Citation

Nicholson, A.K., Borland, R., Davey, M.E., Stevens, M., Thomas, D.P. (2015). Predictors of wanting to quit in a national sample of Aboriginal and Torres Strait Islander smokers. Medical Journal of Australia, 202(10), S26-32.

Abstract

Objective: To describe factors that predict wanting to quit smoking in a national sample of Aboriginal and Torres Strait Islander people.

Design, Setting and Participants: The Talking About The Smokes (TATS) project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. Baseline survey data were collected from 1643 current smokers between April 2012 and October 2013.

Main Outcome Measure: Wanting to quit smoking.

Results: More than two-thirds of smokers (70%) said they want to quit. Many factors were associated with wanting to quit, including past quitting activity. Interest in quitting was lower among men and smokers from economically disadvantaged areas, but there was no difference by age, remoteness or other measures of economic disadvantage. Attitudes and beliefs negatively associated with wanting to quit included enjoying smoking and believing quitting to be very difficult, and those positively associated included regretting ever starting to smoke, perceiving that local Aboriginal and Torres Strait Islander community leaders disapprove of smoking, believing non-smokers set a good example to children, worrying about future smoking-related health effects and believing quitting to be beneficial. Reporting support from family and friends was predictive of wanting to quit, but factors related to smoking in the social network were not. Associations with health and wellbeing were mixed. While most tobacco control policy exposure variables were positively associated with wanting to quit, two - receiving advice to quit from a health professional, and recall of targeted anti-tobacco advertising - appeared to have an effect that extended beyond influencing relevant attitudes and beliefs.

Conclusion: Interest in quitting among Aboriginal and Torres Strait Islander smokers appears to be influenced by a broad range of factors, highlighting the importance of taking a comprehensive approach to tobacco control. Advice from health professionals and targeted advertising appear to be important intervention strategies.

Citation

Im, P.K., McNeill, A., Thompson, M.E., Fong, G.T., Xu, S.S., Quah, A.C.K., Jiang, Y., Shahab, L. (2015). Individual and interpersonal triggers to quit smoking in China: A cross-sectional analysis. Tobacco Control, 24(Suppl 4), iv40-iv47.

Abstract

Aims: To determine the most prominent individual and interpersonal triggers to quit smoking in China and their associations with sociodemographic characteristics.

Methods: Data come from Waves 1-3 (2006-2009) of the International Tobacco Control (ITC) China Survey, analysed cross-sectionally as person-waves (N=14 358). Measures included sociodemographic and smoking characteristics. Those who quit between waves (4.3%) were asked about triggers that 'very much' led them to stop smoking, and continuing smokers about triggers that 'very much' made them think about quitting. Triggers covered individual (personal health concerns, cigarette price, smoking restrictions, advertisements, warning labels) and interpersonal factors (family/societal disapproval of smoking, setting an example to children, concerns about secondhand smoke).

Results: Over a third of respondents (34.9%) endorsed at least one trigger strongly; quitters were more likely than smokers to mention any trigger. While similar proportions of smokers endorsed individual (24.4%) and interpersonal triggers (24.0%), quitters endorsed more individual (61.1%) than interpersonal (48.3%) triggers. However, the most common triggers (personal health concerns; setting an example to children) were the same, endorsed by two-thirds of quitters and a quarter of smokers, as were the least common triggers (warning labels; cigarette price), endorsed by 1 in 10 quitters and 1 in 20 smokers. Lower dependence among smokers and greater education among all respondents were associated with endorsing any trigger.

Conclusions: Individual rather than interpersonal triggers appear more important for quitters. Major opportunities to motivate quit attempts are missed in China, particularly with regard to taxation and risk communication. Interventions need to focus on more dependent and less-educated smokers.

Citation

Li, J., White, J.S., Hu, T.W., Fong, G.T., Jiang, Y. (2015). The heterogeneous effects of cigarette prices on brand choice in China: Implications for tobacco control policy. Tobacco Control, 24(Suppl 3), iii25-iii32.

Abstract

Background: China has long kept its tobacco taxes below international standards. The Chinese government has cited two rationales against raising tobacco tax, namely, the unfair burden it places on low-income smokers and the ability of consumers to switch to cheaper brands.

Objective: This study examines how different socioeconomic subgroups of Chinese smokers switch brands in response to cigarette price changes.

Methods: We model smokers' choice of cigarette tier as a function of tier-specific prices. We examine heterogeneous responses to prices by estimating mixed logit models for different income and education subgroups that allow for random variation in smokers' preferences. We use data from three waves of the longitudinal International Tobacco Control China Survey, collected in six large Chinese cities between 2006 and 2009.

Findings: Low-income and less educated smokers are considerably more likely to switch tiers (including both up-trading and down-trading) than are their high-socioeconomic status (SES) counterparts. For those in the second-to-lowest tier, a ¥1 ($0.16, or roughly 25%) rise in prices increases the likelihood of switching tiers by 5.6% points for low-income smokers and 7.2% points for less educated smokers, compared to 1.6% and 3.0% points for the corresponding high-SES groups. Low-income and less educated groups are also more likely to trade down compared to their high-SES counterparts.

Conclusions: Only a small percentage of low-income and less educated Chinese smokers switched to cheaper brands in response to price increases. Hence, the concern of the Chinese government that a cigarette tax increase will lead to large-scale brand switching is not supported by this study.

