Article

Methods of the ITC Four Country Smoking and Vaping Survey, wave 1 (2016)

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Aim To describe the methods of the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey, conducted in 2016 in Australia (AU), Canada (CA), England (EN), and the United States (US). Methods The respondents were cigarette smokers, former smokers (quit within the previous two years), and at‐least‐weekly vapers, aged 18 and older. Eligible cohort members from the ITC Four Country Survey (4C) were retained. New respondents were sampled by commercial firms from their panels. Where possible, ages 18‐24 and vapers were over‐sampled. Data were collected online, and respondents were remunerated. Survey weights were calibrated to benchmarks from nationally representative surveys. Results Response rates by country for new recruits once invited ranged from 15.2% to 49.6%; cooperation rates were above 90%. Retention rates from the 4C cohort ranged from 35.7% to 44.2%. Sample sizes for smokers/former smokers were 1504 in AU, 3006 in CA, 3773 in EN, and 2239 in the US. Sample sizes for additional vapers were 727 in CA, 551 in EN, and 494 in the US. Conclusion The International Tobacco Control Four Country Smoking and Vaping Survey design and data collection methods allow analyses to examine prospectively the use of cigarettes and nicotine vaping products in jurisdictions with different regulatory policies. The effects on the sampling designs and response quality of recruiting the respondents from commercial panels are mitigated by the use of demographic and geographic quotas in sampling; by quality control measures; and by the construction of survey weights taking into account smoking/vaping status, sex, age, education, and geography.

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... Full details of the ITC 4CV Surveys can be found in the technical reports. [16][17][18] The analytic sample was limited to those who answered whether they would support or oppose a law that reduced the amount of nicotine in cigarettes to make them less addictive. Responses were dichotomised to represent either support (support and strongly support) or lack of support for the law (oppose, strongly oppose and do not know). ...
... Sampling weights were constructed and calibrated using benchmarks from national surveys. 16 Weighted generalised estimated equation models were used to assess changes in support between 2016 and 2020, with an exchangeable correlation structure, robust SEs and a binary log link. After examining the interaction between country and wave, the percentages of support were estimated from the regression coefficients adjusted for smoking and vaping status, country, sociodemographic variables, wave and time-in-sample using margins command. ...
... After examining the interaction between country and wave, the percentages of support were estimated from the regression coefficients adjusted for smoking and vaping status, country, sociodemographic variables, wave and time-in-sample using margins command. All analyses were conducted in Stata V. 16. Table 1 presents the findings for the multivariable logistic models for support of VLNCs. ...
Article
Introduction The USA and New Zealand have sought to establish a product standard to set a maximum nicotine level for cigarettes to reduce their addictiveness. This study examined support for very low nicotine cigarettes (VLNCs) in Australia, Canada, England and the USA between 2016 and 2020. Methods Repeated cross-sectional data were analysed from participants who currently smoke, formerly smoked or vaped and/or currently vape in the 2016 (n=11 150) and/or 2020 (n=5432) International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. Respondents were asked if they would support a law that reduces the amount of nicotine in cigarettes to make them less addictive. Adjusted and weighted logistic regression analyses estimated the prevalence and predictors of support, such as country, age, sex, education, income, race and smoking/vaping status for VLNCs (support vs oppose/do not know). Results A majority of respondents supported a VLNC law, with support highest in Canada (69%; 2016 and 2020 combined), followed by England (61%), Australia (60%) and the USA (58%). Overall, support decreased from 62% in 2016 to 59% in 2020 (p=0.004), which did not differ by country. Levels of support differed by smoking/vaping status, where those who exclusively smoked daily showed the lowest level of support (59%) and those who exclusively vaped non-daily had the highest level of support (72%). Conclusion More than half of respondents in all four countries—including those who smoked daily—supported a hypothetical VLNC standard to render cigarettes less addictive. It is important to examine if support is sustained after policies are implemented.
... В контексте изучения полноты реализации законодательных мер по противодействию потреблению табака онлайн-опрос имеет ряд преимуществ Введение Изучение реализации политических мер по противодействию потреблению табака как на международном, так и национальном уровнях в разных странах проводится при помощи социологических опросов с использованием различных методов сбора данных и методологических подходов [1][2][3][4]. ...
... Методы интернет-опросов и онлайн-рекрут респондентов широко используются в социологических исследованиях [9], в т.ч. в исследованиях по изучению реализации и эффективности норм Рамочной конвенции Всемирной организации здравоохранения по борьбе против табака и национальных антитабачных законов во всем мире и, в частности, в международных исследованиях по оценке политик борьбы против табака [1][2][3][4]9]. Эти исследования похожи по предмету изучения -мер антитабачных национальных законов, а Международный опрос EUREST-PLUS (European Regulatory Science on Tobacco: Policy implementation to reduce lung diseases) направлен на изучение действия Директивы Европейского союза о табачных изделиях 2014г [10]. Все эти исследования для онлайн-рекрута респондентов используют онлайн-панели коммерческих исследовательских фирм. ...
Article
Aim . To describe the methods used to assess the implementation of new national tobacco and nicotine control policies in the regions of the Russian Federation (EPOHA-RF 2). Material and methods . An online survey sample was designed to include a minimum of 1000 respondents in each region, including current smokers and/or users of electronic nicotine delivery systems (ENDS) and former smokers and/or users of ENDS who quit within the past 3 years (800:200 ratio). Participants were aged 15 and older and resided in 12 regions of the Russian Federation. The sample was collected using the river sampling method and was quota-based by sex, age, and settlement type using 2022 Rosstat data. Weighting coefficients were calibrated against control indicators from nationally representative Rosstat surveys. Data were collected in 2023 using a questionnaire programmed on an online platform for self-completion by respondents. The questionnaire included 74 measurable parameters aligned with the anti-tobacco law. Results . The total sample size across the 12 regions was 12662 individuals as follows: Moscow (n=1094), St. Petersburg (n=1041), Chuvash Republic (n=1046), Krasnodar Territory (n=1047), Primorsky Territory (n=1062), Arkhangelsk Region (n=1042), Astrakhan Region (n=1077), Belgorod Region (n=1048), Novosibirsk Region (n=1030), Orenburg Region (n=1042), Samara Region (n=1071), and Tyumen Region (n=1062). The distribution of respondents within each region corresponded to the age, sex, and settlement type distribution of smokers/ENDS users reported by Rosstat. The data collected from the survey underwent a weighting procedure. A database was created in MS Excel format based on the respondents' answers. Conclusion . The structure and data collection methods used to assess the implementation of national tobacco control policies in 12 Russian Federation regions provide results that are highly representative of the opinions of current and former smoker/ENDS users across all age and sex groups in urban and rural areas regarding the implementation of tobacco and nicotine control policies in the Russian Federation.
