Citation

Li, L., Feng, G., Jiang, Y., Yong, H.H., Borland, R., Fong, G.T. (2011). Prospective predictors of quitting behaviours among adult smokers in six cities in China: Findings from the International Tobacco Control (ITC) China Survey. Addiction, 106(7), 1335-1345.

Abstract

Aims: To examine predictors of quitting behaviours among adult smokers in China, in light of existing knowledge from previous research in four western countries and two southeast Asian countries.

Design: Face-to-face interviews were carried out with smokers in 2006 using the International Tobacco Control (ITC) China Survey, with follow-up about 16 months later. A stratified multi-stage cluster sampling design was employed.

Setting: Beijing and five other cities in China.

Participants: A total of 4732 smokers were first surveyed in 2006. Of these, 3863 were re-contacted in 2007, with a retention rate of 81.6%.

Measurements: Baseline measures of socio-demographics, dependence and interest in quitting were used prospectively to predict both making quit attempts and staying quit among those who attempted.

Findings: Overall, 25.3% Chinese smokers reported having made at least one quit attempt between waves 1 and 2; of these, 21.7% were still stopped at wave 2. Independent predictors of making quit attempts included having higher quitting self-efficacy, previous quit attempts, more immediate intentions to quit, longer time to first cigarette upon waking, negative opinion of smoking and having smoking restrictions at home. Independent predictors of staying quit were being older, having longer previous abstinence from smoking and having more immediate quitting intentions.

Conclusions: Predictors of Chinese smokers' quitting behaviours are somewhat different to those found in previous research from other countries. Nicotine dependence and self-efficacy seem to be more important for attempts than for staying quit in China, and quitting intentions are related to both attempts and staying quit.

Citation

Fix, B.V., O’Connor, R.J., Fong, G.T., Borland, R., Cummings, K.M., Hyland, A. (2011). Smokers' reactions to FDA regulation of tobacco products: Findings from the 2009 ITC United States Survey. BioMed Central Public Health, 11, 941-947.

Abstract

Background: On June 22, 2009, the US FDA was granted the authority to regulate tobacco products through the Family Smoking Prevention and Tobacco Control Act (FSPTCA). The intent is to improve public health through regulations on tobacco product marketing and tobacco products themselves. This manuscript reports baseline data on smokers’ attitudes and beliefs on specific issues relevant to the FSPTCA.

Method: Between November 2009 and January 2010, a telephone survey among a nationally representative sample of n = 678 smokers in the US was performed as part of the International Tobacco Control (ITC) United States Survey. Participants answered a battery of questions on their attitudes and beliefs about aspects of the FSPTCA.

Results: Most smokers were unaware of the new FDA tobacco regulations. Smokers indicated support for banning cigarette promotion and nearly a quarter supported requiring tobacco companies to sell cigarettes in plain packaging. Seventy two percent of smokers supported reducing nicotine levels to make cigarettes less addictive if nicotine was made easily available in non-cigarette form.

Conclusion: Most smokers were limited in their understanding of efforts to regulate tobacco products in general. Smokers were supportive of efforts to better inform the public about health risks, restrict advertising, and make tobacco products less addictive.

Citation

Fix, B.V., Hyland, A., Rivard, C., McNeill, A., Fong, G.T., Borland, R., Hammond, D., Cummings, K.M. (2011). Usage patterns of stop smoking medications in Australia, Canada, the United Kingdom, and the United States: Findings from the 2006-2008 International Tobacco Control (ITC) Four Country Survey. International Journal of Environmental Research and Public Health, 8(1), 222-233.

