Citation

Levy, D., Abrams, D.B., Yuan, Z., Lou, Y., Fong, G.T., Borland, R. (2019). A modeling approach to gauging the effects of nicotine vaping product use on cessation from cigarettes: What do we know, what do we need to know? Addiction, 114(Suppl 1), 86-96.

Abstract

Background and Aims: The long term population health impact of nicotine vaping products (NVPs) use among smokers is unknown and subject to a range of plausible assumptions about the use and health consequences of NVPs. While NVPs use may substitute for cigarette smoking and thereby aid in quitting cigarette use, it is also possible that smokers who would have otherwise quit would instead delay quitting cigarettes. We aimed to develop a cohort-specific simulation model of the impact of NVPs on smoking cessation by adult smokers and resulting premature deaths (PD) and life-years lost (LYL).

Design: A cohort-specific simulation model of the impact of NVPs on smoking cessation by adult smokers and resulting premature deaths (PD) and life-years lost (LYL) was developed by gender for two birth-cohorts, age 30 and age 50 in 2012. Extensive sensitivity analyses were conducted.

Setting: United States PARTICIPANTS: Smokers in two birth-cohorts, age 30 and age 50 in 2012 MEASUREMENTS: Data were from the 1965-2012 National Health Interview Surveys and the 2014/5 Tobacco Use Supplement of the Current Population Survey. The model incorporated a range of plausible assumptions from published literature about transition rates from regular smoking to exclusive NVP and dual use, from dual use to exclusive NVP use and from exclusive NVP use to no use.

Findings: Compared with the No-NVP scenario, the male (female) model projected 17.8% (19.3%) fewer PDs and 22.9% (26.6%) fewer LYL for the 1982 cohort and 5.4% (7.3%) fewer PDs and 7.9% (11.4%) fewer LYL for the 1962 cohort. These gains were sensitive to NVP use over time, age of initial NVP use, transitions from smoking to dual, exclusive NVP and no use, and relative NVP mortality risks.

Conclusions: Nicotine vaping product (NVP) use in the US is projected to have a net positive impact on population health over a wide range of plausible levels of NVP use, transitions to dual, exclusive NVP and no use, and NVP risks. However, net impact is sensitive to parameter estimates.

Citation

Branston, J.R., McNeill, A., Gilmore, A., Hiscock, R., Partos, T.R. (2018). Keeping smoking affordable in higher tax environments via smoking thinner roll-your-own cigarettes: Findings from the International Tobacco Control Four Country Survey 2006–15. Drug and Alcohol Dependence, 193, 110-116.

Abstract

Background: Roll-Your-Own tobacco (RYO) use is increasingly popular in many countries: it is generally cheaper than factory-made cigarettes (FM), and smokers can further reduce costs by adjusting the amount of tobacco in each cigarette. However, the level of risk of RYO compared with FM cigarettes is similar and does not meaningfully change with cigarette weight. We assessed the weight of tobacco in RYO cigarettes across jurisdictions with differing tobacco taxes/prices and over time.

Method: Six waves of the International Tobacco Control 4 Country longitudinal study of smokers and recent ex-smokers, providing 3176 observations from exclusive RYO users covering 2006-15, are used to calculate the weight of tobacco used in RYO cigarettes in the US, Canada, Australia, and the UK. Multilevel regression analyses were used to compare weights across countries, socio-demographic factors, and over time.

Results: Smokers in the UK and Australia, where tobacco is relatively expensive, show higher levels of exclusive RYO use (25.8% and 13.8% respectively) and lower mean weights of tobacco per RYO cigarette (0.51 g(sd 0.32 g) and 0.53 g(0.28 g)), compared with both Canada and especially the US (6.0% and 3.5%, and 0.76 g(0.45 g) and 1.07 g(0.51 g)). Smokers in the UK and Australia also exhibited a statistically significant year-on-year decrease in the mean weight of each RYO cigarette.

Conclusions: Taxation of RYO should increase considerably in the UK and Australia so that RYO and FM cigarettes are taxed equivalently to reduce RYO attractiveness and inequalities. Other measures to reduce the price differentials, including taxing RYO solely on weight, are also discussed.

Citation

Heckman, B.W., Cummings, K.M., Stoltman, J.J.K., Dahne, J., Borland, R., Fong, G.T., Carpenter, M.J. (2019). Longer duration of smoking abstinence is associated with waning cessation fatigue. Behaviour Research and Therapy, 115, 12-18.

Abstract

Background: Cessation fatigue, a construct theorized to reflect exhaustion of coping resources due to quitting smoking, has been found to predict relapse. This study examines the association between cessation fatigue and duration of abstinence among 1397 adult former smokers who participated in the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Wave 1 Survey (4CV). We hypothesized lower levels of cessation fatigue will be correlated with longer duration of abstinence.

Method: Data for this cross-sectional study were collected in a web-based survey which recruited national samples from Australia, Canada, England, and United States. Former smokers were abstinent up to five years.

Results: Lower cessation fatigue was associated with longer duration of smoking abstinence. Cessation fatigue was highest in former smokers that had been quit for up to six months, with lower cessation fatigue found in those quit for at least seven months and another drop-off in fatigue observed for those quit for at least two years.

Conclusions: Cessation fatigue is highest soon after quitting smoking but declines over time for those who remain abstinent. Understanding the mechanisms by which cessation fatigue is related to abstinence could potentially offer insights into ways to help individuals sustain quitting.

Citation

Shang, C., Chaloupka, F., Gupta, P.C., Pednekar, M.S., Fong, G.T. (2019). Association between tobacco prices and smoking onset: Evidence from the TCP India Survey. Tobacco Control, 28(Suppl1), S3-S8.

Abstract

Background: Tobacco use is prevalent among youth and adults in India. However, direct evidence on how increasing taxes or prices affect tobacco use onset is scarce.

Objective: To analyse the associations between cigarette and bidi prices and smoking onset in India, and how these associations differ by socioeconomic status.