... This study is part of work package III of the EValuation of the Addictive Potential of E-cigarettes (EVAPE) project [19]. For this cross-sectional analysis, we used data from the International Tobacco This survey comprises a nationally representative sample of smokers and e-cigarette users using standardized survey methods [20]. All participants were recruited into the study as current tobacco cigarette smokers who have smoked at least 100 cigarettes in their life-time, former tobacco cigarette smokers who quit within the previous 2 years or current, at least weekly, e-cigarette users [20]. ...
... For this cross-sectional analysis, we used data from the International Tobacco This survey comprises a nationally representative sample of smokers and e-cigarette users using standardized survey methods [20]. All participants were recruited into the study as current tobacco cigarette smokers who have smoked at least 100 cigarettes in their life-time, former tobacco cigarette smokers who quit within the previous 2 years or current, at least weekly, e-cigarette users [20]. For the present analysis, we only included people who were using e-cigarettes daily or weekly for at least 4 months, who could be exclusive e-cigarette users (non-smokers) or dual-users (concurrent smokers) ( Figure 1). ...
Article
Background and aim: The addictive potential of electronic cigarettes (e-cigarettes) remains to be fully understood. We identified patterns and correlates of perceived addiction to e-cigarettes and perceived addictiveness of e-cigarettes relative to tobacco cigarettes (relative addictiveness) in dual-users as well as exclusive e-cigarette users. Design: Observational study using cross-sectional survey data from England from the International Tobacco Control Project (ITC) Four Country Smoking and Vaping (4CV) survey. Setting: England (2016). Participants: 832 current e-cigarette users who had been vaping for at least 4 months. Measurements: Perceived addiction to e-cigarettes and relative addictiveness of e-cigarettes were examined. Sociodemographic factors were age, gender, and education; markers of addiction included urge to vape, time to first vape after waking, and nicotine strength used; vaping and smoking characteristics included frequency and duration of e-cigarette use, intention to quit, adjustable power or temperature, enjoyment, satisfaction relative to tobacco cigarettes, and tobacco cigarette smoking status. Findings: 16.7% of participants reported feeling very addicted to e-cigarettes, while 42.3% considered e-cigarettes equally/more addictive than tobacco cigarettes. Those who felt very addicted had higher odds of regarding e-cigarettes as more addictive than tobacco cigarettes (odds ratio 3.4, 95%-confidence interval 2.3 - 5.1). All markers of addiction, daily use, and enjoyment were associated with higher perceived addiction, whereas time to first vape after waking, daily vaping, and perceiving vaping as less satisfying than smoking were associated with relative addictiveness. Conclusions: Markers of addiction to e-cigarettes appear to correspond with perceived addiction to e-cigarettes, suggesting that self-reported perceived addiction might serve as an indicator of addiction. Prevalence both of markers of addiction and perceived addiction were comparatively low overall, suggesting a limited, but relevant addictive potential of e-cigarettes. Additionally, positive and negative reinforcement, reflected here by enjoyment and relative satisfaction, might play a role in e-cigarette addiction.
... 'natural experiments') 7 , in which one group exposed to a policy is compared to another, unexposed group; 2) the use of longitudinal cohort designs 8 in which individuals are measured on the same key outcome variables over time 9,10 ; and 3) the measurement of appropriate policy-specific variables that are conceptually close to the policy being evaluated and less likely to be affected by other factors. These innovative strategies, including other explanatory variables (covariates), are unparalleled in the study of population-level interventions and produce a research design with the potential to make strong inferences about policy impact [11][12][13][14][15][16] Surveys have been published to provide evidence on the effectiveness of the Malaysia tobacco control policies implemented between 2005 and 2014, for example on smoke-free policies 17 , cigarette package warning labels 18 , price 19 , and on the FCTC MPOWER measures 20,21 . The previous ITC Malaysia Survey was focused on cigarette smoking and since 2014, the tobacco landscape of Malaysia has dramatically changed with the introduction of alternative tobacco or nicotine products such as heated tobacco products (HTPs) and e-cigarettes (ECs). ...
... The methods are consistent with 30 other ITC countries across the global ITC Project. Using the same protocols enables comparability of analyses across ITC countries 7,8,[11][12][13][14][15][16] . The final sample consisted of 206 non-smokers and 1047 smokers, of whom 103 were female and 944 were male 25 . ...
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The ITC Malaysia Project is part of the 31-country ITC Project, of which the central objective is to evaluate the impact of tobacco control policies of the WHO Framework Convention on Tobacco Control (FCTC). This article describes the methods used in the 2020 International Tobacco Control (ITC) Malaysia (MYS1) Survey. Adult smokers and non-smokers aged ≥18 years in Malaysia were recruited by a commercial survey firm from its online panel. Survey weights, accounting for smoking status, sex, age, education, and region of residence, were calibrated to the Malaysian 2019 National Health and Morbidity Survey. The survey questions were identical or functionally similar to those used in other ITC countries. Questions included demographic measures, patterns of use, quit history, intentions to quit, risk perceptions, beliefs and attitudes about cigarettes, e-cigarettes, and heated tobacco products. Questions also assessed measures assessing the impact of tobacco demand-reduction domains of the FCTC: price/tax (Article 6), smokefree laws (Article 8), health warnings (Article 11), education, communication and public awareness (Article 12), advertising, promotion, and sponsorship restrictions (Article 13), and support for cessation (Article 14). The total sample size was 1253 (1047 cigarette smokers and 206 non-smokers). Response rate was 11.3%, but importantly, the cooperation rate was 95.3%. The 2020 ITC MYS1 Survey findings will provide evidence on current tobacco control policies and evidence needed by Malaysian government regulatory agencies to develop new or strengthen existing tobacco control efforts that could help achieve Malaysia’s endgame, i.e. a tobaccofree nation by 2040.
... The 4CV1 Survey is an ongoing panel-based survey including respondents 18 years or older and who currently smoke, recently quit smoking (quit in previous 2 years), and/or currently vape. Details of the design of the 4CV1 survey can be found elsewhere (Thompson et al., 2019). The survey protocols and all materials including the survey questionnaires, were cleared for ethics by Institutional Review Board, Medical University of South Carolina; Research Ethics Office, King's College London, UK; Office of Research Ethics, University of Waterloo, Canada; and Human Research Ethics, Cancer council Victoria Australia. ...
