Citation

Elkin, L., Wilson, N., Thomson, G. (2010). Connecting world youth with tobacco brands: YouTube and the internet policy vacuum on Web 2.0. Tobacco Control, 5, 361-366.

Abstract

Background: The internet is an ideal forum for tobacco marketing, as it is largely unregulated and there is no global governing body for controlling content. Nevertheless, tobacco companies deny advertising on the internet.

Objective: To assess the extent and nature of English language videos available on the Web 2.0 domain 'YouTube' that contain tobacco brand images or words.

Methods: The authors conducted a YouTube search using five leading non-Chinese cigarette brands worldwide. The themes and content of up to 40 of the most viewed videos returned for each search were analysed: a total of 163 videos.

Results: A majority of the 163 tobacco brand-related videos analysed (71.2%, 95% CI 63.9 to 77.7) had pro-tobacco content, versus a small minority (3.7%) having anti-tobacco content (95% CI 1.4 to 7.8). Most of these videos contained tobacco brand content (70.6%), the brand name in the title (71.2%) or smoking imagery content (50.9%). One pro-smoking music video had been viewed over 2 million times. The four most prominent themes of the videos were celebrity/movies, sports, music and 'archive', the first three of which represent themes of interest to a youth audience.

Conclusions: Pro-tobacco videos have a significant presence on YouTube, consistent with indirect marketing activity by tobacco companies or their proxies. Since content may be removed from YouTube if it is found to breach copyright or if it contains offensive material, there is scope for the public and health organisations to request the removal of pro-tobacco content containing copyright or offensive material. Governments should also consider implementing Framework Convention on Tobacco Control requirements on the internet, to further reduce such pro-tobacco content.

Citation

Wilson, N., Peace, J., Edwards, R., Hoek, J. (2010). Long-term benefit of increasing the prominence of a quitline number on cigarette packaging: 3 years of Quitline call data. New Zealand Medical Journal, 123(1321), 109-111.

Abstract

In 2008 the law required tobacco packaging in New Zealand to include pictorial health warnings (PHWs) and the national Quitline number. Previously, text-only health warnings provided a telephone number, but did not explicitly link this to the “Quitline”. Research indicated that New Zealand smokers became more aware of the Quitline number on packs since PHWs were introduced, and there was an immediate increase in the proportion of new callers who registered with the Quitline following the introduction of PHWs. We investigated whether Quitline callers’ use of packaging to source the Quitline number continued beyond the initial introduction of PHWs.

Methods: The national free-phone Quitline service in New Zealand routinely collects data on where new callers sourced the Quitline number (i.e., a standardised question asked of all new callers). The Quitline service provided us with data on the proportion of new callers who reported obtaining the Quitline number from cigarettes packaging before and after the introduction of PHWs (i.e. for the three-year period March 2007 to February 2010). These data were compared to the proportion of callers who cited television advertising as the source of this number (which was the major source at the start of the study period). We reviewed monthly “target audience rating points” (TARPs) data on the reach and frequency of television advertising for smoking cessation advertisements (most of them showed the Quitline number).

Results and Discussion: During the 12-month pre-PHWs period (March 2007 to February 2008), 7.5% and 34.9% of new callers (out of n=19,558 total callers), cited tobacco packaging and television advertising respectively as their source for the Quitline number (Figure 1). However, in the first full year of the new PHWs (March 2008 to February 2009), the proportions reporting tobacco packaging as the source increased to 26.4% and television advertising declined to 27.1% (out of n=20,152 total callers). The same pattern was still evident in the subsequent 12-month period at 22.9% and 23.3% respectively (n=18,309 for the period March 2009 to February 2010).

Citation

Wilson, N., Weerasekera, D., Edwards, R., Blakely, T. (2009). Smoker support for increased (if dedicated) tobacco tax by individual deprivation level: National survey data. Tobacco Control, 18(6), 512-512.

Abstract

Increasing the price of tobacco products through tobacco taxation is one of the most effective tobacco control interventions. An additional benefit is that a “dedicated tobacco tax” (where some or all of the revenue raised is earmarked for specific spending or programmes) can generate revenue for funding other tobacco control and health programmes. Should dedicated tobacco taxes be introduced, it will be useful for decision makers to know whether there is support from all sociodemographic categories of smokers. Accordingly, we aimed to examine smoker support for tobacco taxes by an individual level measure of deprivation.

Citation

Li, Y., He, L., Wang, H., Zhou, Y. (2009). The current status and the related factors of smoking in the recreational venues in Beijing, China. (Language: Chinese). Chinese Journal of Health Education, 43(12), 1136-1138.