Methodology: The Wave 1 of the Tobacco Control Policy Evaluation India Survey by the International Tobacco Control Project contains information on the age at smoking onset for cigarettes and bidis. Using this information, data were expanded to a yearly pseudo-panel dataset that tracked respondents at risk of smoking onset from 1998 to 2011. The associations between bidi prices and bidi smoking onset, between cigarette prices and cigarette smoking onset, and between bidi and cigarette prices and any smoking onset were examined using a discrete-time hazard model with a logit link function. Stratified analyses were conducted to examine the difference in these associations by rural versus urban division.

Results: We found that higher bidi prices were significantly associated with a lowered hazard of bidi smoking onset (OR 0.42, 95% CI 0.35 to 0.51). Higher cigarette prices were significantly (OR 0.87, 95% CI 0.83 to 0.92) associated with a lowered hazard of cigarette smoking onset among urban residents, but this association was non-significant when SEs were clustered at the state level. In addition, the association between increasing bidis prices and lowered hazards of bidi smoking onset was greater for urban residents than for rural ones (p<0.01).

Conclusions: Under the new regime of a central goods and service system, policymakers may need to raise the prices of tobacco products sufficiently to curb smoking onset.

Citation

Fu, M., Castellano, Y., Tigova, O., Kyriakos, C.N., Fong, G.T., Mons, U., Zatonzki, W.A., Agar, T., Quah, A.C.K., Trofor, A., Demjén, T., Przewoźniak, K., Tountas, Y., Vardavas, C., Fernández, E., on behalf of the EUREST-PLUS Consortium. (2018). Prevalence and correlates of different smoking bans in homes and cars among smokers in 6 countries of the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 85-97.

Abstract

Introduction: Second-hand smoke exposure has decreased in a number of countries due to widespread smoke-free legislation in public places, but exposure is still present in private settings like homes and cars. Our objective was to describe to what extent smokers implement smoking rules in these settings in six European Union (EU) Member States (MS).

Methods: A cross-sectional survey was conducted with a nationally representative sample of adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (ITC six European countries survey, part of the EUREST-PLUS Project). We analysed data from 6011 smokers regarding smoking rules in their homes and in cars with children (no rules, partial ban, total ban). We described the prevalence of smoking rules by EU MS and several sociodemographic and smoking characteristics using prevalence ratios (PR) and 95% confidence intervals (CI) derived from Poisson regression models.

Results: In homes, 26.5% had a total smoking ban (from 13.1% in Spain to 35.5% in Hungary), 44.7% had a partial ban (from 41.3% in Spain to 49.9% in Greece), and 28.8% had no-smoking rules (from 20.2% in Romania to 45.6% in Spain). Prevalence of no-smoking rules in cars with children was 16.2% (from 11.2% in Germany to 20.4% in Spain). The correlates of not restricting smoking in homes and cars included: low education (PR=1.51; 95%CI: 1.20-1.90 and PR=1.55; 95%CI: 1.09-2.20), smoking >30 cigarettes daily (PR=1.53; 95%CI: 1.10-2.14 and PR=2.66; 95%CI: 1.40-5.05) and no attempts to quit ever (PR=1.18; 95%CI: 1.06-1.31 and PR=1.28; 95%CI: 1.06-1.54).

Conclusions: Among smokers in six EU MS, no-smoking rules were more prevalent in homes than in cars with children. Whilst awareness about the health effects of exposure to tobacco smoke on children seemed to be high, more research is needed to better understand the factors that promote private smoke-free environments.

Citation

Shang, C., Chaloupka, F., Fong, G.T., Gupta, P.C., Pednekar, M.S. (2018). The association between state value-added taxes in tobacco use in India: evidence from GATS and TCP India Survey. Nicotine & Tobacco Research, 20(11), 1344-1352.

Abstract

Introduction: State value-added taxes (VAT) on tobacco products have been increased significantly in recent years in India. Evidence on how these VATs were associated with smoking is highly needed.

Methods: State bidi and cigarette VAT rates were linked to Global Adult Tobacco Survey (GATS) India 2009–2010 and Tobacco Control Policy (TCP) India Survey waves 1 (2010–2011) and 2 (2012–2013), respectively. These linked data were used to analyze the associations between bidi VAT rates and bidi smoking, between cigarette VAT rates and cigarette smoking, and between the two VAT rates and dual use of bidis and cigarettes. Weighted logistic regressions were employed to examine GATS cross-sectional data, whereas Generalized Estimating Equations (GEE) were employed to examine longitudinal TCP data. We further stratified the analyses by gender.

Results: A 10% increase in cigarette VAT rates was associated with a 6.5% (p<0.001) decrease in dual use of cigarettes and bidis among adults and a 0.9% decrease (p<0.05) in cigarette smoking among males in TCP; and with a 21.6% decrease (p<0.05) in dual use among adults and a 17.2% decrease (p<0.001) in cigarette smoking among males in GATS. TCP analyses controlling for state fixed effects are less likely to be biased and indicate a cigarette price elasticity of – 0.44. As female smoking prevalence was extremely low, these associations were non-significant for females.

Conclusions: Higher state cigarette VAT rates in India were significantly associated with lower cigarette smoking and lower dual use of cigarettes and bidis. Increasing state VAT rates may significantly reduce smoking in India.

Citation

Xu, S.S., Gravely, S., Meng, G., Elton-Marshall, T., O’Connor, R.J., Quah, A.C.K., Feng, G., Jiang, Y., Hu, G., Fong, G.T. (2019). Impact of China National Tobacco Company’s ‘premiumization’ strategy: Longitudinal findings from the ITC China Project (2006-2015). Tobacco Control, 28(Suppl 1), S68-S76.

