Citation

Yong, H.H., Thompson, M.E., Thrasher, J.F., Borland, R., Fong, G.T., Hammond, D., Cummings, K.M., Nagelhout, G.E., Meng, G., McNeill, A. (2014). Mediational pathways of the impact of cigarette warning labels on quit attempts. Health Psychology, 33(11), 1410-1420.

Abstract

Objective: To test and develop, using structural equation modeling, a robust model of the mediational pathways through which health warning labels exert their influence on smokers' subsequent quitting behavior.

Method: Data come from the International Tobacco Control Four-Country Survey, a longitudinal cohort study conducted in Australia, Canada, the United Kingdom, and the United States. Waves 5-6 data (n = 4,988) were used to calibrate the hypothesized model of warning label impact on subsequent quit attempts via a set of policy-specific and general psychosocial mediators. The finalized model was validated using Waves 6-7 data (n = 5065).

Results: As hypothesized, warning label salience was positively associated with thoughts about risks of smoking stimulated by the warnings (β = .58, p < .001), which in turn were positively related to increased worry about negative outcomes of smoking (β = .52, p < .001); increased worry in turn predicted stronger intention to quit (β = .39, p < .001), which was a strong predictor of subsequent quit attempts (β = .39, p < .001). This calibrated model was successfully replicated using Waves 6-7 data.

Conclusion: Health warning labels seem to influence future quitting attempts primarily through their ability to stimulate thoughts about the risks of smoking, which in turn help to raise smoking-related health concerns, which lead to stronger intentions to quit, a known key predictor of future quit attempts for smokers. By making warning labels more salient and engaging, they should have a greater chance to change behavior.

Citation

Mutti, S., Kennedy, R.D., Thompson, M.E., Fong, G.T. (2014). Prepaid monetary incentives - Predictors of taking the money and completing the survey: Results from the International Tobacco Control (ITC) Four-Country Survey. Sociological Methods & Research, 43(2), 338-355.

Abstract

Prepaid monetary incentives are used to address declining response rates in random-digit dial surveys. There is concern among researchers that some respondents will accept the prepayment but not complete the survey. There is little research to understand check cashing and survey completing behaviors among respondents who receive prepayment. Data from the International Tobacco Control Four-Country Study—a longitudinal survey of smokers in Canada, the United States, the United Kingdom, and Australia—were used to examine the impact of prepayment (in the form of checks, approximately US$10) on sample profile. Approximately 14 percent of respondents cashed their check, but did not complete the survey, while about 14 percent did not cash their checks, but completed the survey. Younger adults (Canada and United States), those of minority status (United States), and those who had been in the survey for only two waves or less (Canada and United States) were more likely to cash their checks and not complete the survey.

Citation

Cowie, G.A., Fong, G.T., Chaloupka, F., Borland, R., Swift, E. (2014). Cigarette brand loyalty in Australia: Findings from the ITC Four Country Survey. Tobacco Control, 23(Suppl 1), i73-i79.

Abstract

Background and aim: There is little academic research on tobacco brand loyalty and switching, and even less in restrictive marketing environments such as Australia. This paper examines tobacco brand family loyalty, reasons for choice of brand and the relation between these and sociodemographic variables over a period of 10 years in Australia.

Methods: Data from current Australian smokers from 9 waves of the International Tobacco Control Policy Evaluation 4-Country Survey covering the period from 2002 to early 2012. Key measures reported were having a regular brand, use for at least 1 year, brand stability (derived from same reported brand at successive waves), and reasons for choosing brands.

Results: Measures of brand loyalty showed little change across the period, with around 80% brand stability and 95% reporting a regular brand. Older adults were more brand-loyal than those under 25. Young people’s brand choice was influenced more by friends, whereas older adults were more concerned about health. Price was the most reported reason for brand switching. Those in the higher income tertiles showed more loyalty than those in the lowest. The least addicted smokers also showed less brand loyalty. We found no clear relationship between brand loyalty and policies that were implemented to affect tobacco use.

Conclusions: Levels of brand loyalty in Australia are quite high and consistent, and do not appear to have been influenced greatly by changes in tobacco control policies.

Abstract

Introduction: The Heaviness of Smoking Index (HSI) is the measure of dependence most strongly predictive of relapse. However, recent research suggests it may not be predictive of longer term relapse. Our aim was to examine its predictive power over the first 2 years after quitting and explore whether use of stop-smoking medications is a moderator.

Methods: Data (n = 7,093) came from the first 7 waves (2002-2009) of the International Tobacco Control Four-Country Survey, an annual cohort survey of smokers in Canada, United States, United Kingdom, and Australia. HSI and its 2 components (cigarettes per day [CPD] and time to first cigarette [TTFC]) were used to predict smoking relapse risk in the 2 years after the start of a quit attempt.

Results: Scores on HSI and its components all strongly predicted relapse, but there was an interaction with time (p < .001). These measures were strong predictors of relapse within the first week of quitting (hazard ratios [HR] = 1.17, 1.24, and 1.30 for HSI, CPD, and TTFC, respectively, all p < .001), less predictive of relapse occurring between 1 week and 1 month, and not clearly predictive beyond 1 month. Among those using medication to quit, hazard ratio for HSI (HR = 1.11, p < .001) was significantly lower than for those not using (HR = 1.24, p < .001) in the first week, but not beyond.

