Citation

Chen, D.T.H., Nargis, N., Fong, G.T., Huq, S., Quah, A.C.K., Filippidis, F.T. (2023). Perceptions and reasons for quitting and transitioning between smoking and smokeless tobacco products: Findings from four waves of the ITC Bangladesh Survey. Tobacco Induced Diseases, 21(February), 25. doi:10.18332/tid/159137.

Abstract

Introduction: Transitions between different tobacco products are frequent among tobacco users in Bangladesh; however, the reasons leading to such transitions and why they quit are not well researched. The aim of the study is to examine perceptions and reasons reported by tobacco users in Bangladesh to transition to other products or quit.

Methods: Data from four waves (2009–2015) of the International Tobacco Control (ITC) Bangladesh Survey were used. Repeated data on perceptions and reasons for exclusive cigarette (n=520), bidi (n=130), and SLT users (n=308) to either start using other products or quit were analyzed with sampling weights. The percentages of responses across waves were used to calculate the pooled proportion data using a meta-analysis approach.

Results: Common reasoning for respondents switching to other tobacco products were influence of friends/family (73.8–86.0%), and curiosity (44.4–71.3%). The perceived calming effect of smoking cigarettes and bidis (43.2–56.9%), and the impression that bidis were less harmful (52.3%) and taste better (71.2%) were major reasons for exclusive SLT users to switch products. Health concerns (16.5– 62.7%) and disapproval from friends/family (29.8–56.4%) were generally the main reasons for quitting. For smoked tobacco users, doctor’s advice (41.6%), package warning labels (32.3%), and price (32.4%) seemed to be the major driving factors to quit.

Conclusions: Results highlight that the reasons for switching between tobacco products and quitting include social factors (e.g. friends/family) and (mis) perceptions regarding the products. Tobacco control policy could emphasize cessation support, increased price and education campaigns as key policies to reduce overall tobacco use in Bangladesh. Data from four waves (2009–2015) of the International Tobacco Control (ITC) Bangladesh Survey were used. Repeated data on perceptions and reasons for exclusive cigarette (n=520), bidi (n=130), and SLT users (n=308) to either start using other products or quit were analyzed with sampling weights. The percentages of responses across waves were used to calculate the pooled proportion data using a meta-analysis approach.

Citation

Gravely, S., Chung-Hall, J., Craig, L.V., Fong, G.T., Cummings, K.M., Borland, R., Yong, H.H., Loewen, R., Martin, N., Quah, A.C.K., Hammond, D., Ouimet, J., Boudreau, C., Thompson, M.E., Driezen, P. (2023). Evaluating the impact of plain packaging among Canadian smokers: Findings from the 2018 and 2020 ITC Smoking and Vaping Surveys. Tobacco Control, 32(2), 153-162. doi:10.1136/tobaccocontrol-2021-056635.

Related resources from the Health Canada Supported Dissemination Project (ITC Canada Survey Findings)

Mar 30, 2021 | Impact of Plain Packaging in Canada

Mar 30, 2021 | Incidence de l'emballage neutre au Canada

Sep 22, 2021 | Impact of Plain Packaging in Canada | Infographic | English

Sept 22, 2021 | Press Release from University of Waterloo: Plain packaging on cigarette packs in Canada advanced efforts for reducing smoking

Abstract

Background: In February 2020, Canada implemented plain packaging without any changes to the size and content of health warning labels (HWLs), which were last updated in 2012 (pictorial HWLs on 75% of the pack front and back). This pre-post evaluation study assessed the impact of plain packaging in Canada on: (1) pack appeal; (2) HWL effectiveness; and (3) support for plain packaging. Additionally, a quasi–experimental design was used to assess the Canadian results relative to two comparator countries: Australia, where plain packaging (with new larger HWLs) was implemented in 2012, and the United States (USA), where plain packaging has not been implemented and the same text warnings have appeared on cigarette packs since 1985.

Methods: Data are from adult smokers who participated in the 2018 and/or 2020 International Tobacco Control Smoking and Vaping Surveys in Canada (n=4600), Australia (n=1834) and the USA (n=3046). Online surveys were conducted before (February to July 2018) and after (February to June 2020) the implementation of plain packaging in Canada. Adjusted regression analyses were conducted on weighted data.

Results: Plain packaging was associated with a significant increase in the percentage of Canadian smokers who did not like the look of their cigarette pack (2018: 28.6% vs 2020: 44.7%, p<0.001), whereas no change in pack appeal was observed among smokers in Australia and the USA over the same period. Plain packaging was not associated with changes in HWL effectiveness in Canada. Support for plain packaging increased significantly among Canadian smokers (2018: 25.6% vs 2020: 33.7%, p><0.001).

Conclusions: Plain packaging in Canada substantially reduced pack appeal and increased support for the policy among adult smokers; however, there was no increase in the effectiveness of Canada’s 8-year-old HWLs. The impact of plain packaging on health warning effectiveness may depend on the design of the warnings and length of time since implementation.

Citation

Lohner, V., McNeill, A., Schneider, S., Vollstädt-Klein, S., Andreas, M., Szafran, D., Grundinger, N., Demjén, T., Fernández, E., Przewoźniak, K., Tountas, Y., Trofor, A.C., Zatoński, W.A., Willemsen, M, Vardavas, C.I., Fong, G.T., Mons, U. (2023). Understanding perceived addiction to and addictiveness of electronic cigarettes among e-cigarette users – a cross-sectional analysis of the International Tobacco Control Smoking and Vaping (ITC 4CV) Europe Surveys. Addiction, 118(7), 1359-1369. doi: 10.1111/add.16162.

Abstract

Background and aims: The addictive potential of electronic cigarettes (e-cigarettes) remains to be fully understood. We identified patterns and correlates of perceived addiction to e-cigarettes and perceived addictiveness of e-cigarettes relative to tobacco cigarettes (relative addictiveness) in dual users as well as exclusive e-cigarette users.

Design, setting and participants: Observational study using cross-sectional survey data from England (2016) from the International Tobacco Control Project (ITC) Four Country Smoking and Vaping (4CV) survey. The study comprised 832 current e-cigarette users who had been vaping for at least 4 months.

