Citation

Gravely, S., Driezen, P., Smith, D.M., Borland, R., Lindblom, E., Hammond, D., McNeill, A., Hyland, A., Cummings, K.M., Chan, G., Thompson, M.E., Boudreau, C., Martin, N., Ouimet, J., Loewen, R., Quah, A.C.K., Goniewicz, M., Thrasher, J.F., Fong, G.T. (2020). International differences in patterns of cannabis use among adult cigarette smokers: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. International Journal of Drug Policy, 79, 102754.

Abstract

Background: Although evidence shows that co-use of cigarettes and cannabis is common, there is little research examining if co-use patterns vary depending on the regulatory environment for cannabis. This study examined patterns of co-use and perceptions of relative harm among cigarette smokers in four countries with different histories, and at different stages of cannabis legalization.

Methods: Data are from the 2018 International Tobacco Control 4CV Survey and included 10035 adult cigarette smokers from Canada, United States (US), Australia, and England. At the time of the survey, Canada and the US had relatively more permissive cannabis regulations compared to Australia and England.

Results: Among this sample of 10035 cigarette smokers, Canada had the highest rate of cannabis co-use in the last 12 months (36.3%), followed by the US (29.1%), England (21.6%), and Australia (21.4%). Among past 12 month co-users (n = 3134), the US (40.2%) and Canada (35.2%) had the highest rates of daily cannabis use, followed by smokers in England (26.3%) and Australia (21.7%); Australian co-users had the highest rate of infrequent (<monthly) cannabis use. The highest proportion of co-users who smoked daily and used cannabis daily was in the US (34.8%), followed by Canada (30.6%), England (25.8%), and Australia (22.7%). More co-users in the US (78.3%) and Canada (73.6%) perceived smoked cannabis to be less harmful than cigarettes than in Australia (65.5%) and England (60.8%). The majority of co-users who used cannabis in the last 30 days had smoked it (92.3%), with those in England more likely to smoke cannabis (95.7%) compared to Canada (88.6%); there were no other differences between countries (US: 92.0%, Australia: 93.0%). Co-users in England (90.4%) and Australia (86.0%) were more likely to mix tobacco with cannabis than co-users in Canada (38.5%) and the US (22.3%).

Conclusion: Patterns of tobacco and cannabis co-use differed between countries. Smokers in Canada and the US had higher rates of co-use, daily cannabis use, dual-daily use of both cannabis and cigarettes, and were more likely to perceive smoked cannabis as less harmful than cigarettes compared to England and Australia.

Citation

van Mourik, D.J.A., Nagelhout, G.E., de Vries, H., van den Putte, B., Cummings, K.M., Borland, R., Fong, G.T., Willemsen, M.C. (2020). Quasi-experimentally examining the impact of introducing tobacco pictorial health warnings: Findings from the International Tobacco Control (ITC) 4C and Netherlands surveys in the Netherlands, Australia, Canada, United Kingdom, and the United States. Drug and Alcohol Dependence, 207, 107818.

Abstract

Background: Our study evaluated the short-term impact of introducing European Union’s tobacco pictorial health warnings (PHWs).

Methods: Longitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N = 3,487) and analyzed using Generalized Estimating Equations.

Results: Between both time-points, only Dutch smokers showed increases in noticing health warnings (β = 0.712, p < 0.001), self-reports of health warnings leading to a cognitive response such as thinking about smoking health-risks (SHRs) (OR = 1.834, p < 0.001), knowledge about SHRs (β = 0.369, p < 0.001), and avoiding health warnings (OR = 9.869, p < 0.001). However, Dutch smokers showed no changes in attitude towards smoking (β = 0.035, p = 0.518), intention to quit smoking (OR = 0.791, p = 0.157), self-efficacy to quit smoking (β=-0.072, p = 0.286), or reporting that health warnings helped them to resist having a cigarette (OR = 1.091, p = 0.714).

Conclusions: Results suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.

Abstract

Background: Our study evaluated the short-term impact of introducing European Union’s tobacco pictorial health warnings (PHWs).

Methods: Longitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N = 3,487) and analyzed using Generalized Estimating Equations.

Results: Between both time-points, only Dutch smokers showed increases in noticing health warnings (β = 0.712, p < 0.001), self-reports of health warnings leading to a cognitive response such as thinking about smoking health-risks (SHRs) (OR = 1.834, p < 0.001), knowledge about SHRs (β = 0.369, p < 0.001), and avoiding health warnings (OR = 9.869, p < 0.001). However, Dutch smokers showed no changes in attitude towards smoking (β = 0.035, p = 0.518), intention to quit smoking (OR = 0.791, p = 0.157), self-efficacy to quit smoking (β=-0.072, p = 0.286), or reporting that health warnings helped them to resist having a cigarette (OR = 1.091, p = 0.714).

Conclusions: Results suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.

Citation

Li, L., Borland, R., O’Connor, R.J., Fong, G.T., McNeill, A., Driezen, P., Cummings, K.M. (2019). The association between smokers' self-reported health problems and quitting: Findings from ITC Four Country Smoking and Vaping Wave 1 Survey. Tobacco Prevention & Cessation, 5(December): 49.

Abstract

Introduction: This study aimed to systematically examine whether having health conditions or concerns related to smoking are associated with quitting activities among smokers across four western countries.

Methods: Data came from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey conducted in Australia, Canada, England and US. We asked smokers and recent quitters (n=11838) whether they had a medical diagnosis for heart disease, cancer, chronic lung disease, depression, anxiety, alcohol problems, diabetes, severe obesity and chronic pain (nine conditions), and whether they believed smoking had harmed/would harm their health, along with questions on quitting activities.

Results: General concerns about smoking harming health and all specific health conditions, except for alcohol problems, were positively associated with quit attempts, but the relationships between health conditions and other quitting measures (being abstinent, planning to quit, use of quitting medications) were less consistent. Positive associations between conditions and use of quitting medications were only significant for depression, anxiety and chronic pain (adjusted odds ratios ranged from 1.4 to 1.5). There was a general tendency to report lower self-efficacy for quitting among those with the health conditions.