Conclusions: HSI and its 2 components are strong predictors of short-term smoking relapse, but they rapidly lose predictive power over the first weeks of an attempt, becoming marginally significant at around 1 month, and not clearly predictive beyond that.

Citation

Gravely, S., Fong, G.T., Cummings, K.M., Yan, M., Quah, A.C.K., Borland, R., Yong, H.H., Hitchman, S.C., McNeill, A., Hammond, D., Thrasher, J.F., Willemsen, M.C., Seo, H.G., Jiang, Y., Cavalcante, T.M., Perez, C., Omar, M., Hummel, K. (2015). Awareness, trial, and current use of electronic cigarettes in 10 countries: findings from the ITC Project. International Journal of Environmental Research and Public Health, 12(5), 4631-4637.

Abstract

Background: In recent years, electronic cigarettes (e-cigarettes) have generated considerable interest and debate on the implications for tobacco control and public health. Although the rapid growth of e-cigarettes is global, at present, little is known about awareness and use. This paper presents self-reported awareness, trial and current use of e-cigarettes in 10 countries surveyed between 2009 and 2013; for six of these countries, we present the first data on e-cigarettes from probability samples of adult smokers.

Methods: A cross-sectional analysis of probability samples of adult (≥ 18 years) current and former smokers participating in the International Tobacco Control (ITC) surveys from 10 countries. Surveys were administered either via phone, face-to-face interviews, or the web. Survey questions included sociodemographic and smoking-related variables, and questions about e-cigarette awareness, trial and current use.

Results: There was considerable cross-country variation by year of data collection and for awareness of e-cigarettes (Netherlands (2013: 88%), Republic of Korea (2010: 79%), United States (2010: 73%), Australia (2013: 66%), Malaysia (2011: 62%), United Kingdom (2010: 54%), Canada (2010: 40%), Brazil (2013: 35%), Mexico (2012: 34%), and China (2009: 31%)), in self-reports of ever having tried e-cigarettes (Australia, (20%), Malaysia (19%), Netherlands (18%), United States (15%), Republic of Korea (11%), United Kingdom (10%), Mexico (4%), Canada (4%), Brazil (3%), and China (2%)), and in current use (Malaysia (14%), Republic of Korea (7%), Australia (7%), United States (6%), United Kingdom (4%), Netherlands (3%), Canada (1%), and China (0.05%)).

Conclusions: The cross-country variability in awareness, trial, and current use of e-cigarettes is likely due to a confluence of country-specific market factors, tobacco control policies and regulations (e.g., the legal status of e-cigarettes and nicotine), and the survey timing along the trajectory of e-cigarette awareness and trial/use in each country. These ITC results constitute an important snapshot of an early stage of what appears to be a rapid progression of global e-cigarette use.

Citation

Hitchman, S.C., Fong, G.T., Zanna, M.P., Thrasher, J.F., Chung-Hall, J., Siahpush, M. (2014). Socioeconomic status and smokers' number of smoking friends: Findings from the International Tobacco Control (ITC) Four Country Survey. Drug and Alcohol Dependence, 143, 158-166.

Abstract

Background: Smoking rates are higher among low socioeconomic (SES) groups, and there is evidence that inequalities in smoking are widening over time in many countries. Low SES smokers may be more likely to smoke and less likely to quit because smoking is heavily concentrated in their social contexts. This study investigated whether low SES smokers (1) have more smoking friends, and (2) are more likely to gain and less likely to lose smoking friends over time. Correlates of having more smoking friends and gaining or losing smoking friends were also considered.

Method: Respondents included 6321 adult current smokers (at recruitment) from Wave 1 (2002) and Wave 2 (2003) of the International Tobacco Control Project (ITC) Four Country Survey, a nationally representative longitudinal cohort survey of smokers in Australia, Canada, UK, and US.

Results: Low SES smokers reported more smoking friends than moderate and high SES smokers. Low SES smokers were also more likely to gain smoking friends over time compared with high SES smokers. Smokers who were male, younger, and lived with other smokers reported more smoking friends, and were also more likely to gain and less likely to lose smoking friends. Smoking behaviours, such as higher nicotine dependence were related to reporting more smoking friends, but not to losing or gain smoking friends.

Conclusions: Smoking is highly concentrated in the social networks of lower SES smokers and this concentration may be increasing over time. Cessation interventions should consider how the structure of low SES smokers' social networks affects quitting.

Citation

Li, L., Borland, R., Fong, G.T., Thrasher, J.F., Hammond, D., Cummings, K.M. (2013). Impact of point-of-sale tobacco display bans: Findings from the International Tobacco Control Four Country Survey. Health Education Research, 28(5), 898-910.

