked (roll-your-own [RYO] vs. factory-made [FM] cigarettes).

Methods: Data came from the International Tobacco Control Southeast Asia Survey, conducted in Thailand and Malaysia, where a representative sample of 2,000 adult smokers from each country were recruited and followed up. We analyzed data from one wave before (Wave 1) and two waves after the implementation of the new pictorial warnings (two sets introduced at Waves 2 and 3, respectively) in Thailand, with Malaysia, having text-only warnings, serving as a control.

Results: Following the warning label change in Thailand, smokers’ reported awareness and their cognitive and behavioral reactions increased markedly, with the cognitive and behavioral effects sustained at the next follow-up. By contrast, no significant change was observed in Malaysia over the same period. Compared to smokers who smoke any FM cigarettes, smokers of only RYO cigarettes reported a lower salience but greater cognitive reactions to the new pictorial warnings.

Conclusions: The new Thai pictorial health warning labels have led to a greater impact than the text-only warning labels, and refreshing the pictorial images may have helped sustain effects. This finding provides strong support for introducing pictorial warning labels in low- and middle-income countries, where the benefits may be even greater, given the lower literacy rates and generally lower levels of readily available health information on the risks of smoking.

Citation

Wakefield, M.A., Bowe, S.J., Durkin, S.J., Yong, H.H., Spittal, M.J., Simpson, J.A., Borland, R. (2013). Does tobacco-control mass media campaign exposure prevent relapse among recent quitters? Nicotine & Tobacco Research, 15(2), 385-392.

Abstract

Objective:To determine whether greater mass media campaign exposure may assist recent quitters to avoid relapse.

Method: Using date of data collection and postcode, media market estimates of televised tobacco-control advertising exposure measured by gross ratings points (GRPs) were merged with a replenished cohort study of 443 Australians who had quit in the past year. Participants' demographic and smoking characteristics prior to quitting, and advertising exposure in the period after quitting, were used to predict relapse 1 year later.

Results: In multivariate analysis, each increase in exposure of 100 GRPs (i.e., 1 anti-smoking advertisement) in the three-month period after the baseline quit was associated with a 5% increase in the odds of not smoking at follow-up (OR = 1.05, 95% CI 1.02-1.07, p < 0.001). This relationship was linear and unmodified by length of time quit prior to the baseline interview. At the mean value of 1081 GRPs in the 3 months after the baseline-quit interview, the predicted probability of being quit at follow-up was 52%, whereas it was 41% for the minimum (0) and 74% for the maximum (3,541) GRPs.

Conclusion: Greater exposure to tobacco-control mass media campaigns may reduce the likelihood of relapse among recent quitters.

Citation

Siahpush, M., Thrasher, J.F., Yong, H.H., Cummings, K.M., Fong, G.T., Saenz-de-Miera Juarez, B., Borland, R. (2013). Cigarette prices, cigarette expenditure and smoking-induced deprivation: Findings from the International Tobacco Control Mexico Survey. Tobacco Control, 22(4), 223-226.

Abstract

Aim: Mexico implemented annual tax increases between 2009 and 2011. We examined among current smokers the association of price paid per cigarette and daily cigarette expenditure with smoking-induced deprivation (SID) and whether the association of price or expenditure with SID varies by income.

Methods: We used data (n=2410) from three waves of the International Tobacco Control Mexico survey (ie, 2008, 2010, 2011) and employed logistic regression to estimate the association of price paid per cigarette and daily cigarette expenditure with the probability of SID ('In the last 6 months, have you spent money on cigarettes that you knew would be better spent on household essentials like food?').

Results: Price paid per cigarette increased from Mex$1.24 in 2008, to Mex$1.36 in 2010, to Mex$1.64 in 2011. Daily cigarette expenditure increased from Mex$6.9, to Mex$7.6 and to Mex$8.4 in the 3 years. There was no evidence of an association between price and SID. However, higher expenditure was associated with a higher probability of SID. There was no evidence that the association of price or expenditure with SID varied by income.

Conclusion: Tax increases in Mexico have resulted in smokers paying more and spending more for their cigarettes. Those with higher cigarette expenditure experience more SID, with no evidence that poorer smokers are more affected.

Citation

Nagelhout, G.E., van den Putte, B., de Vries, H., Crone, M.R., Fong, G.T., Willemsen, M.C. (2012). The influence of newspaper coverage and a media campaign on smokers' support for smoke-free bars and restaurants and on secondhand smoke harm awareness: Findings from the International Tobacco Control (ITC) Netherlands Survey. Tobacco Control, 21(1), 24-29.