Abstract

Publication written in Chinese. Please visit link to view article.

Citation

Wilson, N., Thomson, G., Weerasekera, D., Blakely, T., Edwards, R., Peace, J., Young, D., Gifford, H. (2009). Smoker misperceptions around tobacco: National survey data of particular relevance to protecting Maori health. New Zealand Medical Journal, 122(1306), 123-127.

Abstract

To evaluate relevant issues around smoker knowledge and misperceptions about tobacco smoking, a cohort group of 1376 New Zealand smoking adults aged >18 years and 607 Maori respondents were surveyed between March 2007 and February 2008. Specific questions relevant to possible misinformation included perceptions related to light/mild cigarettes/tobacco, to menthols, and to RYO tobacco. Overall results indicated that sizeable minorities of both Maori and European/other smokers had various misperceptions about tobacco products. Regarding light and mild cigarettes, nearly half (48%) of Maori smokers have at least one of three misperceptions which suggest (erroneously) that these cigarettes have health benefits compared to “regular” cigarettes. Also, New Zealand smokers have misperceptions about mentholated cigarettes (“menthols”) being less harmful relative to “non-mentholated” cigarettes. This misperception was significantly more common (13% vs 7%) among Maori smokers. In addition, a minority (up to 10%) of Maori smokers also have specific misperceptions about the adverse health effects of second-hand smoke. Around a fifth of Maori and European/other smokers gave health reasons for smoking RYO cigarettes. Smokers also have high levels of knowledge deficits and misperceptions around smokeless tobacco products. Finally, a substantial group of smokers agree or strongly agree that “tobacco companies have done everything they can to reduce the harm caused by smoking,” and Maori smokers were significantly more likely to have this view (24%) compared to 18% of European/other. In conclusion, these data on smoker misperceptions are likely to be associated with tobacco industry messages on packaging.

Citation

Peace, J., Wilson, N., Hoek, J., Edwards, R., Thomson, G. (2009). Survey of descriptors on cigarette packs: Still misleading consumers? New Zealand Medical Journal, 122(1303), 90-96.

Abstract

Aim: In September 2008, the New Zealand (NZ) Commerce Commission issued a warning to the major tobacco companies to remove “light” and “mild” descriptors from cigarette packaging. Despite published evidence that suggested tobacco companies had started colour-coding their packs in anticipation of the Commission's decision, the investigation did not consider more general misleading packaging. This study explored changes in tobacco packaging that had been introduced to the New Zealand market, by surveying descriptors used on cigarette packs after the Commerce Commission's warning.

Method: A convenience sample of discarded cigarette packs were collected in four cities and six towns/rural areas between November 2008 and January 2009. The majority of packs (93%) were collected in the capital city (Wellington). Information on the descriptors and pack colours was analysed.

Results: Four percent of the 1208 packs collected still included the terms “light” and “mild”. Almost half the packs (42%) used a colour word (e.g. red, blue, gold) as a descriptor to indicate mildness or strength. A further 18% used other words that suggested mildness/strength (e.g. “subtle”, “mellow”). A quarter of packs used a descriptor that did not connote either mildness or strength; however, the majority of these packs still appeared to be colour-coded.

Conclusion: Although the words “light” and “mild” have been largely removed from tobacco packaging in the New Zealand market, these words have been replaced with associated colours or other words that may continue to communicate “reduced harm” messages to consumers. Further research to test how smokers interpret the new words and colours, and how these influence their behaviour, is desirable. However, government-mandated generic (plain) packaging would remove the opportunity to communicate misleading claims and so would afford the highest level of consumer protection.

Citation

Li, X., Li, Q., Dong, L., Sun, B., Chen, J., Jiang, J., Yang, Y., Zhou, B., Fong, G.T. (2010). Risk factors associated with smoking behaviour in recreational venues: Findings from the International Tobacco Control (ITC) China Survey. Tobacco Control, 19(Suppl 2), i30-i39.

Abstract

Objective: To explore the determinants of smoking behaviour in recreational venues and to provide scientific bases for establishing smoke-free measures applying to these locations.

Methods: The International Tobacco Control (ITC) China Survey—a face-to-face cross-sectional survey of representative adult smokers from six cities (Shenyang, Beijing, Shanghai, Guangzhou, Changsha and Yinchuan) was conducted between April and August 2006. A total of 4815 smokers were selected using multistage sampling methods, and final analyses were conducted on 2875 smokers who reported patronising recreational venues at least once in the last six months. Multivariate logistic regression models were used to identify factors influencing the smoking behaviour within recreational settings.