Abstract

This study examined the impact of point-of-sale (POS) tobacco marketing restrictions in Australia and Canada, in relation to the United Kingdom and the United States where there were no such restrictions during the study period (2006–10). The data came from the International Tobacco Control Four Country Survey, a prospective multi-country cohort survey of adult smokers. In jurisdictions where POS display bans were implemented, smokers’ reported exposure to tobacco marketing declined markedly. From 2006 to 2010, in Canada, the percentages noticing POS tobacco displays declined from 74.1 to 6.1% [adjusted odds ratio (OR)¼0.26, P<0.001]; and reported exposure to POS tobacco advertising decreased from 40.3 to 14.1% (adjusted OR¼0.61, P<0.001). Similarly, in Australia, noticing of POS displays decreased from 73.9 to 42.9%. In contrast, exposure to POS marketing in the United States and United Kingdom remained high during this period. In parallel, there were declines in reported exposures to other forms of advertising/promotion in Canada and Australia, but again, not in the United States or United Kingdom. Impulse purchasing of cigarettes was lower in places that enacted POS display bans. These findings indicate that implementing POS tobacco display bans does result in lower exposure to tobacco marketing and less frequent impulse purchasing of cigarettes.

Citation

Partos, T.R., Borland, R., Yong, H.H., Thrasher, J.F., Hammond, D. (2013). Cigarette packet warning labels can prevent relapse: Findings from the International Tobacco Control 4-Country Policy Evaluation Cohort Study. Tobacco Control, 22(1), 43-50.

Abstract

Objectives: To investigate the links between health warning labels (WLs) on cigarette packets and relapse among recently quit smokers.

Design: Prospective longitudinal cohort survey.

Setting: Australia, Canada, the UK and the USA.

Participants: 1936 recent ex-smokers (44.4% male) from one of the first six waves (2002–2007) of the International Tobacco Control 4-Country policy evaluation survey, who were followed up in the next wave.

Main outcome measures: Whether participants had relapsed at follow-up (approximately 1 year later).

Results: In multivariate analysis, very frequent noticing of WLs among ex-smokers was associated with greater relapse 1 year later (OR: 1.52, 95% CI 1.11 to 2.09, p<0.01), but this effect disappeared after controlling for urges to smoke and self-efficacy (OR: 1.29, 95% CI 0.92 to 1.80, p=0.135). In contrast, reporting that WLs make staying quit ‘a lot’ more likely (compared with ‘not at all’ likely) was associated with a lower likelihood of relapse 1 year later (OR: 0.65, 95% CI 0.49 to 0.86, p<0.01) and this effect remained robust across all models tested, increasing in some.

Conclusions: This study provides the first longitudinal evidence that health warnings can help ex-smokers stay quit. Once the authors control for greater exposure to cigarettes, which is understandably predictive of relapse, WL effects are positive. However, it may be that ex-smokers need to actively use the health consequences that WLs highlight to remind them of their reasons for quitting, rather than it being something that happens automatically. Ex-smokers should be encouraged to use pack warnings to counter urges to resume smoking. Novel warnings may be more likely to facilitate this.

Citation

Kasza, K.A., Hyland, A., Borland, R., McNeill, A., Bansal-Travers, M., Fix, B.V., Hammond, D., Fong, G.T., Cummings, K.M. (2013). Effectiveness of stop-smoking medications: Findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 108(1), 193-202.

Abstract

Aim: To evaluate the population effectiveness of stop-smoking medications while accounting for potential recall bias by controlling for quit attempt recency.

Design: Prospective cohort survey.

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

Participants: A total of 7436 adult smokers (18+ years) selected via random digit dialling and interviewed as part of the International Tobacco Control Four Country Survey (ITC-4) between 2002 and 2009. Primary analyses utilized the subset of respondents who participated in 2006 or later (n = 2550).

Measurements: Continuous abstinence from smoking for 1 month/6 months.

Findings: Among participants who recalled making a quit attempt within 1 month of interview, those who reported using varenicline, bupropion or nicotine patch were more likely to maintain 6-month continuous abstinence from smoking compared to those who attempted to quit without medication [adjusted odds ratio (OR) 5.84, 95% confidence interval (CI) (2.12–16.12), 3.94 (0.87–17.80), 4.09 (1.72–9.74), respectively]; there were no clear effects for oral NRT use. Those who did not use any medication when attempting to quit tended to be younger, to be racial/ethnic minorities, to have lower incomes and to believe that medications do not make quitting easier.

Conclusions: Consistent with evidence from randomized controlled trials, smokers in the United Kingdom, Canada, Australia and the United States are more likely to succeed in quit attempts if they use varenicline, bupropion or nicotine patch. Previous population studies that failed to find an effect failed to control adequately for important sources of bias.

Citation

Adkison, S., O’Connor, R.J., Borland, R., Yong, H.H., Cummings, K.M., Hammond, D., Fong, G.T. (2013). Impact of reduced ignition propensity cigarette regulation on consumer smoking behavior and quit intentions: Evidence from 6 waves (2004–11) of the ITC Four Country Survey. Tobacco Induced Diseases, 11(1), 26.

Abstract

Background: Although on the decline, smoking-related fires remain a leading cause of fire death in the United States and United Kingdom and account for over 10% of fire-related deaths worldwide. This has prompted lawmakers to enact legislation requiring manufacturers to implement reduced ignition propensity (RIP) safety standards for cigarettes. The current research evaluates how implementation of RIP safety standards in different countries influenced smokers’ perceptions of cigarette selfextinguishment, frequency of extinguishment, and the impact on consumer smoking behaviors, including cigarettes smoked per day and planning to quit.