Citation

Cowie, G.A., Swift, E., Partos, T.R., Borland, R. (2015). Quitting activity and tobacco brand switching: Findings from the ITC-4 Country Survey. Australian and New Zealand Journal of Public Health, 39(2), 109-113.

Abstract

Objective: Among Australian smokers, to examine associations between cigarette brand switching, quitting activity and possible causal directions by lagging the relationships in different directions.

Methods: Current smokers from nine waves (2002 to early 2012) of the ITC-4 Country Survey Australian dataset were surveyed. Measures were brand switching, both brand family and product type (roll-your-own versus factory-made cigarettes) reported in adjacent waves, interest in quitting, recent quit attempts, and one month sustained abstinence.

Results: Switching at one interval was unrelated to concurrent quit interest. Quit interest predicted switching at the following interval, but the effect disappeared once subsequent quit attempts were controlled for. Recent quit attempts more strongly predicted switching at concurrent (OR 1.34, 95%CI=1.18-1.52, p<0.001) and subsequent intervals (OR 1.31, 95%CI=1.12-1.53, p=0.001) than switching predicted quit attempts, with greater asymmetry when both types of switching were combined. One month sustained abstinence and switching were unrelated in the same interval; however, after controlling for concurrent switching and excluding type switchers, sustained abstinence predicted lower chance of switching at the following interval (OR=0.66, 95%CI=0.47-0.93, p=0.016).

Conclusions: The asymmetry suggests brand switching does not affect subsequent quitting.

Implications: Brand switching does not appear to interfere with quitting.

Citation

Thrasher, J.F., Osman, A., Moodie, C., Hammond, D., Bansal-Travers, M., Cummings, K.M., Borland, R., Yong, H.H., Hardin, J. (2015). Promoting cessation resources through cigarette package warning labels: A longitudinal survey with adult smokers in Canada, Australia and Mexico. Tobacco Control, 24 (e1), 23-31.

Abstract

Introduction: Health warning labels (HWLs) on tobacco packaging can be used to provide smoking cessation information, but the impact of this information is not well understood.

Methods: Online consumer panels of adult smokers from Canada, Australia and Mexico were surveyed in September 2012, January 2013 and May 2013; replenishment was used to maintain sample sizes of 1000 participants in each country at each wave. Country-stratified logistic Generalised Estimating Equation (GEE) models were estimated to assess correlates of citing HWLs as a source of information on quitlines and cessation websites. GEE models also regressed having called the quitline, and having visited a cessation website, on awareness of these resources because of HWLs.

Results: At baseline, citing HWLs as a source of information about quitlines was highest in Canada, followed by Australia and Mexico (33%, 19% and 16%, respectively). Significant increases over time were only evident in Australia and Mexico. In all countries, citing HWLs as a source of quitline information was significantly associated with self-report of having called a quitline. At baseline, citing HWLs as a source of information about cessation websites was higher in Canada than in Australia (14% and 6%, respectively; Mexico was excluded because HWLs do not include website information), but no significant changes over time were found for either country. Citing HWLs as a source of information about cessation websites was significantly associated with having visited a website in both Canada and Australia.

Conclusions: HWLs are an important source of cessation information.

Citation

Salloum, R., Thrasher, J.F., Kaai, S., Fong, G.T., Quah, A.C.K., Zulu, R., Goma, F., Chelwa, G. (2015, March). Cigarette price and brand loyalty in Zambia: Findings from the ITC Zambia Survey. Poster presentation at the 16th World Conference on Tobacco or Health, Abu Dhabi, United Arab Emirates.

Abstract

Objectives: Little is known about cigarette pricing and brand loyalty in sub-Saharan Africa. This study examines these issues in Zambia, analysing data from the International Tobacco Control (ITC) Zambia Survey.

Methods: Data from Wave 1 of the ITC Zambia Survey (2012) were analysed for current smokers of factory-made (FM) cigarettes compared with those who smoked both FM and roll-your-own (RYO) cigarettes, using multivariate logistic regression models to identify the predictors of brand loyalty and reasons for brand choice.

Results: 75% of FM-only smokers and 64% of FM+RYO smokers reported having a regular brand. Compared with FM-only smokers, FM+RYO smokers were, on average, older (28% vs 20% ≥40 years), low income (64% vs 43%) and had lower education (76% vs 44% < secondary). Mean price across FM brands was ZMW0.50 (US$0.08) per stick. Smokers were significantly less likely to be brand loyal (>1 year) if they were aged 15–17 years (vs 40–54 years) and if they had moderate (vs low) income. Brand choice was predicted mostly by friends, taste and brand popularity. Price was more likely to be a reason for brand loyalty among FM+RYO smokers, among ≥55-year-old smokers and among those who reported being more addicted to cigarettes.

Conclusions: These results in Zambia document the high levels of brand loyalty in a market where price variation is fairly small across cigarette brands. Future research is needed on longitudinal trends to evaluate the effect of tobacco control policies in Zambia.

Citation

White, J.S., Ross, H. (2015). Smokers' strategic responses to sin taxes: Evidence from panel data in Thailand. Health Economics. 24(2), 127-141.

