Citation

Liu, C., Yong, H.H., Gravely, S., East, K.A., Kasza, K., Gartner, C., Cummings, K.M., Fong, G.T. (2023). Gender differences in cigarette smoking cessation attempts among adults who smoke and drink alcohol at high levels: Findings from the 2018-2020 International Tobacco Control Four Country Smoking and Vaping Surveys. Addictive Behaviours, 147, 107817. doi: 10.1016/j.addbeh.2023.107817.

Abstract

Background: This study examined the association between alcohol consumption and smoking cessation behaviour of adults who smoke in four countries.

Methods: Data came from 4275 adults (≥18 years) who smoked tobacco ≥ monthly and participated in the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping Surveys (Australia: n = 720; Canada: n = 1250; US: n = 1011; England: n = 1294). The 2018 Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) survey data coded into three levels ('never/low', 'moderate' or 'heavy' consumption) were analysed using multivariable logistic regression models to predict any smoking cessation attempts and successful cessation by 2020 survey, and whether this differed by gender and country.

Results: Compared to never/low alcohol consumers, only those who drink heavily were less likely to have made a quit smoking attempt (40.4 % vs. 43.8 %; AOR = 0.69, 95 % CI = 0.57-0.83, p < .001). The association differed by gender and country (3-way interaction, p < .001), with females who drink heavily being less likely to attempt to quit smoking in England (AOR = 0.27, 95 % CI = 0.15-0.49, p < .001) and Australia (AOR = 0.38, 95 % CI = 0.19-0.77, p = .008), but for males, those who drink moderately (AOR = 2.18, 95 % CI = 1.17-4.06, p = .014) or heavily (AOR = 2.61, 95 % CI = 1.45-4.68, p = .001) were more likely to make a quit attempt in England only. Alcohol consumption did not predict quit success.

Conclusion: Heavy alcohol use among adults who smoke appears to only undermine the likelihood of trying to quit smoking with some variation by gender and country of residence, but not their chances of succeeding if they tried.

Citation

Lemos, M.K., Taylor, E., Wadsworth, E., Reid, J.L., Hammond, D., East, K.A. (2023). Perceptions of cannabis use risk to mental health among youth in Canada, England, and the United States from 2017 to 2021. Drug and Alcohol Dependence, 250, 110904. doi: 10.1016/j.drugalcdep.2023.110904.

Abstract

Background: There is little research examining perceptions of cannabis use risk to mental health in countries with differing cannabis regulations. This study therefore examines such perceptions among youth between 2017 and 2021 in Canada (non-medical cannabis legalized in October 2018), England (highly-restricted medical cannabis legalized November 2018), and the US (non-medical cannabis legal in some states).

Methods: Seven repeat cross-sectional online surveys were conducted between July 2017 to August 2021 among youth aged 16-19 in Canada (N=29,420), England (N=28,155), and the US (N=32,974). Logistic regression models, stratified by country, were used to examine perceptions of cannabis use risk to mental health over time, adjusting for age group, sex, race/ethnicity, cannabis use and, for the US only, state-level cannabis legalization.

Results: Perceptions that cannabis use posed “no risk” to mental health decreased between July 2017 and August 2021 in Canada (6.1% to 4.4%; AOR=0.64, 95% CI=0.52-0.78) and the US (14.0% to 11.3%; AOR=0.74, 0.65-0.84) but not England (3.7% to 4.5%; AOR=1.21, 0.97-1.52). No significant changes were observed from immediately before (August 2018) to after (August 2019) legalization of non-medical cannabis in Canada (AOR=0.99, 0.83-1.20) or highly-restricted medical cannabis in England (AOR=0.90, 0.70-1.17). In the US, perceptions of “no risk” were more likely in states where cannabis use was illegal (15.0%) compared with legal non-medical (12.2%) (AOR=0.68, 0.63-0.74).

Conclusion: There were modest decreases in perceptions that cannabis use poses no risk to mental health in Canada and the US between 2017 and 2021 but no clear association with cannabis legalization status.

Abstract

Introduction: Electronic nicotine delivery systems (ENDS) are known to contain heavy metals such as lead (Pb), nickel (Ni) and chromium (Cr). The presence of heavy metals in ENDS may be due to contamination of e-liquids or leaching from elements of the ENDS device. This study investigates differences in ENDS metal concentrations between product type, year of purchase, country of purchase and e-liquid flavour.

Methods: Various open-system (refill e-liquids; n=116) and closed-system (prefilled with e-liquid; n=120) products were purchased in 2017 and 2018 from the USA, England, Canada and Australia. Electrothermal atomic absorption spectroscopy was used to analyse each product for Pb, Ni and Cr. Multiple linear regression and Kruskal-Wallis non-parametric statistical tests were conducted using GraphPad.

Results: Linear regression showed system type, year of purchase (not supported by Kruskal-Wallis), country of purchase and flavour type each had significant impacts on heavy metal concentrations. Open-system e-liquid samples showed no quantifiable levels of heavy metals. Closed-system samples contained concerningly high concentrations of Pb, Ni and Cr. Closed-system samples from the USA commonly displayed higher average heavy metal concentrations than those from England. Some fruit and mint-flavoured closed-system products showed higher heavy metal concentrations than tobacco-flavoured products.

Conclusion: The presence of heavy metals only in closed-system products suggests that metals may be leaching from ENDS device parts. Highly variable heavy metal concentrations between ENDS products demonstrate that various product characteristics may affect the degree of leaching and that there is a need for further regulation of these products.

Citation

Block, A.C., Schneller L.M., Leigh, N.J. Heo, J., Goniewicz, M.L., O’Connor, R.J. (2023). Heavy metals in ENDS: a comparison of open versus closed systems purchased from the USA, England, Canada and Australia. Tobacco Control, [Published online Jul 12, doi: 10.1136/tc-2023-057932].

Citation

Gravely, S., Meng, G., Hammond, D., Driezen, P., Thrasher, J.F., Fong, G.T., Craig, L.V., Chung-Hall, J., Quah, A.C.K., Ouimet, J., Bansal-Travers, M., Cummings, K.M. (2023). Support for pictorial health warning labels on cigarette packages in the United States among adults who currently smoke or quit smoking: Findings from the ITC US Smoking and Vaping Surveys. Tobacco Induced Diseases, 21(June), 84. doi: 10.18332/tid/166001.

Abstract

Introduction: In March 2020, the US Food and Drug Administration (FDA) finalized new pictorial health warnings (PHWs), covering 50% of the front and back of the pack; however, legal challenges from cigarette manufacturers have prevented the new warnings from being implemented. About 70% of adults in the general US population support PHWs. This study assessed support for PHWs in 2016, 2018 and 2020 among US adults (aged ≥18 years) who currently smoke or formerly smoked cigarettes. We also assessed factors related to support.

