Citation

Gravely, S., Meng, G., Hammond, D., Hyland, A., Cummings, K.M., Borland, R., Kasza, K., Yong, H.H., Thompson, M.E., Quah, A.C.K., Ouimet, J., Martin, N., O’Connor, R.J., East, K.A., McNeill, A., Boudreau, C., Levy, D.T., Sweanor, D.T., Fong, G.T. (2022). Differences in cigarette smoking quit attempts and cessation between adults who did and did not take up nicotine vaping: Findings from the ITC Four Country Smoking and Vaping Surveys. Addictive Behaviors, 132, 107339.

Abstract

Introduction: There is mixed evidence as to whether nicotine vaping products (NVPs) can help adults who smoke transition away from cigarettes. This study investigated if rates of self-reported attempts to quit smoking and smoking cessation over a period of either 18 or 24 months differed between respondents who initiated nicotine vaping versus those who did not. Outcome comparisons were made between those who: (1) initiated vaping vs. those who did not; (2) initiated daily or non-daily vaping vs. those who did not; and (3) initiated daily or non-daily vaping between surveys and continued to vape at follow-up (daily or non-daily) vs. those who did not initiate vaping.

Methods: This cohort study included 3516 respondents from the ITC Four Country Smoking and Vaping Surveys (Australia, Canada, England, US), recruited at Wave 1 (2016) or 2 (2018) and followed up at Wave 2 (12 months) and/or 3 (2020, 24 months). Adults who smoked daily at baseline and did not have a history of regular vaping were included. Initiation of vaping was defined as beginning to vape at least monthly between surveys. Respondents indicated whether they made an attempt to quit smoking between surveys. Smoking cessation was defined as those who self-reported no longer smoking cigarettes at follow-up.

Results: Relative to those who did not initiate vaping, any daily vaping was associated with a greater likelihood of smokers making a cigarette quit attempt (p<0.001) and quitting smoking (p<0.001). Among smokers who attempted to quit smoking, any daily vaping was associated with a greater likelihood of being abstinent from smoking at follow-up (p=0.001). Respondents who initiated vaping between surveys and were vaping daily at follow up were significantly more likely to have attempted to quit smoking (p<0.001) and to have quit smoking (p<0.001) than those who did not initiate vaping. Respondents who initiated non-daily vaping did not differ significantly from those who did not initiate vaping on any of the outcome measures.

Conclusions: Daily NVP use was associated with increased attempts to quit smoking and abstinence from smoking cigarettes. These findings are consistent with the concept that complete cigarette substitution may be more likely to be achieved when smokers vape nicotine daily.

Citation

Han, M., Seo, D.H., Kim, Y., Seo, H.G., Cho, S., Lee, S., Lim, S., Kaai, S.C., Quah, A.C.K., Yan, M., Xu, S.S., Fong, G.T. (2022). Factors associated with quit intentions among adult smokers in South Korea: Findings from the 2020 ITC Korea Survey. International Journal of Environmental Research and Public Health, 19(17), 10839. doi: 10.3390/ijerph191710839

Abstract

Background: South Korea has made substantial progress on tobacco control, but cigarette smoking prevalence is still high. Previous studies were conducted before the use of nicotine vaping products (NVPs) or heated tobacco products (HTPs) became popular. Thus, whether the concurrent use of NVPs or HTPs affects quit intentions among Korean smokers remains a question that needs to be explored. This study aims to identify predictors of quit intentions among cigarette-only smokers and concurrent users of cigarettes and NVPs or HTPs.

Methods: Data were from the 2020 International Tobacco Control Korea Survey. Included in the analysis were 3778 adult cigarette smokers: 1900 at-least-weekly exclusive smokers and 1878 at-least-weekly concurrent smokers and HTP or NVP users. Bivariate and multivariable logistic regression analyses were conducted.

Results: Quit intentions were reported by 66.4% of respondents. Factors significantly associated with quit intentions included younger age, having a spouse/partner, lower nicotine dependence, reporting a past quit attempt, regretting starting smoking, believing that smoking had damaged health, worrying that smoking will damage future health, and perceiving health benefits of quitting. Current use of NVPs or HTPs was not significantly associated with quit intentions.

Conclusions: This study contributes the following to current literature: intrinsic health-related beliefs were more important than societal norms in shaping quit intentions. These findings should be considered in shaping future smoking cessation policies, such as reinforcing education programs that emphasize the benefits of quitting for personal health reasons, lowering nicotine dependence, and encouraging multiple quit attempts and successful quitting.

Citation

Hammond, D., Reid, J., Rynard, V.L., O’Connor, R.J., Goniewicz, M.L., McNeill, A., Piper, M.E., Bansal-Travers, M. (2022). Indicators of dependence and efforts to quit vaping and smoking among youth in Canada, England, and the United States. Tobacco Control, 31, e25-e34. doi: 10.1136/tobaccocontrol-2020-056269

Abstract

Objective: The current study examined indicators of dependence among youth cigarette smokers and e-cigarette users in Canada, England and the USA, including changes between 2017 and 2019.

Methods: Data are from repeated cross-sectional online surveys conducted in 2017, 2018 and 2019 with national samples of youth aged 16-19 years, in Canada (n=12 018), England (n=11 362) and the USA (n=12 110). Measures included perceived addiction to cigarettes/e-cigarettes, frequency of experiencing strong urges to smoke/use an e-cigarette, plans to quit smoking/using e-cigarettes and past attempts to quit. Logistic regression models were fitted to examine differences between countries and changes over time.

Results: The proportion of ever-users who vaped frequently was significantly higher in 2019 compared with 2017 for all outcomes in each country. Between 2017 and 2019, the proportion of past 30-day vapers reporting strong urges to vape on most days or more often increased in each country (Canada: 35.3%, adjusted OR (AOR) 1.69, 95% CI 1.20 to 2.38; England: 32.8%, AOR 1.55, 1.08 to 2.23; USA: 46.1%, AOR 1.88, 1.41 to 2.50), along with perceptions of being 'a little' or 'very addicted' to e-cigarettes (Canada: 48.3%, AOR 1.99, 1.44 to 2.75; England: 40.1%, AOR 1.44, 1.03 to 2.01; USA: 53.1%, AOR 1.99, 1.50 to 2.63). Indicators of dependence among smokers were consistently greater than e-cigarette users, although differences had narrowed by 2019, particularly in Canada and the USA.

