Citation

Li, L., Borland, R., Cummings, K.M., Gravely, S., Quah, A.C.K., Fong, G.T., Miller, C.R., Goniewicz, M.L., Le Grande, M., McNeill, A. (2021). Patterns of non-cigarette tobacco and nicotine use among current cigarette smokers and recent quitters: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 23(9), 1611-1616. doi: https://doi.org/10.1093/ntr/ntab040.

Abstract

Introduction: This study explores patterns of use of non-cigarette tobacco and nicotine products among adult cigarette smokers and recent ex-smokers. Along with cigarette smoking status we explore differences as a function of countries with different product regulations, gender and age.

Methods: Data came from the ITC Four Country Smoking and Vaping Wave 3 Survey conducted between February-June 2020. The analytic sample consisted of 9112 current cigarette smokers (at least monthly) and 1184 recent ex-smokers (quit cigarettes ≤ 2 years) from Australia, Canada, England, and the US. Respondents were asked about their cigarette smoking and current use of the following non-cigarette products: combustible tobacco (cigars, cigarillos, pipe, waterpipe); non-combustible tobacco (smokeless tobacco, and heated tobacco products (HTPs)); and non-tobacco nicotine products (nicotine vaping products (NVPs), nicotine replacement therapy (NRT), and nicotine pouches)).

Results: Overall, NVPs (13.7%) and NRT (10.9%) were the most reported nicotine products used, followed by cigars (5.3%), cigarillos (4.2%), and HTPs (3.5%). More than 21% current and recent ex-smokers of cigarettes reported using a non-tobacco nicotine product and non-combustible product, with respondents in England reporting the highest levels of use (>26%). Males, younger respondents, and current non-daily cigarette smokers were more likely to use non-cigarette nicotine products. Notably, 11.6% of ex-cigarette smokers were using other combustible tobacco.

Conclusion: Considerable percentages of current cigarette smokers and ex-smokers use non-cigarette nicotine products, and there are unexpectedly high levels of use of other combustible products by those recent ex-smokers of cigarettes which is concerning and has important implications for definitions of smoking cessation.

Implications: The tobacco product market has evolved to include new products which add to existing non-cigarette tobacco products creating a much more diverse nicotine market. This brief report provides a snapshot of use of various combustible and non-combustible nicotine containing products among current cigarette smokers and recent ex-smokers in four western countries. Our results indicate that use of non-cigarette tobacco and nicotine products among these cigarette smokers and recent ex-smokers is not low, particularly among males, younger and non-daily cigarette smokers. Use of other combustible tobacco among respondents that recently quit cigarette smoking is concerning and has important implications for definitions of smoking cessation. Increased emphasis on researching non-cigarette nicotine product use is warranted in tobacco control generally and smoking cessation in particular.

Citation

King, B., Borland, R., Morphett, K., Gartner, C., Fielding, K., O’Connor, R.J., Romijnders, K., Talhout, R. (2021). "It's all the other stuff!" How smokers understand (and misunderstand) chemicals in cigarettes and cigarette smoke. Public Understanding of Science, 30(6), 777-796. doi: 10.1177/0963662521991351.

Abstract

Many people understand chemicals as entities that do not occur naturally, and which are also invariably toxic. Tobacco control messages liberally use the term 'chemicals' to evoke these meanings and create concern among smokers. This may reinforce misunderstandings, potentially leading to smokers making harmful choices. To investigate smokers' understandings of chemicals, we conducted qualitative research using 18 individual interviews and three focus groups with Australian smokers and recently quit smokers. The research was guided by the 'mental models' framework and the recently developed Context, Executive, and Operational Systems theory. We discerned two clusters of mental models: the first cluster focused on combustion as the overarching cause of harm (and were largely consistent with the science) and the second cluster focused on additives as causes of harm. We found most participants displayed limited knowledge of the causes of harm from smoking and some held mutually incompatible beliefs. Most participants believed that cigarettes differ significantly in harmfulness according to whether or not they were believed to contain additives. Only a minority understood that the bulk of the toxicants to which smokers are exposed are combustion products. These findings are directly relevant to tobacco control but also have broader relevance to risk communications about toxic exposures.

Citation

Felicione, N., Cummings, K.M., Gravely, S., Hammond, D., McNeill, A., Borland, R., Fong, G.T., O’Connor, R.J. (2021). “Don’t Know” responses for nicotine vaping product features among adult vapers: Findings from the 2018 and 2020 ITC Four Country Smoking and Vaping Surveys. International Journal of Environmental Research and Public Health, 18(15), 7928. doi: 10.3390/ijerph18157928.

Abstract

Nicotine vaping products (NVPs) have evolved rapidly, and some vapers have difficulty reporting about their NVP. NVP knowledge may be important for providing accurate survey data, understanding the potential risks of NVP use, and assessing legal and regulated products. This paper examines current vapers who responded “don’t know” (DK) regarding their NVP features. Data are from adult daily/weekly vapers in Waves Two (2018, n = 4192) and Three (2020, n = 3894) of the ITC Four Country Smoking and Vaping Survey. Analyses assessed DK responses for NVP features (e.g., type/appearance, nicotine) and consumption. A DK index score was computed based on the percent of all features with DK responses, which was tested for associations with demographics, smoking/vaping status, NVP features, purchase location, and knowledge of NVP relative risks. NVP description and appearance were easily identified, but DK was more common for features such as nicotine content (7.3–9.2%) and tank/cartridge volume capacity (26.6–30.0%). DK responses often differed by vaping/smoking status, NVP type/appearance, purchase location, and country. Vapers who are younger, use box-shaped NVPs, purchase online, and exclusive daily vapers were associated with lower DK index scores. Higher DK index scores were associated with poorer knowledge of relative health risks of NVP use. The diversity of the NVP market and wide variation in how products are used makes it challenging to capture information from users about device features, such as nicotine content and capacity, in population surveys.

Citation

Freitas-Lemos, R., Keith, D.R., Tegge, A.N., Stein, J.S., Cummings, K.M., Bickel, W.K. (2021). Estimating the impact of tobacco parity and harm reduction tax proposals using the Experimental Tobacco Marketplace. International Journal of Environmental Research and Public Health,18(15), 7835. doi: 10.3390/ijerph18157835.