... The adjusted prevalence of daily smokers in each country who "Support" or "Strongly Support" each policy. See Table 1 (Thompson et al., 2019). Table 2 reports demographic and other smoking characteristics for this sample by country. ...
Article
As governments consider policy action to reduce smoking, a key factor in creating political will is the level of public support, particularly among smokers who are most affected by the policies. The goal of this paper is to assess and compare the level of support in Canada, the United States, England, and Australia for five smoking control policies: 1) banning menthol in cigarettes, 2) banning cigarette additives, 3) reducing nicotine in cigarettes to make them less addictive, 4) raising the minimum age to purchase cigarettes to 21 years and older, and 5) requiring pictorial warning labels on cigarette packs (examined in the US only). Data for these analyses come from 8165 daily cigarette smokers who responded to the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. In all countries, the highest level of support was for raising the legal age for purchase to 21 years and older (62–70%) and reducing the nicotine content of cigarettes to make them less addictive (57–70%). Smokers who were less dependent on cigarettes and those expressing interest in quitting were more likely to support all policies. When asked how they would respond to a nicotine reduction policy, the most common response given was to try the non-nicotine cigarettes to see how they liked them (42–48%), with the next most common response being to quit smoking entirely (16–24%). The high level of support for these proposed policies among daily smokers provides important evidence for policymakers to counteract claims that such policies would be unpopular.
... For evaluating quit attempts and changes in smoking frequency, a second analytic sample including only participants with at least one 4-month follow-up survey was used (2900 observations from 1533 individuals) ( Figure 1). Surveys were self-administered online in Spanish using standard questions on tobacco product use and questions on novel tobacco products from the International Tobacco Control (ITC) survey 17 . Participants provided consent before completing the survey, which took a median time of about 23 minutes to complete, and they received standard compensation The flow diagram illustrates the criteria for excluding and retaining observations in the cross-sectional and longitudinal analysis. ...
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INTRODUCTION Heated tobacco products (HTPs) are promoted as less harmful than cigarettes; nonetheless, whether HTPs help smokers quit is uncertain. METHODS Data from 4067 Mexican adult smokers surveyed longitudinally every four months (November 2019–March 2021) were analyzed. Mixed-effects multinomial models regressed HTP use frequency (no use=reference; monthly; weekly; and daily use) on sociodemographics and tobacco/nicotine-related variables. Among participants who completed at least two surveys (n=2900) over four months, the duration of their longest smoking quit attempt (SQA) between surveys (SQAs: <30 days; ≥30 days; no SQA=reference) was regressed on HTP use frequency, and changes in the number of cigarettes smoked per day were regressed on HTP initiation between surveys, adjusting for covariates. RESULTS Consistent predictors of all HTP use frequencies (monthly, weekly, or daily vs no use) were daily smoking >5 cigarettes (ARRR=1.69 [95% CI: 1.12–2.55], 1.88 [95% CI: 1.26–2.81] and 6.46 [95% CI: 3.33–12.52], respectively); e-cigarette use (ARRR =5.68 [95% CI: 3.38–9.53], 6.54 [95% CI: 4.06–10.55] and 2.59 [95% CI: 1.26–5.30]); lower HTP risk perceptions (ARRR=2.12 [95% CI: 1.50–30.00], 2.25 [95% CI: 1.63–3.10] and 2.00 [95% CI: 1.25–3.22]); exposure to HTP information inside (ARRR=2.13 [95% CI: 1.44–3.15], 2.13 [95% CI: 1.49–3.05] and 3.72 [95% CI: 2.28–6.09]) and outside stores (ARRR=2.36 [95% CI: 1.56–3.57], 2.32 [95% CI: 1.65–3.25] and 2.44 [95% CI: 1.41–4.24]) where tobacco is sold; having family (ARRR=2.46 [95% CI: 1.54–3.91], 2.90 [95% CI: 1.93–4.37] and 2.96 [95% CI: 1.52–5.77]) and friends (ARRR=5.78 [95% CI: 3.60–9.30], 4.98 [95% CI: 3.22–7.72] and 6.61 [95% CI: 2.91–15.01]) who use HTPs. HTP use frequency was not associated with quit attempts, except for monthly HTP use predicting SQAs lasting ≥30 days (ARRR=2.12 [95% CI: 1.17–3.85]). Initiation of HTP use was not associated with changes in smoking frequency. Limiting analysis to those who intend to quit smoking also yielded null results. CONCLUSIONS Among Mexican adult smokers, frequency of HTP use was mostly not associated with either cessation behaviors or changes in cigarette consumption, suggesting that HTPs have limited to no effectiveness for smoking cessation.
... Using a nationally representative sample of smokers and vapers from the U.S., one study found that higher frequency of cigarette use leads smokers and vapers to think cigarettes are more expensive and e-cigarette users who use pre-filled cartridges and tank devices are more likely to think e-cigarettes are less expensive than cigarettes. (Thompson et al., 2019) However, given the small sample size of vapers in that study, their conclusions may be largely driven by smokers, with a limited ability to inform e-cigarette users' perceived relative cost. ...
Preprint
Background: Over 20 states and local jurisdictions in the U.S. have imposed e-cigarette taxes. It is important to evaluate how adult vapers, including those who also smoke respond to e-cigarette taxation. The purpose of this study is to examine factors associated with adult vapers' cost perception of e-cigarettes relative to cigarettes and budget allocations between two products. Methods: We recruited a nationally representative sample of 801 adult e-cigarette users in the U.S., who participated in an online survey in April and May 2023. Nested-ordered logit models and ordinary least squares regressions were used in the analysis. Results: On average, monthly e-cigarette spending was 82.22,andcigarettespendingwas82.22, and cigarette spending was 118.77 among dual users. Less frequent e-cigarette use and higher state-level e-cigarette taxes were associated with perceiving smoking as cheaper than vaping. Age and exclusive use of tank systems were associated with perceiving vaping as cheaper than smoking. Exclusive use of tank systems was also associated with lower e-cigarette spending. Adults who used e-cigarettes more frequently preferred to report weekly budget on e-cigarettes (p < 0.01), and among dual users, everyday smokers preferred to report weekly (versus monthly) budget on cigarettes compared to someday smokers (p < 0.001). Conclusion: Among US adult vapers, frequencies of tobacco use and e-cigarette device type are closely related to cost measures; and e-cigarette taxes are associated with cost perception of e-cigarettes relative to cigarettes, suggesting potential financial disincentive for vaping. Policymaker may consider imposing differential taxes by e-cigarette product types due to their different costs to consumers.