Abstract

Varenicline is a new prescription stop smoking medication (SSM) that has been available in the United States since August 1, 2006, in the United Kingdom and other European Union countries since December 5, 2006, in Canada since April 12, 2007, and in Australia since January 1, 2008. There are few population-based studies that have examined use rates of varenicline and other stop smoking medications. We report data from the ITC Four Country survey conducted with smokers in the US, UK, Canada, and Australia who reported an attempt to quit smoking in past year in the 2006 survey (n = 4,022 participants), 2007 (n = 3,790 participants), and 2008 surveys (n = 2,735 participants) Respondents reported use of various stop smoking medications to quit smoking at each survey wave, along with demographic and smoker characteristics. The self-reported use of any stop smoking medication has increased significantly over the 3 year period in all 4 countries, with the sharpest increase occurring in the United States. Varenicline has become the second most used stop smoking medication, behind NRT, in all 4 countries since being introduced. Between 2006 and 2008, varenicline use rates increased from 0.4% to 21.7% in the US, 0.0% to 14.8% in Canada, 0.0% to 14.5% in Australia, and 0.0% to 4.4% in the UK. In contrast, use of NRT and bupropion remained constant in each country. Males and non-whites were significantly less likely to report using any SSM, while more educated smokers were significantly more likely to use any SSM, including varenicline. Our findings suggest that the introduction of varenicline led to an increase in the number of smokers who used evidence-based treatment during their quit attempts, rather than simply gaining market share at the expense of other medications. From a public health perspective, messages regarding increased success rates among medication users and the relative safety of stop smoking medications should be disseminated widely so as to reach all smokers of all socioeconomic classifications equally.

Citation

Kennedy, R.D., Spafford, M., Parkinson, C., Fong, G.T. (2011). Knowledge about the relationship between smoking and blindness in Canada, the United States, the United Kingdom, and Australia: Results from the International Tobacco Control Four-Country Project. Optometry, 82(5), 310-317.

Abstract

Purpose: Smoking is causally associated with certain prevalent visually impairing eye diseases, including age-related macular degeneration and cataract. Studies have found that people are afraid of ‘‘going blind’’ and may be motivated to quit smoking if they know that vision loss is associated with smoking behavior.

Methods: A random-digit dialed telephone survey was used to measure health knowledge of adult smokers in Canada (n=2,765), the United States (n=3,178), the United Kingdom (n=2,767), and Australia (n=2,623) as part of the International Tobacco Control Four-Country Project.

Results: A low proportion of smokers from Canada (13.0%), the United States (9.5%), and the United Kingdom (9.7%) believed that smoking can cause blindness. In contrast, 47.2% of Australian smokers believed that smoking causes blindness. Australia was the only country during the sampling period to have national awareness campaigns about smoking and its effects on eye health.

Conclusion: These findings point to the need across countries to educate the public on this important consequence of smoking. There is an opportunity for the public health and eye health communities to work to educate the public about the impacts smoking has on eye health to improve quit rates and help discourage people from starting to smoke.

Citation

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

Abstract

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

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

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

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

Citation

Kwak, S.M., Seo, H.G., Myung, S.K., Kim, Y., Jung, H.S., Fong, G.T., Quah, A.C.K., Sansone, N., Lee, W.B. (2011). Analysis of smoking-related characteristics over time in Korean adult smokers: Findings from the International Tobacco Control (ITC) Korea Survey (Language: Korean). Korean Journal of Family Practice, 1(3), 192-203.

Abstract

Background: This study aimed to track changes in demographic and smoking-related characteristics, such as perception of smoking and health among Korean adult smokers.

Methods: We conducted the three waves of the International Tobacco Control (ITC) survey-Korea (2005/2008/2010) using random digit-dialing telephone interviews. The ITC sample for each survey included 1,002 respondents at Wave 1, 1,818 at Wave 2 (including 441 cohort respondents from Wave 1), and 1,753 at Wave 3 (including 284 cohort respondents from Wave 1 and 745 from Wave 2).

Results: The largest age group ranged from 40-49 to ≥60, and the percentage of female respondents also has increased from Wave 1 to Wave 3. Even though the mean number of cigarettes per day significantly decreased from 18.2 to 17 in men, the same figure showed an insignificant increase for women from 14.3 to 18.6. As for the knowledge of health risk, awareness regarding the danger of stroke (from 35.5% to 51.4%) and blindness (from 31.6% to 42.1%) due to smoking was significantly improved (P < 0.01), whereas that of impotence, skin wrinkling, and peripheral vascular disease was not improved. The rate of subjects who answered “Health status is poor” increased from 13.2% to 16.4%, whereas rate of subjects who answered “Smoking has damaged health” decreased from 90% to 75.2%.