Conclusions: While those with smoking related conditions are somewhat more aware of the links to their smoking, and are largely taking more action, the extent of this is lower than one might reasonably expect. Enhanced awareness campaigns are needed and health professionals need to do more to use health conditions to motivate quit attempts and to ensure they are made with the most effective forms of help.

Citation

King, B., Borland, R., Yong, H.H., Gartner, C., Hammond, D., Lewandowsky, S, O’Connor, R.J. (2019). Understanding of the component causes of harm from cigarette smoking in Australia. Drug and Alcohol Review, 38(7), 807-817.

Abstract

Introduction and aims: To investigate relationships between smoking-related behaviours and knowledge of the disease risks of smoking and the causes of smoking harms, using a four-way division of 'component causes': nicotine, other substances found in unburned tobacco, combustion products of tobacco and additives.

Design and methods: The data were collected using an on-line survey in Australia with 1047 participants in three groups; young non-smokers (18 to 25), young smokers (18 to 25) and older smokers (26 and above).

Results: Most participants agreed that cancer and heart disease are major risks of smoking but only a quarter accurately quantified the mortality risk of lifetime daily smoking. Very few (two of 1047) correctly estimated the relative contributions of all four component causes. Post-hoc analyses reinterpreting responses as expressions of relative concern about combustion products and nicotine showed that 29% of participants rated combustion products above nicotine. We delineated six relative concern segments, most of which had distinctive patterns of beliefs and actions. However, higher levels of concern about combustion products were only weakly positively associated with harm reducing beliefs and actions.

Discussion and conclusions: Most smokers do not appear to understand the risks of smoking and their causes well enough to be able to think systematically about the courses of action open to them to reduce their health risk. To facilitate informed decision-making, tobacco control communicators may need to better balance the dual aims of creating fear/negative affect about smoking and imparting knowledge about the health harms and their mechanisms.

No abstract is available.

Citation

Aleyan, S., East, K., McNeill, A., Cummings, K.M., Fong, G.T., Yong, H.H., Thrasher, J.F., Borland, R., Hitchman, S.C. (2019). Differences in norms towards the use of nicotine vaping products among adult smokers, former smokers and nicotine vaping product users: Cross-sectional findings from the 2016 ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 97-106.

Abstract

Aims: To examine whether norms towards nicotine vaping product (NVP) use varied between Australia, Canada, England and the United States and by socio‐demographics, smoking and NVP status.

Design: Cross‐sectional data from the 2016 ITC Four Country Smoking and Vaping Survey.

Setting: Four countries with distinct regulatory policies relating to the sale and advertising of NVPs: Australia (most restrictive), Canada (restrictive), England and the United States (least restrictive).

Participants: A total of 10900 adult (age 18+) current smokers, former smokers, or at least weekly NVP users. Respondents were from Australia (n = 1366), Canada (n = 3309), England (n = 3835) and the United States (n = 2390).

Measurements: Questions permitted the categorization of respondents as current smokers, former smokers, NVP users and socio‐demographic categories (sex, age, country, ethnicity, income and education). Further questions were asked regarding the frequency of exposure to NVPs in public, whether they had a partner or close friends who vaped and whether they believed society or those considered important to them approved of NVPs.

Findings: Adjusting for relevant covariates, compared with Australian respondents, those in England, Canada and the United States were more likely to report frequent exposure to NVPs in public (83.1%, 57.3% and 48.3%, respectively, compared to 19.8% in Australia; P < 0.0001), having a partner who vaped (13.8%, 7.1% and 7.7%, respectively, compared to 2.1% in Australia; P < 0.0001) and having close friend(s) who vaped (31.7%, 25.3%, 20.9%, respectively, compared to 10.0% in Australia; P < 0.0001). Compared with Australian respondents, respondents from England were more likely to report that society (27.6% compared to 12.3% in Australia; P < 0.0001) and people important to them approved of NVP use (28.9% compared to 14.3% in Australia; P < 0.0001).

Conclusions: Norms towards nicotine vaping product (NVP) use appear to vary among countries with different regulatory contexts regarding sales and advertising.

Citation

O’Connor, R.J., Fix, B.V., McNeill, A., Goniewicz, M.L., Bansal-Travers-M., Heckman, B.W., Cummings, K.M., Hitchman, S., Borland, R., Hammond, D., Levy, D., Gravely, S., Fong, G.T. (2019). Characteristics of nicotine vaping products used by participants in the 2016 ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 15-23.

Abstract

Background and Aims: The regulatory environment for nicotine vaping products (NVPs) varies widely across countries and this will probably affect the devices used, nicotine content and usage, and hence the ability of NVPs to substitute for cigarettes. We aimed to describe the types of NVPs used by current vapers in four countries with varying regulatory and enforcement approaches toward the marketing and sale of NVPs.

Methods: Data are from wave 1 (July–November 2016) of the ITC Four Country Smoking and Vaping Survey (4CV1), conducted among a cohort of current and former smokers, and current NVP users (n = 5147 adults; ≥ 18 years) in Australia (AU), Canada (CA), England (EN) and the United States (US) reporting either current daily, weekly or occasional NVP use. Devices were described by type, brand, voltage variability and refill capacity. Refill solutions were described by flavour and nicotine content. Descriptive statistics and bivariate analyses were conducted on the overall sample and stratified by country. A multinomial logistic regression examined factors associated with device preference across the whole sample.

Results: The types of NVPs used differed by pattern of use and country. Exclusive, daily vapers were more likely to use refillable pen‐shaped devices [odds ratio (OR) = 10.0] or refillable box‐shaped devices (OR = 5.4) than disposable cigalike devices, when compared with other (non‐daily/dual) users. Nearly all respondents reported using flavoured NVPs, fruit (28.3%) being the most common flavour. Refillable devices were the most popular: refillable box‐shaped devices were more commonly reported by vapers in AU (36.8%) and US (31.4%), whereas in EN (47.4%) and CA (29.7%), vapers more often reported using refillable pen‐style devices. Most users also reported that their products contained nicotine, even in CA (87.8%) and AU (91.2%), where vaping products containing nicotine were technically illegal.