Abstract

Taxes are a demonstrably effective method to suppress tobacco use. This study examined the effects of the tobacco parity (i.e., imposing taxes equally on all tobacco products) and the harm reduction (i.e., applying taxes in proportion to the products’ levels of harm) tax proposals on demand and substitution across products. A crowdsourced sample of cigarette smokers (n = 35) completed purchasing trials with increasing tax magnitudes across different tax tiers in the Experimental Tobacco Marketplace in a repeated-measures design. Products were placed in three tax tiers (high, medium, and no tax) according to each proposal’s goal. The results indicated that total nicotine (mg) purchased was not significantly different between the proposals, with higher taxes yielding lower demand. However, as taxes increased, the tobacco parity proposal decreased the purchasing of all tobacco products and increased the purchasing of medicinal nicotine (i.e., the no tax tier). Conversely, the harm reduction proposal resulted in greater purchases of electronic nicotine delivery systems and smokeless tobacco (i.e., the medium tax tier). These findings support tobacco taxation as a robust tool for suppressing purchasing and suggest that differential taxation in proportion to product risk would be an effective way to incentivize smokers to switch from smoked to unsmoked products. Further studies should investigate the unintended consequences of their implementation.

Citation

Levy, D., Sanchez-Romero, L.M., Douglas, C.E., Sweanor, D. (2021). An analysis of the Altria-Juul labs deal: Antitrust and population health implications. Journal of Competition Law and Economics, 17(2), 458-492. doi: 10.1093/joclec/nhaa033.

Abstract

On December 19, 2018, Altria announced an offer of $12.8 billion for Juul Labs, combining the largest U.S. cigarette manufacturer with the largest U.S. e-cigarette company. This deal is currently being challenged by the Federal Trade Commission (FTC). We consider the antitrust implications. We also consider population health implications, which we argue are essential to a comprehensive analysis of the impact on consumers. Although the FTC antitrust investigation has focused on closed vaping systems, we argue that the relevant market is the broader nicotine delivery product market, which includes all vaping products along with tobacco products. With Altria having a large market share in the key nicotine delivery product submarkets and with important entry barriers, the merger potentially places Altria in a dominant position in the relevant market. In particular, competition in the vaping submarket is reduced, thereby likely to reduce the availability of less harmful alternatives to cigarettes.

Citation

Gravely, S., Cummings, K.M., Hammond, D., Borland, R., McNeill, A., East, K., Loewen, R., Martin, N., Yong, H.H., Li, L., Liber, A., Levy, D.T., Quah, A.C.K., Ouimet, J., Hitchman, S.C., Thompson, M.E., Boudreau, C., Fong, G.T. (2021). Self-reported quit aids and assistance used by smokers at their most recent quit attempt: Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey. Nicotine & Tobacco Research, 23(10), 1699-1707. doi: 10.1093/ntr/ntab068.

Abstract

Introduction: This study retrospectively describes smoking cessation aids, cessation services, and other types of assistance used by current and ex-smokers at last quit attempt (LQA) in four high-income countries.

Methods: Data are from the Wave 3 (2020) International Tobacco Control Four Country Smoking and Vaping Survey in Australia, Canada, England, and the US. Eligible respondents were daily smokers or past-daily recent ex-smokers who made a quit attempt/quit smoking in the last 24-months, resulting in 3,614 respondents. Self-reported quit aids/assistance included: nicotine vaping products (NVPs), nicotine replacement therapy (NRT), other pharmacological therapies (OPT: varenicline/bupropion/cytisine), tobacco (non-combustible: heated tobacco product/smokeless tobacco), cessation services (quitline/counseling/doctor), other cessation support (e.g., mobile apps/website/pamphlets etc.), or no aid.

Results: Among all respondents, at LQA, 28.8% used NRT, 28.0% used an NVP, 12.0% used OPT, 7.8% used a cessation service, 1.7% used a tobacco product, 16.5% other cessation support, and 38.6% used no aid/assistance. Slightly more than half of all smokers and ex-smokers (57.2%) reported using any type of pharmacotherapy (NRT or OPT) and/or an NVP, half used NRT and/or an NVP (49.9%), and 38.4% used any type of pharmacotherapy (NRT and/or OPT). A quarter of smokers/ex-smokers used a combination of aids. NVPs and NRT were the most prevalent types of cessation aids used in all four countries; however, NRT was more commonly used in Australia, relative to NVPs, and in England, NVPs were more commonly used than NRT. The use of NVPs or NRT was more evenly distributed in Canada and the US.

Conclusions: It appears that many smokers are still trying to quit unassisted, rather than utilizing cessation aids or other forms of assistance. Of those who did use assistance, NRT and NVPs were the most common method, which appears to suggest that nicotine substitution is important for smokers when trying to quit smoking.

Citation

Edwards, R., Johnson, E., Stanley, J., Waa, A., Ouimet, J., Fong, G.T. (2021). Support for New Zealand’s Smokefree 2025 goal and key measures to achieve it: Findings from the ITC New Zealand Survey. Australian & New Zealand Journal of Public Health, 45(6), 554-561 .

Abstract

Objectives: To assess support among smokers and recent quitters for the Smokefree New Zealand (NZ) 2025 goal and measures to facilitate its achievement. Methods: Data from CATI interviews with 1,155 (386 Māori) smokers and recent quitters in Wave 1 (August 2016–April 2017) and 1,020 (394 Māori) in Wave 2 (June–December 2018) of the International Tobacco Control (ITC) NZ Survey. Results: (Wave 2 unless stated): Almost all (95%) participants were aware of and more than half (56%) supported the smokefree goal. Support was highest (69–92%) for measures to reduce smoking uptake and protect children from exposure to secondhand smoke. Support was also high for other smokefree policies including mandated denicotinisation of smoked tobacco products (73%) and tobacco retailer licensing (70%, Wave 1). Support was lowest (<30%) for increasing the tobacco tax, but higher (59%) if additional revenue raised was used to help smokers to quit. Support for Smokefree 2025 and key measures to achieve it was generally higher among ex-smokers than smokers but mostly similar among Māori and non-Māori participants. Conclusions: There is substantial support among smokers and ex-smokers for the Smokefree 2025 goal and many measures that could help achieve it. Implications for public health: Implementing a comprehensive strategy to achieve Smokefree 2025 is likely to be acceptable among New Zealand's smokers and ex-smokers.