Conclusion: This study indicates that different strategies for the elderly and women should be developed and implemented because of their increased smoking rates. In addition, efforts to increase cessation rates should aim at increasing awareness of smoking-related diseases and health concern regarding smoking. 

Citation

Mutti, S., Hammond, D., Borland, R., Cummings, K.M., O’Connor, R.J., Fong, G.T. (2011). Beyond light and mild: Cigarette brand descriptors and perceptions of risk in the International Tobacco Control (ITC) Four Country Survey. Addiction, 106(6), 1166-1175.

Abstract

Aims: To examine perceptions of risk related to type of cigarette brand.

Design and setting: Cross-sectional findings from wave 5 of the ITC Four Country Survey, conducted with nationally representative samples of smokers in 2006.

Participants: A total of 8243 current and former adult (≥18 years) smokers from Canada (n = 2022), the United States (n = 2034), the United Kingdom (n = 2019) and Australia (n = 2168).

Measurements: Outcomes included beliefs about the relative risks of cigarettes, including perceptions of ‘own’ brand. Correlates included sociodemographic, smoking-related covariates and brand characteristics.

Findings: One-fifth of smokers believed incorrectly that ‘some cigarette brands could be less harmful’ than others. False beliefs were higher in both the United States and United Kingdom compared to Canada and Australia. Smokers of ‘light/mild’, ‘slim’ and 100 mm/120 mm cigarettes were more likely to believe that some cigarettes could be less harmful [odds ratio (OR) = 1.29, 95% confidence interval (CI) = 1.12–1.48 and that their own brand might be a little less harmful (OR = 2.61, 95% CI = 2.01–3.41). Smokers of ‘gold’, ‘silver’, ‘blue’ or ‘purple’ brands were more likely to believe that their ‘own brand might be a little less harmful’ compared to smokers of ‘red’ or ‘black’ brands (OR = 12.48, 95% CI = 1.45–107.31).

Conclusions: Despite current prohibitions on the words ‘light’ and ‘mild’, smokers in western countries continue to falsely believe that some cigarette brands may be less harmful than others. These beliefs are associated with descriptive words and elements of package design that have yet to be prohibited, including the names of colours and long, slim cigarettes.

Citation

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

Abstract

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

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

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

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

Citation

Sirirassamee, T., Sirirassamee, B., Borland, R., Omar, M., Driezen, P. (2011). Smoking behavior among adolescents in Thailand and Malaysia. Southeast Asian Journal of Tropical Medicine and Public Health, 42(1), 218-224.

Abstract

The objective of this study was to examine the smoking behavior among adolescents in Thailand and Malaysia. Population-based, national surveys were conducted among 1,704 adolescents between the ages of 13 and 18 from Thailand (n = 927) and Malaysia (n = 777). Respondents were selected using multistage cluster sampling. Respondents were asked to complete self-administered questionnaires. Approximately 5% of Thai and Malaysian adolescents were current smokers, while an additional 8.6% of Thai and 8.1% of Malaysian adolescents reported being beginning smokers. On average, Thai smokers reported first smoking a whole cigarette at 14.6 years old (SD = 1.9), while Malaysian smokers at age 13.9 years (SD = 2.2). More than half of Thai smokers (60.4%) reported they bought cigarettes themselves and 29.9% got cigarettes from friends. In Malaysia, most smokers (68.3%) reported they bought cigarettes themselves, only 20.7% got cigarettes from friends. Seventy-six percent of Thai adolescent smokers smoked factory-made brands as their usual brand compared to 27.7% of Malaysian adolescent smokers. Eight percent of Thai adolescents and 10% of Malaysian adolescents reported smoking hand-rolled cigarettes. Approximately half of Thais and more than 40% of Malaysian smokers reported they tried to quit smoking within the past month. The smoking prevalence of Thai adolescents is close to that of Malaysian adolescents. Factory-made cigarette consumption is an important problem in Thai adolescents and needs to be targeted.

Citation

Thrasher, J.F., Villalobos, V., Barnova, J., Sansores, R., O’Connor, R.J. (2011). Consumption of single cigarettes and quitting behavior: A longitudinal analysis of Mexican smokers. BioMed Central Public Health, 11(1), 134.