... The questionnaire was adapted from the International Tobacco Control (ITC) survey. 31 All procedures were approved by the Review Board and Ethics Committee of the National Institute of Public Health of Mexico. ...
Article
Introduction: This study aimed to assess whether two established psychosocial predictors of smoking abstinence, nicotine dependence and time discounting, also apply to a population of predominantly cigarette light smokers, which is the dominant pattern of smoking in countries like Mexico. Relatively infrequent smoking is increasingly prevalent, yet still harmful, making it important to understand the predictors of cessation in this population. Methods: Mexican adult smokers recruited from an online consumer panel were surveyed every four months between November 2018-July 2020. We considered respondents who reported a quit attempt in between surveys (n=1,288). Dependence was measured with a 10-item version of the Wisconsin Inventory of Smoking Dependence (WISDM). Time discounting was assessed with five branching questions about hypothetical reward scenarios. Logistic models regressed sustained quit attempts (≥30 days of abstinence) at time t+1 on study variables at time t. Results: We found strong inter-item reliability (α=0.92) and intra-individual consistency of our brief WISDM (ρ=0.68), but moderate intra-individual consistency of the time-discounting measure (ρ=0.48). 48% of the sample reported sustained quit attempts, and 79% were non-daily or light daily smokers (<=5 cigarettes per day). Smokers with higher WISDM-10 had lower odds of sustained quitting and this result remained when controlling for smoking frequency and the Heaviness of Smoking Index (AOR=0.768). Time-discounting was unassociated with sustained quitting. Conclusions: Our findings suggest that a brief, 10-item multidimensional measure of dependence is useful for predicting sustained quitting in a context of relatively light smoking; time-discounting appears less relevant, although our results are not conclusive due to the low test-retest reliability of our measure. Implications: Given the increase in non-daily and light daily cigarette smoking in many countries, including in Mexico, and the health risks this still poses, it is important to understand the predictors of cessation among relatively light smokers. The WISDM-10 multidimensional measure seems to be a good instrument to assess dependence and predict successful quitting in this population, and possibly more appropriate than physical dependence measures. As such, it could help design and target more suitable cessation treatments for non-daily and daily light cigarette smokers. While this study did not find time discounting to be a relevant predictor of smoking abstinence, future studies should explore other measures.
... National Health Interview Surveys (NHIS) were used as the benchmark to compute weights for US data. Further details about the study procedures, sampling, and data weighting can be found elsewhere [8][9][10] . ...
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Introduction: In March 2020, the US Food and Drug Administration (FDA) finalized new pictorial health warnings (PHWs), covering 50% of the front and back of the pack; however, legal challenges from cigarette manufacturers have prevented the new warnings from being implemented. About 70% of adults in the general US population support PHWs. This study assessed support for PHWs in 2016, 2018 and 2020 among US adults (aged ≥18 years) who currently smoke or formerly smoked cigarettes. We also assessed factors related to support. Methods: Respondents included adults who currently or formerly smoked cigarettes and participated in at least one wave of the US ITC Smoking and Vaping Surveys: Wave 1 (2016, n=2557); Wave 2 (2018, n=2685); and Wave 3 (2020, n=1112). We assessed changes in support for PHWs between 2016 and 2020, and assessed factors related to support (support vs oppose/don't know). Analyses were conducted on weighted data. Results: Overall, 38.0% of respondents supported PHWs in 2016, with a significant increase to 44.7% in 2018 (p<0.001), and leveling off to 45.0% in 2020 (2018 vs 2020, p=0.91). Support was highest among former smokers and lowest among daily smokers in all three survey years. Support for PHWs at all survey years was significantly higher among those who formerly smoked, were younger (aged 18-39 vs ≥40 years), those who identified as Black (vs White), and planned to quit smoking (vs not planning to quit). There were no differences by income level, education level, or sex. Conclusions: Nearly half of US adults who smoke cigarettes or quit smoking supported PHWs in 2020, with support being higher among younger adults, ethnic minorities, and those who formerly smoked. Support increased between 2016 and 2018, but not between 2018 and 2020. Similar to other studies, fewer current and former smokers supported PHWs compared to the US adult general population.
... We analyzed data from the Canadian arm of the 2020 (Wave 3) International Tobacco Control Policy Evaluation Project Four Country Smoking and Vaping (ITC 4CV3) Survey, an online cohort survey designed to evaluate the psychosocial and behavioural impact of tobacco control policies on adult smokers (age ≥ 18 yr) in Australia, Canada, England and the US. [34][35][36][37] The ITC 4CV3 Canada Survey included nationally representative samples of cigarette smokers, former cigarette smokers and e-cigarette users from all 10 provinces. 37 Data were collected from Feb. 24 to May 31, 2020. ...
Article
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Background: Tobacco smoking and cannabis use are independently associated with depression, and evidence suggests that people who use both tobacco and cannabis (co-consumers) are more likely to report mental health problems, greater nicotine dependence and alcohol misuse than those who use either product exclusively. We examined prevalence of cannabis use and depressive symptoms among Canadian adults who smoke cigarettes and tested whether co-consumers of cannabis and tobacco were more likely to report depressive symptoms than cigarette-only smokers; we also tested whether cigarette-only smokers and co-consumers differed on cigarette dependence measures, motivation to quit smoking and risky alcohol use by the presence or absence of depressive symptoms. Methods: We analyzed cross-sectional data from adult (age ≥ 18 yr) current (≥ monthly) cigarette smokers from the Canadian arm of the 2020 International Tobacco Control Policy Evaluation Project Four Country Smoking and Vaping Survey. Canadian respondents were recruited from Leger's online probability panel across all 10 provinces. We estimated weighted percentages for depressive symptoms and cannabis use among all respondents and tested whether co-consumers (≥ monthly use of cannabis and cigarettes) were more likely to report depressive symptoms than cigarette-only smokers. Weighted multivariable regression models were used to identify differences between co-consumers and cigarette-only smokers with and without depressive symptoms. Results: A total of 2843 current smokers were included in the study. The prevalence of past-year, past-30-day and daily cannabis use was 44.0%, 33.2% and 16.1%, respectively (30.4% reported using cannabis at least monthly). Among all respondents, 30.0% screened positive for depressive symptoms, with co-consumers being more likely to report depressive symptoms (36.5%) than those who did not report current cannabis use (27.4%, p < 0.001). Depressive symptoms were associated with planning to quit smoking (p = 0.01), having made multiple attempts to quit smoking (p < 0.001), the perception of being very addicted to cigarettes (p < 0.001) and strong urges to smoke (p = 0.001), whereas cannabis use was not (all p ≥ 0.05). Cannabis use was associated with high-risk alcohol consumption (p < 0.001), whereas depressive symptoms were not (p = 0.1). Interpretation: Co-consumers were more likely to report depressive symptoms and high-risk alcohol consumption; however, only depression, and not cannabis use, was associated with greater motivation to quit smoking and greater perceived dependence on cigarettes. A deeper understanding of how cannabis, alcohol use and depression interact among people who smoke cigarettes is needed, as well as how these factors affect cessation activity over time.
