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.

Citation

Liu, R.L., Yang, Y., Travers, M.J., Fong, G.T., O’Connor, R.J., Hyland, A., Nan, Y., Feng, G., Li, Q., Jiang, Y. (2010). A cross-sectional study on levels of second-hand smoke in restaurants and bars in five cities in China. Tobacco Control, 19(Suppl 2), i24-i29.

Abstract

Objectives: To assess indoor second-hand smoke (SHS) exposure in restaurants and bars via PM2.5 (fine particles 2.5 mm in diameter and smaller) level measurements in five cities in China.

Methods: The study was conducted from July to September in 2007 in Beijing, Xi’an, Wuhan, Kunming and Guiyang. Portable aerosol monitors were used to measure PM2.5 concentrations in 404 restaurants and bars. The occupant density and the active smoker density were calculated for each venue sampled.

Results: Among the 404 surveyed venues, 23 had complete smoking bans, 9 had partial smoking bans and 313 (77.5%) were observed to have allowed smoking during sampling. The geometric mean of indoor PM2.5 levels in venues with smoking observed was 208 mg/m3 and 99 mg/m3 in venues without observed smoking. When outdoor PM2.5 levels were adjusted, indoor PM2.5 levels in venues with smoking observed were consistently significantly higher than in venues without smoking observed (F=80.49, p,0.001). Indoor PM2.5 levels were positively correlated with outdoor PM2.5 levels (partial rho=0.37 p,0.001) and active smoker density (partial rho=0.34, p,0.001).

Conclusions: Consistent with findings in other countries, PM2.5 levels in smoking places are significantly higher than those in smoke-free places and are strongly related to the number and density of active smokers. These findings document the high levels of SHS in hospitality venues in China and point to the urgent need for comprehensive smoke-free laws in China to protect the public from SHS hazards, as called for in Article 8 of the Framework Convention on Tobacco Control, which was ratified by China in 2005.

Citation

Nagelhout, G.E., Willemsen, M.C., Thompson, M.E., Fong, G.T., van den Putte, B., de Vries, H. (2010). Is web interviewing a good alternative to telephone interviewing? Findings from the International Tobacco Control (ITC) Netherlands Survey. BioMed Central Public Health, 10, 351

Abstract

Background: Web interviewing is becoming increasingly popular worldwide, because it has several advantages over telephone interviewing such as lower costs and shorter fieldwork periods. However, there are also concerns about data quality of web surveys. The aim of this study was to compare the International Tobacco Control (ITC) Netherlands web and telephone samples on demographic and smoking related variables to assess differences in data quality.

Methods: Wave 1 of the ITC Netherlands Survey was completed by 1,668 web respondents and 404 telephone respondents of 18 years and older. The two surveys were conducted in parallel among adults who reported smoking at least monthly and had smoked at least 100 cigarettes over their lifetime.

Results: Both the web and telephone survey had a cooperation rate of 78%. Web respondents with a fixed line telephone were significantly more often married, had a lower educational level, and were older than web respondents without a fixed line telephone. Telephone respondents with internet access were significantly more often married, had a higher educational level, and were younger than telephone respondents without internet. Web respondents were significantly less often married and lower educated than the Dutch population of smokers. Telephone respondents were significantly less often married and higher educated than the Dutch population of smokers. Web respondents used the "don't know" options more often than telephone respondents. Telephone respondents were somewhat more negative about smoking, had less intention to quit smoking, and had more self efficacy for quitting. The known association between educational level and self efficacy was present only in the web survey.

Conclusions: Differences between the web and telephone sample were present, but the differences were small and not consistently favourable for either web or telephone interviewing. Our study findings suggested sometimes a better data quality in the web than in the telephone survey. Therefore, web interviewing can be a good alternative to telephone interviewing.

Citation

O’Connor, R.J., Li, Q., Stephens, W.E., Hammond, D., Elton-Marshall, T., Cummings, K.M., Giovino, G.A., Fong, G.T. (2010). Cigarettes sold in China: Design, emissions, and metals. Tobacco Control, 19(Suppl 2), i47-i53.

Abstract

Background: China is the home to the world's largest cigarette maker, China National Tobacco Company (CNTC), yet little is known publicly about the design and emissions of Chinese cigarettes. CNTC is currently in the process of consolidating its brands and has ambitions to export its cigarettes. Machine-measured tar yields of many of its cigarette brands have also been reduced, similar to what occurred in Western countries from the 1970s through the 1990s with so-called ‘low-tar’ cigarettes introduced to address consumer concerns about health risks from smoking.