Conclusions: In Australia, Canada, England and the United States in 2016, refillable nicotine vaping products were the most common type of nicotine vaping products used by daily vapers. Most daily vapers reported using flavoured e‐liquids/refills (with variance across countries) and most reported using products that contain nicotine, even where vaping products with nicotine were banned.

Citation

McNeill, A., Driezen, P., Hitchman, S.C., Cummings, K.M., Fong, G.T., Borland, R. (2019). Indicators of cigarette smoking dependence and relapse in former smokers who vape compared with those who do not: findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 49-60.

Abstract

Background and Aims: It has been proposed that many smokers switch to vaping because their nicotine addiction makes this their only viable route out of smoking. We compared indicators of prior and current cigarette smoking dependence and of relapse in former smokers who were daily users of nicotine vaping products (‘vapers’) or who were not vaping at the time of survey (‘non‐vapers’).

Design: Cross‐sectional survey‐based comparison between vaping and non‐vaping former smokers, including a weighted logistic regression of vaping status onto predictor variables, adjusting for covariates specified below.

Setting: United States, Canada, Australia and England.

Participants: A total of 1070 people aged 18+ years from the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Wave 1 Survey who reported having ever been daily smokers but who stopped less than 2 years ago and who were currently vapers or non‐vapers.

Measurements: Dependent variable was current vaping status. Predictor variables were self‐reported: (1) smoking within 5 minutes of waking and usual daily cigarette consumption, both assessed retrospectively; (2) current perceived addiction to smoking, urges to smoke and confidence in staying quit. Covariates: country, sample sources, sex, age group, ethnicity, income, education, current nicotine replacement therapy use and time since quitting.

Findings: Vapers were more likely than non‐vapers to report: (1) having smoked within 5 minutes of waking [34.3 versus 15.9%, adjusted odds ratio (aOR) = 3.74, 95% confidence interval (CI) = 1.99, 7.03), χ2 = 16.92, P < 0.001]; having smoked > 10 cigarettes/day (74.4 versus 47.2%, aOR = 4.39, 95% CI = 2.22, 8.68), χ2 = 18.18, P < 0.001); (2) perceiving themselves to be still very addicted to smoking (41.3 versus 26.2%, aOR = 2.89, 95% CI = 1.58, 5.30, χ2 = 11.87, P < 0.001) and feeling extremely confident about staying quit (62.1 versus 36.6%, aOR = 3.22, 95% CI = 1.86, 5.59, χ2 = 17.36, P < 0.001). Vapers were not more likely to report any urges to smoke than non‐vapers (27.7 versus 38.8%, aOR = 0.86, 95% CI = 0.44, 1.65, χ2 = 0.21, P = 0.643).

Conclusions: While former smokers who currently vape nicotine daily report higher levels of cigarette smoking dependence pre‐ and post‐cessation compared with former smokers who are current non‐vapers, they report greater confidence in staying quit and similar strength of urges to smoke.

Citation

Nahhas, G., Braak, D., Cummings, K.M., Heckman, B.W., Alberg, A.J., Yong, H.H., Fong, G.T., Boudreau, C., Hitchman, S.C., McNeill, A. (2019). Rules about smoking and vaping in the home: Findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 107-114.

Abstract

Aims: To examine rules about smoking and vaping in the home in relation to beliefs about the relative harm of second-hand vapor (SHV) compared with second-hand smoke (SHS) in four countries: Canada, United States, England and Australia.

Design: Data were available from 12 294 adults (18+) who participated in the 2016 (wave 1) International Tobacco Control Four Country Smoking and Vaping (ITC 4CV1) Survey.

Participants: All participants were current or recent former adult smokers.

Measurements: Data were analyzed by weighted logistic regression on rules about smoking and vaping in the home; odds ratios and 95% confidence intervals were reported, adjusted for demographic and behavioral variables.

Findings: Of all respondents, 37.4% allowed smoking inside their home. Among a subset who were current vapers (n = 6135), 60.4% allowed vaping in their homes. After controlling for demographic and behavioral characteristics, beliefs about the harm of SHV compared with SHS was not associated with allowing smoking in the home, but was associated with allowing vaping in the home [odds ratio (OR) = 2.86 in Canada, OR = 1.82 in the United States and OR = 1.68 in England]. Characteristics that were associated with rules about vaping inside the home included daily vaping (OR = 2.95, 2.04-4.26; OR = 7.00, 4.12-11.87; OR = 5.50, 3.40-8.88; OR = 7.78, 1.90-31.80), living with a spouse who vapes (OR = 2.48, 1.54-3.98; OR = 2.69, 1.42-5.11; OR = 4.67, 2.74-7.95; OR = 21.82, 2.16-220.9) and living with children aged under 18 years (OR = 0.50, 0.37-0.68; OR = 0.89, 0.48-1.65; OR = 0.76, 0.53-1.09; OR = 0.26, = 0.11-0.61) in Canada, the United States, England and Australia, respectively. Similar characteristics were associated with rules about smoking inside the home.

Conclusions: Among current and former smokers in 2016 in Canada, the United States, England and Australia, 37.4% allowed smoking in the home; 60.4% of current vapers allowed vaping. Both concurrent users and exclusive vapers were more likely to allow vaping than smoking inside the home. Allowing vaping inside the home was correlated with the belief that second-hand vapor is less harmful than second-hand smoke.

Citation

East, K., Hitchman, S.C., McNeill, A., Ferguson, S., Yong, H.H., Cummings, K.M., Fong, G.T., Borland, R. (2021). Trends in social norms towards smoking between 2002 and 2015 among daily smokers: Findings from the International Tobacco Control Four Country Survey (ITC 4C). Nicotine and Tobacco Research, 23(1), 203-211. doi: 10.1093/ntr/ntz179

Abstract

Objective: To assess trends in daily smokers' social norms and opinions of smoking between 2002 and 2015 in Canada, the United States, the United Kingdom, and Australia.