... As in any longitudinal study, some participants did not complete all follow-ups, which may raise concern about non-response bias Thompson et al., 2019 ). However, previously-reported analyses suggest limited bias due to missed follow-ups in ADJUSST Shiffman et al., 2021b ). ...
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Background: Electronic nicotine delivery systems (ENDS) are substitute sources of nicotine for adults who smoke cigarettes. Understanding changes in dependence as people switch from cigarettes to ENDS is relevant to public health. This study assessed changes in dependence among adults who switched completely or partially (dual users) from cigarettes to JUUL-brand ENDS over 12 months. Methods: US adults who smoke and purchased a JUUL Starter Kit (n = 17,619) completed a baseline assessment and were invited to 1-, 2-, 3-, 6-, 9- and 12-month follow-ups. Dependence on cigarettes at baseline and on JUUL at follow-ups was assessed with the Tobacco Dependence Index (TDI; Range 1-5). Analyses estimated the minimal important difference (MID) for the scale, compared JUUL dependence to baseline cigarette dependence and assessed changes in JUUL dependence over 1-year, including among those using JUUL at all follow-ups. Results: Participants who switched at month 2 had month 1 JUUL TDI scores 0.24 points greater than those who continued smoking (p<0.001); thus MID=0.24. Among both switchers and dual users overall, dependence on JUUL 1 and 12 months later was lower than baseline dependence on cigarettes (ps<0.001); participants who smoked every day showed more consistent and larger reductions. Among participants who persistently used JUUL without smoking, dependence increased 0.01 points per month (p<0.001), but was leveling off over time. Conclusions: Dependence on JUUL was lower than baseline cigarette dependence. Increases in JUUL dependence were small over 12 months of continual JUUL use. These data indicate that ENDS, including JUUL, have lower dependence potential than cigarettes.
... Further details about the methods can be found elsewhere. [22][23][24] Eligible respondents for this study included US residents who were frequent ENDS users (vape≥weekly) who were currently smoking (smoke≥monthly; referred to herein as 'dual users') or had quit smoking (<5 years; 'ex-smokers') at the time of the survey. Respondents with complete data on ENDS flavour/ device use in 2018 and/or 2020 were included in the prevalence analysis. ...
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Background: In February 2020, the US Food and Drug Administration (FDA) prioritised enforcement efforts against flavoured prefilled cartridge/pod electronic nicotine delivery systems (ENDS), with the exception of tobacco and menthol. This study examined changes between prepriority enforcement (2018) and early postenforcement (February-June 2020) among adults on: ENDS flavours and devices used most often; location of last purchase of fruit/other-flavoured cartridges (covered under the enforcement priority); and smoking and vaping. Methods: Prevalence estimates came from 1608 adult frequent (≥weekly) ENDS users (current smokers (n=1072), ex-smokers (n=536)) who participated in the 2018 and/or 2020 US ITC Smoking and Vaping Surveys. Transitions between flavours/devices and changes in smoking/vaping were assessed among baseline respondents who were followed up in 2020 (n=360). Respondents self-reported the ENDS device (disposable, cartridge/pod or tank) and the flavor that they used most often: (1) tobacco flavors (tobacco/tobacco-menthol mix) or unflavored; (2) menthol/mint; (3) fruit/other flavors. Results: Compared to 2018, in the first 5 months of the 2020 enforcement priority, there were significant increases in the prevalence of fruit/other-flavoured cartridges (7.9% to 12.4%,p=0.026) and menthol/mint cartridges (7.1% to 13.0%, p<0.01) and decreases in tobacco-flavoured tanks (15.5% to 10.0%,p=0.002) and fruit/other-flavoured tanks (38.7% to 33.6%,p=0.038). Fewer than 10% of adults used disposables in 2018 and 2020. Among the cohort sample, the most pronounced transitions between flavours/devices occurred among those who used flavoured cartridges covered under the enforcement priority (54.6% switched to a flavour and/or device excluded from enforcement). There was an increase in purchasing fruit/other-flavoured cartridges online and a decrease in retail locations except for vape shops. Overall, there were few changes in smoking and vaping behaviours. Conclusions: Between 2018 and the early phase of the FDA's 2020 enforcement priority, prevalence of menthol/mint and fruit/other-flavoured cartridges increased among adults. Half of vapers using cartridge flavours covered in the enforcement switched to other flavours and/or devices that were exempt, with the exception of disposables. The extent to which more comprehensive restrictions may be problematic for adults who prefer a range of ENDS flavours remains uncertain.
... Full descriptions of the ITC Project conceptual framework 34 and methods 35,36 have been published elsewhere. In brief, the ITC Four Country Smoking and Vaping Wave 1 Survey (4CV1) sample comprised the following cohorts: (1) smokers and ex-smokers who participated in the previous wave of the ITC 4C Project, regardless of vaping status (recontact sample), (2) newly-recruited current smokers and ex-smokers (quit in the past 24 months) from country-specific panels, regardless of vaping status, and (3) newly-recruited current vapers (use a vaping device at least weekly) from country-specific panels. ...