Citation

Sánchez-Romero, L.M., Zavala-Arciniega, L., Reynales-Shigematsu, L.M., Sáenz de Miera-Juárez, B., Yuan, Z., Li, Y., Lau, Y.K., Fleischer, N.L., Meza, R., Thrasher, J.F., Levy, D.T. (2021). The Mexico SimSmoke tobacco control policy model: Development of a simulation model of daily and nondaily cigarette smoking. PLoS One, 16(6), e0248215. doi: 10.1371/journal.pone.0248215.

Abstract

Background: Nondaily smoking has been on the rise, especially in Mexico. While Mexico has strengthened its tobacco control policies, their effects on nondaily smokers have gone largely unexamined. We developed a simulation model to estimate the impact of tobacco control policies on daily and nondaily smoking in Mexico.

Methods: A previously validated Mexico SimSmoke model that estimated overall trends in smoking prevalence from 2002 through 2013 was extended to 2018 and adapted to distinguish daily and nondaily smoking prevalence. The model was then validated using data from Mexican surveys through 2016. To gauge the potential effects of policies, we compared the trends in smoking under current policies with trends from policies kept at their 2002 levels.

Results: Between 2002 and 2016, Mexico SimSmoke underestimated the reduction in male and female daily smoking rates. For nondaily smoking, SimSmoke predicted a decline among both males and females, while survey rates showed increasing rates in both genders, primarily among ages 15–44. Of the total reduction in smoking rates predicted by the model by 2018, tax policies account for more than 55%, followed by health warnings, cessation treatment, smoke-free air laws, and tobacco control spending.

Conclusions: Although Mexico SimSmoke did not successfully explain trends in daily and nondaily smoking, it helps to identify gaps in surveillance and policy evaluation for nondaily smokers. Future research should consider appropriate measures of nondaily smoking prevalence, trajectories between daily and nondaily smoking, and the separate impact of tobacco control policies on each group.

Citation

King, B., Borland, R., Le Grande, M., O’Connor, R.J., Fong, G.T., McNeill, A., Hatsukami, K., Cummings, K.M. (2021). Smokers’ awareness of filter ventilation, and how they believe it affects them: Findings from the ITC Four Country Smoking and Vaping Survey. Tobacco Control, [Published online June 15, doi: 10.1136/tobaccocontrol-2020-056134].

Abstract

Background: Filter ventilation creates sensations of ‘lightness’ or ‘smoothness’ and is also highly effective for controlling machine-tested yields of tar, nicotine and carbon monoxide. Nearly all factory-made cigarettes (FMC) now have filter ventilation in countries such as Australia, Canada, the UK and the USA. Research conducted before ‘light’ and ‘mild’ labelling was banned found low smoker awareness of filter ventilation and its effects. This study explores current levels of awareness of filter ventilation and current understanding of its effects in these four countries.

Methods: We used data from the 2018 wave of the ITC Four Country Smoking and Vaping Survey with samples from USA, England, Canada and Australia. Analyses were conducted initially on a weighted sample of 11 844, and subsequently on 7541 daily FMC smokers.

Findings: Only 40.3% of all respondents reported being aware of filter ventilation. Among daily FMC smokers, only 9.4% believed their cigarettes had filter ventilation. Believing that their usual cigarettes are smoother was positively associated with believing they are also less harmful. Both these beliefs independently predict believing their cigarettes are ventilated (smoother OR=1.97 (95% CI 1.50 to 2.59) and less harmful OR=2.41 (95% CI 1.66 to 3.49) in relation to those believing each characteristic is average.

Interpretation: Awareness of filter ventilation is currently low, despite decades of public ‘education efforts around the misleading nature of ‘light’ and ‘mild” descriptors. Few smokers realise that their cigarettes almost certainly are vented. Smokers who believed their cigarettes have filter ventilation were more likely to believe they were both smoother and less harmful. Awareness of the technology appears to be insufficient to prevent smokers being deceived by it. Filter ventilation is inherently misleading to smokers and it is time to ban it.

Citation

Gravely, S., Craig, L., Cummings, K.M., Ouimet, J., Loewen, R., Martin, N., Chung-Hall, J., Driezen, P., Hitchman, S.C., McNeill, A., Hyland, A., Quah, A.C.K., O’Connor, R.J., Borland, R., Thompson, M.E., Boudreau, C., Fong, G.T. (2021). Smokers’ cognitive and behavioural reactions during the early phase of the COVID-19 pandemic: Findings from the 2020 ITC Four Country Smoking and Vaping Survey. PLoS One, 16(6), e0252427. doi: 10.1371/journal.pone.0252427.

July 14, 2021 | Press Release from University of Waterloo: Unlike other global crises, COVID-19 pandemic did not spark more smoking in its initial stage

Abstract

Introduction: COVID-19 is primarily a respiratory illness, and smoking adversely impacts the respiratory and immune systems; this confluence may therefore incentivize smokers to quit. The present study, conducted in four high-income countries during the first global wave of COVID-19, examined the association between COVID-19 and: (1) thoughts about quitting smoking; (2) changes in smoking (quit attempt, reduced or increased smoking, or no change); and (3) factors related to a positive change (making a quit attempt or reducing smoking) based on an adapted framework of the Health Belief Model.

Methods: This cross-sectional study included 6,870 adult smokers participating in the Wave 3 (2020) ITC Four Country Smoking and Vaping Survey conducted in Australia, Canada, England, and United States (US). These four countries had varying responses to the pandemic by governments and public health, ranging from advising voluntary social distancing to implementing national and subnational staged lockdowns. Considering these varying responses, and the differences in the number of confirmed cases and deaths (greatest in England and the US and lowest in Australia), smoking behaviours related to COVID-19 may have differed between countries. Other factors that may be related to changes in smoking because of COVID-19 were also explored (e.g., sociodemographics, nicotine dependence, perceptions about personal and general risks of smoking on COVID-19). Regression analyses were conducted on weighted data.