Methods: Respondents included adults who currently or formerly smoked cigarettes and participated in at least one wave of the US ITC Smoking and Vaping Surveys: Wave 1 (2016, n=2557); Wave 2 (2018, n=2685); and Wave 3 (2020, n=1112). We assessed changes in support for PHWs between 2016 and 2020, and assessed factors related to support (support vs oppose/don’t know). Analyses were conducted on weighted data.

Results: Overall, 38.0% of respondents supported PHWs in 2016, with a significant increase to 44.7% in 2018 (p<0.001), and leveling off to 45.0% in 2020 (2018 vs 2020, p=0.91). Support was highest among former smokers and lowest among daily smokers in all three survey years. Support for PHWs at all survey years was significantly higher among those who formerly smoked, were younger (aged 18–39 vs ≥40 years), those who identified as Black (vs White), and planned to quit smoking (vs not planning to quit). There were no differences by income level, education level, or sex.

Conclusions: Nearly half of US adults who smoke cigarettes or quit smoking supported PHWs in 2020, with support being higher among younger adults, ethnic minorities, and those who formerly smoked. Support increased between 2016 and 2018, but not between 2018 and 2020. Similar to other studies, fewer current and former smokers supported PHWs compared to the US adult general population.

Citation

Mechili, E.A., Przewoźniak, K., Driezen, P., Kyriakos, C.N., Girvalaki, C., Mons, U., Quah, A.C.K., Fernández, E., Trofor, A.C., Demjén, T., Katsaounou, P.A., Zatoński, W.A., Fong, G.T., Vardavas, C.I. (2023). Smokers' support for the ban on sale of slim cigarettes in six European countries: Findings from the EUREST PLUS ITC Europe Surveys. Open Research Europe, 1, 52. doi: 10.12688/openreseurope.13405.4.

Abstract

Background: Efforts to regulate tobacco products and reduce consumption in the European Union (EU) include the European Tobacco Products Directive (TPD), which went into force in May 2016. Despite the initial discussion to include a ban on sale of slim cigarettes, it was excluded in the final TPD. The main goal of this study was to examine support for a ban on slim cigarettes among smokers in six European Countries.

Methods: Data from the 2018 (Wave 2) International Tobacco Control Policy Evaluation Project 6 European Country (ITC 6E) EUREST PLUS project survey, a cross sectional study of adult smokers (n=5592) fro m Germany, Greece, Hungary, Poland, Romania, and Spain, was analysed. Descriptive statistics were used to estimate support for a ban on slim cigarettes by sociodemographic characteristics and smoking behaviors. Logistic regression analysis was used to examine factors associated with support for a ban on slim cigarettes and perceptions of harm.

Results: Support for a ban on slims varied across countries, with highest support in Romania (33.8%), and lowest in Greece (18.0%). Female smokers (OR=0.78; 95%CI=0. 67 0.91, daily smokers (OR=0.68; 95%CI=0.47 0.97), menthol smokers (OR=0.55; 95%CI=0.36 0.86), and smokers who did not have plans to quit within next six months (OR=0.45; 95%CI=0.36 0.56) had significantly lower odds of supporting a ban on slim cigarettes. Overall, 21% of smokers perceived slim cigarettes as less harmful than regular cigarettes.

Conclusions: Support for a ban of slim cigarettes was relatively low among smokers, while misperceptions that slim cigarettes are less harmful is high, particularly among countries where slim cigarette use is more revalent. Findings support a ban on slim cigarettes to reduce misperceptions around slim cigarettes being less harmful.

Citation

Gravely, S., Driezen, P., McClure, E., Smith, D.M., Fong, G.T. (2023). Prevalence of depressive symptoms and cannabis use among adult cigarette smokers in Canada: cross-sectional findings from the 2020 International Tobacco Control Policy Evaluation Project Canada Smoking and Vaping Survey. Canadian Medical Association Journal Open, 11(3), E516-E526. doi: 10.9778/cmajo.20220081.

Abstract

Background: Tobacco smoking and cannabis use are independently associated with depression, and evidence suggests that people who use both tobacco and cannabis (co-consumers) are more likely to report mental health problems, greater nicotine dependence and alcohol misuse than those who use either product exclusively. We examined prevalence of cannabis use and depressive symptoms among Canadian adults who smoke cigarettes and tested whether co-consumers of cannabis and tobacco were more likely to report depressive symptoms than cigarette-only smokers; we also tested whether cigarette-only smokers and co-consumers differed on cigarette dependence measures, motivation to quit smoking and risky alcohol use by the presence or absence of depressive symptoms.

Methods: We analyzed cross-sectional data from adult (age ≥ 18 yr) current (≥ monthly) cigarette smokers from the Canadian arm of the 2020 International Tobacco Control Policy Evaluation Project Four Country Smoking and Vaping Survey. Canadian respondents were recruited from Leger’s online probability panel across all 10 provinces. We estimated weighted percentages for depressive symptoms and cannabis use among all respondents and tested whether co-consumers (≥ monthly use of cannabis and cigarettes) were more likely to report depressive symptoms than cigarette-only smokers. Weighted multivariable regression models were used to identify differences between co-consumers and cigarette-only smokers with and without depressive symptoms.

Results: A total of 2843 current smokers were included in the study. The prevalence of past-year, past-30-day and daily cannabis use was 44.0%, 33.2% and 16.1%, respectively (30.4% reported using cannabis at least monthly). Among all respondents, 30.0% screened positive for depressive symptoms, with co-consumers being more likely to report depressive symptoms (36.5%) than those who did not report current cannabis use (27.4%, p < 0.001). Depressive symptoms were associated with planning to quit smoking (p = 0.01), having made multiple attempts to quit smoking (p < 0.001), the perception of being very addicted to cigarettes (p < 0.001) and strong urges to smoke (p = 0.001), whereas cannabis use was not (all p ≥ 0.05). Cannabis use was associated with high-risk alcohol consumption (p < 0.001), whereas depressive symptoms were not (p = 0.1).

Interpretation: Co-consumers were more likely to report depressive symptoms and high-risk alcohol consumption; however, only depression, and not cannabis use, was associated with greater motivation to quit smoking and greater perceived dependence on cigarettes. A deeper understanding of how cannabis, alcohol use and depression interact among people who smoke cigarettes is needed, as well as how these factors affect cessation activity over time.