Methods: Participants for this research come from Waves 3 through 8 of the International Tobacco Control (ITC) Four Country Survey conducted longitudinally from 2004 through 2011 in the United States, United Kingdom, Australia, and Canada.

Results: Perceptions of cigarette self-extinguishment and frequency of extinguishment increased concurrently with an increase in the prevalence of RIP safety standards for cigarettes. Presence of RIP safety standards was also associated with a greater intention to quit smoking, but was not associated with the number of cigarettes smoked per day. Intention to quit was higher among those who were more likely to report that their cigarettes self-extinguish sometimes and often, but we found no evidence of an interaction between frequency of extinguishment and RIP safety standards on quit intentions.

Conclusions: Overall, because these standards largely do not influence consumer smoking behavior, RIP implementation may significantly reduce the number of cigarette-related fires and the associated death and damages. Further research should assess how implementation of RIP safety standards has influenced smoking-related fire incidence, deaths, and other costs associated with smoking-related fires.

Citation

Cooper, J., Borland, R., Yong, H.H., Hyland, A., Cummings, K.M. (2013). Variations in daily cigarette consumption on work days compared with nonwork days and associations with quitting: Findings from the International Tobacco Control Four-Country Survey. Nicotine & Tobacco Research, 15(1), 192-198.

Abstract

Introduction: We explore whether reported daily cigarette consumption differs between work days and nonwork days and whether variation in consumption between work days and nonwork days influences quitting and abstinence from smoking. We also explore whether effects are independent of measures of addiction and smoking restrictions at work and home.

Methods: Data were from 5,732 respondents from the first five waves of the International Tobacco Control FourCountry Survey, occurring between 2002 and 2006. Respondents were current smokers employed outside the home. Variation in daily cigarette consumption on work days compared with nonwork days at one wave was used to predict the likelihood of making an attempt and the likelihood of maintaining a quit attempt for at least a month at the next wave. Generalized estimating equations were used to combine data for multiple waves.

Results: Just under half reported smoking more on a nonwork day, a little over a third reported no difference, and around one fifth reported smoking more on a work day. Controlling for possible confounding factors, smoking more on a work day was associated with making quit attempts. Among people who made a quit attempt, variation in consumption did not consistently predict one month's abstinence, being positive in Australia, but negative in the United Kingdom.

Conclusion: Those who smoke more on work days try to quit more. Country differences for success may be related to the extent of bans on smoking, with those smoking more on work days more likely to succeed where bans in workplaces and public places were more prevalent, such as Australia at the time.

Citation

McKee, S., Young-Wolff, K.C., Harrison, E.L., Cummings, K.M., Borland, R., Kahler, C.W., Fong, G.T., Hyland, A. (2013). Longitudinal associations between smoking cessation medications and alcohol consumption among smokers in the International Tobacco Control Four Country Survey. Alcoholism Clinical and Experimental Research, 37(5), 804-810.

Abstract

Background: Available evidence suggests that quitting smoking does not alter alcohol consumption. However, smoking cessation medications may have a direct impact on alcohol consumption independent of any effects on smoking cessation. Using an international longitudinal epidemiological sample of smokers, we evaluated whether smoking cessation medications altered alcohol consumption independent of quitting smoking.

Methods: Longitudinal data were analyzed from the International Tobacco Control Four Country (ITC-4) Survey between 2007 and 2008, a telephone survey of nationally representative samples of smokers from the United Kingdom, Australia, Canada, and the United States (n = 4,995). Quantity and frequency of alcohol consumption, use of smoking cessation medications (varenicline, nicotine replacement [NRT], and no medications), and smoking behavior were assessed across 2 yearly waves. Controlling for baseline drinking and changes in smoking status, we evaluated whether smoking cessation medications were associated with reduced alcohol consumption.

Results: Varenicline was associated with a reduced likelihood of any drinking compared with nicotine replacement (OR = 0.56; 95% CI = 0.34 to 0.94), and consuming alcohol once a month or more compared to nicotine replacement (OR = 0.43; 95% CI = 0.27 to 0.69) or no medication (OR = 0.63; 95% CI = 0.41 to 0.99). Nicotine replacement was associated with an increased likelihood of consuming alcohol once a month or more compared to no medication (OR = 1.14; 95% CI = 1.03 to 1.25). Smoking cessation medications were not associated with more frequent drinking (once a week or more) or typical quantity consumed per episode. Medication effects on drinking frequency were independent of smoking cessation.

Conclusions: This epidemiological investigation demonstrated that varenicline was associated with a reduced frequency of alcohol consumption. Continued work should clarify under what conditions nicotine replacement therapies may increase or decrease patterns of alcohol consumption.

Citation

Adkison, S., O’Connor, R.J., Bansal-Travers, M., Hyland, A., Borland, R., Yong, H.H., Cummings, K.M., McNeill, A., Thrasher, J.F., Hammond, D., Fong, G.T. (2013). Electronic nicotine delivery systems: International Tobacco Control Four-Country Survey. American Journal of Preventive Medicine, 44(3), 207-215.

Abstract

Background: Electronic nicotine delivery systems (ENDS) initially emerged in 2003 and have since become widely available globally, particularly over the Internet.