Method: The current study examines the design and physical characteristics, labelled smoke emissions and tobacco metals content of leading brands of Chinese cigarettes from seven cities purchased in 2005–6 and in 2007.

Results: Findings suggest that similar to most countries, tar levels of Chinese cigarettes are predicted primarily by tobacco weight and filter ventilation. Ventilation explained approximately 50% of variation observed in tar and 60% variation in carbon monoxide yields. We found little significant change in key design features of cigarettes purchased in both rounds. We observed significant levels of various metals, averaging 0.82 μg/g arsenic (range 0.3–3.3), 3.21 μg/g cadmium (range 2.0–5.4) and 2.65 μg/g lead (range 1.2–6.5) in a subsample of 13 brands in 2005–6, substantially higher than contemporary Canadian products.

Conclusion: Results suggest that cigarettes in China increasingly resemble those sold in Western countries, but with tobacco containing higher levels of heavy metals. As CNTC looks to export its product around the world, independent surveillance of tobacco product characteristics, including tobacco blend characteristics, will become increasingly important.

Citation

Siahpush, M., Yong, H.H., Borland, R., Reid, J. (2010). Socioeconomic position and abrupt versus gradual method of quitting smoking: Findings from the International Tobacco Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S58-63.

Abstract

Introduction: Our aim was to investigate the association between socioeconomic position (income and education) and abrupt versus gradual method of smoking cessation.

Methods: The analysis used data (n = 5,629) from Waves 1 through 6 (2002–2008) of the International Tobacco Control Four-Country Survey, a prospective study of a cohort of smokers in the United States, Canada, the United Kingdom, and Australia.

Results: Logistic regression analyses using generalized estimating equations showed that higher income (p < .001) and higher education (p = .011) were associated with a higher probability of abrupt versus gradual quitting. The odds of adopting abrupt versus gradual quitting were about 40% higher among respondents with high income ($60,000 and more in the United States/Canada/Australia and £30,000 and more in the United Kingdom) compared with those with low income (less than $30,000 in the United States/Canada/Australia; £15,000 and less in the United Kingdom). Similarly, the odds of abrupt versus gradual quitting were about 30% higher among respondents with a high level of education (university degree) compared with those with a low level of education (high school diploma or lower).

Discussion: Higher socioeconomic position is associated with a higher probability of quitting abruptly rather than gradually reducing smoking before quitting.

Citation

Thomson, G., Wilson, N., Blakely, T., Edwards, R. (2010). Ending appreciable tobacco use in a nation: Using a sinking lid on supply. Tobacco Control, 19(5), 431-435.

Abstract

We discuss some of the practical and ethical questions that may arise for a jurisdiction where a sinking lid endgame strategy for tobacco supply is implemented. Such a strategy would involve regular required reductions in the amount of tobacco released to the market for sale, sufficient to achieve the desired level of commercial sales by a target date. Tobacco manufacturers would periodically bid to the government for a residual quota. Prices would increase as supply reduced. The price level would be influenced by demand, which in turn would reflect the impact of other interventions to reduce demand and the changing normality of smoking. Higher priced tobacco could result in increased smuggling, theft, illegal sales and short-to-medium-term aggravation of some social inequalities. We suggest that the strategy be introduced in conjunction with a range of complementary interventions that would help reduce demand, and thus help ensure that the possible adverse effects are minimised. These complementary interventions include: providing comprehensive best practice smoking cessation support, better information to smokers and the public, strengthened regulation of tobacco retailing and supply, further controlling the pack and product design, measures to restrict supplies that bypass the increases in product price, strengthened enforcement and combating industry attacks. General prerequisites for a sinking lid strategy include public support for the goal of a tobacco-free society, and strong political leadership. The likely context for initial success in jurisdictions includes geographical isolation and/or strong border controls, absence of significant tobacco production and/or manufacturing and low government corruption.

Citation

Wilson, N., Weerasekera, D., Edwards, R., Thomson, G., Devlin, M., Gifford, H. (2010). Characteristics of smoker support for increasing a dedicated tobacco tax: National survey data from New Zealand. Nicotine & Tobacco Research, 12(2), 168-173.

Abstract

Aim: To examine smoker support for tobacco tax and for increased dedicated tobacco taxes, along with associations forany such support.

Methods: The New Zealand (NZ) arm of the International Tobacco Control Policy Evaluation Survey utilizes the NZ Health Survey (a national sample). From this sample, we surveyed adult smokers (N = 1,376).