Outcome Measure: Whether a smoker reported smoking in recreational venues during the last 6 months.

Results: 84% of subjects reported smoking in recreational venues. 32.0% of patrons reported partial The following factors were significant predicators of smoking in recreational venues: absence of bans on smoking, support for non-bans, being aged 18–24 years, positive smoking-related attitudes, low number of health effects reported and not living in Beijing.

Conclusions: The findings point to the importance of informing Chinese smokers about the active smoking and passive smoking harmfulness in both building support for smoke-free laws and in reducing smokers’ desire to smoke within recreational venues. They also point to the importance of good enforcement of smoke-free laws when implemented. Such strategies could also serve to de-normalise smoking in China.

Citation

Thomson, G., Weerasekera, D., Peace, J., Wilson, N. (2009). New Zealand smokers' attitudes to smokefree cars containing preschool children: Very high support across all sociodemographic groups. New Zealand Medical Journal, 122(1300), 84-86.

Abstract

In 2008 we published the overall support by New Zealand smokers for smokefree cars containing preschool children (96%).1 To provide further detail on the support by different groups, we examined the support by age-groups, gender, ethnicity, level of socioeconomic deprivation, and level of financial stress. The data came from the wave 1 of the New Zealand arm of the International Tobacco Control Policy Evaluation Survey (NZ ITC Project). This wave involved surveying a national sample of 1376 New Zealand adult (18+ years) smokers in 2007–2008. We asked: Do you think smoking should be allowed in cars with preschool children in them? Further detail on the survey methods is available elsewhere.2 We found that smokers in all age-groups, both men and women, those in the four ethnic groups considered, and those in all small area deprivation quintiles, disagreed with the statement at a level of 92%+ (Table 1). Of those smokers who reported suffering from two different types of smoking-related financial stress (those unable to pay any important bills on time due to a shortage of money, and those not spending on household essentials due to spending on smoking) over 92% also disagreed (see Table 1). The key finding is that New Zealand smokers from different socio-demographic groups appear to give very high support for not allowing smoking in cars carrying preschool children. These data are further supported by results from a 2008 national survey of the New Zealand public, which found 91% (82% for smokers) agreeing with the statement ‘that smoking should not be allowed in cars with children under the age of 14 in them’.3 These results indicate that there is strong support across a very wide range of smokers (and from the public) for active government intervention to protect New Zealand children from tobacco smoke pollution in cars. We need to consider why New Zealand is lagging behind 11 states and provinces in Australia, Canada, and the USA, which have all passed laws to protect their children from smoking in cars.4 While further social marketing campaigns on this theme are desirable, we suggest that smokefree car legislation is an appropriate use of the law, and would provide a strong signal on the priority of child protection from tobacco smoke. If the New Zealand Parliament is going to consider banning cell phone use while car driving, they could consider smokefree cars at the same time.

Citation

Lee, W.B., Fong, G.T., Zanna, M.P., Omar, M., Sirirassamee, B., Borland, R. (2009). Regret and rationalization among smokers in Thailand and Malaysia: Findings from the International Tobacco Control Southeast Asia Survey. Health Psychology, 28(4), 457-464.

Abstract

Objective: To test whether differences of history and strength in tobacco control policies will influence social norms, which, in turn, will influence quit intentions, by influencing smokers’ regret and rationalization.

Design: The data were from the International Tobacco Control (ITC) Policy Evaluation Southeast Asia Survey, a cohort survey of representative samples of adult smokers in Thailand (N _2,000) and Malaysia (N _ 2,006). The survey used a stratified multistage sampling design.

Main Outcome Measures: Measures included regret, rationalization, social norms, and quit intention.

Results: Thai smokers were more likely to have quit intentions than Malaysian smokers. This difference in quit intentions was, in part, explained by the country differences in social norms, regret, and rationalization. Reflecting Thailand’s history of stronger tobacco control policies, Thai smokers, compared with Malaysian smokers, perceived more negative social norms toward smoking, were more likely to regret, and less likely to rationalize smoking. Mediational analyses revealed that these differences in social norms, accounted, in part, for the country-quit intention relation and that regret and rationalization accounted, in part, for the social norm-quit intention relation.

Conclusion: The results suggest that social norms toward smoking, which are shaped by tobacco control policies, and smokers’ regret and rationalization influence quit intentions.

Citation

Siahpush, M., Yong, H.H., Borland, R., Reid, J., Hammond, D. (2009). Smokers with financial stress are more likely to want to quit but less likely to try or succeed: Findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 104(8), 1382-1390.

