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

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

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

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

Li, L., Borland, R., Yong, H.H., Hitchman, S.C., Wakefield, M.A., Kasza, K.A., Fong, G.T. (2012). The association between exposure to point-of-sale anti-smoking warnings and smokers' interest in quitting and quit attempts: Findings from the International Tobacco Control Four Country Survey. Addiction, 107(2), 425-433.

Abstract

Aims: This study aimed to examine the associations between reported exposure to anti-smoking warnings at the point-of-sale (POS) and smokers’ interest in quitting and their subsequent quit attempts by comparing reactions in Australia where warnings are prominent to smokers in other countries.

Design: A prospective multi-country cohort design was employed.

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

Participants: A total of 21 613 adult smokers who completed at least one of the seven waves (2002–08) of the International Tobacco Control Four Country Survey were included in the analysis.

Measurements: Reported exposure to POS anti-smoking warnings and smokers’ interest in quitting at the same wave and quit attempts over the following year.

Findings: Compared to smokers in Canada, the United Kingdom and the United States, Australian smokers reported higher levels of awareness of POS anti-smoking warnings, and this difference was consistent over the study period. Over waves in Australia (but not in the other three countries) there was a significantly positive association between reported exposure to POS anti-smoking warnings and interest in quitting [adjusted odds ratio = 1.139, 95% confidence interval (CI) 1.039–1.249, P < 0.01] and prospective quit attempts (adjusted odds ratio = 1.216, 95% CI 1.114–1.327, P < 0.001) when controlling for demographics, smoking characteristics, overall salience of anti-smoking information and awareness of anti-smoking material from channels other than POS.

Conclusions: Point-of-sale health warnings about tobacco are more prominent in Australia than the United Kingdom, the United States or Canada and appear to act as a prompt to quitting.

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

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.

Citation

Borland, R., Li, L., Driezen, P., Wilson, N., Hammond, D., Thompson, M.E., Fong, G.T., Mons, U., Willemsen, M.C., McNeill, A., Thrasher, J.F., Cummings, K.M. (2012). Cessation assistance reported by smokers in 15 countries participating in the International Tobacco Control (ITC) Policy Evaluation Survey. Addiction, 107(1), 197-205.

Abstract

Aims: To describe some of the variability across the world in levels of quit smoking attempts and use of various forms of cessation support.

Design: Use of the International Tobacco Control Policy Evaluation Project surveys of smokers, using the 2007 survey wave (or later, where necessary).

Settings: Australia, Canada, China, France, Germany, Ireland, Malaysia, Mexico, the Netherlands, New Zealand, South Korea, Thailand, United Kingdom, Uruguay and United States.

Participants: Samples of smokers from 15 countries.

Measurements: Self-report on use of cessation aids and on visits to health professionals and provision of cessation advice during the visits.

Findings: Prevalence of quit attempts in the last year varied from less than 20% to more than 50% across countries. Similarly, smokers varied greatly in reporting visiting health professionals in the last year (<20% to over 70%), and among those who did, provision of advice to quit also varied greatly. There was also marked variability in the levels and types of help reported. Use of medication was generally more common than use of behavioural support, except where medications are not readily available.

Conclusions: There is wide variation across countries in rates of attempts to stop smoking and use of assistance with higher overall use of medication than behavioural support. There is also wide variation in the provision of brief advice to stop by health professionals.

Citation

Ross, H., Blecher, E., Yan, L., Cummings, K.M. (2011, February). Predictors of what smokers say they will do in response to future price increases: Findings from the ITC Four Country Study. Poster presentation at the Society for Research on Nicotine and Tobacco Annual Meeting, Toronto, Ontario, Canada.

Abstract

Introduction: Given the impact of higher tobacco prices on smoking cessation, we studied the role of future cigarette prices on forming expectation about smoking behavior.

Methods: Using a random sample of 9,058 adult cigarette smokers from the United States, Canada, Australia, and the United Kingdom collected in 2002, we examined predictors of what smokers say they will do in response to a hypothetical 50% increase in the price they paid for their last cigarette purchase. A series of regression analyses examined factors associated with intentions that have a positive impact on health, that is, intentions to quit and/or to consume fewer cigarettes.