Article
Background: Little is known about the continued use of nicotine following smoking cessation on perceived well-being in comparison to complete cessation of nicotine use. Aims: To explore aspects of perceived well-being and coping among recent ex-smokers as a function of vaping status. Methods: Ever-daily smokers in the International Tobacco Control 4 country smoking and vaping surveys in 2016 (W1 N=883) and 2018 (W2 N=1088). Cross-sectional associations and longitudinal samples for those who quit between waves and those quit at W1 who maintained abstinence to W2. Main outcome measures were: past 30 days depression symptoms, perceived stress, stress management since quitting and change in perceived day-to-day health. Results: In the cross-sectional analyses vapers were more likely to report both improved stress management (aOR = 1.71, 95% CI 1.23-2.36) and perceived day-to-day health (aOR = 1.65, 95% CI 1.26-2.16) than nicotine abstainers. In the longitudinal analyses, smokers who switched to vaping between waves (n=372) were more likely to report depression symptoms at W2 (aOR = 2.00, 95% CI 1.09-3.65) but reported improved perceived health (aOR = 1.92, 95% CI 1.16-3.20). For the past daily smokers who remained quit between waves (n=382), vapers were more likely to report improved stress management relative to abstainers (RRR =5.05. 95% CI 1.19-21.40). There were no other significant differences between vapers and nicotine abstainers. Conclusions: There is little evidence to support the view that perceptions of well-being deteriorate in vapers compared to complete nicotine abstainers in the immediate years after smoking cessation. Implications: This study could find no conclusive evidence that the continued use of nicotine via e-cigarettes was detrimental to health compared to completely stopping nicotine intake altogether. Our results would suggest that continuing to use nicotine may even result in some benefits in the short term such as improved stress management, however further longitudinal studies are required to examine if these effects are restricted to the early post-quitting phase and whether other positive or negative effects on psychosocial health emerge in the future.
... All data were collected online, and respondents were remunerated. Further methodological information can be found in the technical reports [32][33][34] and Thomson et al. [35]. ...
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This study examined reasons why adults who currently smoke or formerly smoked cigarettes use nicotine vaping products (NVPs) by vaping frequency (daily vs. weekly) stratified by smoking status. This cross-sectional study included 3070 adults from the 2020 ITC Four Country Smoking and Vaping Survey (Australia, Canada, England, United States) who reported using a NVP (vaping) at least weekly and who either currently smoke (n = 2467) or formerly smoked (n = 603). Respondents were asked to select the reason(s) they use NVPs, including to manage their smoking (reduce/quit or remain quit) and/or for reasons unrelated to managing smoking (e.g., to save money, enjoyment, flavours). We found that both current and former smokers endorsed an average of six reasons for vaping, with those vaping daily reporting significantly more reasons than those vaping weekly. Among current smokers, 72.8% reported vaping may help them quit smoking, 13.0% reported vaping to reduce smoking but not to quit, and 14.2% reported vaping only for reasons other than to reduce or quit smoking. The most common reason for vaping among current smokers was to reduce smoking (81.3%). Current smokers vaping daily were significantly more likely than those vaping weekly to report using a NVP to reduce smoking, for enjoyment, to reduce harm to themselves and others, to quit smoking, likeable flavours, and to save money. The most common reason cited for vaping by respondents who formerly smoked was enjoyment, with those who vaped daily more likely than those who vaped weekly to report vaping for enjoyment and to reduce harm to themselves. Nearly all reported vaping to help stay abstinent from smoking (92.3%), with no significant difference by vaping frequency. In conclusion, a majority of respondents reported using NVPs to manage their smoking (reduce/quit smoking or remain quit), particularly those vaping daily. Those who were vaping daily also endorsed a greater number of reasons other than managing smoking relative to those who were vaping weekly.
... We restricted the sample to ex-daily smokers, as we would not expect much impact on the dependent measures among those who were not smoking much. More details about the ITC 4CV surveys are reported elsewhere [18,19]. ...
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Background and aims: There has been limited research addressing changes in subjective well-being as a result of quitting smoking. This paper examines recent ex-smokers' well-being related experiences overall and as a function of (1) duration of cessation and (2) continued nicotine use from vaping. Methods: A sample of 1379 ever-daily smoking ex-smokers (quit for up to 5 years) from the 2020 ITC Four Country Smoking and Vaping Survey (Australia, Canada, the UK, and the US), of which 27.1% currently vaped daily. Well-being measures were perceived changes post-quitting in emotion coping (stress and negative emotions), enjoyment of life, and day-to-day functioning. We also assessed the level of persisting worry about past smoking leading to future health problems. Results: Overall, among those answering all four well-being measures, 51.8% of the ex-smokers reported positive effects and no negatives, but 27.3% reported at least one negative effect, with the remainder reporting no change in any measure. Positive effects were greater among those who had quit more than 1 year prior. The largest improvement (56.3%) was for daily functioning, which showed improvement over time since having quit. Current daily vapers reported similar well-being as those not vaping; however, fewer daily vapers reported worsening ability to cope with stress (10.2% vs. 20.7%). Overall, 84% reported being worried about future negative health effects of smoking, with no clear differences by quitting duration or vaping status. Conclusions: Most ex-smokers reported changes in their well-being since quitting, with more reporting improvements than declines. Well-being improved with duration of time since quitting, but did not appear to be influenced by daily vaping use, but stress coping may be better among vapers. Persisting worries about possible future health effects from smoking may be reducing the experienced benefits of quitting smoking for some.
... The sample in each country was designed to be as representative as possible of smokers and vapers and used either probability-based sampling frames or nonprobability quota samples. Details of the conceptual framework and the survey methodology can be found in Fong et al. 34 and Thompson et al., 35 and in the technical reports. 36,37 We limited the analytical sample for this analysis to current cigarette smokers (regardless of whether they used any NVPs or not), who reported smoking at least 10 cigarettes per day in 2016, made a quit attempt by the 2018 follow-up, and completed both the 2016 and 2018 surveys (see Supplementary Figure S1). ...
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Aim This study examined whether smokers’ harm perceptions of nicotine replacement therapy (NRT) and nicotine vaping products (NVPs) relative to cigarettes predicted their subsequent use as smoking cessation aids during their last quit attempt (LQA). Methods We analyzed data from 1,315 current daily smokers (10+ cigarettes per day) who were recruited at Wave 1 (2016), and who reported making a quit attempt by Wave 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the US. We used multinomial logistic regression models to examine prospective associations between harm perceptions of a) NRT and b) NVPs and their use at LQA, controlling for socio-demographic and other potential confounders. Results Smokers who perceive that a) NRT and b) NVPs are much less harmful than cigarettes were more likely to subsequently use the respective product as an aid than using no aid or other aids during LQA (adjusted relative risk ratio [aRRR]=3.79, 95%CI=2.16-6.66; and aRRR=2.11, 95%CI=1.29-3.45, respectively) compared to smokers who perceive these products as equally or more harmful. Additionally, those who perceive NVPs as much less harmful than cigarettes were less likely to use NRT as a quit aid (aRRR=0.34, 95%CI=0.20-0.60). No country variations for these associations were found. Conclusion This study found that smokers’ perceptions of the harmfulness of a) NRT and b) NVPs relative to cigarettes predicted the respective product use when trying to quit smoking. Corrective education targeting misperceptions of nicotine products’ relative harmfulness may facilitate their use for smoking cessation. IMPLICATIONS What this study adds:Nicotine replacement therapy and nicotine vaping products are two commonly used smoking cessation aids. This study demonstrates that misperceptions of the harms of nicotine products relative to cigarettes influence their use for smoking cessation. Believing that nicotine vaping products are much less harmful than cigarette smoking may lead some smokers to prefer these products over nicotine replacement therapy to aid smoking cessation. Education targeting misperceptions of nicotine products’ harmfulness relative to cigarettes may enable smokers to make informed choices about which are appropriate to aid smoking cessation.