Abstract

Objective: To assess the influence of newspaper coverage and a media campaign about Dutch smoke-free legislation on smokers’ support for smoke-free bars and restaurants and on secondhand smoke (SHS) harm awareness.

Design and main outcome measures: A content analysis was conducted of 1041 newspaper articles on the smoke-free legislation published in six Dutch newspapers from March 2008 to April 2009. Smokers who were regular readers of at least one of these newspapers (n¼677) were selected from the pre-ban and post-ban waves of the International Tobacco Control Netherlands Survey. Exposure to newspaper coverage and the implementation campaign was correlated with changes in smokers’ support for smoke-free bars and restaurants and SHS harm awareness.

Results: Most newspaper coverage was found to be negative towards the smoking ban (57%) and focused on economic aspects (59%) rather than health aspects (22%). Exposure to this coverage had a small but significantly negative effect on support for smoke-free bars and restaurants (b¼_0.09, p¼0.013). Among higher educated smokers, exposure to positive newspaper coverage had a more positive effect on support for smoke-free bars and restaurants. In addition, exposure to the implementation campaign had a small but significantly positive effect on SHS harm awareness (b¼0.11, p¼0.001).

Conclusion: Media attention on smoke-free legislation can influence smokers’ support for the legislation and SHS harm awareness. Tobacco control advocates should aim to establish positive media attention that puts forward the health arguments for the legislation.

Citation

Partos, T.R., Borland, R., Siahpush, M. (2012). Socio-economic disadvantage at the area level poses few direct barriers to smoking cessation for Australian smokers: Findings from the International Tobacco Control Australian Cohort Survey. Drug and Alcohol Review, 31(5), 653-663.

Abstract

Introduction: Area-level indicators of socio-economic variation are frequently included in models of individual health outcomes. Area disadvantage is linearly related to smoking prevalence, but its relation to cessation outcomes is less well understood.

Aims: To explore the relationship between area-level disadvantage and prospective data on smoking cessation.

Design and Methods: The Australian cohort of the International Tobacco Control Four-Country Survey (N = 3503) was used to prospectively examine the contribution of area-level socio-economic disadvantage to predicting three important smoking-cessation outcomes: making a quit attempt, achieving 1 month abstinence and achieving 6 month abstinence from smoking, while controlling for individual-level socio-economic indicators and other individual-level covariates related to smoking cessation.

Results: Only two independent associations were observed between socio-economic disadvantage and cessation outcomes. Area-level disadvantage was related to 1 month abstinence in a non-linear fashion, and the individual experience of smoking-induced deprivation was associated with a lower likelihood of making quit attempts.

Discussion: Despite the documented higher prevalence of smoking among the more disadvantaged and in more disadvantaged areas, socio-economic disadvantage was not consistently related to making quit attempts, nor to medium-term success. Nevertheless, indirect effects of disadvantage, like its impact on psychological distress, cannot be ruled out, and considering smokers’ individual psychosocial circumstances is likely to aid cessation efforts.

Conclusion: Socio-economic disadvantage, particularly at the area level, poses few direct barriers to smoking cessation

Citation

Nagelhout, G.E., de Vries, H., Fong, G.T., Candel, M.J.J.M., Thrasher, J.F., van den Putte, B., Thompson, M.E., Cummings, K.M., Willemsen, M.C. (2012). Pathways of change explaining the effect of smoke-free legislation on smoking cessation in the Netherlands. An application of the International Tobacco Control (ITC) Conceptual Model. Nicotine & Tobacco Research, 14(12), 1474-1482.

Abstract

Introduction: This study aims to test the pathways of change from individual exposure to smoke-free legislation on smoking cessation, as hypothesized in the International Tobacco Control (ITC) Conceptual Model.

Methods: A nationally representative sample of Dutch smokers aged 15 years and older was surveyed during 4 consecutive annual surveys. Of the 1,820 baseline smokers, 1,012 participated in the fourth survey. Structural Equation Modeling was employed to test a model of the effects of individual exposure to smoke-free legislation through policy-specific variables (support for smoke-free legislation and awareness of the harm of [secondhand] smoking) and psychosocial mediators (attitudes, subjective norm, self-efficacy, and intention to quit) on quit attempts and quit success.