Abstract

In addition to quitting and cutting consumption, smokers faced with higher cigarette prices may compensate in several ways that mute the health impact of cigarette taxes. This study examines three price avoidance strategies among adult male smokers in Thailand: trading down to a lower-priced brand, buying individual sticks of cigarettes instead of packs, and substituting roll-your-own tobacco for factory manufactured cigarettes. Using two panels of microlevel data from the International Tobacco Control Southeast Asia Study, collected in 2005 and 2006, we estimate the effects of a substantial excise tax increase implemented throughout Thailand inDecember 2005. We present estimates of the marginal effects and price elasticities for each of five consumer behaviors. We find that, controlling for baseline smoking characteristics, sociodemographics, and policy variables, quitting is highly sensitive to changes in cigarette prices, but so are brand choice, stick-buying, and use of roll-your-own tobacco. Neglecting such strategic responses leads to overestimates of a sin tax’s health impact, and neglecting product substitution distorts estimates of the price elasticity of cigarette demand. We discuss the implications for consumer welfare and several policies that mitigate the adverse impact of consumer responses.

Citation

Li, L., Borland, R., Fong, G.T., Jiang, Y., Yang, Y., Wang, L., Partos, T.R., Thrasher, J.F. (2015). Smoking-related thoughts and microbehaviours, and their predictive power for quitting: Findings from the International Tobacco Control (ITC) China Survey. Tobacco Control, 24(4), 354-361.

Abstract

Background: Negative attitudes to smoking are well-established predictors of intentions to quit and quit behaviours, but less attention has been given to whether quitting is influenced by smoking-related thoughts and microbehaviours that reflect a concern about smoking.

Objectives: This paper aimed to describe the occurrence of smoking-related thoughts and microbehaviours among Chinese smokers, and to examine their predictive power for making quit attempts and sustained abstinence.

Methods: The data came from the first three waves of the International Tobacco Control China Survey. Four measures of recent thoughts about smoking and two microbehaviour measures (collectively referred to as microindicators) were examined.

Results: Most smokers (around three-quarters) reported thinking about harms of smoking to themselves or to others at least occasionally, and an increasing minority reported the two microbehaviours of prematurely butting out cigarettes and forgoing them. All microindicators were positively related to subsequent quit attempts in individual predictor analyses, but only serious thoughts about quitting and butting out cigarettes had independent relationships. Overall, there was no clear relationship between these microindicators and sustained abstinence.

Conclusions: There was a moderately high level of occurrence of recent smoking-related thoughts and microbehaviours among the Chinese adult smokers in the six cities studied. Like in the West, microindicators of concern about smoking were positively associated with subsequent quit attempts, but unlike in the West, they were largely unrelated to sustained abstinence.

Citation

Yao, T., Huang, J., Sung, H.Y., Ong, M., Mao, Z., Jiang, Y., Fong, G.T., Max, W. (2015). Determinants of smoking-induced deprivation in China. Tobacco Control, 24(Suppl 4), iv35-iv39.

Abstract

Objective: Spending on cigarettes may deprive households of other items like food. The goal of this study was to examine the prevalence of and factors associated with this smoking-induced deprivation among adult smokers in China.

Methods: The data came from waves 1-3 of the International Tobacco Control (ITC) China Survey, conducted from 2006 to 2009 among urban adults aged 18 years or older in China. We focus on the samples of current smokers from six cities (N=7981). Smoking-induced deprivation was measured with the survey question, “In the last six months, have you spent money on cigarettes that you knew would be better spent on household essentials like food?” We examined whether sociodemographic factors, smoking intensity and price paid per pack of cigarettes were associated with smoking-induced deprivation using generalised estimating equations modelling.

Findings: 7.3% of smokers reported smoking-induced deprivation due to purchasing cigarettes. Lowincome and middle-income smokers were more likely to have smoking-induced deprivation compared with high-income smokers (adjusted OR (AOR)=2.06, 95% CI 1.32 to 2.31; AOR=1.44, 95% CI 1.10 to 1.69); smokers living in Shenyang (AOR=1.68, 95% CI 1.25 to 2.24) and Yinchuan (AOR=2.50, 95% CI 1.89 to 3.32) were more likely to have smoking-induced deprivation compared with smokers living in Beijing. Retired smokers were less likely to have smoking-induced deprivation compared with employed smokers (AOR=0.67, 95% CI 0.52 to 0.87). There was no statistically significant relationship between smoking intensity, price paid per pack of cigarettes and smoking-induced deprivation.

Conclusions: Our findings indicate that certain groups of smokers in China acknowledge spending money on cigarettes that could be better spent on household essentials. Tobacco control policies that reduce smoking in China may improve household living standards by reducing smoking-induced deprivation.

Citation

Huang, L.L., Thrasher, J.F., Jiang, Y., Li, Q., Fong, G.T., Chang, Y., Walsemann, K.M., Friedman, D. (2015). Impact of the ‘Giving Cigarettes is Giving Harm’ campaign on knowledge and attitudes of Chinese smokers. Tobacco Control, 24(Suppl 4), iv28-iv34.

Abstract

Objective: To date there is limited published evidence on the efficacy of tobacco control mass media campaigns in China. This study aimed to evaluate the impact of a mass media campaign 'Giving Cigarettes is Giving Harm' (GCGH) on Chinese smokers' knowledge of smoking-related harms and attitudes towards cigarette gifts.