Results: The quit and/or smoke less intentions were more pronounced among those who lived in areas with higher average cigarette prices and who paid higher prices for their brand of choice during the last purchase. The magnitude of the price increase is a more important predictor of an intention to quit/smoke less compared with the average cigarette price.

Conclusions: The availability of alternative (cheaper) cigarette sources may reduce but would not eliminate the impact of higher prices/taxes on smokers’ expected behavior that has been linked to actual quit intentions and quitting in follow-up surveys.

Citation

Licht, A.S., Hyland, A., O’Connor, R.J., Chaloupka, F., Borland, R., Fong, G.T., Nargis, N., Cummings, K.M. (2011). How do price minimizing behaviors impact smoking cessation? Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(5), 1671-1691.

Abstract

This paper examines how price minimizing behaviors impact efforts to stop smoking. Data on 4,988 participants from the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey who were smokers at baseline (wave 5) and interviewed at a 1 year follow-up were used. We examined whether price minimizing behaviors at baseline predicted: (1) cessation, (2) quit attempts, and (3) successful quit attempts at one year follow up using multivariate logistic regression modeling. A subset analysis included 3,387 participants who were current smokers at waves 5 and 6 and were followed through wave 7 to explore effects of changing purchase patterns on cessation. Statistical tests for interaction were performed to examine the joint effect of SES and price/tax avoidance behaviors on cessation outcomes. Smokers who engaged in any price/tax avoidance behaviors were 28% less likely to report cessation. Persons using low/untaxed sources were less likely to quit at follow up, those purchasing cartons were less likely to make quit attempts and quit, and those using discount cigarettes were less likely to succeed, conditional on making attempts. Respondents who utilized multiple behaviors simultaneously were less likely to make quit attempts and to succeed. SES did not modify the effects of price minimizing behaviors on cessation outcomes. The data from this paper indicate that the availability of lower priced cigarette alternatives may attenuate public health efforts aimed at to reduce reducing smoking prevalence through price and tax increases among all SES groups.

Citation

Kasza, K.A., Hyland, A., Brown, A., Siahpush, M., Yong, H.H., McNeill, A., Li, L., Cummings, K.M. (2011). The effectiveness of tobacco marketing regulations on reducing smokers' exposure to advertising and promotion: Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(2), 321-340.

Abstract

Exposure to tobacco product marketing promotes the initiation, continuation, and reuptake of cigarette smoking and as a result the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) has called upon member Parties to enact comprehensive bans on tobacco advertising and promotion. This study examines the immediate and long term effectiveness of advertising restrictions enacted in different countries on exposure to different forms of product marketing, and examines differences in exposure across different socioeconomic status (SES) groups. Nationally representative data from the United Kingdom, Canada, Australia, and the United States, collected from adult smokers between 2002 and 2008 using the International Tobacco Control Four Country Survey (ITC-4), were used in this study (N = 21,615). In light of the specific marketing regulation changes that occurred during the course of this study period, changes in awareness of tobacco marketing via various channels were assessed for each country, and for different SES groups within countries. Tobacco marketing regulations, once implemented, were associated with significant reductions in smokers’ reported awareness of prosmoking cues, and the observed reductions were greatest immediately following the enactment of regulations. Changes in reported awareness were generally the same across different SES groups, although some exceptions were noted. While tobacco marketing regulations have been effective in reducing exposure to certain types of product marketing there still remain gaps, especially with regard to in-store marketing and price promotions.

Citation

Licht, A.S., Hyland, A., O’Connor, R.J., Chaloupka, F., Borland, R., Fong, G.T., Nargis, N., Cummings, K.M. (2011). Socio-economic variation in price minimizing behaviors: Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(1), 234-252.