Results: The effect of individual exposure to smoke-free legislation on smoking cessation was mediated by 1 pathway via support for smoke-free legislation, attitudes about quitting, and intention to quit smoking. Exposure to smoke-free legislation also influenced awareness of the harm of (secondhand) smoking, which in turn influenced the subjective norm about quitting. However, only attitudes about quitting were significantly associated with intention to quit smoking, whereas subjective norm and self-efficacy for quitting were not. Intention to quit predicted quit attempts and quit success, and self-efficacy for quitting predicted quit success.

Conclusion: Our findings support the ITC Conceptual Model, which hypothesized that policies influence smoking cessation through policy-specific variables and psychosocial mediators. Smoke-free legislation may increase smoking cessation, provided that it succeeds in influencing support for the legislation.

Citation

Caleyachetty, A., Lewis, S., McNeill, A., Leonardi-Bee, J. (2012). Struggling to make ends meet: Exploring pathways to understand why smokers in financial difficulties are less likely to quit successfully. European Journal of Public Health, 22(Suppl 1), 41-48.

Abstract

Background: This paper prospectively examined two kinds of social normative beliefs about smoking, secular versus religious norms.

Purpose: The purpose of this paper is to determine the relative importance of these beliefs in influencing quitting behaviour among Muslim Malaysian and Buddhist Thai smokers.

Methods: Data come from 2,166 Muslim Malaysian and 2,463 Buddhist Thai adult smokers who participated in the first three waves of the International Tobacco Control Southeast Asia project. Respondents were followed up about 18 months later with replenishment. Respondents were asked at baseline about whether their society disapproved of smoking and whether their religion discouraged smoking, and those recontacted at follow-up were asked about their quitting activity.

Results: Majority of both religious groups perceived that their religion discouraged smoking (78% Muslim Malaysians and 86% Buddhist Thais) but considerably more Buddhist Thais than Muslim Malaysians perceived that their society disapproved of smoking (80% versus 25%). Among Muslim Malaysians, religious, but not societal, norms had an independent effect on quit attempts. By contrast, among the Buddhist Thais, while both normative beliefs had an independent positive effect on quit attempts, the effect was greater for societal norms. The two kinds of normative beliefs, however, were unrelated to quit success among those who tried.

Conclusions: The findings suggest that religious norms about smoking may play a greater role than secular norms in driving behaviour change in an environment, like Malaysia where tobacco control has been relatively weak until more recently, but, in the context of a strong tobacco control environment like Thailand, secular norms about smoking become the dominant force.

Citation

Caleyachetty, A., Lewis, S., McNeill, A., Leonardi-Bee, J. (2012). Struggling to make ends meet: Exploring pathways to understand why smokers in financial difficulties are less likely to quit successfully. European Journal of Public Health, 22(Suppl 1), 41-48.

Abstract

Background: In high-income countries, those with low-to-middle incomes have been observing stagnating median wages and marginal improvements in their living standards. Smokers in financial difficulties appear to be less likely to quit smoking. Understanding the reasons for this is essential to intervening to improve cessation outcomes in this population, and reduce smoking-related health inequalities.

Methods: We used longitudinal data from Waves 4 to 7 of the ITC Four Country Survey (ITC-4), and included those with data from at least two consecutive waves. Associations between financial difficulties and making a quit attempt, and quit success were analysed using generalised estimating equations, with adjustment for confounders. Mediation analysis was conducted to identify potential mediators of the observed effects of financial difficulties on cessation outcomes.

Results: Having financial difficulties had little impact on making quit attempts (adjusted OR 0.84, 95% CI 0.70-1.01). Smokers with financial difficulties were substantially less likely to succeed at quitting (adjusted OR 0.55, 95% CI 0.39-0.76); an effect which was consistent over the survey years. Among the potential mediators examined, those relating to cognition of health-related and quality of life-related consequences of smoking were the most important mediators, though the proportion of the effect mediated by the largest mediator was small (6.8%).

Conclusion: Having financial difficulties remains an important barrier to smokers achieving quit success. This effect does not appear to be due to anticipated factors such as reduced use of cessation services or treatment. Further research is required to determine strong mediators of the financial difficulties effect on quit success and to tailor more effective cessation programmes.

Citation

Mons, U., Nagelhout, G.E., Guignard, R., McNeill, A., van den Putte, B., Willemsen, M.C., Brenner, H., Pötschke-Langer, M., Breitling, L.P. (2012). Comprehensive smoke-free policies attract more support from smokers in Europe than partial policies. European Journal of Public Health, 22(Suppl 1), 10-16.