Abstract

Background: Previous cross-sectional research has suggested single cigarettes could either promote or inhibit consumption. The present study aimed to assess the effects of single cigarette availability and consumption on downstream quit behavior.

Methods: We analyzed population-based, longitudinal data from adult smokers who participated in the 2008 and 2010 administrations of the International Tobacco Control Policy Evaluation Survey in Mexico.

Results: At baseline, 30% of smokers saw single cigarettes for sale on a daily basis, 17% bought singles at their last purchase, and 7% bought singles daily. Smokers who most frequently purchased singles, both in general and specifically to control their consumption, were no more likely to attempt to quit over the 14 month follow-up period than those who did not purchase singles. Frequency of buying singles to reduce consumption had a non-monotonic association with being quit at followup. The odds of being quit was only statistically significant when comparing those who had not bought singles to reduce consumption with those who had done so on a more irregular basis (AOR = 2.30; 95% CI 1.19, 4.45), whereas those who did so more regularly were no more likely to be quit at followup. Frequency of self-reported urges to smoke upon seeing singles for sale was unassociated with either quit attempts or being quit at followup.

Conclusions: These results suggest that the relationship between singles consumption and quit behavior is complex, with no clear evidence that singles either promote or inhibit downstream quit behavior.

Citation

Thrasher, J.F., Quah, A.C.K., Dominick, G., Borland, R., Driezen, P., Awang, R., Omar, M., Hosking, W., Sirirassamee, B., Boado Martinez, M. (2011). Using cognitive interviewing and behavioral coding to determine measurement equivalence across linguistic and cultural groups: An example from the International Tobacco Control Policy Evaluation Project. Field Methods, 23(4), 439-460.

Abstract

This study examined and compared results from two questionnaire pretesting methods (i.e., behavioral coding and cognitive interviewing [CI]) to assess systematic measurement bias in survey questions for adult smokers across six countries (United States, Australia, Uruguay, Mexico, Malaysia, and Thailand). Protocol development and translation involved multiple bilingual partners in each linguistic/cultural group. The study was conducted with convenience samples of 20 adult smokers in each country. Behavioral coding and CI methods produced similar conclusions regarding measurement bias for some questions; however, CI was more likely to identify potential response errors than behavioral coding. Coordinated qualitative pretesting of survey questions (or postsurvey evaluation) is feasible across cultural groups and can provide important information on comprehension and comparability. The CI appears to be a more robust technique than behavioral coding, although combinations of the two might be even better.

Citation

Vangeli, E., Stapleton, J., Smit, E.S., Borland, R., West, R. (2011). Predictors of attempts to stop smoking and theirsuccess in adult general population samples: A systematic review. Addiction, 106(12), 2110-2121.

Abstract

Aims: To identify the predictors of attempts to stop smoking and the predictors of quit attempt success in adult general population samples.

Methods: We performed an electronic search of EMBASE, Pubmed, Web of Science, PsychINFO and the Cochrane Tobacco Addiction Group specialized register for articles that examined, in prospective adult general population samples, predictors of quit attempts and the success of quit attempts. Experts were contacted for knowledge of other relevant studies. Eight studies met the inclusion criteria and results were extracted independently by two researchers.

Results: There was considerable methodological heterogeneity between studies. Motivational factors dominated the prediction of quit attempts, whereas only cigarette dependence consistently predicted success after an attempt had been made. Social grade also appeared to predict success but was only examined in two studies. None of the other socio-demographic factors consistently predicted making a quit attempt or success.

Conclusions: Population-level studies from a number of countries show that past quit attempts and measures of motivation to stop are highly predictive of quit attempts, whereas only measures of dependence are consistently predictive of success of those attempts. Gender, age and marital status and educational level are not related consistently to quit attempts or quit success across countries.

Citation

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

Abstract

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

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

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

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

Citation

Yong, H.H., Borland, R., Cummings, K.M., Hammond, D., O’Connor, R.J., Hastings, G., King, B. (2011). Impact of the removal of misleading terms on cigarette pack on smokers' beliefs about "light/mild" cigarettes: Cross-country comparisons. Addiction, 106(12), 2204-2213.

