Citation

Kyriakos, C.N., Driezen, P., Girvalaki, C., Hitchman, S.C., Filippidis, F.T., Gravely, S., Balmford, J., Nikitara, K., Mons, U., Fernández, E., Przewoźniak, K., Trofor, A.C., Demjén, T., Zatoński, W.A., Tountas, Y., Fong, G.T., Vardavas, C.I. (2020). Awareness and correlates of noticing changes to cigarette packaging design after implementation of the European Tobacco Products Directive: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl 3), iii98-iii107.

Abstract

Background:

The European Tobacco Products Directive (TPD), which went into effect in May 2016, regulates packaging design and labelling of cigarettes and roll-your-own (RYO) tobacco. The aim of the current study was to examine whether smokers and recent quitters in six European Union (EU) countries (Germany, Greece, Hungary, Poland, Romania and Spain) reported noticing TPD-related changes to packaging, and correlates of noticing these changes.

Methods:

Cross-sectional data from the Wave 2 of the ITC 6 European Country Survey in 2018 after implementation of the TPD. Bivariate analyses included adult smokers (n = 5597) and recent quitters (n = 412). Adjusted logistic regression analyses were restricted to the subset of current smokers (n = 5597) and conducted using SAS-callable SUDAAN.

Results:

Over half of smokers (58.2%) and 30% of quitters noticed at least one of five types of TPD related pack changes. Over one-quarter of all respondents noticed changes to health warnings (30.0%), standardized openings (27.7%), minimum pack unit size (27.9%), and the removal of tar, nicotine and carbon monoxide information (26.7%) on packaging. Cross-country differences were observed across all measures, with noticing all pack changes markedly lower in Spain than the other countries. Correlates of noticing specific pack changes included sociodemographic characteristics, smoking behaviours and related to packaging.

Conclusions:

This is one of the first cross-country studies to examine the extent to which TPD changes to cigarette and RYO tobacco packaging are being noticed by smokers and recent quitters. Findings indicate that the majority of smokers noticed at least one type of pack change, but this varied across countries and sub-populations.

Citation

Lotrean, L.M., Trofor, A.C., Radu-Loghin, C., Eremia, M., Mihaltan, F., Driezen, P., Kyriakos, C.N., Mons, U., Demjén, T., Fernández, E., Katsaounou, P.A., Przewoźniak, K., McNeill, A., Filippidis, F.T., Gravely, S., Fong, G.T., Vardavas, C.I. (2020). Awareness and use of heated tobacco products among adult smokers in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl 3), iii78-iii83.

Abstract

Background:

The study assessed awareness and use of heated tobacco products (HTPs) and factors that influenced these issues among cigarette smokers from six European countries in 2016 (Wave 1) and 2018 (Wave 2).

Methods:

A survey was conducted among a nationally representative sample of cigarette smokers aged 18 years or older from Germany, Greece, Hungary, Poland, Romania and Spain in 2016 (N = 6011) and 2018 (N = 6027; 53% of smokers from the previous wave were retained, regardless of smoking status and dropouts were replaced by a replenishment sample of smokers). Data were collected through face-to-face interviews. Estimates were produced using weighted data. The study presents the cross-sectional results.

Results:

Awareness of HTPs increased from 8% to 17% between the two waves. At Wave 1, 1.1% of the smokers declared having used HTPs at least once during their lifetime; and at Wave 2, this increased to 1.9% (around 1% or less in four countries, except for Greece and Romania where it was around 4%). Factors associated with HTPs use among those who had ever heard about these products at Wave 1 were country of residence, being a daily cigarette smoker and ever use of electronic cigarettes. At Wave 2, ever use of HTPs was significantly higher among those who had tried to quit smoking combustible cigarettes in the last 12 months, had tried electronic cigarettes during lifetime and perceived HTPs as less dangerous than combustible cigarettes; the country of residence was also associated with HTPs use.

Conclusion:

This study offers insights into the behaviours and perceptions of European adult smokers regarding HTPs, an important emerging issue in the field of tobacco control.

Citation

McDermott, M., East, K., Hitchman, S.C., McNeill, A., Tountas, Y., Demjén, T., Fernández, E., Mons, U., Trofor, A.C., Herbec, A., Janik-Koncewicz, K., Fong, G.T., Vardavas, C.I. (2020). Social norms for ecigarettes and smoking: Associations with initiation of e-cigarette use, intentions to quit smoking and quit attempts: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii46-iii54

Abstract

Background:

Social norms have received little attention in relation to electronic cigarettes (EC). The current study examine social norms for EC use and smoking tobacco, and their associations with (i) initiation of EC use, (ii) intention to quit smoking and (iii) attempts to quit smoking.