Method: Data were from wave 1 (2002) to wave 9 (2013–2015) of the longitudinal International Tobacco Control Four Country Survey (Canada, the United States, the United Kingdom, Australia), involving 23 831 adult daily smokers. Generalized estimating equation logistic regression models, adjusted for demographics and survey design effects, assessed associations of wave and country with outcomes: (A) over half of five closest friends smoke, (B) agreeing that people important to you believe you should not smoke, (C) agreeing that society disapproves of smoking, and (D) negative opinion of smoking.

Results: Between 2002 and 2015, adjusting for covariates, (A) over half of five closest friends smoke did not change (56% vs. 55%; adjusted odds ratio [AOR] = 0.95 [95% Confidence Interval = 0.85–1.07]), (B) agreeing that people important to you believe you should not smoke generally decreased (89% vs. 82%; AOR = 0.54 [0.46–0.64]) despite an increase around 2006–2007, (C) agreeing that society disapproves of smoking increased between 2002 and 2006–2007 (83% vs. 87%; AOR = 1.38 [1.24–1.54]) then decreased until 2013–2015 (78%; AOR = 0.74 [0.63–0.88]), and (D) negative opinion of smoking decreased between 2002 and 2010–2011 (54% vs. 49%; AOR = 0.83 [0.75–0.91]) despite an increase around 2005–2006 and at the final wave (2013–2015). Except friend smoking, Canada had the greatest, and the United Kingdom the lowest, antismoking social norms and opinions.

Conclusions: Except friend smoking and opinion of smoking, daily smokers' social norms became less antismoking between 2002 and 2015 despite increases around 2006–2007. Several potential explanations are discussed yet remain undetermined.

Implications: Increasingly comprehensive tobacco control policies alongside decreasing smoking prevalence in Canada, the United States, the United Kingdom, and Australia have led to the assumption that smoking has become denormalized in these countries. Absent from the literature is any formal assessment of social norms towards smoking over time. Contrary to our hypotheses, this study found that the injunctive social norms of daily smokers became less antismoking between 2002 and 2015, despite increases around 2006–2007. There was no change over time in the proportion of daily smokers who report that over half of their five closest friends smoke.

Citation

Li, L., Borland, R., O’Connor, R., Fong, G.T., McNeill, A., Driezen, P., Cummings, K.M. (2019). How are self-reported physical and mental health conditions related to vaping activities among smokers and quitters: Findings from the ITC Four Country Smoking and Vaping Wave 1 Survey. International Journal of Environmental Research and Public Health, 16(8), e1412.

Abstract

This study examines whether having health conditions or concerns related to smoking is associated with use of vaping products. Data came from the 2016 wave of the International Tobacco Control Four Country Smoking and Vaping Survey. Smokers and recent quitters (n = 11,344) were asked whether they had a medical diagnosis for nine health conditions (i.e., depression, anxiety, alcohol problems, severe obesity, chronic pain, diabetes, heart disease, cancer, and chronic lung disease) and concerns about past and future health effects of smoking, and their vaping activities. Respondents with depression and alcohol problems were more likely to be current vapers both daily (Adjusted odds ratio, AOR = 1.42, 95% confidence interval, CI 1.09–1.85, p < 0.05 for depression; and AOR = 1.52, 95% CI 1.02–2.27, p < 0.05 for alcohol) and monthly (AOR = 1.32, 95% CI 1.11–1.57 for depression, p < 0.01; and AOR = 1.43, 95% CI 1.06–1.90, p < 0.05 for alcohol). Vaping was more likely at monthly level for those with severe obesity (AOR = 1.77, 95% CI 1.29–2.43, p < 0.001), cancer (AOR = 5.19, 95% CI 2.20–12.24, p < 0.001), and concerns about future effects of smoking (AOR = 1.83, 95% CI 1.47–2.28, p < 0.001). Positive associations were also found between chronic pain and concerns about past health effects of smoking and daily vaping. Only having heart disease was, in this case negatively, associated with use of vaping products on their last quit attempt (AOR = 0.72, 95% CI 0.43–0.91, p < 0.05). Self-reported health condition or reduced health associated with smoking is not systematically leading to increased vaping or increased likelihood of using vaping as a quitting strategy.

Citation

Ngo, A., Fong, G.T., Craig, L., Shang, C. (2019). Analysis of gender differences in the impact of taxation and taxation structure on cigarette consumption in 17 ITC countries. International Journal of Environmental Research and Public Health, 16(7), e1275.

Abstract

Although increasing taxes has been established as the most effective tobacco control policy, it is not clear whether these policies reduce cigarette consumption equally among women and men. In this study, we examine whether the association between taxation/taxation structure and cigarette consumption differs by gender. The data is from the International Tobacco Control Policy Evaluation (ITC) Projects in 17 countries. Cigarette consumption was measured by gender for each ITC country. Generalized estimating equations (GEE) were employed to investigate gender differences in the association between cigarette consumption and tax structures, while controlling for time-variant demographic characteristics such as unemployment rates, proportions of adults, and percent of female population. Tiered tax structures are associated with higher cigarette consumption among both males and females. Female smokers are more responsive to an average tax increase than male smokers. Among males, higher ad valorem share in excise taxes is associated with lower cigarette consumption, but it is not the case for females. Females may not be as responsive to the prices raised by ad valorem taxes, despite being responsive to average taxes, suggesting that smokers by gender may face different prices.

Citation

Yong, H.H., Borland, R., Cummings, K.M., Gravely, S., Thrasher, J., McNeill, A., Hitchman, S.C., Greenhalgh, B., Thompson, M.E., Fong, G.T. (2019). Reasons for regular vaping and for its discontinuation among smokers and recent ex-smokers: findings from the 2016 ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 35-48.

Abstract

Aims: To examine current and ex‐ smokers’ reasons for continuing or discontinuing regular use of nicotine vaping products (NVPs).

Design and participants: Cross‐sectional study of 2,722 current daily/weekly, and 921 ex‐daily/weekly, adult vapers who were either current or ex‐cigarette smokers when surveyed.