Abstract

Objectives: To measure changes in prevalence and predictors of home smoking bans (HSBs) among smokers in four European countries after the implementation of national smoke-free legislation.

Design: Two waves of the International Tobacco Control Policy Evaluation Project Europe Surveys, which is a prospective panel study. Pre- and post-legislation data were used from Ireland, France, Germany and the Netherlands. Two pre-legislation waves from the UK were used as control. Participants: 4634 respondents from the intervention countries and 1080 from the control country completed both baseline and follow-up and were included in the present analyses.

Methods: Multiple logistic regression models to identify predictors of having or of adopting a total HSB, and Generalised Estimating Equation models to compare patterns of change after implementation of smoke-free legislation to a control country without such legislation.

Results: Most smokers had at least partial smoking restrictions in their home, but the proportions varied significantly between countries. After implementation of national smoke-free legislation, the proportion of smokers with a total HSB increased significantly in all four countries. Among continuing smokers, the number of cigarettes smoked per day either remained stable or decreased significantly. Multiple logistic regression models indicated that having a young child in the household and supporting smoking bans in bars were important correlates of having a pre-legislation HSB. Prospective predictors of imposing a HSB between survey waves were planning to quit smoking, supporting a total smoking ban in bars and the birth of a child. Generalised Estimating Equation models indicated that the change in total HSB in the intervention countries was greater than that in the control country.

Conclusions: The findings suggest that smoke-free legislation does not lead to more smoking in smokers' homes. On the contrary, our findings demonstrate that smoke-free legislation may stimulate smokers to establish total smoking bans in their homes.

Citation

McNeill, A., Craig, L., Willemsen, M.C., Fong, G.T. (2012). Tobacco control in Europe: A deadly lack of progress. European Journal of Public Health, 22(Suppl 1), 1-3.

Abstract

Cigarettes are uniquely dangerous, killing half of all those who regularly use them and damaging the health of those who breathe in users’ smoke, particularly children. Just under a third of European adults currently smoke, and smoking has become increasingly associated with poverty, contributing significantly to widening health inequalities across the EU. In 2004, the ASPECT report, a comprehensive review of tobacco use and tobacco control policies in the EU, found that tobacco use caused well over half a million deaths in Europe annually and on top of that constituted a huge economic burden, estimated conservatively at €98-130 billion a year.1 This review also identified that whilst some European countries were observing declines in tobacco use and mortality, in other countries tobacco use was still increasing, particularly among women. The ASPECT report identified 43 recommendations to combat the epidemic, covering tobacco control policy, interventions and research. Yet to date, few of these recommendations have been implemented, and as a result, future prospects for curbing the smoking epidemic across Europe are currently very bleak.

Citation

Arnott, D., Berteletti, F., Britton, J., Cardone, A., Clancy, L., Craig, L., Fong, G.T., Glantz, S.A., Joossens, L., Rudolphie, M.T., Rutgers, M.R., Smith, S.C., Stam, H., West, R., Willemsen, M.C. (2012). Can the Dutch government really be abandoning smokers to their fate? The Lancet, 379(9811), 121-122.

Abstract

There is no abstract available for this publication.

Citation

Myung, S.K., Seo, H.G., Cheong, Y., Park, S., Lee, E.S., Fong, G.T. (2012). Association of socio-demographic factors, smoking-related beliefs, and smoking restrictions with intention to quit smoking in Korean adults: Findings from the ITC Korea Survey. Journal of Epidemiology, 22(1), 21-27.

Abstract

Background: Few studies have reported the factors associated with intention to quit smoking among
Korean adult smokers. This study aimed to examine sociodemographic characteristics, smoking-related
beliefs, and smoking restriction variables associated with intention to quit smoking among Korean adult
smokers.

Methods: We used data from the International Tobacco Control Korea Survey, which was conducted
from November through December 2005 by using random-digit dialing and computer-assisted telephone
interviewing of male and female smokers aged 19 years or older in 16 metropolitan areas and provinces
of Korea. We performed univariate analysis and multiple logistic regression analysis to identify predictors
of intention to quit.

Results: A total of 995 respondents were included in the final analysis. Of those, 74.9% (n = 745)
intended to quit smoking. In univariate analyses, smokers with an intention to quit were younger, smoked
fewer cigarettes per day, had a higher annual income, were more educated, were more likely to have a
religious affiliation, drank less alcohol per week, were less likely to have self-exempting beliefs, and were
more likely to have self-efficacy beliefs regarding quitting, to believe that smoking had damaged their
health, and to report that smoking was never allowed anywhere in their home. In multiple logistic
regression analysis, higher education level, having a religious affiliation, and a higher self-efficacy
regarding quitting were significantly associated with intention to quit.

