Citation

Wilson, N., Peace, J., Edwards, R., Weerasekera, D. (2011). Smokers commonly misperceive that nicotine is a major carcinogen: National survey data. Thorax, 66(4), 353-354.

Abstract

We aimed to assess view in New Zealand (NZ) smokers, with the context being a country in which NRT is provided in a heavily subsidised form and widely distributed via the national quitline service. Data were collected through the NZ arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) which derives its sample of smokers from the NZ Health Survey (a representative national sample).

Citation

Wilson, N., Weerasekera, D., Collings, S., Edwards, R., van der Deen, F.S. (2010). Poorer mental health in many NewZealand smokers: National survey data from the ITC Project. New Zealand Medical Journal, 123(1326), 129-132.

Abstract

There is international evidence that smoking and poorer mental health are associated.1–5 This association has also been studied in New Zealand (e.g., in longitudinal studies6–8) with the most recent work indicating that smoking has a causal role in depressive symptoms.9 Furthermore, in this country it has been estimated that 33% of all cigarettes are consumed by people with current mental disorders.10 We were able to further explore some aspects of the smoking and mental health issue in New Zealand as part of the International Tobacco Control Policy Evaluation Survey (ITC Project).

Methods: The ITC Project (NZ arm) surveyed a nationally representative sample of adult smokers (n=1376 in Wave 1 in 2007/8, n=923 in Wave 2 in 2008/9). This study derives its sample from the New Zealand Health Survey (NZHS) which is a national sample with boosted sampling of Māori, Pacific and Asian New Zealanders. We measured their mental health and alcohol use status using the SF-36, the Kessler-10 (K10), and the AUDIT. Also assessed were smoking-related beliefs and behaviours, including quit rates. Some comparisons were made with non-smoking participants in the NZHS. All results are weighted and adjusted for the complex sample design. Further details of the methods (including response rates, attrition and weighting processes) are available in online Methods Reports11-13 and related publications.14 15

Results: In terms of overall mental health, smokers had significantly lower SF-36 (mental health) scores (i.e., poorer mental health status) than the general adult population (80.6, 95%CI: 79.6–81.6; vs 82.2, 95%CI: 81.9–82.6). Reporting ever having been diagnosed with a mental disorder was significantly more common for adult smokers than for non-smokers (at 20.3%, 95%CI: 17.4% – 23.1%; vs 11.5%, 95%CI: 10.8%–12.2%). Here the non-smoker comparison group was from the full NZHS sample and “mental disorders” were any in a list of eight items used in the NZHS.

Citation

Hoek, J., Wilson, N., Allen, M., Edwards, R., Thomson, G., Li, J. (2010). Lessons from New Zealand's introduction of pictorial health warnings on tobacco packaging. Bulletin of the World Health Organization, 88 (11), 861-866.

Abstract

While international evidence suggests that featuring pictorial health warnings on tobacco packaging is an effective tobacco control intervention, the process used to introduce these new warnings has not been well documented. We examined relevant documents and interviewed officials responsible for this process in New Zealand. We found that, despite tobacco companies’ opposition to pictorial health warnings and the resource constraints facing health authorities, the implementation process was generally robust and successful. Potential lessons for other countries planning to introduce or refresh existing pictorial health warnings include: (i) strengthening the link between image research and policy; (ii) requiring frequent image development and refreshment; (iii) using larger pictures (e.g. 80% of the front of the packet); (iv) developing themes that recognize concerns held by different smoker sub-groups; and (v) running integrated mass media campaigns when the warnings are introduced. All countries could also support moves by the World Health Organization Framework Convention on Tobacco Control’s Secretariat to develop an international bank of copyright-free warnings.

Citation

Elton-Marshall, T., Fong, G.T., Zanna, M.P., Jiang, Y., Hammond, D., O’Connor, R.J., Yong, H.H., Li, L., King, B., Li, Q., Borland, R., Cummings, K.M., Driezen, P. (2010). Beliefs about the relative harm of "light" and "low tar" cigarettes: Findings from the International Tobacco Control (ITC) China Survey. Tobacco Control, 19(Suppl 2), i54-i62.

Abstract

Background: Many smokers in Western countries perceive ‘‘light’’ or ‘‘low tar’’ cigarettes as less harmful and less addictive than ‘‘regular’’ or ‘‘full flavoured’’ cigarettes. However, there is little research on whether similar perceptions exist among smokers in low and middle incomes, including China.

Objective: To characterise beliefs about ‘‘light’’ and ‘‘low tar’’ cigarettes among adult urban smokers in China.

Methods: We analysed data from Wave 1 of the ITC China Survey, a face-to-face household survey of 4732 adult Chinese smokers randomly selected from six cities in China in 2006. Households were sampled using a stratified multistage design.

Findings: Half (50.0%) of smokers in our sample reported having ever tried a cigarette described as ‘‘light,’’ ‘‘mild’’ or ‘‘low tar’’. The majority of smokers in our sample (71%) believed that ‘‘light’’ and/or ‘‘low tar’’ cigarettes are less harmful compared to ‘‘full flavoured’’ cigarettes. By far the strongest predictor of the belief that ‘‘light’’ and/or ‘‘low tar’’ cigarettes are less harmful was the belief that ‘‘light’’ and/or ‘‘low tar’’ cigarettes feel smoother on the respiratory system (p,0.001, OR=53.87, 95% CI 41.28 to 70.31).