Setting: 2016 ITC Four Country Smoking and Vaping Wave 1 (4CV1) surveys conducted in the United States (n=1159), England (n=1269), Canada (n=964), and Australia (n=251).

Measurements: Current vapers were asked about the following reasons for regular NVP use: less harmful to others, social acceptance, enjoyment, use in smoke‐free areas, affordability, and managing smoking behaviour. Ex‐vapers were asked about the following reasons for discontinuing regular NVP use: addiction concerns, affordability, negative experiences, perceived social unacceptability, safety concerns, product dissatisfaction, inconvenience, unhelpfulness for quitting, unhelpfulness for managing cravings, and not needed for smoking relapse prevention. Possible correlates of NVP use and discontinuation, including smoking status, smoking/vaping frequency, quit duration (ex‐smokers only), country, age, and type of NVP device used, were examined using multivariate logistic regression models.

Findings: For current smokers, the top three reasons for current regular NVP use were: helpful for cutting down smoking (86%), less harmful to others (78%), and helpful for quitting smoking (77%). The top three reasons for discontinuing vaping were: not being satisfying (78%), unhelpfulness for cravings (63%), and unhelpfulness for quitting smoking (52%). For ex‐smokers, the top three reasons for current vaping were: enjoyment (91%), less harmful to others (90%) and affordability (90%); and for discontinuing were: not needed to stay quit (77%), not being satisfying (50%) and safety concerns (44%). Reported reasons varied by user characteristics, including age, country and NVP device‐type.

Conclusions: Regular use of nicotine vaping products is mainly motivated by its perceived benefits, especially for reducing or quitting smoking, whereas its discontinuation is motivated by perceived lack of such benefits, with some variation by user characteristics.

Citation

Morphett, K., Weier, M., Borland, R., Yong, H.H., Gartner, C. (2019). Barriers and facilitators to switching from smoking to vaping: Advice from vapers. Drug and Alcohol Review, 38(3), 234-243.

Abstract

Introduction and Aims: Information available to consumers about nicotine vaping products varies according to the regulatory environment. A common information source in Australia, where nicotine vaping products are highly regulated, is advice from vapers. The aim of this study was to report on what advice current vapers would give to someone new to vaping.

Design and Methods: Australian vapers were recruited in 2016 via the International Tobacco Control Four‐Country Smoking and Vaping survey of smokers and ex‐smokers, as well as a separate recruitment process that targeted vapers. A total of 384 of 559 eligible participants responded to an open‐ended question about barriers to switching from smoking to vaping, and what advice they would give to new vapers.

Results: While some participants reported switching from smoking to vaping easily, others described an adjustment period. Difficulties included learning about technical aspects of nicotine vaping products, finding the ‘right’ combination of device and liquid, and accessing nicotine liquid given that it cannot legally be sold. Many accounts of satisfaction with quitting smoking and improved health were provided.

Discussion and Conclusions: Advice from current vapers is likely to be particularly influential in Australia, where information about vaping is not easily available from health organisations or official government sources. This research shows that advice to new vaper centres around experimentation with devices and flavours and finding trustworthy suppliers of nicotine liquid. It provides an insight into the initial challenges associated with switching from smoking to nicotine vaping products in environments where access to nicotine liquid is highly restricted.

Citation

Borland, R., Murray, K., Gravely, S., Fong, G.T., Thompson, M.E., McNeill, A., O’Connor, R.J., Goniewicz, M., Yong, H.H., Levy, D., Heckman, B., Cummings, K.M. (2019). A new classification system for describing concurrent use of nicotine vaping products alongside cigarettes (so-called "dual use"): Findings from the ITC 4-Country Smoking and Vaping Wave 1 Survey. Addiction, 114(Suppl 1), 24-34.

Abstract

Aims: To determine whether a simple combination of level of smoking and level of vaping results in a useful typology for characterising smoking and vaping behaviours.

Methods: Cross‐sectional data from adults (≥18 years) in the 2016 Wave 1 ITC Four Country Smoking and Vaping Survey in the United States (n=2291), England (n=3591), Australia (n=1376), and Canada (n=2784) were used. Participants who either smoked, vaped or concurrently used both at least monthly were included and divided into 8 groups based on use frequency of each product (daily, non‐daily, no current use). This resulted in 4 concurrent use groups (predominant smokers, dual daily users, predominant vapers and concurrent non‐daily users). These groups were compared with each other and with the 4 exclusive use groups, on socio‐demographics, nicotine dependence, beliefs and attitudes about both products, and quit‐related measures using data weighted to reference population surveys in each country.

Results: 10.8% of the sample were concurrent users, with daily smokers vaping non‐daily (predominant smokers) constituting 51.6% of this group. All 8 categories differed from other categories on at least some measures. Concurrent daily nicotine users reported higher levels of indicators of nicotine dependence, and generally more positive attitudes toward both smoking and vaping than concurrent non‐daily users. Among daily nicotine users, compared with exclusive daily smokers, reports of interest in quitting were higher in all concurrent use groups. Dual daily users had the most positive attitudes about smoking overall, and saw it as the least denormalised, and at the same time were equally interested in quitting as other concurrent users and were most likely to report intending to continue vaping.

Conclusions: In Australia, Canada, England and the United States in 2016, daily nicotine users differed considerably from non‐daily nicotine users. Among daily nicotine users, dual daily users (those who smoke and vape concurrently) should be treated as a distinct grouping when studying relationships between smoking and vaping. The 8 level typology characterising concurrent and exclusive use of smoking and vaping should be considered when studying both products.

Citation

Cheng, K.-W., Chaloupka, F.J., Shang, C., Ngo, A., Fong, G.T., Borland, R., Heckman, B.W., Levy, D.T., Cummings, K.M. (2019). Prices, use restrictions and electronic cigarette use—evidence from Wave 1 (2016) US data of the ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 115-122.

Abstract

Aims: To determine if there are associations between changes in the explicit (i.e., price) and implicit (i.e., use restrictions in public places) costs of cigarettes and nicotine vaping products (NVPs) and their use patterns in the United States.