Measurements: Perceived addiction to e-cigarettes and relative addictiveness of e-cigarettes were examined. Socio-demographic factors were age, gender and education; markers of addiction included urge to vape, time to first vape after waking and nicotine strength used; vaping and smoking characteristics included frequency and duration of e-cigarette use, intention to quit, adjustable power or temperature, enjoyment, satisfaction relative to tobacco cigarettes and tobacco cigarette smoking status.

Findings: A total of 17% of participants reported feeling very addicted to e-cigarettes, while 40% considered e-cigarettes equally/more addictive than tobacco cigarettes. Those who felt very addicted had higher odds of regarding e-cigarettes as more addictive than tobacco cigarettes (odds ratio 3.4, 95% confidence interval 2.3-5.1). All markers of addiction, daily use and enjoyment were associated with higher perceived addiction, whereas time to first vape after waking, daily vaping and perceiving vaping as less satisfying than smoking were associated with relative addictiveness.

Conclusions: Markers of addiction to e-cigarettes appear to correspond with perceived addiction to e-cigarettes, suggesting that self-reported perceived addiction might serve as an indicator of addiction. Prevalence both of markers of addiction and perceived addiction were comparatively low overall, suggesting a limited but relevant addictive potential of e-cigarettes. Additionally, positive and negative reinforcement, reflected here by enjoyment and relative satisfaction, might play a role in e-cigarette addiction.

Citation

Levy, D.T., Gartner, C., Liber, A.C., Sánchez-Romero, L.M., Yuan, Z., Li, Y., Cummings, K.M., Borland, R. (2023). The Australia Smoking and Vaping Model: The potential impact of increasing access to nicotine vaping products. Nicotine and Tobacco Research, 25(3), 486-497. doi: 10.1093/ntr/ntac210.

Abstract

Background: We model the potential impact of relaxing current nicotine vaping product (NVP) restrictions on public health in Australia.

Methods: A Restricted NVP Scenario was first developed to project current smoking and vaping rates, where a US smoking model was calibrated to recent Australian trends. To model less restrictive NVP policies, a Permissive NVP Scenario applied rates of switching from smoking to vaping, initiation into NVP and cigarette use, and cessation from smoking and vaping based on US trends. The model measures vaping risk relative to the excess mortality rate of smoking. The public health impacts are measured as the difference between smoking- and vaping-attributable deaths (SVADs) and life years lost (LYLs) in the Restricted and Permissive NVP Scenarios with sensitivity analysis regarding the NVP excess risk and other factors.

Results: Assuming an NVP excess risk of 5% that of smoking, 104.2 thousand SVADs (7.7% reduction) and 2.05 million LYLs (17.3% reduction) are averted during 2017-2080 in the Permissive NVP Scenario compared to the Restricted NVP Scenario. Assuming 40% NVP excess risk, 70 thousand SVADs and 1.2 million LYLs are averted. The impact is sensitive to the rate at which smokers switch to NVPs and quit smoking, and relatively insensitive to the smoking initiation and NVP initiation and cessation rates.

Conclusions: The model suggests the potential for public health gains to be achieved by relaxing NVP access regulations. However, the model would benefit from better information regarding the impact of NVPs on smoking under a relaxation of current restrictions.

Implications: Australia has implemented a strong array of cigarette-oriented policies but has restricted access to nicotine vaping products (NVPs). The Smoking and Vaping Model offers a framework for modeling hypothetical policy scenarios. The Australian model shows the potential for public health gains by maintaining cigarette-oriented policies while relaxing the current restrictive NVP policy. Modeling results under a permissive NVP policy are particularly sensitive to the estimated rates of smoking cessation and switching to vaping, which are not well established and will likely depend on past and future cigarette-oriented policies and the specific NVP policies implemented in Australia.

Citation

Le Grande, M.R., Balmford, J., Borland, R., McNeill, A. (2023). Perceived health and capacity to cope with stress in recent ex-smokers: Impact of vaping versus quitting all nicotine. Nicotine and Tobacco Research, 25(3), 553-562. doi: 10.1093/ntr/ntac252.

Abstract

Introduction: Little is known about the continued use of nicotine following smoking cessation on perceived well-being in comparison to complete cessation of nicotine use.

Aims and Methods: To explore aspects of perceived well-being and coping among recent ex-smokers as a function of vaping status. Ever-daily smokers in the International Tobacco Control 4 country smoking and vaping surveys in 2016 (w1 N = 883) and 2018 (w2 N = 1088). Cross-sectional associations and longitudinal samples for those who quit between waves and those who quit at w1 and maintained abstinence to w2. Main outcome measures were: Past 30 days of depression symptoms, perceived stress, stress management since quitting, and change in perceived day-to-day health.

Results: In the cross-sectional analyses vapers were more likely to report both improved stress management (aOR = 1.71, 95% CI 1.23–2.36) and perceived day-to-day health (aOR = 1.65, 95% CI 1.26–2.16) than nicotine abstainers. In the longitudinal analyses, smokers who switched to vaping between waves (n = 372) were more likely to report depression symptoms at w2 (aOR = 2.00, 95% CI 1.09–3.65) but reported improved perceived health (aOR = 1.92, 95% CI 1.16–3.20). For the past daily smokers who remained quit between waves (n = 382), vapers were more likely to report improved stress management relative to abstainers (RRR = 5.05. 95% CI 1.19–21.40). There were no other significant differences between vapers and nicotine abstainers.

Conclusions: There is little evidence to support the view that perceptions of well-being deteriorate in vapers compared to complete nicotine abstainers in the immediate years after smoking cessation.

Implications: This study could find no conclusive evidence that the continued use of nicotine via e-cigarettes was detrimental to health compared to completely stopping nicotine intake altogether. Our results would suggest that continuing to use nicotine may even result in some benefits in the short term such as improved stress management, however further longitudinal studies are required to examine if these effects are restricted to the early post-quitting phase and whether other positive or negative effects on psychosocial health emerge in the future.

Citation

Freitas Lemos, R., Tegge, A.N., Athamneh, L.N., Tomlinson, D.C., Stein, J.S., Bickel, W.K. (2023). Narrative theory V: Narratives about penalties resulting from illegal tobacco purchases increase psychological distress. Experimental and Clinical Psychopharmacology, 31(1), 29-36. doi: 10.1037/pha0000551.

Abstract

Previous research with individuals with substance use disorder indicated that different narratives have different effects on one's behaviors and decision-making. One question that remains unanswered is whether simulating real-world consequences of illegal purchases using narratives would induce psychological distress levels as expected in real-world situations.

