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.

Citation

Geboers, C., Shang, C., Nagelhout, G.E., de Vries, H., van den Putte, B., Fong, G.T., Candel, M., Willemsen, M.C. (2021). Demand for factory-made cigarettes and roll-your-own tobacco and differences between age and socioeconomic groups: Findings from the International Tobacco Control (ITC) Netherlands Survey. Nicotine & Tobacco Research, 24(4), 529-535.

Abstract

Introduction: Macroeconomic studies have shown that young individuals who smoke, and have a low socioeconomic status respond more strongly to price increases. Most of this evidence stems from research on factory-made (FM) cigarettes. With the rising popularity of roll-your-own (RYO) tobacco, there is a need for studies on cigarette demand that distinguish between both.

Aims and Methods: This study examined whether individual demand differed for FM and RYO tobacco, and across age, and socioeconomic (income and education) groups. Purchase tasks for FM and RYO cigarettes were included in the 2020 International Tobacco Control (ITC) Netherlands Survey. Adults who smoke daily (n = 1620) stated how many cigarettes they would smoke in 24 hours across eight prices. Four demand indices were derived: intensity (consumption at zero costs), alpha (rate of change in elasticity), P max (turning point elasticity), and breakpoint (lowest price where consumption equals zero). The indices were tested for subgroup differences.

Results: Individuals who smoke RYO tobacco indicated higher intensity, and greater alpha than individuals who smoke FM cigarettes. Participants aged 25–39 had lower P max, and 18–24 year olds displayed higher breakpoints. Participants with low income displayed higher intensity, and lower P max than other income groups. No associations were found with education.

Conclusions: Individuals who smoke RYO tobacco indicated higher price sensitivity than those smoking FM cigarettes, supporting the need to harmonize tobacco taxation. Taxation may be especially beneficial to reducing consumption among individuals with a low income or smoke RYO tobacco. Substantially higher prices are needed in the Netherlands to achieve the desired results.

Implications: Individuals who smoke daily were willing to pay substantially higher prices than the current market prices, indicating the room and need for much higher taxation levels. Demand for RYO tobacco was more sensitive to price changes than demand for FM cigarettes. Taxation should be raised at equivalent rates for FM and RYO cigarettes. Taxation appears to be especially effective in reducing consumption among people who smoke RYO tobacco and low-income individuals. It remains important to combine increased taxation with other tobacco control measures.

Citation

Driezen, P., Amer Nordin, A.M., Mohd Hairi, F., Yee, A., Ahmad Tajuddin, N.A., Hasan, S.I., Danaee, M., Kamaludin, I.S., Kaai, S.C., Yan, M., Grey, M., Quah, A.C.K., Thompson, M.E., Fong, G.T. (2022). E-cigarette prevalence among Malaysian adults and types and flavours of e-cigarette products used by cigarette smokers who vape: Finding from the 2020 ITC Malaysia Survey. Tobacco Induced Diseases, 20(March), 32. doi: https://doi.org/10.18332/tid/146363

Abstract

Introduction: E-cigarettes (ECs) have become increasingly common in many countries, including Malaysia. The prevalence of EC use increased in Malaysia from 0.8% in 2011 to 4.9% in 2019. Three quarters of Malaysian EC users also smoke combustible cigarettes, and the prevalence of EC use among Malaysian smokers in 2014 was consistent with the prevalence of use among smokers from Canada and the US in 2016. The purpose of this study was to estimate the prevalence of EC use among Malaysian adults aged ≥18 years in 2020 and the types of EC products and flavors used by cigarette smokers who also used ECs at least monthly.

Methods: Data came from 1253 adults aged ≥18 years who participated in the 2020 International Tobacco Control Malaysia Wave 1 Survey. Weighted descriptive statistics were used to estimate the prevalence of adults who reported ever using ECs and the prevalence who used ECs either monthly, weekly, or daily. The types of EC products and flavors used were compared by frequency of EC use among current smokers who used ECs at least monthly (n=459).

Results: Overall, 5.4% (95% CI: 3.7–7.5) of Malaysian adults reported using ECs on a daily basis in 2020. Among current cigarette smokers who used ECs daily, 81.0% (95% CI: 72.5–87.7) used nicotine in their ECs, 46.2% (95% CI: 37.8–54.7) used pre-filled ECs, and 60.4% (95% CI: 51.9–68.6) reported being somewhat/very addicted to ECs. The most common EC flavors were fruit, coffee, and menthol/ mint.

Conclusions: Continued surveillance of EC use is necessary to monitor EC use in non-tobacco using populations while longitudinal research is needed to determine the extent to which ECs are, or are not, related to quitting smoking.

Citation

Mohd Hairi, F., Goh, K.T., Driezen, P., Amer Nordin, A.S., Yee, A., Tajuddin, N.A.A., Hasan, S.I., Danaee, M., Kamaluddin, I.S., Kaai, S.C., Yan, M., Grey, M., Quah, A.C.K., Thompson, M.E., Fong, G.T. (2022). Reasons for using e-cigarettes and support for e-cigarette regulations, Findings from the 2020 ITC Malaysia Survey. Methods of the 2020 (Wave 1) International Tobacco Control (ITC) Malaysia Project. Tobacco Induced Diseases, 20(March), 33. doi: https://doi.org/10.18332/tid/146364

Abstract

Introduction: Malaysia has the largest e-cigarette (EC) market in Southeast Asia, and it has been estimated that 17% of adult daily cigarette smokers also used ECs on a daily basis in 2020. However, few studies have examined the reasons people use ECs in Malaysia. This cross-sectional study of adult cigarette smokers from Malaysia assessed reasons for EC use and their support for key proposed EC regulations.

Material and Methods: Data are from the 2020 International Tobacco Control (ITC) Malaysia Wave 1 Survey of adult (aged ≥18 years) smokers who reported that they used ECs at least monthly (N=459 out of 1047 smokers). Weighted analyses were conducted on EC users’ reasons for using ECs and their support for various EC regulations.