Methods: Population-based, representative data were analysed from a longitudinal cohort of 3709 adult smokers who participated in the International Tobacco Control (ITC) China Survey conducted in six Chinese cities before and after the campaign. Logistic regression models were estimated to examine associations between campaign exposure and attitudes towards cigarette gifts measured postcampaign. Poisson regression models were estimated to assess the effects of campaign exposure on postcampaign knowledge, adjusting for precampaign knowledge.

Findings: Fourteen percent (n=335) of participants recalled the campaign within the cities where the GCGH campaign was implemented. Participants in the intervention cities who recalled the campaign were more likely to disagree that cigarettes are good gifts (71% vs 58%, p<0.01) and had greater levels of campaign-targeted knowledge than those who did not recall the campaign (mean=1.97 vs 1.62, p<0.01). Disagreeing that cigarettes are good gifts was higher in intervention cities than in control cities. Changes in campaign-targeted knowledge were similar in both cities, perhaps due to a secular trend, low campaign recall or contamination issues.

Conclusions: These findings suggest that the GCGH campaign increased knowledge of smoking harms, which could promote downstream cessation. This study provides evidence to support future campaign development to effectively fight the tobacco epidemic in China.

Citation

Cornelius, M.E., Driezen, P., Hyland, A., Fong, G.T., Chaloupka, F., Cummings, K.M. (2015). Trends in cigarette pricing and purchasing patterns in a sample of US smokers: Findings from the ITC US Surveys (2002-2011). Tobacco Control, 24(Suppl 3), iiii4-iiii10.

Abstract

Objective: This paper examines trends in cigarette prices and corresponding purchasing patterns over a 9-year period and explores characteristics associated with the quantity and location of cigarettes purchased by adult smokers in the USA.

Methods: The data for this paper come from a nationally representative longitudinal survey of 6669 adult smokers (18 years and older) who were recruited and surveyed between 2002 and 2011. Telephone interviews were conducted annually, and smokers were asked a series of questions about the location, quantity (ie, single vs multiple packs or cartons) and price paid for their most recent cigarette purchase. Generalised estimating equations were used to assess trends and model characteristics associated with cigarette purchasing behaviours.

Results: Between 2002 and 2011, the reported purchase of cigarette cartons and the use of coupons declined while multipack purchases increased. Compared with those purchasing by single packs, those who purchased by multipacks and cartons saved an average of $0.53 and $1.63, respectively. Purchases in grocery and discount stores declined, while purchases in tobacco only outlets increased slightly. Female, older, white smokers were more likely to purchase cigarettes by the carton or in multipacks and in locations commonly associated with tax avoidance (ie, duty free shops, Indian reservations).

Conclusions: As cigarette prices have risen, smokers have begun purchasing via multipacks instead of cartons. As carton sales have declined, purchases from grocery and discount stores have also declined, while an increasing number of smokers report low tax sources as their usual purchase location for cigarettes.

Citation

Fleischer, N., Thrasher, J.F., Saenz-de-Miera Juarez, B., Reynales-Shigematsu, L.M., Arillo-Santillán, E., Osman, A., Siahpush, M., Fong, G.T. (2015). Neighbourhood deprivation and smoking and quit behaviour among smokers in Mexico: Findings from the ITC Mexico Survey. Tobacco Control, 24(Suppl 3), iii56-iii63.

Abstract

Background: In high-income countries (HICs), higher neighbourhood socioeconomic deprivation is associated with higher levels of smoking. Few studies in low-income and middle-income countries (LMICs) have investigated the role of the neighbourhood environment on smoking behaviour.

Objective: To determine whether neighbourhood socioeconomic deprivation is related to smoking intensity, quit attempts, quit success and smoking relapse among a cohort of smokers in Mexico from 2010 to 2012.

Methods: Data were analysed from adult smokers and recent ex-smokers who participated in waves 4- 6 of the International Tobacco Control (ITC) Mexico Survey. Data were linked to the Mexican government's composite index of neighbourhood socioeconomic deprivation, which is based on 2010 Mexican Census data. We used generalised estimating equations to determine associations between neighbourhood deprivation and individual smoking behaviours.

Findings: Contrary to past findings in HICs, higher neighbourhood socioeconomic deprivation was associated with lower smoking intensity. Quit attempts showed a U-shaped pattern whereby smokers living in high/very high deprivation neighbourhoods and smokers living in very low deprivation neighbourhoods were more likely to make a quit attempt than smokers living in other neighbourhoods. We did not find significant differences in neighbourhood deprivation on relapse or successful quitting, with the possible exception of people living in medium-deprivation neighbourhoods having a higher likelihood of successful quitting than people living in very low deprivation neighbourhoods (p=0.06).

Conclusions: Neighbourhood socioeconomic environments in Mexico appear to operate in an opposing manner to those in HICs. Further research should investigate whether rapid implementation of strong tobacco control policies in LMICs, as occurred in Mexico during the follow-up period, avoids the concentration of tobacco-related disparities among socioeconomically disadvantaged groups.

Citation

Hall, M., Fleischer, N., Reynales-Shigematsu, L.M., Arillo-Santillán, E., Thrasher, J.F. (2015). Increasing availability and consumption of single cigarettes: Trends and implications for smoking cessation from the ITC Mexico Survey. Tobacco Control, 24(Suppl 3), iii64-iii70.

Abstract

Objective: Determine (1) trends in single cigarette availability and purchasing in Mexico and (2) the association between neighbourhood access to singles and cessation behaviour among adult Mexican smokers.

