Citation

Hammond, D., Reid, J., Burkhalter, R., Rynard, V.L. (2020). E-cigarette marketing regulations and youth vaping: Cross-sectional surveys, 2017-2019. Pediatrics, 146(1), e20194020.

Abstract

Background

Increased electronic cigarette (e-cigarette) use among young people is often attributed to industry marketing practices; however, the effectiveness of regulations that limit e-cigarette advertising and promotions has yet to be examined. New federal legislation that liberalized the Canadian e-cigarette market in May 2018, along with differences in provincial regulations, provides an opportunity to examine the impact of regulatory restrictions on e-cigarette marketing.

Methods

Repeat cross-sectional surveys of 12 004 16- to 19-year-olds in Canada, completed online in 2017, 2018, and 2019. Logistic regression models were used to examine differences over time in exposure to e-cigarette marketing and e-cigarette use, including between provinces with differing strengths of marketing restrictions. Results: The percentage of youth surveyed who reported noticing e-cigarette promotions often or very often approximately doubled between 2017 and 2019 (13.6% vs 26.0%; adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.97-2.56). Overall exposure to marketing was generally more prevalent in provinces with fewer regulatory restrictions. Respondents who reported noticing marketing often or very often were more likely to report vaping in the past 30 days (AOR = 1.41, 95% CI = 1.23-1.62), past week (AOR = 1.44, 95% CI = 1.22-1.70), and ≥20 days in the past month (AOR = 1.42, 95% CI = 1.11-1.81, P = .005). Provinces with low restrictions on marketing had higher prevalence of vaping in the past 30 days (AOR = 1.50, 95% CI = 1.25-1.80, P < .001), and in the past week (AOR = 1.65, 95% CI = 1.332.05, P < .001).

Conclusions

Exposure to marketing and the prevalence of vaping increased among Canadian youth after the liberalization of the e-cigarette market in 2018. Comprehensive provincial restrictions on e-cigarette marketing were associated with lower levels of exposure to marketing and lower prevalence of e-cigarette use

Citation

Kahnert, S., Driezen, P., Balmford, J., Kyriakos, C.N., Demjén, T., Fernández, E., Katsaounou, P.A., Trofor, A.C., Przewoźniak, K., Zatoński, W.A., Fong, G.T., Vardavas, C.I., Mons, U. (2020). Impact of the Tobacco Products Directive on self-reported exposure to e-cigarette advertising, promotion and sponsorship in smokers: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Supplement_3), iii55-iii61.

Abstract

Background

Advertising, promotion and sponsorship of electronic cigarettes (ECAPS) have increased in recent years. Since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) prohibits ECAPS in various advertising channels, including media that have cross-border effects. The objective of this study was to investigate changes in exposure to ECAPS in a cohort of smokers from six European Union member states after implementation of TPD2.

Methods

Self-reported exposure to ECAPS overall and in various media and localities was examined over two International Tobacco Control Policy Evaluation survey waves (2016 and 2018) in a cohort of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal generalized estimating equations models.

Results

Self-reported ECAPS exposure at both timepoints varied between countries and across examined advertising channels. Overall, there was a significant increase in ECAPS exposure [adjusted odds ratio (aOR): 1.25, 95% CI: 1.09–1.44]. Between waves, no consistent patterns of change in ECAPS exposure across countries and different media were observed. Generally, ECAPS exposure tended to decline in some channels regulated by TPD2, particularly on television and radio, while exposure tended to increase in some unregulated channels, such as at points of sale.

Conclusions

The findings suggest that the TPD2 was generally effective in reducing ECAPS in regulated channels. Nonetheless, further research is warranted to evaluate its role in reducing ECAPS exposure, possibly by triangulation with additional sources of data.

Citation

Levy, D., Douglas, C.E., Sanchez-Romero, L.M., Cummings, K.M., Sweanor, D. (2020). An analysis of the FCTC’s attempt to stop the Altria-Juul Labs deal. Tobacco Regulatory Science, 6(4), 302-305.

Abstract

On 20 December 2018, Altria, the largest US cigarette company, announced an offer for a 35% share of the large and rapidly growing vaping product company, Juul Labs. On 2 April, 2020, the Federal Trade Commission issued a complaint that the deal was anticompetitive and should be voided. This paper analyzes the deal. We find that the deal gives Altria market power in the e-cigarette market through its support of Juul in retail stores and through the agreement not to otherwise compete in the e-cigarette market. The deal also has implications for its marketing of heated tobacco product IQOS and generally may provide Altria greater control of the broader nicotine delivery product market.

Citation

Edwards, R., Hoek, J., & Waa, A. (2020). E-cigarettes, vaping and a Smokefree Aotearoa: where to next?. The New Zealand Medical Journal (Online), 133(1517), 14-17.

Citation

Braak, D., Cummings, K.M., Nahhas, G.J., Reid, J., Hammond, D. (2020). How are adolescents getting their vaping products? Findings from the International Tobacco Control (ITC) Youth Tobacco and Vaping Survey. Addictive Behaviors, 105, 106345.