... The data for this study of Mexican adults (18 years old and higher) who were current smokers (smoked in the last 30 days) are from the Mexico administration of International Tobacco Control (ITC) Smoking and Vaping Survey. 22 For each survey, quotas were used for educational attainment (eg, at least 500 with high school education or less) and for an oversample of current e-cigarette users (at least 500 who used e-cigarettes in the last 30 days), to ensure adequate sample size for evaluating these groups. Participants were recruited by email from the provider's existing panel, screened for eligibility, and compensated upon survey completion using a point system. ...
Article
Purpose Flavor capsule cigarettes are rapidly gaining global market share, particularly in Latin America. This paper compares profiles and perceptions of smokers who prefer flavor capsule cigarettes and those who do not in Mexico. Methods We analyzed data from six online surveys of adult Mexican smokers (n=4488) from 2018-2020. Participants identified their preferred brand variety characteristics (no capsule; one capsule; two capsules), and reported perceptions of their brand varieties’ flavor, smoothness, harmfulness, and whether they smoke to control their appetite. Separate multinomial logistic models regressed preferred cigarette type on sociodemographic and smoking-related variables, as well as perceived benefits on preferred cigarette type, adjusting for covariates. Results Most participants preferred capsule cigarettes (single capsule=47.5%; double capsule=12.9%). Flavor capsule users reported that their preferred varieties mostly tasted like menthol/mint (59% of single capsule users and 23% of double capsule users), cucumber (12% and 27%, respectively) or berries (10% and 22%, respectively). Females were more likely than males to prefer either single or double capsule cigarettes (AOR=2.26 and 2.01, respectively). Preference for flavor capsules was also higher among younger smokers, e-cigarette users, those who smoke less frequently, and those who recently tried or plan to quit. Smokers who preferred capsules were more likely than non-capsule smokers to perceive their cigarettes as smoother, less harmful, and to smoke to control their appetite. Conclusions The high prevalence of capsule use and widespread perceptions of the benefits of capsules over traditional cigarettes may help explain why tobacco control policies have not reduced smoking prevalence in Mexico.
... The authors designed the instrument drawing on their survey expertise and using guidance and items from existing resources. [21][22][23][24] The instrument was reviewed and revised by coauthors and pilot tested with five Central Valley residents who provided feedback. The instrument is available in online supplemental material. ...
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Introduction Flavoured tobacco control policy exemptions and electronic cigarette products may contribute to increased youth access and tobacco use disparities. Methods We assessed public support among California Central Valley residents for four policies to regulate flavoured tobacco products and e-cigarettes. The probability-based, multimode survey was conducted with English-speaking and Spanish-speaking registered voters (n=845) across 11 counties between 13 and 18 August 2020. Weighted logistic regression analyses measured odds of policy support, adjusting for predictor variables (attitudes and beliefs) and covariates. Results The weighted sample was 50% female and predominantly Latino (30%) or non-Hispanic white (46%); 26% had a high school education or less, and 22% an annual household income <US$30 000. Overall, 58% support a comprehensive flavoured tobacco product sales ban, and 59% support a flavoured e-cigarette product sales ban. In addition, 81% support limiting the amount of nicotine in e-cigarette pods, and 91% support mandating vaping health warning signs at local retailers. Flavour bans were more likely to be backed by women, seniors, Latinos, non-smokers and non-vapers. Participants who believe minors have more access to flavoured products had greater odds of supporting all policies. Those aware of the association between e-cigarettes and lung injury were more likely to support non-ban policies. Participants who believe e-cigarettes help to reduce tobacco use or e-cigarettes are relatively less addictive were less likely to support bans. Discussion Findings add to mounting evidence of support for policies to regulate flavoured tobacco and e-cigarette products. Results on attitudes and beliefs elucidate how these factors influence support.
... Surveys were administered in Spanish using standard questions on tobacco product use (International Agency for Research on Cancer, 2008) and questions on novel tobacco products from the International Tobacco Control (ITC) survey (Thompson et al., 2019). The survey took on average between 20 and 25 min to complete, and the panel provider gave standard compensation for participation (e.g., points-based or monetary rewards, chances to win prizes). ...
Article
Background Little is known about the use of novel heated tobacco products (HTPs) in low- and middle-income countries. We examined among smokers in Mexico the prevalence and correlates of HTP use, as well as reasons for using HTPs. Methods We analyzed data from five surveys (November 2019-March 2021) of an open cohort of adult smokers (n=6,500), including an oversample of those who also use e-cigarettes. Mixed-effects multinomial logistic models were used to estimate associations between study variables and current HTP use or prior HTP trial relative to never trying HTPs. Results The weighted prevalence of current HTP use was 1.1%. Independent correlates of current HTP use included greater smoking frequency, intention to quit, e-cigarette use, having partners/family-members who use e-cigarettes or HTPs, and exposure to HTP information inside/outside tobacco shops. Having partners/family members who smoke and not knowing about the harm of HTPs relative to cigarettes were associated with lower likelihood of current HTP use. Having tried HTPs was more likely among smokers with partners/family who use e-cigarettes or HTPs and exposure to HTP information outside shops and on newspapers/magazines. Among current users, the top two reasons for using HTPs were greater social acceptability (50.2%) and lower perceived harm (40.0%) relative to cigarettes. Conclusions Uptake of HTPs appears relatively low among Mexican smokers, and correlates of use are similar to those for e-cigarette use. Further research is needed to determine if HTPs use promotes or impedes smoking cessation, given current HTP users are also likely to use various nicotine products.
... The current study combined and analysed three waves of the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey (Wave 1, 2016; Wave 2, 2018; Wave 3, 2020). Full descriptions of the ITC Project conceptual framework and methods have been published elsewhere [47,48]. Briefly, the cohorts come from four countries: England, US, Canada, and Australia and the data were collected using a mix of telephone interviews and web surveys. ...