Abstract

Background: In 2009, the China National Tobacco Company (CNTC) began their Premiumization Strategy, designed to encourage smokers to trade up to more expensive brands, mainly by promoting the concept that higher class cigarettes are better quality and less harmful. This study is the first evaluation of the strategy’s impact on: (1) prevalence of premium brand cigarettes (PBC), mid-priced brand cigarettes (MBC) and discount brand cigarettes (DBC) over 9 years, from 3 years pre-strategy (2006) to 6 years post-strategy (2015); and (2) changes in reasons for choosing PBCs, MBCs and DBCs.

Methods: A representative cohort of adult Chinese smokers (n=9047) in seven cities who participated in five waves of the International Tobacco Control (ITC) China Survey: pre-implementation (Wave 1 (2006; n=3452), Wave 2 (2007–2008; n=3586)); mid-implementation (Wave 3 (2009; n=4172)); and post-implementation (Wave 4 (2011–2012; n=4070), Wave 5 (2013–2015; n=2775)). Generalised estimating equations were conducted to examine changes in prevalence of PBCs, MBCs and DBCs, and reasons for brand choice from pre-implementation to post-implementation.

Results: From pre-implementation to post-implementation, there was an increase in prevalence of PBCs (5.4% to 23.2%, p<0.001) and MBCs (40.0% to 50.4%, p<0.001), and a decrease in DBCs (54.6% to 26.5%, p<0.001). There was an increase in smokers who chose their current brand because they believed it to be less harmful, both for MBC smokers (+13.0%, p=0.001) and PBC smokers (+9.0%, p=0.06). There was an increase for smokers in all brand classes for choosing their current brand because they were ‘higher in quality’ and because of affordable price, but the greatest increase was among PBC smokers (+18.6%, p<0.001 and +34.9%, p<0.001, respectively).

Conclusions: Our findings demonstrate that the rising trend in Chinese smokers’ choice of ‘less harmful’, ‘higher quality’ and ‘affordable’ cigarettes, particularly PBCs, is likely due to CNTC’s aggressive marketing strategies. Strong tobacco control policies that prohibit CNTC’s marketing activities are critical in order to dispel erroneous beliefs that sustain continued smoking in China, where the global tobacco epidemic is exerting its greatest toll.

Citation

Stein, J., Heckman, B.W., Pope, D.A., Perry, E.S., Fong, G.T., Cummings, K.M., Bickel, W.K. (2018). Delay discounting and e-cigarette use: an investigation in current, former, and never cigarette smokers. Drug and Alcohol Dependence, 191, 165-173.

Abstract

Background: Cigarette smokers show greater delay discounting (devaluation of delayed consequences) than non-smokers, suggesting that rapid devaluation of the future contributes to tobacco use through a mechanism in which tobacco-related health consequences are too delayed to discourage smoking. However, little work has quantified delay discounting in relation to electronic cigarette (EC) use, a tobacco product that many users believe to pose fewer negative health consequences than cigarettes.

Methods: We assessed discounting of delayed monetary rewards in a web-based sample of 976 participants, stratified by both EC use (current and never) and cigarette use (current, former, and never).

Results: Controlling for demographic variance, current EC users generally showed greater discounting than never EC users (p = .019). Current cigarette smokers also showed greater discounting than former and never smokers (p < .001). However, the between-group difference for EC use was much smaller (ηp2 = .006) than for cigarette use (ηp2 = .026). Moreover, differences in discounting in relation to EC use were not statistically apparent in most pairwise comparisons. Most notably, the difference between former smokers who achieved smoking cessation by transitioning to ECs (i.e., exclusive EC users) and those who have never used ECs or cigarettes was nonsignificant and small (ηp2 = .010).

Conclusions: The smaller effect size for the association between delay discounting and current EC use, relative to current cigarette use, suggests that public perception of ECs as a safer alternative to cigarettes attenuates the role of delay discounting in decisions to use ECs.

Citation

Kyriakos, C.N., Filippidis, F., Hitchman, S.C., Girvalaki, C., Tzavara, C.K., Demjén, T., Fernández, E., Mons, U., Trofor, A., Tountas, Y., Zatoński, M., Zatoński, W., Fong, G.T., Vardavas, C., on behalf of the EUREST-PLUS Consortium. (2018). Characteristics and correlates of electronic cigarette product attributes and undesirable events during e-cigarette use in six countries of the EUREST-PLUS ITC Europe Surveys. Tobacco Induced Diseases, 16(Suppl 2), 21-33

Abstract

Introduction: This study assessed characteristics and correlates associated with e-cigarette product attributes and identified correlates of experiencing undesirable events during e-cigarette use among adult smokers across six European Union (EU) Members States (MS) prior to the implementation of the Tobacco Products Directive (TPD) in 2016.

Methods: We conducted a cross-sectional survey with a nationally representative sample of adult cigarette smokers from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) reporting e-cigarette use; randomly selected through a multistage cluster sampling design from June to September 2016. Stepwise logistic regressions were used to identify factors associated with use of flavors, noticing health warnings, mixing e-liquids, experiencing ‘dry puff’, e-liquid leaking during use and e-liquid spilling during refill.

Results: Current daily or weekly prevalence of e-cigarette use among this sample of adult smokers was 7.5%. The most common attributes of e-cigarettes used included those that are flavored, contain nicotine, and are of tank style. Noticing health warnings on e-cigarette packaging and leaflets, respectively, was low (10.2% and 28%, respectively). Use of e-liquid refill nozzle caps, described as easy for a child to open, was associated with spilling during refill (OR=6.73; 95% CI: 2.02–22.37). Participants who adjusted occasionally or regularly the power (voltage) or temperature of their e-cigarette had greater odds of ever experiencing a ‘dry puff’ (OR=6.01; 95% CI: 2.68–13.46). Mixing different e-liquids was associated with leaking during use (OR=7.78; 95% CI: 2.45–24.73) and spilling during refill (OR=8.54; 95% CI: 2.29–31.88).

Conclusions: Ongoing evaluation of factors associated with e-cigarette attributes and of the correlates of experiencing e-cigarette undesirable events during use, related to product design, is crucial to monitoring the impact of the implementing Acts of the EU TPD.