Abstract

Objective: To examine the association of financial stress with interest in quitting smoking, making a quit attempt and quit success.

Design and participants: The analysis used data from 4984 smokers who participated in waves 4 and 5 (2005–07) of the International Tobacco Control (ITC) Four Country Survey, a prospective study of a cohort of smokers in the United States, Canada, the United Kingdom and Australia.

Measurement: The outcomes were interest in quitting at wave 4, making a quit attempt and quit success at wave 5. The main predictor was financial stress at wave 4: ‘. . . because of a shortage of money, were you unable to pay any important bills on time, such as electricity, telephone or rent bills?’. Additional socio-demographic and smoking-related covariates were also examined.

Findings: Smokers with financial stress were more likely than others to have an interest in quitting at baseline [odds ratio (OR): 1.63; 95% confidence interval (CI): 1.22–2.19], but were less likely to have made a quit attempt at follow-up (OR: 0.74; 95% CI: 0.57–0.96). Among those who made a quit attempt, financial stress was associated with a lower probability of abstinence at follow-up (OR: 0.53; 95% CI: 0.33–0.87).

Conclusions: Cessation treatment efforts should consider assessing routinely the financial stress of their clients and providing additional counseling and resources for smokers who experience financial stress. Social policies that provide a safety net for people who might otherwise face severe financial problems, such as not being able to pay for rent or food, may have a favorable impact on cessation rates.

Citation

Parkinson, C., Hammond, D., Fong, G.T., Borland, R., Omar, M., Sirirassamee, B., Awang, R., Driezen, P., Thompson, M.E. (2009). Smoking beliefs and behavior among youth in Malaysia and Thailand. American Journal of Health Behavior, 33(4), 366-375.

Abstract

Objective: To characterize smoking beliefs among Thai and Malaysian youth and to examine associations with gender, antismoking media exposure, and smoking status.

Methods: Nationally representative samples of youth completed self-administered questionnaires.

Results: A substantial proportion of youth reported positive beliefs about smoking. Those reporting positive beliefs were more likely to be susceptible to smoking. Youth who noticed antismoking media were less likely to report positive beliefs about smoking.

Conclusions: As in Western countries, beliefs about smoking held by youth in Southeast Asia are associated with smoking status. Antismoking media may be an important means of targeting beliefs about smoking among youth.

Citation

Hyland, A., Higbee, C., Borland, R., Travers, M.J., Hastings, G., Fong, G.T., Cummings, K.M. (2009). Attitudes and beliefs about secondhand smoke and smoke-free policies in four countries: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 11(6), 642-649.

Abstract

Introduction: This paper describes the varying levels of smoking policies in nationally representative samples of smokers in four countries and examines how these policies are associated with changes in attitudes and beliefs about secondhand smoke over time.

Methods: We report data on 5,788 respondents to Wave 1 of the International Tobacco Control Four Country Survey who were employed at the time of the survey. A cohort of these respondents was followed up with two additional survey waves approximately 12 months apart. Respondents ’ attitudes and beliefs about secondhand smoke as well as self-reported policies in their workplace and in bars and restaurants in their community were assessed at all waves.

Results: The level of comprehensive smoke-free policies in workplaces, restaurants, and bars increased over the study period for all countries combined and was highest in Canada (30%) and lowest in the United Kingdom (0%) in 2004. In both crosssectional and longitudinal analyses, stronger secondhand smoke policies were associated with more favorable attitudes and support for comprehensive regulations. The associations were the strongest for smokers who reported comprehensive policies in restaurants, bars, and their workplace for all three survey waves.

Discussion: Comprehensive smoke-free policies are increasing over time, and stronger policies and the public education opportunities surrounding their passage are associated with more favorable attitudes toward secondhand smoke regulations. The implication for policy makers is that, although the initial debate over smoke-free policies may be tumultuous, once people understand the rationale for implementing smoke-free policies and experience their benefits, public support increases even among smokers, and compliance with smoke-free regulations increases over time.

Citation

Li, Z., Jiang, H., Jiao, S., Zhao, J., Zhu, G., Luo, B., Li, X., Li, Q., Feng, G., Yang, Y. (2008). Cross-sectional study on nicotine dependence of adult smokers in six cities. Practical Preventive Medicine, 15(6), 1691-1694.

Abstract

Objective: To collect the information on nicotine dependence of Chinese adult smokers and understand the related factors of high nicotine dependence in adult smokers.

Methods: Used 4800 adult smokers, interviewed in Beijing, Shenyang, Shanghai, Changsha, Guangzhou and Yinchuan 1,800 smokers in each city were selected with multiple stages sampling method.