Methods:

Cross-sectional and longitudinal data analysis from Waves 1 and 2 of the ITC 6 European Country Survey and corresponding waves from England (the ITC Four Country Smoking and Vaping Survey). Current smokers at baseline, who heard of ECs and provided data at both waves were included (n = 3702). Complex samples logistic regression examined associations between the outcomes and descriptive (seeing EC use in public, close friends using ECs/smoking) and injunctive (public approves of ECs/smoking) norms, adjusting for country, demographics, EC use and heaviness of smoking.

Results:

In longitudinal analyses, seeing EC use in public at least some days was the only social norm that predicted initiation of EC use between waves (OR = 1.66, 95%CI = 1.08–2.56). In the cross-sectional analysis, having an intention to quit was associated with seeing EC use in public (OR = 1.37, 95%CI = 1.04–1.81) and reporting fewer than three close friends smoke (OR = 0.59, 95%CI = 0.44–0.80). There was no association between any social norm and making a quit attempt between waves.

Conclusions:

Initiation of EC use is predicted by seeing EC use in public, which was also associated with greater intention to quit smoking. Friends’ smoking was associated with lower intention to quit. These findings may allay concerns that increased visibility of ECs is renormalizing smoking amongst current smokers.

Citation

Nikitara, K., Girvalaki, C., Kyriakos, C.N., Driezen, P., Filippidis, F.T., Kahnert, S., Hitchman, S.C., Mons, U., Fernández, E., Trofor, A.C., Przewoźniak, K., Demjén, T., Katsaounou, P.A., Zatoński, W.A., Fong, G.T., Vardavas, C.I. (2020). Changes in electronic cigarette use and label awareness among smokers before and after the European Tobacco Products Directive implementation in six European countries: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii62-iii67.

Abstract

Background:

Article 20 of the European Tobacco Product Directive (TPD), which went into effect in May 2016, regulates electronic cigarettes (e-cigarettes) in the European Union (EU). The aim of this study was to evaluate changes in e-cigarette use, design attributes of the products used and awareness of e-cigarette labelling and packaging among smokers from six EU Member States (MS) before and after TPD implementation.

Methods:

Data come from Wave 1 (2016, pre-TPD) and Wave 2 (2018, post-TPD) of the ITC Six European Country Survey among a sample of smokers and recent quitters who use e-cigarettes from six EU MS. Weighted logistic generalized estimating equations regression models were estimated to test the change in binary outcomes between Waves 1 and 2 using SAS-callable SUDAAN.

Results:

In 2018, current daily/weekly e-cigarette use among adult smokers was just over 2%, but this varied from the highest in Greece (4%) to lowest in Poland (1.2%). From Waves 1 to 2, there was a significant increase in respondents reporting noticing and reading health and product safety information on leaflets inside e-cigarette packaging (8.39–11.62%, P < 0.001). There were no significant changes between waves of respondents reporting noticing or reading warning labels on e-cigarette packages/vials.

Conclusions:

E-cigarette use among smokers in these six EU countries is low. Although reported noticing and reading leaflets included in the packaging of e-cigarettes increased significantly from before to after the TPD, there was no significant change in reported noticing and reading of warning labels. Findings indicate the importance of continued monitoring of TPD provisions around e-cigarettes.

Citation

Nogueira, S.O., Tigova, O., Driezen, P., Fu, M., Kyriakos, C.N., Zatoński, M., Mons, U., Quah, A.C.K., Demjén, T., Trofor, A.C., Przewoźniak, K., Katsaounou, P.A., Fong, G.T., Vardavas, C.I., Fernández, E. (2020). Do smokers want to protect non-smokers from the harms of secondhand smoke in cars? Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii108- iii112.

Abstract

Background:

There is currently no comprehensive legislation protecting non-smokers and children from second-hand smoke (SHS) exposure in private cars at the European Union (EU) level. This study aims to assess smokers’ support for smoke-free cars legislation in six EU countries.

Methods:

Data come from the EUREST-PLUS ITC Europe Surveys: Wave 1 (2016, n = 6011) and Wave 2 (2018, n = 6027) conducted in Germany, Greece, Hungary, Poland, Romania and Spain. Support for smoke-free cars carrying pre-school children and non-smokers and voluntary implementation of smoke-free cars were assessed among adult smokers. Generalized estimating equations models were used to assess changes in support between waves.