Conclusions: Prevalence of dependence symptoms among young e-cigarette users increased between 2017 and 2019, more so in Canada and the USA compared with England. Dependence symptom prevalence was lower for e-cigarettes than smoking; however, the gap has narrowed over time.

Citation

Li, L., Borland, R., Yong, H.H., Gravley, S., Fong, G.T., Cummings, K.M., East, K.A., Le Grande, M. (2022). Experienced effects on well-being following smoking cessation: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. International Journal of Environmental Research and Public Health, 19(16), 10037. doi: 10.3390/ijerph191610037

Abstract

Background and Aims: There has been limited research addressing changes in subjective well-being as a result of quitting smoking. This paper examines recent ex-smokers’ well-being related experiences overall and as a function of (1) duration of cessation and (2) continued nicotine use from vaping.

Methods: A sample of 1379 ever-daily smoking ex-smokers (quit for up to 5 years) from the 2020 ITC Four Country Smoking and Vaping Survey (Australia, Canada, the UK, and the US), of which 27.1% currently vaped daily. Well-being measures were perceived changes post-quitting in emotion coping (stress and negative emotions), enjoyment of life, and day-to-day functioning. We also assessed the level of persisting worry about past smoking leading to future health problems.

Results: Overall, among those answering all four well-being measures, 51.8% of the ex-smokers reported positive effects and no negatives, but 27.3% reported at least one negative effect, with the remainder reporting no change in any measure. Positive effects were greater among those who had quit more than 1 year prior. The largest improvement (56.3%) was for daily functioning, which showed improvement over time since having quit. Current daily vapers reported similar well-being as those not vaping; however, fewer daily vapers reported worsening ability to cope with stress (10.2% vs. 20.7%). Overall, 84% reported being worried about future negative health effects of smoking, with no clear differences by quitting duration or vaping status.

Conclusions: Most ex-smokers reported changes in their well-being since quitting, with more reporting improvements than declines. Well-being improved with duration of time since quitting, but did not appear to be influenced by daily vaping use, but stress coping may be better among vapers. Persisting worries about possible future health effects from smoking may be reducing the experienced benefits of quitting smoking for some.

Citation

East, K., Reid, J., Hitchman, S.C., Hammond, D. (2022). Purchasing and sourcing of e-cigarettes among youth in Scotland and England following Scotland's implementation of an e-cigarette retail register and prohibition of e-cigarette sales to under-18s. Qeios, [Published online, doi:10.32388/1JZU74].

Abstract

Background. Scotland implemented new e-cigarette regulations in April 2017 prohibiting sales to under18s, requiring age verification, and requiring retailer registration. This study examined purchasing and sourcing of e-cigarettes among minors aged 16-17, and youth aged 18-19, in the short- (4 months) and longer-term (16 months) after regulations were implemented, compared with England.

Methods. Data were from the July/August 2017 and August/September 2018 cross-sectional online ITC Youth Tobacco and Vaping Surveys of 16- to 19-year-olds in Scotland (n2017/2018=434/377) and England (n2017/2018=3,791/3,743). Logistic regressions were used to examine differences in past-12- month purchasing, past-12-month sale refusal, and past-30-day sourcing of e-cigarettes between 2017 and 2018, by country and age group.

Results. Among vapers aged 16-17 in Scotland, from 4 to 16 months post-regulations, e-cigarette purchasing increased from 21% to 50% and sale refusal increased from 14% to 16%, but these changes were not significant and did not differ from changes observed in 18-19-year-olds or England (p>.05). Purchasing and sale refusal were most common in vape shops. Purchasing from a vape shop increased among vapers aged 16-17 in Scotland from 4 to 16 months post-regulations (17% to 85%, p=.003) but not among 18-19-year-olds or in England (p>.05). Among past-30-day vapers, social sources were most common.

Conclusions. Youth vapers in Scotland showed no significant changes in overall purchasing, sale refusal, or sourcing of e-cigarettes, from 4 to 16 months post-regulations, and changes did not differ by age group or from England. Findings suggest low compliance with age-of-sale regulations in Scotland and England.

Citation

Yong, H.H., Gravely, S., Borland, R., Gartner, C., Cummings, K.M., East, K., Tagliaferri, S., Elton-Marshall, T., Hyland, A., Bansal-Travers, M., Fong, G.T. (2022). Do smokers’ perceptions of the harmfulness of nicotine replacement therapy and nicotine vaping products as compared to cigarettes influence their use as an aid for smoking cessation? Findings from the ITC Four Country Smoking and Vaping Surveys. Nicotine & Tobacco Research, 24(9), 1413-1421. doi: 10.1093/ntr/ntac087.

Abstract

Aim: This study examined whether smokers' harm perceptions of nicotine replacement therapy (NRT) and nicotine vaping products (NVPs) relative to cigarettes predicted their subsequent use as smoking cessation aids during their last quit attempt (LQA).

Methods: We analyzed data from 1,315 current daily smokers (10+ cigarettes per day) who were recruited at Wave 1 (2016), and who reported making a quit attempt by Wave 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the US. We used multinomial logistic regression models to examine prospective associations between harm perceptions of a) NRT and b) NVPs and their use at LQA, controlling for socio-demographic and other potential confounders.

Results: Smokers who perceive that a) NRT and b) NVPs are much less harmful than cigarettes were more likely to subsequently use the respective product as an aid than using no aid or other aids during LQA (adjusted relative risk ratio [aRRR]=3.79, 95%CI=2.16-6.66; and aRRR=2.11, 95%CI=1.29-3.45, respectively) compared to smokers who perceive these products as equally or more harmful. Additionally, those who perceive NVPs as much less harmful than cigarettes were less likely to use NRT as a quit aid (aRRR=0.34, 95%CI=0.20-0.60). No country variations for these associations were found.

Conclusion: This study found that smokers' perceptions of the harmfulness of a) NRT and b) NVPs relative to cigarettes predicted the respective product use when trying to quit smoking. Corrective education targeting misperceptions of nicotine products' relative harmfulness may facilitate their use for smoking cessation.

Implications: What this study adds: Nicotine replacement therapy and nicotine vaping products are two commonly used smoking cessation aids. This study demonstrates that misperceptions of the harms of nicotine products relative to cigarettes influence their use for smoking cessation. Believing that nicotine vaping products are much less harmful than cigarette smoking may lead some smokers to prefer these products over nicotine replacement therapy to aid smoking cessation. Education targeting misperceptions of nicotine products' harmfulness relative to cigarettes may enable smokers to make informed choices about which are appropriate to aid smoking cessation.

