Citation

Thompson, M.E., Fong, G.T., Hammond, D., Boudreau, C., Driezen, P., Hyland, A., Borland, R., Cummings, K.M., Hastings, G., Siahpush, M., MacKintosh, A.M., Laux, F. (2006). Methods of the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii12-iii18.

Abstract

This paper outlines the design features, data collection methods and analytic strategies of the International Tobacco Control (ITC) Four Country Survey, a prospective study of more than 2000 longitudinal respondents per country with yearly replenishments. This survey possesses unique features that sets it apart among surveys on tobacco use and cessation. One of these features is the use of theory-driven conceptual models. In this paper, however, the focus is on the two key statistical features of the survey: longitudinal and “quasi-experimental” designs. Although it is often possible to address the same scientific questions with a cross-sectional or a longitudinal study, the latter has the major advantage of being able to distinguish changes over time within individuals from differences among people at baseline (that is, differences between age and cohort effects). Furthermore, quasi-experiments, where countries not implementing a given new tobacco control policy act as the control group to which the country implementing such a policy will be compared, provide much stronger evidence than observational studies on the effects of national-level tobacco control policies. In summary, application of rigorous research methods enables this survey to be a rich data resource, not only to evaluate policies, but also to gain new insights into the natural history of smoking cessation, through longitudinal analyses of smoker behaviour.

Citation

Thrasher, J.F., Chaloupka, F., Hammond, D., Fong, G.T., Borland, R., Hastings, G., Cummings, K.M. (2006). Evaluación de las políticas contra el tabaquismo en paises Latino Americanos en la era del Convenio Marco para el Control del Tabaco [Evaluating tobacco control policy in Latin American countries during the era of the Framework Convention on Tobacco Control]. Salud Publica de Mexico, 48(Suppl 1), S155-S166.

Abstract

Objective: The Framework Convention on Tobacco Control (FCTC) aims to coordinate tobacco control policies around the world that reduce tobacco consumption. The FCTC's recommended policies are likely to be effective in low- and middle-income countries. Nevertheless, policy evaluation studies are needed to determine policy impact and potential synergies across policies.

Materials and methods: The International Tobacco Control Policy Evaluation Project (ITC) is an international collaboration to assess the psychosocial and behavioral impact of the FCTC's policies among adult smokers in nine countries. The ITC evaluation framework utilizes multiple country controls, a longitudinal design, and a theory-driven conceptual model to test hypotheses about the anticipated effects of given policies.

Results: ITC Project results generally confirm previous studies that form the evidence base for FCTC policy recommendations, in particular: the use of graphic warning labels; banning of "light" and "mild" descriptors; smoking bans; increasing tax and price; banning advertising; and using new cigarette product testing methods.

Conclusions: Initial findings from the ITC Project suggest that Latin American countries could use similar methods to monitor and evaluate their own tobacco control policies while contributing to the evidence base for policy interventions in other countries.

Citation

Young, D., Borland, R., Hammond, D., Cummings, K.M., Devlin, E., Yong, H.H., O’Connor, R.J. (2006). Prevalence and attributes of roll-your-own smokers in the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl 3), iii76-iii82.

Abstract

Background: Roll-your-own (RYO) cigarettes are often substantially less expensive than factory made (FM) cigarettes, and appear to be increasing in popularity—perhaps because smokers seek out less expensive options to maintain their nicotine addiction. There is surprisingly little research available on the actual prevalence of RYO cigarette usage, and even less on the attributes of those who smoke RYO cigarettes.

Objectives: This study has two objectives: (1) to compare the prevalence of RYO versus FM cigarette usage among adult smokers in Australia, Canada, the United Kingdom, and the United States; and (2) to compare the attributes of exclusive FM smokers, exclusive RYO smokers, and those who report “mixed” RYO and FM use.

Design: The data were collected from the International Tobacco Control (ITC) Four Country Survey (ITC-4), a random digit dialed telephone survey of representative samples of over 9046 adult smokers from the following four countries: Australia (n  =  2301), Canada (n  =  2,206), the UK (n  =  2400), and the USA (n  =  2,139), surveyed between October and December 2002, and on 6075 smokers followed-up, on average, seven months later.