Results:

In 2018, 96.3% [95% confidence interval (CI) 95.4–97.0%] of the overall sample supported smoke-free legislation for cars carrying pre-school children, representing an increase of 2.4 percentage points in comparison to 2016. Smoke-free legislation for cars transporting non-smokers was supported by 85.2% (95% CI 83.1–87.1%) of smokers’ in 2016 and 90.2% (95% CI 88.6–91.7%) in 2018. Among smokers who owned cars, there was a significant 7.2 percentage points increase in voluntary implementation of smoke-free cars carrying children from 2016 (60.7%, 95% CI 57.2–64.0%) to 2018 (67.9%, 95% CI 65.1–70.5%). All sociodemographic groups of smokers reported support higher than 80% in 2018.

Conclusion:

The vast majority of smokers in all six EU countries support smoke-free legislation for cars carrying pre-school children and non-smokers. This almost universal support across countries and sociodemographic groups is a clear indicator of a window of opportunity for the introduction of comprehensive legislation to protect non-smokers and children from SHS exposure in cars.

Citation

Vardavas, C.I., Kyriakos, C.N., Driezen, P., Girvalaki, C., Nikitara, K., Filippidis, F.T., Fernández, E., Mons, U., Przewoźniak, K., Trofor, A.C., Demjén, T., Katsaounou, P.A., Zatoński, W.A., Willemsen, M.C., Fong, G.T. (2020). Transitions in product use during the implementation of the European Tobacco Products Directive: Cohort study findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Suppl_3), iii10-iii17.

Abstract

Background:

The emergence of new types of tobacco and tobacco-related products on the European Union (EU) market has precipitated the possibility for both poly-tobacco use and transitions between products. In the EU, the regulatory environment has shifted with the implementation of the European Tobacco Products Directive (TPD) in May 2016, which may influence consumer transitions between products.

Methods:

The aim of this paper was to examine trends and transitions in tobacco products from 2016 to 2018 -before and after implementation of the TPD in the EU. Data come from Wave 1 (preTPD) and Wave 2 (post-TPD) of the EUREST-PLUS ITC Six European Country Survey, a cohort study of adults who at the time of recruitment were smokers from six EU countries- Germany, Greece, Hungary, Poland, Romania, and Spain. D (N = 3195). Bivariate and logistic regression analyses of weighted data was conducted using SAS-callable SUDAAN

Results:

Overall, among those who smoked factorymade cigarettes (FM) only at Wave 1, 4.3% switched to roll-your-own tobacco (RYO) only. Among RYO only users at Wave 1, 17.0% switched to FM only, however compared to all other countries, respondents from Hungary had the highest percentage of FM only users at Wave 1 switch to RYO only at Wave 2 (18.0%).

Conclusions:

The most prominent transition overall was from smoking RYO exclusively at Wave 1 to smoking FM tobacco exclusively at Wave 2, however this varied across countries. As the tobacco control regulatory environment of the EU develops, it is important to continue to monitor transitions between types of products, as well as trends in cessation.

Citation

Zatoński, M., Herbec, A., Zatoński, W.A., Janik-Koncewicz, K., Driezen, P., Demjén, T., Fernández, E., Fong, G.T., Quah, A.C.K., Kyriakos, C.N., McNeill, A., Willemsen, M.C., Mons, U., Tountas, Y., Trofor, A.C., Vardavas, C.I. (2020). Cessation behaviours among smokers of menthol and flavoured cigarettes following the implementation of the EU Tobacco Products Directive: Findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 30(Supplement_3), iii34-iii37.

Abstract

The European Tobacco Products Directive (TPD) introduced a ban on characterizing flavours in cigarettes (2016), including menthol (2020). The longitudinal data analysis of the EUREST-PLUS International Tobacco Control (ITC) Project Europe Surveys (n = 16 534; Wave 1 in 2016 and Wave 2 in 2018) found significant but small declines in the weighted prevalence of menthol (by 0.94%; P = 0.041) and other flavoured cigarette use (by 1.32%; P < 0.001) following the 2016 TPD. The declines tended to be driven primarily by the menthol and flavoured cigarette (MFC) smokers switching to unflavoured tobacco. Cigarette consumption declined between waves, but there were no statistically significant difference in decline between MFC and unflavoured tobacco smokers on smoking and cessation behaviours between the waves.