Citation

Felicione, N., Fix, B., McNeill, A., Cummings, K.M., Goniewicz, M.L., Hammond, D., Borland, R., Heckman, B.W., Bansal-Travers, M., Gravely, S., Hitchman, S.C., Levy, D.T., Fong, G.T., O’Connor, R.J. (2022). Characteristics and changes over time of nicotine vaping products used by participants in the 2016 and 2018 ITC Four Country Smoking and Vaping Surveys. Tobacco Control, 31(e1), e66-e73. doi: 10.1136/tobaccocontrol-2020-056239

Abstract

Objectives: Regulation of nicotine vaping products (NVPs) varies between countries, impacting the availability and use of these products. This study updated the analyses of O'Connor et al on types of NVPs used and examined changes in NVP features used over 18 months in four countries with differing regulatory environments.

Design: Data are from 4,734 adult current vapers in Australia, Canada, England, and the USA from Waves 1 (2016) and 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Survey. NVP characteristics included device description, adjustable voltage, nicotine content and tank size. Longitudinal analyses (n=1,058) assessed movement towards or away from more complex/modifiable NVPs. A logistic regression was used to examine factors associated with changes in device description from 2016 to 2018.

Results: Like 2016, box-tanks were the most popular NVP (37.3%) in all four countries in 2018. Over 80% of vapers continued using the same NVP and nicotine content between waves, though movement tended towards more complex/modifiable devices (14.4% of vapers). Box-tank users, exclusive daily vapers and older vapers were most likely to continue using the same device description. Certain NVPs and features differed by country, such as higher nicotine contents in the USA (11.5% use 21+ mg/mL) and greater device stability over time in Australia (90.8% stability).

Conclusions: Most vapers continued using the same vaping device and features over 18 months. Differences in NVP types and features were observed between countries, suggesting that differing NVP regulations affect consumer choices regarding the type of vaping device to use.

Citation

Freitas Lemos, R., Tegge, A.N., Craft, W.H., Tomlinson, D.C., Stein, J., Bickel, W.K. (2022). Understanding data quality: Instructional comprehension as a practical metric in crowdsourced investigations of behavioural economic cigarette demand. Experimental and Clinical Psychopharmacology, 30(4),415-423.

Abstract

Crowdsourcing platforms allow researchers to quickly recruit and collect behavioral economic measures in substance-using populations, such as cigarette smokers. Despite the broad utility and flexibility, data quality issues have been an object of concern. In two separate studies recruiting cigarette smokers, we sought to investigate the association between a practical quality control measure (accuracy on an instruction quiz), on internal consistency of number of cigarettes smoked per day and purchasing patterns of tobacco products in an experimental tobacco marketplace (ETM; Study 1), and in a cigarette purchase task (CPT; Study 2). Participants (N = 312 in Study 1; N = 119 in Study 2) were recruited from Amazon mechanical turk. Both studies included task instructions, a quiz, a purchase task, cigarette usage and dependence questions, and demographics. The results show that participants who answered all instruction items correctly: (a) reported the number of cigarettes per day more consistently (partial η2 = 0.11, p < .001, Study 1; partial η2 = 0.09, p = .016, Study 2), (b) demonstrated increased model fit among the cigarette demand curves (partial η2 = 0.23, p < .001, Study 1; partial η2 = 0.08, p = .002, Study 2), and purchased tobacco products in the ETM more consistently with their current usage. We conclude that instruction quizzes before purchase tasks may be useful for researchers evaluating demand data. Instruction quizzes with multiple items may allow researchers to choose the level of data quality appropriate for their studies.

Citation

Cho, Y., Thrasher, J.F., Gravely, S., Alberg, A.J., Borland, R., Yong, H.H., Cummings, K.M., Hitchman, S.C., Fong, G.T. (2022). Adult smokers’ discussions about vaping with health professionals and subsequent behavior change: a cohort study. Addiction, 117(11), 2933-2942. doi: 10.1111/add.15994.

Abstract

Aims: To measure the prevalence and changes in smokers' discussions with health professionals (HPs) about nicotine vaping products (NVPs) and HPs' recommendations about NVPs between 2016 and 2020, and their associations with tobacco product use transitions.

Design: Cohort study using multinomial logistic regression analyses on data from Waves 1 (2016), 2 (2018), and 3 (2020) from the International Tobacco Control Four Country Smoking and Vaping Surveys.

Setting: Four countries with varying NVP regulatory environments: 'most restrictive' (Australia), 'somewhat restrictive' (Canada), and 'less restrictive' (England and the US).

Participants: Adult exclusive daily smokers who did not report NVP use at the time of their baseline survey and had visited a HP in the last 12-24 months. Prevalence data came from 4,125, 4,503, and 4,277 respondents respectively for each year. Longitudinal data were from 4,859 respondents who participated in at least two consecutive surveys.

Measurements: (1) Prevalence of self-reported discussions with HPs and recommendations from HPs about NVPs and (2) longitudinal transitions from smoking to vaping (either exclusively or concurrently with smoking) and quitting (regardless of NVP uptake).

Findings: The prevalence of NVP discussions was low across countries with varying regulatory environments and study waves (range=1.4%-6.2%). In 2020, a low percentage of smokers who discussed NVPs with a HP reported that their HPs recommended they use NVPs in the US (14.7%), Australia (20.2%), Canada (25.7%), with a higher percentage in England (55.7%) where clinical guidelines for smoking cessation include NVPs. Compared with 12.0% of smokers who reported no discussion, 37.0% of those whose HPs recommended NVPs transitioned to vaping at follow-up. Transition to quitting was 9.6% with HPs' recommendation of NVPs versus 13.5% without discussion, a non-significant difference.

Conclusions: In Australia, Canada, England, and the United States between 2016 and 2020, health professionals' discussions with smokers about nicotine vaping products (NVPs) were infrequent. NVP discussions were associated with NVP uptake, but not with quitting smoking.

Citation

Chung-Hall, J., Fong, G.T., Meng, G., Cummings, K.M., Hyland, A., O’Connor, R.J., Quah, A.C.K., Craig, L. (2022). Evaluating the impact of menthol cigarette bans on cessation and smoking behaviours in Canada: Longitudinal findings from the Canadian arm of the 2016-2018 ITC 4 Country Smoking and Vaping Surveys. Tobacco Control, 31(4), 556-563. doi: 10.1136/tobaccocontrol-2020-056259.