The present experiment used a between-group design to study how different narratives regarding penalties impact smokers' affective state and more specifically, psychological distress. Participants (N = 93) were randomized into one of the three groups: (a) legal tobacco purchases (LTP), (b) illegal tobacco purchases with fines (ITP_F), and (c) illegal tobacco purchases with fines, criminal record, and negative public exposure (ITP_F + CR + NPE) to complete an online survey. The survey contained one narrative randomly assigned to each participant, demographic questions, the heaviness of smoking index, the Positive and Negative Affect Schedule (PANAS), and a single-item psychological distress question.

The results showed that (a) narratives about making illegal tobacco purchases significantly increased psychological distress when compared to narratives about making LTP, (b) no differences were observed on psychological distress and negative affective state between a narrative describing a fine and a narrative describing a fine, a criminal record, and negative public exposure, and (c) a narrative about a criminal record had the greatest effect on psychological distress among the different narratives about penalty types. Narratives involving illegal purchases increase psychological distress, which varies according to the hypothetical penalties described. More research regarding the use of narratives on decision-making and purchasing of hypothetical substances is warranted.

Citation

Kasza, K.A., Hammond, D., Gravely, S., O’Connor, R.J., Meng, G., East, K.A., Borland, R., Cummings, K.M., Fong, G.T., Hyland, A. (2023). Associations between nicotine vaping uptake and cigarette smoking cessation vary by smokers’ plans to quit: Longitudinal findings from the International Tobacco Control (ITC) Four Country Smoking and Vaping Surveys. Addiction, 118(2), 340-352. doi: 10.1111/add.16050.

Abstract

Background and aims: Most population studies that evaluate the relationship between nicotine vaping and cigarette cessation focus on limited segments of the smoker population. We evaluated vaping uptake and smoking cessation considering differences in smokers' plans to quit.

Design: Longitudinal ITC Four Country Smoking and Vaping Surveys conducted in 2016, 2018, and 2020. Setting: US, Canada, England, Australia.

Participants: Adult daily cigarette smokers who had not vaped in the past 6 months at baseline and had participated in two or more consecutive waves of the ITC Four Country Smoking and Vaping Surveys (n= 2,815).

Measurements: Plans to quit cigarette smoking at baseline (within 6 months, beyond 6 months, not planning to quit) and at follow-up (within 6 months versus not within 6 months); cigarette smoking cessation at follow-up (smoking less than monthly [including complete cessation] versus daily/weekly/monthly smoking); inter-wave vaping uptake (none, only nondaily vaping, any daily vaping). Generalized estimating equations were used to evaluate whether inter-wave vaping uptake was associated with smoking cessation at follow-up, and with planning to quit at follow-up, each stratified by plans to quit smoking at baseline.

Findings: Overall, 12.7% of smokers quit smoking. Smokers not initially planning to quit within 6 months experienced higher odds of smoking cessation when they took up daily vaping (32.4%) versus no vaping (6.8%; adjusted odds ratio [AOR]=8.58, 95% confidence interval [CI]:5.06-14.54). Among smokers planning to quit, smoking cessation rates were similar between those who did and did not take up daily vaping (25.1% vs. 16.8%; AOR=1.91, 95%CI:0.91-4.00), though we could not account for potential use of cessation aids. Daily vaping uptake was associated with planning to quit smoking at follow-up among those initially not planning to quit (AOR=6.32, 95%CI:4.17-9.59).

Conclusions: Uptake of nicotine vaping appears to be strongly associated with cigarette smoking cessation among smokers with no initial plans to quit smoking. Excluding smokers not planning to quit from studies on vaping and smoking cessation may underestimate potential benefit of daily vaping for daily smokers.

Citation

Levy, D.T., Thirlway, F., Sweanor, D.T., Liber, A.C., Sánchez-Romero, L.M., Meza, R., Douglas, C.E., Cummings, K.M. (2023). Do tobacco companies have an incentive to promote harm reduction products? The role of competition. Nicotine and Tobacco Research, 25(12), 1810-1821. doi: 10.1093/ntr/ntad014.

Abstract

Background: Some cigarette companies have started to talk about replacing cigarettes with less harmful alternatives, which might include nicotine vaping products (NVPs), heated tobacco products (HTPs) and oral nicotine delivery products (ONDPs). We consider market competition as a primary driver of whether cigarette companies follow through on their stated intentions.

Methods: We focus on the behavior of cigarette companies in the US. We compare competition in the pre- and post-2012 time periods, analyze the impact of the growth in NVPs on smoking prevalence and cigarette company profits, and examine the potential future role of competition.

Results: Since 2006, consumers have broadened their use of non-combustible nicotine delivery products (NCNDPs) to include, inter alia, NVPs, HTPs and ONDPs. US cigarette companies have acquired major stakes in each of these product categories which corresponds to a period of rapidly declining adult smoking prevalence, especially among younger adults (ages 18-24 years). The shifting dynamics of the nicotine product marketplace are also reflected in cigarette company stock prices. While cigarette companies are likely to promote HTPs and ONDPs over NVPs, their incentives will be directly related to competition from independent firms, which in turn will depend on government regulation.

Conclusions: While cigarette companies will back alternatives to combusted tobacco when threatened by competition, the prospects for their lasting conversion to NCNDPs will depend on the extent of such competition, which will be influenced by government regulation of tobacco products.

Implications: Regulations that limit competition from independent firms while also protecting cigarette company profits risk slowing or even reversing recent declines in smoking, especially among youth and young adults. Regulations that reduce the appeal and addictiveness of combusted tobacco products, such as higher cigarette taxes or a reduced nicotine standard, will encourage smokers to quit and/or switch to less harmful non-combusted forms of tobacco. The regulation of non-combustible nicotine delivery products and cigarettes should be proportionate to their relative risks, so that smokers have incentives to switch from combustibles to safer alternatives, and cigarette companies have incentives to promote safer products.

Citation

Chung-Hall, J., Fong, G.T., Meng, G., Craig, L.V. (2023). Illicit cigarette purchasing after implementation of menthol ban in Canada: Findings from the 2016-2018 ITC Four Country Smoking and Vaping Surveys. Tobacco Control, [Published online, doi:10.1136/tc-2022-057697].