Results: Smokers who used ECs at least monthly were more likely to be male, aged 25–39 years, of Malay ethnicity, married, more highly educated, and living in Peninsular Malaysia. Smokers who used ECs daily reported using ECs to reduce the number of cigarettes smoked (91.3%), pleasant taste (90.1%), to quit smoking (87.9%), and enjoyment (87.5%). Smokers who used ECs less than daily reported using ECs for their pleasant taste (weekly 89.4%, monthly 87.5%), curiosity (weekly 79.5%, monthly 88.8%), being offered EC by someone (weekly 76.3%, monthly 81.6%), and to reduce the number of cigarettes smoked (weekly 76.2%, monthly 77.6%). Smokers who also used ECs were most likely to support EC regulations requiring a minimum purchasing age (88.3%) and limiting nicotine concentration (79.6%), and least likely to support regulations banning EC fruit and candy flavors (27.1%).

Conclusions: The most prevalent reasons for using ECs in Malaysia are comparable to those of other ITC countries, including Canada, US, England, and Australia. An understanding of use patterns of ECs, especially their interaction with cigarettes, are important in developing evidence-based regulations in Malaysia.

Citation

Amer Nordin, A.S., Mohamad, A.S., Quah, A.C.K., Mohd Hairi, F., Yee, A.H.A., Ahmad Tajuddin, N.A., Hasan, S.I.B., Danaee, M., Kaai, S.C., Grey, M., Driezen, P., Fong, G.T., Thompson, M.E. (2022). Methods of the 2020 (Wave 1) International Tobacco Control (ITC) Malaysia Project. Tobacco Induced Diseases, 20(March), 31. doi: 10.18332/tid/146568

Abstract

The ITC Malaysia Project is part of the 31-country ITC Project, of which the central objective is to evaluate the impact of tobacco control policies of the WHO Framework Convention on Tobacco Control (FCTC). This article describes the methods used in the 2020 International Tobacco Control (ITC) Malaysia (MYS1) Survey. Adult smokers and non-smokers aged ≥18 years in Malaysia were recruited by a commercial survey firm from its online panel. Survey weights, accounting for smoking status, sex, age, education, and region of residence, were calibrated to the Malaysian 2019 National Health and Morbidity Survey. The survey questions were identical or functionally similar to those used in other ITC countries. Questions included demographic measures, patterns of use, quit history, intentions to quit, risk perceptions, beliefs and attitudes about cigarettes, e-cigarettes, and heated tobacco products. Questions also assessed measures assessing the impact of tobacco demand-reduction domains of the FCTC: price/tax (Article 6), smoke-free laws (Article 8), health warnings (Article 11), education, communication and public awareness (Article 12), advertising, promotion, and sponsorship restrictions (Article 13), and support for cessation (Article 14). The total sample size was 1253 (1047 cigarette smokers and 206 non-smokers). Response rate was 11.3%, but importantly, the cooperation rate was 95.3%. The 2020 ITC MYS1 Survey findings will provide evidence on current tobacco control policies and evidence needed by Malaysian government regulatory agencies to develop new or strengthen existing tobacco control efforts that could help achieve Malaysia’s endgame, i.e. a tobacco-free nation by 2040.

Citation

Quah, A.C.K., Lee, S., Seo, H.G., Cho, S., Lim, S., Kim, Y., Xu, S.S., Grey, M., Yan, M., Boudreau, C., Thompson, M.E., Driezen, P., Fong, G.T. (2022). Methods of the 2020 (Wave 1) International Tobacco Control (ITC) Korea Survey. Tobacco Prevention & Cessation, 8(March), 13. doi: https://doi.org/10.18332/tpc/146685

Abstract

This article presents methods used in the 2020 International TC Korea Wave 1 (KRA1) Survey. To date, three cohorts of Korean respondents have participated in the larger ITC Korea Project (cohort 1: 2005–2014, cohort 2: 2016, and cohort 3: 2020–present). The overall objectives of the ITC KRA1 Survey were to examine the use of cigarettes, heated tobacco products (HTPs), e-cigarettes (ECs); whether HTPs might help smokers quit; and the effectiveness of tobacco control policies, such as large graphic warnings, high cigarette taxes, and smoking bans in public places. The KRA1 Survey measures were identical or functionally similar to those of the ITC Japan Survey and, to a lesser extent, those of other ITC countries. Key measures assessed sociodemographic characteristics of respondents; the use of combustible cigarettes, e-cigarettes, and heated tobacco products; and measures assessing policies of the WHO Framework Convention on Tobacco Control, including price and tax (Article 6), smoke-free laws (Article 8), health warnings (Article 11), education, communication and public awareness (Article 12), advertising, promotion, and sponsorship restrictions (Article 13), and support for cessation (Article 14). Adult tobacco and/or nicotine users aged ≥19 years in South Korea were recruited by a commercial survey firm from its online panel. Overall, 4794 respondents completed the KRA1 Survey. The cooperation rate was 97.4% and the response rate was 15.2%. The cohort design permits assessment of transitions in products used among users in South Korea and evaluations of the impact of policies on tobacco and/or nicotine products used and transitions in use.

Citation

Lyu, J., Sung, H.-Y., Yao, T., Quah, A.C.K., Jiang, Y., Fong, G.T., Max, W. (2022). Receiving and giving electronic cigarettes as gifts in China: Findings from the International Tobacco Control China Survey. Preventive Medicine Reports, 27, 101763. doi: 10.1016/j.pmedr.2022.101763

Abstract

Cigarette gifting is pervasive in China. As the Chinese are increasingly aware of harm from smoking cigarettes, e-cigarettes, often promoted as less harmful alternatives to cigarettes, may be viewed as appropriate gifts. This study is the first using population-based survey data to examine receiving and giving e-cigarettes as gifts in China. We analyzed 9,274 adults from Wave 5 of the International Tobacco Control China Survey, which was completed in July 2015. We found that the prevalence of receiving e-cigarettes as gifts was 1.3% among all respondents and 5.3% among urban smokers; the prevalence of giving e-cigarettes as gifts was 0.5% among all respondents and 1.2% among urban smokers. These prevalence estimates were very low among nonsmokers and rural respondents. Further analysis on urban smokers (N = 3,312) found that those aged 40-54 and 55+, those with high education levels, heavy smokers, and those who perceived e-cigarettes as equally/more harmful than cigarettes were more likely to receive e-cigarette gifts; and those who ever used e-cigarettes were significantly more likely to both receive and give e-cigarette gifts. Urban smokers with positive attitude about cigarette gifting were also more likely to give e-cigarette gifts to others, but those aged 55+ were less likely to gift e-cigarettes. Findings of this study indicate that the Chinese may perceive e-cigarettes as appropriate gifts for smokers, especially heavy smokers. Precautions should be taken to prevent e-cigarettes from becoming a gift choice for nonsmokers. Health campaigns designed to combat the social acceptance of cigarette gifting may also help reduce e-cigarette gifting.