Citation

Vardavas, C. I., Kyriakos, C. N., McNeill, A., & Fong, G. T. (2020). Evaluating the impact of the Tobacco Products Directive within the context of the FCTC in Europe—findings from the EUREST-PLUS ITC Europe Surveys: introductory Commentary. European Journal of Public Health, 30(Supplement_3), iii1-iii3.

No abstract available.

Citation

Edwards, R., Stanley, J., Waa, A., White, M., Kaai, S.C., Ouimet, J., Quah, A.C.K., Fong, G.T. (2020). Patterns of use of vaping products among smokers: Findings from the 2016-2018 ITC New Zealand Surveys. International Journal of Environmental Research and Public Health, 17(18), 6629.

Abstract

Alternative nicotine products like e-cigarettes could help achieve an end to the epidemic of ill health and death caused by smoking. However, in-depth information about their use is often limited. Our study investigated patterns of use of e-cigarettes and attitudes and beliefs among smokers and ex-smokers in New Zealand (NZ), a country with an ‘endgame’ goal for smoked tobacco. Data came from smokers and ex-smokers in Waves 1 and 2 of the International Tobacco Control (ITC) NZ Survey (Wave 1 August 2016–April 2017, 1155 participants; Wave 2, June–December 2018, 1020 participants). Trial, current and daily use of e-cigarettes was common: daily use was 7.9% among smokers and 22.6% among ex-smokers in Wave 2, and increased between surveys. Use was commonest among 18–24 years and ex-smokers, but was similar among Māori and non-Māori participants, and by socio-economic status. Most participants used e-cigarettes to help them quit or reduce their smoking. The most common motivating factor for use was cost and the most common barrier to use cited was that e-cigarettes were less satisfying than smoking. The findings could inform developing interventions in order to maximize the contribution of e-cigarettes to achieving an equitable smoke-free Aotearoa, and to minimize any potential adverse impacts.

Citation

Soneji, S., Knutzen, K.E., Gravely, S., Elton-Marshall, T., Sargent, J., Lambert, E., Hilmi, N., Sharma, E., Jackson, K.J., Wang, B., Robinson, J., Driezen, P., Bover-Manderski, M., Bansal-Travers, M., Hyland, A., Travers, M.J., Yang, D-H., Dang, R., Fong, G.T. (2020). Transitions in frequency of hookah smoking among youth and adults: Findings from Wave 1 and Wave 2 of the Population Assessment of Tobacco and Health (PATH) Study, 2013-2015. Addiction, [Published online, doi:https://doi.org/10.1111/add.15250].

Abstract

Background and aims:

The prevalence of hookah smoking has increased in the United States since at least 2010, especially among youth and young adults. This study assessed self-reported reasons for hookah smoking cessation and transition to or maintenance of high-frequency hookah smoking among current hookah smokers.

Design:

Separately analyzed data from the Population Assessment of Tobacco and Health (PATH) Study, a longitudinal cohort study. Frequency of and reasons for hookah smoking were ascertained at Wave 1 (2013-2014); frequency of hookah smoking and past-year cessation were ascertained at Wave 2 (2014-2015). Weighted multivariable logistic and ordinal logistic regression models were fit to predict hookah smoking cessation and frequency of hookah smoking at Wave 2, respectively, accounting for demographic and behavioral risk factors, reasons for hookah smoking, and frequency of hookah smoking at Wave 1.

Setting:

USA

Participants:

A total of 693 youth and 4400 adult past-year hookah smokers. Measurements: Self-reported tobacco-use patterns and associated health behaviors were measured via audio computer-assisted self-interviews (ACASI).

Findings:

At Wave 1, 5.9% of youth and 7.5% of adults were past-year hookah smokers. Across all age groups, the leading reasons for hookah smoking were enjoyment of socializing while smoking, availability of appealing flavors, and believing that it was less harmful than cigarette smoking. The odds of cessation were lower for adults who liked hookah flavors (adjusted odds ratio [aOR]=0.62; 95% confidence interval [CI]: 0.45-0.84) compared with adults who did not like hookah flavors. The odds of transitioning to, or maintaining, monthly-or-more-frequent hookah smoking at Wave 2, compared with cessation or less-than monthly smoking, were higher for adults who liked hookah flavors (adjusted proportional odds ratio [aPOR]=1.47; 95% CI: 1.16-1.88) and enjoyed socializing while smoking hookah (aPOR =1.48; 95% CI: 1.01-2.18) compared with adults who did not like hookah flavors or socializing.