Citation

Gravely, S., Yong, H.H., Reid, J.L., East, K.A., Liber, A.C., Cummings, K.M., Quah, A.C.K., Fong, G.T., Hammond, D. (2023). An examination of quitting smoking as a reason for vaping by the type of nicotine vaping device used most often among adults who smoke and vape: Findings from the Canada, England and the United States 2020 ITC Smoking and Vaping Survey. Preventive Medicine Reports, 33, 102201. doi: 10.1016/j.pmedr.2023.102201.

Abstract

Several nicotine vaping product (NVP) device types are available to consumers, and many people who smoke report vaping to help them quit. This study included data from the Wave 3 (2020) ITC Smoking and Vaping Survey in the US, Canada, and England and included 2324 adults who were smoking cigarettes and vaping at least weekly. Device types currently used most often (disposables, cartridges/pods, or tank systems) were assessed using weighted descriptive statistics. Multivariable regression analyses were used to compare differences between respondents who reported vaping to quit smoking (‘yes’ vs. ‘no/don’t know’) by device type, overall and by country. Overall, 71.3% of respondents reported vaping to help them quit smoking, with no country differences (p = 0.12). Those using tanks (78.7%, p < 0.001) and cartridges/pods (69.5%, p = 0.02) were more likely to report this reason for vaping than those using disposables (59.3%); respondents using tanks were also more likely than those using cartridges/pods (p = 0.001) to report this reason. By country, respondents in England using cartridges/pods or tanks (vs. disposables) were more likely to report vaping to quit smoking (with no difference between cartridges/pods and tanks). In Canada, respondents using tanks were more likely to report vaping to quit smoking than those using cartridges/pods or disposables (no difference between disposables and cartridges/pods). No significant differences by device type were found in the US. In conclusion, most adult respondents who smoked and vaped reported using either cartridges/pods or tanks, which were associated with greater odds of vaping for the purpose of quitting smoking versus disposables, with some country variations.

Citation

Gallien, M., Occhiali, G., Ross, H. (2023). An overlooked market: loose cigarettes, informal vendors and their implications for tobacco taxation. Tobacco Control, [Published online May 23, doi: 10.1136/tc-2023-057965].

Abstract

Objective: To examine the features of markets for loose cigarettes in several low-income and middle-income countries and their effects on tobacco control policies, particularly taxation.

Design: An analysis of survey data targeting people who smoke in two African, one Southeast Asian and two South Asian countries and retailers across 16 African countries to study loose cigarette markets and examine how prices in these markets move relative to the prices for cigarette packs.

Results: Markets for loose cigarettes are large, and their consumer base tends to differ from the wider population of people who smoke. Loose cigarette prices are on average higher than those of cigarettes bought in packs, and they respond differently to tax increases, at least partially due to a denomination effect.

Conclusions: The features of the loose cigarette markets present a challenge for tobacco control policy, especially tobacco tax policy. One way to overcome this challenge is to aim for large, rather than incremental, tax increases.

Citation

Yong, H.H., Karmakar, C., Motin, M. A., Borland, R., Cummings, K.M., Gravely, S., Fong, G.T. (2023). Individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies relative to combustible cigarettes among people who smoke: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 25(9), 1594-1602. doi: 10.1093/ntr/ntad075.

Abstract

Introduction: This study examined individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies (NRTs) relative to combustible cigarettes (CCs).

Methods: Data analyzed came from 8,642 adults (18+ years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n=1213), Canada (n=2633), England (n=3057), and United States (US, n=1739). Respondents were asked: Compared to smoking cigarettes, how harmful do you think nicotine replacement products are? Responses were dichotomised into much less vs. otherwise for analysis using multivariable logistic regression models, complemented by decision-tree analysis to identify conjoint factors.

Results: Percentages believing that NRTs are much less harmful than CCs were 29.7% (95% CI:26.2-33.5%) in Australia, 27.4% (95% CI=25.1-29.8%) in England, 26.4% (95% CI=24.4-28.4%) in Canada and 21.7% (95% CI=19.2-24.3%) in the US. Across all countries, believing nicotine is not at all/slightly harmful to health (aOR=1.53-2.27), endorsing nicotine vaping products as less harmful than CCs (much less harmful: aOR=7.24-14.27; somewhat less harmful: aOR=1.97-3.23), and possessing higher knowledge of smoking harms (aOR=1.23-1.88) were individual factors associated with increased odds of believing NRTs are much less harmful than CCs. With some country variations, these nicotine-related measures also interacted with each other and socio-demographic variables to serve as conjoint factors associated with the likelihood of accurate NRT relative harm belief.

Conclusions: Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors.

Implications: This study demonstrates that despite past efforts to educate people who smoke about the harms of NRTs relative to CCs, misperceptions around the relative harmfulness of NRTs remain substantial. In all four studied countries, subgroups of people who smoke regularly who are misinformed about the relative harmfulness of NRTs, and who may be reluctant to use NRTs for smoking cessation can be reliably identified for corrective interventions based o n their understanding of the harms related to nicotine, NVPs and smoking along with sociodemographic markers. The identified subgroup information can be used to prioritize and inform the development of effective interventions to specifically address the gaps in knowledge and understanding of the various subgroups identified. Our results suggest these may need to be tailored for each country.

Citation

Taylor, E., East, K.A., Reid, J., Hammond, D. (2023). Awareness and use of short-fill e-liquids by youth in England in 2021: Findings from the ITC Youth Survey. Tobacco Control, [Published online May 2, doi:10.1136/tc-2022-057871].

Abstract

Background: Refillable e-cigarettes were popular among youth in England in 2021. The UK Tobacco and Related Products Regulations (TRPR) limits e-liquids to 20 mg/mL of nicotine in a 10 mL bottle. Short-fill e-liquids, which are not covered by TRPR regulations, are typically nicotine-free and come in larger, underfilled bottles allowing customisation with the addition of ‘nicotine shots’. This paper investigates awareness, use, and reasons for use of short-fill e-liquids among youth in England.

Methods: Data are from the online 2021 International Tobacco Control Youth Survey, comprising 4224 youth (aged 16–19 years) in England. Weighted logistic regression models investigated associations between awareness and past 30-day use of short-fills by smoking status, vaping status, nicotine strength vaped and participant demographics. Reasons for use were also reported.

Results: Approximately one-quarter (23.0%) of youth in England reported awareness of short-fill e-liquids. Among youth who had vaped in the past 30 days, 22.1% had used short-fills in the past 30 days; use was most prevalent among those who were also smoking (43.2%) and those who reported usually vaping nicotine concentrations of 2.1% (21 mg/mL) or more (40.8%). ‘Convenience of a bigger bottle’ was the most selected reason for use (45.0%), followed by ‘less expensive than regular e-liquids’ (37.6%).