Results: The level of HIS was 215 ±117 in adult smokers in China, 215 ±117 for male and 119 ±117 for female, which were lower than that of smokers in developed countries1 The result of logistic regressions for predicting the probability of high nicotine dependence showed that gender, age, education, years after becoming a regular smoker, health consciousness and p rice per pack of last purchase could enter the equation1 Male (OR = 21352) and lower education had significant associations with high nicotine dependence. The lower education the smokers had, the higher nicotine dependence they were (the high education as contrasted, the OR of the medium education was 11417; the OR of low education was 11853) People who had smoked more than 10 years had high nicotine dependence (OR = 41519) People who regarded smoking was neither good nor bad for their own health (OR = 11345) , regarded smoking was good for their own health (OR = 21419) and purchased below 4 yuan per pack (OR = 11635) had high nicotine dependence.

Conclusion: Compared with developed countries, the HSI level was lower in China Male, higher age, lower education, smoking more than 10 years, failing to understand smoking damage, and purchasing cheap cigarettes were associated with high nicotine dependence.

Citation

Wilson, N., Weerasekera, D., Peace, J., Edwards, R., Thomson, G., Devlin, M. (2009). Misperceptions of “light” cigarettes abound: National survey data. BioMed Central Public Health, 9(1), 126.

Abstract

Background: Many smokers believe that "light" cigarettes are less harmful than regular cigarettes, which is at variance with the scientific evidence. The Framework Convention on Tobacco Control (FCTC) aims to address this problem in Article 11 which deals with misleading labelling of tobacco products. In this study we aimed to determine smokers' use and beliefs concerning "light" and "mild" cigarettes ("lights"), including in relation to ethnicity, deprivation and other socio-demographic characteristics.

Methods: The New Zealand (NZ) arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) uses as its sampling frame the NZ Health Survey. This is a national sample with boosted sampling of Maori, Pacific peoples and Asians. From this sample we surveyed adult smokers (n = 1376) about use and beliefs relating to "light" cigarettes. We assessed the associations with smoking "lights" after adjusting for socio-demographic variables, and smoking-related behaviours and beliefs.

Results: Many smokers of "lights" believed that smoking "lights" made it easier to quit smoking (25%), that "lights" are less harmful (42%), and that smokers of "lights" take in less tar (43%). Overall most "lights" smokers (60%) had at least one of these three beliefs, a proportion significantly higher than for smokers of "regular" cigarettes at 45% (adjusted odds ratio (aOR) = 1.96, 95% CI = 1.29 – 2.96). While "lights" smokers had significantly lower tobacco consumption and were more aware of smoking harms, they were no more likely to be intending to quit or have made a previous quit attempt. By ethnicity, both Maori and Pacific people were less likely to smoke "lights" than Europeans (aOR = 0.53, 95% CI = 0.35 – 0.80 and aOR = 0.14, 95% CI = 0.05 – 0.40 respectively). In contrast there was no significant difference by level of deprivation. Roll-your-own (RYO) tobacco smokers were less likely to smoke "light" forms of RYO tobacco while both older and women smokers were more likely to smoke "lights".

Conclusion: Most "lights" smokers have one or more misperceptions about the product they use, and were no more likely to intend to quit or to have made a quit attempt. In response to such misperceptions, governments could act further to eliminate all misleading tobacco marketing. Ideally, they could not only adopt FCTC requirements, but go further by requiring plain packaging for all tobacco products.

Citation

Li, L., Yong, H.H., Borland, R., Fong, G.T., Thompson, M.E., Jiang, Y., Yang, Y., Sirirassamee, B., Hastings, G., Harris, F. (2009). Reported awareness of tobacco advertising and promotion in China compared to Thailand, Australia and the USA. Tobacco Control, 18(3), 222-227.

Abstract

Background: China currently does not have comprehensive laws or regulations on tobacco advertising and promotion, although it ratified the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in October 2005 and promised to ban all tobacco advertising by January 2011. Much effort is needed to monitor the current situation of tobacco advertising and promotion in China.

Objective: This study aims to examine levels of awareness of tobacco advertising and promotion among smokers in China as compared to other countries with different levels of restrictions.

Methods: One developing country (Thailand) and two developed countries (Australia and the USA) were selected for comparison. All four countries are part of the International Tobacco Control (ITC) Policy Evaluation Survey project. Between 2005 and 2006, parallel ITC surveys were conducted among adult smokers (at least smoked weekly) in China (n=4763), Thailand (n=2000), Australia (n=1767) and the USA (n=1780). Unprompted and prompted recall of noticing tobacco advertising and promotion were measured.