Results: Overall, 46.7% of smokers reported thinking about quitting because of COVID-19, which differed by country (p<0.001): England highest (50.9%) and Australia lowest (37.6%). Thinking about quitting smoking because of COVID-19 was more frequent among: females, ethnic minorities, those with financial stress, current vapers, less dependent smokers (non-daily and fewer cigarettes smoked/day), those with greater concern about personal susceptibility of infection, and those who believe COVID-19 is more severe for smokers. Smoking behaviour changes due to COVID-19 were: 1.1% attempted to quit, 14.2% reduced smoking, and 14.6% increased smoking (70.2% reported no change). Positive behaviour change (tried to quit/reduced smoking) was reported by 15.5% of smokers, which differed by country (p = 0.02), where Australia had significantly lower rates than the other three countries. A positive behavioural smoking change was more likely among smokers with: lower dependence, greater concern about personal susceptibility to infection, and believing that COVID-19 is more severe for smokers.

Conclusions: Though nearly half of smokers reported thinking about quitting because of COVID-19, the vast majority did not change their smoking behaviour. Smokers were more likely to try and quit or reduce their smoking if they had greater concern about susceptibility and severity of COVID-19 related to smoking. Smokers in Australia were least likely to reduce or try to quit smoking, which could be related to the significantly lower impact of COVID-19 during the early phase of the pandemic, relative to the other countries.

Citation

Freitas Lemos, R, Stein, J.S., Pope, D.A., Brown, J., Feinstein, M, Stamborski, KM, Tegge, A.N., Heckman, B.W., Bickel, W.K. (2022). E-liquid purchase as a function of workplace restriction in the Experimental Tobacco Marketplace. Experimental and Clinical Psychopharmacology, 30(3), 371-377.

Abstract

E-cigarette use is prohibited in most smoke-free environments. The effect of this policy on tobacco consumption could be examined using the Experimental Tobacco Marketplace (ETM). The ETM allows observation of policy on smokers’ purchasing behavior under conditions that simulate “real-world” circumstances. A within-subject design was used to evaluate the effect of workplace policy (Vaping Allowed vs. Not Allowed) and nicotine concentration (24 mg/mL vs. 0 mg/mL) on tobacco product consumption. Participants (n = 31) completed one sampling and two ETM/workplace sessions per week for 2 weeks. During the sampling session, participants were given an e-cigarette with a 2-day supply of a commercially available e-liquid of their preferred flavor. Before purchasing, participants were informed whether e-cigarette use was permitted. During the four ETM sessions, participants purchased for the following 24 hr, including the 4-hr work shift that started immediately after buying products in the ETM. The workplace session consisted of data entry tasks in a mock office environment. Participants could use any purchased tobacco products during two 15-min breaks. Condition order was counterbalanced. The results show that permitting E-cigarette use in the workplace increased e-liquid purchase on average, but nicotine concentration had no effect on e-liquid demand. Cigarette demand was unaltered across conditions. The present study suggests that allowing e-cigarette use in the workplace would increase demand for e-liquid regardless of nicotine strength. However, it would not change conventional cigarette demand.

Citation

Fong, G.T., Yuan, J., Craig, L.V., Xu, S.S., Meng, G., Quah, A.C.K., Seo, H.G., Lee, S., Yoshimi, I., Katanoda, K., Tabuchi, T. (2021). Achieving the Goals of Healthy China 2030 Depends on Increasing Smoking Cessation in China: Comparative Findings from the ITC Project in China, Japan, and the Republic of Korea. China CDC Weekly, 3(22), 463-467. doi: 10.46234/ccdcw2021.120.

Abstract

Tobacco smoking is the number one preventable cause of disease and death in China, as it is globally. Indeed, the toll of smoking in China is much greater than its status as the world’s most populous country. There is a persistent and continuing need for China to implement the measures specified in the global tobacco control treaty, the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), which China ratified in 2005. The theme for the 2021 WHO World No Tobacco Day focuses on the need to support smoking cessation. This article presents findings from the International Tobacco Control (ITC) Policy Evaluation Project cohort surveys in China, in comparison to ITC cohort surveys in two neighboring countries: Japan and the Republic of Korea. These findings demonstrate that smokers in China very much want to quit, but these intentions are not being translated into quit attempts, relative to smokers in Japan and the Republic of Korea. Additionally, about 80% of Chinese smokers want the Chinese government to do more to control smoking. These findings reaffirm the need for China to implement strong, evidence based measures to reduce smoking. The objective of Healthy China 2030 to reduce deaths from noncommunicable diseases by 30% can be achieved by reducing smoking prevalence from its current 26.6% to 20%, and this reduction can be achieved through strong implementation of FCTC measures.

Citation

Freitas Lemos, R., Stein, J.S., Tegge, A.N., Kaplan, B.A., Heckman, B.W., Cummings, K.M., Bickel, W.K. (2021). The Illegal Experimental Tobacco Marketplace I: Effects of vaping product bans. Nicotine and Tobacco Research, 23(10), 1744–1753.

Abstract

Objectives: Banning vaping products may have unintended outcomes, such as increased demand for illegal products. This study experimentally examined the effects of a vaping ban and a flavored vaping ban on the probability of purchasing illicit vaping products, and factors affecting purchasing from a hypothetical illegal marketplace.

Methods: A crowdsourced sample of exclusive cigarette smokers, exclusive e-cigarette users, and frequent dual users (n=150) completed hypothetical purchasing trials in an Experimental Tobacco Marketplace under three conditions (no ban, vaping ban, flavored vaping ban). Participants chose to purchase in a hypothetical legal experimental tobacco marketplace (LETM) or illegal experimental tobacco marketplace (IETM). Vaping products were available in each marketplace depending on the condition. Other tobacco products were always available in the LETM. A hypothetical illicit purchase task with five fine amounts assessed the effect of monetary penalties.