Purpose: Data on ENDS usage patterns are limited. The current paper examines patterns of ENDS awareness, use, and product-associated beliefs among current and former smokers in four countries.

Methods: Data come from Wave 8 of the International Tobacco Control Four-Country Survey, collected July 2010 to June 2011 and analyzed through June 2012. Respondents included 5939 current and former smokers in Canada (n_1581); the U.S. (n_1520); the United Kingdom (UK; n_1325); and Australia (n_1513).

Results: Overall, 46.6% were aware of ENDS (U.S.: 73%, UK: 54%, Canada: 40%, Australia: 20%); 7.6% had tried ENDS (16% of those aware of ENDS); and 2.9% were current users (39% of triers). Awareness of ENDS was higher among younger, non-minority smokers with higher incomes who were heavier smokers. Prevalence of trying ENDS was higher among younger, nondaily smokers with a high income and among those who perceived ENDS as less harmful than traditional cigarettes. Current use was higher among both nondaily and heavy (_20 cigarettes per day) smokers. In all, 79.8% reported using ENDS because they were considered less harmful than traditional cigarettes; 75.4% stated that they used ENDS to help them reduce their smoking; and 85.1% reported using ENDS to help them quit smoking.

Conclusions: Awareness of ENDS is high, especially in countries where they are legal (i.e., the U.S. and UK). Because trial was associated with nondaily smoking and a desire to quit smoking, ENDS may have the potential to serve as a cessation aid.

Citation

Partos, T.R., Borland, R., Yong, H.H., Hyland, A., Cummings, K.M. (2013). The quitting rollercoaster: How recent quitting history affects future cessation outcomes (data from the International Tobacco Control 4-Country Cohort Study). Nicotine & Tobacco Research, 15(9), 1578-1587.

Abstract

Introduction: Most smokers have a history of unsuccessful quit attempts. This study used data from 7 waves (2002–2009) of the International Tobacco Control 4-country cohort study to examine the role of smokers’ quitting history (e.g., recency, length, and number of previous quit attempts) on their subsequent likelihood of making a quit attempt and achieving at least 6 months of sustained abstinence.

Methods: Generalized estimating equations were used, allowing for estimation of relationships between variables across repeated observations while controlling for correlations from multiple responses by the same individual (29,682 observations from 13,417 individuals).

Results: The likelihood of a future quit attempt increased independently with recency and number of prior attempts. By contrast, the likelihood of achieving sustained abstinence of at least 6 months was reduced for smokers with a failed quit attempt within the last year (15.1% vs. 27.1% for those without, p < .001). Two or more failed attempts (vs. only one) in the previous year were also associated with a lower likelihood of achieving sustained abstinence (OR: 0.57, 95% CI: 0.38–0.85). Effects persisted after controlling for levels of addiction, self-efficacy to quit, and use of stop-smoking medications.

Conclusions: There appears to be a subset of smokers who repeatedly attempt but fail to remain abstinent from tobacco. Understanding why repeated attempts might be less successful in the long term is an important research priority because it implies a need to tailor treatment approaches for those who are motivated to quit but persistently relapse back to smoking.

Citation

Wakefield, M.A., Bowe, S.J., Durkin, S.J., Yong, H.H., Spittal, M.J., Simpson, J.A., Borland, R. (2013). Does tobacco-control mass media campaign exposure prevent relapse among recent quitters? Nicotine & Tobacco Research, 15(2), 385-392.

Abstract

Objective:To determine whether greater mass media campaign exposure may assist recent quitters to avoid relapse.

Method: Using date of data collection and postcode, media market estimates of televised tobacco-control advertising exposure measured by gross ratings points (GRPs) were merged with a replenished cohort study of 443 Australians who had quit in the past year. Participants' demographic and smoking characteristics prior to quitting, and advertising exposure in the period after quitting, were used to predict relapse 1 year later.

Results: In multivariate analysis, each increase in exposure of 100 GRPs (i.e., 1 anti-smoking advertisement) in the three-month period after the baseline quit was associated with a 5% increase in the odds of not smoking at follow-up (OR = 1.05, 95% CI 1.02-1.07, p < 0.001). This relationship was linear and unmodified by length of time quit prior to the baseline interview. At the mean value of 1081 GRPs in the 3 months after the baseline-quit interview, the predicted probability of being quit at follow-up was 52%, whereas it was 41% for the minimum (0) and 74% for the maximum (3,541) GRPs.

Conclusion: Greater exposure to tobacco-control mass media campaigns may reduce the likelihood of relapse among recent quitters.

Citation

Partos, T.R., Borland, R., Siahpush, M. (2012). Socio-economic disadvantage at the area level poses few direct barriers to smoking cessation for Australian smokers: Findings from the International Tobacco Control Australian Cohort Survey. Drug and Alcohol Review, 31(5), 653-663.

Abstract

Introduction: Area-level indicators of socio-economic variation are frequently included in models of individual health outcomes. Area disadvantage is linearly related to smoking prevalence, but its relation to cessation outcomes is less well understood.

Aims: To explore the relationship between area-level disadvantage and prospective data on smoking cessation.