Conclusion: Sociodemographic factors, smoking-related beliefs, and smoking restrictions at home were
associated with intention to quit smoking among Korean adults.

Citation

Fotuhi, O., Fong, G.T., Zanna, M.P., Borland, R., Yong, H.H., Cummings, K.M. (2013). Patterns of cognitive dissonance-reducing beliefs among smokers: A longitudinal analysis from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 22(1), 52-58.

Abstract

Objective: The purpose of this paper is to assess whether smokers adjust their beliefs in a pattern that is consistent with Cognitive Dissonance Theory. This is accomplished by examining the longitudinal pattern of belief change among smokers as their smoking behaviours change.

Methods: A telephone survey was conducted of nationally representative samples of adult smokers from Canada, the USA, the UK and Australia from the International Tobacco Control Four Country Survey. Smokers were followed across three waves (October 2002 to December 2004), during which they were asked to report on their smoking-related beliefs and their quitting behaviour.

Findings: Smokers with no history of quitting across the three waves exhibited the highest levels of rationalisations for smoking. When smokers quit smoking, they reported having fewer rationalisations for smoking compared with when they had previously been smoking. However, among those who attempted to quit but then relapsed, there was once again a renewed tendency to rationalise their smoking. This rebound in the use of rationalisations was higher for functional beliefs than for risk-minimising beliefs, as predicted by social psychological theory.

Conclusions: Smokers are motivated to rationalise their behaviour through the endorsement of more positive beliefs about smoking, and these beliefs change systematically with changes in smoking status. More work is needed to determine if this cognitive dissonance-reducing function has an inhibiting effect on any subsequent intentions to quit.

Citation

Brown, A., Boudreau, C., Moodie, C., Fong, G.T., Li, Q., McNeill, A., Thompson, M.E., Hassan, L.M., Hyland, A., Thrasher, J.F., Yong, H.H., Borland, R., Hastings, G., Hammond, D. (2012). Support for removal of point-of-purchase tobacco advertising and displays: Findings from the International Tobacco Control (ITC) Canada Survey. Tobacco Control, 21(6), 555-559.

Abstract

Background: Although most countries now have at least some restrictions on tobacco marketing, the tobacco industry meet these restrictions by re-allocating expenditure to unregulated channels, such as at point-of-purchase.

Methods: Longitudinal data from 10 Canadian provinces in the International Tobacco Control Survey was analysed to examine adult smokers' support for a ban on tobacco advertising and displays in stores and whether this support is associated with noticing either advertising or displays in stores, and quit intentions, over time. In total, there were 4580 respondents in wave 5 (October 2006 to February 2007), wave 6 (September 2007 to February 2008) and wave 7 (October 2008 to June 2009). The surveys were conducted before, during and in some cases after the implementation of display bans in most Canadian provinces and territories.

Results: Smokers in all provinces showed strong support for a ban on tobacco displays over the study period. Levels of support for an advertising and display ban were comparable between Canadian provinces over time, irrespective of whether they had been banned or not. Noticing tobacco displays and signs in-store was demonstrably less likely to predict support for display (OR=0.73, p=0.005) and advertising (OR=0.78, p=0.02) ban, respectively. Smokers intending to quit were more likely to support advertising and display bans over time.

Conclusion: This study serves as a timely reminder that the implementation of tobacco control measures, such as the removal of tobacco displays, appear to sustain support among smokers, those most likely to oppose such measures.

Citation

Hitchman, S.C., Mons, U., Nagelhout, G.E., Guignard, R., McNeill, A., Willemsen, M.C., Driezen, P., Wilquin, J.L., Beck, F., Du-Roscoat, E., Pötschke-Langer, M., Hammond, D., Fong, G.T. (2012). Effectiveness of the European Union text-only cigarette health warnings: Findings from four countries. European Journal of Public Health, 22(5), 693-699.

Abstract

Background: The European Commission requires tobacco products sold in the European Union to display standardized text health warnings. This article examines the effectiveness of the text health warnings among daily cigarette smokers in four Member States.