Abstract

Aim: This paper examines how smokers’ beliefs about “light/ mild” cigarettes in Australia, Canada and the UK were affected by the removal of misleading “light/mild” terms from packs.

Design, setting and participants: The data come from the first 7 waves (2002-2009) of the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey, an annual cohort telephone survey of adult smokers in Canada, United States, United Kingdom, and Australia (21,613 individual cases). “Light” and “mild” descriptors were removed in 2003 in the UK, in 2006 in Australia, and in 2007 in Canada. We compare beliefs about “light” cigarettes both before and after the bans, with those of smokers in the US serving as the control condition.

Findings: The proportions of respondents reporting misperceptions about light cigarettes declined between 2002 and 2009 in all four countries. There were marked temporary reductions in reported misperceptions in the UK and Australia but not in Canada following the removal of “light/mild” descriptors.

Conclusions: Removal of “light/mild” descriptors and tar, nicotine and carbon monoxide yield information from cigarette packs is insufficient to effectively eliminate false beliefs. The combination of alternative descriptors and design features that produce differences in taste strength and harshness, independent of actual intakes, are sufficient to produce or sustain the same misbeliefs.

Citation

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

Abstract

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

Citation

Young, D., Borland, R. (2011). Conceptual challenges in the translation of research into practice: It’s not just a matter of "communication". International Journal of Translational Behavioural Medicine, 1(2), 256-269.

Abstract

This paper identifies key barriers to the translation of science into practice and policy and makes recommendations for addressing them. It focuses on the challenges of translation within the field of tobacco control, but we argue that the insights are widely generalisable. Actor-Network Theory is used to frame an analysis, supplemented by focussed discussions with international tobacco control practitioners (service delivery and advocacy) and researchers. The central challenge to translation is that researchers and practitioners have different “practical ontologies”. Researchers use findings from specific contexts to generalise to universal principles, while practitioners try to use these generalisations to inform their work in what are typically a somewhat different set of specific contexts. Neglecting the need to translate back from the general to the particular means research syntheses are not framed to meet practitioners’ needs. Traditional knowledge broking roles need to be extended to better align the needs of researchers and practitioners. This may be facilitated by more creative use of “social computing” to enable real-time input into research syntheses from all interested parties, including input to the questions that research addresses. To do this systematically requires that we construct “generalisation gradients” to help practitioners apply general research conclusions to their particular situation and researchers to identify the relevance of their work. Disadvantaged communities in particular need help, since there is typically less research directly applicable to their contexts; thus, they need to generalise more.

Citation

Wilson, N., Peace, J., Edwards, R., Weerasekera, D. (2011). Smokers commonly misperceive that nicotine is a major carcinogen: National survey data. Thorax, 66(4), 353-354.

Abstract

We aimed to assess view in New Zealand (NZ) smokers, with the context being a country in which NRT is provided in a heavily subsidised form and widely distributed via the national quitline service. Data were collected through the NZ arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) which derives its sample of smokers from the NZ Health Survey (a representative national sample).

Citation

Wilson, N., Weerasekera, D., Collings, S., Edwards, R., van der Deen, F.S. (2010). Poorer mental health in many NewZealand smokers: National survey data from the ITC Project. New Zealand Medical Journal, 123(1326), 129-132.

Abstract

There is international evidence that smoking and poorer mental health are associated.1–5 This association has also been studied in New Zealand (e.g., in longitudinal studies6–8) with the most recent work indicating that smoking has a causal role in depressive symptoms.9 Furthermore, in this country it has been estimated that 33% of all cigarettes are consumed by people with current mental disorders.10 We were able to further explore some aspects of the smoking and mental health issue in New Zealand as part of the International Tobacco Control Policy Evaluation Survey (ITC Project).