Abstract

Objective: To examine the sources of vaping products reported by adolescents, and the characteristics of adolescents who reported purchasing a vaping product in the past year in the United States (US), Canada (CA), and England (EN).

Methods: Data were from the 2017 ITC Youth Tobacco and Vaping Survey, a web-based survey of 12,128 respondents aged 16-19 years recruited from commercial panels in the US, CA, and EN. Respondents who have vaped in the past 12 months were asked whether they had purchased a vaping product, and from where (vape shop, online, retail), as well as whether anyone refused to sell them a vaping product because of their age. Respondents who reported vaping in the past 30 days were asked where they had obtained their vaping product from a social and/or commercial source.

Results: Only about 7.5% of respondents reported having purchased a vaping product in the past year. Among those who had vaped in the past year, 32.6% reported having purchased a vaping product in the past year. Purchasing prevalence was significantly higher among US respondents compared to those from CA and EN; purchase prevalence was also higher among Canadian adolescents than respondents from England. The most commonly reported purchase location for vaping products in all counties was vape shops. Among past 30-day vapers, 42.5% reported getting their vaping products only from social sources, 41.4% only from commercial sources, and 13.4% from both types of sources. Purchasing a vaping product in the past year was associated with being male, of legal age to buy tobacco and vaping products, and greater frequency of smoking and vaping in the past 30 days.

Conclusions: Most adolescents have not purchased a vaping product, but among those who had, vape shops were the mostly commonly reported location for buying a vaping product. Purchasing of a vape product was more commonly reported by those who vape more frequently and by those of legal age to buy a vaping product.

Citation

Fong, G. T., & Jiang, Y. (2020). The Importance of Reducing Smoking in China: To Achieve Healthy China 2030 While Reducing the Severity of the COVID-19 Pandemic. China CDC Weekly, 2(22), 404-406.

No abstract available.

Citation

Thomas, D.P., Davey, M.E., van der Sterren, A.E., Panaretto, K.S., Lyons, L. (2020). Do stress, life satisfaction, depression and alcohol use predict quitting among Aboriginal and Torres Strait Islander smokers? Australian and New Zealand Journal of Public Health, 44(3), 186-192.

Abstract

Objective: To examine whether baseline measures of stress, life satisfaction, depression and alcohol use predict making or sustaining quit attempts in a national cohort of Aboriginal and Torres Strait Islander smokers.

Methods: We analysed data from the nationally representative quota sample of 1,549 Aboriginal and Torres Strait Islander adults who reported smoking at least weekly in the Talking About The Smokes baseline survey (April 2012–October 2013) and the 759 who completed a follow‐up survey a year later (August 2013–August 2014).

Results: More smokers who reported negative life satisfaction, feeling depressed, higher stress or drinking heavily less often than once a week at baseline made a quit attempt between the baseline and follow‐up surveys. In contrast, of these smokers who had made quit attempts between surveys, more who reported higher stress were able to sustain abstinence for at least one month; other associations were inconclusive.

Conclusions and implications for public health: Health staff and Aboriginal and Torres Strait Islander smokers need not see being more stressed as an obstacle to quitting among Aboriginal and Torres Strait Islander people. Health staff should emphasise the benefits to mental health that come with successfully quitting smoking.

Citation

Cummings, K.M., Nahhas, G., Sweanor, D. (2020). What is accounting for the rapid decline in cigarette sales in Japan? International Journal of Environmental Research and Public Health, 17(10), 3570.

Abstract

This study describes how trends in the sale of cigarettes in Japan between 2011 and 2019 correspond to the sales of heated tobacco products (HTPs) that were introduced into the Japanese market in late 2015. Data used for this study come from the Tobacco Institute of Japan and Philip Morris International. The findings show that the accelerated decline in cigarette only sales in Japan since 2016 corresponds to the introduction and growth in the sales of HTPs.

Citation

Hammond, D., Rynard, V.L., Reid, J. (2020). Changes in prevalence of vaping among youth in the United States, Canada, and England, 2017 to 2019. JAMA Pediatrics, 174(8), 797-800.

Abstract

This cohort study examines rates of vaping and smoking among youths aged 16 to 19 years in the United States, Canada, and England from 2017 to 2019

Citation

van Mourik, D.J.A., Nagelhout, G.E., Willemsen, M.C., van den Putte, B., de Vries, H. (2020). Differences in smokers’ awareness of the health risks of smoking before and after introducing pictorial tobacco health warnings: Findings from the 2012–2017 International Tobacco Control (ITC) Netherlands Surveys. BMC Public Health, 20, 512.

Abstract

Background: As of May 2016, pictorial health warnings (PHWs) showing the harms of smoking were implemented in the European Union. After one year they had to be fully implemented. We studied changes in awareness of the health risks of smoking after implementation of PHWs among smokers from the Netherlands, whether the trend before the implementation changed after the implementation, and whether there were differences between subgroups.