Citation

Levy, D., Yuan, Z., Abrams, D.B. (2018). The relationship of e-cigarette use to cigarette quit attempts and cessation: insights from a large, nationally representative U.S. Survey. Nicotine and Tobacco Research, 20(8), 931-939.

Abstract

Objectives: While cessation from cigarettes is a top priority for public health, controversy surrounds the role of e-cigarettes for quitting cigarettes. This study examines the role of e-cigarettes in quit attempts and 3-month cigarette abstinence using a large, recent nationally representative US sample.

Methods: Data from the 2014/15 Tobacco Use Supplement-Current Population Survey (TUS-CPS) on cigarette and e-cigarette use and individual characteristics were supplemented with information on state tobacco control policies. We estimated frequencies and multivariate logistic equations for making a quit attempt among those who smoked 1 year earlier and for remaining abstinent at least 3 months among those making a quit attempt. These two outcomes were related to demographic characteristics, tobacco control policies and different frequency measures of e-cigarette use (ever, at least 1, 5, 20 of the last 30 days, a continuous measure of days use).

Results: Having made a quit attempt was more likely among smokers using e-cigarettes than non-users. Among those making at least one quit attempt, quit success was lower among ever users, but higher among those with at least 5 days use of e-cigarettes in the last month. Both quit attempts and quit success were linearly related to the frequency of e-cigarette use.

Conclusions: Consistent with randomized trials and those observational studies that measure frequency of e-cigarette use, both quit attempts and quit success were positively associated with increased frequency of e-cigarette use. Frequency of e-cigarette use was important in gauging the nature of these relationships.

Implications: Previous studies have obtained mixed results regarding the relationship of e-cigarette use to cigarette smoking cessation. This study provides a more precise methodology for considering the relationship of e-cigarette use to quit attempts and to quit success, and finds that quit attempts and quit success increase with the number of days use in the past month.

Citation

Partos, T.R., Branston, J.R., Hiscock, R., Gilmore, A., McNeill, A. (2019). Individualised tobacco affordability in the UK 2002-2014: Findings from the International Tobacco Control Policy Evaluation Project. Tobacco Control, 28(Suppl 1), S9-S19.

Abstract

Objective: The existing measures of tobacco affordability (smokers' purchasing power for tobacco) use national estimates of income and average cigarette prices, and exclude roll-your-own (RYO) tobacco. This study developed an individualised measure of tobacco affordability using smokers' own incomes and factory-made (FM) or RYO tobacco purchase prices, and explored how it was impacted by taxation changes, individual characteristics and purchase patterns.

Design: Cross-sectional survey data collated from 10 waves of a longitudinal cohort study.

Data Sources: Adult smokers (n=4062) from the International Tobacco Control Policy Evaluation Project United Kingdom (UK), surveyed between 2002 and 2014, providing 8943 observations over 10 surveys.

Analysis: Affordability was calculated as the percentage of annual income remaining with the individuals after their annual tobacco expenditure. Multilevel linear regression models were used with affordability as the outcome using time, sex, age, geographical region, ethnicity, education, nicotine dependence and tobacco purchase source as the predictor variables.

Results: Affordability of FM cigarettes decreased significantly from 91.5% (±95% CI: 91.0% to 91.9%) in 2002 to 87.8% (87.0% to 88.5%) in 2014; and RYO from 96.3% (95.7% to 96.9%) in 2006 to 93.7% (93.0% to 94.4%) in 2014. Affordability was significantly lower for FM than RYO. Year-on-year decreases were not statistically significant. Tobacco was more affordable for males, those with higher education, less dependent smokers and those purchasing from non-store (potentially illicit) or non-UK sources.

Conclusions: An individualised measure of tobacco affordability provided useful insights on the impact of tobacco taxes, social inequalities and purchase patterns in the UK. Although tobacco became less affordable, the annual rate of decline was low, suggesting annual tax rises were not large enough.

Citation

Fong, G.T., Chung-Hall, J., Craig, L.V., for the WHO FCTC Impact Assessment Expert Group. (2019). Impact assessment of the WHO FCTC over its first decade: Methodology of the Expert Group. Tobacco Control, 28(Suppl 2), S84-88.

Abstract

Background: At its sixth meeting (Moscow, November 2014), the Conference of the Parties (COP) adopted decision FCTC/COP6(13) that called for an impact assessment to 'examine the impact of the WHO Framework Convention on Tobacco Control (FCTC) on the implementation of tobacco control measures and on the effectiveness of its implementation' after its first 10 years. An independent expert group (EG) was established to conduct the impact assessment, and report their findings at COP7 (Delhi, November 2016). This article describes the methodology used by the EG to conduct the first comprehensive multi-method assessment of the possible causal impact of the FCTC on global tobacco control over the past decade.

Methods: The EG developed and followed a four-stage process model to conduct the impact assessment: (1) desk review of literature on FCTC impact; (2) collection and analysis of interview data from 12 country missions; (3) data synthesis and interpretation; and (4) preparation of a final report.

Conclusions: The EG developed and engaged in a transparent and systematic process to conduct the FCTC impact assessment. The methods employed were rigorous, and explicitly guided by concerns about the difficulty of ascribing cause-and-effect relations. The EG's report and supporting documents represent important sources of the positive impact of the Convention over its first decade. As development of the FCTC increasingly shifts to mechanisms for accelerating global implementation, the EG's process model can be used as a methodology to assist Parties in carrying out their own assessments of the impact of the Treaty.

Citation

Thomas, D., Davey, M.E., Panaretto, K.S., van der Sterren, A.E. (2018). Cannabis use among two national samples of Aboriginal and Torres Strait Islander tobacco smokers. Drug and Alcohol Review, 37(Suppl 1), S394-S403.

Abstract

Introduction and Aims: There is a concern that cannabis use is an important barrier to reducing Aboriginal and Torres Strait Islander smoking. We investigate the associations of cannabis use and tobacco smoking and quitting in two large national samples.