Results: Participants from all groups were more likely to purchase from the IETM when product availability in the LETM was more restricted, with e-cigarette users being most affected. The likelihood of purchasing illegal products was systematically decreased as monetary penalties associated with the IETM increased, with e-cigarette users showing greater persistence in defending their illicit purchases.

Conclusions: Restricting vaping products from the marketplace may shift preference towards purchasing vaping products in the illegal marketplace. Nevertheless, penalties imposed on consumer's behavior might be effective in preventing illicit trade. The IETM is a methodological extension that supports the utility and flexibility of the ETM as a framework for understanding the impact of different tobacco regulatory policies.

Citation

Smith, T., Nahhas, G., Borland, R., Cho, Y., Chung-Hall, J., Fairman, R.T., Fong, G.T., McNeill, A., Popova, L., Thrasher, J.F., Cummings, K.M. (2021). Which tobacco control policies do smokers support? Findings from the International Tobacco Control Smoking and Vaping Survey. Preventive Medicine, 149, 106600 .

Abstract

As governments consider policy action to reduce smoking, a key factor in creating political will is the level of public support, particularly among smokers who are most affected by the policies. The goal of this paper is to assess and compare the level of support in Canada, the United States, England, and Australia for five smoking control policies: 1) banning menthol in cigarettes, 2) banning cigarette additives, 3) reducing nicotine in cigarettes to make them less addictive, 4) raising the minimum age to purchase cigarettes to 21 years and older, and 5) requiring pictorial warning labels on cigarette packs (examined in the US only). Data for these analyses come from 8165 daily cigarette smokers who responded to the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. In all countries, the highest level of support was for raising the legal age for purchase to 21 years and older (62-70%) and reducing the nicotine content of cigarettes to make them less addictive (57-70%). Smokers who were less dependent on cigarettes and those expressing interest in quitting were more likely to support all policies. When asked how they would respond to a nicotine reduction policy, the most common response given was to try the non-nicotine cigarettes to see how they liked them (42-48%), with the next most common response being to quit smoking entirely (16-24%). The high level of support for these proposed policies among daily smokers provides important evidence for policymakers to counteract claims that such policies would be unpopular.

Citation

Levy, D.T., Sánchez-Romero, L.M., Travis, N., Yuan, Z., Li, Y., Skolnick, S., Jeon, J., Tam, J., Meza, R. (2021). US nicotine vaping product SimSmoke Simulation Model: The effect of vaping and tobacco control policies on smoking prevalence and smoking-attributable deaths. International Journal of Environmental Research and Public Health, 18(9), 4876. doi:10.3390/ijerph18094876.

Abstract

The public health impact of nicotine vaping products (NVPs) is subject to a complex set of uncertain transitions between NVP and cigarette use. Instead, we apply an indirect method to gauge the impact of NVP use on smoking prevalence and smoking-attributable deaths (SADs) using the well-established SimSmoke tobacco control policy simulation model. Upon validating the model before NVPs were more widely used, we project a No-NVP (i.e., in the absence of NVPs) while controlling for the impact of cigarette-oriented policies. The net impact of NVPs on smoking prevalence is inferred by comparing the projected No-NVP smoking trends to corresponding trends from two US national surveys. Using the TUS-CPS estimates for the period 2012–2018, we estimate that adult smoking prevalence declined in relative terms by 9.7% (95% CI: 7.5–11.7%) for males and 10.7% (95% CI: 9.1–13.0%) for females. Compared to NHIS, smoking prevalence declined by 10.7% (95% CI: 6.8–14.6%) for males and 11.3% (95% CI: 7.4–15.6%) for females. These impacts were confined mainly to ages 18–44. Vaping-related reductions in smoking prevalence were projected to avert nearly 0.4 million SADs between 2012 and 2052. Our analysis indicates that NVP use is associated with substantial reductions in US smoking prevalence among younger adults.

Citation

Levy, D., Sánchez-Romero, L.M., Li, Y., Yuan, Z., Travis, N., Jarvis, M.J., Brown, J., McNeill, A. (2021). England SimSmoke: The impact of nicotine vaping on smoking prevalence and smoking-attributable deaths in England. Addiction, 116(5), 1196-1211.

Abstract

Background and Aims: Whereas the use of nicotine vaping products (NVPs) is widespread, their impact on smoking prevalence is controversial. This study considered the potential impact of NVPs on smoking prevalence in England.

Design: Indirect simulation model. The England SimSmoke model is validated through 2012, before NVP use became more widely used by smokers. Because information on NVP‐related transitions is limited, an indirect method is used; the difference in observed smoking prevalence (reflecting NVPs) is compared with a 2012–2019 counterfactual No‐NVP scenario (without NVPs) to estimate the impact of NVPs on smoking and smoking‐attributable deaths.

Setting: England, 2000–2019.

Participants: Nationally representative sample of population.

Measurements: England's population, mortality rates and smoking prevalence estimates from three national surveys and tobacco control policies.

Findings: Between 2000 and 2012, SimSmoke projected a decline in age 18+ smoking prevalence of 23.5% in men and 27.0% in women. These projections, as well as those by specific age groups, were generally consistent with findings from the three national surveys. Comparing 2012–2019 relative reduction in age 18+ prevalence from the Annual Population Survey (males, 27.5%) with the model‐predicted No‐NVP reduction (males, 7.3%), the implied NVP‐attributable relative reduction in adult smoking prevalence was 20.2% (95% CI, 18.8%–22.0%) for males and 20.4% (18.7%–22.2%) for females. The NVP‐attributable reduction was 27.2% (22.8%–31.6%) for males and 31.7% (27.4%–36.5%) for females ages 18–24 and 18.6% (15.2%–21.8%) for males and 15.0% (11.1%–18.8%) for females ages 25–34, with similar reductions for ages 35+. The implied reduction in smoking prevalence between 2012 and 2019 equates to 165 660 (132 453–199 501) averted deaths by 2052. Other surveys yielded smaller, but relatively consistent results.