Methods: Data came from the Wave 1 (2016) US data of the ITC Four Country Smoking and Vaping Survey (ITC US 4CV1) and Nielsen Scanner Track database. A multiple logistic regression model was applied to estimate the likelihoods of NVP use (vaping at least monthly), cigarette/NVP concurrent use (vaping and smoking at least monthly), and switch from cigarettes to NVPs (had quit smoking < 24 months and currently vape) among ever smokers, conditioning upon cigarette/NVP prices, use restrictions and socio‐demographics.

Results: Living in places where vaping is allowed in smoke‐free areas was significantly associated with an increase in the likelihood of vaping (Marginal Effect, M.E. = 0.17; p<0.05) and the concurrent use of cigarettes and NVPs (M.E. = 0.11; p<0.05). Higher NVP prices were associated with decreased likelihood of NVP use, concurrent use, and complete switch (P>0.05). Higher cigarette prices were associated with greater likelihood of cigarette and NVP concurrent use (P>0.05). Working in places where vaping is banned is associated with lower likelihood of vaping and NVP and cigarette concurrent use (P>0.05).

Conclusions: Higher prices for nicotine vaping products (NVPs) and vaping restrictions in public places are associated with less NVP use and less concurrent use of vaping and smoking. Public policies that increase prices for vaping devices and supplies (i.e., regulations, taxes) and restrict where vaping is allowed are likely to suppress vaping.

Citation

Braak, D., Cummings, K.M., Nahhas, G.J., Heckman, B.W., Borland, R., Fong, G.T., Hammond, D., Boudreau, C., McNeill, A., Levy, D.T., Shang, C. (2019). Where do vapers buy their vaping supplies? Findings from the International Tobacco Control (ITC) 4 Country Smoking and Vaping Survey. International Journal of Environmental Research and Public Health, 16(3), 338.

Abstract

Aim: This study examines where vapers purchase their vaping refills in countries having different regulations over such devices, Canada (CA), the United States (US), England (EN), and Australia (AU).

Methods: Data were available from 1899 current adult daily and weekly vapers who participated in the 2016 (Wave 1) International Tobacco Control Four Country Smoking and Vaping. The outcome was purchase location of vaping supplies (online, vape shop, other). Adjusted odds ratios and 95% confidence intervals were reported for between country comparisons.

Results: Overall, 41.4% of current vapers bought their vaping products from vape shops, 27.5% bought them online, and 31.1% from other retail locations. The vast majority of vapers (91.1%) reported using nicotine-containing e-liquids. In AU, vapers were more likely to buy online vs other locations compared to CA (OR = 6.4, 2.3–17.9), the US (OR = 4.1, 1.54–10.7), and EN (OR = 7.9, 2.9–21.8). In the US, they were more likely to buy from vape shops (OR = 3.3, 1.8–6.2) or online (OR = 1.9, 1.0–3.8) vs other retail locations when compared to those in EN. In CA, vapers were more likely to purchase at vape shops than at other retail locations when compared to vapers in EN (5.9, 3.2–10.9) and the US (1.87, 1.0–3.1).

Conclusions: The regulatory environment and enforcement of such regulations appear to influence the location where vapers buy their vaping products. In AU, banning the retail sale of nicotine vaping products has led vapers to rely mainly on online purchasing sources, whereas the lack of enforcement of the same regulation in CA has allowed specialty vape shops to flourish.

Citation

Gravely, S., Driezen, P., Ouimet, J., Quah, A.C.K., Cummings, K.M., Thompson, M.E., Boudreau, C., Hammond, D., McNeill, A., Borland, R., Thrasher, J.F., Edwards, R., Omar, M., Hitchman, S., Yong, H-H., Barrientos-Gutierrez, T., Willemsen, M.C., Bianco, E., Boado, M., Goma, F., Seo, H.G., Nargis, N., Jiang, Y., Perez, C., & Fong, G.T. (2019). Prevalence of awareness, ever-use, and current use of nicotine vaping products (NVPs) among adult current smokers and ex-smokers in 14 countries with differing regulations on sales and marketing of NVPs: Cross-sectional findings from the ITC Project. Addiction, 114(6), 1060-1073.

Abstract

Aims: This paper presents updated prevalence estimates of awareness, ever‐use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing.

Design, setting, participants and measurements: A cross‐sectional analysis of adult (≥18 years) current smokers and ex‐smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013 to 2017. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs): not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs): not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand (NZ); (3) less restrictive policies (LRPs): legal to be sold and marketed with regulations: England, Netherlands, Republic of Korea, United States (US); (4) no regulatory policies (NRPs): Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country‐specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily vs. non‐daily).

Findings: NVP awareness and use were lowest in NRP countries. Generally, ever‐ and current use of NVPs were lower in MRP countries [ever‐use: 7.1% to 48.9%; current use: 0.3% to 3.5%] relative to LRP countries [ever‐use: 38.9% to 66.6%; current use: 5.5% to 17.2%] and RP countries [ever‐use: 10.0% to 62.4%; current use: 1.4% to 15.5%]. NVP use was highest among high income countries, followed by upper‐middle income countries, and then by lower‐middle income countries.

Conclusions: With a few exceptions, awareness and use of nicotine vaping products (NVPs) varies by the strength of national regulations governing NVP sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in NVPs in these countries where smoking populations are predominantly poorer. The higher awareness and use of NVPs in high income countries with moderately (e.g., Canada, NZ) and less (e.g., England, US) restrictive policies, is likely due to the greater availability and affordability of NVPs.

Citation

McDermott, M., Li, G., McNeill, A., Hammond, D., Thrasher, J.F., O’Connor, R.J., Cummings, K.M., Borland, R., Fong, G.T., Hitchman, S.C. (2019). Exposure to and perceptions of health warning labels on nicotine vaping products: Findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 134-143.

Abstract

Background and Aims: The presence and content of health warning labels (HWLs) on nicotine vaping products (NVPs), such as electronic cigarettes, varies by country and manufacturer. We compared proportions of people who report (i) noticing HWLs on NVPs and (ii) feeling concerned having noticed HWLs, by country and by smoking or vaping status. We also examined recall of HWL content and whether this varies by country.