Methods: We used survey data from six yearly waves of the International Tobacco Control (ITC) Netherlands Survey from 2012 to 2017. The number of participating smokers ranged between 1236 and 1604 per wave. Data were analyzed using Generalized Estimating Equations (GEE) analyses.

Results: Indicators of awareness of the health risks of smoking that did not change between 2015 and 2017 were perceived susceptibility (β = 0.043, p = 0.059) and perceived severity (β = − 0.006, p = 0.679) regarding lung problems. Perceived susceptibility, however, was more pronounced between 2015 and 2017 than between 2012 and 2015(p value of interaction: p = 0.044). Noticing information about the dangers of smoking (β = 0.119, p < 0.001) and knowledge about the health risks of smoking (β = 0.184, p < 0.001) increased between 2015 and 2017. These increases were both more pronounced when compared to 2012–2015 (p values of interactions: p = 0.002 and p < 0.001 respectively). Compared to high educated smokers, low educated smokers (β = − 1.137, p < 0.001) and moderate educated smokers (β = − 0.894, p < 0.001) were less knowledgeable about the health risks of smoking in 2016 and 2017.

Conclusions: Introducing PHWs coincided with an increase in smokers’ knowledge about the health risks of smoking. Dutch tobacco control policy and campaigns should focus on improving Dutch smokers’ awareness of the health risks of smoking even more, especially among low educated smokers.

Citation

Schneller, L., Bansal-Travers, M., Mahoney, M.C., McCann, SE, O’Connor, R.J. (2020). Menthol, nicotine, and flavoring content of capsule cigarettes in the US. Tobacco Regulatory Science, 6(3), 196-204.

Abstract

Objectives: In this paper, we characterize physical design features of cigarette brands sold in the United States according to the delivery method of menthol that may affect sensory perception among users.

Methods: We used 12 cigarette brands, mentholated and non-mentholated, for analyses of the physical design characteristics, quantification of nicotine and menthol, and identification of flavor additives.

Results: Physical design characteristics did not differ significantly between the various cigarette brands. However, we found statistically significant differences in levels of menthol. Menthol levels were greatest in products that had dual delivery methods of menthol (6.7mg/cigarette; SE = 0.27) followed by products mentholated in a filter capsule only (5.7mg/cigarette; SE = 0.25), and those mentholated in the tobacco only (3.8mg/cigarette; SE = 0.12); products that were not mentholated had the least (0.38mg/cigarette; SE = 0.31). Finally, flavor additives with a mint flavor profile other than menthol were identified, such as pulegone and limonene, and differed between cigarette brands, which are likely contributing to the menthol flavor experience associated with use of these products.

Conclusions: The regulation of menthol delivery method, flavorings added to the capsule, and/or menthol concentration may be beneficial for the public health as these factors are likely creating unique sensory experiences.

Abstract

Objective: To estimate the pooled prevalence of smokeless tobacco consumption (STC) by gender and location in Bangladesh, India and Myanmar and to identify periodic changes in STC prevalence using data extracted from published studies.

Methods: We searched for a combination of keywords in electronic databases and used a standard form to extract data from each article. We undertook a meta-analysis to estimate pooled prevalence and confidence intervals within these countries. To compare periodic changes in STC prevalence, we grouped studies into five-year periods (2000-2004, 2005-2009, 2010-2014 and 2015-2019).

Results: The pooled estimates of STC prevalence were 25% (95% CI: 22-28%), 22% (95% CI: 15-28%) and 21% (95% CI: 14-28%) for Bangladesh, India and Myanmar, respectively. In pooled estimates across these countries, we found higher STC prevalence for men (30%; 95% CI: 24-35%) than women (16%; 95% CI: 10-23%) and for rural dwellings (24%; 95% CI: 18-31%) than urban dwellings (17%; 95% CI: 10-24%). We found significant decrease in STC in Bangladesh and India in the period 2010-2014 and 2015-2019, respectively. In Myanmar, STC prevalence increased significantly and substantially in 2010-2014, to levels higher than in Bangladesh and India.

Conclusions: The prevalence of STC in Bangladesh, India and Myanmar is highest in rural areas and among men. Public health prevention strategies are needed to maintain decrease in STC in Bangladesh and India, and to reverse the increased use in Myanmar.

Citation

Cho, Y., Thrasher, J.F., Cummings, K.M., Yong, H.H., Hitchman, S.C., McNeill, A., Fong, G.T., Hammond, D., Hardin, J., Li, L., Lindblom, E. (2020). Cross-country comparison of cigarette and vaping product marketing exposure and use: Findings from the 2016 ITC Four Country Smoking and Vaping Survey. Tobacco Control, 29(3), 295-304.

Abstract

Objective: To compare exposure to and use of certain cigarette and vaping product marketing among adult smokers and vapers in four countries with contrasting regulations—Australia (AU), Canada, England and the USA.

Data sources: Adult smokers and vapers (n=12 294) from the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Survey (4CV1).