Abstract

Objective: To examine the impact of menthol cigarette bans on use and purchasing of illicit cigarettes among menthol and non-menthol smokers in seven Canadian provinces.

Methods: Data from 1098 non-menthol smokers and 138 menthol smokers in Canada who completed the ITC Four Country Smoking and Vaping Survey in 2016 (pre-ban) and 2018 (post-ban). Brand validation analysis was conducted to (1) compare self-reported use of menthols versus actual use of menthols as regular brand, and verify self-reported purchasing of menthols among pre-ban menthol smokers at post-ban; and (2) assess pre-post ban changes in purchasing of illicit cigarettes from First Nations reserves among non-menthol smokers and menthol smokers.

Results: Among the subset of 138 pre-ban menthol smokers, 36 (19.5%) reported smoking menthols at post-ban. Brand validation analyses showed that 19 (9.0%) were actually using a non-menthol brand; of the 17 (10.5%) who were actually using a menthol brand, 13 (7.9%) bought a menthol brand at last purchase, and 4 (2.6%) bought a non-menthol brand. Among the full sample of smokers who purchased cigarettes from First Nations reserves at both pre-ban and post-ban, there was no change in purchasing of menthols (n=9 menthol smokers; 51.2% vs 51.2%, p=1.00), non-menthols (n=1024 non-menthol smokers; 9.1% vs 8.7%, p=0.69) or all cigarettes (menthol+non-menthol) (n=1086 smokers; 9.7% vs 9.2%, p=0.56).

Conclusions: Actual rates of brand-verified menthol smoking were substantially lower than self-reported rates at post-ban. After Canada’s menthol ban, there was no increase in illicit purchasing of menthol or non-menthol cigarettes from First Nations reserves.

Press:

January 12, 2023 | UW News | Study refutes industry claims that ban on menthol cigarettes leads to increased use of illegal smokes

Citation

Fix, B.V., O’Connor, R.J., Goniewicz, M.L., Leigh, N.J., Cummings, K.M., Hitchman, S.C., Fong, G.T., Nahhas, G.J., Hammond, D., McNeill, A., Borland, R., King, B., Palumbo, M. (2023). Characterisation of vaping liquids used in vaping devices across four countries: Results from an analysis of selected vaping liquids reported by users in the 2016 ITC Four Country Smoking and Vaping Survey. Tobacco Control, 32(1), 51-59. doi: 10.1136/tobaccocontrol-2020-056338.

Abstract

Objectives: This study presents an analysis of vaping products (VPs) purchased in the USA, Canada, England and Australia and assesses whether differences in regulations were associated with differences in the chemical composition of the VPs.

Methods: April-September 2017, a total of 234 VP refill liquids and prefilled cartridges were purchased in convenience samples of retail locations in each country. Products were chosen from brands and styles most commonly reported by current VP users in the 2016 ITC Four Country Smoking and Vaping Survey. All products were tested for nicotine, tobacco-specific nitrosamines (TSNAs), minor tobacco alkaloids, organic acids and flavouring chemicals.

Results: Consistent with the laws in Canada and Australia at the time of product purchase, nicotine was not detected in any of the VPs (n=10 in Canada; n=15 in Australia). US liquids (n=54) had a mean nicotine concentration of 16.2 mg/mL, (range=0.0-58.6) and English liquids (n=166) had a mean concentration of 11.9 mg/mL ((range=0.0-31.2) F(3244)=12.32, p<0.001). About 5% of English samples exceeded the UK's 20 mg/mL nicotine limit. Substantial country differences were observed in levels of TSNAs, with the USA being higher than elsewhere. Of all products tested, 18.8% contained at least one organic acid. Liquids purchased in England contained far more identifiable flavouring chemicals than those in the other countries.

Conclusions: VP composition, particularly with respect to nicotine and flavouring, varies by country, likely reflecting both marketplace preferences and country-specific regulations. There are differences between nicotine levels claimed on the package and actual levels, particularly in England.

Citation

Hammond, D., Reid, J., Burkhalter, R., O’Connor, R.J., Goniewicz, M.L., Wackowski, O.A., Thrasher, J.F., Hitchman, S.C. (2023). Trends in e-cigarette brands, devices and the nicotine profile of products used by youth in England, Canada and the USA: 2017-2019. Tobacco Control, 32(1), 19-29. doi: 10.1136/tobaccocontrol-2020-056371.

Abstract

Background: The e-cigarette market has rapidly evolved, with a shift towards higher nicotine concentration and salt-based products, such as JUUL; however, the implications for youth vaping remain unclear.

Methods: Repeat cross-sectional online surveys were conducted in 2017, 2018 and 2019, with national samples of youth aged 16–19 years recruited from commercial panels in Canada (n=12 018), England (n=11 362) and the USA (n=12 110). Regression models examined differences between countries and over time in the types of e-cigarette products used (design and nicotine content), reasons for using brands and differences in patterns of use, sociodemographics and dependence symptoms by brand/nicotine content.

Results: In 2019, the use of pod- or cartridge-style e-cigarettes was greater in Canada and the USA than England, with Smok and JUUL the leading brands in all countries. In 2019, youth vapers in England were less likely to report using e-cigarettes with ≥2% nicotine (12.8%) compared with Canada (40.5%; adjusted OR (AOR)=4.96; 95% CI 3.51 to 7.01) and the USA (37.0%; AOR=3.99, 95% CI 2.79 to 5.71) and less likely to report using nicotine salt-based products (12.3%) compared with Canada (27.1%; AOR=2.77, 95% CI 1.93 to 3.99) and the USA (21.9%; AOR=2.00, 95% CI 1.36 to 2.95). In 2019, self-reported use of products with higher nicotine concentration was associated with significantly greater frequency of vaping, urges to vape and perceived vaping addiction (p<0.05 for all).

Conclusions: The use of high-nicotine salt-based products is associated with greater symptoms of dependence, including JUUL and other higher-nicotine brands. Greater use of high-nicotine salt-based products may account for recent increases in the frequency of vaping among youth in Canada and the USA.

Citation

Li, L., Borland, R., Cummings, K.M., Fong, G.T., Hyland, A., Le Grande, M., McNeill, A. (2023). Non-cigarette combustible tobacco use and its associations with subsequent cessation of smoking among daily cigarette smokers: Findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2016-2020). Addiction, 118(1), 140-148. doi: 10.1111/add.16023.