Conclusion: Misperceptions about ‘‘light’’ and/or ‘‘low tar’’ cigarettes were strongly related to the belief that these cigarettes are smoother on the respiratory system. Future tobacco control policies should go beyond eliminating labelling and marketing that promotes ‘‘light’’ and ‘‘low tar’’ cigarettes by regulation of product characteristics (for example, additives, filter vents) that reinforce perceptions that ‘‘light’’ and ‘‘low tar’’ cigarettes are smoother on the respiratory system and therefore less harmful.

Citation

Feng, G., Jiang, Y., Li, Q., Yong, H.H., Elton-Marshall, T., Yang, J., Li, L., Sansone, N., Fong, G.T. (2010). Individual-level factors associated with intentions to quit smoking among adult smokers in six cities of China: Findings from the ITC China Survey. Tobacco Control, 19(Suppl 2), i6-i11.

Abstract

Background: Over 350 million smokers live in China, and this represents nearly one-third of the smoking population of the world. Smoking cessation is critically needed to help reduce the harms and burden caused by smoking-related diseases. It is therefore important to identify the determinants of quitting and of quit intentions among smokers in China. Such knowledge would have potential to guide future tobacco control policies and programs that could increase quit rates in China.

Objective: To identify the correlates of intentions to quit smoking among a representative sample of adult smokers in six cities in China.

Methods: Data from wave 1 (2006) of the International Tobacco Control (ITC) Policy Evaluation Project China Survey, a face-to-face survey of adult Chinese smokers in six cities: Beijing, Shenyang, Shanghai, Changsha, Guangzhou and Yinchuan, was analysed. Households were sampled using a stratified multistage design. About 800 smokers were surveyed in each selected city (total n¼4815).

Results: Past quit attempts, duration of past attempts, Heaviness of Smoking Index (HSI), outcome expectancy of quitting, worry about future health and overall opinion of smoking were found to be independently associated with intentions to quit smoking, but demographic characteristics were not.

Conclusions: The determinants of quit intentions among smokers in China are fairly similar to those found among smokers in Western countries, despite the fact that interest in quitting is considerably lower among Chinese smokers. Identifying the determinants of quit intentions provides possibilities for shaping effective policies and programs for increasing quitting among smokers in China.

Citation

Jiang, Y., Elton-Marshall, T., Fong, G.T., Li, Q. (2010). Quitting smoking in China: Findings from the ITC China Survey. Tobacco Control, 19(Suppl 2), i12-i17.

Abstract

Background: Few studies have examined interest in quitting smoking and factors associated with quitting in mainland China.

Objective: To characterise interest in quitting, quitting behaviour, the use of cessation methods and reasons for thinking about quitting among adult urban smokers in six cities in China.

Methods: Data is from Wave 1 of the ITC China Survey, a face-to-face household survey of 4732 adult smokers randomly selected from six cities in China in 2006. Households were sampled using a stratified multistage design.

Findings: The majority of smokers had no plan to quit smoking (75.6%). Over half (52.7%) of respondents had ever tried to quit smoking. Few respondents thought that they could successfully quit smoking (26.5%). Smokers were aware of stop-smoking medications (73.5%) but few had used these medications (5.6%). Only 48.2% had received advice from a physician to quit smoking. The number one reason for thinking about quitting smoking in the last 6 months was concern for personal health (55.0%). Most smokers also believed that the government should do more to control smoking (75.2%).

Conclusion: These findings demonstrate the need to: (1) increase awareness of the dangers of smoking; (2) provide cessation support for smokers; (3) have physicians encourage smokers to quit; (4) deformalize tobacco use so that smokers feel pressured to quit; (5) implement smoke-free laws to encourage quitting; (6) develop stronger warning labels about the specific dangers of smoking and provide resources for obtaining further cessation assistance; and (7) increase taxes and raise the price of cigarettes.

Citation

Cooper, J., Borland, R., Yong, H.H., McNeill, A., Murray, R.L., O’Connor, R.J., Cummings, K.M. (2010). To what extent do smokers make spontaneous quit attempts and what are the implications for smoking cessation maintenance? Findings from the International Tobacco Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S51-57.

Abstract

Aim: To assess the extent to which quit attempts are spontaneous and to evaluate if this is a determinant of smoking cessation maintenance, with better control for memory effects.

Methods: We use data from 3,022 smokers who made quit attempts between Waves 4 and 5 and/or Waves 5 and 6 of the International Tobacco Control Four country survey. Outcomes (quitting for 6 months) were confirmed at the next wave for cases where the attempt began within the previous 6 months. We assessed the length of delay between the decision to quit and implementation and whether the attempt followed a “spur-of-the-moment” decision or some serious prior consideration. Outcomes were modeled using generalized estimating equations.