Conclusion:

The availability of appealing flavors, affordability, and socialization while smoking hookah in the US are associated with reduced likelihood of cessation and increased likelihood of high-frequency hookah smoking.

Citation

Pierce, J., Benmarhnia, T., Chen, R., White, M., Abrams, D.B., Ambrose, B.K., Blanco, C., Borek, N., Choi, K., Coleman, B., Compton, W., Cummings, K.M., Delnevo, C.D., Elton-Marshall, T., Goniewicz, M., Gravely, S., Fong, G.T., Hatsukami, D., Henrie, J., Kasza, K.A., Kealey, S., Kimmel, H., Limpert, J., Niaura, R., Ramôa, C., Sharma, E., Silveira, M., Stanton, C., Steinberg, M.B., Taylor, E., Bansal-Travers, M., Trinidad, D.R., Gardner, L.D., Hyland, A., Soneji, S., Messer, K. (2020). Role of e-cigarettes and pharmacotherapy during attempts to quit cigarette smoking: The PATH Study 2013-16. PLOS One, 15(9), e0237938.

Abstract

Background:

More smokers report using e-cigarettes to help them quit than FDA-approved pharmacotherapy.

Objective:

To assess the association of e-cigarettes with future abstinence from cigarette and tobacco use.

Design:

Cohort study of US sample, with annual follow-up.

Participants:

US adult (ages 18+) daily cigarette smokers identified at Wave 1 (W1; 2013-14) of the PATH Study, who reported a quit attempt before W2 and completed W3 (n = 2443).

Exposures:

Use of e-cigarettes, pharmacotherapy (including nicotine replacement therapy), or no product for last quit attempt (LQA), and current daily e-cigarette use at W2.

Analysis:

Propensity score matching (PSM) of groups using different methods to quit.

Outcome measures:

12+ months abstinence at W3 from cigarettes and from all tobacco (including e-cigarettes). 30+ days abstinence at W3 was a secondary outcome.

Results:

Among daily smokers with an LQA, 23.5% used e-cigarettes, 19.3% used pharmacotherapy only (including NRT) and 57.2% used no product. Cigarette abstinence for 12+ months at W3 was ~10% in each group. Half of the cigarette abstainers in the e-cigarette group were using e-cigarettes at W3. Different methods to help quitting had statistically comparable 12+ month cigarette abstinence at W3 (ecigarettes vs no product: Risk Difference (RD) = 0.01, 95% CI: -0.04 to 0.06; e-cigarettes vs pharmacotherapy: RD = 0.02, 95% CI:-0.04 to 0.09). Likewise, daily e-cigarette users at W2 did not show a cessation benefit over comparable no-e-cigarette users and this finding was robust to sensitivity analyses. Abstinence for 30+ days at W3 was also similar across products.

Limitations:

The frequency of e-cigarette use during the LQA was not assessed, nor was it possible to assess continuous abstinence from the LQA.

Conclusion:

Among US daily smokers who quit cigarettes in 2014-15, use of e-cigarettes in that attempt compared to approved cessation aids or no products showed similar abstinence rates 1-2 years later.

Citation

Girvalaki, C., Filippidis, F.T., Kyriakos, C.N., Driezen, P., Herbec, A., Mons, U., Papadakis, S., Mechili, A, Katsaounou, P.A., Przewoźniak, K., Fernández, E., Trofor, A.C., Demjén, T., Fong, G.T., Vardavas, C.I. (2020). Perceptions, predictors of and motivation for quitting among smokers from six European countries from 2016 to 2018: Findings from EUREST-PLUS ITC Europe Surveys. International Journal of Environmental Research and Public Health, 17(17), 6263.

Abstract

The European Tobacco Products Directive (TPD) was introduced in 2016 in an effort to decrease prevalence of smoking and increase cessation in the European Union (EU). This study aimed to explore quitting behaviours, motivation, reasons and perceptions about quitting, as well as predictors (reported before the TPD implementation) associated with post-TPD quit status. A cohort study was conducted involving adult smokers from six EU countries (n = 3195). Data collection occurred pre-(Wave 1; 2016) and post-(Wave 2; 2018) TPD implementation. Bivariate and logistic regression analyses of weighted data were conducted. Within this cohort sample, 415 (13.0%) respondents reported quitting at Wave 2. Predictors of quitting were moderate or high education, fewer cigarettes smoked per day at baseline, a past quit attempt, lower level of perceived addiction, plans for quitting and the presence of a smoking related comorbidity. Health concerns, price of cigarettes and being a good example for children were among the most important reasons that predicted being a quitter at Wave 2. Our findings show that the factors influencing decisions about quitting may be shared among European countries. European policy and the revised version of TPD could emphasize these factors through health warnings and/or campaigns and other policies.