Conclusions: Awareness of short-fills was common among youth in 2021, including among those who had never vaped or smoked. Among youth who vaped in the past 30 days, short-fill use was more prevalent among those who also smoked and those who vaped nicotine-containing e-liquids. Integration of short-fill products into existing e-cigarette regulations should be considered.

Citation

Reid, J., Burkhalter, R., Kasza, K.A., Seo, Y., East, K.A., Hyland, A., Hammond, D. (2023). Minimum legal age laws and perceived access to cigarettes, e-cigarettes, and other substances among youth in Canada, England, and the United States: 2017-2021. International Journal of Drug Policy, 115, 104003. doi: 10.1016/j.drugpo.2023.104003.

Abstract

Background: Minimum legal age (MLA) restrictions are a core policy to reduce youth use of tobacco, e-cigarettes, and other substances. We examined trends in perceived ease of access to tobacco and other substances across three countries with differing MLA policies, including the United States (US), which increased the federal MLA for tobacco products from 18 to 21 in 2019.

Methods: Repeat cross-sectional data were analyzed from seven waves of the International Tobacco Control (ITC) Youth Tobacco and Vaping Survey conducted between 2017 and 2021. Online surveys were conducted with non-probability samples of 91,647 youth aged 16-19 in Canada, England, and the US. Regression models were used to examine differences in perceived ease of accessing each of 7 substances (analyzed as "very easy" or "fairly easy" versus else), and differences between countries and over time (including before and after any MLA changes) for cigarettes, e-cigarettes, cannabis, and alcohol; additional models examined sub-national variation in MLA.

Results: Perceived access varied by substance and across countries: in August/September 2021, perceived ease of accessing cigarettes and e-cigarettes was greater in Canada where MLA was 18-19 (61.7% cigarettes, 66.4% e-cigarettes) and England where MLA was 18 (66.9%, 69.6%), compared to the US where MLA was 21 (48.0%, 60.9%; p < 0.001 for all). Perceived ease of accessing cannabis was greatest in Canada (53.3%), followed by the US (44.1%) and England (34.0%; p < 0.001 for all). Following the federal MLA increase for tobacco products in the US, perceived ease of access decreased significantly for cigarettes (65.1% in 2019Aug to 59.7% in 2020Feb; aOR=0.80 (95%CI=0.71-0.89)) and e-cigarettes (72.4% in 2019Aug to 69.4% in 2020Feb; aOR=0.87 (95%CI=0.77-0.98)).

Conclusions: Higher MLA was strongly associated with fewer youth perceiving easy access to substances: perceived access varied between countries with differing MLA, as well as within-country before and after changes to MLA.

Citation

Fu, M., Castellano, Y., Tigova, O., Driezen, P., Thompson, M.E., Kaai, S.C., Quah, A.C.K., Fong, G.T., Vardavas, C.I., Fern á ndez, E. (2023). ITC EUREST PLUS España: protocolo de un estudio longitudinal de fumadores en España [ITC EUREST PLUS Spain: Protocol of a longitudinal study of smokers in Spain]. Gaceta Sanitaria, 37, 102307. doi: 10.1016/j.gaceta.2023.102307.

Abstract

Objective: The ITC EUREST-PLUS Spain Survey is a longitudinal study of a representative sample of Spanish adult (≥18 years old) smokers. This protocol describes the methods of the 2021 follow-up survey.

Method:The ITC EUREST-PLUS Survey, a prospective cohort study of a representative sample of smokers in six European countries, was conducted in 2016 (baseline) and 2018 (waves 1 and 2). The 2021 ITC EUREST-PLUS Spain Survey is a continuation of the Spanish cohort with a new interview in 2021 (wave 3). Lost participants were replaced with new smokers recruited using the same multi-stage sampling design. This latest follow-up aims to examine current patterns and transitions of tobacco use and to evaluate the impact of new tobacco-related policies.

Citation

Yimsaard, P., Gravely, S., Meng, G., Fong, G.T., Cummings, K.M., Hyland, A., Borland, R., Hammond, D., Kasza, K.A., Li, L., Quah, A.C.K. (2023). Differences in smoking cessation behaviours and vaping status among adult daily smokers with or without depression, anxiety, hazardous alcohol use: Findings from the 2018 and 2020 ITC Four Country Smoking and Vaping Survey. International Journal of Mental Health and Addiction. doi:10.1007/s11469-023-01058.

Abstract

This study examined differences in quit attempts, 1-month quit success, and vaping status at follow-up among a cohort of 3709 daily smokers with and without depression, anxiety, and regular alcohol use who participated in both the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys. At baseline, a survey with validated screening tools was used to classify respondents as having no, or one or more of the following: 1) depression, 2) anxiety, and 3) regular alcohol use. Multivariable adjusted regression analyses were used to examine whether baseline (2018) self-report conditions were associated with quit attempts; quit success; and vaping status by follow-up (2020). Results showed that respondents who reported depressive symptoms were more likely than those without to have made a quit attempt (aOR = 1.32, 95% CI:1.03–1.70, p = 0.03), but were less likely to have quit (aOR = 0.55, 95% CI:0.34–0.89, p = 0.01). There were no differences in quit attempts or quit success between those with and without self-reported anxiety diagnoses or regular alcohol use. Among successful quitters, respondents with baseline depressive symptoms and self-reported anxiety diagnoses were more likely than those without to report vaping at follow-up (aOR = 2.58, 95% CI:1.16–5.74, p = 0.02, and aOR = 3.35 95% CI:1.14–9.87, p = 0.03). In summary, it appears that smokers with depression are motivated to quit smoking but were less likely to manage to stay quit, and more likely to be vaping if successfully quit. As smoking rates are higher among people with mental health conditions, it is crucial for healthcare professionals to identify these vulnerable groups and offer tailored smoking cessation support and continued support during their quit attempt.

Citation

Geboers, C., Candel, M.J.J.M., Nagelhout, G.E., de Vries, H., van den Putte, B., Fong, G.T., Willemsen, M.C. (2023). Smokers’ strategies to reduce tobacco spending: self-reported use and differences across subgroups. Findings from the International Tobacco Control (ITC) Netherlands Survey. BMC Public Health, 23(1), 738. doi:10.1186/s12889-023-15678-9.

Abstract

Background: The cost of tobacco is one of the most reported reasons for smoking cessation. Rather than quitting, smokers can use also strategies to reduce tobacco expenditure while continuing smoking, such as smoking less or using price-minimising strategies. The Netherlands announced to increase the price of a pack cigarettes from seven (2018) to ten euros (2023), to reduce tobacco prevalence and consumption. This study explores the self-reported strategies to reduce tobacco spending among Dutch smokers, and whether this differed per age, income, and education. Additionally, we analysed among quitters in these subgroups whether price played a role in their decision to quit.