Results: Prior consideration of quitting was unrelated to the outcome, but there were complex relationships for the delay between choosing a quit day and implementation. Those who reported quitting on the day they decided and those who delayed for 1 week or more had comparable rates of 6-month abstinence. Delaying for 1–6 days was associated with a greater relapse rate than those who quit on the day, although this effect became non-significant in multivariate analyses.

Conclusions: Quitting is on most smokers’ minds regularly and most attempts are not preceded by a long lead in period following the decision to try. Neither prior consideration nor delay between the decision to quit and implementation was clearly related to outcomes. Previous findings of greater success for spontaneous quit attempts may be because they conflate setting a date in advance with planning and also perhaps some differential memory effects.

Citation

Gibson, J.E., Murray, R.L., Borland, R., Cummings, K.M., Fong, G.T., Hammond, D., McNeill, A. (2010). The impact of the United Kingdom's national smoking cessation strategy on quit attempts and use of cessation services: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S64-71.

Abstract

Introduction: The World Health Organization Framework Convention on Tobacco Control recommends that provision of cessation support should be included in national tobacco control strategies. This study examines the impact of the United Kingdom’s national smoking cessation strategy on quit attempts, use of treatment and short-term abstinence, relative to the United States, Canada, and Australia where less support is provided.

Methods: Data on quitting behavior and use of support were obtained for all smokers enrolled in the International Tobacco Control 4 Country Survey between 2002 and 2005. Generalized estimating equations were used to calculate the relative odds (adjusted by age, sex, and Heaviness of Smoking Index) that smokers in each country made quit attempts, used behavioral or pharmacological support, and to compare rates of short-term (28 days) abstinence between countries and users of different forms of support.

Results: U.K. smokers were less likely to have attempted to quit smoking than those in Australia (odds ratio [OR] = 1.25, 95% CI: 1.12–1.40), Canada (OR = 1.50, 95% CI: 1.34–1.67), and the United States (OR = 1.25, 95% CI: 1.11–1.40) but were more likely to use pharmacotherapy and/or support from a clinic, helpline, or health professional when attempting to quit than smokers in the other countries. U.K. smokers making quit attempts were significantly more likely to achieve 28-day abstinence than those in Australia (OR = 0.59, 95% CI: 0.49–0.71), Canada (OR = 0.72, 95% CI: 0.61–0.87), and the United States (OR = 0.51, 95% CI: 0.42–0.62).

Conclusions: U.K. smokers report fewer quit attempts but are more likely to use support when quitting and to achieve short-term abstinence.

Citation

Reid, J., Hammond, D., Boudreau, C., Fong, G.T., Siahpush, M. (2010). Socioeconomic disparities in quit intentions, quit attempts, and smoking abstinence among smokers in four western countries: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S20-33.

Abstract

Introduction: Lower socioeconomic status (SES) groups have higher rates of tobacco use, are less likely to successfully quit, and may also be less likely to intend or attempt to quit. However, results are inconsistent for some outcomes, and little is known about how socioeconomic disparities vary across countries and over time.

Methods: This study examined the associations between SES and quitting-related behaviors among representative samples of smokers in Canada, the United States, the United Kingdom, and Australia, using data from the first five waves (2002–2006/2007) of the International Tobacco Control Four Country Survey (35,532 observations from 16,458 respondents). Generalized estimating equations modeling was used to examine whether education and income were related to intentions to quit, incidence of quit attempts, and smoking abstinence. Potential differences in the associations over time and across countries were also considered.

Results: Smokers with higher education were more likely to intend to quit, to make a quit attempt, and to be abstinent for at least 1 and 6 months; smokers with higher income were more likely to intend to quit and to be abstinent for at least 1 month. Some between-country differences were observed: U.K. and U.S. smokers were less likely to intend to quit than Australians and Canadians; and, although U.K. respondents were least likely to attempt to quit, those that did were more likely to be abstinent.

Discussion: The results suggest that socioeconomic disparities exist at multiple stages in the path to smoking cessation. Potential effects on socioeconomic disparities should be considered when implementing cessation interventions.

Citation

Wilson, N., Weerasekera, D., Borland, R., Edwards, R., Bullen, C., Li, J. (2010). Use of a national quitline and variation in use by smoker characteristics. Nicotine & Tobacco Research, 12(Suppl 1), S78-84.

Abstract

Introduction: We aimed to describe use of a national quitline service and the variation in its use by smoker characteristics (particularly ethnicity and deprivation). The setting was New Zealand (NZ), which takes proactive measures to attract disadvantaged smokers to this service.

Methods: The NZ arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) utilizes the New Zealand Health Survey (a national sample) from which we surveyed adult smokers in two waves (N = 1,376 and N = 923) 1 year apart.

Results: Quitline use in the last 12 months rose from 8.1% (95% CI = 6.3%–9.8%) in Wave 1 to 11.2% (95% CI = 8.4%–14.0%) at Wave 2. Māori (the indigenous people of NZ) were significantly more likely to call the Quitline than were European/other smokers. Relatively higher call rates also occurred among those reporting higher deprivation, financial stress, a past mental health disorder, a past drug-related disorder, and higher psychological distress (Kessler 10-item index). Independent associations in the multivariate analyses of Quitline use were being Māori, reporting financial stress, and ever having been diagnosed with a mental health disorder.