Analysis: Self-reported exposure to cigarette and vaping product advertising through point-of-sale, websites/social media, emails/texts, as well as exposure to and use of price offers were assessed for country differences using logistic regression models adjusted for multiple covariates.

Results: Reported exposure to cigarette advertising exposure at point-of-sale was higher in the USA (52.1%) than in AU, Canada and England (10.5%–18.5%). Exposure to cigarette advertising on websites/social media and emails/texts was low overall (1.5%–10.4%). Reported exposure to vaping ads at point-of-sale was higher in England (49.3%) and USA (45.9%) than in Canada (32.5%), but vaping ad exposure on websites/social media in Canada (15.1%) was similar with England (18.4%) and the USA (12.1%). Exposure to vaping ads via emails/texts was low overall (3.1%–9.9%). Exposure to, and use of, cigarette price offers was highest in the USA (34.0 % and 17.8 %, respectively), but the use rate among those exposed was highest in AU (64.9%). Exposure to, and use of, price offers for vaping products was higher in the USA (42.3 % and 21.7 %) than in AU, Canada and England (25.9%–31.5 % and 7.4%–10.3 %).

Conclusions: Patterns of cigarette and vaping product marketing exposure generally reflected country-specific policies, except for online vaping ads. Implications for research and policy are discussed.

Citation

Hammond, D., Wackowski, O.A., Reid, J., O’Connor, R.J. (2020). Use of JUUL e-cigarettes among youth in the United States. Nicotine and Tobacco Research, 22(5), 827-832.

Abstract

Introduction: JUUL has emerged as the leading brand in a rapidly evolving electronic cigarette (ecigarette) market. JUUL is distinctive for its novel nicotine delivery method that results in high nicotine concentrations, as well as its sleek, discreet design. This study examined national estimates of JUUL among youth in the United States, including whether JUUL users report different patterns of use compared to users of other e-cigarettes.

Methods: Data were analyzed from the US arm of the International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and E-cigarette Survey, an online survey conducted in July-August 2017 with youth aged 16-19 years recruited from consumer panels (n = 4086).

Results: Overall, 14.2% of respondents had used an e-cigarette in the past 30 days. JUUL was the second-most popular brand reported by past-30-day e-cigarette users (9.7%). Compared to e-cigarette users of other brands, JUUL users were significantly older (adjusted odds ratio [aOR] = 2.50, 95% confidence interval [CI] = 1.56 to 4.01) and reported a greater number of computers in the household (a socioeconomic status proxy; aOR = 1.55, 95% CI = 1.22 to 1.96), with no differences by sex, race/ethnicity, or student status. Controlling for sociodemographic variables, JUUL users were more likely than other e-cigarette users to have ever tried to quit e-cigarettes (aOR = 2.65, 95% CI = 1.12 to 6.30), with no differences observed by smoking status, frequency of e-cigarette use, urges to use e-cigarettes, or perceived addiction to e-cigarettes.

Conclusions: JUUL was among the most popular e-cigarette brands among youth, and there were few differences in sociodemographic profile or patterns of use between users of JUUL and other e-cigarette brands.

Implications: This study examined national estimates of JUUL e-cigarette use among youth in the United States, during the early phase of JUUL's popularity. JUUL was among the most popular ecigarette brands among youth, and there were few differences in sociodemographic profile or patterns of use between JUUL and other e-cigarette brands. The findings help to characterize the rapid rise of this new product category within the rapidly evolving e-cigarette market at a time when the US Food and Drug Administration and public health community are seeking to understand JUUL and its appeal among young people.

Citation

Pope, D.A., Poe, L., Stein, J.S., Kaplan, B.A., DeHart, W.B., Mellis, A.M., Heckman, B.W., Epstein, L.H., Chaloupka, F.J., Bickel, W.K. (2020). The Experimental Tobacco Marketplace: Demand and substitutability as a function of cigarette taxes and e-liquid subsidies. Nicotine and Tobacco Research, 22(5), 782-790.

Abstract

Introduction: The experimental tobacco marketplace (ETM) approximates real-world situations by estimating the effects of several, concurrently available products and policies on budgeted purchasing. Although the effects of increasing cigarette price on potentially less harmful substitutability are well documented, the effects of other, nuanced pricing policies remain speculative. This study used the ETM as a tool to assess the effects of two pricing policies, conventional cigarette taxation and e-liquid subsidization, on demand and substitutability.

Methods: During sampling periods, participants were provided 2-day samples of 24 mg/mL e-liquid, after which ETM purchase sessions occurred. Across two ETM sessions, conventional cigarettes were taxed or e-liquid was subsidized in combination with increasing cigarette price. The other four available products were always price constant and not taxed or subsidized.

Results: E-liquid functioned as a substitute for conventional cigarettes across all conditions. Increasing cigarette taxation and e-liquid subsidization increased the number of participants for which e-liquid functioned as a substitute. Cigarette taxation decreased cigarette demand, by decreasing demand intensity, and marginally increased the initial intensity of e-liquid substitution, but did not affect the functions' slopes (substitutability). E-liquid subsidization resulted in large increases in the initial intensity of e-liquid substitution, but did not affect e-liquid substitutability nor cigarette demand.