Abstract

Aims: To examine whether poly-use of cigarettes and other smoked products (poly-smoking) is predictive of quit attempts and quit success.

Design: A prospective multi-country cohort design.

Setting: Australia, Canada, England and the US.

Participants: 3983 adult daily cigarette smokers were surveyed in 2016 (Wave 1 of data collection) and were recontacted in 2018 (Wave 2) (i.e., Wave 1–Wave 2 cohort) in the International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys; and 3736 smokers were surveyed in 2018 and recontacted in 2020 (Wave 3) (i.e., Wave 2–Wave 3 cohort).

Measurements: Participants were asked about their cigarette smoking and use of cigars, cigarillos, pipes, and waterpipes. Outcomes were quit attempts between two survey waves and success, defined as having quit smoking all the combustible tobacco at the subsequent survey for 1 month or more.

Findings: Levels of poly-smoking were 12.7% in the Wave 1–Wave 2 cohort and 10.5% for the Wave 2–Wave 3 cohort. Compared with cigarette-only smokers, poly-smokers were more likely to attempt between Waves 1 and 2 (54.9% vs. 42.7%, adjusted odds ratio (aOR)=1.37, 95% confidence interval [CI] 1.08-1.74, p<0.01), but not between Waves 2 and 3 (43.8% vs. 40.1%, aOR=0.94, 95%CI 0.72-1.22). Poly-smoking predicted reduced likelihood of success in both cohorts among attempters and the overall samples. Between Waves 2 and 3 there were significantly more transitions to non-daily smoking among the poly-smokers (12.4% vs. 5.3%, 2=40.4, p<0.001).

Conclusions: There is a consistent association between poly-smoking (use of cigarettes along with other smoked products) and reduced quit success for combustible tobacco, but it is likely due to increased likelihood of transitioning to non-daily use rather than complete cessation.

Citation

Cheng, K-W., Liu, G., Pesko, M., Levy, D.T., Fong, G.T., Cummings, K.M. (2023). Impact of vaping restrictions in public places on smoking and vaping in the US: Evidence using a difference-in-differences approach. Addiction, 118(1), 160-166. doi: 10.1111/add.16039.

Abstract

Aims: To estimate whether and to what extent extending indoor smoking restrictions to include electronic cigarettes (ECs) impact the use of ECs and cigarette smoking among adults in the US. Design: Observational study using a linear probability model and applying a difference-in-differences analysis SETTING: USA PARTICIPANTS: People aged 18 to 54 who lived in US counties where comprehensive indoor smoking laws in bars, restaurants, and private workplaces have been in place prior to 2010 (N = 45,111 for EC use analysis, N = 75,959 for cigarette use analysis). Measurements: Data on cigarette smoking, use of ECs, and place of residence from the Tobacco Use Supplement of the Current Population Survey (TUS-CPS 2010-2011, 2014-2015, and 2018-2019) were combined with the American Nonsmokers' Rights Foundation (ANRF) database of state and local indoor smoking and vaping restriction laws. Findings: Indoor vaping restriction (IVR) coverage was not significantly associated with the likelihood of adult EC use (coefficient estimate = 0.001; 95% confidence interval [CI] =-0.009, 0.013, P-value = 0.783). In addition, IVR coverage was not significantly associated with adult cigarette smoking (coefficient estimate = -0.00; 95% CI = -0.016, 0.015, P-value = 0.954). The non-significant results appeared in different socio-demographic subgroups. Conclusions: Indoor vaping restrictions do not appear to decrease electronic cigarette use among US adults. There is no evidence that indoor vaping restrictions increase or decrease cigarette smoking among US adults.

Citation

Soriano, J.B., Fu, M., Castellano, Y., Ancochea, J., Fong, G.T., Fernández, E. (2023). Face mask exemptions, respiratory patients, and COVID-19 in Spain: Data from the 2021 ITC EUREST-PLUS Spain Survey. Open Respiratory Archives, 5(1), 100218. doi: 10.1016/j.opresp.2022.100218.

Citation

Gravely, S., Driezen, P., McClure, E., Hammond, D., Cummings, K.M., Chan, G.C.K., Hyland, A., Borland, R., East, K., Fong, G.T., Schauer, G.L., Quah, A.C.K., Ouimet, J., Smith, D.M. (2022). Differences between adults who smoke cigarettes daily and do and do not co-use cannabis: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Addictive Behaviours, 135, 107434. doi: 10.1016/j.addbeh.2022.107434.

Abstract

Background: Little is known about population-level differences between adults who exclusively smoke cigarettes and those who smoke cigarettes and also use cannabis (co-consumers). Thus, this study describes differences on sociodemographic, cigarette-dependence, health and behavioral variables, and risk perceptions associated with smoking cannabis.

Methods: This cross-sectional study included 6941 respondents from the 2020 ITC Four Country Smoking and Vaping Survey (US, Canada, Australia, England). Adult daily cigarette smokers were included and categorized as: cigarette-only smokers (never used cannabis/previously used cannabis, but not in the past 12 months, n=4857); occasional co-consumers (cannabis use in the past 12 months, but<weekly use, n=739); or regular co-consumers (use cannabis ≥weekly, n=1345). All outcomes were self-reported. Regression models were conducted on weighted data.

Results: Overall, 19.9% of respondents reported regular cannabis co-use and 10.1% reported occasional co-use. Regular co-use was highest in Canada (27.2%), followed by the US (24.4%), England (12.7%) and Australia (12.3%). Compared to cigarette-only smokers, regular co-consumers were more likely to be male and report chest/breathing problems (p<0.001). All co-consumers were more likely to be younger, have lower income, be experiencing financial stress, reside in Canada, have depressive symptoms, use alcohol more frequently and binge drink, use other tobacco/nicotine products, and perceive smoking cannabis as low health risk and less harmful than smoking cigarettes (all p><0.001). Cigarette dependence measures were similar between co-consumers and cigarette-only smokers (all p≥0.05).

Conclusions: Although there were no differences on cigarette dependence measures between daily cigarette smokers who do and do not use cannabis, there are several other risk factors that may affect tobacco use and abstinence among co-consumers (e.g., greater depression, high-risk alcohol consumption). Thus, tobacco cessation treatment may require multi-pronged strategies to address other health behaviors. Continued surveillance is needed to determine the nature and health implications of co-use considering changing policies, markets, and products.