Citation

Hasan, S.I., Kaai, S.C., Amer Nordin, A.S., Mohd Hairi, F., Danaee, M., Yee, A., Ahmad Tajuddin, N.A., Kamaludin, I.S., Grey, M., Yan, M., Driezen, P., Thompson, M.E., Quah, A.C.K., Fong, G.T. (2022). Who are more likely to have quit intentions among Malaysian adult smokers: Findings from the 2020 ITC Malaysia Survey. International Journal of Environmental Research and Public Health, 19(5), 3035. doi: https://doi.org/10.3390/ijerph19053035

Abstract

Increasing quitting among smokers is essential to reduce the population burden of smoking-related diseases. Smokers’ intentions to quit smoking are among the strongest predictors of future quit attempts. It is therefore important to understand factors associated with intentions to quit, and this is particularly important in low- and middle-income countries, where there have been few studies on quit intentions. The present study was conducted to identify factors associated with quit intentions among smokers in Malaysia. Data came from the 2020 International Tobacco Control (ITC) Malaysia Survey, a self-administered online survey of 1047 adult (18+) Malaysian smokers. Smokers who reported that they planned to quit smoking in the next month, within the next six months, or sometime beyond six months were classified as having intentions to quit smoking. Factors associated with quit intentions were examined by using multivariable logistic regression. Most smokers (85.2%) intended to quit smoking. Smokers were more likely to have quit intentions if they were of Malay ethnicity vs. other ethnicities (adjusted odds ratio (AOR) = 1.82, 95% confidence interval (CI) = 1.03–3.20), of moderate (AOR = 2.11, 95% CI = 1.12–3.99) or high level of education vs. low level of education (AOR = 1.97, 95% CI = 1.04–3.75), if they had ever tried to quit smoking vs. no quit attempt (AOR = 8.81, 95% CI = 5.09–15.27), if they received advice to quit from a healthcare provider vs. not receiving any quit advice (AOR = 3.78, 95% CI = 1.62–8.83), and if they reported worrying about future health because of smoking (AOR = 3.11, 95% CI = 1.35–7.15 (a little worried/moderately worried vs. not worried); AOR = 7.35, 95% CI = 2.47–21.83 (very worried vs. not worried)). The factors associated with intentions to quit smoking among Malaysian smokers were consistent with those identified in other countries. A better understanding of the factors influencing intentions to quit can strengthen existing cessation programs and guide the development of more effective smoking-cessation programs in Malaysia.

Citation

Cruz-Jiménez, L., Barrientos-Gutiérrez, I., Zavala-Arciniega, L., Arillo-Santillan, E., Gallegos-Carrillo, K., Rodrigues-Bolanos, R., Gravley, S., Thrasher, J.F. (2022). Heated tobacco product use, its correlates, and reasons for use among Mexican smokers. Drug and Alcohol Dependence, 232(2022), 1092983. Doi: 10.1016/j.drugalcdep.2022.109283

Abstract

Background: Little is known about the use of novel heated tobacco products (HTPs) in low- and middle-income countries. We examined among smokers in Mexico the prevalence and correlates of HTP use, as well as reasons for using HTPs.

Methods: We analyzed data from five surveys (November 2019-March 2021) of an open cohort of adult smokers (n = 6500), including an oversample of those who also use e-cigarettes. Mixed-effects multinomial logistic models were used to estimate associations between study variables and current HTP use or prior HTP trial relative to never trying HTPs.

Results: The weighted prevalence of current HTP use was 1.1%. Independent correlates of current HTP use included smoking frequency, intention to quit, e-cigarette use, having partners/family-members who use e- cigarettes, friends who use HTPs, and exposure to HTP information inside/outside tobacco shops. Having partners/family members who smoke and not knowing about the harm of HTPs relative to cigarettes were associated with lower likelihood of current HTP use. Having tried HTPs was more likely among light daily smokers, those with family who use HTPs and exposure to HTP information outside shops and on newspapers/magazines. Among current users, the top reasons for using HTPs were greater social acceptability (50.6%) and lower perceived harm (34.9%) relative to cigarettes.

Conclusions: Uptake of HTPs appears relatively low among Mexican smokers, and correlates of use are similar to those for e-cigarette use. Further research is needed to determine if HTPs use promotes or impedes smoking cessation, given current HTP users are also likely to use various nicotine products.

Citation

Gravely, S., Smith, D.M., Liber, A.C., Cummings, K.M., East, K., Hammond, D., Hyland, A., O’Connor, R.J., Kasza, K.A., Quah, A.C.K., Loewen, R., Martin, N., Meng, G., Ouimet, J., Thompson, M.E., Boudreau, C., McNeill, A., Sweanor, D., Fong, G.T. (2022). Responses to potential nicotine vaping product flavor restrictions among regular vapers using non-tobacco flavors: Findings from the 2020 ITC Smoking and Vaping Survey in Canada, England and the United States. Addictive Behaviors, 125, 107152.

Abstract

Introduction: Some jurisdictions have implemented nicotine vaping product (NVP) flavor restrictions because of concerns about rising adolescent use. However, little is known how these restrictions may impact adult vapers. This study describes the level of support and predictive behavioral responses to a hypothetical NVP ban on non-tobacco flavors among regular adult vapers who only use flavors that would be banned.