Discussion: This national Quitline service is successfully stimulating disproportionately more calls by Māori smokers and those with some measures of disadvantage. It may therefore be contributing to reducing health inequalities. It appears possible to target quitlines to reach those smokers in greatest need.

Citation

Saenz-de-Miera Juarez, B., Thrasher, J.F., Chaloupka, F., Waters, H.R., Hernández-Ávila, M., Fong, G.T. (2010). Self-reported price of cigarettes, consumption and compensatory behaviours in a cohort of Mexican smokers before and after a cigarette tax increase. Tobacco Control, 19(6), 481-487.

Abstract

Objective: To assess the impact of a 2007 cigarette tax increase from 110% to 140% of the price to the retailer on cigarette price and consumption among Mexican smokers, including efforts to offset price increases.

Methods: Data were analysed from the 2006 and 2007 administrations of the International Tobacco Control (ITC) Policy Evaluation Survey in Mexico, which is a population-based cohort of adult smokers. Self-reported price of last cigarette purchase, place of last purchase, preferred brand, daily consumption and quit behaviour were assessed at baseline and follow-up.

Results: Self-reported cigarette prices increased by 12.7% after the tax increase, with prices for international brands increasing more than for national brands (13.5% vs 8.7%, respectively). Although the tax increases were not fully passed onto consumers particularly on national brands, no evidence was found for smokers changing behaviour to offset price increases. Consistent declines in consumption across groups defined by sociodemographic and smoking-related psychosocial variables suggest a relatively uniform impact of the tax increase across subpopulations. However, decreased consumption appeared limited to people who smoked relatively more cigarettes a day (>5 cigarettes/day). Average daily consumption among lighter smokers did not significantly decline. A total of 13% (n=98) of the sample reported being quit for a month or more at follow-up. In multivariate models, lighter smokers were more likely than heavier smokers to be quit.

Conclusions: Results suggest that the 2007 tax increase was passed on to consumers, whose consumption generally declined. Since no other tobacco control policies or programmes were implemented during the period analysed, the tax increase appears likely to have decreased consumption.

Citation

King, B., Yong, H.H., Borland, R., Omar, M., Ahmad, A.A., Sirirassamee, B., Hamann, S.L., O’Connor, R.J., Bansal-Travers, M., Elton-Marshall, T., Lee, W.B., Hammond, D., Thrasher, J.F. (2010). Malaysian and Thai smokers' beliefs about the harmfulness of 'light' and menthol cigarettes. Tobacco Control, 19(6), 444-450.

Abstract

Objective: This study explored the extent to which Malaysian and Thai smokers believe “light” and menthol cigarettes are less harmful than “regular” cigarettes and the correlates of these beliefs.

Methods: The study used data from wave 1 of the International Tobacco Control Southeast Asia Survey. 2006 adult smokers (95.3% male) from Malaysia and 2000 adult smokers (94.5% male) from Thailand were interviewed face to face in 2005.

Results: 29% of Malaysian respondents reported currently smoking light cigarettes and 14% menthols, with 19% agreeing that lights are less harmful and 16% agreeing that menthols are less harmful. 38% of Thai respondents reported currently smoking light cigarettes and 19% menthols, with 46% agreeing that lights are less harmful and 35% agreeing that menthols are less harmful. Malaysian smokers reporting current use of light or menthol cigarettes were more likely to believe that they are less harmful. Reported use of lights did not relate to beliefs for Thai respondents. The belief that light and/or menthol cigarettes are less harmful was strongly related to the belief that they have smoother smoke.

Conclusions: The experience of smoother smoke is likely to produce some level of belief in reduced harm, regardless of how brands are labelled and whether or not Federal Trade Commission FTC/International Organisation for Standardisation tar, nicotine and carbon monoxide yield figures are used.

Citation

Li, Q., Hyland, A., O’Connor, R.J., Zhao, G., Du, L., Li, X., Fong, G.T. (2010). Support for smoke-free policies among smokers and non-smokers in six cities in China: ITC China Survey. Tobacco Control, 19(Suppl 2), i40-i46.

Abstract

Objective: To examine levels of support for comprehensive smoke-free policies in six large Chinese cities.

Methods: Data from Wave 1 of the International Tobacco Control (ITC) China Survey (April–August 2006) were
analysed. The ITC China Survey employed a multistage sampling design in Beijing, Shenyang, Shanghai, Changsha, Guangzhou and Yinchuan (none of which has comprehensive smokefree policies in place). Face-to-face interviews were conducted with 4815 smokers and 1270 nonsmokers.Multivariate logistic regression models were used to identify factors associated with support for comprehensive smoke-free policies.

Results: About one in two Chinese urban smokers and four in five non-smokers believed that secondhand smoke (SHS) causes lung cancer. The majority of respondents supported comprehensive smoke-free policies in hospitals, schools and public transport vehicles while support for smoke-free workplaces, restaurants and bars was lower. Levels of support were generally comparable between smokers and non-smokers. Support for comprehensive smoke-free policies was positively associated with knowledge about the harm of SHS.
Respondents who worked in a smoke-free worksite or who frequented smoke-free indoor entertainment places were more likely to support comprehensive smoking restriction in bars and restaurants.