Methods: We analysed data from Wave 4 (2010), Wave 5 (2011) and Wave 6 (2012) of the Mexican International Tobacco Control Policy Evaluation Survey. We used data from all three waves to examine time trends in singles availability and purchasing. To explore the association between neighbourhood access to singles and cessation behaviour, we used data from participants who were smokers at Wave 5 and followed up at Wave 6 (n=1272).

Findings: The percentage of participants who saw singles sold daily (45.2% in 2010; 51.4% in 2011; 64.9% in 2012), who bought singles at least once a week (22.3% in 2010; 29.1% in 2011; 29.1% in 2012) and whose last cigarette purchase was a single (16.6% in 2010; 20.7% in 2011; 25.8% in 2012) increased significantly from 2010 to 2012 (all p<0.001). The average percentage of residents who reported seeing singles sold daily in their neighbourhood in 2012 was 60% (SD=25%). In adjusted analyses, smokers living in neighbourhoods with higher access to singles were less likely to make a quit attempt (risk ratio (RR)=0.72; 95% CI 0.46 to 1.12), and more likely to relapse (RR=1.30; CI 0.94 to 1.82), but these results were not statistically significant.

Conclusions: Single cigarettes appear widely accessible in Mexico and growing in availability. Future research should explore potential explanations, consequences and effective methods for reducing the availability of single cigarettes.

Citation

Schneller, L., Zwierzchowski, B., Caruso, R., Li, Q., Jiang, Y., Fong, G.T., O’Connor, R.J. (2015). Changes in tar yields and cigarette design in samples of Chinese cigarettes, 2009-2012. Tobacco Control, 24(Suppl 4), iv60-iv63.

Abstract

Background: China is home to the greatest number of smokers as well as the greatest number of smoking-related deaths. An active and growing market of cigarettes marketed as ‘light’ or ‘low tar’ may keep health-concerned smokers from quitting, wrongly believing that such brands are less harmful.

Objective: This study sought to observe changes in cigarette design characteristics and reported tar, nicotine and carbon monoxide (TNCO) levels in a sample of cigarette brands obtained in seven Chinese cities from 2009 to 2012.

Methods: Cigarettes were purchased and shipped to Roswell Park Cancer Institute, where 91 pairs of packs were selected for physical cigarette design characteristic testing and recording of TNCO values. Data analysis was conducted using SPSS, and was initially characterised using descriptive statistics, correlations and generalised estimating equations to observe changes in brand varieties over time.

Findings: Reported TNCO values on packs saw mean tar, nicotine and CO levels decrease from 2009 to 2012 by 7.9%, 4.5% and 6.0%, respectively. Ventilation was the only cigarette design feature that significantly changed over time (p<0.001), with an increase of 31.7%. Significant predictors of tar and CO yield overall were ventilation and per-cigarette tobacco weight, while for nicotine tobacco moisture was also an independent predictor of yield.

Conclusions: The use of ventilation to decrease TNCO emissions is misleading smokers to believe that they are smoking a ‘light/low’ tar cigarette that is healthier, and is potentially forestalling the quitting behaviours that would begin to reduce the health burden of tobacco in China, and so should be prohibited.

Citation

Elton-Marshall, T., Fong, G.T., Yong, H.H., Borland, R., Xu, S.S., Quah, A.C.K., Feng, G., Jiang, Y. (2015). Smokers’ sensory beliefs mediate the relation between smoking a ‘light/low tar’ cigarette and perceptions of harm. Tobacco Control, 24(Suppl 4), iv21-iv27.

Abstract

Background: The sensory belief that ‘light/low tar’ cigarettes are smoother can also influence the belief that ‘light/low tar’ cigarettes are less harmful. However, the ‘light’ concept is one of several factors influencing beliefs. No studies have examined the impact of the sensory belief about one's own brand of cigarettes on perceptions of harm.

Objective: The current study examines whether a smoker's sensory belief that their brand is smoother is associated with the belief that their brand is less harmful and whether sensory beliefs mediate the relation between smoking a ‘light/low tar’ cigarette and relative perceptions of harm among smokers in China.

Methods: Data are from 5209 smokers who were recruited using a stratified multistage sampling design and participated in wave 3 of the International Tobacco Control (ITC) China Survey, a face-to-face survey of adult smokers and non-smokers in seven cities.

Results: Smokers who agreed that their brand of cigarettes was smoother were significantly more likely to say that their brand of cigarettes was less harmful (p<0.001, OR=6.86, 95% CI 5.64 to 8.33). Mediational analyses using the bootstrapping procedure indicated that both the direct effect of ‘light/low tar’ cigarette smokers on the belief that their cigarettes are less harmful (b=0.24, bootstrapped bias corrected 95% CI 0.13 to 0.34, p<0.001) and the indirect effect via their belief that their cigarettes are smoother were significant (b=0.32, bootstrapped bias-corrected 95% CI 0.28 to 0.37, p<0.001), suggesting that the mediation was partial.

Conclusions: These results demonstrate the importance of implementing tobacco control policies that address the impact that cigarette design and marketing can have in capitalising on the smoker's natural associations between smoother sensations and lowered perceptions of harm.

Citation

Swift, E., Borland, R., Cummings, K.M., Fong, G.T., McNeill, A., Hammond, D., Thrasher, J.F., Partos, T.R., Yong, H.H. (2015). Australian smokers’ support for plain or standardised packs before and after implementation: Findings from the ITC Four Country Survey. Tobacco Control, 24(6), 16-21.