Results: Chinese respondents reported noticing tobacco advertisements in a range of channels and venues, with highest exposure levels on television (34.5%), billboards (33.4%) and in stores (29.2%). A quarter of respondents noticed tobacco sponsorships, and a high level of awareness of promotion was reported. Cross-country comparison reveals that overall reported awareness was significantly higher in China than in Thailand (particularly) and Australia, but lower than in the USA.

Conclusions: There is a big gap between China and the better-performing countries such as Thailand and Australia regarding tobacco promotion restrictions. China needs to do more, including enhanced policy and more robust enforcement.

Citation

Brown, A., Moodie, C., Hastings, G. (2009). A longitudinal study of policy effect (smoke-free legislation) on smoking norms: ITC Scotland/United Kingdom. Nicotine & Tobacco Research, 11(8), 924-932.

Abstract

Introduction: The longitudinal ITC Scotland/U.K. survey was used to investigate adult smokers ’ support for smoke-free legislation and whether this support was associated with higher quit intentions at follow-up, either directly or indirectly, via the mediation of perceived social unacceptability of smoking.

Methods: Structural equation modeling was employed to compare differences between the two samples (507 adult smokers from Scotland and 507 from the rest of the United Kingdom) across two waves (February/March 2006 and March 2007). During these two waves, a smoking ban was introduced in Scotland but not the rest of the United Kingdom.

Results: For smokers in both samples, support for smoke-free legislation at baseline significantly heightened perceived unacceptability of smoking, although perceptions of unacceptability were somewhat stronger in Scotland than the rest of the United Kingdom post ban. Unlike the rest of the United Kingdom, support for a ban at baseline among smokers in Scotland was associated with higher quit intentions at follow-up. For both samples, quit intentions were significantly associated with heightened perceived unacceptability at follow-up. The overall variance explained in quit intentions was greater in Scotland than in the rest of the United Kingdom but not significantly so.

Discussion: Support for smoke-free legislation at baseline significantly increased support at follow-up for both samples. However, this did not independently increase quit intentions among smokers from both Scotland and the rest of the United Kingdom. The findings suggest that normative influences are one of the mechanisms through which comprehensive smokefree legislation influences quit intentions.

Citation

Fathelrahman, A., Omar, M., Awang, R., Borland, R., Fong, G.T., Hammond, D., Zain, Z. (2009). Smokers' responses toward cigarette pack warning labels in predicting quit intention, stage of change, and self-efficacy. Nicotine & Tobacco Research, 11(3), 248-253.

Abstract

Introduction: This paper is concerned with the effects of cigarette pack warning labels on quitting intentions. We examined whether different responses among smokers toward cigarette pack warning labels could predict quit intentions and self-efficacy in quitting. Variables studied were “noticing warning labels during last month,” “reading or looking closely at warning labels,” “avoiding looking at labels during last month,” “thinking about health risks of smoking because of the warning labels, “more likely to quit because of the warning labels,” and “stopping from having a cigarette when about to smoke one because of the labels.”

Methods: A total of 2,006 adult smokers in Malaysia were surveyed in face-to-face interviews using a standardized questionnaire. Of those, 1,919 male smokers were included in the analyses.

Results: The responses “more likely to quit because of the warning labels” and “stopped from having a cigarette when about to smoke one ” significantly predicted all stages of change and self-efficacy, independent of the other measures. In addition, thinking about the health risks and reading the warnings more often added extra predictive capacity but only in the early stages of contemplating change.

Discussion: Less intense processing of the information may be important in initiating thoughts, but cognitions about quitting and foregoing cigarettes are the key mechanisms by which warnings stimulate quitting intentions and help smokers feel capable of succeeding. Malaysian smokers appear to respond to warnings in ways comparable with those from developed countries.

Citation

Cummings, K.M., Fong, G.T., Borland, R. (2009). Environmental influences on tobacco use: Evidence from societal and community influences on tobacco use and dependence. Annual Review of Clinical Psychology, 5, 433-458.

Abstract

There is little doubt that nicotine addiction sustains tobacco use in most people and that individual variation in response to tobacco has a strong biological basis. However, the great diversity in tobacco use behaviors observed between countries and within countries over time suggests that biology alone cannot fully explain these variations. This review examines the role of the social environment in understanding tobacco use behaviors and efforts to curb tobacco use at the population level. We conclude that the social environment plays a critical role in determining how innate biological factors involved in nicotine dependency actually get expressed at the population level. Tobacco use as reflected in population trends is seen as the product of the interaction of agent, host, and environmental factors. Government policies are seen as an important modifiable environmental influence that can alter how tobacco products are designed and marketed (agent factors) and how consumers perceive the risks and benefits of smoking (host factors). Evidence suggests that synergy is gained when tobacco control interventions directed at agent, host, and environmental factors are implemented together.