Conclusion: Considerable support for smoke-free policies exists in these six large cities in China. Greater public education about the dangers of SHS may further increase support. Experiencing the benefits of smoke-free indoor entertainment places and/or workplaces increases support for these policies and suggests that some initial smoke-free policy implementation may hasten the diffusion of these public health policies.

Citation

Wilson, N., Peace, J., Weerasekera, D., Hoek, J., Edwards, R. (2010). Smoker (mis)perceptions associated with pack colouring: National survey data. New Zealand Medical Journal, 123(1320), 121-125.

Abstract

Background: Several studies have concluded that “light” and “mild” descriptors on cigarette packs lead smokers to assume that cigarettes labelled in this way pose a lower health risk than “full flavour” or “regular” cigarettes.

In response to the bans several countries have imposed on these descriptors, the tobacco industry has introduced “colour coded” packs and specific pack colours for different brand variants,a pattern that is also evident in New Zealand. As a result, smokers have been conditioned to interpret lighter pack colours (e.g. white, silver or blue) to signify “lighter” cigarettes.

This is a health issue given that smokers mistakenly believe cigarettes from lightly coloured packs are less harmful and less addictive.We therefore aimed to determine how New Zealand smokers interpret cigarette pack colouring.

Citation

Wilson, N., Hoek, J., Peace, J., Gifford, H., Thomson, G., Edwards, R. (2010). Marketing tobacco to New Zealand women: 8 ways to reflect on World No Tobacco Day. New Zealand Medical Journal, 123(1315), 85-90.

Abstract

Background: This year’s “World No Tobacco Day” on 31 May 2010 (“World Smokefree Day” in New Zealand) focuses on how tobacco is marketed to women. This topic is particularly relevant given the current inquiry by the Māori Affairs Select Committee into tobacco issues and the very high smoking prevalence among Māori women. Prior to middle age, the health consequences of women smoking are more serious than those caused by male smokers. This is because of the impacts of smoking in pregnancy to the fetus (e.g., perinatal mortality, low birth weight, preterm delivery etc) and the effects of exposing infants and children to second-hand smoke (e.g., sudden infant death syndrome and asthma). Such impacts are experienced disproportionately by Māori. Evidence from the United States reveals tobacco companies have a long history of marketing to women and brands such as Virginia Slims, Eve, Satin, Capri, and Misty were specifically designed to appeal to women. Overt targeting of women led the US Surgeon General to conclude that “tobacco industry marketing is a factor influencing susceptibility to and initiation of smoking among girls”. Evidence that tobacco companies have systematically and successfully recruited female smokers has prompted us to investigate tobacco marketing to girls and women in New Zealand, an area that has previously been analysed only very briefly.

Methods: We searched for relevant New Zealand literature (Medline) and survey data (e.g., the Ministry of Health website). We also analysed mentholated tobacco use data from the ITC Project survey. This is a national survey of 1376 New Zealand adult (18+ years) smokers surveyed between March 2007 and February 2008. Wave two in the subsequent 12 months involved 923 respondents. Further detail on the survey methods are available in an online Methods Report and in publications. In addition we reexamined a collection of discarded cigarette packs obtained for other research purposes (with the methodology detailed elsewhere). Further contextual data came from a search of tobacco products for sale via online retail websites and hand searching imported magazines held in Wellington Central Library (May 2010). We used a variant of the “five Ps” of marketing as employed by British American Tobacco in the UK (i.e., product, price, place, promotion and packaging) to consider how tobacco companies’ marketing might reach New Zealand women.

Results and Discussion: In total, we identified at least eight mechanisms used to market tobacco products to New Zealand women (see Table 1). These covered four of the “five Ps” of marketing in the framework used (i.e., not particularly “place”). Given the advertising and sponsorship restrictions contained in the Smoke-free Environments Act 1990 (SFEA), persistent marketing represents “policy incoherence” that we have previously discussed.

Citation

Ashley, D.L., O’Connor, R.J., Bernert, J.T., Watson, C.H., Polzin, G.M., Jain, R.B., Hammond, D., Hatsukami, D., Giovino, G.A., Cummings, K.M., McNeill, A., Shahab, L., King, B., Fong, G.T., Zhang, L., Xia, Y., Yan, X. (2010). Effect of differing levels of tobacco-specific nitrosamines in cigarette smoke on the levels of biomarkers in smokers. Cancer Epidemiology Biomarkers & Prevention, 19(6), 1389-1398.

Abstract

Background: Smokers are exposed to significant doses of carcinogens, including tobacco-specific nitrosamines (TSNA). Previous studies have shown significant global differences in the levels of TSNAs in cigarette smoke because of the variation in tobacco blending and curing practices around the world.

Methods: Mouth-level exposure to 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) measured in cigarette butts and urinary concentrations of its major metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) were examined among 126 daily smokers in four countries over a 24-hour study period.