Implications: 24 mg/mL e-cigarette e-liquid was the only product to significantly substitute for cigarettes in at least one condition throughout the experiment; it functioned as a significant substitute throughout all four tax and all four subsidy conditions. Increasing cigarette taxes decreased cigarette demand through decreases in demand intensity but did not affect e-cigarette substitution. Increasing e-liquid subsidies increased e-liquid initial intensity of substitution but did not affect cigarette demand.

Conclusions: This study extended research on the behavioral economics of conventional cigarette demand and e-liquid substitutability in a complex marketplace. The results suggest that the most efficacious method to decrease conventional cigarette purchasing and increase e-liquid purchasing may involve greatly increasing cigarette taxes while also increasing the value of e-liquid through potentially less harmful product subsidization or differential taxation.

Citation

Gravely, S., Driezen, P., Smith, D.M., Borland, R., Lindblom, E., Hammond, D., McNeill, A., Hyland, A., Cummings, K.M., Chan, G., Thompson, M.E., Boudreau, C., Martin, N., Ouimet, J., Loewen, R., Quah, A.C.K., Goniewicz, M., Thrasher, J.F., Fong, G.T. (2020). International differences in patterns of cannabis use among adult cigarette smokers: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. International Journal of Drug Policy, 79, 102754.

Abstract

Background: Although evidence shows that co-use of cigarettes and cannabis is common, there is little research examining if co-use patterns vary depending on the regulatory environment for cannabis. This study examined patterns of co-use and perceptions of relative harm among cigarette smokers in four countries with different histories, and at different stages of cannabis legalization.

Methods: Data are from the 2018 International Tobacco Control 4CV Survey and included 10035 adult cigarette smokers from Canada, United States (US), Australia, and England. At the time of the survey, Canada and the US had relatively more permissive cannabis regulations compared to Australia and England.

Results: Among this sample of 10035 cigarette smokers, Canada had the highest rate of cannabis co-use in the last 12 months (36.3%), followed by the US (29.1%), England (21.6%), and Australia (21.4%). Among past 12 month co-users (n = 3134), the US (40.2%) and Canada (35.2%) had the highest rates of daily cannabis use, followed by smokers in England (26.3%) and Australia (21.7%); Australian co-users had the highest rate of infrequent (<monthly) cannabis use. The highest proportion of co-users who smoked daily and used cannabis daily was in the US (34.8%), followed by Canada (30.6%), England (25.8%), and Australia (22.7%). More co-users in the US (78.3%) and Canada (73.6%) perceived smoked cannabis to be less harmful than cigarettes than in Australia (65.5%) and England (60.8%). The majority of co-users who used cannabis in the last 30 days had smoked it (92.3%), with those in England more likely to smoke cannabis (95.7%) compared to Canada (88.6%); there were no other differences between countries (US: 92.0%, Australia: 93.0%). Co-users in England (90.4%) and Australia (86.0%) were more likely to mix tobacco with cannabis than co-users in Canada (38.5%) and the US (22.3%).

Conclusion: Patterns of tobacco and cannabis co-use differed between countries. Smokers in Canada and the US had higher rates of co-use, daily cannabis use, dual-daily use of both cannabis and cigarettes, and were more likely to perceive smoked cannabis as less harmful than cigarettes compared to England and Australia.

Citation

Thompson, M.E., Boudreau, C., Quah, A.C.K., Ouimet, J., Li, G., Yan, M., Mochizuki, Y., Yoshimi, I., Fong, G.T. (2020). Survey Methods of the 2018 International Tobacco Control (ITC) Japan Survey. International Journal of Environmental Research and Public Health, 17(7), 2598

Abstract

This paper describes the methods of the Wave 1 (2018) International Tobacco Control (ITC) Japan Survey. The respondents were adults aged 20 years and older in one of four user groups: (1) cigarette-only smokers who smoked at least monthly and used heated tobacco products (HTPs) not at all or less than weekly, (2) HTP-only users who used HTPs at least weekly and smoked cigarettes not at all or less than monthly, (3) cigarette-HTP dual users who smoked at least monthly and used HTPs at least weekly, and (4) non-users who had never smoked or who smoked less than monthly and used HTPs less than weekly. Eligible respondents were recruited by a commercial survey firm from its online panel. Respondents were allocated proportionally to sample strata based on demographic, geographic, and user type specifications benchmarked to a national reference. Survey weights, accounting for smoking/HTP use status, sex, age, education, and geography, were calibrated to benchmarks from a nationally representative survey in Japan. Response rate was 45.1% and cooperation rate was 96.3%. The total sample size was 4615 (3288 cigarette smokers, 164 exclusive HTP users, 549 cigarette-HTP dual users, and 614 non-users). The 2018 ITC Japan Survey sampling design and survey data collection methods will allow analyses to examine prospectively the use of cigarettes and HTPs in Japan and factors associated with the use of both products and of transitions between them.