Abstract

Background: Plain packaging (PP) for tobacco products was fully implemented in Australia on 1 December 2012 along with larger graphic health warnings. Using longitudinal data from the Australian arm of the ITC Four Country Survey, we examined attitudes to the new packs before and after implementation, predictors of attitudinal change, and the relationship between support and quitting activity.

Methods: A population-based cohort study design, with some cross-sectional analyses. Surveys of Australian smokers assessed attitudes to PP at four time points prior to implementation (from 2007 to 2012) and one post-implementation wave collected (early/mid-2013).

Results: Trend analysis showed a slight rise in opposition to PP among smokers in the waves leading up to their implementation, but no change in support. Support for PP increased significantly after implementation (28.2% pre vs 49% post), such that post-PP more smokers were supportive than opposed (49% vs 34.7%). Multivariate analysis showed support either before or after implementation was predicted by belief in greater adverse health impacts of smoking, desire to quit and lower addiction. Among those not supportive before implementation, having no clear opinion about PP (versus being opposed) prior to the changes also predicted support post-implementation. Support for PP was prospectively associated with higher levels of quitting activity.

Conclusions: Since implementation of PP along with larger warnings, support among Australian smokers has increased. Support is related to lower addiction, stronger beliefs in the negative health impacts of smoking, and higher levels of quitting activity.

Citation

Kasza, K.A., Cummings, K.M., Carpenter, M.J., Cornelius, M.E., Hyland, A., Fong, G.T. (2015). Use of stop-smoking medications in the United States before and after the introduction of varenicline. Addiction, 110(2), 346-355.

Abstract

Aims: To evaluate trends in use of stop-smoking medications (SSMs) before and after varenicline (Chantix™) was introduced to the market-place in the United States, and to determine whether varenicline reached segments of the population unlikely to use other SSMs.

Design: Cohort survey.

Setting: United States.

Participants: A nationally representative sample of adult smokers in the United States interviewed as part of the International Tobacco Control Four Country Survey between 2004 and 2011. Primary analyses used cross-sectional data from 1737 smokers who attempted to quit (∼450 per wave).

Measurements: Reporting an attempt to quit smoking; use of each of the following types of SSMs for the purpose of quitting smoking: nicotine gum, nicotine patch, other nicotine replacement therapy, bupropion and varenicline.

Findings: There was a significant increase in the rate of use of any SSM among quit attempters across the study period [odds ratio (OR) = 1.15, 95% confidence interval (CI) = 1.10-1.21 per year]. This increase was largest after varenicline was introduced (OR = 1.16, 95% CI = 1.07-1.26 per year); however, there was a decline in nicotine patch use during this time (OR = 0.87, 95% CI = 0.76-0.99 per year). Varenicline users were generally similar to users of other SSMs but differed from those who did not use any SSMs, in that they tended to be older (OR = 5.46, P = 0.024), to be white (OR = 2.33, P = 0.002), to have high incomes (OR = 1.85, P = 0.005), to have high nicotine dependence prior to quitting (OR = 2.40, P = 0.001) and to have used medication in the past (OR = 3.29, P < 0.001).

Conclusions: The introduction of varenicline in the United States coincided with a net increase in attempts to quit smoking and, among these, a net increase in use of stop-smoking medications. The demographic profile of varenicline users is similar to the profile of those who use other stop-smoking medications and different from the profile of those who attempt to quit without any medication .

Citation

Cornelius, M.E., Cummings, K.M., Fong, G.T., Hyland, A., Driezen, P., Chaloupka, F., Hammond, D., O’Connor, R.J., Bansal-Travers, M. (2015). The prevalence of brand switching among adult smokers in the USA, 2006-2011: Findings from the ITC US Surveys. Tobacco Control, 24(6), 609-615.

Abstract

Background: Recent studies have suggested that about 1 in 5 smokers report switching brands per year. However, these studies only report switching between brands. The current study estimated the rates of switching both within and between brand families and examining factors associated with brand and brand style switching.

Methods: Data for this analysis are from the International Tobacco Control 2006-2011 US adult smoker cohort survey waves 5-8 (N=3248). A switch between brands was defined as reporting two different cigarette brand names for two successive waves, while switching within brand was defined as reporting the same brand name, but a different brand style. Repeated measures regression was used to determine factors associated with both switch types.

Results: A total of 1475 participants reported at least two successive waves of data with complete information on brand name and style. Overall switching increased from 44.9% in 2007-2008 to 58.4% in 2010-2011. Switching between brand names increased from 16% to 29%, while switches within the same brand name to a different style ranged from 29% to 33%. Between-brand switching was associated with younger age, lower income, non-white racial group and use of a discount brand, whereas, within-brand switching was associated with younger age and the use of a premium brand cigarette.

Conclusions: Nearly half of smokers in the USA switched their cigarette brand or brand style within a year. Switching between brands may be more price motivated, while switching within brands may be motivated by price and other brand characteristics such as product length.

Citation

Li, L., Borland, R., Yong, H.H., Prohmmo, A., Thrasher, J.F., Hitchman, S.C., Fong, G.T., Hammond, D., Bansal-Travers, M. (2015). Longer term impact of cigarette package warnings in Australia compared to the United Kingdom and Canada: Findings from the International Tobacco Control (ITC) Four Country Survey. Health Education Research, 30(1), 67-80.