Methods: Data came from 851 regular vapers (all current or ex-smokers) participating in the 2020 ITC Four Country Smoking and Vaping Survey in Canada, England, and the United States (US). A random sample of respondents in each country received and completed the questions about flavor bans: (1) do you support or oppose a ban on all non-tobacco flavors; and (2) what would you do if all flavors were banned, with the exception of tobacco in the US, and tobacco and menthol in Canada and England. Those who used tobacco-flavored or unflavored NVPs were excluded from all analyses, and additionally, vapers of menthol flavor in Canada and England were excluded from Aim 2.

Results: Overall, 53.6% of vapers were strongly opposed to flavor bans, 28.2% were opposed, 9.3% were in support, 3.6% were in strong support, and 5.2% did not know. Predicted behavioral responses were: 28.8% would continue vaping an available flavor, 28.3% would find a way to get their banned flavor(s), 17.1% would stop vaping and smoke instead, 12.9% said that they would stop vaping and not smoke, and 12.9% do not know what they would do. Responses to a potential flavor ban largely varied by smoking and vaping status, and by the level of support of a flavor restriction policy.

Conclusions: At this time, it is not clear what net population-level consequences would occur if non-tobacco flavored NVPs were prohibited. While a majority of vapers in this study opposed this policy, and many vapers would not be willing to switch to available flavors, there was considerable variability in predicted behavioral responses.

Citation

Liao, Y., Tang, J., Quah, A.C.K., Fong, G.T., McNeill, A. (2022). Attitudes towards smoking and COVID19, and changes of smoking behaviors before and after the outbreak of COVID-19: A nationwide cross-sectional survey study in China. Tobacco Induced Diseases, 20, 18.

Abstract

Introduction: China has more than 300 million current smokers. There is a controversy over smokers’ risk of COVID-19 infection. Smoking is a risk factor for COVID-19 disease progression, and the outbreak of COVID-19 may change people’s smoking behaviors. This study assessed people’s attitudes towards ‘smoking and COVID-19’ and changes of smoking behaviors before and after the outbreak of COVID-19.

Material and Methods: A cross-sectional web survey of 11009 adults in China was conducted between 7 May and 3 August 2020. Attitudes towards ‘smoking and COVID-19’ were compared among non-smokers (n=8837), ex-smokers (n=399) and current smokers (n=1773), and changes in smoking behaviors before and after the outbreak of COVID-19 were assessed among current smokers.

Results: Fewer current smokers (26.2%) agreed with the statement that ‘Current smokers are more likely than ex-smokers or non-smokers to contract COVID-19’ compared with non-smokers (53%) or ex-smokers (41.4%); fewer current smokers (55.9%) agreed with the statement ‘If contracted, current smokers are more likely than ex-smokers or non-smokers to risk disease progression’ compared with nonsmokers (75.5%) or ex-smokers (68.7%). There were no changes in cigarettes smoked per day (mean ± SD: 13.3 ± 9.55 vs 13.4 ± 9.69, p=0.414), percentage of daily smokers (70.8% vs 71.1%, p=0.882) and percentage of smokers with motivation to quit (intend to quit within the next 6 months, 9.4% vs 10.9%, p=0.148) before and after the outbreak of COVID-19.

Conclusions: The survey found that fewer current smokers agreed that smoking is a risk-factor for COVID-19 compared with non-smokers or ex-smokers. Among current smokers, there were no changes in their cigarette consumption and motivation to quit before and after the outbreak of COVID-19. More efforts are needed to educate smokers about the health risks of smoking, as well as efforts to promote their motivation to quit.

Citation

Cho, Y. J., Thrasher, J. F., Driezen, P., Hitchman, S. C., Reid, J. L., & Hammond, D. (2022). Trends in exposure to and perceptions of e-cigarette marketing among youth in England, Canada and the United States between 2017 and 2019. Health education research, 36(6), 657–668. https://doi.org/10.1093/her/cyab039

Abstract

E-Cigarette marketing may influence e-cigarette use among youth. This study examined reported exposure to and perceptions of e-cigarette marketing among youth between 2017 and 2019 across countries with varying e-cigarette marketing restrictions. Cross-sectional online surveys were conducted with 35 490 youth aged 16-19 from England, Canada and the United States in 2017, 2018 and 2019. Weighted logistic regression models examined trends in the adjusted prevalence of self-reported exposure to e-cigarette marketing and the perceived appeal of e-cigarette ads between 2017 and 2019, by country and by smoking/vaping status. Reports of frequent exposure to e-cigarette marketing increased between 2017 and 2019 in all countries, but less so in England, where e-cigarette marketing is more restricted. Perceiving e-cigarette marketing as appealing increased from 2017 to 2019 in Canada and the United States, but not in England. In England, exposure to e-cigarette marketing did not increase in prohibited channels between 2017 and 2019. Between 2017 and 2019, never-users' reports increased for exposure to and appeal of e-cigarette marketing. The results suggest some effectiveness of e-cigarette marketing bans in England and receptivity to e-cigarette marketing among youth never users.

Citation

Levy, D.T., Liber, A.C., Cadham, C., Sanchez-Romero, L.M., Hyland, A., Cummings, K.M., Douglas, C.E., Meza, R., Henriksen, L. (2022). Follow the money: a closer look at US tobacco industry marketing expenditures. Tobacco Control, [Published online, doi:10.1136/tobaccocontrol-2021-056971].

Abstract

Introduction: While much of the concern with tobacco industry marketing has focused on direct media advertising, a less explored form of marketing strategy is to discount prices. Price discounting is important because it keeps the purchase price low and can undermine the impact of tax increases.

Methods: We examine annual US marketing expenditures from 1975 to 2019 by the largest cigarette and smokeless tobacco companies as reported to the Federal Trade Commission. We consider three categories: direct advertising, promotional allowances and price discounting. In addition to considering trends in these expenditures, we examine how price discounting expenditures relate to changes in product prices and excise taxes.