Design and Methods: The Australian cohort of the International Tobacco Control Four-Country Survey (N = 3503) was used to prospectively examine the contribution of area-level socio-economic disadvantage to predicting three important smoking-cessation outcomes: making a quit attempt, achieving 1 month abstinence and achieving 6 month abstinence from smoking, while controlling for individual-level socio-economic indicators and other individual-level covariates related to smoking cessation.

Results: Only two independent associations were observed between socio-economic disadvantage and cessation outcomes. Area-level disadvantage was related to 1 month abstinence in a non-linear fashion, and the individual experience of smoking-induced deprivation was associated with a lower likelihood of making quit attempts.

Discussion: Despite the documented higher prevalence of smoking among the more disadvantaged and in more disadvantaged areas, socio-economic disadvantage was not consistently related to making quit attempts, nor to medium-term success. Nevertheless, indirect effects of disadvantage, like its impact on psychological distress, cannot be ruled out, and considering smokers’ individual psychosocial circumstances is likely to aid cessation efforts.

Conclusion: Socio-economic disadvantage, particularly at the area level, poses few direct barriers to smoking cessation

Citation

Caleyachetty, A., Lewis, S., McNeill, A., Leonardi-Bee, J. (2012). Struggling to make ends meet: Exploring pathways to understand why smokers in financial difficulties are less likely to quit successfully. European Journal of Public Health, 22(Suppl 1), 41-48.

Abstract

Background: In high-income countries, those with low-to-middle incomes have been observing stagnating median wages and marginal improvements in their living standards. Smokers in financial difficulties appear to be less likely to quit smoking. Understanding the reasons for this is essential to intervening to improve cessation outcomes in this population, and reduce smoking-related health inequalities.

Methods: We used longitudinal data from Waves 4 to 7 of the ITC Four Country Survey (ITC-4), and included those with data from at least two consecutive waves. Associations between financial difficulties and making a quit attempt, and quit success were analysed using generalised estimating equations, with adjustment for confounders. Mediation analysis was conducted to identify potential mediators of the observed effects of financial difficulties on cessation outcomes.

Results: Having financial difficulties had little impact on making quit attempts (adjusted OR 0.84, 95% CI 0.70-1.01). Smokers with financial difficulties were substantially less likely to succeed at quitting (adjusted OR 0.55, 95% CI 0.39-0.76); an effect which was consistent over the survey years. Among the potential mediators examined, those relating to cognition of health-related and quality of life-related consequences of smoking were the most important mediators, though the proportion of the effect mediated by the largest mediator was small (6.8%).

Conclusion: Having financial difficulties remains an important barrier to smokers achieving quit success. This effect does not appear to be due to anticipated factors such as reduced use of cessation services or treatment. Further research is required to determine strong mediators of the financial difficulties effect on quit success and to tailor more effective cessation programmes.

Citation

Fotuhi, O., Fong, G.T., Zanna, M.P., Borland, R., Yong, H.H., Cummings, K.M. (2013). Patterns of cognitive dissonance-reducing beliefs among smokers: A longitudinal analysis from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 22(1), 52-58.

Abstract

Objective: The purpose of this paper is to assess whether smokers adjust their beliefs in a pattern that is consistent with Cognitive Dissonance Theory. This is accomplished by examining the longitudinal pattern of belief change among smokers as their smoking behaviours change.

Methods: A telephone survey was conducted of nationally representative samples of adult smokers from Canada, the USA, the UK and Australia from the International Tobacco Control Four Country Survey. Smokers were followed across three waves (October 2002 to December 2004), during which they were asked to report on their smoking-related beliefs and their quitting behaviour.

Findings: Smokers with no history of quitting across the three waves exhibited the highest levels of rationalisations for smoking. When smokers quit smoking, they reported having fewer rationalisations for smoking compared with when they had previously been smoking. However, among those who attempted to quit but then relapsed, there was once again a renewed tendency to rationalise their smoking. This rebound in the use of rationalisations was higher for functional beliefs than for risk-minimising beliefs, as predicted by social psychological theory.

Conclusions: Smokers are motivated to rationalise their behaviour through the endorsement of more positive beliefs about smoking, and these beliefs change systematically with changes in smoking status. More work is needed to determine if this cognitive dissonance-reducing function has an inhibiting effect on any subsequent intentions to quit.

Citation

King, B., White, V., Balmford, J., Cooper, J., Borland, R. (2012). The decline of menthol cigarette smoking in Australia, 1980-2008. Nicotine & Tobacco Research, 14(10), 1213-1220.

Abstract

Introduction: Concerns have been expressed that menthol cigarettes are highly conducive to uptake and hence function as “starter cigarettes” for adolescents. There is strong evidence for this in the United States. If menthol cigarettes are critical to uptake for some adolescents, they might be expected to remain popular among adolescents independent of promotional activity. We analyzed trends in the market share of menthol brands in Australia among both adolescents and adults to provide further insights into the determinants of menthol cigarette smoking.

Methods: We used the Australian Secondary Students Alcohol and Drug Survey (1984–2008), the Smoking and Health Survey (1980–1998), and the International Tobacco Control Four Nations Survey (2002–2008) to estimate market share of brands. Measures were reported use of all menthol brands for adults and use of the Alpine brand for adolescents.