Citation

Bommelé, J., Hopman, P., Hipple Walters, B., Geboers, C., Croes, E., Fong, G.T., Quah, A.C.K., Willemsen, M.C. (2020). The double-edged relationship between COVID-19 stress and smoking: Implications for smoking cessation. Tobacco Induced Diseases, 18(July), 63.

Abstract

Introduction: Although recent research shows that smokers respond differently to the COVID-19 pandemic, it offers little explanation of why some have increased their smoking, while others decreased it. In this study, we examined a possible explanation for these different responses: pandemic-related stress.

Material and Methods: We conducted an online survey among a representative sample of Dutch current smokers from 11–18 May 2020 (n=957). During that period, COVID-19 was six weeks past the (initial) peak of cases and deaths in the Netherlands. Included in the survey were measures of how the COVID-19 pandemic had changed their smoking, if at all (no change, increased smoking, decreased smoking), and a measure of stress due to COVID-19.

Results: Overall, while 14.1% of smokers reported smoking less due to the COVID-19 pandemic, 18.9% of smokers reported smoking more. A multinomial logistic regression analysis revealed that there was a dose-response effect of stress: smokers who were somewhat stressed were more likely to have either increased (OR=2.37; 95% CI: 1.49–3.78) or reduced (OR=1.80; 95% CI: 1.07–3.05) their smoking. Severely stressed smokers were even more likely to have either increased (OR=3.75; 95% CI: 1.84–7.64) or reduced (OR=3.97; 95% CI: 1.70–9.28) their smoking. Thus, stress was associated with both increased and reduced smoking, independently from perceived difficulty of quitting and level of motivation to quit.

Conclusions: Stress related to the COVID-19 pandemic appears to affect smokers in different ways, some smokers increase their smoking while others decrease it. While boredom and restrictions in movement might have stimulated smoking, the threat of contracting COVID-19 and becoming severely ill might have motivated others to improve their health by quitting smoking. These data highlight the importance of providing greater resources for cessation services and the importance of creating public campaigns to enhance cessation in this dramatic time.

Citation

Hawkins, S., Chung-Hall, J., Craig, L., Fong, G.T., Borland, R., Cummings, K.M., Levy, D., Hitchman, S.C. (2020). Support for minimum legal sales age laws set to 21 across Australia, Canada, England and US: Findings from the 2018 ITC Four Country Smoking and Vaping Survey. Nicotine and Tobacco Research, 22(12), 2266-2270.

Abstract

Introduction: Although the United States has seen a rapid increase in tobacco minimum legal sales age (MLSA) laws set to age 21, there is wide variation across high-income countries and less is known about policy support outside of the United States. We examined the prevalence of support for tobacco MLSA 21 laws as well as associations by sociodemographic, smoking, and household characteristics among current and former adult smokers.

Methods: In this cross-sectional analysis, we used the 2018 International Tobacco Control Four Country Smoking and Vaping Survey to examine support for MLSA 21 laws among 12 904 respondents from Australia, Canada, England, and United States.

Results: Support for raising the legal age of purchasing cigarettes/tobacco to 21 ranged from 62.2% in the United States to 70.8% in Canada. Endorsement also varied by age, such that 40.6% of 18–20 years old supported the policy compared with 69.3% of those aged ≥60 years. In the adjusted regression model, there was also higher support among respondents who were female than male, non-white than white, those who did not allow smoking in the household than those that did, and those who had children in the household than those that did not. There were no differences by household income, education, or smoking status.

Conclusions: Most current and former smokers, including a sizable minority of those aged ≤20 years, support raising the legal age of purchasing cigarettes/tobacco to 21.

Implications: There was strong support for MLSA 21 laws among smokers and former smokers across Australia, Canada, England, and the United States, providing evidence for the increasing public support of the passage of these laws beyond the United States.

Citation

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

Abstract

Background

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

Methods

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

Conclusions

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

Citation

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

Abstract

Background

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

Methods

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

Results

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

Conclusions

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

Citation

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

Abstract

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

Citation

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

Citation

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

Abstract

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

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

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

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

Citation

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

No abstract available.

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

Citation

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

Abstract

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

Citation

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

Abstract

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

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

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

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

Citation

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

Abstract

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

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

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

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