Design and Methods: The 2012–2013 National Aboriginal and Torres Strait Islander Health Survey was a national stratified random household survey conducted between April 2012 and February 2013, and included 2580 adult Aboriginal and Torres Strait Islander smokers. The Talking About The Smokes Project interviewed a national quota sample of 1301 Aboriginal and Torres Strait Islander adult smokers between August 2013 and August 2014. Both surveys asked about tobacco smoking and quitting, cannabis use and socio‐demographic factors.

Results: Both surveys estimated that cannabis use is common among Aboriginal and Torres Strait Islander smokers (National Aboriginal and Torres Strait Islander Health Survey: 32%, Talking About The Smokes: 24%). Both surveys found a higher prevalence of cannabis use among smokers who were male, younger, unemployed or who more frequently consumed five or more alcoholic drinks in a day. However, the two surveys provided inconsistent evidence about whether cannabis use is associated with not quitting smoking tobacco.

Discussion and Conclusions: We did not find consistent evidence in this setting that cannabis use is an obstacle to quitting tobacco smoking. Nevertheless, we would still recommend that clinicians counselling Aboriginal and Torres Strait Islander tobacco smokers about quitting talk about cannabis use because its use is common and almost all mix it with tobacco.

Citation

Wadsworth, E., McNeill, A., Li, L., Hammond, D., Thrasher, J.F., Yong, H.H., Cummings, K.M., Fong, G.T., Hitchman, S.C. (2018). Reported exposure to e-cigarette advertising and promotion in different regulatory environments: findings from the International Tobacco Control Four Country (ITC-4C) Survey. Preventive Medicine, 112, 130-37.

Abstract

Electronic cigarette (e-cigarette) advertising regulations differ across countries. This study examines how differences in e-cigarette advertising regulations influence exposure to e-cigarette advertising, and perceptions about what participants had seen and read about e-cigarettes. Data come from the ITC Four Country Survey (Canada [CA], United States [US], Australia [AU] and United Kingdom [UK]) carried out between August 2013 and March 2015 (n = 3460). In 2014, AU and CA had laws prohibiting the retail sale of e-cigarettes containing nicotine while the US and UK had no restrictions, although a voluntary agreement restricting advertising in the UK was introduced during fieldwork. Smokers and ex-smokers were asked whether in the last six months they had noticed e-cigarettes advertisements and received free samples/special offers (promotion), and about their perceptions (positive or otherwise) of what they had seen or read about e-cigarettes. Data were analyzed in 2017. US and UK participants were more likely to report that they had noticed e-cigarette advertisements and received promotions compared to CA or AU participants. For TV and radio advertisements, reported exposure was higher in US compared to UK. For all types of advertisements, reported exposure was higher in CA than AU. Overall, nearly half of AU (44.0%) and UK (47.8%) participants perceived everything they had seen and read about e-cigarettes to be positive, with no significant differences between AU and UK. Participants in countries with permissive e-cigarette advertising restrictions and less restrictive e-cigarette regulations were more likely to notice advertisements than participants in countries with more restrictive e-cigarette regulations.

Citation

Casado, L., Thrasher, J.F., de Abreu Perez, C., Thuler, L.C.S., Fong, G.T. (2018). Factors associated with quit attempts and smoking cessation in Brazil: Findings from the International Tobacco Control Brazil Survey. Tobacco Induced Diseases, 16(Suppl 1), A343.

Abstract

Background: In Brazil, the treatment of tobacco dependence is available at no cost. This study aimed to identify factors associated with attempting to quit and of successful smoking cessation in a population-based sample of Brazilian smokers.

Methods: Data came from the first two waves of the International Tobacco Control (ITC) Brazil Survey, conducted in 2009 and 2012/2013 in three cities: Rio de Janeiro, São Paulo, and Porto Alegre. Prospective cohort data were collected from 488 adults (&#8805;18 years) who smoked at Wave 1 who were resurveyed at Wave 2. Crude and adjusted relative risks (RR) for two outcomes (making a quit attempt between Wave 1 and Wave 2 and successfully quitting by Wave 2) were estimated. Multivariable multilevel logistic regression models were used, whereby variables were added to the models in a series of blocks.

Results: Nearly two-thirds (65.6%) of smokers attempted to quit between waves, and 23.4% had quit at Wave 2. Intention to quit smoking at Wave 1 was the only variable associated with attempt to quit by Wave 2 (OR=2.85; 95%CI 1.64-4.94; p< 0.001). Smokers of higher socioeconomic status (ORhigh versus low=1.80; 95%CI 1.05-3.10; p=0.03) and lower nicotine dependence (ORlow HSI versus high HSI=1.94; 95%CI 1.10-3.43; p=0.02) were more likely to successfully quit. The presence of another adult smoker at home was negatively related to successful quitting (OR=0.50; 95%CI 0.26-0.94; p= 0.03).

Conclusions: These results are generally consistent with prior research and have potential to inform governmental interventions to promote tobacco cessation, particularly among disadvantaged groups.

Citation

Puntambekar, N., Pednekar, M., Adhikari, K., Quah, A.C.K., Fong, G.T., Driezen, P.*, Gupta, P. C. (2018). Awareness of tobacco advertising, promotion and sponsorship in four states: findings from TCP India Survey - Wave 1 and Wave 2. Tobacco Induced Diseases, 16(Suppl1), A191.

Abstract

Background: India's Cigarette and Other Tobacco Products Act (COTPA) of 2003 prescribes a complete ban on all forms of tobacco advertisements, promotions and sponsorships (TAPS) of events by tobacco companies across India. We examined the level of variation and predictors of awareness of TAPS in four Indian states.