Methods: Cross-sectional survey data from the International Tobacco Control (ITC) Netherlands Wave 2 (September-November 2020, N = 1915) was used. Strategies to reduce spending among smokers (N = 1790) were: reducing consumption, bulk buying, switching to cheaper products or buying from low-taxed sources. These were collapsed into: reducing consumption (solely or in combination with other behaviours), solely price-minimising behaviours (such as buying cheaper brands), or no strategies to reduce spending. Associations between strategies and characteristics were analysed through multinomial and binary logistic regression models. Second, we explored which subgroups were more likely to report that price played a role in their decision to quit among quitters (N = 125).

Results: The majority of smokers used strategies to reduce tobacco spending: 35.6% reduced consumption and 19.3% used solely price-minimising strategies. 82.1% of quitters reported that price played a role in their decision to quit. Low-income individuals were more likely to report price as a reason for quitting and reduce consumption, but also to buy cheaper products. Highly nicotine dependent smokers were more likely to use price-minimising behaviours, and less likely to reduce consumption.

Conclusions: The majority reported using strategies to reduce spending or that price played a role in their decision to quit. Reducing consumption was the most reported strategy. Low-income smokers were more likely to reportedly reduce consumption, buy cheaper products, or quit. Price policies have the potential to reduce socioeconomic inequalities in smoking. To discourage price-minimising behaviours, such as switching to cheaper products, reducing price differences between products should be prioritized.

Citation

Kyriakos, C.N., Driezen, P., Fong, G.T., Chung-Hall, J., Hyland, A., Geboers, C., Craig, L.V., Willemsen, M., Filippidis, F.T. (2023). Illicit purchasing and use of flavour accessories after the European Union menthol cigarette ban: Findings from the 2020-2021 ITC Netherlands Surveys. European Journal of Public Health, 33(4), 619 626. doi: 10.1093/eurpub/ckad049.

Abstract

Background: The 2020 European Union (EU) menthol cigarette ban increased quitting among pre-ban menthol smokers in the Netherlands, but some reported continuing to smoke menthol cigarettes. This study examined three possible explanations for post-ban menthol use—(i) illicit purchasing, (ii) use of flavour accessories and (iii) use of non-menthol replacement brands marketed for menthol smokers.

Methods: Data were from the ITC Netherlands Cohort Surveys among adult smokers before the menthol ban (Wave 1: February–March 2020, N = 2067) and after the ban (Wave 2: September–November 2020, N = 1752; Wave 3: June–July 2021, N = 1721). Bivariate, logistic regression and generalized estimating equation model analyses were conducted on weighted data.

Results: Illicit purchasing remained low from pre-ban (2.4%, 95% CI: 1.8–3.2, Wave 1) to post-ban (1.7%, 1.2–2.5%, Wave 3), with no difference between menthol and non-menthol smokers from Wave 1 to Wave 3. About 4.4% of post-ban menthol smokers last purchased their usual brand outside of the EU and 3.6% from the internet; 42.5% of post-ban menthol smokers and 4.4% of smokers overall reported using flavour accessories, with greater odds among those aged 25–39 years vs. 55+ (aOR = 3.16, P = 0.002). Approximately 70% of post-ban smokers who reported using a menthol brand were actually using a non-menthol replacement brand.

Conclusions: There was no increase in illicit purchasing or of smuggling outside the EU among menthol and non-menthol smokers in the Netherlands 1 year after the EU menthol cigarette ban. Use of flavour accessories and non-menthol replacement brands best explain post-ban menthol use, suggesting the need to ban accessories and ensure industry compliance.

Citation

Chen, D.T.H., Nargis, N., Fong, G.T., Huq, S., Quah, A.C.K., Millet, C., Filippidis, F.T. (2023). A longitudinal study of transitions between smoking and smokeless tobacco use from the ITC Bangladesh Surveys: Implications for tobacco control in the Southeast Asia region. The Lancet Regional Health - Southeast Asia, 14, 100185. doi: 10.1016/j.lansea.2023.100185.

Abstract

Background: In Southeast Asia, tobacco use is a major public health threat. Tobacco users in this region may switch between or concurrently use smoked tobacco and smokeless tobacco (SLT), which makes effective tobacco control challenging. This study tracks transitions of use among different product users (cigarettes, bidis, and SLT) in Bangladesh, one of the largest consumers of tobacco in the region, and examines factors related to transitions and cessation.

Methods: Four waves (2009–2015) of the International Tobacco Control (ITC) Bangladesh Survey with a cohort sample of 3245 tobacco users were analysed. Generalized Estimating Equations (GEE) models were used to explore the socioeconomic correlates of transitions from the exclusive use of cigarettes, bidis, or SLT to the use of other tobacco products or quitting over time.

Findings: Among exclusive cigarette users, most remained as exclusive cigarette users (68.1%). However, rural smokers were more likely than urban smokers to transition to bidi use (odds ratio [OR] = 3.02, 95% confidence interval [CI] = 1.45–6.29); to SLT use (OR = 2.68, 95% CI = 1.79–4.02) and to quit tobacco (OR = 1.57, 95% CI = 1.06–2.33). Among exclusive bidi users, transitional patterns were more volatile. Fewer than half (43.3%) of the exclusive bidi users maintained their status throughout the waves. Those with higher socio-economic status (SES) were more likely to quit (OR = 4.16, 95% CI = 1.08–13.12) compared to low SES smokers. Exclusive SLT users either continued using SLT or quit with minimal transitions to other products (≤2%). Nevertheless, males were more likely to switch to other tobacco products; younger (OR = 2.94, 95% CI = 1.23–6.90 vs. older), more educated (OR = 1.55, 95% CI = 1.77–3.12 vs. less educated), and urban SLT users (OR = 0.52, 95% CI = 0.30–0.86 for rural vs. urban users) were more likely to quit.

Interpretation: Complex transitional patterns were found among different types of tobacco product users over time in Bangladesh. These findings can inform more comprehensive and multi-faceted approaches to tackle diversified tobacco use in Bangladesh and neighbouring countries in the Southeast Asia region with similar tobacco user profiles of smoked tobacco and SLT products.

Citation

Lyu, J., Sung, H.Y., Yao, T., Jiang, N., Quah, A.C.K., Meng, G., Jiang, Y., Fong, G.T., Max, W. (2023). Cigarette gifting among non-smokers in China: Findings from the International Tobacco Control China Survey. Nicotine & Tobacco Research, 25(5), 928-936. doi: 10.1093/ntr/ntac294.