Results: As mouth-level exposure of NNK increased, the urinary NNAL increased even after adjustment for other covariates (beta = 0.46, P = 0.004). The relationship between mouth-level exposure to nicotine and its salivary metabolite, cotinine, was not statistically significant (beta = 0.29, P = 0.057), likely because of the very limited range of differences in mouth-level nicotine exposure in this population.

Conclusions: We have shown a direct association between the 24-hour mouth-level exposure of NNK resulting from cigarette smoking and the concentration of its primary metabolite, NNAL, in the urine of smokers. Internal dose concentrations of urinary NNAL are significantly lower in smokers in countries that have lower TSNA levels in cigarettes such as Canada and Australia in contrast to countries that have high levels of these carcinogens in cigarettes, such as the United States.

Impact: Lowering the levels of NNK in the mainstream smoke of cigarettes through the use of specific tobacco types and known curing practices can significantly affect the exposure of smokers to this known carcinogen.

Citation

Borland, R., Yong, H.H., Balmford, J., Cooper, J., Cummings, K.M., O’Connor, R.J., McNeill, A., Zanna, M.P., Fong, G.T. (2010). Motivational factors predict quit attempts but not maintenance of smoking cessation: Findings from the International Tobacco Control Four Country Project. Nicotine & Tobacco Research, 12(Suppl 1), S4-11.

Abstract

Aim: To explore whether measures of motivation to quit smoking have different predictive relationships with making quit attempts and the maintenance of those attempts.

Methods: Data are from three wave-to-wave transitions of the International Tobacco Control Four (ITC-4) country project. Smokers' responses at one wave were used to predict the likelihood of making an attempt and among those trying the likelihood of maintaining an attempt for at least a month at the next wave. For both outcomes, hierarchical logistic regressions were used to explore the predictive capacity of seven measures of motivation to quit smoking, controlling for a range of other known or possible predictors.

Results: Bivariate analyses indicate that measures of motivation to quit are predictive of making quit attempts, but they predict relapse among those making attempts. Multivariate analyses identified wanting to quit and frequency of prematurely butting out cigarettes as the main positive predictors of making attempts, but this was reduced by intention and recency of last attempt. For maintenance, premature butting out was the main motivation variable predicting relapse and was essentially unaffected by other measures.

Discussion: The findings show that it is wrong to suggest that all one needs to quit is to be motivated to do so. The reality is that one needs to be motivated to prompt action to stop smoking, but this is not sufficient in and of itself to ensure that cessation is maintained. These findings call attention to the importance of understanding the differential roles that prequit and postquit experiences play in smoking cessation and of providing help to smokers to stay off cigarettes.

Citation

Borland, R., Yong, H.H., O’Connor, R.J., Hyland, A., Thompson, M.E. (2010). The reliability and predictive validity of the Heaviness of Smoking Index and its two components: Findings from the International Tobacco Control Four Country Study. Nicotine & Tobacco Research, 12(Suppl 1), S45-50.

Abstract

Background: There is increasing recognition that the two measures in the Heaviness of Smoking Index (HSI), time to first cigarette of the day (TTFC) and daily consumption (cigarettes per day [CPD]), are strong predictors of quitting behavior.

Methods: Use of Waves 1-4 of International Tobacco Control cohort with around 8,000 respondents per wave and 6,000 for prediction of quit outcomes at the next wave. We measured TTFC and CPD at each wave and quit outcomes at the next wave. We also looked at the relative utility of the standard categorical scoring compared with a continuous score using the square root of CPD minus the natural log of TTFC in minutes.

Results: We found considerable consistency of the measures across years with a small decrease as duration between measurements increased. For a 3-year gap, the correlations were .72 and .70 for the continuous and categorical composite HSI measures, respectively, and were at least .63 for the individual components. Both TTFC and CPD independently predicted maintenance of quit attempts (for at least 1 month) in each of the three wave-to-wave replications, and these effects were maintained when controlling for demographic factors. CPD also predicted making attempts consistently, but the results for TTFC was not consistently significant.

Discussion: Both TTFC and CPD are fairly reliable over time and are important predictors of quitting. There are only small effects of mode of computing the scores, and the two items can be used either individually or combined as the HSI.

Citation

Cooper, J., Borland, R., Yong, H.H., Hyland, A. (2010). Compliance and support for bans on smoking in licensed venues in Australia: Findings from the International Tobacco Control Four Country Survey. Australian and New Zealand Journal of Public Health, 34(4), 379-385.

Abstract

Objective: To examine attitudes towards and compliance with the recent Australian bans on smoking in licensed venues, and to explore effects on smoking behaviour.

Methods: Three Australian states (Queensland, Tasmania and Western Australia) implemented a total ban on smoking in all enclosed licensed premises in 2006, and two others (Victoria and New South Wales) did so in mid-2007. We used data from smokers residing in these states for each of the six waves of the ITC-4 country survey (2002-2007; average n=1,694).

Results: Consistent with the majority of international findings, observed compliance was reported by more than 90% of smokers from a pre-ban situation of indoor smoking being the norm. Attitudes became more positive in the year before the ban, but more than doubled in the year the bans were implemented. The associations found for the leading states were replicated by the lagging states a year later. We found no evidence for any increase in permitting smoking inside the home after the bans took effect. Further, we were unable to find any evidence of reductions in daily cigarette consumption or any increase in quitting activity due to the bans.