Results: US direct advertising expenditures for cigarettes fell from 80% of total industry marketing expenditures in 1975 to less than 3% in 2019, while falling from 39% in 1985 to 6% in 2019 for smokeless tobacco. Price discounting expenditures for cigarettes became prominent after the Master Settlement Agreement and related tax increases in 2002. By 2019, 87% of cigarette marketing expenditures were for price discounts and 7% for promotional allowances. Smokeless marketing expenditures were similar: 72% for price promotions and 13% for promotional allowances. Price discounting increased with prices and taxes until reaching their currently high levels.

Conclusions: Between 1975 and 2019, direct advertising dramatically fell while price discounting and promotional expenditures increased. Local, state and federal policies are needed that apply non-tax mechanisms to increase tobacco prices and restrict industry contracts to offset industry marketing strategies. Further study is needed to better understand industry decisions about marketing expenditures.

Citation

Usidame, O., Xie, Y., Thrasher, J.F., Lozano, P., Elliot, M.R., Fong, G.T., Fleischer, N.L. (2022). Differential impact of the Canadian point-of-sale tobacco display bans on quit attempts and smoking cessation outcomes by sex, income, and education: Longitudinal findings from the ITC Canada Survey. Tobacco Control, [Published online January 11, doi: 10.1136/tobaccocontrol-2021-056805].

Abstract

Significance: This study examines the differential effects of Canadian point-of-sale (POS) tobacco display bans across provinces on quit attempts and smoking cessation, by sex, education and income.

Methods: We analysed survey data from five waves (waves 4–8) of the International Tobacco Control Canada Survey, a population-based, longitudinal survey, where provinces implemented display bans between 2004 and 2010. Primary outcomes were quit attempts and successful cessation. We used generalised estimating equation Poisson regression models to estimate associations between living in a province with or without a POS ban (with a 24-month threshold) and smoking outcomes. We tested whether these associations varied by sex, education and income by including interaction terms.

Results: Across survey waves, the percentage of participants in provinces with POS bans established for more than 24 months increased from 5.0% to 95.8%. There was no association between POS bans and quit attempts for provinces with bans in place for 0–24 months or more than 24 months, respectively (adjusted relative risk (aRR)=0.99, 95% CI: 0.89 to 1.10; 1.03, 95% CI: 0.88 to 1.20). However, we found a differential impact of POS bans on quit attempts by sex, whereby bans were more effective for women than men for bans of 0–24 months. Participants living in a province with a POS ban for at least 24 months had a higher chance of successful cessation (aRR=1.49; 95% CI: 1.08 to 2.05) compared with those in a province without a ban. We found no differences in the association between POS bans and quit attempts or cessation by education or income, and no differences by sex for cessation.

Conclusion: POS bans are associated with increased smoking cessation overall and more quit attempts among women than men.

Citation

Borland, R., Le Grande, M., Heckman, B., Fong, G.T., Bickel, W.K., Stein, J., East, K., Hall, P.A., Cummings, K.M. (2022). The predictive utility of valuing the future for smoking cessation: Findings from the ITC Four Country Smoking and Vaping Surveys. International Journal of Environmental Research and Public Health, 19(2), 631.

Abstract

Background: Delay discounting (DD) and time perspective (TP) are conceptually related constructs that are theorized as important determinants of the pursuit of future outcomes over present inclinations. This study explores their predictive relationships for smoking cessation.

Methods: 5006 daily smokers at a baseline wave provided 6710 paired observations of quitting activity between two waves. Data are from the International Tobacco Control (ITC) smoking and vaping surveys with samples from the USA, Canada, England, and Australia, across three waves conducted in 2016, 2018 and 2020. Smokers were assessed for TP and DD, plus smoking-specific predictors at one wave of cessation outcomes defined as either making a quit attempt and/or success among those who tried to quit which was ascertained at the subsequent survey wave.

Results: TP and DD were essentially uncorrelated. TP predicted making quit attempts, both on its own and controlling for other potential predictors but was negatively associated with quit success. By contrast, DD was not related to making quit attempts, but high DD predicted relapse. The presence of financial stress at baseline resulted in some moderation of effects.

Conclusions: Understanding the mechanisms of action of TP and DD can advance our understanding of, and ability to enhance, goal-directed behavioural change. TP appears to contribute to future intention formation, but not necessarily practical thought of how to achieve goals. DD is more likely an index of capacity to effectively generate competing future possibilities in response to immediate gratification.

Citation

Miller, C., Sutanto, E., Smith, D.M., Hitchman, S.C., Gravely, S., Yong, H.H., Borland, R., O’Connor, R.J., Cummings, K.M., Fong, G.T., Hyland, A., Quah, A.C.K., Goniewicz, M. (2022). Awareness, trial, and use of heated tobacco products among adult cigarette smokers and e-cigarettes users: Findings from the 2018 ITC Four Country Smoking & Vaping Survey. Tobacco Control, 31(1), 11-18.

Abstract

Objective:

To evaluate heated tobacco product (HTP) awareness, trial and current use among adult cigarette smokers and vaping product users in four countries with varying regulations governing HTP sales.

Design:

Data came from Wave 2 of the ITC Four Country Smoking and Vaping Survey, collected from February to July 2018. Respondents were current and former smokers and/or users of vaping products (18 years or older) from Canada (CA; n=3778), England (EN; n=4848), the USA (US; n=2846) and Australia (AU; n=1515). At the time of the survey, only Canada and England permitted the sale of contemporary HTPs (eg, IQOS).

Results:

Overall, 30.2% of respondents reported being aware of HTPs (CA=30.4%; EN=31.0%; US=30.2%; AU=27.4%; p=0.346), 2.4% had ever tried HTPs (CA=3.3%; EN=2.4%; US=2.0%; AU=0.9%; p=0.001) and 0.9% currently used HTPs at least monthly (CA=0.8%; EN=1.2%; US=0.7%; AU=0.2%; p<0.001). Trial and current use were higher among those who concurrently smoked and vaped (at least monthly) versus other nicotine use categories (trial: 10.9% v. 1.2%-2.0%, p><0.001; current use: 8.4% v. 0.1%-1.0%, p><0.001). In multivariable analyses, HTP awareness did not differ across countries, whereas odds of trial and current use were lower where HTPs were unavailable. Odds of HTP trial did not differ by regulatory environment when restricting analysis to HTP-aware concurrent smokers-vapers.