Citation

Gravely, S., Meng, G., Hammond, D., Reid, J., Hyland, A., Cummings, K.M., Rivard, C., Fong, G.T., Seo, Y., Kasza, K.A. (2022). Electronic nicotine delivery systems (ENDS) flavors and devices used by adults before and after the 2020 US FDA ENDS enforcement priority: Findings from the 2018 and 2020 US ITC Smoking and Vaping Surveys. Tobacco Control, 31 (Suppl3), s167-s175.

Abstract

Background: In February 2020, the US Food and Drug Administration (FDA) prioritised enforcement efforts against flavoured prefilled cartridge/pod electronic nicotine delivery systems (ENDS), with the exception of tobacco and menthol. This study examined changes between prepriority enforcement (2018) and early postenforcement (February-June 2020) among adults on: ENDS flavours and devices used most often; location of last purchase of fruit/other-flavoured cartridges (covered under the enforcement priority); and smoking and vaping.

Methods: Prevalence estimates came from 1608 adult frequent (≥weekly) ENDS users (current smokers (n=1072), ex-smokers (n=536)) who participated in the 2018 and/or 2020 US ITC Smoking and Vaping Surveys. Transitions between flavours/devices and changes in smoking/vaping were assessed among baseline respondents who were followed up in 2020 (n=360). Respondents self-reported the ENDS device (disposable, cartridge/pod or tank) and the flavor that they used most often: (1) tobacco flavors (tobacco/tobacco-menthol mix) or unflavored; (2) menthol/mint; (3) fruit/other flavors.

Results: Compared to 2018, in the first 5 months of the 2020 enforcement priority, there were significant increases in the prevalence of fruit/other-flavoured cartridges (7.9% to 12.4%, p=0.026) and menthol/mint cartridges (7.1% to 13.0%, p<0.01) and decreases in tobacco-flavoured tanks (15.5% to 10.0%, p=0.002) and fruit/other-flavoured tanks (38.7% to 33.6%, p=0.038). Fewer than 10% of adults used disposables in 2018 and 2020. Among the cohort sample, the most pronounced transitions between flavours/devices occurred among those who used flavoured cartridges covered under the enforcement priority (54.6% switched to a flavour and/or device excluded from enforcement). There was an increase in purchasing fruit/other-flavoured cartridges online and a decrease in retail locations except for vape shops. Overall, there were few changes in smoking and vaping behaviours.

Conclusions: Between 2018 and the early phase of the FDA's 2020 enforcement priority, prevalence of menthol/mint and fruit/other-flavoured cartridges increased among adults. Half of vapers using cartridge flavours covered in the enforcement switched to other flavours and/or devices that were exempt, with the exception of disposables. The extent to which more comprehensive restrictions may be problematic for adults who prefer a range of ENDS flavours remains uncertain.

Citation

Schneller, L., Kasza, K, Hammond, D., Bansal-Travers, M., O’Connor, R.J., Hyland, A. (2022). E-cigarette and tobacco product use among NYS youth before and after a state-wide vaping flavour restriction policy, 2020-2021. Tobacco Control, 31 (Suppl3), s161-s166.

Abstract

Significance: Reducing youth e-cigarette use is a New York State (NYS) public health priority. In May 2020, a state-wide restriction on flavoured e-cigarettes, except tobacco flavour, was passed. This study examines changes in nicotine product use behaviour among youth around the time of the state-wide vaping flavour restriction.

Methods: NYS data from the US International Tobacco Control Policy Evaluation Project Youth Tobacco and E-cigarette Tobacco and Vaping Survey were analysed cross-sectionally from February 2020 (n=955), August 2020 (n=946), February 2021 (n=1030), and August 2021 (n=753). Online surveys were conducted among youth 16–19 years. Weighted descriptive statistics and regression models were used to describe changes in nicotine product use behaviour. Models were adjusted for age, sex, race/ethnicity and perceived family socioeconomic status.

Results: Significant decreases in past 30-day e-cigarette use (20%–11%), cigarette (7%-4%), and dual use of e-cigarettes and cigarettes (5%–2%) were observed over the 2-year period in NYS. Over 95% of vapers still reported using a non-tobacco-flavoured e-cigarette following the restriction, with fruit-flavoured being the most popular at each time point.

Conclusions: Nearly all NYS youth continued to vape flavours that were restricted in NYS. While youth past 30-day vaping prevalence decreased significantly from 2020 to 2021, increased flavour restriction compliance could result in an even greater decrease. Continuous monitoring is important to better understand perceptions, use patterns and access at the individual level, retail level and population level to inform future enforcement and restrictions.

Citation

Freitas Lemos, R., Stein, J.S., Tegge, A.N., Kaplan, B.A., Heckman, B.W., McNeill, A., Cummings, K.M., Fong, G.T., Bickel, W.K. (2022). The Illegal Experimental Tobacco Marketplace II: Effects of vaping product bans - findings from the 2020 International Tobacco Control Project. Tobacco Control, 31(Suppl 3), s214-s222.

Abstract

Significance: Restrictive e-cigarette policies may increase purchases from illegal sources. The Illegal Experimental Tobacco Marketplace (IETM) allows examination of how restrictions impact illegal purchases. We investigated (1) the effect of a vaping ban, total flavour vaping ban and partial flavour vaping ban on the probability of purchasing illegal vaping products among different regulatory environments (USA, Canada and England) and tobacco user types (cigarette smokers, dual users and e-cigarette users); and (2) the relation between ban endorsement and illegal purchases.

Methods: Participants (N=459) from the International Tobacco Control Survey rated their support of bans and chose to purchase from a hypothetical legal experimental tobacco marketplace or IETM under control and the three ban conditions.

Results: In total, 25% of cigarette smokers, 67% of dual users and 79% of e-cigarette users made IETM purchases. Cross-country comparisons depicted dual users from Canada (OR: 19.8), and e-cigarette users from the USA (OR: 12.9) exhibited higher illegal purchases odds than the same user type in England. Within-country comparisons showed e-cigarette and dual users are more likely to purchase from the IETM than cigarette smokers in the most restrictive condition, with the largest effects in e-cigarette users (England-OR: 1722.6, USA-OR: 22725.3, Canada-OR: 6125.0). Increased opposition towards partial or total flavour ban was associated with increased IETM purchasing in the corresponding condition.