Methods: The ITC Project (NZ arm) surveyed a nationally representative sample of adult smokers (n=1376 in Wave 1 in 2007/8, n=923 in Wave 2 in 2008/9). This study derives its sample from the New Zealand Health Survey (NZHS) which is a national sample with boosted sampling of Māori, Pacific and Asian New Zealanders. We measured their mental health and alcohol use status using the SF-36, the Kessler-10 (K10), and the AUDIT. Also assessed were smoking-related beliefs and behaviours, including quit rates. Some comparisons were made with non-smoking participants in the NZHS. All results are weighted and adjusted for the complex sample design. Further details of the methods (including response rates, attrition and weighting processes) are available in online Methods Reports11-13 and related publications.14 15

Results: In terms of overall mental health, smokers had significantly lower SF-36 (mental health) scores (i.e., poorer mental health status) than the general adult population (80.6, 95%CI: 79.6–81.6; vs 82.2, 95%CI: 81.9–82.6). Reporting ever having been diagnosed with a mental disorder was significantly more common for adult smokers than for non-smokers (at 20.3%, 95%CI: 17.4% – 23.1%; vs 11.5%, 95%CI: 10.8%–12.2%). Here the non-smoker comparison group was from the full NZHS sample and “mental disorders” were any in a list of eight items used in the NZHS.

Citation

Hoek, J., Wilson, N., Allen, M., Edwards, R., Thomson, G., Li, J. (2010). Lessons from New Zealand's introduction of pictorial health warnings on tobacco packaging. Bulletin of the World Health Organization, 88 (11), 861-866.

Abstract

While international evidence suggests that featuring pictorial health warnings on tobacco packaging is an effective tobacco control intervention, the process used to introduce these new warnings has not been well documented. We examined relevant documents and interviewed officials responsible for this process in New Zealand. We found that, despite tobacco companies’ opposition to pictorial health warnings and the resource constraints facing health authorities, the implementation process was generally robust and successful. Potential lessons for other countries planning to introduce or refresh existing pictorial health warnings include: (i) strengthening the link between image research and policy; (ii) requiring frequent image development and refreshment; (iii) using larger pictures (e.g. 80% of the front of the packet); (iv) developing themes that recognize concerns held by different smoker sub-groups; and (v) running integrated mass media campaigns when the warnings are introduced. All countries could also support moves by the World Health Organization Framework Convention on Tobacco Control’s Secretariat to develop an international bank of copyright-free warnings.

Citation

Elton-Marshall, T., Fong, G.T., Zanna, M.P., Jiang, Y., Hammond, D., O’Connor, R.J., Yong, H.H., Li, L., King, B., Li, Q., Borland, R., Cummings, K.M., Driezen, P. (2010). Beliefs about the relative harm of "light" and "low tar" cigarettes: Findings from the International Tobacco Control (ITC) China Survey. Tobacco Control, 19(Suppl 2), i54-i62.

Abstract

Background: Many smokers in Western countries perceive ‘‘light’’ or ‘‘low tar’’ cigarettes as less harmful and less addictive than ‘‘regular’’ or ‘‘full flavoured’’ cigarettes. However, there is little research on whether similar perceptions exist among smokers in low and middle incomes, including China.

Objective: To characterise beliefs about ‘‘light’’ and ‘‘low tar’’ cigarettes among adult urban smokers in China.

Methods: We analysed data from Wave 1 of the ITC China Survey, a face-to-face household survey of 4732 adult Chinese smokers randomly selected from six cities in China in 2006. Households were sampled using a stratified multistage design.

Findings: Half (50.0%) of smokers in our sample reported having ever tried a cigarette described as ‘‘light,’’ ‘‘mild’’ or ‘‘low tar’’. The majority of smokers in our sample (71%) believed that ‘‘light’’ and/or ‘‘low tar’’ cigarettes are less harmful compared to ‘‘full flavoured’’ cigarettes. By far the strongest predictor of the belief that ‘‘light’’ and/or ‘‘low tar’’ cigarettes are less harmful was the belief that ‘‘light’’ and/or ‘‘low tar’’ cigarettes feel smoother on the respiratory system (p,0.001, OR=53.87, 95% CI 41.28 to 70.31).

Conclusion: Misperceptions about ‘‘light’’ and/or ‘‘low tar’’ cigarettes were strongly related to the belief that these cigarettes are smoother on the respiratory system. Future tobacco control policies should go beyond eliminating labelling and marketing that promotes ‘‘light’’ and ‘‘low tar’’ cigarettes by regulation of product characteristics (for example, additives, filter vents) that reinforce perceptions that ‘‘light’’ and ‘‘low tar’’ cigarettes are smoother on the respiratory system and therefore less harmful.