Abstract

Objective To evaluate the impact of menthol cigarette bans in seven Canadian provinces between 2016 and 2018.

Methods Longitudinal data from the Canadian arm of the 2016 and 2018 ITC Four Country Smoking and Vaping Survey. 1098 non-menthol and 138 menthol smokers were surveyed pre-menthol and post-menthol cigarette bans. Multivariate logistic regression models examined associations between pre-post ban changes in smoking behaviour, including differences between menthol and non-menthol smokers in quit attempts and quitting.

Results At follow-up, 59.1% of pre-ban menthol smokers switched to non-menthol cigarettes; 21.5% quit smoking and 19.5% still smoked menthols, primarily purchased from First Nations reserves. Menthol smokers were more likely than non-menthol smokers to make a quit attempt (adjusted OR (aOR)=1.61, 95% CI 1.03 to 2.51), and to remain quit (aOR=2.30, 95% CI 1.06 to 5.01). Menthol smokers did not differ significantly from non-menthol smokers in quit success (aOR=1.72, 95% CI 0.98 to 3.01); however, daily menthol smokers were more likely than daily non-menthol smokers to quit (aOR=2.21, 95% CI 1.15 to 4.24), and daily menthol smokers who quit before the ban were more likely than daily non-menthol smokers to remain quit (aOR=2.81, 95% CI 1.15 to 6.85).

Conclusions Although menthol smokers were most likely to switch to non-menthol cigarettes, the menthol ban was also significantly associated with higher rates of quit attempts and quit success among menthol smokers compared with non-menthol smokers, and may have helped to prevent relapse among menthol smokers who had quit smoking before the ban. Results confirm and extend evaluation of Ontario’s menthol ban across provinces covering 83% of the Canadian population.

Related reports:

Apr 28, 2021 | Impact of Canada's Menthol Ban on Quitting: Implications for the United States | English

Apr 25, 2021 | ITC Evaluation of Canada's Menthol Ban: Infographic | English

Apr 5, 2021 | Canada's Menthol Ban Did NOT Increase Illicit Purchasing | English

Apr 5, 2021 | Impact of Canada's Menthol Ban on Quitting: Implications for California | English

Citation

Zhao, Y., Yong, H., Borland, R., Cummings, K.M., Thrasher, J., Hitchman, S.C., Bansal-Travers, M., Fong, G.T. (2022). Do numbers of smoking friends and changes over time predict smoking relapse? Findings from the International Tobacco Control Four-Country Survey. Journal of Substance Abuse Treatment, 138, 108763.

Abstract

Background: Past research indicates that smokers with a large number of smoking friends within their social network are less interested in quitting, less likely to attempt to quit, and less likely to successfully quit. The extent to which a pro-smoking social network may increase relapse risk among ex-smokers is unclear. This study investigated among ex-smokers whether the number of close friends who smoke and changes in this number influence relapse risk.

Methods: The study was a prospective cohort study of 551 adults who participated in the Australian and UK arms of the International Tobacco Control (ITC) project and were ex-smokers at wave 9 (2013) and followed up to wave 10 (2014). Logistic models regressed smoking relapse at follow-up on the baseline number of their five closest friends who smoked and changes in this number over time.

Results: Ex-smokers who reported having 4 or 5 smokers among their five closest friends were more likely to relapse than those who had no smokers among their five closest friends (adjusted odds ratio [AOR] = 4.86, 95% confidence interval [CI] = 1.48-15.99, p = .009). Ex-smokers who gained smoking friends over time, but not those who lost smoking friends, were also more likely to relapse compared to those with the same number of smoking friends over time (AOR = 4.52, 95% CI = 2.15-9.52, p < .001; AOR = 1.08, 95% CI = 0.49-2.36, p = .848, respectively).

Conclusions: This study demonstrated that relapse risk was elevated among ex-smokers who had more smokers among their close friends and also among those where the number of smokers in their social network increased over time.

Citation

Hammond, D., Reid, J.L., Burkhalter, R., Bansal-Travers, M., Gravely, S., Hyland, A., Kasza, K., McNeill, A. (2022). E-cigarette flavors, devices and brands used by youth before and after partial flavor restrictions in the US: Canada, England, and the US, 2017-2020. American Journal of Public Health, 112(7), 1014-1024. doi:10.2105/AJPH.2022.306780.

Abstract

Objectives: To examine the impact of US restrictions implemented in February 2020 prohibiting flavors other than menthol and tobacco in cartridge-based e-cigarettes.

Methods: We analyzed 5 cross-sectional waves of the International Tobacco Control Policy Evaluation Project Youth Tobacco and Vaping Surveys, conducted online with youths aged 16 to 19 years in the United States, Canada, and England, for differences in usual e-cigarette flavor, device, and brand reported by past-30-day vapers (n = 9512) before (2017, 2018, 2019), during (February 2020), and after (August 2020) implementation of US flavor restrictions.

Results: In August 2020, 78.7% of vapers in the United States reported using a flavor prohibited in cartridges or pods, versus 86.3% in Canada (adjusted odds ratio [AOR] = 1.73; 95% CI = 1.25, 1.40) and 79.8% in England (AOR = 1.10; 95% CI = 0.78, 1.55). Disposable e-cigarettes (exempt from flavor restrictions) increased to a greater extent among vapers in the United States (13.2% to 36.8%) versus Canada (7.7% to 14.2%; AOR = 2.01; 95% CI = 1.33, 3.04) and England (10.8% to 16.4%; AOR = 2.33; 95% CI = 1.52, 3.57). Puff Bar (disposable) emerged as the most popular brand in the United States.

Conclusions. Usual flavors used by youth vapers in the United States were unchanged after 2020 restrictions on cartridge-based e-cigarettes. Youths used brands and devices exempt from the restrictions.

Citation

Taylor, E., Aleyan, S., East, K., Cummings, K.M., Thrasher, J.F., Fong, G.T., Quah, A.C.K., Li, G., Borland, R., Hammond, D., Hitchman, S.C. (2022). Associations between noticing nicotine vaping product health warning labels, harm perceptions, and use among adult vapers, current and former smokers: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 24(7), 1020-1027.

Abstract

Background: The number of countries mandating a nicotine addiction warning label (‘warnings’) on nicotine vaping products (NVPs) has been increasing. This study examined associations between noticing NVP warnings, perceptions of NVPs, and intentions to use NVPs.