Abstract

This study examines the effects of different cigarette package warnings in Australia, Canada and the United Kingdom up to 5 years post-implementation. The data came from the International Tobacco Control Surveys. Measures included salience of warnings, cognitive responses, forgoing cigarettes and avoiding warnings. Although salience of the UK warnings was higher than the Australian and Canadian pictorial warnings, this did not lead to greater levels of cognitive reactions, forgoing or avoiding. There was no difference in ratings between the Australian and UK warnings for cognitive responses and forgoing, but the Canadian warnings were responded to more strongly. Avoidance of the Australian warnings was greater than to UK ones, but less than to the Canadian warnings. The impact of warnings declined over time in all three countries. Declines were comparable between Australia and the United Kingdom on all measures except avoiding, where Australia had a greater rate of decline; and for salience where the decline was slower in Canada. Having two rotating sets of warnings does not appear to reduce wear-out over a single set of warnings. Warning size may be more important than warning type in preventing wear-out, although both probably contribute interactively.

Citation

Hummel, K., Hoving, C., Nagelhout, G.E., de Vries, H., van den Putte, B., Candel, M.J.J.M., Borland, R., Willemsen, M.C. (2015). Prevalence and reasons for use of electronic cigarettes among smokers: Findings from the International Tobacco Control (ITC) Netherlands Survey. International Journal of Drug Policy, 26(6), 601-608.

Abstract

Background: Not much is known about how people in the Netherlands respond to electronic cigarettes (ecigarettes); how many know about them, which people try them, keep using them and why, and what are changes over time regarding awareness and use?

Methods: We used samples of smokers aged 15 years and older from 2008 (n = 1,820), 2010 (n = 1,702), 2013 (n = 1,530), and 2014 (n = 1,550) as part of the International Tobacco Control (ITC) Netherlands Survey. Reasons for use and characteristics of smokers were examined using the sample from 2014. Logistic regression analyses were conducted to evaluate the associations between smoking-related variables with ever trying e-cigarettes and current e-cigarette use.

Results: In 2014, 91.4% of Dutch smokers reported being aware of e-cigarettes (97.1% in 2008, 89.2% in 2010, and 85.5% in 2013), 40.0% reported having ever tried them (13.4% in 2008, 14.5% in 2010, and 19.6% in 2013), and 15.9% were currently using them (4.0% in 2008, 1% in 2010, and 3.9% in 2013). The main reason given for using e-cigarettes was to reduce the number of regular cigarettes smoked per day (79%). Ever trying e-cigarettes among those aware of e-cigarettes was associated with being young, smoking more regular cigarettes per day, having made a quit attempt in the last year, having used smoking cessation pharmacotherapy in the last year, and reporting high awareness of the price of regular cigarettes. Smokers who kept using e-cigarettes had a higher educational background, had higher harm awareness for the health of others, and were less likely to have a total smoking ban at home.

Conclusion: E-cigarettes are increasingly used by Dutch smokers. Commonly endorsed motivations for current e-cigarette use were to reduce tobacco smoking and because e-cigarettes are considered to be less harmful than tobacco cigarettes.

Citation

Wu, C., Thompson, M.E., Fong, G.T., Jiang, Y., Yang, Y., Feng, G., Quah, A.C.K. (2015). Methods of the International Tobacco Control (ITC) China Survey: Waves 1, 2, and 3. Tobacco Control, 24(Suppl 4), iv1-iv5.

Abstract

This paper describes the methods of sampling design and data collection of waves 1, 2 and 3 of the International Tobacco Control (ITC) China Survey, with major focus on longitudinal features of the study. Key measures of quality of the survey data, such as retention rates and final sample sizes, are presented. Sample replenishment procedures are outlined, including the addition of a new city, Kunming, at wave 3. Methods for constructing the longitudinal and cross-sectional survey weights are briefly described.

Citation

Azagba, S., Burhoo, P., Chaloupka, F., Fong, G.T. (2015). Effect of cigarette tax increase in combination with mass media campaign on smoking behaviour in Mauritius: Findings from the ITC Survey. Tobacco Control, 24(Suppl 3), iii71-iii75.

Abstract

Background: Mauritius has made great strides in adopting evidence-based tobacco control measures, including an increase in its cigarette excise tax and antitobacco mass media (Sponge) campaign. The primary objective of this study is to examine the combined effect of these measures on smoking behaviour.

Methods: This study used longitudinal data from the International Tobacco Control Mauritius Survey, 2009-2011. Waves 1 and 2 were conducted before the tax increase and wave 3 was conducted shortly after the Sponge campaign and 6 months after the cigarette excise tax increase. Generalised estimating equations were used to examine the effects of these two key tobacco control measures on smoking prevalence and the quantity of cigarettes smoked.

Results: The results showed that the combination of cigarette tax increase and the Sponge campaign had a significantly negative effect on the prevalence of smoking in Mauritius and the number of cigarettes smoked among continuing smokers. Specifically, the measures significantly reduced the odds of being a smoker (adjusted OR 0.88, 95% CI 0.81 to 0.97). For average daily cigarettes smoked, the measures had a significant reduction in cigarettes per day by about 6% (incidence rate ratios 0.94, 95% CI 0.89 to 0.99).