Implications: These results add to a growing body of international research that suggests that smokers are readily able to comply with, and increasingly support, smoke-free bars, though the bans may have limited effect on their smoking habits.

Citation

Fix, B.V., O’Connor, R.J., Hammond, D., King, B., McNeill, A., Thrasher, J.F., Boado Martinez, M., Cummings, K.M., Yong, H.H., Thompson, M.E., Hyland, A. (2010). ITC spit and butts pilot study: The feasibility of collecting saliva and cigarette butt samples from smokers to evaluate policy. Nicotine & Tobacco Research, 12(3), 185-190.

Abstract

Introduction: Large-scale epidemiological surveys have frequently relied upon clinic-based sample collection to incorporate biological data, which can be costly and result in non-representative data. Collecting samples in a nonclinical setting (i.e., through postal mail or at the subject’s home) offers an alternative option that is minimally invasive and can be incorporated into large population-based studies.

Objectives: (a) To assess the feasibility of collecting biological data from a cohort of smokers in the International Tobacco Control (ITC) study, through the mail and in the home; (b) to examine whether participants are representative of the population under consideration; and (c) to evaluate how the added burden of providing biomarker samples might impact subsequent participation in a follow-up survey.

Methods: Participants were asked to provide a saliva sample and five cigarette butts from cigarettes smoked on a single day, using standardized procedures. Sample collection kits were mailed to a random sample of 400 daily cigarette smokers who were involved in the 2006 annual ITC Four Country (United Kingdom, United States, Canada, and Australia) telephone survey and agreed to participate in sample collection. A random sample of 179 daily smokers who participated in a face-to-face ITC survey in Mexico and Uruguay and agreed to participate in sample collection were also asked to provide samples.

Results: Samples were collected from 96% of invited participants in the face-to-face surveys and 52% of participants in the telephone survey. The added burden of the sample collection did not reduce survey retention rates. Participants who initially agreed to participate in the sample collection were more likely to participate in the subsequent survey than participants who were not asked or declined to participate (odds ratio [OR] = 1.28; 95% CI = 1.01–1.62, p = .021). Further, those who provided samples were also more likely to participate in the subsequent survey than those who did not (OR = 2.78; 95% CI = 1.71–4.52, p < .001).

Discussion: Collecting saliva and cigarette butt samples from a group of smokers is feasible, yields a representative sample, and the added participant burden does not reduce subsequent survey response rates.

Citation

Fong, G.T., Hammond, D., Jiang, Y., Quah, A.C.K., Driezen, P., Yan, M. (2010). Perceptions of tobacco health warnings in China compared with picture and text-only health warnings from other countries: An experimental study. Tobacco Control, 19(Suppl 2), i69-i77.

Abstract

Objective: To assess the perceived effectiveness of cigarette health warnings in China, compared with picture and text-only warnings from other countries.

Method: 1169 individuals (adult smokers, adult nonsmokers and youth) from four Chinese cities (Beijing, Shanghai, Kunming and Yinchuan) viewed 10 health warnings on cigarette packages, which included (a) the current Chinese text warnings covering 30% of the front/back of the pack (introduced October 2008); (b) the former Chinese text warning located on the side of the pack; (c) four picture warnings covering 50% of the front/back of the pack from Canada (lung cancer), Singapore (mouth disease), Hong Kong (gangrene) and European Union (clogged arteries); and (d) the same four warnings without the picture. Participants rated and ranked the 10 warnings on dimensions including how effective each would be in motivating smokers to quit and in convincing youth not to start smoking.

Results: Both Chinese warnings were consistently rated as least effective, with the new Chinese warning rated only slightly higher than the old warning. The picture warnings were consistently ranked or rated as most effective, with the text-only versions in the middle. Results were consistent across subject group, city and sex.

Conclusions: (1) Picture warnings are rated as much more effective than the same warnings without pictures. (2) The revised health warnings in China, introduced in October 2008, are only marginally more effective than the previous warning and far less effective than even text warnings from other countries. These results, coupled with population-based evaluation studies, suggest that pictorial warnings would significantly increase the impact of health warnings in China.

Citation

Hitchman, S.C., Fong, G.T., Borland, R., Hyland, A. (2010). Predictors of smoking in cars with nonsmokers: Findings from the 2007 Wave of the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(4), 374-380.

Abstract

Objective: This study examines the proportion and characteristics of smokers who smoke in cars with nonsmokers across four countries and the potentially modifiable correlates of this behavior.

Methods: Respondents included a total of 6,786 current adult smokers from Wave 6 (September 2007– February 2008) of the International Tobacco Control Four Country Survey, a random digit-dial telephone survey of nationally representative samples of adult smokers in Australia, the United Kingdom, Canada, and the United States.

Results: Reports of smoking in cars with nonsmokers ranged from a low of 29% in Australia and the United Kingdom, to 34% in Canada, and to a high of 44% in the United States. Daily smokers who were from the United States, male, and younger were the most likely to smoke in cars with nonsmokers. Several potentially modifiable factors were also found to be related to this behavior, including smoke-free homes and beliefs about the dangers of cigarette smoke exposure to nonsmokers.