Methods: We used data from the International Tobacco Control Policy (TCP) Survey India from Wave1 (Aug 2010- Dec 2011) and Wave2 (Aug 2012-Dec 2013) consisting of 10,585 and 10,501 respondents, respectively, surveyed from Madhya Pradesh (MP), Bihar (BR), Maharashtra (MH) and West Bengal (WB). Bivariate analysis and multivariable logistic regression was used to investigate associations between sociodemographic factors, states and TAPS awareness. All analyses were performed using SPSS V. 20.0

Results: Noticing tobacco advertisements was highest in MH (78.5%) and lowest in WB (50.1%) in Wave 1, while in Wave 2, it was highest in MP (83.5%) and lowest in WB (32.6%). Noticing tobacco promotions and sponsorships was highest in MP (promotions: 35.7%, sponsorships: 14.4%) in Wave 1, while in Wave 2, it was highest in WB (promotions:15.0%, sponsorships:10.8%). Across waves, education was a predictor of noticing tobacco advertisements, promotions and sponsorships. In Wave 1, but not Wave 2, noticing tobacco advertisements (OR:2.11) and promotions (OR:2.02) was highest among the youngest age group (15-17yrs) compared to corresponding oldest age group (55yrs+). Noticing advertisements and sponsorships remained consistent in urban areas across both waves. In Wave 1 tobacco promotions were observed twice as frequently among rural population as compared urban population but the association was reversed in Wave 2.

Conclusions: Awareness of tobacco marketing varied across the four states of India to observe a greater impact of the tobacco control legislation. This study suggests that even though policies are the same in all states, a coordinated effort is required to implement the law on TAPS ban consistently.

Citation

Yong, H.H., Borland, R., Cummings, K.M., Partos, T. (2018). Do predictors of smoking relapse change as a function of duration of abstinence? Findings from the United States, Canada, United Kingdom and Australia. Addiction, 113(7), 1295-1304.

Abstract

Aims: To estimate predictors of time to smoking relapse and test if prediction varied by quit duration.

Design: Longitudinal cohort data from the International Tobacco Control Four-Country survey with annual follow up collected between 2002 and 2015.

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

Participants: A total of 9171 eligible adult smokers who had made at least one quit attempt during the study period.

Measurements: Time to relapse was the main outcome. Predictor variables included pre-quit baseline measures of nicotine dependence, smoking and quitting-related motivations, quitting capacity and social influence, and also two post-quit measures, use of stop-smoking medications and quit duration (1–7 days, 8–14 days, 15–31 days, 1–3 months, 3–6 months, 6–12 months, 1–2 years and 2+ years), along with socio-demographics.

Findings: All factors were predictive of relapse within the first 6 months of quitting but only wanting to quit, quit intentions and number of friends who smoke were still predictive of relapse in the 6–12-month period of quitting [hazard ratios (HR) = 1.20, P < 0.05; 1.13, P < 0.05; and 1.21, P < 0.001, respectively]. Number of friends smoking was the only remaining predictor of relapse in the 1–2 years quit period (HR = 1.19, P = 0.001) with none predictive beyond the 2-year quit period. Use of stop-smoking medications during quit attempts was related negatively to relapse during the first 2 weeks of quitting (HR = 0.71–0.84), but related positively to relapse in the 1–6-month quit period (HR = 1.29–1.54). Predictive effects of all factors showed significant interaction with quit duration except for perceiving smoking as an important part of life, prematurely stubbing out a cigarette and wanting to quit.

Conclusions: Among adult smokers in the United States, Canada, United Kingdom and Australia, factors associated with smoking relapse differ between the early and later stages of a quit attempt, suggesting that the determinants of relapse change as a function of abstinence duration.

Citation

Ma, B., Yong, H.H., Borland, R., McNeill, A., Hitchman, S.C. (2018). Factors associated with future intentions to use personal vaporizers among those with some experience of vaping. Drug and Alcohol Review, 37(2), 216-225.

Abstract

Introduction and Aims: Personal vaporisers (PV), including e-cigarettes, may be a harm reduction strategy for tobacco control. This study aims to identify factors associated with future intentions to vape among smokers and ex-smokers in Australia and the UK.

Design and Methods: Cross-sectional data of smokers and ex-smokers (n = 1199, mean age = 45.3 years, 44.8% male), collected in 2014/2015 and divided into four subgroups: smoking past vapers (SPV), smoking vapers (SV), ex-smoking past vapers (ESPV) and ex-smoking vapers (ESV), from the International Tobacco Control Australia and UK surveys were analysed by using regression models.

Results: Higher vaping satisfaction increased vaping intentions for all groups except ESPV. Perceiving PVs as less harmful predicted intentions to vape for all groups except ESV. The importance of PVs for stopping smoking predicted lower intentions to continue vaping for SV, but higher intentions to initiate vaping for SPV. The importance of PVs for cutting down smoking was a positive predictor only for SPV. Among ex-smokers, importance for maintaining not smoking was a positive predictor for ESPV, but not for ESV. The importance of perceiving vapour being less harmful also depended on vaping status for ex-smokers. The only country interaction was that only in the UK was perceiving PVs as less harmful associated with intention among SPV.

Discussion and Conclusion: Factors influencing intentions vary by smoking and/or vaping status, with greater differences between the ex-smoker subgroups. This is consistent with PVs being seen as a way of managing smoking, rather than something that has intrinsic value, for all except the ex-smoking vapers.

Citation

Ma, B., Yong, H.H., Borland, R., McNeill, A., Hitchman, S.C. (2018). Factors associated with future intentions to use personal vaporizers among those with some experience of vaping. Drug and Alcohol Review, 37(2), 216-225.

Abstract

Introduction and Aims. Personal vaporisers (PV), including e‐cigarettes, may be a harm reduction strategy for tobacco control. This study aims to identify factors associated with future intentions to vape among smokers and ex‐smokers in Australia and the UK.

Design and Methods. Cross‐sectional data of smokers and ex‐smokers (n = 1199, mean age = 45.3 years, 44.8% male), collected in 2014/2015 and divided into four subgroups: smoking past vapers (SPV), smoking vapers (SV), ex‐smoking past vapers (ESPV) and ex‐smoking vapers (ESV), from the International Tobacco Control Australia and UK surveys were analysed by using regression models.