Design: Cross‐sectional survey

Setting: Australia (AU), Canada (CA), England (EN), and the United States (US). At the time of data collection, HWLs on NVPs were only mandatory in EN.

Participants: A total of 11561 respondents from the following samples in the 2016 International Tobacco Control 4‐Country Project: (1) re‐contacted smokers and quitters who had participated in the previous wave of the project; (2) newly recruited current smokers and recent quitters, and (3) newly recruited current vapers from CA, EN and US.

Measurements: Outcomes included: 1) having noticed HWLs on NVPs, 2) feeling concerned having noticed HWLs, and 3) recall of HWL message content.

Findings: Compared with respondents in EN, respondents in CA were more likely to report having noticed HWLs (OR=1.58, p=0.02) whereas respondents in AU (OR=0.76, p=1.00) and the US (OR=1.54, p=0.09) were not significantly more or less likely to report having noticed HWLs. Compared with concurrent smokers and vapers, daily smokers, non‐daily smokers, and quitters were less likely to report having noticed HWLs, (ORs=0.21, 0.33 and 0.19 respectively, all p<0.001). There were no significant differences in reports of noticing HWLs when comparing concurrent smokers and vapers with daily (OR=1.62, p=0.91) or non‐daily (OR=1.15, p=1.00) vapers. There were no significant differences by country in reporting that HWLs made them concerned about using NVPs. Daily vapers were less likely to report feeling concerned than concurrent users (OR=0.11, p=0.017). Among those who reported reading HWLs (n=688), there was little evidence of differences in recall of the HWL content.

Conclusions: Respondents in England, where health warning labels on nicotine vaping products are not mandatory, were not significantly more likely to report having noticed such warnings than those in Australia, Canada and the US where warnings are not mandatory.

Citation

Shang, C., Myung Lee, H., Chaloupka, F., Fong, G.T., Thompson, M.E., O’Connor, R.J. (2019). Association between tax structure and cigarette consumption: findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 28(Suppl 1), S31-S36.

Abstract

Background: Recent studies show that greater price variability and more opportunities for tax avoidance are associated with tax structures that depart from a specific uniform one. These findings indicate that tax structures other than a specific uniform one may lead to more cigarette consumption.

Objective: This paper aims to examine how cigarette tax structure is associated with cigarette consumption.

Methods: We used survey data taken from the International Tobacco Control Policy Evaluation Project in 17 countries to conduct the analysis. Self-reported cigarette consumption was aggregated to average measures for each surveyed country and wave. The effect of tax structures on cigarette consumption was estimated using generalised estimating equations after adjusting for sociodemographic characteristics, average taxes and year fixed effects.

Findings: Our study provides important empirical evidence of a relationship between tax structure and cigarette consumption. We find that a change from a specific to an ad valorem structure is associated with a 6%–11% higher cigarette consumption. In addition, a change from uniform to tiered structure is associated with a 34%–65% higher cigarette consumption. The results are consistent with existing evidence and suggest that a uniform and specific tax structure is the most effective tax structure for reducing tobacco consumption.

Citation

Chan, C.K.G., Morphett, K., Gartner, C., Leung, J., Yong, H.H., Hall, W., Borland, R. (2019). Predicting vaping uptake, vaping frequency and ongoing vaping among daily smokers using longitudinal data from the International Tobacco Control (ITC) Four Country Surveys. Addiction, 114(Suppl 1), 61-70.

Abstract

Aim: To assess (1) how far smoking patterns, depression and smoking‐related beliefs and intentions predict vaping uptake, current vaping and vaping frequency among daily smokers; and (2) how far the aforementioned predictors and baseline vaping frequency predict current vaping among those who reported ever vaped.

Design: Analysis of data from six waves of a longitudinal survey over 8 years. Longitudinal associations between predictors and outcomes were examined using multi‐level models.

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

Participants: A total of 6296 daily smokers (53% females) who contributed data to at least two consecutive survey waves.

Measurements: The outcome variables were vaping uptake, vaping frequency and current vaping at follow‐up. The key predictor variables, measured in previous waves, were time to first cigarette, cigarettes smoked per day, depressive symptoms, intention to quit smoking, quitting self‐efficacy and worry about adverse health effects of smoking.

Findings: Number of cigarettes smoked daily was associated with (1) subsequent vaping uptake [odds ratio (OR) = 1.69, 95% confidence interval (CI) = 1.19, 2.39 for 30+ cigarette per day; reference category: 0–10 cigarettes] and (2) a higher frequency of current vaping (OR = 1.97, 95% CI = 1.36, 2.85 for 30+ cigarettes). Intention to quit was associated with a higher frequency of current vaping (OR = 1.48, 95% CI = 1.21, 1.82). Among those who reported ever vaped, higher baseline vaping frequency (OR = 11.98, 95% CI = 6.00, 23.93 for daily vaping at baseline; reference category: vaped less than monthly) predicted current vaping.

Conclusion: Among daily smokers, amount smoked and intention to quit smoking appear to predict subsequent vaping uptake. Vaping frequency at baseline appears to predict current vaping at follow‐up.

Citation

Thompson, M.E., Fong, G.T., Boudreau, C., Driezen, P., Li, G., Gravely, S., Cummings, K.M., Heckman, B.W., O’Connor, R.J., Thrasher, J.F., Nahhas, G., Borland, R., Yong, H.H., McNeill, A., Hitchman, S.C., Quah, A.C.K. (2019). Methods of the ITC Four Country Smoking and Vaping Survey, Wave 1 (2016). Addiction, 114(Suppl 1) 6-14.

Abstract

Aim: To describe the methods of the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey, conducted in 2016 in Australia (AU), Canada (CA), England (EN) and the United States (US).

Methods: The respondents were cigarette smokers, former smokers (quit within the previous 2 years), and at‐least‐weekly vapers, aged 18 years and older. Eligible cohort members from the ITC Four Country Survey (4C) were retained. New respondents were sampled by commercial firms from their panels. Where possible, ages 18–24 and vapers were oversampled. Data were collected online, and respondents were remunerated. Survey weights were calibrated to benchmarks from nationally representative surveys.