Methods: Cross-sectional analysis of 12,619 adult NVP users, cigarette smokers, concurrent users of both cigarettes and NVPs, and quitters who participated in the 2018 International Tobacco Control (ITC) Project Four Country Smoking and Vaping Survey (England, Australia, Canada, US). Logistic regression analyses examined associations between noticing warnings in the past 30 days and perceptions of nicotine harm, NVP harm relative to cigarettes, and NVP addictiveness relative to cigarettes. Associations were also explored between noticing warnings and intentions to use NVPs.

Results: Noticing warnings was higher among NVP users (18.8%) than non-users (2.1%). Noticing warnings was associated with perceiving nicotine to pose little or no harm to health among NVP users, but there was no association among non-users. There was little evidence of an association between noticing warnings and perceptions of NVP harms relative to smoking among NVP users and non-users. Noticing warnings was associated with perceiving NVPs as less addictive than cigarettes among non-users but not NVP users. Among exclusive smokers, noticing warnings was associated with intending to start using NVPs. Among NVP users, there was little evidence of an association between noticing warnings and intentions to continue using/stopping NVPs.

Conclusions: Noticing NVP warnings was not associated with increased NVP and nicotine harm perceptions or decreased intentions to use NVPs among adult smokers and vapers

Citation

Miller, C., Xu, S.S., Smith, D.M., Sutanto, E., Goniewicz, M.L., Quah, A.C.K., Fong, G.T. (2022). Assessing use of inhalable nicotine products within complex markets: The dilemma of heated tobacco products. Tobacco Control, [Published online, doi:10.1136/tobaccocontrol-2021-057081].

Abstract

The introduction of electronic inhalable products, such as nicotine vaping products (NVPs) and heated tobacco products (HTPs), has further diversified the nicotine market landscape. This poses unique challenges in measuring self-reported nicotine use behaviours, which have been the hallmark of tobacco surveillance systems. This paper raises concerns of potential measurement error for electronic inhalable product use in surveys due to similarities in product design between NVPs and HTPs, as well as changing trends in cannabis administration. We identify several strategies for addressing this issue (eg, including descriptive preambles in surveys that differentiate product classes from one another; incorporating survey questions that probe beyond an initial question regarding product use). In the absence of comprehensive validation studies, caution is warranted when interpreting survey results that rely on self-reported HTP use.

Citation

Felicione, N., Schneller, L., Goniewicz, M.L., Hyland, A., Cummings, K.M., Bansal-Travers, M., Fong, G.T., O’Connor, R.J. (2022). Oral nicotine product awareness and use among people who smoke and vape in the US. American Journal of Preventive Medicine, 63(4), 611-618. doi: 10.1016/j.amepre.2022.04.019.

Abstract

Introduction: Tobacco-free oral nicotine products are an emerging class of noncombustible nicotine products. Oral nicotine product sales have increased since 2016, although little research has investigated consumer awareness, use, or correlates of oral nicotine product use. The purpose of this analysis was to assess the prevalence and correlates of oral nicotine product awareness and use.

Methods: This paper is a cross-sectional analysis of 2,507 U.S. participants from Wave 3 (February–June 2020) of the International Tobacco Control Four Country Smoking and Vaping Survey, a population-based survey of current and former cigarette smokers and nicotine vaping product users in the U.S. Oral nicotine product awareness and use prevalence were compared with those of heated tobacco products. Analyses conducted in late 2021 assessed the correlates of oral nicotine product awareness and use such as demographic characteristics, tobacco use (cigarettes, nicotine vaping products, smokeless tobacco), and tobacco quit attempts.

Results: Almost 1 in 5 respondents claimed to have heard of oral nicotine products, 3.0% reported ever use, and 0.9% were current users, all of which were lower than for heated tobacco products. Ever use of oral nicotine products was more common among younger adults (e.g., aged 18–24 years), males, and current users of smokeless tobacco. Oral nicotine product prevalence was higher among those who reported having made attempts to stop smoking or vaping.

Conclusions: Oral nicotine product use was low among current and former smokers and nicotine vaping product users. Oral nicotine product users were demographically similar to use among individuals who smoke/vape and also use smokeless tobacco. Future studies are needed to understand emerging oral nicotine products, particularly whether they are being used as product supplements (dual use), replacements (switching), or cessation aids (quitting).

Citation

Kyriakos, C.N., Fong, G.T., Perez, C., Szklo, A., Driezen, P., Quah, A.C.K., Figueiredo, V., Filippidis, F. (2022). Brazilian smokers are ready for the ban on flavour additives in tobacco to be implemented. Preventive Medicine, 160, 107074. doi: 10.1016/j.ypmed.2022.107074

Abstract

Brazil became the first country to approve a national policy to ban all flavour additives in all tobacco leaf products in 2012. However, as of February 2022, the policy remained to be implemented. Cross-sectional data come from the International Tobacco Control (ITC) Brazil Wave 3 Survey among adult smokers (N = 1216) in 2016–2017. The majority of smokers supported a ban on menthol (56.0%; 95%CI: 51.7–60.2%) and a ban on all additives (61.7%; 57.5–65.8%), with no significant differences across sociodemographic groups in adjusted logistic regression models. More than half of menthol smokers reported they would either quit or reduce the amount they smoked if menthol cigarettes were banned. Findings suggest that there is support for Brazil's ban on flavour additives, which is a determinant of successful policy implemented. Continued delays will postpone an important measure with demonstrated public health gains.

Citation

Usidame, O., Meng, G., Thrasher, J.F., Thompson, M.E., Fong, G.T., Fleischer, N.L. (2022). The differential impact of the 2000 Canadian graphic warning label policy on smoking prevalence by sex and education: A difference-in-difference-in-difference model. Nicotine and Tobacco Research, 24(11), 1732-1740. doi: 10.1093/ntr/ntac122.

Abstract

Introduction: Using a quasi-experimental design, we compared the impact of the 2000 Canadian introduction of graphic warning labels (GWLs) on differences in smoking prevalence by sex and education, to the United States (US), where no GWLs were introduced.

Methods: We pooled 1999-2004 data from the Canadian Tobacco Use Monitoring Survey (CTUMS) and the US Behavioral Risk Factor Surveillance System (BRFSS). We used a difference-in-difference (DD) model to assess the impact of Canadian policy introduction on smoking prevalence, and a difference-indifference-in-difference (DDD) model to examine differences in the policy impact by sex and education, comparing Canada (the treatment group) with the US (the control group).