Abstract

This paper examines how socio-economic status (SES) modifies how smokers adjust to changes in the price of tobacco products through utilization of multiple price minimizing techniques. Data come from the International Tobacco Control Policy Evaluation (ITC) Four Country Survey, nationally representative samples of adult smokers and includes respondents from Canada, the United States, the United Kingdom and Australia. Cross-sectional analyses were completed among 8,243 respondents (7,038 current smokers) from the survey wave conducted between October 2006 and February 2007. Analyses examined predictors of purchasing from low/untaxed sources, using discount cigarettes or roll-your-own (RYO) tobacco, purchasing cigarettes in cartons, and engaging in high levels of price and tax avoidance at last purchase. All analyses tested for interactions with SES and were weighted to account for changing and under-represented demographics. Relatively high levels of price and tax avoidance behaviors were present; 8% reported buying from low or untaxed source; 36% used discount or generic brands, 13.5% used RYO tobacco, 29% reported purchasing cartons, and 63% reported using at least one of these high price avoidance behaviors. Respondents categorized as having low SES were approximately 26% less likely to report using low or untaxed sources and 43% less likely to purchase tobacco by the carton. However, respondents with low SES were 85% more likely to report using discount brands/RYO compared to participants with higher SES. Overall, lower SES smokers were 25% more likely to engage in at least one or more tax avoidance behaviors compared to their higher SES counterparts. Price and tax avoidance behaviors are relatively common among smokers of all SES strata, but strategies differed with higher SES groups more likely to report traveling to a low-tax location to avoid paying higher prices, purchase duty free tobacco, and purchase by cartons instead of packs all of which were less commonly reported by low SES smokers. Because of the strategies lower SES respondents are more likely to use, reducing price differentials between discount and premium brands may have a greater impact on them, potentially increasing the likelihood of quitting.

Citation

King, B., Hyland, A., Borland, R., McNeill, A., Cummings, K.M. (2011). Socioeconomic variation in the prevalence, introduction, retention, and removal of smoke-free policies among smokers: Findings from the International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(2), 411-434.

Abstract

Introduction: Exposure to secondhand smoke causes premature death and disease in non-smokers and indoor smoke-free policies have become increasingly prevalent worldwide. Although socioeconomic disparities have been documented in tobacco use and cessation, the association between socioeconomic status (SES) and smoke-free policies is less well studied.

Methods: Data were obtained from the 2006 and 2007 Waves of the International Tobacco Control Four Country Survey (ITC-4), a prospective study of nationally representative samples of smokers in Canada, the United States, the United Kingdom, and Australia. Telephone interviews were administered to 8,245 current and former adult smokers from October 2006 to February 2007. Between September 2007 and February 2008, 5,866 respondents were re-interviewed. Self-reported education and annual household income were used to create SES tertiles. Outcomes included the presence, introduction, and removal of smoke-free policies in homes, worksites, bars, and restaurants.

Results: Smokers with high SES had increased odds of both having [OR: 1.54, 95% CI: 1.27–2.87] and introducing [OR: 1.49, 95% CI: 1.04–2.13] a total ban on smoking in the home compared to low SES smokers. Continuing smokers with high SES also had decreased odds of removing a total ban [OR: 0.44, 95% CI: 0.26–0.73]. No consistent association was observed between SES and the presence or introduction of bans in worksites, bars, or restaurants.

Conclusions: The presence, introduction, and retention of smoke-free homes increases with increasing SES, but no consistent socioeconomic variation exists in the presence or introduction of total smoking bans in worksites, bars, or restaurants. Opportunities exist to reduce SES disparities in smoke-free homes, while the lack of socioeconomic differences in public workplace, bar, and restaurant smoke-free policies suggest these measures are now equitably distributed in these four countries.

Citation

Wakefield, M.A., Spittal, M.J., Yong, H.H., Durkin, S.J., Borland, R. (2011). Effects of mass media campaign exposure intensity and durability on quit attempts in a population-based cohort study. Health Education Research, 26(6), 988-997.

Abstract

Objective: To assess the extent to which intensity and timing of televised anti-smoking advertising emphasizing the serious harms of smoking influences quit attempts.

Methods: Using advertising gross rating points (GRPs), we estimated exposure to tobacco control and nicotine replacement therapy (NRT) advertising in the 3, 4-6, 7-9 and 10-12 months prior to follow-up of a replenished cohort of 3037 Australian smokers during 2002-08. Using generalized estimating equations, we related the intensity and timing of advertising exposure from each source to the likelihood of making a quit attempt in the 3 months prior to follow-up.

Results: Tobacco control advertising in the 3-month period prior to follow-up, but not in more distant past periods, was related to a higher likelihood of making a quit attempt. Each 1000 GRP increase per quarter was associated with an 11% increase in making a quit attempt [odds ratio (OR) = 1.11, 95% confidence interval (CI) 1.03-1.19, P = 0.009)]. NRT advertising was unrelated to quit attempts.