Conclusions: The combination of policy measures significantly reduced the consumption of cigarettes in Mauritius. While these results are encouraging, these efforts must be part of a sustained effort to further reduce the smoking prevalence in Mauritius .

Citation

Shang, C., Chaloupka, F., Fong, G.T., Thompson, M.E., Siahpush, M., Ridgeway, W. (2014, June). Weight control belief and its impact on cigarettes consumption and quit attempts: Findings from the ITC Project. Oral presentation at the American Society of Health Economists Conference, Los Angeles, California, United States.

Abstract

Background: Weight concerns are widely documented as one of the major barriers for girls and young adult women to quit smoking. Therefore, it is important to investigate whether smokers who have weight concerns respond to tobacco control policies differently than smokers who do not in terms of quit attempts, and how this difference varies by gender and country.

Objective: This study aims to investigate, by gender and country, whether smokers who believe that smoking helps control weight are less responsive to tobacco control policies with regards to quit attempts than those who do not.

Methods: We use longitudinal data from the International Tobacco Control Policy Evaluation Project in the USA, Canada, the UK and Australia to conduct the analysis. We first constructed a dichotomous indicator for smokers who have the weight control belief and then examined the disparity in policy responsiveness in terms of quit attempts by directly estimating the interaction terms of policies and the weight control belief indicator using generalised estimating equations.

Findings: We find that weight control belief significantly attenuates the policy impact of tobacco control measures on quit attempts among US female smokers and among UK smokers. This pattern was not found among smokers in Canada and Australia.

Conclusions: Although our results vary by gender and country, the findings suggest that weight concerns do alter policy responsiveness in quit attempts in certain populations. Policy makers should take this into account and alleviate weight concerns to enhance the effectiveness of existing tobacco control policies on promoting quitting smoking.

Citation

Liber, A.C., Ross, H., Omar, M., Chaloupka, F. (2015). The impact of the Malaysian minimum cigarette price law: Findings from the ITC Malaysia Survey. Tobacco Control, 24(Suppl 3), iii83-iii87.

Abstract

Objectives: Study the effects of the 2011 Malaysian minimum price law (MPL) on prices of licit and illicit cigarette brands. Identify barriers to the MPL achieving positive public health effects.

Methods: The International Tobacco Control Project's Southeast Asia survey collected information on Malaysian smokers' cigarette purchases (n=7520) in five survey waves between 2005 and 2012. Consumption-weighted comparisons of proportions tests and adjusted Wald tests were used to evaluate changes over time in violation rates of the inflation-adjusted MPL, the proportion of illicit cigarette purchases and mean prices.

Results: After the passage of the MPL, the proportion of licit brand cigarette purchases that were below the inflation-adjusted 2011 minimum price level fell substantially (before 3.9%, after 1.8%, p=0.002), while violation of the MPL for illicit brand cigarette purchases was unchanged (before 89.8%, after 91.9%, p=0.496). At the same time, the mean real price of licit cigarettes rose (p=0.006), while the mean real price of illicit cigarettes remained unchanged (p=0.134). The proportion of illicit cigarette purchases rose as well (before 13.4%, after 16.5%, p=0.041).

Discussion: The MPL appears not to have meaningfully changed cigarette prices in Malaysia, as licit brand prices remained well above and illicit brand prices remained well below the minimum price level before and after MPL's implementation. The increasing proportion of illicit cigarettes on the market may have undermined any positive health effects of the Malaysian MPL. The illicit cigarette trade must be addressed before a full evaluation of the Malaysian MPL's impact on public health can take place. The authors encourage the continued use of specific excise tax increases to reliably increase the price and decrease the consumption of cigarettes in Malaysia and elsewhere.

Citation

Curti, D., Shang, C., Ridgeway, W., Chaloupka, F., Fong, G.T. (2015). The use of legal, illegal, and roll-your-own cigarettes to increasing tobacco excise taxes and comprehensive tobacco control policies: Findings from the ITC Uruguay Survey. Tobacco Control, 24(Suppl 3), iii17-iii24

Abstract

Background: Little research has been done to examine whether smokers switch to illegal or roll-yourown (RYO) cigarettes in response to a change in their relative price.

Objective: This paper explores how relative prices between three cigarette forms (manufactured legal, manufactured illegal and RYO cigarettes) are associated with the choice of one form over another after controlling for covariates, including sociodemographic characteristics, smokers' exposure to antismoking messaging, health warning labels and tobacco marketing.

Methods: Generalised estimating equations were employed to analyse the association between the price ratio of two different cigarette forms and the usage of one form over the other.

Findings: A 10% increase in the relative price ratio of legal to RYO cigarettes is associated with a 4.6% increase in the probability of consuming RYO cigarettes over manufactured legal cigarettes (p≤0.05). In addition, more exposure to antismoking messaging is associated with a lower odds of choosing RYO cigarettes over manufactured legal cigarettes (p≤0.05). Non-significant associations exist between the manufactured illegal to legal cigarette price ratios and choosing manufactured illegal cigarettes, suggesting that smokers do not switch to manufactured illegal cigarettes as prices of legal ones increase. However, these non-significant findings may be due to lack of variation in the price ratio measures. To improve the effectiveness of increased taxes and prices in reducing smoking, policymakers need to narrow price variability in the tobacco market. Moreover, increasing antismoking messaging reduces tax avoidance in the form of switching to cheaper RYO cigarettes in Uruguay.