Abstract

Introduction: Cigarette gifting is commonly practiced in China and has contributed to the social acceptability and high prevalence of cigarette smoking in the country. As a result, nonsmokers in China are particularly susceptible to smoking. While previous studies have examined cigarette gifting behaviors among smokers, little is known about cigarette gifting among nonsmokers.

Aims and Methods: This study aimed to examine the percentage and correlates of giving and receiving cigarettes as gifts among adult nonsmokers in China. We analyzed nonsmokers (N = 1813) aged ≥18 years using data from the International Tobacco Control China Wave 5 Survey. Descriptive statistics summarized the characteristics of those who gave and received cigarettes as gifts. Multivariable logistic regression models were used to identify factors associated with the two behaviors.

Results: Among nonsmokers, 9.9% reported giving cigarettes as gifts to family or friends in the last 6 months. A higher level of knowledge about smoking harms was associated with lower adjusted odds of gifting cigarettes. Nonsmokers aged 25–39 years, with middle income, positive attitude toward cigarette gifts, exposure to anti-smoking information, and exposure to smoking promotion, and those who reported receiving cigarettes as gifts from family or friends were more likely to give cigarettes as gifts. A total of 6.6% of nonsmokers reported receiving cigarettes as gifts in the last 6 months. High education, neutral or positive attitude toward cigarette gifts, exposure to anti-smoking information, exposure to smoking promotion, and having smoking friends were associated with receiving cigarettes as gifts.

Conclusions: It is concerning that Chinese cultural norms that support cigarette gifting have extended to giving nonsmokers cigarettes as gifts. Effective anti-smoking messages are needed. Changing the norms around cigarette gifting and increasing knowledge about smoking harms should help reduce cigarette gifting among nonsmokers.

Implications: Easy access to cigarettes received as gifts, along with the wide acceptance of smoking in China, places Chinese nonsmokers in a risky position. More educational campaigns targeting nonsmokers to proactively prevent them from smoking are called for. The ineffectiveness of existing anti-smoking information highlights the need for more effective anti-smoking messages. That attitude toward cigarette gifts is the strongest predictor of giving cigarettes as gifts suggests the need for interventions to reverse the positive attitude about cigarette gifting to decrease the popularity of this activity.

Citation

Nagelhout, G.E., Poole, N., Geboers, C., Magnée, T., Kaag, A.M., van den Brand, F.A., van den Putte, B., de Vries, H., Fong, G.T., Willemsen, M.C. (2023). Smoking cessation among gender minority populations, cis-women, and cis-men: Findings from the International Tobacco Control (ITC) Netherlands Survey. Nicotine and Tobacco Research, 25(5), 945-953. doi:10.1093/ntr/ntac283.

Abstract

Background: Little is known about smoking cessation among gender minority populations compared to cis-gender individuals (whose gender matches their sex assigned at birth). We examined differences between smokers from gender minority populations, cis-women, and cis-men in heaviness of smoking, quit intentions, use of cessation assistance, quit attempts (ever tried and number), and triggers for thinking about quitting.

Aims and Methods: We used cross-sectional data from the 2020 International Tobacco Control (ITC) Netherlands Survey. Among smoking respondents, we distinguished (1) cis-women (female sex, identified as women, and having feminine gender roles; n=670), (2) cis-men (male sex, identified as men, and having masculine gender roles; n=897), and (3) gender minorities (individuals who were intersex, who identified as nonbinary, genderqueer, had a sex/gender identity not listed, whose gender roles were not feminine or masculine, or whose gender identity and/or roles were not congruent with sex assigned at birth; n=220).

Results: Although gender minorities did not differ from cis-women and cis-men in heaviness of smoking, plans to quit smoking, and quit attempts, they were significantly more likely to use cessation assistance (20% in the past six months) than cis-women (12%) and cis-men (9%). Gender minorities were also significantly more likely to report several triggers for thinking about quitting smoking, e.g. quit advice from a doctor, an anti-smoking message/campaign, and the availability of a telephone helpline.

Conclusion: Despite equal levels of quit attempts and heaviness of smoking, gender minority smokers make more use of smoking assistance, and respond stronger to triggers for thinking about quitting smoking.

Implications: Smoking cessation counselors should be sensitive to the stressors that individuals from any minority population face, such as stigmatization, discrimination, and loneliness, and should educate their smoking clients on effective coping mechanisms to prevent relapse into smoking after they experience these stressors. Developing tailored smoking cessation programs or campaigns specifically for gender minority populations can also be useful. Based on the results of our subgroup analyses, programs or campaigns for younger gender minority smokers could focus on the availability of telephone helplines and on how friends and family think about their smoking behavior.

Citation

Usidame, O., Meng, G., Thrasher, J.F., Thompson, M.E., Fong, G.T., Fleischer, N.L. (2023). Examining the effectiveness of the 2012 Canadian graphic warning label policy change by sex, income, and education. Nicotine and Tobacco Research, 25(4), 763-772. doi: 10.1093/ntr/ntac235.

Abstract

Background: We examined the differential impact of the 2012 Canadian GWL policy changes on key indicators of warning label impact and quit intentions using national cohorts of Canadian and US adults who smoke.

Methods: We used data from all waves of the International Tobacco Control surveys (2002-2020) in Canada and the US. Our key measures were quit intentions and an index of warning label effectiveness (salience, cognitive and behavioral reactions). We estimated overall policy impact by comparing Canada (treatment group) with the US (control group) using controlled interrupted time series (CITS) regression models, with interactions to examine whether policy impact varied by sex, education, and income.

Results: The CITS model showed a statistically significant increase in the warning label effectiveness in Canada post-policy, compared to the US (β= 0.84, 95% CI 0.35,1.33). Similarly, the odds of quit intentions were relatively higher among adults who smoked in Canada compared to the US (OR= 1.89, 95% CI 1.51,2.36) post-policy. The three-way interaction model showed that these associations were greater among adults from low socioeconomic status (SES) groups than in high SES groups.

Discussion: The 2012 change in the Canadian GWL policy was associated with stronger cognitive and behavioral responses to GWLs and higher odds of quit intentions among adults who smoked in Canada when compared to the US, specifically among individuals from low SES groups, suggesting a positive equity impact. Our findings affirm the need for countries to implement or enhance GWLs, in line with the WHO Framework Convention on Tobacco Control.

Implications: The evidence on the potential health equity benefit of GWL policies is mixed. To further understand the influence of GWL policies on tobacco use disparities, more systematic research using pre/post policy designs with control groups is needed. Using a controlled interrupted time series model, we aimed to strengthen the available evidence on the causal influence of this tobacco control approach. Our findings show that the 2012 GWL policy change had a greater impact on adults who smoked from low SES groups than it did on adults who smoked from high SES groups, indicating a potentially positive equity impact and confirming the need for countries to implement or maximize the size of GWLs, as recommended by the WHO Framework Convention on Tobacco Control.