Citation

Feng, G., Jiang, Y., Li, Q., Yong, H.H., Elton-Marshall, T., Yang, J., Li, L., Sansone, N., Fong, G.T. (2010). Individual-level factors associated with intentions to quit smoking among adult smokers in six cities of China: Findings from the ITC China Survey. Tobacco Control, 19(Suppl 2), i6-i11.

Abstract

Background: Over 350 million smokers live in China, and this represents nearly one-third of the smoking population of the world. Smoking cessation is critically needed to help reduce the harms and burden caused by smoking-related diseases. It is therefore important to identify the determinants of quitting and of quit intentions among smokers in China. Such knowledge would have potential to guide future tobacco control policies and programs that could increase quit rates in China.

Objective: To identify the correlates of intentions to quit smoking among a representative sample of adult smokers in six cities in China.

Methods: Data from wave 1 (2006) of the International Tobacco Control (ITC) Policy Evaluation Project China Survey, a face-to-face survey of adult Chinese smokers in six cities: Beijing, Shenyang, Shanghai, Changsha, Guangzhou and Yinchuan, was analysed. Households were sampled using a stratified multistage design. About 800 smokers were surveyed in each selected city (total n¼4815).

Results: Past quit attempts, duration of past attempts, Heaviness of Smoking Index (HSI), outcome expectancy of quitting, worry about future health and overall opinion of smoking were found to be independently associated with intentions to quit smoking, but demographic characteristics were not.

Conclusions: The determinants of quit intentions among smokers in China are fairly similar to those found among smokers in Western countries, despite the fact that interest in quitting is considerably lower among Chinese smokers. Identifying the determinants of quit intentions provides possibilities for shaping effective policies and programs for increasing quitting among smokers in China.

Citation

Jiang, Y., Elton-Marshall, T., Fong, G.T., Li, Q. (2010). Quitting smoking in China: Findings from the ITC China Survey. Tobacco Control, 19(Suppl 2), i12-i17.

Abstract

Background: Few studies have examined interest in quitting smoking and factors associated with quitting in mainland China.

Objective: To characterise interest in quitting, quitting behaviour, the use of cessation methods and reasons for thinking about quitting among adult urban smokers in six cities in China.

Methods: Data is from Wave 1 of the ITC China Survey, a face-to-face household survey of 4732 adult smokers randomly selected from six cities in China in 2006. Households were sampled using a stratified multistage design.

Findings: The majority of smokers had no plan to quit smoking (75.6%). Over half (52.7%) of respondents had ever tried to quit smoking. Few respondents thought that they could successfully quit smoking (26.5%). Smokers were aware of stop-smoking medications (73.5%) but few had used these medications (5.6%). Only 48.2% had received advice from a physician to quit smoking. The number one reason for thinking about quitting smoking in the last 6 months was concern for personal health (55.0%). Most smokers also believed that the government should do more to control smoking (75.2%).

Conclusion: These findings demonstrate the need to: (1) increase awareness of the dangers of smoking; (2) provide cessation support for smokers; (3) have physicians encourage smokers to quit; (4) deformalize tobacco use so that smokers feel pressured to quit; (5) implement smoke-free laws to encourage quitting; (6) develop stronger warning labels about the specific dangers of smoking and provide resources for obtaining further cessation assistance; and (7) increase taxes and raise the price of cigarettes.

Citation

Cooper, J., Borland, R., Yong, H.H., McNeill, A., Murray, R.L., O’Connor, R.J., Cummings, K.M. (2010). To what extent do smokers make spontaneous quit attempts and what are the implications for smoking cessation maintenance? Findings from the International Tobacco Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S51-57.

Abstract

Aim: To assess the extent to which quit attempts are spontaneous and to evaluate if this is a determinant of smoking cessation maintenance, with better control for memory effects.

Methods: We use data from 3,022 smokers who made quit attempts between Waves 4 and 5 and/or Waves 5 and 6 of the International Tobacco Control Four country survey. Outcomes (quitting for 6 months) were confirmed at the next wave for cases where the attempt began within the previous 6 months. We assessed the length of delay between the decision to quit and implementation and whether the attempt followed a “spur-of-the-moment” decision or some serious prior consideration. Outcomes were modeled using generalized estimating equations.