Conclusions: A considerable proportion of smokers continue to smoke in cars with nonsmokers across the four countries, particularly in the United States. Public health campaigns should educate smokers about the hazards of cigarette smoke exposure and promote the need for smoke-free cars. These findings provide a foundation of evidence relevant for jurisdictions

Citation

Kahler, C.W., Borland, R., Hyland, A., McKee, S., O’Connor, R.J., Fong, G.T., Cummings, K.M. (2010). Quitting smoking and change in alcohol consumption in the International Tobacco Control (ITC) Four Country Survey. Drug and Alcohol Dependence, 110(1-2), 101-107.

Abstract

Although frequent heavy drinking has been associated with decreased odds of quitting smoking, the extent to which smoking cessation is associated with decreased alcohol consumption is less clear. The present study examined over a 2-year period whether individuals who quit smoking for at least 6 months, compared to those making a quit attempt but continuing to smoke and to those not making any attempt to quit smoking, showed greater reductions in drinking frequency, average weekly quantity of alcohol consumption, and frequency of heavy drinking. Data were drawn from the International Tobacco Control Four Country Survey, a prospective cohort study of smokers in Australia, Canada, the UK, and the US. A total of 3614 participants provided alcohol data at one study wave and were re-interviewed 2 years later regarding smoking and alcohol use. Consistent with prior studies, individuals who drank heavily (4+/5+ drinks for women and men, respectively) more than once a week had especially low rates of quitting smoking. There was little evidence, however, that those who achieved sustained smoking cessation made greater reductions in drinking compared to those who continued to smoke. These results were consistent across countries and sexes and did not differ significantly by heaviness of smoking. Results indicate that quitting smoking, in and of itself, does not lead to meaningful changes in alcohol use. Therefore, interventions and policies directed towards increasing smoking cessation are unlikely to affect rates of hazardous drinking unless they include specific elements that address alcohol consumption.

Citation

Li, L., Borland, R., Yong, H.H., Fong, G.T., Bansal-Travers, M., Quah, A.C.K., Sirirassamee, B., Omar, M., Zanna, M.P., Fotuhi, O. (2010). Predictors of smoking cessation among adult smokers in Malaysia and Thailand: Findings from the International Tobacco Control Southeast Asia Survey. Nicotine & Tobacco Research, 12(Suppl 1), S34-44.

Abstract

Introduction: Limited longitudinal studies on smoking cessation have been reported in Asia, and it remains unclear whether determinants of quitting are similar to those found in Western countries. This study examined prospective predictors of smoking cessation among adult smokers in Thailand and Malaysia.

Methods: Four thousand and four smokers were surveyed in Malaysia and Thailand in 2005. Of these, 2,426 smokers were followed up in 2006 (61% retention). Baseline measures of sociodemographics, dependence, and interest in quitting were used to predict both making quit attempts and point prevalence maintenance of cessation.

Results: More Thai than Malaysian smokers reported having made quit attempts between waves, but among those who tried, the rates of staying quit were not considerably different between Malaysians and Thais. Multivariate analyses showed that smoking fewer cigarettes per day, higher levels of self-efficacy, and more immediate quitting intentions were predictive of both making a quit attempt and staying quit in both countries. Previous shorter quit attempts and higher health concerns about smoking were only predictive of making an attempt, whereas prior abstinence for 6 months or more and older age were associated with maintenance.

Discussion: In Malaysia and Thailand, predictors of quitting activity appear to be similar. However, as in the West, predictors of making quit attempts are not all the same as those who predict maintenance. The actual predictors differ in potentially important ways from those found in the West. We need to determine the relative contributions of cultural factors and the shorter history of efforts to encourage quitting in Asia.

Citation

Li, Q., Hyland, A., Fong, G.T., Wang, H., Zhengzhong, M. (2010). Use of less expensive cigarettes in six cities in China: Findings from the ITC China Survey. Tobacco Control, 19(Suppl 2), i63-i68.

Abstract

Objective: The existence of less expensive cigarettes in China may undermine public health. The aim of the current study is to examine the use of less expensive cigarettes in six cities in China.

Methods: Data was from the baseline wave of the International Tobacco Control (ITC) China Survey of 4815 adult urban smokers in 6 cities, conducted between April and August 2006. The percentage of smokers who reported buying less expensive cigarettes (the lowest pricing tertile within each city) at last purchase was computed. Complex sample multivariate logistic regression models were used to identify factors associated with use of less expensive cigarettes. The association between the use of less expensive cigarettes and intention to quit smoking was also examined.

Results: Smokers who reported buying less expensive cigarettes at last purchase tended to be older, heavier smokers, to have lower education and income, and to think more about the money spent on smoking in the last month. Smokers who bought less expensive cigarettes at the last purchase and who were less knowledgeable about the health harm of smoking were less likely to intend to quit smoking.

Conclusions: Measures need to be taken to minimise the price differential among cigarette brands and to increase smokers' health knowledge, which may in turn increase their intentions to quit.