Conclusion:

Approximately one third of respondents were aware of HTPs, even in the USA and Australia, where contemporary HTPs were not yet on the market. Trial and use were uncommon, except among concurrent smokers-vapers. Restrictions on availability may have limited HTP use generally, but less so for concurrent smokers-vapers.

Citation

Taylor, E., East, K., McNeill, A., Cummings, K.M., Thrasher, J.F., Fong, G.T., Quah, A.C.K., McDermott, M., Li, G., Borland, R., Hammond, D., Aleyan, S., Hitchman, S.C. (2022). Changes in responses to nicotine vaping product warnings and leaflets in England compared with Canada, the US, and Australia: Findings from the 2016-2018 ITC Four Country Smoking and Vaping Surveys. Tobacco Control, 31(1), 107-111.

Abstract

Background and aims:

In May 2017, black-and-white text nicotine addiction warning labels ('warnings') and health and safety leaflets ('leaflets') became mandatory for nicotine vaping products (NVPs) in England, in accordance with the European Union's Tobacco Products Directive. We compared changes over time in noticing warnings and leaflets, recall of warnings about nicotine and concerns about using NVP due to noticing warnings in England, compared with Canada, the US and Australia, where no warnings and leaflets were mandated.

Design:

19005 adult (aged 18+) NVP users, smokers and quitters of cigarettes and NVP from the 2016 and 2018 International Tobacco Control Four Country Smoking and Vaping Surveys in England, Canada, the US and Australia, recruited via probability and non-probability sampling.

Findings:

Noticing warnings increased in England from 4.9% (2016) to 9.4% (2018) (adjusted OR/AOR=1.64, 95% CI=1.15-2.36); this change was larger than changes in Canada (AOR=2.51, 95% CI=1.71-3.69) and the US (AOR=2.22, 95% CI=1.45-3.39). Recall of a nicotine warning increased in England from 86% (2016) to 94.9% (2018) (AOR=5.50, 95% CI=1.57-19.27) but not significantly elsewhere. Noticing leaflets increased in England from 14.6% (2016) to 19.1% (2018) (AOR=1.42, 95% CI=1.15-1.74); this change was larger than in Canada (AOR=1.42, 95% CI=1.12-1.79), the US (AOR=1.55, 95% CI=1.17-2.06) and Australia (AOR=1.51, 95% CI=1.02-2.22). Among those noticing warnings, concern about NVP use did not change significantly between 2016 and 2018 (all countries p>0.081).

Conclusions:

Introduction of mandatory NVP warnings and leaflets in England was associated with small increases in noticing them but not with changes in concerns about NVP use.

Citation

Thomas, D.P., Panaretto, K.S. (2022). Predictors and reasons for quitting smoking in remote Aboriginal and Torres Strait Islander communities. Health Promotion Journal of Australia, 33 (1), 261-271.

Abstract

Issue addressed: National smoking prevalence is decreasing among Aboriginal and Torres Strait Islander people. In remote areas, Aboriginal and Torres Strait Islander smoking prevalence remains higher than in nonremote areas and is not improving.

Methods: We analysed data from 539 daily and weekly smokers from remote areas who completed baseline surveys at either Wave 1 (April 2012-October 2013) or Wave 2 (August 2013-August 2014), including 157 from Wave 1 who also completed Wave 2, from the Talking About The Smokes project. We assessed associations between baseline predictor measures and having made any quit attempt in the past year and, among those who did, having sustained the last quit attempt for one month or more.

Results: More smokers had made a quit attempt if they were younger or reported being unable to buy essentials due to money spent on smokes, being more stressed, having several pro-quitting motivations and attitudes, having an effective smoke-free home, or being encouraged to quit by a health professional or by family/friends. Of these, more had sustained their last quit attempt for one month or more if they reported being more socially advantaged, no smoking-induced deprivation, being less dependent, chewing pituri or an having effective smoke-free home.

Conclusions: Health staff should consider the quite different factors associated with starting and then sustaining a quit attempt.

Citation

Driezen, P., Gravely, S., Wadsworth, E., Smith, D.M., Loewen, R., Hammond, D., Li, L., Abramovici, H., McNeill, A., Borland, R., Cummings, K.M., Thompson, M.E., Fong, G.T. (2022). Increasing cannabis use is associated with poorer cigarette smoking cessation outcomes: Findings from the ITC Four Country Smoking and Vaping Surveys, 2016-2018. Nicotine and Tobacco Research, 24(1), 53-59.

Abstract

Introduction: Concurrent use (co-use) of tobacco and cannabis may impede successful cigarette smoking cessation. This study examined whether changes in cannabis use frequency were associated with smoking cessation.

Methods: Nationally representative samples of adult cigarette smokers from Canada (n=1455), the United States (n=892), England (n=1416), and Australia (n=717) were surveyed in 2016 and 2018. In each year, smokers reported how often they used cannabis in the previous 12 months. Reports were compared to determine whether cannabis use increased, remained unchanged, or decreased. Smoking cessation outcomes, measured in 2018, were (1) any attempt to quit in the previous year, (2) currently quit, and (3) currently quit for at least 6 months. Weighted multivariable logistic regression estimated the association between changes in cannabis use and cessation outcomes.

Results: Cigarette smokers who increased their frequency of cannabis use were significantly less likely to be currently quit than non-cannabis using smokers (adjusted odds ratio (aOR) = 0.52, 95% CI: 0.31, 0.86); they were also less likely to have quit for at least 6 months (aOR = 0.30; 95% CI: 0.15, 0.62).

Conclusions: Smokers who increase their frequency of cannabis use have poorer smoking cessation outcomes compared to non-cannabis using smokers. It will be important to monitor the impact of cannabis legalization on patterns of cannabis use, and whether this influences cigarette smoking cessation rates.