Conclusions: Vaping restrictions may shift users' preference to the illegal marketplace in a regulatory environment. Evidence of the IETM generalisability in a geographically dispersed sample enhances its utility in tobacco regulatory science.

Citation

Loewen, R., Bauer, E., Thompson, M.E., Martin, N., Quah, A.C.K., Fong, G.T. (2022). Timing estimates for complex programmed surveys. Survey Practice, 15(1). doi: 10.29115/SP-2022-0011.

Abstract

Developing a method for estimating average survey completion time—easily, accurately, and repeatedly—was a many-years-long aspiration for the International Tobacco Control Policy Evaluation (ITC) Project. This article describes the three survey length estimation methods used for the ITC Project’s complex programmed surveys, with their respective merits and disadvantages. Method I, Read-Throughs, required staff to read through different versions of the survey. Automating this approach in Method II, Word Counts, replaced staff reading with question word counts and a postulated reading speed, but still required creation of multiple versions that were timed separately. Method III, Weighted Questions, also automated, was streamlined by weighting individual questions, rather than survey versions, by the proportion of respondents likely to answer them. The two automated methods greatly reduced staff time cost, provided surprisingly accurate time estimates, and made it possible to quickly re-estimate the length after each survey revision. Other survey researchers using surveys with complex branching may benefit from our experimentation and results.

Citation

Gravely, S., Yong, H.H., Reid, J., East, K.A., Gartner, C., Levy, D.T., Cummings, K.M., Borland, R., Quah, A.C.K., Bansal-Travers, M., Ouimet, J., Fong, G.T. (2022). Do current smokers and ex-smokers who use nicotine vaping products daily versus weekly differ on their reasons for vaping? Findings from the ITC Four Country Smoking and Vaping Survey. International Journal of Environmental Research and Public Health, 19(21), 14130. doi: 10.3390/ijerph192114130.

Abstract

This study examined reasons why adults who currently smoke or formerly smoked cigarettes use nicotine vaping products (NVPs) by vaping frequency (daily vs. weekly) stratified by smoking status.

This crosssectional study included 3070 adults from the 2020 ITC Four Country Smoking and Vaping Survey (Australia, Canada, England, United States) who reported using a NVP (vaping) at least weekly and who either currently smoke (n = 2467) or formerly smoked (n = 603). Respondents were asked to select the reason(s) they use NVPs, including to manage their smoking (reduce/quit or remain quit) and/or for reasons unrelated to managing smoking (e.g., to save money, enjoyment, flavours).

We found that both current and former smokers endorsed an average of six reasons for vaping, with those vaping daily reporting significantly more reasons than those vaping weekly. Among current smokers, 72.8% reported vaping may help them quit smoking, 13.0% reported vaping to reduce smoking but not to quit, and 14.2% reported vaping only for reasons other than to reduce or quit smoking. The most common reason for vaping among current smokers was to reduce smoking (81.3%). Current smokers vaping daily were significantly more likely than those vaping weekly to report using a NVP to reduce smoking, for enjoyment, to reduce harm to themselves and others, to quit smoking, likeable flavours, and to save money. The most common reason cited for vaping by respondents who formerly smoked was enjoyment, with those who vaped daily more likely than those who vaped weekly to report vaping for enjoyment and to reduce harm to themselves. Nearly all reported vaping to help stay abstinent from smoking (92.3%), with no significant difference by vaping frequency.

In conclusion, a majority of respondents reported using NVPs to manage their smoking (reduce/quit smoking or remain quit), particularly those vaping daily. Those who were vaping daily also endorsed a greater number of reasons other than managing smoking relative to those who were vaping weekly.

Citation

Nogueira, S.O., Driezen, P., Fu, M., Hitchman, S.C., Tigova, O., Castellano, Y., Kyriakos, C.N., Zatoński, M., Mons, U., Quah, A.C.K., Demjén, T., Trofor, A.C., Przewoźniak, K., Katsaounou, P.A., Fong, G.T., Vardavas, C.I., Fernández, E. (2022). Beyond the European Union Tobacco Products Directive: Smokers' and recent quitters' support for further tobacco control measures (2016-2018). Tobacco Control, 31(6), 765-769. doi: 10.1136/tobaccocontrol-2020-056177

Abstract

Background: Several measures recommended by the WHO Framework Convention on Tobacco Control have not been implemented in the European Union, despite changes in the legislation such as the Tobacco Products Directive (TPD). This study aims to understand smokers' and recent quitters' levels of support for tobacco control measures that go beyond the TPD during and after its implementation.

Methods: Data from wave 1 (2016, n=6011) and wave 2 (2018, n=6027) of the EUREST-PLUS International Tobacco Control Policy Evaluation Project Six European Countries Survey, a cohort of adult smokers in Germany, Greece, Hungary, Poland, Romania, Spain were used to estimate the level of support for seven different tobacco control measures, overall and by country.

Results: In 2018, the highest support was for implementing measures to further regulate tobacco products (50.5%) and for holding tobacco companies accountable for the harm caused by smoking (48.8%). Additionally, in 2018, 40% of smokers and recent quitters supported a total ban on cigarettes and other tobacco products within ten years, if assistance to quit smoking is provided. Overall, support for tobacco control measures among smokers and recent quitters after the implementation of the TPD remained stable over time.

Conclusion: There is considerable support among smokers and recent quitters for tobacco control measures that go beyond the current measures implemented. A significant percentage of smokers would support a ban on tobacco products in the future if the government provided assistance to quit smoking. This highlights the importance of implementing measures to increase smoking cessation in conjunction with other policies.

Citation

Craig, L., Chung-Hall, J., Meng, G., Fong, G.T. (2022). Calculating the potential environmental impact of a menthol cigarette ban in the United States. Tobacco Control, [Published online October 13, doi: 10.1136/tc-2022-057563].

Infographics: Oct 2022 | Calculating the Potential Environmental Impact of a Menthol Cigarette Ban in the USA

Press Release: Oct 13, 2022 | Proposed menthol ban in U.S. would cut littering by 3.8 billion cigarettes butts annually

Media & Related Documents:

Nov 7, 2022 | The environmental argument for banning menthol cigarettes - Popular Science, Carla Delgado

Nov 7, 2022 | Craig, L.V., & Fong, G.T. (2022). Answers to questions about the impact of a proposed US menthol cigarette ban on reducing cigarette litter. Sent to Carla Delgado, Popular Science.