Conclusions: An indirect method of simulation modelling indicates that substantial reductions in smoking prevalence occurred in England from 2012–2019 coinciding with the growth in nicotine vaping product use.

Citation

Yimsaard, P., McNeill, A., Yong, H.H., Cummings, K.M., Chung-Hall, J., Hawkins, S., Quah, A.C.K., Fong, G.T., O’Connor, R.J., Hitchman, S.C. (2021). Gender differences in reasons for using electronic cigarettes and product characteristics: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 23(4), 678-686.

Abstract

Introduction:

Little is known about why males are more likely to use electronic cigarettes (ECs) compared to females. This study examined gender differences in reasons for vaping and characteristics of EC used (device type, device capacity, e-liquid nicotine strength, and flavour).

Methods:

Data from 3,938 current adult (18+ years) at-least-weekly EC users who participated in Wave 2 (2018) ITC Four Country Smoking and Vaping Survey in Canada, the United States, England, and Australia.

Results:

Of the sample, 54% were male. The most commonly cited reasons for vaping in females were ‘less harmful to others’ (85.8%) and in males were ‘less harmful than cigarettes’ (85.5%), with females being more likely to cite ‘less harmful to others’ (adjusted odds ratio (aOR)=1.64, p=0.001) and ‘help cut down on cigarettes’ (aOR=1.60, p=0.001) than males. Significant gender differences were found in EC device type used (χ2=35.05, p=0.043). Females were less likely to report using e-liquids containing >20 mg/ml of nicotine, and tank devices with >2ml capacity (aOR=0.41, p<0.001 and aOR=0.65, p=0.026, respectively) than males. There was no significant gender difference in use of flavoured e-liquids, with fruit being the most common flavour for both males (54.5%) and females (50.2%).

Conclusion:

There were some gender differences in reasons for vaping and characteristics of the product used. Monitoring of gender differences in patterns of EC use would be useful to inform outreach activities and interventions for EC use.

Implications:

Our findings provide some evidence of gender differences in reasons for vaping and characteristics of EC used. The most common reason for vaping reported by females was ‘less harmful to others’, which may reflect greater concern by female vapers about the adverse effects of second-hand smoke compared to male vapers. Gender differences might be considered when designing gender sensitive smoking cessation policies. Regarding characteristics of EC products used, we found gender differences in preferences for e-liquid nicotine strength and device capacity. Further studies should examine whether the observed gender differences in EC use reasons and product characteristics are predictive of smoking cessation. Furthermore, studies monitoring gender-based marketing of ECs may be considered.

Citation

Levy, D., Tam, J., Sanchez-Romero, L.M., Li, Y., Yuan, Z., Travis, N, Jeon, J, Meza, R. (2021). Public health implications of vaping in the USA: The smoking and vaping simulation model. Population Health Metrics, 19(1), 19. doi: 10.1186/s12963-021-00250-7.

Abstract

Background: Nicotine vaping products (NVPs) are increasingly popular worldwide. They may provide public health benefits if used as a substitute for smoking, but may create public health harms if used as a gateway to smoking or to discourage smoking cessation. This paper presents the Smoking and Vaping Model (SAVM), a user-friendly model which estimates the public health implications of NVPs in the USA.

Methods: SAVM adopts a cohort approach. We derive public health implications by comparing smoking- and NVP-attributable deaths and life-years lost under a No-NVP and an NVP Scenario. The No-NVP Scenario projects current, former, and never smoking rates via smoking initiation and cessation rates, with their respective mortality rates. The NVP Scenario allows for smoking- and NVP-specific mortality rates, switching from cigarette to NVP use, separate NVP and smoking initiation rates, and separate NVP and smoking cessation rates. After validating the model against recent US survey data, we present the base model with extensive sensitivity analyses.

Results: The SAVM projects that under current patterns of US NVP use and substitution, NVP use will translate into 1.8 million premature smoking- and vaping-attributable deaths avoided and 38.9 million life-years gained between 2013 and 2060. When the NVP relative risk is set to 5%, the results are sensitive to the level of switching and smoking cessation rates and to a lesser extent smoking initiation rates. When the NVP relative risk is raised to 40%, the public health gains in terms of averted deaths and LYL are reduced by 42% in the base case, and the results become much more sensitive to variations in the base case parameters.

Discussion: Policymakers, researchers, and other public health stakeholders can apply the SAVM to estimate the potential public health impact of NVPs in their country or region using their own data sources. In developing new simulation models involving NVPs, it will be important to conduct extensive sensitivity analysis and continually update and validate with new data.

Conclusion: The SAVM indicates the potential benefits of NVP use. However, given the uncertainty surrounding model parameters, extensive sensitivity analysis becomes particularly important.

Citation

Levy, D., Cummings, K.M., Heckman, B.W., Li, Y., Yuan, Z., Smith, T., Meza, R. (2021). The public health gains had cigarette companies chosen to sell very low nicotine cigarettes. Nicotine and Tobacco Research, 23(3), 438-446

Abstract

Introduction: The U.S. Food and Drug Administration (FDA) has proposed lowering the nicotine content of cigarettes to a minimally addictive level to increase smoking cessation and reduce initiation. This study has two aims: (1) to determine when cigarette manufacturers had the technical capability to reduce cigarette nicotine content and (2) to estimate the lost public health benefits of implementing a standard in 1965, 1975, or 1985.

Methods: To determine the technical capability of cigarette companies, we reviewed public patents and internal cigarette company business records using the Truth Tobacco Industry Documents. To evaluate the impact of a very low nicotine content cigarette (VLNC) standard on smoking attributable deaths (SADs) and life-years lost (LYLs), we applied a validated (CISNET) model that uses past smoking data, along with estimates of the potential impact of VLNCs derived from expert elicitation.

Results: Cigarette manufacturers recognized that cigarettes were deadly and addictive before 1964. Manufacturers have had the technical capability to lower cigarette nicotine content for decades. Our model projected that a standard implemented in 1965 could have averted 21 million SADs (54% reduction) and 272 million LYLs (64% reduction) from 1965 to 2064, a standard implemented in 1975 could have averted 18.9 million SADs and 245.4 million LYLs from 1975 to 2074, and a standard implemented in 1985 could have averted 16.3 million SADs and 211.5 million LYLs from 1985 to 2084.