Citation

Hammond, D., Kin, F., Prohmmo, A., Kungskulniti, N., Lian, T.Y., Sharma, S.K., Sirirassamee, B., Borland, R., Fong, G.T. (2008). Patterns of smoking among adolescents in Malaysia and Thailand: Findings from the International Tobacco Control Southeast Asia Survey. Asia-Pacific Journal of Public Health, 20(3), 193-203.

Abstract

At present, 70% of the world's 1.1 billion smokers are in developing countries, with over 50% in Asia alone. The current study examined patterns of youth smoking in Thailand and Malaysia. Respondents were 2002 youths between the ages of 13 and 17 from Thailand (n = 1000) and Malaysia (n = 1002). Respondents were selected using a multistage cluster sampling design and surveyed between January 2005 and March 2005. Approximately 3% of youth between the ages of 13 and 17 were current smokers, with an additional 10% to 12% reporting experimental smoking. Males were between 7 and 15 times more likely to report smoking behavior than females. Less than 1% of females respondents in either country met the criteria for current smoking, and less than 5% met the criteria for experimental smoking. In contrast, more than 50% Thai males and approximately one-third of Malaysian males aged 17 met the criteria for either experimental or current smoking.

Citation

Borland, R., Yong, H.H., Balmford, J., Fong, G.T., Zanna, M.P., Hastings, G. (2009). Do risk-minimizing beliefs about smoking inhibit quitting? Findings from the International Tobacco Control (ITC) Four Country Survey. Preventive Medicine, 19(2-3), 219-223.

Abstract

Objective: To replicate findings that risk-minimizing and self-exempting beliefs lower quit intentions, and to extend this by testing their capacity to prospectively predict smoking cessation.

Method: 13,324 adult (≥ 18 years) cigarette smokers from the USA, Canada, UK, and Australia from one of the first three waves (2002-2004) of the International Tobacco Control 4-Country survey were employed for the predictive analysis where beliefs measured in one wave (1-3) of a cohort were used to predict cessation outcomes in the next wave (2-4).

Results: Both types of belief were negatively associated with both intention to quit in the same wave and making a quit attempt at the next wave. When taken together and controlling for demographic factors, the risk-minimizing beliefs continued to be predictive, but the self-exempting belief was not. Some of the effects of risk-minimizing beliefs on quit attempts seem to be independent of intentions, but not consistently independent of other known predictors. There were no consistent predictive effects on sustained cessation among those who made attempts to quit for either measure.

Conclusions: Countering risk-minimizing beliefs may facilitate increased quitting, but this may not be so important for self-exempting beliefs.

Citation

Borland, R., Yong, H.H., Wilson, N., Fong, G.T., Hammond, D., Cummings, K.M., Hosking, W., McNeill, A. (2009). How reactions to cigarette packet health warnings influence quitting: Findings from the ITC Four Country Survey. Addiction, 104(4), 669-675.

Abstract

Objectives: To examine prospectively the impact of health warnings on quitting activity.

Design: Five waves (2002–06) of a cohort survey where reactions to health warnings at one survey wave are used to predict cessation activity at the next wave, controlling for country (proxy for warning differences) and other factors. These analyses were replicated on four wave-to-wave transitions.

Setting and participants: Smokers from Australia, Canada, the United Kingdom and the United States. Samples were waves 1–2: n = 6525; waves 2–3: n = 5257; waves 3–4: n = 4439; and waves 4–5: n = 3993.

Measures: Warning salience, cognitive responses (thoughts of harm and of quitting), forgoing of cigarettes and avoidance of warnings were examined as predictors of quit attempts, and of quitting success among those who tried (1 month sustained abstinence), replicated across four wave-to-wave transitions.

Results: All four responses to warnings were independently predictive of quitting activity in bivariate analyses. In multivariate analyses, both forgoing cigarettes and cognitive responses to the warnings predicted prospectively making quit attempts in all replications. However, avoiding warnings did not add predictive value consistently, and there was no consistent pattern for warning salience. There were no interactions by country. Some, but not all, the effects were mediated by quitting intentions. There were no consistent effects on quit success.

Conclusions: This study adds to the evidence that forgoing cigarettes as a result of noticing warnings and quit-related cognitive reactions to warnings are consistent prospective predictors of making quit attempts. This work strengthens the evidence base for governments to go beyond the Framework Convention on Tobacco Control to mandate health warnings on tobacco products that stimulate the highest possible levels of these reactions.