Citation

Filippidis, F.T., Driezen, P., Kyriakos, C.N., Katsaounou, P.A., Petroulia, I., Girvalaki, C., Fu, M., Fernández, E., Mons, U., Trofor, A.C., Demjén, T., Przewoźniak, K., Zatoński, W.A., Fong, G.T., Tountas, Y., Vardavas, C.I. (2020). Transitions from and to roll-your-own tobacco, perceptions and health beliefs among smokers: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl 3), iii18-iii25.

Abstract

Background: The prevalence of roll-your-own tobacco (RYO) in Europe has been increasing. The aim of this study was to investigate transitions between factory-made (FM) cigarettes and RYO in a longitudinal sample of European smokers, and their perceptions of relative harmfulness and knowledge of health effects.

Methods: We used data collected from the EUREST-PLUS ITC 6 European Country (6E) Surveys in 2016 (n = 6011 smokers) and in 2018 (n = 6027) in Germany, Greece, Hungary, Poland, Romania and Spain. A total of 3195 cohort respondents were interviewed in both years. Use of RYO and FM, knowledge of health effects of smoking as well as perceptions about RYO were assessed. We used logistic regression models to explore sociodemographic correlates of transitions from one product to the other, of perceptions and knowledge related to smoking health effects.

Results: Approximately 7.4% of exclusive FM smokers transitioned to RYO and 29.5% of exclusive RYO smokers transitioned to FM cigarettes from 2016 to 2018. RYO use in 2018 was more frequent among smokers of low education and income, but none of these factors were associated with transitions. Most RYO smokers perceived RYO as cheaper than FM and 21.7% of them considered RYO to be less harmful than FM. Knowledge of the health effects of smoking was not associated with type of product smoked.

Conclusions: RYO is popular among European smokers; its lower cost seems to be a major factor for RYO users; reasons for transitions to and from RYO are less clear and need to be further investigated.

Citation

Gravely, S., Fong, G.T., Sutanto, E., Loewen, R., Ouimet, J., Xu, S.S., Quah, A.C.K., Thompson, M.E., Bordereau, C., Li, G., Goniewicz, M., Yoshimi, I., Mochizuki, Y., Elton-Marshall, T., Thrasher, J.F., Tabuchi, T. (2020). Perceptions of harmfulness of heated tobacco products compared to combustible cigarettes among adult smokers in Japan: Findings from the 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 17(7), 2394.

Abstract

In Japan, the tobacco industry promotes heated tobacco products (HTPs) as a reduced-risk tobacco product. This study examines: (1) smokers’ harm perceptions of HTPs relative to combustible cigarettes; (2) differences in relative harm perceptions between exclusive smokers and smokers who use HTPs (concurrent users) and between concurrent users based on frequency of product use; and (3) if smokers who were exposed to HTP advertising hold beliefs that are consistent with marketing messages of lower harmfulness. This cross-sectional study included 2614 adult exclusive cigarette smokers and 986 concurrent users who reported their perceptions of harmfulness of HTPs compared to cigarettes, as well as their exposure to HTP advertising in the last six months. Among all smokers, 47.5% perceive that HTPs are less harmful than cigarettes, 24.6% perceive HTPs to be equally as harmful, 1.8% perceive HTPs as more harmful, and 26.1% did not know. Concurrent users are more likely than exclusive smokers to believe that HTPs are less harmful (62.1% versus 43.8%, p < 0.0001) and less likely to report that they did not know (14.3% versus 29.4%, p < 0.0001). Frequent HTP users are more likely than infrequent users to believe that HTPs are less harmful (71.7% versus 57.1%, p ≤ 0.001). Believing that HTPs are less harmful than cigarettes was associated with noticing HTP advertising on TV (p = 0.0005), in newspapers/magazines (p = 0.0001), on posters/billboards (p < 0.0001), in stores where tobacco (p < 0.0001) or where HTPs (p < 0.0001) are sold, on social media (p < 0.0001), or in bars/pubs (p = 0.04). HTP users were significantly more likely than non-HTP users to believe that HTPs are less harmful than cigarettes, with this belief being more prominent among frequent users. Smokers who have been exposed to HTP advertising were more likely to perceive HTPs as less harmful than cigarettes.

Citation

Yong, H.H., Karmakar, C., Borland, R., Kusmakar, S., Fuller-Tyszkiewicz, M., Yearwood, J. (2020). Identifying smoker subgroups with high versus low smoking cessation attempt probability: A decision tree analysis approach. Nicotine and Tobacco Research, 103, 106258.

Abstract

Background: Regression-based research has successfully identified independent predictors of smoking cessation, both its initiation and maintenance. However, it is unclear how these various independent predictors interact with each other and conjointly influence smoking behaviour. As a proof-of-concept, this study used decision tree analysis (DTA) to identify the characteristics of smoker subgroups with high versus low smoking cessation initiation probability based on the conjoint effects of four predictor variables, and determine any variations by socio-economic status (SES).