Conclusions: Millions of premature deaths could have been averted if companies had only sold VLNCs decades ago. FDA should act immediately to implement a VLNC standard.

Implications: Prior research has shown that a mandated reduction in the nicotine content of cigarettes could reduce the prevalence of smoking and improve public health. Here we report that cigarette manufacturers have had the ability to voluntarily implement such a standard for decades. We use a well-validated model to demonstrate that millions of smoking attributable deaths and life-years lost would have been averted if the industry had implemented such a standard.

Citation

Hammond, D., Wadsworth, E., Reid, J., Burkhalter, R. (2021). Prevalence and modes of cannabis use among youth in Canada, England, and the US, 2017 to 2019. Drug and Alcohol Dependence, 219, 108505.

Abstract

Objective: Cannabis markets are evolving in terms of greater diversity and potency of products. The current study examined changes in cannabis use and modes of consumption among 16- to 19-year-olds in three markets with different regulatory frameworks: England, Canada, and the United States (US).

Methods: Repeat cross-sectional online surveys were conducted in 2017, 2018, and 2019, with samples of 16- to 19-year-olds recruited from commercial panels in Canada (n = 11,779), England (n = 11,117), and the US (n = 11,869). Regression models examined changes in the prevalence of any cannabis use and use of seven modes of consumption, across the countries.

Results: Cannabis use among youth was more prevalent among respondents in Canada and the US than in England in all years and increased to a greater extent between 2017 and 2019 (p < .001 for all contrasts). Among past 30-day cannabis consumers, the prevalence of vaping oils/liquids and the use of cannabis extracts (oil, wax and shatter) increased in all countries, and was significantly higher in Canada and US. For example, the prevalence of vaping oils/liquids increased from 24.2 % in 2017 to 52.1 % in 2019 among past 30-day cannabis consumers in the US (AOR = 3.46, 95 %CI = 2.57-4.66).

Conclusion: Prevalence is increasing for the most potent categories of cannabis products, particularly among youth in Canada and the US. Future research should examine the potential risks of these products and whether shifts in modes of cannabis reflect recent permissive changes to cannabis policy.

Citation

Le Grande, M., Borland, R., Yong, H.H., Cummings, K.M., McNeill, A., Thompson, M.E., Fong, G.T. (2021). Predictive power of dependence measures for quitting smoking: Findings from the 2016-2018 ITC Four Country Smoking and Vaping Surveys. Nicotine and Tobacco Research, 23(2), 276-285.

Abstract

Objective: To test whether urges to smoke and perceived addiction to smoking, have independent predictive value for quit attempts and short-term quit success over and above the Heaviness of Smoking Index (HSI). Methods: Data were from the International Tobacco Control Four Country Smoking and Vaping Wave 1 (2016) and Wave 2 (2018) surveys. 3661 daily smokers (daily vapers excluded) provided data in both waves. A series of multivariable logistic regression models assessed the association of each dependence measure on odds of making a quit attempt and ≥1 month smoking abstinence.

Results: Of the 3661 participants, 1594 (43.5%) reported a quit attempt. Of those who reported a quit attempt, 546 (34.9%) reported short-term quit success. Fully adjusted models showed that making quit attempts was associated with lower HSI [adjusted odds ratio (aOR) = 0.81, 95% confidence interval (CI) = 0.73-0.90, P < 0.001), stronger urges to smoke (aOR = 1.08, 95% CI = 1.04-1.20, P = 0.002), and higher perceived addiction to smoking (aOR =0.52, 95% CI 0.32-0.84, P =0.008). Lower HSI (aOR = 0.57, 95% CI = 0.40–0.87, P < 0.001) weaker urges to smoke (aOR = 0.85, 95% CI = 0.76–0.95, P = 0.006), and lower perceived addiction to smoking (aOR = 0.55, 95% CI =0.32-0.91, P = 0.021) were associated with greater odds of short-term quit success. In both cases overall R2 was around 0.5.

Conclusions: The two additional dependence measures were complementary to HSI adding explanatory power to smoking cessation models, but variance explained remains small.

Implications: Strength of urges to smoke and perceived addiction to smoking may significantly improve prediction of cessation attempts and short-term quit success over and above routinely assessed demographic variables and the HSI. Stratification of analyses by age group is recommended since the relationship between dependence measures and outcomes differ significantly for younger (age 18-39) compared to older (age over 40) participants. Even with the addition of these extra measures of dependence, the overall variance explained in predicting smoking cessation outcomes remains very low. These measures can only be thought of as assessing some aspects of dependence. Current understanding of the factors that ultimately determine quit success remains limited.

Abstract

Introduction: Smokeless tobacco (ST) is the predominant form of tobacco used in Bangladesh and is associated with adverse health outcomes. Bangladesh ratified the World Health Organization's Framework Convention on Tobacco Control (FCTC) in 2004. There are concerns that FCTC legislation and implementation of ST control policy is insufficient in Bangladesh. The aim of this study was to investigate the achievements and challenges of ST policy in Bangladesh and its alignment with the FCTC.

Methods: We conducted semi-structured key informant interviews with 20 stakeholders from government and non-government offices and international funding agencies, including tobacco control advocates, policy makers and non-governmental organisation workers. We used NVivo software to create key themes and the framework method for thematic analysis.

Results: Our findings revealed a lack of national policy in terms of disclosure of harmful contents, illicit trade and standardised packaging of ST. Legislation remains ineffective in relation to graphical health warnings and tax measures. Challenges to ST control identified included inadequate law enforcement; paucity of research, surveillance, and evidence generation; and supply chain control. We identified lack of congruence of ST policies with FCTC due to slow progress in implementation of FCTC measures, lack of a country-specific policy and industry interference. To comply with FCTC, participants recommended strong leadership and political commitment, co-ordination between public and private sectors and proper use of tobacco control resources.