Results: From 1999 to 2004, smoking prevalence decreased from 23.7% to 18.6% in Canada, and from 21.7% to 20.0% in the US. Results from the DD regression models showed that Canadian respondents reported lower odds of being a current smoker compared to the US respondents following the 2000 introduction of GWLs (OR= 0.84, 95 % CI 0.74-0.94). The DDD model showed that the impact of the Canadian GWLs vs. the US did not differ by sex or education.

Conclusions: The 2000 Canadian GWL policy reduced smoking prevalence overall, with similar reductions for males and females and across education levels. The impact of the Canadian GWLs in reducing smoking prevalence did not reduce differences by sex or education. Although beneficial for all smokers, GWLs may not serve to decrease existing disparities, especially those by socioeconomic status.

Implications: Existing evidence shows that GWL implementation is associated with reductions in smoking prevalence. But there is limited evidence from past evaluation studies on whether the impact of GWLs on smoking prevalence differs by sociodemographic subgroup. Our findings confirm existing studies that the 2000 implementation of GWLs in Canada was significantly associated with an overall reduction in smoking prevalence in Canada compared to the US. However, our study improves existing evidence by showing that the impact of the Canadian GWLs on smoking prevalence did not differ by sex or education, and thus did not reduce existing smoking disparities by educational levels.

Citation

East, K.A., Reid, J.L., Burkhalter, R., Kock, L., Hyland, A., Fong, G.T., & Hammond, D. (2022). Evaluating the impact of the menthol cigarette ban in England by comparing menthol cigarette smoking among youth in England, Canada, and the US from 2018-2020. JAMA Network Open, 5(5), e2210029. doi: 10.1001/jamanetworkopen.2022.10029.

Abstract

Importance: Menthol cigarettes were prohibited in England in May 2020 and nationally in Canada in October 2017 but remain permitted in the US. Evidence on the outcomes of menthol cigarette bans among youth outside of Canada, and the characteristics of youth smokers, is lacking.

Objectives: To evaluate the outcomes of menthol cigarette bans on youth menthol cigarette smoking and to characterize youth menthol cigarette smokers in terms of demographics and cigarette consumption and dependence.

Design, Setting, and Participants: This survey study uses data from online repeat cross-sectional International Tobacco Control Youth Tobacco and Vaping Surveys conducted in 2018, 2019, February 2020, and August 2020. Participants included past 30-day smokers aged 16 to 19 years. Data analysis was performed from March 2021 to January 2022.

Main Outcomes and Measures: Usually smoke a brand of cigarettes that was menthol, including capsule.

Exposures: Menthol cigarette ban, comparing 3 countries over time: Canada, where a ban already existed, England, where a ban was implemented during the study, and the US, where no national ban was present. Age, sex, race, and consumption and dependence were also examined by menthol smoking in each country, and in England before vs after the ban.

Results: The analytical sample comprised 7067 participants aged 16 to 19 years, of whom 4129 were female and 5019 were White. In England, the weighted percentage of youth smokers who reported smoking a menthol or capsule cigarette brand was stable in the 3 survey waves before the menthol ban (2018 to February 2020, 9.4% vs 12.1%; adjusted odds ratio [AOR], 1.03; 95% CI, 0.99-1.06; P = .15) but decreased to 3.0% after the ban (February 2020 vs August 2020, AOR, 1.07; 95% CI, 1.04-1.10; P < .001). The decrease between February and August 2020 in England was similar across all demographic groups but was greater among youth who perceived themselves as addicted to cigarettes (AOR, 0.37; 95% CI, 0.41-0.97; P = .04). In the 2 comparison countries, menthol or capsule smoking was stable across all waves (2018 to August 2020: US, 33.6%-36.9%; Canada, 3.1%-2.3%) and was more prevalent in the US than in England (AOR, 5.58; 95% CI, 4.63-6.72; P >< .001). Menthol or capsule smoking was also more prevalent among smokers in England who were female vs male (10.9% vs 7.2%; AOR, 1.04; 95% CI, 1.01-1.06; P = .002); among smokers in the US who identified as Black vs White (60.6% vs 31.9%; AOR, 1.33; 95% CI, 1.23-1.44; P >< .001) or who were frequent smokers (AOR, 1.07; 95% CI, 1.01-1.13; P = .03), smoked more cigarettes per day (2-5 vs 1, AOR, 1.09; 95% CI, 1.02-1.15; P = .006; >5 vs 1, AOR, 1.10; 95% CI, 1.03-1.18; P = .007), or had urges to smoke every or most days (AOR, 1.08; 95% CI, 1.02-1.14; P = .006); and among smokers in Canada who perceived themselves as addicted to cigarettes (AOR, 1.02; 95% CI, 1.00-1.03; P = .01).

Conclusions and Relevance: In this survey study, the proportion of youth smokers who smoke menthol (including capsule) cigarettes decreased substantially after the menthol ban in England. This association was consistent across all demographic groups. Perceived addiction among menthol smokers was also lower where menthol cigarettes were banned.

Citation

Gorniak, B., Yong, H.H., Borland, R., Cummings, K.M., Thrasher, J.F., McNeill, A., Hyland, A., Fong, G.T. (2021). Do post-quitting experiences predict smoking relapse among former smokers in Australia and the United Kingdom? Findings from the International Tobacco Control Surveys. Drug and Alcohol Review, 41(4), 883-889.

Abstract

Introduction: Many smokers attempt to stop smoking every year, but the vast majority of quit attempts fail. This study examined prospectively the association between post-quitting experiences and smoking relapse among ex-smokers in Australia and the United Kingdom.

Methods: Data came from 584 adult ex-smokers from Australia and the United Kingdom who participated in Wave 9 of the International Tobacco Control Four Country Survey and successfully followed up a year later (Wave 10). Binary logistic regression was used to examine whether baseline post-quitting experiences predicted relapse back to smoking at follow-up.

Results: Ex-smokers who perceived their stress coping ability had gotten worse since quitting were more likely to relapse back to smoking compared to their counterparts who reported no change (odds ratio = 5.77, 95% confidence interval = 1.64, 20.31, P < 0.01). Ex-smokers who reported their homes had become fresher and cleaner post quitting were less likely to relapse compared to those who did not notice any change (odds ratio = 0.34, 95% confidence interval = 0.13, 0.93, P < 0.05). Perceived changes in life enjoyment, negative affect control, social confidence, work performance, leisure time and financial situation did not independently predict relapse. No country differences were found.