Results. Higher vaping satisfaction increased vaping intentions for all groups except ESPV. Perceiving PVs as less harmful predicted intentions to vape for all groups except ESV. The importance of PVs for stopping smoking predicted lower intentions to continue vaping for SV, but higher intentions to initiate vaping for SPV. The importance of PVs for cutting down smoking was a positive predictor only for SPV. Among ex‐smokers, importance for maintaining not smoking was a positive predictor for ESPV, but not for ESV. The importance of perceiving vapour being less harmful also depended on vaping status for ex‐smokers. The only country interaction was that only in the UK was perceiving PVs as less harmful associated with intention among SPV.

Discussion and Conclusion. Factors influencing intentions vary by smoking and/or vaping status, with greater differences between the ex‐smoker subgroups. This is consistent with PVs being seen as a way of managing smoking, rather than something that has intrinsic value, for all except the ex‐smoking vapers.

Citation

Seo, H.G., Kim, Y., Xu, S.S., Quah, A.C.K., Boudreau, C., Yan, M., Thompson, M.E., Fong, G.T. (2018). Tobacco control policies in the Republic of Korea and the methods of the ITC Korea Surveys. Journal of the Korean Society for Research on Nicotine and Tobacco, 9(Suppl 1), S1-10.

Abstract

Policies that promote the social unacceptability of smoking may also result in smoking-related stigma. The aim of this study is to evaluate how norms against smoking and socioeconomic status (SES) are associated with stigma among smokers. We used data from a panel of adult smokers who participated in the 2008–2012 administrations of the International Tobacco Control Policy Evaluation Survey in Mexico (n = 6670 observations) and Uruguay (n = 3296 observations).

Generalized estimating equations were used to account for correlations in the outcomes over time within individuals. We evaluated if injunctive smoking norms (i.e. significant other norms and societal norms), descriptive smoking norms (i.e. number of smoking friends), and two markers of SES (i.e. education and income) were associated with different aspects of smoking-related stigma (i.e. feeling uncomfortable, negative stereotype of smokers, and perceived marginalization). We found that stronger anti-smoking injunctive norms were associated with higher levels of all indicators of perceived stigma in Mexico and Uruguay. Having fewer smoking friends was associated with feeling uncomfortable and perceived marginalization in Mexico. Higher income and education were associated with a stronger negative stereotype of smokers in Mexico.

Lower income and education were associated with a stronger negative stereotype of smokers in Uruguay. Study results suggest that factors that drive the social unacceptability of tobacco may stigmatize smokers, although further research is needed to determine whether policy-promoted stigmatization produces undesirable outcomes (e.g. lower cessation rates).

Citation

Lee, E.S., Seo, H.G., Fong, G.T., Yan, M., Driezen, P. (2018). Awareness of Korean adult smokers about national smoking cessation programs in Korea: findings from the 2016 International Tobacco Control Policy Evaluation Korea Survey. Journal of the Korean Society for Research on Nicotine and Tobacco, 9(Suppl 1), S22-30.

Abstract

Background: There are effective intervention program for smoking cessation such as clinics at public health centres, quitlines, residential cessation program, and insurance program in South Korea. The purpose of this study is to investigate awareness and utilization of smoking cessation program in current smokers.
Methods: We analyzed data from the ITC Korea Survey, a telephone survey of a nationally representative sample of 2,000 adult smokers, conducted from June 2015 to June 2016. Frequency of awareness, intention to use, and utilization about smoking cessation program were reported in current smokers. To evaluate influence of smoking related factors like nicotine dependence on awareness, intention to use, and use about smoking cessation program of current smokers, logistic regression was used. All analyses were performed with use of STATA version 11.
Results: In case of the insurance program to help quit, current smokers have an awareness about it (36.9%) and an interest in using it (50.3%). The proportion of current smoker utilizing quit program was 32.3% for public clinic, 0.9% for residential program, 7.4% for insurance program to help quit, and 3.0% for Quitlines. Higher utilization was observed current smokers over 40 years of age, married, with daily smoking amount (above 10/d), with quit attempt in the last 1 year (OR 1.32, 95% CI 1.04-1.68), and with smoking cessation plan (OR 2.47, 95% CI 1.85-3.29).
Conclusion: A small percentage of current smokers participated the government providing smoking cessation program in Korea, even though their awareness is relatively good. Further strategy is necessary to encourage current smoker to participate smoking cessation program.

Abstract

Background: This paper aimed to present proportion of awareness and use of e-cigarettes and vaping behaviors among adult smokers in South Korea.

Methods: We used data of current adult smokers participating in the International Tobacco Control (ITC) survey Korea in 2016. The frequency analysis and cross analysis were used to present the proportion of awareness, experience, current use, reasons for use and vaping behaviors of e-cigarettes, and logistic regression analysis was used to present factors associated with awareness, experience, and current e-cigarette use. All data were submitted to complex sample survey data analysis using SPSS version 23.0 (SPSS Inc., Chicago, IL, USA) and weighted to represent the Korean population.

Results: Out of 2000 adult smokers, the proportion of awareness, experience, and current use e-cigarettes were 93.8%, 33.8%, and 5.5%, respectively. In multivariable logistic regression analysis, younger age groups were associated with increased odds ratios (ORs) for awareness, higher consumption of tobacco and no past quit attempt were associated with increased ORs for experience, and higher income groups were associated with increased ORs for current use of e-cigarettes. The common reasons for using e-cigarettes were because of thinking that using e-cigarettes were more acceptable than smoking and less harmful to other people, and makes it easier to cut down on smoking. Most e-cigarette users vaped nicotine-contained e-cigarettes and bought them at e-cigarettes shop.

Conclusion: E-cigarette awareness and use increased among Korean smokers especially among higher income groups. Careful monitoring of behavior of using e-cigarettes is needed.