Results: Response rates by country for new recruits once invited ranged from 15.2 to 49.6%. Sample sizes for smokers/former smokers were 1504 in AU, 3006 in CA, 3773 in EN and 2239 in the US. Sample sizes for additional vapers were 727 in CA, 551 in EN and 494 in the US.

Conclusion: The International Tobacco Control Four Country Smoking and Vaping Survey design and data collection methods allow analyses to examine prospectively the use of cigarettes and nicotine vaping products in jurisdictions with different regulatory policies. The effects on the sampling designs and response quality of recruiting the respondents from commercial panels are mitigated by the use of demographic and geographic quotas in sampling; by quality control measures; and by the construction of survey weights taking into account smoking/vaping status, sex, age, education and geography.

Citation

Gravely, S., Thrasher, F.J., Cummings, K.M., Ouimet, J., McNeill, A., Meng, G., Lindblom, E.N., Loewen, R., O’Connor, R., Thompson, M.E., Hitchman, S., Hammond, D., Heckman, B.W., Borland, R., Yong, H.H., Elton-Marshall, T., Bansal-Travers, M., Gartner, C., Fong, G.T. (2019). Discussions between health professionals and smokers about nicotine vaping products: Results from the 2016 ITC Four Country Smoking and Vaping Survey. Addiction, 114(Suppl 1), 71-85.

Abstract

Background and Aims: Debate exists about whether health professionals (HPs) should advise smokers to use nicotine vaping products (NVPs) to quit smoking. The objectives were to examine in four countries: (1) the prevalence of HP discussions and recommendations to use an NVP; (2) who initiated NVP discussions; (3) the type of HP advice received about NVPs; and (4) smoker's characteristics related to receiving advice about NVPs.

Design: Cross‐sectional study using multivariable logistic regression analyses on weighted data from the 2016 ITC Four Country Smoking and Vaping Survey (ITC 4CV1).

Setting: Four countries with varying regulations governing the sale and marketing of NVPs: ‘most restrictive’ (Australia), ‘restrictive’ (Canada) or ‘less restrictive’ (England and United States).

Participants: A total of 6615 adult smokers who reported having visited an HP in the last year (drawn from the total sample of 12 294 4CV1 respondents, of whom 9398 reported smoking cigarettes daily or weekly). Respondents were from the United States (n = 1518), England (n = 2116), Australia (n = 1046), and Canada (n = 1935).

Measurements: Participants’ survey responses indicated if they were current daily or weekly smokers and had visited an HP in the past year. Among those participants, further questions asked participants to report (1) whether NVPs were discussed, (2) who raised the topic, (3) advice received on use of NVPs and (4) advice received on quitting smoking.

Findings: Among the 6615 smokers who visited an HP in the last year, 6.8% reported discussing NVPs with an HP and 2.1% of smokers were encouraged to use an NVP (36.1% of those who had a discussion). Compared with Australia (4.3%), discussing NVPs with an HP was more likely in the United States [8.8%, odds ratio (OR) = 2.15, 95% confidence interval (CI) = 1.41–3.29] and Canada (7.8%, OR = 1.87, 95% CI = 1.26–2.78). Smokers in Australia were less likely to discuss NVPs than smokers in England (6.2%), although this was not statistically significant (OR = 1.47, 95% CI = 0.98–2.20). Overall, the prevalence of HPs recommending NVPs was three times more likely in the United States than in Australia (OR = 3.07, 95% CI = 1.45–6.47), and twice as likely in Canada (OR = 2.28, 95% CI = 1.06–4.87) than in Australia. Australia and England did not differ (OR = 1.76, 95% CI = 0.83–3.74). Just over half (54%) of respondents brought up NVPs themselves; there were no significant differences among countries.

Conclusions: Discussions in Australia, Canada, England, and the United States between smokers and health professionals about nicotine vaping products appear to be infrequent, regardless of the regulatory environment. A low percentage of health professionals recommended vaping products. This was particularly evident in Australia, which has the most restrictive regulatory environment of the four countries studied.

Citation

Branston, J.R., McNeill, A., Gilmore, A., Hiscock, R., Partos, T.R. (2018). Keeping smoking affordable in higher tax environments via smoking thinner roll-your-own cigarettes: Findings from the International Tobacco Control Four Country Survey 2006–15. Drug and Alcohol Dependence, 193, 110-116.

Abstract

Background: Roll-Your-Own tobacco (RYO) use is increasingly popular in many countries: it is generally cheaper than factory-made cigarettes (FM), and smokers can further reduce costs by adjusting the amount of tobacco in each cigarette. However, the level of risk of RYO compared with FM cigarettes is similar and does not meaningfully change with cigarette weight. We assessed the weight of tobacco in RYO cigarettes across jurisdictions with differing tobacco taxes/prices and over time.

Method: Six waves of the International Tobacco Control 4 Country longitudinal study of smokers and recent ex-smokers, providing 3176 observations from exclusive RYO users covering 2006-15, are used to calculate the weight of tobacco used in RYO cigarettes in the US, Canada, Australia, and the UK. Multilevel regression analyses were used to compare weights across countries, socio-demographic factors, and over time.

Results: Smokers in the UK and Australia, where tobacco is relatively expensive, show higher levels of exclusive RYO use (25.8% and 13.8% respectively) and lower mean weights of tobacco per RYO cigarette (0.51 g(sd 0.32 g) and 0.53 g(0.28 g)), compared with both Canada and especially the US (6.0% and 3.5%, and 0.76 g(0.45 g) and 1.07 g(0.51 g)). Smokers in the UK and Australia also exhibited a statistically significant year-on-year decrease in the mean weight of each RYO cigarette.

Conclusions: Taxation of RYO should increase considerably in the UK and Australia so that RYO and FM cigarettes are taxed equivalently to reduce RYO attractiveness and inequalities. Other measures to reduce the price differentials, including taxing RYO solely on weight, are also discussed.