Methods: Data come from the Australian arm of the ITC project, a longitudinal cohort study of adult smokers followed up approximately annually. Reported wanting to quit smoking, worries about smoking negative health impact, quitting self-efficacy and quit intentions assessed in 2005 were used as predictors and reported quit attempts at the 2006 follow-up survey were used as the outcome for the initial model calibration and validation analyses (n = 1475), and further cross-validated using the 2012-2013 data (n = 787).

Results: DTA revealed that while all four predictor variables conjointly contributed to the identification of subgroups with high versus low smoking cessation initiation probability, quit intention was the most important predictor common across all SES strata. The relative importance of the other predictors showed differences by SES.

Conclusions: Modifiable characteristics of smoker subgroups associated with making a quit attempt and any variations by SES can be successfully identified using a decision tree analysis approach, to provide insights as to who might benefit from targeted intervention, thus, underscoring the value of this approach to complement the conventional regression-based approach.

Citation

Sutanto, E., Miller, C., Smith, D.M., Borland, R., Hyland, A., Cummings, K.M., Quah, A.C.K., Xu, S.S., Fong, G.T., Ouimet, J., Yoshimi, I., Mochizuki, Y., Tabuchi, T., O’Connor, R.J., Goniewicz, M. (2020). Concurrent daily and non-daily use of heated tobacco products with combustible cigarettes: Findings from the 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 17(6), 2098

Abstract

Use of heated tobacco products (HTPs) among current smokers is becoming increasingly popular in Japan. This study aims to compare characteristics and tobacco-related behaviors among concurrent users of HTPs and combustible cigarettes (n = 644) with exclusive smokers (n = 3194) or exclusive HTP users (n = 164). The secondary aim was to explore heterogeneity within concurrent use subgroups. Data were from Wave 1 of the ITC Japan Survey, a nationally representative web survey conducted from February to March 2018. Concurrent cigarette-HTP users were younger and wealthier than exclusive smokers. However, there were no difference in the frequency of smoking, number of cigarettes per day, and smoking cessation behaviors between the two groups, suggesting that HTPs reinforce nicotine dependence. Compared to exclusive HTP users, concurrent cigarette-HTP users reported higher frequency of non-daily HTP use, and lower number of tobacco-containing inserts per day. Almost all concurrent cigarette-HTP users smoked every day (93.9%); 48.4% both smoked and used HTPs daily (dual daily users, n = 396), while 45.5% were daily smokers and non-daily HTP users (predominant smokers, n = 213). Concurrent user subgroups differed from each other on age, tobacco use behaviors, and quit intention. Alongside heterogeneity between concurrent and exclusive product users, differences across concurrent use subgroups highlight the importance of considering frequency of use in characterizing poly-tobacco users.

Citation

Nargis, N., Hussain, A.K.M.G., Goodchild, M., Quah, A.C.K., Fong, G.T. (2020). Tobacco Industry Pricing Undermines Tobacco Tax Policy: A Tale from Bangladesh. Preventive medicine, 132, 105991. doi: 10.1016/j.ypmed.2020.105991.

Abstract

The effectiveness of tax increase in reducing tobacco use depends on the extent to which the industry passes on the tax to consumers. Evidence suggests that tobacco industry may absorb or raise the price more than the tax increase depending on the price segment of tobacco products. In this paper, we examined the industry's pricing strategy by price segment of the cigarette market in Bangladesh by observing the deviation between the market retail prices (MRP) of cigarettes faced by consumers and government recommended retail prices (RRP) used as tax base in a four-tiered ad valorem tax structure. The RRPs by brands were collected from government sources. The MRPs by brands were collected by the International Tobacco Control Bangladesh Wave 3 Survey 2011-12 and Wave 4 Survey 2014-15. Applying linear regression to the deviation of MRP from RRP by price tiers, we found MRPs were higher than RRPs for higher-price brands allowing extra profit margin from the high end while lowering the relative price of and expanding demand for cheaper brands. Bangladesh cigarette industry adopted a differential pricing strategy that undermined the intended effect of tax policy change in reducing cigarette consumption and improving public health. This pricing strategy was supported by the tiered excise tax structure which should be replaced with a uniform specific excise system. In the face of growing cigarette affordability, it is crucial that the specific tax be increased routinely by an amount that induces cigarette price increases large enough to make cigarettes less affordable over time.

Citation

Thompson, M.E., Driezen, P., Boudreau, C., Bécuwe, N., Agar, T.K., Quah, A.C.K., Zatoński, W.A., Przewoźniak, K., Mons, U., Demjén, T., Tountas, Y., Trofor, A.C., Fernández, E., McNeill, A., Willemsen, M.C., Vardavas, C.I., Fong, G.T. (2020). Methods of the International Tobacco Control (ITC) EURESTPLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii4-iii9.