Discussion and conclusions: The study showed that ex-smokers' relapse risk was elevated if they perceived any negative impact of quitting on their stress coping whereas relapse risk was reduced if they perceived any positive impact of quitting on the home (e.g. fresher and cleaner). Helping ex-smokers to develop alternative stress coping strategies and highlighting the positive impacts of quitting smoking on the homes may help protect against smoking relapse.

Citation

Hao, P., Xu, S.S., Sung, H.Y., Yao, T., Jiang, Y., Quah, A.C.K., Fong, G.T. (2022). Local brand smoking among adult smokers in China: Findings from the Wave 5 International Tobacco Control China Survey. China CDC Weekly, 4(21), 452-459.

Abstract

The objective of this study was to assess the percentage of local brand (LB) smoking among adult smokers in a diversity of cities in China and to identify factors associated with LB smoking including demographic characteristics and patterns of smoking such as cigarettes per day. This project analyzed data from the Wave 5 International Tobacco Control (ITC) China Survey that was conducted between November 2013 and July 2015. The ITC China Survey is a longitudinal cohort survey of smoking behavior and knowledge, beliefs, opinions, and attitudes about cigarette smoking and tobacco use among adults aged 18 and older in China. The Wave 5 Survey was conducted in 10 locations, including urban residents in 5 large cities (Beijing, Guangzhou, Kunming, Shanghai, and Shenyang) and residents in 5 rural areas (Changzhi, Huzhou, Tongren, Yichun, and Xining). The 10 locations were selected based on size, geographical representations, and levels of economic development.

Citation

Fong, G.T., Chung-Hall, J., Meng, G., Craig, L., Thompson, M.E., Quah, A.C.K., Cummings, K.M., Hyland, A., O’Connor, R.J., Levy, D., Delnevo, C.D., Ganz, O., Eissenberg, T., Soule, E.K., Schwartz, R., Cohen, J.E., Chaiton, M.O. (2022). The impact of Canada’s menthol cigarette ban on quitting among menthol smokers: Pooled analysis of pre-post evaluation from the ITC Project and the Ontario Menthol Ban Study and projections of impact in the United States. Tobacco Control, [Published online April 28, doi: 10.1136/tobaccocontrol-2021-057227].

Abstract

Introduction: Between 2015 and 2018, Canada banned menthol cigarettes. This study pooled data from two pre–post cohort studies (the Ontario Menthol Ban Study, and the International Tobacco Control Policy Evaluation (ITC) Canada Survey, conducted in seven provinces) to derive more precise estimates of the impact of Canada’s menthol ban on quitting and to apply these estimates to project the impact of a menthol ban in the USA.

Methods: Weighted multivariable logistic analyses compared post-ban quit success of menthol smokers with non-menthol smokers (for daily smokers and for all (daily + non-daily) smokers), controlling for sex, age, ethnicity, education, baseline smoking status, baseline cigarettes per day and study regions. Projections to the USA were created by multiplying the effect size of the Canadian menthol ban on quitting (percentage of increased quitting among menthol smokers) by the number of menthol smokers overall and among African Americans, from the 2019 National Survey on Drug Use and Health.

Results: After the menthol cigarette ban, menthol smokers were more likely than non-menthol smokers to have quit smoking among daily smokers (difference=8.0%; 95% CI: 2.4% to 13.7%,p=0.005) and all (daily+non-daily) smokers (difference=7.3%; 95% CI: 2.1% to 12.5%,p=0.006). The projected number of smokers who would quit after a US menthol ban would be 789 724 daily smokers (including 199 732 African Americans) and 1 337 988 daily+non-daily smokers (including 381 272 African Americans).

Conclusions: This pooled analysis of Canada’s menthol cigarette ban provides the foundation for estimating the impact of menthol bans in the USA and other countries. Projections suggest that a US menthol cigarette ban would have a substantial impact on increasing quitting.

Press:

April 28, 2022 | University of Waterloo | More than a million smokers likely to quit after U.S. bans menthol cigarettes

April 28, 2022 | Washington Post | In a milestone, FDA proposes ban on menthol cigarettes, flavored cigars

April 28, 2022 | Wall Street Journal | FDA Advances Ban on Menthol Cigarettes

April 28, 2022 | The New York Times | F.D.A. Moves to Ban Sales of Menthol Cigarettes

April 28, 2022 | The Hill | More than a million smokers may quit if US bans menthol cigarettes, study finds

April 28, 2022 | NBC Nightly News | FDA moves to ban sale of menthol cigarettes

Citation

Kaai, S.C., Fong, G.T., Ong’ang’o, J.R., Goma, F., Meng, G., Craig, L.V., Ikamari, L., Quah, A.C.K., Elton-Marshall, T. (2022). Prevalence, perceptions, and factors associated with menthol cigarette smoking: Findings from the ITC Kenya and Zambia Surveys. Tobacco Control, [Published online April 22, doi: http://dx.doi.org/10.1136/tobaccocontrol-2021-057100].

Abstract

Background: Menthol masks the harshness of cigarette smoke, promotes youth smoking and encourages health-concerned smokers who incorrectly believe that menthols are less harmful to smoke menthols. This study of smokers in Kenya and Zambia is the first study in Africa to examine menthol use, smokers’ beliefs about its harmfulness and the factors associated with menthols.

Methods: Data were from the International Tobacco Control (ITC) Kenya Wave 2 (2018) and Zambia Wave 2 Survey (2014), involving nationally representative samples of smokers. This study focuses on 1246 adult smokers (644 in Kenya, 602 in Zambia) who reported smoking a usual brand of cigarettes (menthol or non-menthol).

Results: Overall, menthol use was significantly higher among smokers in Zambia than in Kenya (48.0% vs 19.0%), females (45.6% vs 31.2% males), non-daily smokers (43.8% vs 30.0% daily) and those who exclusively smoked factory-made (FM) cigarettes (43.0% vs 15.2%). The erroneous belief that menthols are less harmful was more likely among smokers in Zambia than in Kenya (53.4% vs 29.3%) and among female smokers (38.5% vs 28.2%). In Kenya, menthol smoking was associated with being female (adjusted odds ratios (AOR)=3.07; p=0.03), worrying about future health (AOR=2.28; p=0.02) and disagreeing with the statement that smoking was calming (AOR=2.05; p=0.04). In Zambia, menthol use was associated with being female (AOR=3.91; p=0.002), completing primary school (AOR=2.14; p=0.03), being a non-daily smoker (AOR=2.29; p=0.03), exclusively using FM cigarettes (AOR=14.7; p<0.001), having a past quit attempt (AOR=1.54; p=0.02), believing that menthols are less harmful (AOR=3.80; p<0.001) and choosing menthols because they believed it was less harmful (AOR=3.52; p<0.001).