Results: Prior consideration of quitting was unrelated to the outcome, but there were complex relationships for the delay between choosing a quit day and implementation. Those who reported quitting on the day they decided and those who delayed for 1 week or more had comparable rates of 6-month abstinence. Delaying for 1–6 days was associated with a greater relapse rate than those who quit on the day, although this effect became non-significant in multivariate analyses.

Conclusions: Quitting is on most smokers’ minds regularly and most attempts are not preceded by a long lead in period following the decision to try. Neither prior consideration nor delay between the decision to quit and implementation was clearly related to outcomes. Previous findings of greater success for spontaneous quit attempts may be because they conflate setting a date in advance with planning and also perhaps some differential memory effects.

Citation

Gibson, J.E., Murray, R.L., Borland, R., Cummings, K.M., Fong, G.T., Hammond, D., McNeill, A. (2010). The impact of the United Kingdom's national smoking cessation strategy on quit attempts and use of cessation services: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S64-71.

Abstract

Introduction: The World Health Organization Framework Convention on Tobacco Control recommends that provision of cessation support should be included in national tobacco control strategies. This study examines the impact of the United Kingdom’s national smoking cessation strategy on quit attempts, use of treatment and short-term abstinence, relative to the United States, Canada, and Australia where less support is provided.

Methods: Data on quitting behavior and use of support were obtained for all smokers enrolled in the International Tobacco Control 4 Country Survey between 2002 and 2005. Generalized estimating equations were used to calculate the relative odds (adjusted by age, sex, and Heaviness of Smoking Index) that smokers in each country made quit attempts, used behavioral or pharmacological support, and to compare rates of short-term (28 days) abstinence between countries and users of different forms of support.

Results: U.K. smokers were less likely to have attempted to quit smoking than those in Australia (odds ratio [OR] = 1.25, 95% CI: 1.12–1.40), Canada (OR = 1.50, 95% CI: 1.34–1.67), and the United States (OR = 1.25, 95% CI: 1.11–1.40) but were more likely to use pharmacotherapy and/or support from a clinic, helpline, or health professional when attempting to quit than smokers in the other countries. U.K. smokers making quit attempts were significantly more likely to achieve 28-day abstinence than those in Australia (OR = 0.59, 95% CI: 0.49–0.71), Canada (OR = 0.72, 95% CI: 0.61–0.87), and the United States (OR = 0.51, 95% CI: 0.42–0.62).

Conclusions: U.K. smokers report fewer quit attempts but are more likely to use support when quitting and to achieve short-term abstinence.

Citation

Reid, J., Hammond, D., Boudreau, C., Fong, G.T., Siahpush, M. (2010). Socioeconomic disparities in quit intentions, quit attempts, and smoking abstinence among smokers in four western countries: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research, 12(Suppl 1), S20-33.

Abstract

Introduction: Lower socioeconomic status (SES) groups have higher rates of tobacco use, are less likely to successfully quit, and may also be less likely to intend or attempt to quit. However, results are inconsistent for some outcomes, and little is known about how socioeconomic disparities vary across countries and over time.

Methods: This study examined the associations between SES and quitting-related behaviors among representative samples of smokers in Canada, the United States, the United Kingdom, and Australia, using data from the first five waves (2002–2006/2007) of the International Tobacco Control Four Country Survey (35,532 observations from 16,458 respondents). Generalized estimating equations modeling was used to examine whether education and income were related to intentions to quit, incidence of quit attempts, and smoking abstinence. Potential differences in the associations over time and across countries were also considered.

Results: Smokers with higher education were more likely to intend to quit, to make a quit attempt, and to be abstinent for at least 1 and 6 months; smokers with higher income were more likely to intend to quit and to be abstinent for at least 1 month. Some between-country differences were observed: U.K. and U.S. smokers were less likely to intend to quit than Australians and Canadians; and, although U.K. respondents were least likely to attempt to quit, those that did were more likely to be abstinent.

Discussion: The results suggest that socioeconomic disparities exist at multiple stages in the path to smoking cessation. Potential effects on socioeconomic disparities should be considered when implementing cessation interventions.