Results: Menthol smoking was much more popular among female smokers of all age groups in the early 1980s. During the 1980s and 1990s, use declined markedly in the 18–29 age groups, while remaining relatively stable among older smokers. Use of Alpine declined markedly among adolescents in the 1980s and 1990s. However, during this period, Alpine remained more popular among experimenting than regular smokers.

Conclusions: Both Alpine and other menthol brands are now primarily “older women’s cigarettes” in Australia. The trends in declining popularity among younger smokers suggest that targeted marketing plays a major role in determining menthol brand market share. Alpine has played a role as a “starter” cigarette in Australia but that role has decreased markedly since the 1980s. Within the Australian context, “light/mild” brands may have taken over the role of easier-to-smoke cigarettes that attract experimenting smokers.

Citation

Young, D., Yong, H.H., Borland, R., Shahab, L., Hammond, D., Cummings, K.M., Wilson, N. (2012). Trends in roll your own smoking: Findings from the ITC Four Country Survey (2002-2008). Journal of Environmental and Public Health, 2012, 1-7.

Abstract

Objective: To establish the trends in prevalence, and correlates, of roll-your-own (RYO) use in Canada, USA, UK and Australia, 2002–2008.

Methods: Participants were 19,456 cigarette smokers interviewed during the longitudinal International Tobacco Control (ITC) Four-Country Survey in Canada, USA, UK, and Australia.

Results: “Predominant” RYO use (i.e., >50% of cigarettes smoked) increased significantly in the UK and USA as a proportion of all cigarette use (both P < .001) and in all countries as a proportion of any RYO use (all P < .010). Younger, financially stressed smokers are disproportionately contributing to “some” use (i.e., ≤50% of cigarettes smoked). Relative cost was the major reason given for using RYO, and predominant RYO use is consistently and significantly associated with low income.

Conclusion: RYO market trends reflect the price advantages accruing to RYO (a product of favourable taxation regimes in some jurisdictions reinforced by the enhanced control over the amount of tobacco used), especially following the impact of the Global Financial Crisis; the availability of competing low-cost alternatives to RYO; accessibility of duty-free RYO tobacco; and tobacco industry niche marketing strategies. If policy makers want to ensure that the RYO option does not inhibit the fight to end the tobacco epidemic, especially amongst the disadvantaged, they need to reduce the price advantage, target additional health messages at (young) RYO users, and challenge niche marketing of RYO by the industry.

Citation

Borland, R., Partos, T.R., Cummings, K.M. (2012). Systematic biases in cross-sectional community studies may underestimate the effectiveness of stop-smoking medications. Nicotine & Tobacco Research, 14(12), 1483-1487.

Abstract

Introduction: Randomized, controlled trials typically indicate stop-smoking medications (SSMs: e.g., Varenicline, Bupropion, and over-the-counter nicotine replacement therapies) to be effective, whereas cross-sectional community-based studies have found them to be less effective, ineffective, or even associated with higher risk of relapse. Consequently, some critics have suggested SSMs have no useful applications in “real-world” settings. This discrepancy may, however, be due to systematic biases affecting cross-sectional survey outcomes. Namely, failed quit attempts where SSMs were used may be better recalled than failed unassisted attempts. Moreover, smokers who choose to quit using SSMs may be more addicted and thus less likely to succeed. Either of these factors would lead to an overrepresentation of failed quit attempts among SSM users in cross-sectional surveys even if there were real benefits.

Methods: We report on data from the International Tobacco Control 4-country cohort study to examine the relationship between SSM use, level of nicotine addiction, and the reported date since the start of participants’ (N = 1,101) most recent quit attempt.

Results: The last quit attempt was reported to have begun longer ago among participants who used SSMs than those who did not. Scores on the Heaviness of Smoking Index, measuring addiction severity, were also higher among SSM users, with no interactions.

Conclusion: Better recall of quit attempts and stronger addiction to nicotine are two characteristics found more often among smokers using SSMs compared with self-quitters, which could potentially bias the assessed effects of SSMs on cessation outcomes in cross-sectional surveys.

Citation

Yong, H.H., Borland, R., Thrasher, J.F., Thompson, M.E. (2012). Stability of cigarette consumption over time among continuing smokers: A latent growth curve analysis. Nicotine & Tobacco Research, 14(5), 531-539.

Abstract

Objectives: This paper examined the stability over time of daily cigarette consumption of continuing smokers and explored factors that might account for the patterns of change in consumption using a latent growth curve (LGC) analytic approach.

Methods: Data come from the first 5 waves of the International Tobacco Control Four-Country Survey, conducted in Canada, the United States, the United Kingdom, and Australia where a cohort of over 2,000 smokers from each country were recruited and followed up annually with replenishment.

Results: Raw data revealed that continuing smokers showed a marked steep decline in cigarettes per day during the first 2 waves followed by a gentler linear decline in consumption over the remaining waves of the study period. This pattern of change in cigarette consumption was best modelled using a piecewise linear LGC model. Baseline consumption level was highest in Australia and lowest in the United Kingdom, although the rate of decline was similar across the 4 countries. Being older than 55 years and having made at least 1 quit attempt were related to greater rate of decline in consumption.