Conclusions: Menthols are highly prevalent among females in both countries. There is a need in African countries to combat the myth that menthols are less harmful and to ban menthol and other flavourings.

Citation

Driezen, P., Kasza, K.A., Gravely, S., Thompson, M.E., Fong, G.T., Cummings, K.M., Hyland, A. (2022). Was COVID-19 associated with increased cigarette purchasing, consumption, and smoking at home among US smokers in early 2020? Findings from the US arm of the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. Addictive Behaviours, 129, 107276.

Abstract

Evidence of the impact of COVID-19 and mandatory stay-at-home orders on cigarette smoking is mixed. In the United States, household tobacco purchases increased in early 2020, but it is unclear whether this was associated with increased smoking. Using individual-level, longitudinal data from a representative cohort of US smokers (n = 3046), this study tested whether (1) carton purchases of cigarettes increased in early 2020 relative to the same calendar period in 2018, (2) more smokers permitted smoking inside their homes, and (3) smokers increased the number of cigarettes they smoked per day. Weighted multivariable logistic regression tested whether trends in carton purchasing and smoke-free homes differed in 2020 compared to 2018 while weighted multivariable linear regression tested whether trends in cigarette consumption differed in 2020 compared to 2018. Overall, 24.0% of US smokers last purchased cigarettes by the carton in early 2018; this increased to 28.8% in early 2020 (p = 0.007). Average daily cigarette consumption and the percentage of smokers reporting that smoking was not allowed inside their homes did not differ between 2018 and 2020 (p = 0.92 and p = 0.054, respectively). Overall, these findings suggest that COVID-19 mitigation measures implemented in the spring of 2020 had limited impact on the smoking behavior of US adult smokers.

Citation

Le Grande, M., Borland, R., Yong, H.H., McNeill, A., Fong, G.T., Cummings, K.M. (2022). Age related interactions on key theoretical determinants of smoking cessation: Findings from the ITC Four Country Smoking and Vaping Surveys (2016-2020). Nicotine & Tobacco Research, 24(5), 679-689. doi: 10.1093/ntr/ntab230

Abstract

Background: This paper explores whether plans to quit, wanting to quit and quit efficacy add predictive value over measures of habit strength and dependence in making quit attempts and/or attaining smoking abstinence.

Aims and methods: We used three waves of the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey conducted in 2016, 2018, and 2020. Baseline daily smokers (N=6710) who provided data for at least one wave-to-wave transition (W1 to W2, N=3511 or W2 to W3, N=3199) and providing outcome data at the next wave (follow-up) formed the analytic sample. Generalized estimating equations (GEE) logistic regression analyses examined predictors of quit attempts and abstinence at follow-up (1 and 6 months sustained abstinence).

Results: Wanting and planning to quit were significantly positively associated with making quit attempts, but negatively associated with smoking abstinence. A significant interaction between the Heaviness of Smoking Index and age warranted an age-stratified analysis for both abstinence outcomes. Lower HSI predicted abstinence in only the younger smokers Motivation and plans to quit were positively associated with abstinence in younger smokers, but surprisingly were negatively associated with abstinence in older smokers. Quit efficacy was associated with abstinence in the older, but not the younger smokers.

Conclusions: Models of smoking abstinence are significantly improved by including motivational predictors of smoking. Age was an important moderator of the association between abstinence for both dependence and motivational variables.

Implications: The findings from this large cohort study indicate there are age-related differences in predictors of smoking abstinence but not quit attempts. These associations may reflect differential experiences of older and younger cohorts of smokers, which may have implications for interventions to motivate and assist smokers in quitting.

Citation

East, K.A., Reid, J., Burkhalter, R., Wackowski, O.A., Thrasher, J.F., Tattan-Birch, H., Boudreau, C., Bansal-Travers, M., Liber, A.C., McNeill, A., Hammond, D. (2022). Exposure to negative news stories about vaping, and harm perceptions of vaping, among youth in England, Canada, and the United States before and after the outbreak of E-cigarette or Vaping-Associated Lung Injury (EVALI). Nicotine and Tobacco Research, 24(9), 1386-1395. doi: https://doi.org/10.1093/ntr/ntac088.

Abstract

Introduction: Little is known about the international impact of ‘EVALI’ on youth perceptions of vaping harms.

Methods: Repeat cross-sectional online surveys of youth aged 16-19 in England, Canada, and the US before (2017, 2018), during (2019Aug/Sept), and after (2020Feb/Mar, 2020Aug) the ‘EVALI’ outbreak (N=63,380). Logistic regressions assessed trends, country differences, and associations between exposure to negative news stories about vaping and vaping harm perceptions.

Results: Exposure to negative news stories increased between 2017 and Feb/Mar 2020 in England (12.6% to 34.2%), Canada (16.7% to 56.9%), and the US (18.0% to 64.6%), accelerating during (2019) and immediately after (Feb/Mar 2020) the outbreak (p<.001) before returning to 2019 levels by Aug 2020. Similarly, accurate perception that vaping is less harmful than smoking declined between 2017 and Feb/Mar 2020 in England (77.3% to 62.2%), Canada (66.3% to 43.3%), and the US (61.3% to 34.0%), again accelerating during and immediately after the outbreak (p<.001). Perception that vaping takes less than a year to harm users’ health and worry that vaping will damage health also doubled over this period (p≤.001). Time trends were most pronounced in the US. Exposure to negative news stories predicted perception that vaping takes less than a year to harm health (AOR=1.55, 1.48-1.61) and worry that vaping will damage health (AOR=1.32, 1.18-1.48).

Conclusions: Between 2017 and February/March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. Effects were seen in all countries but were most pronounced in the US.

Implications: This is the first study to examine changes in exposure to news stories about vaping, and perceptions of vaping harms, among youth in England, Canada, and the US before, during, and after ‘EVALI’. Between 2017 and February/March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. By August 2020, exposure to negative news stories returned to 2019 levels, while perceptions of harm were sustained. Exposure to negative news stories also predicted two of three harm perceptions measures. Overall, findings suggest ‘EVALI’ may have exacerbated youth’s perceptions of vaping harms internationally.