Citation

Geboers, C., Candel, M.J.J.M., Chaloupka, F.J., Nagelhout, G.E., de Vries, H., van den Putte, B., Shang, C., Fong, G.T., Willemsen, M.C. (2023). Trends in individualized affordability of factory-made cigarettes: findings of the 2008-2020 International Tobacco Control (ITC) Netherlands Surveys. Nicotine and Tobacco Research, 25(4), 746-754. doi:10.1093/ntr/ntac259.

Abstract

Introduction: Cigarette affordability, the price of tobacco relative to consumer income, is a key determinant of tobacco consumption. This study examined trends over 12 years in individualized factorymade cigarette affordability in the Netherlands, and whether these trends differed by sex, age, and education.

Methods: Data from 10 waves (2008-2020) of the International Tobacco Control (ITC) Netherlands Surveys were used to estimate individualized affordability, measured as the percentage of income required to buy 100 cigarette packs (Relative Income Price, RIP), using self-reported prices and income. The higher the RIP, the less affordable cigarettes are. Generalized estimating equation regression models assessed trends in individualized affordability over time and by sex, age, and education.

Results: Affordability decreased significantly between 2008 and 2020, with RIP increasing from 1.89% (2008) to 2.64% (2020) (p≤.001), Except for 2008-2010, no significant year-on-year changes in affordability were found. Lower affordability was found among subgroups who have a lower income level: females (versus males), 18-24- and 25–39-year-olds (versus 55 and over) and low or moderate educated individuals (versus high educated). Interactions between wave and education (p=.007) were found, but not with sex (p=.653) or age (p=.295). A decreasing linear trend in affordability was found for moderately (p=.041) and high-educated (p=.025), but not for low-educated individuals (p=.149).

Conclusions: Cigarettes in the Netherlands have become less affordable between 2008 and 2020, yet this was mostly due to the decrease in affordability between 2008 and 2010. There is a need for more significant increases in tax to further decrease affordability.

Implications: Our findings suggest that cigarettes have become less affordable in the Netherlands between 2008 and 2020. But this appears to be the result of a steep decrease in affordability between 2008 and 2010. Affordability was lower among groups who have on average lower incomes (females, young adults, low- and moderate educated individuals), and differences in trends across education levels could be explained by per capita income changes. Our individualized measure indicated lower affordability than published aggregate affordability estimations. Future tax increases should be large enough to result in a lower affordability.

Citation

Seo, H.G., Xu, S.S., Li, G., Gravely, S., Quah, A.C.K., Lee, S., Lim, S., Cho, S., Kim, Y., Lee, E.S., Choi, Y.J., Miller, C., Goniewicz, M.L., O’Connor, R.J., Fong, G.T. (2023). Reasons for initiation and regular use of heated tobacco products among current and former smokers in South Korea: Findings from the 2020 ITC Korea Survey. International Journal of Environmental Research and Public Health, 20(6), 49-63. doi: 10.3390/ijerph20064963

Abstract

South Korea is the world’s second-largest heated tobacco product (HTP) market after Japan. HTP sales in South Korea have increased rapidly since May 2017, accounting for 10.6% of the total tobacco market in 2020. Despite this, little is known as to why HTP consumers who were current and former smokers started using HTPs and used them regularly. We analyzed cross-sectional data for 1815 adults (aged 19+) who participated in the 2020 International Tobacco Control (ITC) Korea Survey, of whom 1650 were HTP-cigarette consumers (those who reported smoking cigarettes and using HTPs ≥ weekly) and 165 were exclusive HTP consumers (using HTPs ≥ weekly) who were former or occasional smokers (smoking cigarette < weekly). Respondents were asked to report the reason(s) they used HTPs, with 25 possible reasons for HTP-cigarette consumers and 22 for exclusive HTP consumers. The most common reasons for initiating HTP use among all HTP consumers were out of curiosity (58.9%), family and friends use HTPs (45.5%), and they like the HTP technology (35.9%). The most common reasons for regularly using HTPs among all HTP consumers were that they were less smelly than cigarettes (71.3%), HTPs are less harmful to own health than cigarettes (48.6%), and stress reduction (47.4%). Overall, 35.4% of HTP-cigarette consumers reported using HTPs to quit smoking, 14.7% to reduce smoking but not to quit, and 49.7% for other reasons besides quitting or reducing smoking. In conclusion, several common reasons for initiating and regularly using HTPs were endorsed by all HTP consumers who were smoking, had quit smoking completely, or occasionally smoked. Notably, only about one-third of HTP-cigarette consumers said they were using HTPs to quit smoking, suggesting that most had no intention of using HTPs as an aid to quit smoking in South Korea.

Citation

Kaai, S.C., Sansone, G., Meng, G., Ong’ang’o, J., Goma, F., Ikamari, L., Quah, A.C.K., Fong, G. (2023). Quasi-experimental evaluation of Kenya’s pictorial health warnings versus Zambia’s single text-only warning: Findings from the International Tobacco Control (ITC) Project. Tobacco Control, 32(2), 139-145. doi: 10.1136/tobaccocontrol 2020 056396.

Abstract

Background: Population studies in mostly high-income countries have shown that pictorial health warnings (PHWs) are much more effective than text-only warnings. This is the first quasi-experimental evaluation of the introduction of PHWs in Africa, comparing the change from text-only to PHWs in Kenya to the unchanged text-only health warning in Zambia.

Methods: Data were from International Tobacco Control (ITC) Surveys in Kenya (n=1495), and Zambia (n=1628), cohort surveys of nationally representative samples of adult smokers in each country. The ITC Kenya Survey was conducted in 2012 and 2018 (2 years after the 2016 introduction of three PHWs). The ITC Zambia Survey was conducted in 2012 and 2014 with no change to the single text-only warning. Validated indicators of health warning effectiveness (HWIs) (salience: noticing, reading; cognitive reactions: thinking about health risks, thinking about quitting; and behavioural reactions: avoiding warnings; forgoing a cigarette because of the warnings), and a summary measure-the Labels Impact Index (LII)-measured changes in warning impact between the two countries.

Results: PHWs implemented in Kenya led to a significant increase in all HWIs and the LII, compared with the text-only warning in Zambia. The failure to implement PHWs in Zambia led to a substantial missed opportunity to increase warning effectiveness (eg, an estimated additional 168 392 smokers in Zambia would have noticed the warnings).

Conclusions: The introduction of PHWs in Kenya substantially increased the effectiveness of warnings. These results provide strong empirical support for 34 African countries that still have text-only warnings, of which 31 are Parties of the Framework Convention on Tobacco Control and are thus obligated to implement PHWs.