Results: The prevalence of RYO cigarette usage varied widely across the four countries, with a low of 6.7% in the USA, to 28.4% in the UK. Exclusive use of RYO cigarettes was more common in the UK than in the other three countries. The use of RYO cigarettes was associated with having a lower annual income, male sex, younger average age, higher level of nicotine addiction, a stronger belief that RYO tobacco is less harmful compared to other forms of tobacco, and a more positive perception of tobacco use. Prevalence of RYO use was relatively stable within each of the four countries between the baseline and follow-up survey. RYO use was unrelated to quitting activity at follow-up, although mixed RYO users who had made a quit attempt were more likely to relapse than either exclusive FM or exclusive RYO smokers.

Conclusions: Patterns of RYO use vary considerably across Australia, Canada, the USA, and the UK. RYO smokers are a heterogeneous group; however, the factors associated with RYO use appear to be the same across the four countries studied.

Citation

Thompson, M.E., Boudreau, C., Driezen, P. (2005). Incorporating time-in-sample in longitudinal survey models. Proceedings: Symposium 2005, Methodological Challenges for Future Information Needs. Session 12: Challenges in Using Data from Longitudinal Surveys. Statistics Canada.

Abstract

Time-in-sample effects include rotation group biases, memory errors changing over time, and panel conditioning. It is clearly important to take such possibilities into account when designing and analyzing longitudinal survey data before and after an intervention. The question arises of how these effects can be separated from effects of attrition and the true impacts of intervention. It is suggested that using comparable control groups and newly recruited sample at each wave should help with modeling and identification of time-in-sample effects. We illustrate this with data from the International Tobacco Control Four Country Survey, a longitudinal survey of smokers in four countries in which tobacco control interventions are being introduced.

Citation

Yong, H.H., Borland, R., Siahpush, M. (2005). Quitting-related beliefs, intentions, and motivations of older smokers in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Addictive Behaviours, 30(4), 777-788.

Abstract

Older smokers represent an important subgroup that has been shown to benefit considerably from quitting smoking. However, to date little is known about relevant beliefs, intentions, and motivations. This study examined factors associated with older smokers' (aged 60 years and above) intention to quit smoking using data gathered via the International Tobacco Control Policy Evaluation Survey (ITCPES), a random digit dialed telephone survey of over 9000 adult smokers from United Kingdom, United States, Canada, and Australia. Having smoked for a long time and having survived, it was hypothesized that older smokers would perceive themselves as being less vulnerable to the harm of smoking (self-exempting beliefs); be less concerned about the health effects of smoking; be less confident about being able to quit successfully (self-efficacy); not perceive any health benefit of quitting, and hence be less willing to want to quit. Controlling for possible confounders, the hypotheses were all confirmed. Further analysis into reported considerations for quitting revealed that price of cigarettes, health professional advice, cheap quitting medication, and information on health risks were important predictors of quitting intention, with cigarette price and cheap medication also associated with recent quit attempts. Together, these findings have important implications for developing strategies for encouraging older smokers to give up smoking.

Citation

Hammond, D., Fong, G.T., McDonald, P., Brown, K.S., Cameron, R. (2004). Graphic Canadian cigarette warning labels and adverse outcomes: Evidence from Canadian smokers. American Journal of Public Health, 94(8), 1442-1445.

Abstract

Objectives: We assessed the impact of graphic Canadian cigarette warning labels.

Methods: We used a longitudinal telephone survey of 616 adult smokers.

Results: Approximately one fifth of participants reported smoking less as a result of the labels; only 1% reported smoking more. Although participants reported negative emotional responses to the warnings including fear (44%) and disgust (58%), smokers who reported greater negative emotion were more likely to have quit, attempted to quit, or reduced their smoking 3 months later. Participants who attempted to avoid the warnings (30%) were no less likely to think about the warnings or engage in cessation behavior at follow-up.

Conclusions: Policymakers should not be reluctant to introduce vivid or graphic warnings for fear of adverse outcomes.

Citation

Giovino, G.A., Sidney, S., Gfroerer, J.C., O'Malley, P.M., Allen, J.A., Richter, P.A., Cummings, K.M. (2004). Epidemiology of menthol cigarette use. Nicotine and Tobacco Research, 6(Suppl1), 67-81.