Citation

Hummel, K., Candel, M.J.J.M., Nagelhout, G.E., Brown, J., van den Putte, B., Kotz, D., Willemsen, M.C., Fong, G.T., West, R., de Vries, H. (2018). Construct and predictive validity of three measures of intention to quit smoking: Findings from the International Tobacco Control (ITC) Netherlands Survey. Nicotine and Tobacco Research, 20(9), 1101-1108.

Abstract

Introduction: The aim of the study was to compare the construct validity and the predictive validity of three instruments to measure intention to quit smoking: a Stages of Change measure, the Motivation To Stop Scale (MTSS) and a Likert scale. We used the Theory of Planned Behaviour as theoretical framework.

Methods: We used data from the International Tobacco Control (ITC) Netherlands Survey. We included smokers who participated in three consecutive survey waves (n=980). We measured attitude, subjective norm, and perceived behavioural control in 2012, intention to quit with three instruments in 2013, and having made a quit attempt in the last year in 2014. We conducted Structural Equation Modelling with three models for the instruments of intention separately, and with one model that included the three instruments simultaneously.

Results: All three instruments of intention were significantly and positively related to attitude and perceived behavioural control but none was related to subjective norm. All three instruments were significantly and positively related to making a quit attempt. The relation of the Likert scale with making a quit attempt (β=0.38) was somewhat stronger than that of the Stages of Change measure (β=0.35) and the MTSS (β=0.22). When entering the three instruments together into one model, only the Likert scale was significantly related to making a quit attempt.

Conclusions: All three instruments showed reasonable construct validity and comparable predictive validity. Under the studied conditions, the Likert scale performed slightly better than the Stages of Change measure and the MTSS.

Implications: An assessment of the Stages of Change, the Motivation To Stop Scale (MTSS) and a Likert scale showed comparable predictive and construct validity as measures for intention to quit smoking. All three instruments can be used in future research; however, under the studied theoretical framework, i.e. the Theory of Planned Behaviour, the Likert scale performed slightly better than the other two instruments.

Citation

El-Toukhy, S., Choi, K., Hitchman, S.C., Bansal-Travers, M., Thrasher, J.F., Yong, H.H., O’Connor, R.J., Shang, C. (2018). Banning tobacco price promotions, smoking-related beliefs, and behaviour: findings from the International Tobacco Control Four Country (ITC 4C) Survey. Tobacco Control, 27(3), 310-318.

Abstract

Background: Ecological models emphasise multilevel influences on health behaviours. While studies show that exposure to price promotions is associated with smoking behaviour and its antecedents, less is known about whether these associations differ by macro-level factors such as national price promotion policies.

Methods: Current and former smokers (N=4698) from the International Tobacco Control Policy Evaluation Project four-country cohort were included in weighted multivariate logistic regression models to examine individual-level associations between exposure to price promotions at waves 7 and 8 (conducted in 2008–2009 and 2010–2011) and beliefs (social and injunctive norms, functional value of smoking, misconceptions around smoking and beliefs of tobacco industry and its regulations) and behaviour at wave 8, stratified by whether countries allow (Australia and USA) or ban (Canada and UK) price promotions.

Results: Associations between exposure to price promotions and smoking-related beliefs and behaviour differed by national price promotion policies. In countries that allow price promotions, participants repeatedly exposed to price promotions at waves 7 and 8 were more likely to associate functional values to smoking (ie, calms down when stressed (adjusted OR (AOR) 1.83) and to be current smokers at wave 8 (AOR 1.94). In countries that ban price promotions, participants repeatedly exposed to price promotions were less likely to hold misconceptions around smoking (ie, harsher smoke is more dangerous).

Conclusions: Differential associations emerged between exposure to price promotions, smoking-related beliefs and behaviour across countries with and without a price promotions ban. Adopting price promotion bans could ameliorate the associations between exposure to price promotions and smoking beliefs and behaviours.

Citation

Cho, Y. J., Thrasher, J. F., Yong, H.-H., Szklo, A. S., O'Connor, R. J., Bansal-Travers, M., Hammond, D., Fong, G. T., Hardin, J., Borland, R. (2018). Path analysis of warning label effects on negative emotions and quit attempts: A longitudinal study of smokers in Australia, Canada, Mexico, and the US. Social Science & Medicine, 197, 226-234.

Abstract

Background: Cigarette pack health warning labels can elicit negative emotions among smokers, yet little is known about how these negative emotions influence behavior change.

Objective: Guided by psychological theories emphasizing the role of emotions on risk concern and behavior change, we investigated whether smokers who reported stronger negative emotional responses when viewing warnings reported stronger responses to warnings in daily life and were more likely to try to quit at follow-up.

Methods: We analyzed data from 5439 adult smokers from Australia, Canada, Mexico, and the US, who were surveyed every four months from September 2012 to September 2014. Participants were shown warnings already implemented on packs in their country and reported negative emotional responses (i.e., fear, disgust, worry), which were averaged (range = 1 to 9). Country-stratified logistic and linear generalized estimating equations were used to analyze the effect of negative emotional responses on self-reported responses to warnings in daily life (i.e., attention, risk concern, avoidance of warnings, forgoing planned cigarettes) and quit attempts at follow-up. Models were adjusted for socio-demographic and smoking-related characteristics, survey wave, and the number of prior surveys answered.

Results: Smokers who reported stronger negative emotions were more likely to make quit attempts at follow-up (Adjusted ORs ranged from 1.09 [95% CI 1.04 to 1.14] to 1.17 [95% CI 1.12 to 1.23]; p < .001) than those who reported lower negative emotions. This relationship was mediated through attention to warnings and behavioral responses to warnings. There was no significant interaction of negative emotions with self-efficacy or nicotine dependence.

Conclusion: Negative emotions elicited by warnings encourage behavior change, promoting attention to warnings and behavioral responses that positively predict quit attempts.