Methods: Data were drawn from nationally representative samples of smokers from the International Tobacco Control Policy Evaluation Project surveys in France (2007), Germany (2007), the Netherlands (2008) and the UK (2006). We examined: (i) smokers' ratings of the health warnings on warning salience, thoughts of harm and quitting and forgoing of cigarettes; (ii) impact of the warnings using a Labels Impact Index (LII), with higher scores signifying greater impact; and (iii) differences on the LII by demographic characteristics and smoking behaviour.

Results: Scores on the LII differed significantly across countries. Scores were highest in France, lower in the UK, and lowest in Germany and the Netherlands. Across all countries, scores were significantly higher among low-income smokers, smokers who had made a quit attempt in the past year and smokers who smoked fewer cigarettes per day.

Conclusion: The impact of the health warnings varies greatly across countries. Impact tended to be highest in countries with more comprehensive tobacco control programmes. Because the impact of the warnings was highest among smokers with the lowest socioeconomic status (SES), this research suggests that health warnings could be more effective among smokers from lower SES groups. Differences in warning label impact by SES should be further investigated.

Citation

Borland, R., Partos, T.R., Cummings, K.M. (2012). Systematic biases in cross-sectional community studies may underestimate the effectiveness of stop-smoking medications. Nicotine & Tobacco Research, 14(12), 1483-1487.

Abstract

Introduction: Randomized, controlled trials typically indicate stop-smoking medications (SSMs: e.g., Varenicline, Bupropion, and over-the-counter nicotine replacement therapies) to be effective, whereas cross-sectional community-based studies have found them to be less effective, ineffective, or even associated with higher risk of relapse. Consequently, some critics have suggested SSMs have no useful applications in “real-world” settings. This discrepancy may, however, be due to systematic biases affecting cross-sectional survey outcomes. Namely, failed quit attempts where SSMs were used may be better recalled than failed unassisted attempts. Moreover, smokers who choose to quit using SSMs may be more addicted and thus less likely to succeed. Either of these factors would lead to an overrepresentation of failed quit attempts among SSM users in cross-sectional surveys even if there were real benefits.

Methods: We report on data from the International Tobacco Control 4-country cohort study to examine the relationship between SSM use, level of nicotine addiction, and the reported date since the start of participants’ (N = 1,101) most recent quit attempt.

Results: The last quit attempt was reported to have begun longer ago among participants who used SSMs than those who did not. Scores on the Heaviness of Smoking Index, measuring addiction severity, were also higher among SSM users, with no interactions.

Conclusion: Better recall of quit attempts and stronger addiction to nicotine are two characteristics found more often among smokers using SSMs compared with self-quitters, which could potentially bias the assessed effects of SSMs on cessation outcomes in cross-sectional surveys.

Citation

Brown, A., McNeill, A., Mons, U., Guignard, R. (2012). Do smokers in Europe think all cigarettes are equally harmful? European Journal of Public Health, 22(Suppl 1), 35-40.

Abstract

Background: Despite the ban on misleading descriptors such as light or mild cigarettes in Europe, there are still widespread misperceptions of the relative harmfulness of different brands of cigarettes among smokers. This study examined the extent to which smokers in three European countries believed that some cigarette brands are less harmful and why, using data from the International Tobacco Control (ITC) Europe surveys.

Methods: Cross-sectional analyses were completed among nationally representative samples of 4,956 current smokers (aged_18) from Germany (n = 1,515), France (n = 1,735) and the United Kingdom (n = 1,706) conducted between September 2006 and November 2007. Logistic regression models examined whether outcomes, including beliefs that some cigarettes could be less harmful than others, varied by socio-demographic and country of residence.

Findings: Around a quarter of smokers in the UK and France, and a third in Germany believed some cigarettes are less harmful than others. Overall, of smokers who falsely believed that some cigarettes are less harmful, 86.3% thought that tar/ nicotine yields, 48.7% taste, and 40.4% terms on packs such as ‘smooth’ or ‘ultra’ indicated less harmful brands. About a fifth of smokers across all countries chose their brand based on health reasons, and a similar proportion gave tar yields as a reason for choosing brands.

Conclusions: Our research suggests that the current European Tobacco Products Directive is inadequate in eliminating misperceptions about the relative risk of brand descriptors on cigarettes. There is therefore an urgent need to protect smokers in Europe from these misperceptions via stronger measures such as plain packaging regulations.

Citation

Hitchman, S.C., Guignard, R., Nagelhout, G.E., Mons, U., Beck, F., van den Putte, B., Crone, M.R., de Vries, H., Hyland, A., Fong, G.T. (2012). Predictors of car smoking rules among smokers in France, Germany, and the Netherlands. European Journal of Public Health, 22(Suppl 1), 17-22.