Results: Most smokers considered that the current level of tobacco tax is "too high" (68%), but a majority (59%) would support an increase in tobacco tax if the extra revenue was used to promote healthy lifestyles and support quitting. There was majority support for a dedicated tobacco tax increase among all sociodemographic groups of smokers (including Māori, Pacific, and Asian smokers). In the fully adjusted multivariate model, significant associations with support for a dedicated tax increase included higher deprivation level (adjusted odds ratio [AOR] = 1.15) and suffering one form of financial stress (AOR = 1.81, 95% CI = 1.18-2.78). Other significant associations with support included concern about the smoking impacts on health and quality of life (AOR = 1.41), expressing support for tobacco control regulation (AOR = 1.83), and strength of intention to quit (AOR = 1.30).

Discussion: A majority of smokers from all sociodemographic groups supported an increase in tobacco tax if it was dedicated to quitting support and health promotion. The higher support among smokers with stronger intentions to quit is consistent with other evidence that smokers value tobacco control regulation such as high taxes to help them achieve their long-term quitting goals.

Citation

Wilson, N., Weerasekera, D., Blakely, T., Edwards, R., Thomson, G., Gifford, H. (2010). What is behind smoker support for new smokefree areas? National survey data. BioMed Central Public Health, 10(1), 498.

Abstract

Background: Some countries have started to extend indoor smokefree laws to cover cars and various outdoor settings. However, policy-modifiable factors around smoker support for these new laws are not well described.

Methods: The New Zealand (NZ) arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) derives its sample from the NZ Health Survey (a national sample). From this sample we surveyed adult smokers (n = 1376).

Results: For the six settings considered, 59% of smokers supported at least three new completely smokefree areas. Only 2% favoured smoking being allowed in all the six new settings. Support among Maori, Pacific and Asian smokers relative to European smokers was elevated in multivariate analyses, but confidence intervals often included 1.0.

Also in the multivariate analyses, "strong support" by smokers for new smokefree area laws was associated with greater knowledge of the second-hand smoke (SHS) hazard, and with behaviours to reduce SHS exposure towards others. Strong support was also associated with reporting having smokefree cars (aOR = 1.68, 95% CI = 1.21 - 2.34); and support for tobacco control regulatory measures by government (aOR = 1.63, 95% CI = 1.32 - 2.01). There was also stronger support by smokers with a form of financial stress (not spending on household essentials).

Conclusions: Smokers from a range of population groups can show majority support for new outdoor and smokefree car laws. Some of these findings are consistent with the use of public health strategies to support new smokefree laws, such as enhancing public knowledge of the second-hand smoke hazard.

Citation

Wilson, N., Weerasekera, D., Hoek, J., Li, J., Edwards, R. (2010). Increased smoker recognition of a national quitline number following introduction of improved pack warnings: ITC Project New Zealand. Nicotine & Tobacco Research, 12(Suppl 1), S72-77.

Abstract

Introduction: We examined how recognition of a national quitline number changed after new health warnings were required on tobacco packaging in New Zealand (NZ).

Methods: The NZ arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) is a cohort study that surveyed smokers in two waves (N = 1,376 and N = 923). Wave 1 respondents were exposed to text-based warnings with a quitline number but no wording to indicate that it was the "Quitline" number. Wave 2 respondents were exposed to pictorial health warnings (PHWs) that included the word "Quitline" beside the number as well as a cessation message featuring the Quitline number and repeating the word "Quitline."

Results: The introduction of the new PHWs was associated with a 24 absolute percentage point between-wave increase in Quitline number recognition (from 37% to 61%, p < .001). Recognition increased from a minority of respondents to a majority for all age groups, genders, deprivation levels (using small area and individual measures), financial stress (two measures), and ethnic groups (e.g., the level for Maori in Wave 2: 62%, Pacific peoples: 61%, and European/other: 62%). There was also an equalizing effect on previous differences in Quitline recognition by gender, ethnic group, and for both deprivation measures.

Discussion: This study provides some evidence for the value of clearly identifying quitline numbers on tobacco packaging as part of PHWs. While this finding is consistent with previously published studies, the finding that this intervention appeared to benefit all sociodemographic groups is novel.

Citation

Wu, C., Thompson, M.E., Fong, G.T., Li, Q., Jiang, Y., Yang, Y., Feng, G. (2010). Methods of the International Tobacco Control (ITC) China Survey. Tobacco Control, 19(Suppl 2), i1-i5.

Abstract

This paper describes the design features, data collection methods and analytical strategies of the ITC China Survey, a prospective cohort study of 800 adult smokers and 200 adult non-smokers in each of six cities in China . In addition to features and methods which are common to ITC surveys in other countries, the ITC China Survey possesses unique features in frame construction, a large first phase data enumeration and sampling selection; and it uses special techniques and measures in training, field work organisation and quality control. It also faces technical challenges in sample selection and weight calculation when some selected upper level clusters need to be replaced by new ones owing to massive relocation exercises within the cities.