Citation

Nogueira, S.O., Fernández, E., Driezen, P., Fu, M., Tigova, O., Castellano, Y., Mons, U., Herbec, A., Kyriakos, C.N., Demjen, T., Trofor, A.C., Przewozniak, K., Katsaounou, P.A., Vardavas, C.I., Fong, G.T., on behalf of the EUREST-PLUS Consortium. (2022). Secondhand smoke exposure in European countries with different smoke-free legislation: Findings from the EUREST-PLUS ITC Europe Surveys. Nicotine and Tobacco Research, 24(1), 85-92.

Abstract

Introduction: Exposure to secondhand smoke (SHS) poses serious and extensive health and economic-related consequences to European society and worldwide. Smoking bans are a key measure to reducing SHS exposure but have been implemented with varying levels of success. We assessed changes in the prevalence of self-reported SHS exposure and smoking behavior in public places among smokers in six European countries and the influence of the country’s type of smoking ban (partial or total ban) on such exposure and smoking behavior.

Aims and Methods: The EUREST-PLUS ITC Europe Surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, and Spain in 2016 (Wave 1, n = 6011) and 2018 (Wave 2, n = 6027). We used generalized estimating equations models to assess changes between Waves 1 and 2 and to test the interaction between the type of smoking ban and (1) self-reported SHS exposure, (2) self-reported smoking in several public places.

Results: A significant decrease in self-reported SHS exposure was observed in workplaces, from 19.1% in 2016 to 14.0% in 2018 (−5.1%; 95% CI: −8.0%; −2.2%). Self-reported smoking did not change significantly inside bars (22.7% in Wave 2), restaurants (13.2% in Wave 2) and discos/nightclubs (34.0% in W2). SHS exposure in public places was significantly less likely (adjusted odds ratio = 0.35; 95% CI: 0.26–0.47) in the countries with total bans as compared to those countries with partial bans.

Conclusion: The inverse association between smoking in public places and smoking bans indicates an opportunity for strengthening smoke-free legislation and protecting bystanders from exposure to SHS in public places.

Implications: Prevalence of smokers engaging in and being exposed to smoking in public places varied by type of smoke-free legislation across six European Union countries in our study; those with total smoke bans reported significantly less exposure to SHS than those with partial or no bans. Our results indicate room for improvement, not only to decrease the prevalence of exposure to SHS in Europe but also to diminish the variability between countries through common, more restrictive smoke-free legislation, and importantly, strong and sustained enforcement.

Citation

Xhao, P., Haziza, D., Wu, C. (2022). Empirical likelihood and the design-based oracle variable selection theory. Statistica Sinica, 32, 1-23.

Abstract

The sample empirical likelihood approach provides a powerful tool for the analysis of complex survey data. We present sample empirical likelihood results for point estimation and linear or nonlinear hypothesis tests on finite population parameters. These parameters are defined using just-identified or over-identified estimating equation systems with smooth or nondifferentiable estimating functions under general unequal probability sampling designs. We propose a penalized sample empirical likelihood for variable selection and establish its oracle property under the design-based framework. Practical implementations of the methods are also discussed. We investigate the finite sample performances of the proposed methods for quantile regression and variable selection using simulation studies. Lastly, we apply these methods to a survey data set from the International Tobacco Control (ITC) Policy Evaluation Project to demonstrate the effectiveness of the variable selection method for linear and quantile regression models

Citation

Przewoźniak, K., Kyriakos, C.N., Hiscock, R., Radu-Loghin, C., Fong, G.T. (2021). Effects of and challenges to bans on menthol and other flavours in tobacco products. Tobacco Prevention & Cessation, 7, 68.

Abstract

In May 2020, the European Tobacco Products Directive (TPD), which bans characterizing flavors in cigarettes and roll-your-own tobacco (RYO) in the European Union (EU), extended its application to menthol1,2. Countries which were early adopters of flavor bans include Brazil, Canada, Ethiopia, the United Kingdom (UK), amongst others3. Two main regulatory approaches exist: a ban on characterizing flavors that allows for the presence of additives but not at detectable sensory levels (e.g. EU, UK), and a total ban on flavor additives that eliminates their presence altogether (e.g. Brazil, Canada). As more countries work towards adopting tobacco flavor bans, it is critical to understand how these policies are implemented, ascertain their population-level impact, and identify the regulatory challenges.

Citation

Miller, C., Sutanto, E., Smith, D.M., Hitchman, S.C., Gravely, S., Yong, H.H., Borland, R., O’Connor, R., Cummings, K.M., Fong, G.T., Hyland, A., Quah, A.C.K., Goniewicz, M. (2022). Characterizing heated tobacco product use among adult cigarette smokers and nicotine vaping product users in the 2018 ITC Four Country Smoking & Vaping Survey. Nicotine and Tobacco Research, 24(4), 493-502. doi: 10.1093/ntr/ntab27.

Abstract

Introduction: Heated tobacco products (HTP) have diversified global tobacco markets, and user characteristics remain understudied. This study evaluated sociodemographic characteristics, nicotine-related perceptions and behaviors of current HTP users within a sample of adult (18+ years) nicotine users across four countries.

Methods: Data were from current smokers or nicotine vaping product (NVP; known as "e-cigarettes") users from Canada, England, the United States and Australia (n=11,421) who participated in the 2018 ITC Four Country Smoking and Vaping Survey. Current (at-least-monthly) HTP users were characterized (n=441), and weighted multivariable logistic regressions examined correlates of HTP use.

Results: Compared to non-users, current HTP users were younger (mean age: 44.4 vs 31.0 years; p<0.001) and had higher socioeconomic status (p<0.001). A majority of current HTP users used HTPs non-daily (daily: 40.3% vs non-daily: 59.7%). Most HTP users concurrently used both cigarettes and NVPs (90.5%). Among concurrent cigarette-HTP-NVP users, 36.2% used all three products daily. Use of other combusted tobacco products (cigars, cigarillos, pipe, waterpipe/hookah), cannabis, and binge drinking were each associated with current HTP use. HTP use was more common among smokers intending to quit within 6 months or reporting a quit attempt in the past 18 months, and vapers who had experienced negative side effects.