Abstract

Background: The EUREST-PLUS ITC Europe surveys aim to evaluate the impact of the European Union’s Tobacco Products Directive (EU TPD) implementation within the context of the WHO FCTC. This article describes the methodology of the 2016 (Wave 1) and 2018 (Wave 2) International Tobacco Control 6 European (6E) Country Survey in Germany, Greece, Hungary, Poland, Romania and Spain; the England arm of the 2016 (Wave 1) and 2018 (Wave 2) ITC 4 Country Smoking and Vaping (4CV) Survey; and the 2016 (Wave 10) and 2017 (Wave 11) ITC Netherlands (NL) Survey. All three ITC surveys covering a total of eight countries are prospective cohort studies with nationally representative samples of smokers.

Methods: In the three surveys across the eight countries, the recruited respondents were cigarette smokers who smoked at least monthly, and were aged 18 and older. At each survey wave, eligible cohort members from the previous waves were retained, regardless of smoking status, and dropouts were replaced by a replenishment sample.

Results: Retention rates between the two waves of the ITC 6E Survey by country were 70.5% for Germany, 41.3% for Greece, 35.7% for Hungary, 45.6% for Poland, 54.4% for Romania and 71.3% for Spain. The retention rate for England between ITC 4CV1 and ITC 4CV2 was 39.1%; the retention rates for the ITC Netherlands Survey were 76.6% at Wave 10 (2016) and 80.9% at Wave 11 (2017).

Conclusion: The ITC sampling design and data collection methods in these three ITC surveys allow analyses to examine prospectively the impact of policy environment changes on the use of cigarettes and other tobacco products in each country, to make comparisons across the eight countries.

Citation

Smith, T., Wahlquist, A.E., Heckman, B.W., Cummings, K.M., Carpenter, M.J. (2020). Impact of e-cigarette sampling on cigarette dependence and reinforcement value. Nicotine and Tobacco Research, 22(2), 297-301. doi: 10.1093/ntr/nty258

Abstract

Introduction: E-cigarettes have risen in prevalence in recent years, and most public health experts agree they deliver fewer toxicants than combustible tobacco products such as cigarettes. Thus, it is important to understand how use of e-cigarettes by current smokers impacts dependence on combustible cigarettes.

Methods: The present study is a secondary analysis of a randomized pilot trial of e-cigarette sampling. Nontreatment seeking current smokers were randomized in a 2:1 ratio to either receive or not receive a weekly supply of e-cigarettes for 3 weeks. Participants completed the Brief Wisconsin Inventory of Smoking Dependence Motives (WISDM) scale and the cigarette purchase task before and after the sampling period and at monthly follow-up visits for 3 months.

Results: Individuals assigned to receive an e-cigarette had significantly lower mean WISDM scores at the end of sampling and the end of the follow-up period compared with those in the control group. Both frequency of e-cigarette use as well as nicotine concentration of the e-cigarette given to smokers were significant predictors of changes in the mean WISDM score. E-cigarette sampling significantly reduced the demand parameter Omax, which measures the maximum amount of money participants estimate they would spend on cigarettes in a single day.

Conclusions: These data suggest that current smokers who try using an e-cigarette may experience reductions in dependence on combustible cigarettes.

Implications: The present analysis suggests that providing an e-cigarette to current cigarette smokers is likely to reduce cigarette dependence, especially if the e-cigarette delivers sufficient nicotine and is used frequently.

Citation

Chung-Hall, J., Fong, G.T., Meng, G., Yan, M., Tabuchi, T., Yoshimi, I., Mochizuki, Y., Craig, L., Ouimet, J., Quah, A.C.K. (2020). Effectiveness of Text-only Cigarette Health Warnings in Japan: Findings from the 2018 International Tobacco Control (ITC) Japan Survey. International Journal of Environmental Research and Public Health, 17(13), 952. Doi: https://doi.org/10.3390/ijerph17030952.

Abstract

Health warnings are an effective strategy for communicating the health harms of smoking, encouraging quitting, and preventing smoking initiation. This study examines the effectiveness of existing text-only health warnings, identifies key predictors of warning effectiveness, and assesses support for pictorial warnings in Japan. Data are from the 2018 International Tobacco Control (ITC) Japan Survey, a cohort survey of adult cigarette smokers (n = 3306), dual users of cigarettes and heated tobacco products (n = 555), and non-cigarette smokers (n = 823). Weighted multivariable logistic regression models were used to assess predictors of warning effectiveness and support for pictorial warnings. Overall, 15.6% of respondents noticed warnings, and 7.9% read or looked closely at warnings. Overall, 10.3% of smokers and dual users said the warnings stopped them from having a cigarette, and 7.2% avoided warnings. Overall, 27.5% of respondents said the warnings made them think about health risks of smoking, but only 2.7% of smokers and dual users said the warnings made them more likely to quit. Overall, 57.6% of respondents supported pictorial warnings. The weak effectiveness of Japan’s text-only warnings is consistent with that in other countries with similar warnings. There is majority support for pictorial warnings in Japan, although the level of support is lower than in other countries.