Abstract

Approximately one-fourth of all cigarettes sold in the United States are mentholated. An understanding of the consequences, patterns, and correlates of menthol cigarette use can guide the development and implementation of strategies to reduce smoking prevalence and smoking-attributable morbidity and mortality. This paper summarizes the literature on the health effects of mentholated cigarettes and describes various patterns of use as indicated by consumption and survey data from the United States and other nations. The epidemiological literature on menthol cigarettes and cancer risk is inconclusive regarding whether these cigarettes confer a risk for cancer above that of nonmentholated varieties. Available data indicate that mentholated cigarettes are at least as dangerous as their nonmentholated counterparts. In addition, because mentholation improves the taste of cigarettes for a substantial segment of the smoking population and appears to mask disease symptoms, this additive may facilitate initiation or inhibit quitting. Menthol market share is high in the Philippines (60%), Cameroon (35%–40%), Hong Kong (26%), the United States (26%), and Singapore (22%). Newport has become the leading menthol brand in the United States. Surveys from four nations indicate that menthol use among adult smokers is more common among females than males. Among U.S. smokers, 68.9% of Blacks, 29.2% of Hispanics, and 22.4% of Whites reported smoking mentholated variety. Research is needed to better explain factors that may influence menthol preference, such as marketing, risk perceptions, brand formulation, and taste preferences. Such research would guide the development of potentially more effective programs and policies.

Citation

Borland, R., Yong, H.H., King, B., Cummings, K.M., Fong, G.T., Elton-Marshall, T., Hammond, D., McNeill, A. (2004). Use of and beliefs about light cigarettes in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Nicotine & Tobacco Research, 6(Suppl 3), S311-321.

Abstract

This study examined reported use of, and beliefs about, so-called light cigarettes among adult smokers in four countries: Australia (Aus), Canada (Can), the United Kingdom (U.K.) and the United States (U.S.). The method used was parallel telephone surveys among 9,046 smokers across the four countries. The results indicated that more than half of all smokers in each country except the U.K. reported smoking light cigarette brands. A majority of smokers surveyed in each country except Canada continue to believe that light cigarettes offer some health benefit compared to regular cigarettes (Canada 43%, U.S. 51%, Australia 55%, U.K. 70%). A majority of smokers in all four countries believed that light cigarettes are smoother on the throat and chest than regular cigarettes. Predictors of use of light cigarettes and beliefs about possible benefits were very similar in the four countries. These results demonstrate an ongoing need for public education about why light cigarettes do not reduce harm and do not make quitting easier. The results provide further evidence for the need for regulatory measures in all four countries to prohibit the use of misleading light and mild descriptors including package imagery in product marketing (as prescribed in Article 11 of the Framework Convention on Tobacco Control), abandon the use of standard FTC/ISO tar and nicotine yields as consumer information, and adopt policies to regulate deceptive design features of cigarettes, such as ventilated filters.

Citation

Fong, G.T., Hammond, D., Laux, F., Zanna, M.P., Cummings, K.M., Borland, R., Ross, H. (2004). The near-universal experience of regret among smokers in four countries: Findings from the International Tobacco Control Policy Evaluation Survey. Nicotine & Tobacco Research, 6(Suppl 3), S341-351.

Abstract

Regret may be a key variable in understanding the experience of smokers, the vast majority of whom continue to smoke while desiring to quit. We present data from the baseline wave (October-December 2002) of the International Tobacco Control Policy Evaluation Survey, a random-digit-dialed telephone survey of a cohort of over 8,000 adult smokers across four countries--Canada, the United States, the United Kingdom, and Australia--to estimate the prevalence of regret and to identify its predictors. The proportion of smokers who agreed or agreed strongly with the statement "If you had to do it over again, you would not have started smoking" was extremely high--about 90%--and nearly identical across the four countries. Regret was more likely to be experienced by older smokers, women, those who had tried to quit more often, those who perceived quitting as conferring benefits, those with higher levels of perceived addiction, those who worried about future damage to health, those who perceived smoking as lowering their quality of life, those who perceived higher monetary costs of smoking, and those who believed that smoking is not socially acceptable. This predictive model was the same in all four countries. Regret is thus a near-universal experience among smokers in all four countries, and the factors that predict regret are universal across these four countries. Among other implications for cessation treatment and smoking prevention, this near universality of regret casts doubt on the view of some policy analysts and economists that the decisions to take up and continue smoking are welfare-maximizing for the consumer.

Citation

Hammond, D., McDonald, P., Fong, G.T., Borland, R. (2004). Do smokers know how to quit? Knowledge and perceived effectiveness of cessation assistance as predictors of cessation behaviour. Addiction, 99(8), 1042-1048.