Discussion and conclusions: Bangladesh has adopted several important FCTC

Citation

East, K., Hitchman, S.C., McNeill, A., Ferguson, S., Yong, H.H., Cummings, K.M., Fong, G.T., Borland, R. (2021). Trends in social norms towards smoking between 2002 and 2015 among daily smokers: Findings from the International Tobacco Control Four Country Survey (ITC 4C). Nicotine and Tobacco Research, 23(1), 203-211. doi: 10.1093/ntr/ntz179

Abstract

Objective: To assess trends in daily smokers’ social norms and opinions of smoking between 2002 and 2015 in Canada, US, UK and Australia.

Method: Data were from Waves-1 (2002) to -9 (2013-2015) of the longitudinal International Tobacco Control Four Country Survey (Canada, US, UK, Australia), involving 23,831 adult daily smokers. Generalised estimating equation logistic regression models, adjusted for demographics and survey design effects, assessed associations of Wave and country with outcomes: (i) over half of five closest friends smoke, (ii) agreeing that people important to you believe you should not smoke, (iii) agreeing that society disapproves of smoking, and (iv) negative opinion of smoking.

Results: Between 2002 and 2015, adjusting for covariates, (i) over half of five closest friends smoke did not change (56% vs. 55%; Adjusted Odds Ratio [AOR]=0.95[95% Confidence Interval=0.85-1.07]), (ii) agreeing that people important to you believe you should not smoke generally decreased (89% vs. 82%; AOR=0.54[0.46-0.64]) despite an increase around 2006-2007, (iii) agreeing that society disapproves of smoking increased between 2002 and 2006-2007 (83% vs. 87%; AOR=1.38[1.24-1.54]) then decreased until 2013-2015 (78%; AOR=0.74[0.63-0.88]), and (iv) negative opinion of smoking decreased between 2002 and 2010-2011 (54% vs. 49%; AOR=0.83[0.75-0.91]) despite an increase around 2005-2006 and at the final Wave (2013-2015). Except friend smoking, Canada had the greatest, and UK the lowest, anti-smoking social norms and opinions.

Conclusions: Except friend smoking and opinion of smoking, daily smokers’ social norms became less anti-smoking between 2002 and 2015 despite increases around 2006-2007. Several potential explanations are discussed yet remain undetermined.

Implications: Increasingly comprehensive tobacco control policies alongside decreasing smoking prevalence in Canada, the US, the UK, and Australia have led to the assumption that smoking has become increasingly denormalised in these countries. Absent from the literature is any formal assessment of social norms towards smoking over time. Contrary to our hypotheses, this study found that the injunctive social norms of daily smokers became less anti-smoking between 2002 and 2015, despite increases around 2006-2007. There was no change over time in the proportion of daily smokers who report that over half of their five closest friends smoke.

Citation

Callaghan, L., Yong, H., Borland, R., Cummings, K.M., Hitchman, S., Fong, G.T. (2021). What kind of smoking identity following quitting would elevate smokers relapse risk? Addictive Behaviors, 112, 106654.

Abstract

Background: Research has suggested that smokers who quit smoking and continue to identify themselves as a smoker versus a non-smoker are at greater risk of relapse. This study examines the relationship between post-quit smoker identities and relapse risk of former smokers in Australia and the UK comparing those who still identified as a smoker with firm choice to no longer smoke versus those not expressing a firm choice. Cross-country differences were examined.

Methods: Data analysed came from 544 former smokers (quit 1 month or more) who participated in the Australian and UK Waves 9 (2013) and 10 (2014) of the International Tobacco Control (ITC) surveys. Post-quit smoker identities were assessed at baseline and smoking relapse at follow-up.

Results: Baseline self-reported smoker identity independently predicted smoking relapse at 12-month follow-up (p < .01). Compared with the subgroup who identified themselves as smokers trying to quit, those who identified themselves as smokers who had chosen to no longer smoke (OR = 0.01, 95% CI = 0.01-0.25, p < .001), ex-smokers (OR = 0.05, CI = 0.01-0.25, p < .001) or non-smokers (OR = 0.07, CI = 0.02-0.37, p < .001) were less likely to relapse at follow-up. No cross-country differences were found.

Conclusions: Following quitting, smokers who maintained a smoker identity with a firm choice to no longer smoke or adopted a non-smoker or ex-smoker identity were less likely to relapse than those who failed to do so, suggesting that a clear rule/commitment to not smoke and/or a shift to a non-smoking identity may be protective of relapse.

Citation

Cheng, K.-W., Shang, C., Lee, H.M., Chaloupka, F.J., Fong, G.T., Borland, R., Heckman, B.W., Hithchman, S.C., O’Connor, R.J., Levy, D.T., Cummings, K.M. (2021). Costs of vaping: Evidence from ITC Four Country Smoking and Vaping Survey. Tobacco Control, 30(1), 94-97.

Abstract

Study objectives: To compare the prices paid for nicotine vaping products (NVPs) and supplies among current NVP users to prices paid for cigarettes among current smokers.

Data: The 2016 International Tobacco Control Four Country Vaping and Smoking Survey (4CV1). Key measures included: (1) self-reported prices paid for reusable NVPs (eg, rechargeable devices with cartridges and tank system devices with e-liquids) in the 3-month period prior to the survey among current NVP users, (2) prices paid for disposable NVPs, cartridges and e-liquids purchased in the last 30 days among current NVP users and (3) self-reported prices paid for cigarettes among current smokers.

Results: Disposable NVP price was higher than the price of a comparable unit for combustible cigarettes in England (EN), USA and Canada (CA). Prefilled cartridge price was higher than the price of a comparable unit of cigarettes in USA and CA, but lower in EN and Australia. E-liquid price was consistently lower than the price of a comparable unit of cigarettes across four countries. For start-up costs, price of a rechargeable device is approximately 3–5 times higher than a pack of cigarettes in four countries.

Conclusion: NVP prices were generally higher than prices of combustible cigarettes, especially the high upfront NVP devices. The high upfront costs of purchasing a reusable NVP may discourage some smokers from switching to vaping. However, the average lower costs of cartridges and e-liquids relative to a package of cigarettes make switching to a NVP an attractive alternative to smoking in the long term so long as smokers switch completely to vaping.