Abstract

Background: As exposure to tobacco smoke pollution (TSP) has been identified as a cause of premature death and disease in non-smokers, and studies have demonstrated that smoking in cars produces high levels of TSP, this study will investigate smokers’ rules for smoking in their cars, and predictors of car smoking rules, including potentially modifiable correlates.

Methods: Data were drawn from nationally representative samples of current smokers from the International Tobacco Control Policy Evaluation Project surveys in France (2007), Germany (2007), and the Netherlands (2008). Smokers in France and Germany were asked about smoking rules in their cars, and smokers in the Netherlands were asked about smoking rules in cars carrying children.

Results: In France and Germany, 59% and 52% of smokers respectively, allowed smoking in their cars. In the Netherlands, 36% of smokers allowed smoking in cars carrying children. Predictors of allowing smoking in cars included: being a daily vs. non-daily smoker, being younger vs. older age, having no (young) children in the home, being a heavier smoker, and allowing smoking in the home. In the Netherlands, smokers who agreed that TSP is dangerous to nonsmokers were less likely to allow smoking in cars carrying children.

Conclusion: Overall, a sizeable proportion of smokers allowed smoking in their cars across the three countries. Media campaigns with information about the dangers of TSP may increase the adoption of smoke-free cars. These media campaigns could target smokers who are most likely to allow smoking in cars.

Citation

Kennedy, R.D., Behm, I., Craig, L., Thompson, M.E., Fong, G.T., Guignard, R., Beck, F. (2012). Outdoor smoking behaviour and support for outdoor smoking restrictions before and after France's national smoking ban. European Journal of Public Health, 22(Suppl 1), 29-34.

Abstract

Background: On January 1, 2008, the French government implemented a national ban on indoor smoking in hospitality venues. Survey results indicate the indoor ban has been successful at dramatically reducing indoor smoking; however, there are reports of an increased number of outdoor hospitality spaces (patios) where smoking can take place. This study sought to understand if the indoor ban simply moved smoking to the outdoors, and to assess levels of support for smoking restrictions in outdoor hospitality settings after the smoke-free law.

Methods: Telephone interviews were conducted among 1067 adult smokers before and after the 2008 indoor ban as part of the International Tobacco Control (ITC) France Survey. Among other topics, this survey measures how the smoking ban has influenced smoking behaviour relevant to outdoor sections of hospitality venues. In addition, 414 non-smoking adults and 164 respondents who had quit smoking between waves were also asked about support for outdoor smoking restrictions.

Results: Reported smoking outdoors at cafes/pubs/bars increased from 33.6% of smokers at Wave 1 to 75.9% at Wave 2. At restaurants, smoking outdoors increased from 28.9% to 59.0%. There was also an increase in reported non-smoking for both visits to cafe´ s/pubs/bars, and restaurants from 13.4% to 24.7%, and 30.4% to 40.8% respectively. The majority of smokers (74.5%), non-smokers (89.4%) and quitters (74.0%) support a partial or complete ban on smoking in outdoor areas of restaurants.

Conclusion: The indoor smoking ban moved smoking to outdoor spaces; however, the ban is also associated with increased non-smoking behaviour. The majority of respondents support outdoor smoking restrictions in patio environments.

Citation

Kennedy, R.D., Behm, I., Craig, L., Thompson, M.E., Fong, G.T., Guignard, R., Beck, F. (2012). Smoking cessation interventions from health care providers before and after the national smoke-free law in France. European Journal of Public Health, 22(Suppl 1), 23-28.

Abstract

Background: Smoking cessation advice from health care providers (HCP) is well-known to be associated with increased quitting. This study sought to understand the extent to which smokers in France who visited a HCP around the time of the implementation of the national ban on smoking received encouragement to quit from a HCP and what kinds of intervention were provided. HCP may have a unique opportunity during the implementation phase of smoke-free laws to address their patients’ smoking behaviours to increase the likelihood of success at a time when smokers’ readiness and interest in quitting may be higher.

Methods: Telephone interviews were conducted among adult smokers (n = 1067) before and after the two-phase 2007 and 2008) national ban on indoor smoking as part of the International Tobacco Control (ITC) France Survey. In the survey, smokers were asked whether they had visited a HCP in the past 6 months and, if so, whether they had received cessation encouragement, and/or other interventions to support quitting such as prescriptions for stop-smoking medication.