Abstract

Aims: Despite the existence of effective cessation methods, the vast majority of smokers attempt to quit on their own. To date, there is little evidence to explain the low adoption rates for effective forms of cessation assistance, including pharmaceutical aids. This study sought to assess smokers' awareness and perceived effectiveness of cessation methods and to examine the relationship of this knowledge to cessation behaviour.

Design: A random-digit-dial telephone survey (response rate = 76%) with 3-month follow-up was conducted with 616 adult daily smokers in South-Western Ontario, Canada.

Measurements: A baseline survey assessed smoking behaviour, as well as smokers' awareness and perceived effectiveness of cessation assistance. A follow-up survey measured changes in smoking behaviour and adoption of cessation assistance at 3 months.

Findings: Participants demonstrated a poor recall of cessation methods: 45% of participants did not recall nicotine gum, 33% did not recall the nicotine patch and 57% did not recall bupropion. Also, many participants did not believe that the following cessation methods would increase their likelihood of quitting: nicotine replacement therapies (36%), bupropion (35%), counselling from a health professional (66%) and group counselling/quit programmes (50%). In addition, 78% of smokers indicated that they were just as likely to quit on their own as they were with assistance. Most important, participants who perceived cessation methods to be effective at baseline, were more likely to intend to quit (OR = 1.80, 95% CI: 1.12-2.90), make a quit attempt at follow-up (OR = 1.80, 95% CI: 1.03-3.16) and to adopt cessation assistance when doing so (OR = 3.62, 95% CI: 1.04-12.58).

Conclusions: This research suggests that many smokers may be unaware of effective cessation methods and most underestimate their benefit. Further, this lack of knowledge may represent a significant barrier to treatment adoption.

Citation

Hammond, D., Fong, G.T., McDonald, P., Cameron, R., Brown, K.S. (2003). Impact of the graphic Canadian warning labels on adult smoking behaviour. Tobacco Control, 12(4), 291-395.

Abstract

Objective: To assess the impact of graphic Canadian cigarette warning labels on current adult smokers.

Design: A random-digit-dial telephone survey was conducted with 616 adult smokers in south western Ontario, Canada in October/November 2001, with three month follow up.

Main outcome measures: Smoking behaviour (quitting, quit attempts, and reduced smoking), intentions to quit, and salience of the warning labels.

Results: Virtually all smokers (91%) reported having read the warning labels and smokers demonstrated a thorough knowledge of their content. A strong positive relation was observed between a measure of cognitive processing—the extent to which smokers reported reading, thinking about, and discussing the new labels—and smokers’ intentions to quit (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.16; p < 0.001). Most important, cognitive processing predicted cessation behaviour at follow up. Smokers who had read, thought about, and discussed the new labels at baseline were more likely to have quit, made a quit attempt, or reduced their smoking three months later, after adjusting for intentions to quit and smoking status at baseline (OR 1.07, 95% CI 1.03 to 1.12; p < 0.001).

Conclusions: Graphic cigarette warning labels serve as an effective population based smoking cessation intervention. The findings add to the growing literature on health warnings and provide strong support for the effectiveness of Canada’s tobacco labelling policy.

Citation

Siahpush, M., Borland, R., Scollo, M. (2003). Factors associated with smoking cessation in a national sample of Australians. Nicotine and Tobacco Research, 5(4), 597-602.

Abstract

The association of sociodemographic and selected behavioral and social environmental factors with successful smoking cessation was examined using cross-sectional data from the 1998 Australian National Drug Strategy Household Survey, which used an area multistage stratified design. Data collection involved a mixture of interviews and self-administered questionnaires. We used a subsample of 2,526 Australians aged 14 years and older. The outcome measure distinguished between current smokers and those who had stopped smoking in the past 2 years and had not smoked for at least 1 month prior to the survey. Knowing that environmental tobacco smoke is harmful and having first smoked at age 14 or younger were associated with a higher likelihood of cessation. The odds of having quit smoking were 4.5 times greater for respondents who lived in households where smoking was not permitted than for those in households with no smoking restrictions. The odds of having quit were 3.2 times greater for respondents who reported that few or none of their friends smoked than for those who said most or all of their friends smoked. After including social environmental variables, associations of education and cessation disappeared. The study confirmed the difficulty of quitting if the proximal social environment is filled with smokers. Results call for an integrated approach in which smoking cessation interventions target the social environment as well as the individual. Efforts to intervene in smoking behavior will have limited effectiveness unless they take into account the social contexts in which smoking behavior takes place.