Citation

Borland, R., Wilson, N., Fong, G.T., Hammond, D., Cummings, K.M., Yong, H.H., Hosking, W., Hastings, G., Thrasher, J.F., McNeill, A. (2009). Impact of graphic and text warnings on cigarette packs: Findings from four countries over five years. Tobacco Control, 18(5), 358-364.

Abstract

Objectives: To examine the impact of health warnings on smokers by comparing the short-term impact of new graphic (2006) Australian warnings with: (i) earlier (2003) United Kingdom larger text-based warnings; (ii) and Canadian graphic warnings (late 2000); and also to extend our understanding of warning wear-out.

Methods: The International Tobacco Control Policy Evaluation Survey (ITC Project) follows prospective cohorts (with replenishment) of adult smokers annually (five waves: 2002–2006), in Canada, United States, UK and Australia (around 2000 per country per wave; total n=17 773). Measures were of pack warning salience (reading and noticing); cognitive responses (thoughts of harm and quitting); and two behavioural responses: forgoing cigarettes and avoiding the warnings.

Results: All four indicators of impact increased markedly among Australian smokers following the introduction of graphic warnings. Controlling for date of introduction, they stimulated more cognitive responses than the UK (textonly) changes, and were avoided more, did not significantly increase forgoing cigarettes, but were read and noticed less. The findings also extend previous work showing partial wear-out of both graphic and text-only warnings, but the Canadian warnings have more sustained effects than UK ones.

Conclusions: Australia’s new health warnings increased reactions that are prospectively predictive of cessation activity. Warning size increases warning effectiveness and graphic warnings may be superior to text-based warnings. While there is partial wear-out in the initial impact associated with all warnings, stronger warnings tend to sustain their effects for longer. These findings support arguments for governments to exceed minimum FCTC requirements on warnings.

Citation

Jiang, Y., Fong, G.T., Li, Q., Hammond, D., Quah, A.C.K., Yang, Y., Driezen, P., Yan, M. (2009). Evaluation of the effectiveness of health warnings on cigarette packs in China, 2008 (Language: Chinese). Chinese Journal of Health Education, 25(6), 411-430.

Abstract

Objective: To evaluate the effectiveness of health warnings on cigarette packs among Chinese residents.

Methods: 1169 individuals, including adult smokers, adult non-smokers and youth, balanced on gender, were selected from Bejing, Shanghai, Kunming, Yinchuan cities. The participants rated and ranked 10 real-size photographs of cigarette packs with a health warning. In addition to the two Chinese text warnings (one old and one new), there were 4 Chinese versions health warnings from foreign countries and the same 4 warnings with the picture removed.

Results: Regarding the effectiveness of motivating smokers to quit and convincing youth not to start smoking, the picture warnings were consistently ranked or rated in the top positions, followed by the 4 foreign text-only warnings. The old Chinese text warnings were consistently ranked or rated in the bottom. Results were very consistent across subject groups, cities and gender.

Conclusions: The new Chinese warning gained a small enhancement in term of effectiveness. It is necessary to use powerful health warnings on cigarette packs following the Article 11 of Framework Convention on Tobacco Control to improve the effectiveness of the communication of health harm knowledge to the publics.

Keywords: Cigarette package; Health warning; Health knowledge

Citation

Feng, G., Jiying, X., Liang, B., Jiang, Y., Yang, Y., Li, Q. (2009). Analysis on factors associated with intention to quit smoking of adult smokers in six cities of China (Language: Chinese). Chinese Journal of Prevention and Control of Chronic Diseases, 17(5), 476-478.

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 n=4815).

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

Fong, G.T., Hammond, D., Hitchman, S.C. (2009). The impact of pictures on the effectiveness of tobacco warnings. Bulletin of the World Health Organization, 87(8), 640-643.

Abstract

Cigarette packages in most countries carry a health warning; however, the position, size and general strength of these warnings vary considerably across jurisdictions.1 Article 11 of the WHO Framework Convention on Tobacco Control (FCTC) and the Article 11 Guidelines adopted at the Third Conference of the Parties in November 2008 have put the spotlight on the inclusion of pictures on tobacco package health warnings. Beginning with Canada in 2001, 28 countries have introduced pictorial warnings and many other countries are in the process of drafting regulations for pictorial warnings (Box 1 and Box 2). This paper presents a brief review of the research studies that support pictorial warnings, reviewed in greater depth by Hammond and by the International Tobacco Control (ITC) Policy Evaluation Project.