Conclusion: Continuing smokers who are unwilling or unable to quit smoking can and do attempt to reduce their daily cigarette consumption over time. Factors such as making a quit attempt even if unsuccessful and experiencing smoking bans at work and at homes can contribute to reduced smoking among this group, which suggests that interventions focusing in on these factors, along with providing cessation help, may greatly improve their chances of quitting smoking altogether.

Citation

Borland, R., Partos, T.R., Yong, H.H., Cummings, K.M., Hyland, A. (2012). How much unsuccessful quitting activity is going on among adult smokers? Data from the International Tobacco Control 4-Country Cohort Survey. Addiction, 107(3), 673-682.

Abstract

Aims: To document accurately the amount of quitting, length of quit attempts and prevalence of plans and serious thought about quitting among smokers.

Design: We used longitudinal data from 7 waves of the International Tobacco Control Policy Evaluation Four Country Survey (ITC-4). We considered point-prevalence data and cumulative prevalence over the 7 years of the study. We also derived annual estimates of quit activity from reports of quit attempts starting only within more recent time-frames, to control for biased recall.

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

Participants: A total of 21 613 smokers recruited across seven waves.

Measurements: Reported life-time quit attempts, annual quit attempts, length of attempts, time since last attempt started, frequency of aborted attempts, plans to quit and serious thought about quitting.

Findings: Around 40.1% (95% CI: 39.6–40.6) of smokers report attempts to quit in a given year and report an average of 2.1 attempts. Based on free recall, this translates to an average annual quit attempt rate of 0.82 attempts per smoker. Estimates derived only from the preceding month to adjust for recall bias indicate an annual rate of approximately one attempt per smoker. There is a high prevalence of quitrelated activity, with more than a third of smokers reporting thoughts or actions related to quitting in a given month. More than half the surveyed smokers eventually succeeded in quitting for at least 1 month, and a majority of these for over 6 months.

Conclusions: Smokers think a great deal about stopping and make many unsuccessful quit attempts. Many have been able to last for extended periods and yet they still relapsed. More attention needs to be focused on translating quit-related activity into long-term abstinence.

Citation

Siahpush, M., Borland, R., Yong, H.H., Cummings, K.M., Fong, G.T. (2012). Tobacco expenditure, smoking-induced deprivation and financial stress: Results from the International Tobacco Control (ITC) Four-Country Survey. Drug and Alcohol Review, 31(5), 664-671.

Abstract

Introduction and Aims: While higher tobacco prices lead to a reduction in smoking prevalence, there is a concern that paying more for cigarettes can lead to excess financial burden. Our primary aim was to examine the association of daily cigarette expenditure with smoking-induced deprivation (SID) and financial stress (FS).

Design and Methods: We used data from wave 7 (2008–2009) of the International Tobacco Control (ITC) Four-Country Survey which is a survey of smokers in Canada, the USA, the UK and Australia (n = 5887). Logistic regressions were used to assess the association of daily cigarette expenditure with SID and FS.

Results: In multivariate analyses, a one standard deviation increase in daily cigarette expenditure was associated with an increase of 24% (P = 0.004) in the probability of experiencing SID. While we found no association between daily cigarette expenditure and FS, we found that SID is a strong predictor of FS (odds ratio 6.25; P < 0.001). This suggests that cigarette expenditure indirectly affects FS through SID. Results showed no evidence of an interaction between cigarette expenditure and income or education in their effect on SID or FS.

Conclusions: Our results imply that spending more on tobacco may result in SID but surprisingly has no direct effect on FS. While most smokers may be adjusting their incomes and consumption to minimise FS, some fail to do so occasionally as indexed by the SID measure. Future studies need to prospectively examine the effect of increased tobacco expenditure on financial burden of smokers.

Citation

Hall, P.A., Fong, G.T., Yong, H.H., Sansone, G.C., Borland, R., Siahpush, M. (2012). Do time perspective and sensation-seeking predict quitting activity among smokers? Findings from the International Tobacco Control (ITC) Four Country Survey. Addictive Behaviours, 37(12), 1307-1313.

Abstract

Personality factors such as time perspective and sensation-seeking have been shown to predict smoking uptake. However, little is known about the influences of these variables on quitting behavior, and no prior studies have examined the association cross-nationally in a large probability sample. In the current study it was hypothesized that future time perspective would enhance – while sensation-seeking would inhibit – quitting activity among smokers. It was anticipated that the effects would be similar across English speaking countries. Using a prospective cohort design, this cross-national study of adult smokers (N=8845) examined the associations among time perspective, sensation-seeking and quitting activity using the first three waves of data gathered from the International Tobacco Control Four Country Survey (ITC-4), a random digit dialed telephone survey of adult smokers from the United Kingdom, United States, Canada and Australia. Findings revealed that future time perspective (but not sensation-seeking) was a significant predictor of quitting attempts over the 8-month follow-up after adjusting for socio-demographic variables, factors known to inhibit quitting (e.g., perceived addiction, enjoyment of smoking, and perceived value of smoking), and factors known to enhance quitting (e.g., quit intention strength, perceived benefit of quitting, concerns about health effects of smoking). The latter, particularly intention, were significant mediators of the effect of time perspective on quitting activity. The effects of time perspective on quitting activity were similar across all four English speaking countries sampled. If these associations are causal in nature, it may be the case that interventions and health communications that enhance future-orientation may foster more quit attempts among current smokers.