Citation

East, K.A., Miller, C., Hitchman, S.C., McNeill, A., Tompkins, C. (2023). 'It's not what you'd term normal smoking ': a qualitative exploration of language used to describe heated tobacco product use and associated user identity. Addiction, 118(3), 533-538. doi: 10.1111/add.16051.

Abstract

Background and aims: Tobacco and nicotine marketplaces have diversified over the past decade, including with the introduction of heated tobacco products (HTPs), such as the brand IQOS. HTPs typically heat tobacco to generate an aerosol that is inhaled. HTP nomenclature is lacking, and how HTP users define and identify themselves remains understudied. Research in this area is important because language can construct identity, and identity can shape behaviour. This study aimed to explore users' language choice when describing IQOS use, and how language relates to user identity.

Methods: Qualitative interviews in London, United Kingdom, with 30 adult current and former IQOS users. Analyses were guided by Iterative Categorization.

Results: Overall, participants expressed confusion and a lack of suitable terminology for how to describe IQOS use. Verbs such as heating and IQOSing were rarely endorsed. Most often, participants reverted to smoking when describing IQOS use and commonly referred to HEETS (tobacco sticks) as cigarettes. Yet the lack of combustion, electronic device, cleaner experience and perceived reductions in health risks led some to frame IQOS as distinct from smoking. Vaping was generally considered inappropriate for describing IQOS use. Participants also manipulated language to suit their circumstances and manage their identity, whereas some IQOS users embraced the terms smoking and smoker, most were eager to distinguish between using IQOS and being labelled a smoker because of the associated negative connotations and to align with perceptions of IQOS use as a better, less harmful behaviour. Instead, when describing their identity, IQOS users more willingly identified as vapers, or ex-smokers, or created new identities (e.g. HEET user).

Conclusions: People who use or have used IQOS (a brand of heated tobacco product) are ambiguous about IQOS terminology. Participants in this study commonly referred to IQOS use as smoking for lack of a more suitable term, but also resisted being labelled as smokers, a choice that may influence smoking cessation. Clear terminology must be used in surveys and by healthcare professionals when asking about cigarette smoking and e-cigarette and heated tobacco product use.

Citation

Yong, H.H., Chow, R., East, K.A., Thrasher, J.F., Hitchman, S.C., Borland, R., Cummings, K.M., Fong, G.T. (2023). Do social norms for cigarette smoking and nicotine vaping product use predict trying nicotine vaping products and attempts to quit cigarette smoking amongst adult smokers? Findings from the 2016-2020 ITC Four Country Smoking and Vaping Surveys. Nicotine and Tobacco Research, 25(3), 505-513. doi: 10.1093/ntr/ntac212.

Abstract

Objectives: To examine whether perceived injunctive and descriptive social norms towards cigarette and nicotine vaping product (NVP) use predicted subsequent trying NVPs and attempts to quit cigarette smoking amongst current smokers, and whether associations varied across countries.

Method: Three waves of longitudinal cohort data from the International Tobacco Control Four Country Smoking and Vaping Survey collected between 2016 and 2020 from 2,290 adult smokers in Canada, Australia, England, and the United States who had never used NVPs at baseline (either Wave 1 or Wave 2) and followed up at the subsequent wave (Wave 2 or Wave 3, respectively) were analysed using Generalised Estimating Equations.

Results: Of the injunctive and descriptive norm measures for smoking and NVP use, NVP initiation was only independently predicted by the injunctive interpersonal norm for NVP use, with perceived approval of NVP use by important others predicting higher odds of trying NVPs (AOR=1.65, 95% CI=1.20-2.27). This predictive effect was independent of baseline quit intention with no country variations found. By contrast, making cigarette smoking quit attempts was independently predicted by both injunctive and descriptive interpersonal norms with perceived disapproval of smoking by important others (AOR=1.65, 95% CI=1.38-1.99) and close friends using NVPs (AOR=1.37, 95% CI=1.04-1.79), both associated with higher odds of smoking quit attempts.

Conclusions: Adult smokers who perceive NVP use as normative, either because such behaviour is socially approved or common within their close social networks, appear more inclined to try NVPs or make smoking quit attempts than smokers who do not.

Implications: What this study adds: Social norms can shape a person's behaviour and result in behaviour change. This study shows that initiation of NVP use behaviour among smokers can be reliably predicted by their perception of whether NVP use is acceptable to those important to them within their close social networks. Similarly, any attempts to stop cigarette smoking can be predicted by their perception of how acceptable cigarette smoking is among those who are important to them and whether any of their close friends use NVPs. Changing social norms towards cigarette smoking and NVP use could therefore be incorporated into smoking cessation interventions to help smokers to quit and/or switch to NVP use.

Citation

Schneller, L., Felicione, N., Hammond, D., Goniewicz, M.L., O’Connor, R.J. (2023). Tobacco-free oral nicotine product use among youth in the U.S., 2019-2021. American Journal of Preventive Medicine Focus, 2(1), 100061. doi: 10.1016/j.focus.2022.100061

Abstract

Introduction: Novel tobacco-free oral nicotine products are not combusted, easy to conceal, available in flavors, and do not contain tobacco leaf. Since 2016, oral nicotine product sales have increased and may be gaining popularity among youth. This study aims to examine the trends in the prevalence and correlates of oral nicotine product use among U.S. youth.

Methods: Data from participants aged 16–19 years in the U.S. International Tobacco Control Policy Evaluation Project Youth Tobacco and Vaping Survey were analyzed cross-sectionally from August 2019, February 2020, August 2020, February 2021, and August 2021. Weighted descriptive statistics and logistic regressions were used to describe the use and correlates of oral nicotine products.

Results: Oral nicotine product use significantly increased from 3.5% in August 2019 to 4.1% in August 2021. Oral nicotine product use was most prevalent among those aged 18 years, male, and non-Hispanic White. Those who used cigarettes (AOR=2.18, 95% CI=19.37, 40.88), nicotine vaping products (AOR=4.27, 95% CI=3.02, 6.04), and smokeless tobacco (AOR=28.14, 95% CI=19.37, 40.88) in the past 30 days were more likely to report recent use of oral nicotine products.

Conclusions: Although oral nicotine products are less popular among U.S. youth than cigarettes, nicotine vaping products, and smokeless tobacco, their prevalence of use significantly increased. Oral nicotine product users are more likely to use other nicotine products, but the availability of flavors and easy-to-conceal design may be appealing to those who may not use nicotine products. Researchers should continue to observe the behaviors associated with oral nicotine product use to inform the need for future regulatory efforts.