Conclusion: HTP users in this sample tended to be younger and more affluent. Most reported concurrent use of multiple nicotine products and other substances. Those cigarette smokers who used HTPs appeared more interested in smoking cessation, while some characteristics of concurrent HTP-NVP users were suggestive of dissatisfaction with NVPs.

Implications: Few studies have scrutinized characteristics of HTP early-adopters in emerging markets. Our results indicate that in 2018, characteristics of established nicotine users who adopted HTP use in four high-income Western countries mirror those of HTP users in East Asian markets (South Korea and Japan) where HTPs are popular. HTP users reported high levels of concurrent use of non-cigarette combusted tobacco products (e.g., cigars, pipe tobacco). These findings point to the need for future longitudinal studies of HTP use given the implications of those use patterns on the harm reduction potential of HTPs. HTP user characteristics may yield important information to consider in regulation of these products.

Citation

East, K., Reid, J., Rynard, V.L., Hammond, D. (2021). Trends and patterns of tobacco and nicotine product use among youth in Canada, England, and the US from 2017-2019. Journal of Adolescent Health, 69(3), 447-456. doi: 10.1016/j.jadohealth.2021.02.011.

Abstract

Purpose: The tobacco and nicotine market is diversifying. Implications for public health will depend on trends in use, including overall use, and who is using these products. This study examined differences over time (2017–2019), across countries (Canada, England, the United States (US)), and by smoking and vaping, in use of other tobacco/nicotine products and overall use.

Methods: The study includes online repeat cross-sectional surveys of youth aged 16–19 years in Canada (N = 11,714), England (N = 11,170), US (N = 11,838) in 2017, 2018, and 2019. Past 30-day use of tobacco/nicotine products (any, cigarette, e-cigarette, other combusted [cigars/cigarillos/waterpipe], other non-combusted [smokeless tobacco/nicotine replacement therapies) were examined by country, year, and, for other combusted and non-combusted products, past 30-day cigarette smoking and vaping. Use of emerging products (IQOS, nicotine pouches) was explored in 2018–2019.

Results: From 2017 to 2019, use of any product increased in Canada (17.1%–23.2%, AOR = 1.07 [95% CI = 1.04–1.09]) and the US (18.0%–24.0%, AOR = 1.06 [1.04–1.09]) but not England (20.8%–21.7%, AOR = 1.01 [.99–1.03]). Use of other combusted products (cigars/cigarillos/waterpipe) showed little change (Canada: 8.1%–7.8%; England: 6.3%–7.3%; US: 8.6%–8.5%; p ≥ .151). Use of other non-combusted products (smokeless/nicotine replacement therapies) increased in all countries (Canada: 1.5%–3.2%, AOR = 1.02 [1.01–1.02]; England: 1.4%–2.6%, AOR = 1.02 [1.01–1.03]; US: 3.3%–4.9%, AOR = 1.02 [1.01–1.02]). Vaping increased in all countries (Canada: 8.4%–17.8%; England: 8.7%–12.6%; United States: 11.1%–18.5%; all p < .001). Smokers and vapers reported greater use of other combusted and non-combusted products than those who neither smoked/vaped (p < .001). Emerging product use was rare (≤1.5%).

Conclusions: Youth past 30-day tobacco and nicotine product use increased from 2017 to 2019 in Canada and the United States, largely due to increases in vaping and other non-combusted products. “Other” tobacco/nicotine products were used predominantly by youth who smoked cigarettes and/or vaped.

Citation

Li, L., Borland, R., Cummings, K.M., Fong, G.T., Gravely, S., Smith, D.M., Goniewicz, M., O’Connor, R.J., Thompson, M.E., McNeill, A. (2021). How Does the Use of Flavored Nicotine Vaping Products Relate to Progression Toward Quitting Smoking? Findings From the 2016 and 2018 ITC 4CV Surveys. Nicotine and Tobacco Research, 23(9), 1490-1497. doi: https://doi.org/10.1093/ntr/ntab033.

Abstract

Introduction: There is limited research on the role of flavors in nicotine vaping products (NVPs) in relation to smoking. We examined patterns of flavor use in NVPs in relation to progression towards quitting.

Methods: Data come from 886 concurrent users of NVPs (at least weekly) and cigarettes who were first surveyed in 2016 and then successfully recontacted in 2018 as part of the ITC 4CV Surveys conducted in Australia, Canada, England and the United States. Participants were asked about their main vaping flavor categorized as: 1) tobacco or unflavored, 2) menthol/mint flavored, and 3) “sweet” flavors (e.g., fruit/candy). We examined whether flavor was associated with progression towards quitting smoking between survey years.

Results: Overall, 11.1% of baseline concurrent users quit smoking by 2018. Compared to users of tobacco flavors, those vaping “sweet” flavors were more likely to quit smoking between surveys (13.8% vs. 9.6%; adjusted OR=1.61, 95% CI 1.01-2.58, p<0.05), but those using menthol flavors were no more likely to quit smoking (8.3% vs. 9.6%, aOR=0.87, 95% CI 0.43-1.47, p=0.69). Among those who had quit smoking in 2018, 52.0% were still vaping, which was lower than the 65.8% among continuing smokers (aOR=0.60, 95% CI 0.39-0.92, p=0.02). Sweet flavor users were no more likely to continue vaping compared to tobacco flavor users, either for those continuing smoking or those having quit smoking by 2018. There was a net shift away from tobacco flavor among those who continued to vape at follow-up.

Conclusions: Use of fruit and other sweet flavored e-liquids is positively related to smokers’ transition away from cigarettes.

Implications: With multiple jurisdictions considering limiting or banning the sale of flavored NVPs, it is important to consider how such policies may impact smokers using NVPs to transition away from cigarette smoking. Our results indicate that vapers who used sweet flavors were more likely to transition away from cigarette smoking and quit cigarette use, at least in the short term, compared to those who used tobacco or unflavored NVPs. Randomized clinical trials are needed to establish if the observed association between use of flavored e-liquids and smoking cessation is due to self-selection or is truly causal.