Citation

Geboers, C., Nagelhout, G.E., de Vries, H., Candel, M.J.J.M., Driezen, P., Mons, U., Andler, R., Fong, G.T., Willemsen, M.C. (2022). Price minimizing behaviours by smokers in Europe (2006-2020): evidence from the International Tobacco Control Project. European Journal of Public Health, 32(6), 905-912. doi:10.1093/eurpub/ckac115

Abstract

Background: Effectiveness of tobacco taxation can be undermined through smokers applying price-minimizing behaviours rather than quitting or reducing consumption. Common price-minimizing strategies are buying cheaper tobacco [discount brands or roll-your-own (RYO) tobacco], bulk buying and cross-border purchasing. This study analyses trends in and factors associated with such behaviours in four European countries from 2006 to 2020.

Methods: Data came from adult smokers participating in the International Tobacco Control (ITC) Surveys conducted between 2006 and 2020 in England (9 waves, n = 768-4149), France (4 waves, n = 1415-1735), Germany (5 waves, n = 513-1515) and the Netherlands (10 waves, n = 1191-2177). Country-specific generalized estimating equation regression models were fit to assess trends in smoking RYO tobacco, discount brands, bulk buying and cross-border purchasing within the European Union.

Results: Buying discount brands or RYO tobacco was the most common strategy in all countries, except France. Except for buying discount brands, estimates of price-minimizing behaviours were highest in France (2019: RYO = 27.2%, discount brands = 17.3%, bulk buying = 34.1%, cross-border purchasing = 34.2%), and lowest in Germany (2018: RYO = 18.6%, discount brands = 43.7%, bulk buying = 8.0%, cross-border purchasing = 9.8%). Direction and magnitude of trends differed by country, and behaviour. Young smokers were less likely to buy in bulk. Low-income and low-education smokers were more likely to purchase RYO tobacco or discount brands. The association with discount brands was not found for French low-income smokers.

Conclusions: Smoking cheaper tobacco is the most prevalent price-minimizing strategy in three countries (England, Germany and Netherlands), and more prevalent among low-income individuals. Harmonizing prices across products and countries would reduce switching to cheaper tobacco.

Citation

Kyriakos, C.N., Driezen, P., Fong, G.T., Chung-Hall, J., Hyland, A., Geboers, C., Quah, A.C.K., Willemsen, M.C., Filippidis, F. (2022). Impact of the European Union’s menthol cigarette ban on smoking cessation outcomes: Longitudinal findings from the 2020-2021 ITC Netherlands Surveys. Tobacco Control, [Published online September 26, doi: 10.1136/tc-2022-057428].

Abstract

Introduction: To reduce the appeal of tobacco, the European Union (EU) banned menthol as a characterising flavour in cigarettes in May 2020. This pre/post-study evaluated the impact of the menthol ban on smoking cessation outcomes among a representative cohort of Dutch smokers.

Methods: Adult (18+ years) smokers were recruited at wave 1 (pre-ban) of the International Tobacco Control Netherlands Surveys (February–March 2020) and followed post-ban at wave 2 (September–November 2020) and wave 3 (June–July 2021) (N=1326 participated in all three waves). Weighted bivariate, logistic regression and generalised estimating equation model analyses were conducted.

Results: Usual menthol use decreased from pre-ban (7.8%) to post-ban (4.0% at wave 2 and 4.4% at wave 3) (p<0.001). Pre-ban menthol smokers had greater odds of making a post-ban quit attempt than non-menthol smokers (66.9% vs 49.6%, adjusted OR (aOR)=1.89, 95% CI: 1.13 to 3.16). Compared with pre-ban non-menthol smokers, a higher proportion of menthol smokers quit by wave 2 (17.8% vs 10.2%, p=0.025) and by wave 3 (26.1% vs 14.1%, p=0.002), although this was not significant after adjusting for other factors. Female pre-ban menthol smokers had greater odds of quitting by wave 3 than female non-menthol smokers (aOR=2.23, 95% CI: 1.10 to 4.51). Most pre-ban menthol smokers (n=99) switched to non-menthol cigarettes (40.0%) or reported that they continued to smoke menthol cigarettes (33.0%) at wave 3.

Conclusions: The EU menthol ban was effective in reducing menthol use and in increasing quit attempts and quitting among pre-ban menthol smokers. Impact could be maximised by closing gaps that allow post-ban menthol cigarette use.

Citation

Subramaniyan, M., Yee, A., Mohd Hairi, F., Kaai, S.C., Amer Nordin, A.S., Danaee, M., Pravinassh, R., Mohamad, A.S., Kamaludin, I.S., Hasan, S.I., Yan, M., Quah, A.C.K., Driezen, P., Fong, G.T. (2022). Are smoking restrictions at public venues and psychosocial beliefs associated with intentions to quit smoking among smokers in Malaysia? Journal of Ethnicity in Substance Abuse, [Published online, doi:10.1080/15332640.2022.2123421].

Abstract

The Malaysian government reinforced smoking restrictions at public venues to protect nonsmokers from secondhand smoke (SHS) exposure. This study examined whether smokers' reports about smoking restrictions and psychosocial beliefs were associated with quit intentions among Malaysian smokers. Data from 1047 cigarette smokers (103 females and 944 males) aged 18 and older from the 2020 International Tobacco Control (ITC) Malaysia Wave 1 Survey were analyzed with bivariate and multivariable logistic regression models. Most Malaysian smokers (85.2%) reported having quit intentions. Smoking was completely restricted in 34.8% of the nighttime venues, 85.3% of air-conditioned (AC) food and beverage (F&B) venues (restaurants, food courts, coffee shops), 87.3% of non-AC F&B, and 69.4% of indoor workplaces. Smokers who visited nighttime entertainment venues where smoking was fully restricted were less likely to have quit intentions. There was no significant association found with quit intentions for smokers who visited AC and non-AC F&B venues and indoor workplaces where smoking was fully restricted. All five psychosocial beliefs assessed, age, and education were positively associated with quit intentions. Malaysian smokers are interested in quitting and psychosocial beliefs were positively associated with quit intentions. There is a need for the Malaysian government to implement and reinforce comprehensive smoking restrictions in all public venues and indoor workplaces to protect nonsmokers from SHS exposure and to encourage smokers to think about quitting, which may influence their quit intentions.