Results: Most smokers (61%) reported visiting a HCP in the 6 months prior to the first phase of the national smoke-free ban, and 58% after the time of the hospitality ban. Of these, most reported they did not receive any assistance from a HCP before (54%) or after (64%) the smoke-free law. Among those who reported an intervention, the most common were only encouragement to quit (58% in Wave 1 and 49% in Wave 2), or receiving both encouragement and a pamphlet (31% in both Wave 1 and 2). The combination of prescriptions for stop-smoking medicine and encouragement to quit increased from 8% in 2007 to 22% in 2008. The smokers who received an intervention were more likely (OR 1.9, 95% CI: 1.2–2.9) to report that they were thinking about quitting.

Discussion: This study demonstrates that HCP in France are well positioned to provide smoking cessation encouragement and other interventions to a majority of smokers and thus the importance of taking measures to increase their involvement, particularly when populationlevel tobacco control policies, such as smoke-free laws, are being implemented.

Citation

King, B., White, V., Balmford, J., Cooper, J., Borland, R. (2012). The decline of menthol cigarette smoking in Australia, 1980-2008. Nicotine & Tobacco Research, 14(10), 1213-1220.

Abstract

Introduction: Concerns have been expressed that menthol cigarettes are highly conducive to uptake and hence function as “starter cigarettes” for adolescents. There is strong evidence for this in the United States. If menthol cigarettes are critical to uptake for some adolescents, they might be expected to remain popular among adolescents independent of promotional activity. We analyzed trends in the market share of menthol brands in Australia among both adolescents and adults to provide further insights into the determinants of menthol cigarette smoking.

Methods: We used the Australian Secondary Students Alcohol and Drug Survey (1984–2008), the Smoking and Health Survey (1980–1998), and the International Tobacco Control Four Nations Survey (2002–2008) to estimate market share of brands. Measures were reported use of all menthol brands for adults and use of the Alpine brand for adolescents.

Results: Menthol smoking was much more popular among female smokers of all age groups in the early 1980s. During the 1980s and 1990s, use declined markedly in the 18–29 age groups, while remaining relatively stable among older smokers. Use of Alpine declined markedly among adolescents in the 1980s and 1990s. However, during this period, Alpine remained more popular among experimenting than regular smokers.

Conclusions: Both Alpine and other menthol brands are now primarily “older women’s cigarettes” in Australia. The trends in declining popularity among younger smokers suggest that targeted marketing plays a major role in determining menthol brand market share. Alpine has played a role as a “starter” cigarette in Australia but that role has decreased markedly since the 1980s. Within the Australian context, “light/mild” brands may have taken over the role of easier-to-smoke cigarettes that attract experimenting smokers.

Citation

Borland, R., Partos, T.R., Yong, H.H., Cummings, K.M., Hyland, A. (2012). How much unsuccessful quitting activity is going on among adult smokers? Data from the International Tobacco Control 4-Country Cohort Survey. Addiction, 107(3), 673-682.

Abstract

Aims: To document accurately the amount of quitting, length of quit attempts and prevalence of plans and serious thought about quitting among smokers.

Design: We used longitudinal data from 7 waves of the International Tobacco Control Policy Evaluation Four Country Survey (ITC-4). We considered point-prevalence data and cumulative prevalence over the 7 years of the study. We also derived annual estimates of quit activity from reports of quit attempts starting only within more recent time-frames, to control for biased recall.

Setting: Australia, Canada, the United Kingdom and the United States.

Participants: A total of 21 613 smokers recruited across seven waves.

Measurements: Reported life-time quit attempts, annual quit attempts, length of attempts, time since last attempt started, frequency of aborted attempts, plans to quit and serious thought about quitting.

Findings: Around 40.1% (95% CI: 39.6–40.6) of smokers report attempts to quit in a given year and report an average of 2.1 attempts. Based on free recall, this translates to an average annual quit attempt rate of 0.82 attempts per smoker. Estimates derived only from the preceding month to adjust for recall bias indicate an annual rate of approximately one attempt per smoker. There is a high prevalence of quitrelated activity, with more than a third of smokers reporting thoughts or actions related to quitting in a given month. More than half the surveyed smokers eventually succeeded in quitting for at least 1 month, and a majority of these for over 6 months.

Conclusions: Smokers think a great deal about stopping and make many unsuccessful quit attempts. Many have been able to last for extended periods and yet they still relapsed. More attention needs to be focused on translating quit-related activity into long-term abstinence.