Conclusions: Tobacco control advertising emphasizing the serious harms of smoking is associated with short-term increases in the likelihood of smokers making a quit attempt. Repeated cycles of higher intensity tobacco control media campaigns are needed to sustain high levels of quit attempts.

Citation

Zhang, J.Y., Borland, R., Coghill, K., Petrovic-Lazarevic, S., Young, D., Yeh, C.H., Bedingfield, S. (2011). Evaluating the effect of health warnings in influencing Australian smokers' psychosocial and quitting behaviours using fuzzy causal network. Expert Systems with Applications, 38(6), 6430-6438.

Abstract

This paper explores the application of fuzzy causal networks (FCNs) to evaluating effect of health warnings in influencing Australian smokers’ psychosocial and quitting behaviour. The sample data used in this study are selected from the International Tobacco Control Policy Evaluation Survey project. Our research findings have demonstrated that new health warnings implemented in Australia have obvious impacts on smokers’ psychosocial and quitting behaviours. FCN is a useful framework to investigate such impacts that overcome the limitation of using traditional statistical techniques, such as linear regression and logistics regression, to analyse non-linear data.

Citation

Hitchman, S.C., Fong, G.T., Zanna, M.P., Hyland, A., Bansal-Travers, M. (2011). Support and correlates of support for banning smoking in cars with children: Findings from the ITC Four Country Survey. European Journal of Public Health, 21(3), 360-365.

Abstract

Background: Since 2006, banning smoking in cars with children has become a rapidly growing tobacco control policy. However, to date, there have been few studies examining support and correlates of support for car smoking bans, and none of the existing studies have been international in nature. We conducted such a study among smokers in four countries.

Methods: 6716 adult current smokers from the 2007 Wave of the International Tobacco Control Four Country Survey, a nationally representative, longitudinal cohort telephone survey of smokers in the USA, Canada, UK and Australia. Controlling for demographics, heaviness of smoking, smoking health knowledge/beliefs and quit intentions, we compared support and correlates of support for banning smoking in cars with children across the four countries.

Results: The majority of smokers supported banning smoking in cars with children. Support was highest in Australia (83%), followed by the UK (75%) and Canada (74%); support was lower—but still high—in the USA (60%). Support was highest among smokers who: had stronger quit intentions, were lighter smokers, had lower education, had no children in the home, believed that cigarette smoke is dangerous to non-smokers and could cause asthma in children, and were concerned about modelling smoking to children.

Conclusions: These findings indicate that a majority of smokers in the four countries support banning smoking in cars with children, and lend support to banning smoking in cars with children. Additionally, they suggest that support may be increased by educating smokers about the dangers of cigarette smoke exposure.

Citation

Seidenberg, A.B., Rees, V.W., Alpert, H.R., O’Connor, R.J., Connolly, G.N. (2011). Ignition strength of 25 international cigarette brands. Tobacco Control, 20(1), 77-80.

Abstract

Background: Cigarette-ignited fires are a leading cause of fire death and injury throughout the world and remain a global public health and safety problem. To reduce this harm, a small number of countries now require cigarettes to have reduced ignition propensity (RIP). It is not known if cigarette manufacturers are voluntarily introducing RIP cigarettes in other countries to help save lives.

Methods: Using the ASTM E2187-04 test method, per cent full length burn (%FLB) was measured for three popular brands from each of seven countries that did not have RIP legislation at the time of purchase. Results were compared with %FLB measurements from four popular US brands purchased in a jurisdiction (Vermont) with an RIP law. SRM 1082 reference cigarette was also tested to assure laboratory quality control.

Results: All cigarette brands purchased in countries not requiring fire safety standards for cigarettes exceeded 75% FLB. In contrast, none of the cigarette brands from the USA exceeded 10% FLB. The SRM 1082 reference cigarette demonstrated 5% FLB.

Conclusion: Cigarette ignition propensity can be greatly reduced through legislation that requires cigarette fire safety standards. RIP cigarettes have the potential to significantly decrease the number of fire deaths, injuries and destruction of property caused by cigarette-ignited fires. Appropriate standards should be applied in cigarette markets globally.