Citation

Yang, J., Hammond, D., Driezen, P., Fong, G.T., Jiang, Y. (2010). Health knowledge and perception of risks among Chinese smokers and non-smokers: Findings from ITC China Survey. Tobacco Control, 19(Suppl 2), i18-i23.

Abstract

Background: Awareness of health risks of smoking is strongly associated with smoking behaviour. However, there are no population-based studies of smoking-related health knowledge in China.

Objective: The aim of current study was to use a population-based sample from the International Tobacco Control China Wave 1 survey to examine variations between current, former and never smokers' health knowledge about smoking and the impact of health knowledge awareness on smokers' intention to quit.

Methods: A face-to-face interview was conducted with 5986 adult smokers and non-smokers from six cities in China. Respondents were asked whether they believed smoking causes heart disease, stroke, impotence, lung cancer, emphysema, stained teeth, premature ageing in smokers and lung cancer in non-smokers. Current smokers were also asked additional questions on how smoking affects their current and future health as well as whether they had plans to quit smoking and if they believe they would have health benefit from quitting.

Findings: The overall awareness of health risks of smoking in China was low compared to developed countries. Current smokers in China were less likely than non-smokers and former smokers to acknowledge the consequences of smoking. Current smokers who were more aware of the health consequences of smoking were more likely to intend to quit smoking.

Conclusion: These findings highlight the need to increase awareness about the health effects of smoking in China, particularly among current smokers to increase quitting.

Citation

Yang, Y., Li, L., Yong, H.H., Borland, R., Wu, X., Li, Q., Wu, C., Kin, F. (2010). Regional differences in awareness of tobacco advertising and promotion in China: Findings from the ITC China Survey. Tobacco Control, 19(2), 117-124.

Abstract

Objective: To examine whether levels of, and factors related to, awareness of tobacco advertising and promotion differ across six cities in China.

Methods: Data from wave 1 of the International Tobacco Control (ITC) China Survey (April to August 2006) were analysed. The ITC China Survey employed a multistage sampling design in Beijing, Shenyang, Shanghai, Changsha, Guangzhou and Yinchuan. Face-to-face interviews were conducted with a total of 4763 smokers and 1259 non-smokers. Multivariate logistic regression models were used to identify factors associated with awareness of tobacco advertising and promotion.

Results: The overall levels of noticing advertisements varied considerably by city. Cities reporting lower levels of advertising tended to report higher levels of point of sale activity. Noticing tobacco industry promotions was associated with more positive attitudes to tobacco companies.

Conclusion: The awareness of tobacco advertising and promotional activities was not homogeneous across the six Chinese cities, suggesting variations in the tobacco industry's activities and the diversity of implementing a central set of laws to restrict tobacco promotion. This study clearly demonstrates the need to work with the implementation agencies if national laws are to be properly enforced.

Citation

Yong, H.H., Borland, R., Cooper, J., Cummings, K.M. (2010). Postquitting experiences and expectations of adult smokers and their association with subsequent relapse: Findings from the International Tobacco Control (ITC) Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S12-19.

Abstract

Introduction: This paper explores postquitting experiences and expectations of adult ex-smokers and their utility as predictors of smoking relapse after prolonged abstinence.

Methods: Data are from 1,449 ex-smokers (providing 2,234 observations) recruited as smokers as part of the International Tobacco Control (ITC) Four Country Survey (Australia, Canada, the United Kingdom, and the United States) but surveyed after they had quit. Controlling for length of time quit, reported postquitting experiences, and expectations assessed at one of three waves were used as predictors. Smoking status (whether they had relapsed) at the next wave was used as the outcome of interest.

Results: Postquitting experiences and expectations, such as capacity to enjoy life’s simple pleasures, ability to cope with stress, ability to control negative emotions, and health concerns, changed systematically over time but at different rates. The trajectory of change for life enjoyment and health concerns followed a rapidly asymptoting logarithmic function, while that of stress and negative affect coping followed a slower asymptoting square root function. After controlling for sociodemographic and abstinence duration, only reported decline in capacity to control negative affect since quitting was associated with increased relapse risk.

Discussion: The varying patterns of change in postquitting experiences suggest that psychological gains over time following smoking cessation do not all occur at the same rate. The relative importance of each factor in maintaining abstinence is also not the same with deficits in perceived control of negative emotions being the only one predictive of subsequent relapse. Strategies to improve impulse control over negative emotions postquitting may help to reduce relapse risk.