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Background: Delay discounting (DD) and time perspective (TP) are conceptually related constructs that are theorized as important determinants of the pursuit of future outcomes over present inclinations. This study explores their predictive relationships for smoking cessation. Methods: 5006 daily smokers at a baseline wave provided 6710 paired observations of quitting activity between two waves. Data are from the International Tobacco Control (ITC) smoking and vaping surveys with samples from the USA, Canada, England, and Australia, across three waves conducted in 2016, 2018 and 2020. Smokers were assessed for TP and DD, plus smoking-specific predictors at one wave of cessation outcomes defined as either making a quit attempt and/or success among those who tried to quit which was ascertained at the subsequent survey wave. Results: TP and DD were essentially uncorrelated. TP predicted making quit attempts, both on its own and controlling for other potential predictors but was negatively associated with quit success. By contrast, DD was not related to making quit attempts, but high DD predicted relapse. The presence of financial stress at baseline resulted in some moderation of effects. Conclusions: Understanding the mechanisms of action of TP and DD can advance our understanding of, and ability to enhance, goal-directed behavioural change. TP appears to contribute to future intention formation, but not necessarily practical thought of how to achieve goals. DD is more likely an index of capacity to effectively generate competing future possibilities in response to immediate gratification.
... The current study combined and analyzed three waves of the 20 and methods 21,22 have been published elsewhere. Briefly, the cohorts of 4CV are adult (≥18 years) smokers, vapers, and concurrent users sampled from four countries: England, US, Canada, and Australia. ...
Article
Background: This paper explores whether plans to quit, wanting to quit and quit efficacy add predictive value over measures of habit strength and dependence in making quit attempts and/or attaining smoking abstinence. Aims and methods: We used three waves of the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey conducted in 2016, 2018, and 2020. Baseline daily smokers (N=6710) who provided data for at least one wave-to-wave transition (W1 to W2, N=3511 or W2 to W3, N=3199) and providing outcome data at the next wave (follow-up) formed the analytic sample. Generalized estimating equations (GEE) logistic regression analyses examined predictors of quit attempts and abstinence at follow-up (1 and 6 months sustained abstinence). Results: Wanting and planning to quit were significantly positively associated with making quit attempts, but negatively associated with smoking abstinence. A significant interaction between the Heaviness of Smoking Index and age warranted an age-stratified analysis for both abstinence outcomes. Lower HSI predicted abstinence in only the younger smokers Motivation and plans to quit were positively associated with abstinence in younger smokers, but surprisingly were negatively associated with abstinence in older smokers. Quit efficacy was associated with abstinence in the older, but not the younger smokers. Conclusions: Models of smoking abstinence are significantly improved by including motivational predictors of smoking. Age was an important moderator of the association between abstinence for both dependence and motivational variables. Implications: The findings from this large cohort study indicate there are age-related differences in predictors of smoking abstinence but not quit attempts. These associations may reflect differential experiences of older and younger cohorts of smokers, which may have implications for interventions to motivate and assist smokers in quitting.
... The survey was administered online and took approximately 20-25 minutes to complete. All questions were administered in Spanish using questions from the International Tobacco Control (ITC) Smoking and Vaping survey [51,52] and the International Agency for Research on Cancer (IARC) [53]. Study procedures were approved by the Institutional Review Board and Ethics Committee of the National Institute of Public Health of Mexico (Ethical Approval Code: CI 1572). ...
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Mexico is one of the countries most affected by COVID-19. Studies have found that smoking behaviors have been impacted by the pandemic as well; however, results have varied across studies, and it remains unclear what is causing the changes. This study of an open cohort of smokers recruited from a consumer panel (n = 2753) examined changes in cigarettes per day (CPD), daily vs. non-daily smoking, recent quit attempts, perceived stress, depression, and perceived severity of COVID-19 at two points during the pandemic: March and July 2020. Differences in CPD between waves were estimated with Poisson regression using generalized estimating equations (GEE). Differences in perceived stress were estimated with linear regression using GEE, and differences in recent quit attempts, depression, and perceived severity of COVID-19 were estimated using separate logistic regression GEE models. Rates of depression were higher in July compared to March (AOR = 1.55, 95% C.I. 1.31–1.85), and the likelihood of recent quit attempt was lower in July compared to March (AOR = 0.85, 95% C.I. 0.75–0.98). There was no statistically significant change in CPD, daily smoking, or perceived stress. Perceived COVID-19 severity for oneself increased significantly (AOR: 1.24, 95% C.I. 1.02–1.52); however, the perceived COVID-19 severity for smokers remained constant. Our study suggests that as the COVID-19 pandemic expanded in Mexico, smoking frequency remained stable, and quit attempts decreased, even as adult smokers increasingly perceived infection with COVID-19 for themselves as severe. These results can aid in the development of health communication strategies to educate smokers about their risk for COVID-19, potentially capitalizing on concerns that stem from this syndemic of communicable and smoking-related non-communicable disease.
... After the weighting was applied, the sample in each country was designed to be nationally representative of cigarette smokers. [31][32][33][34] Weighted multivariable logistic regression was used to estimate the percentage of smokers reporting changes for: (1) pack appeal (limited to those smokers having a regular brand); and (2) HWL effectiveness (all smokers). Logistic regression models were estimated using generalised estimating equations to account for within-subject correlation among smokers participating in both surveys. ...
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Background In February 2020, Canada implemented plain packaging without any changes to the size and content of health warning labels (HWLs), which were last updated in 2012 (pictorial HWLs on 75% of the pack front and back). This pre-post evaluation study assessed the impact of plain packaging in Canada on: (1) pack appeal; (2) HWL effectiveness; and (3) support for plain packaging. Additionally, a quasi–experimental design was used to assess the Canadian results relative to two comparator countries: Australia, where plain packaging (with new larger HWLs) was implemented in 2012, and the United States (USA), where plain packaging has not been implemented and the same text warnings have appeared on cigarette packs since 1985. Methods Data are from adult smokers who participated in the 2018 and/or 2020 International Tobacco Control Smoking and Vaping Surveys in Canada (n=4600), Australia (n=1834) and the USA (n=3046). Online surveys were conducted before (February to July 2018) and after (February to June 2020) the implementation of plain packaging in Canada. Adjusted regression analyses were conducted on weighted data. Results Plain packaging was associated with a significant increase in the percentage of Canadian smokers who did not like the look of their cigarette pack (2018: 28.6% vs 2020: 44.7%, p<0.001), whereas no change in pack appeal was observed among smokers in Australia and the USA over the same period. Plain packaging was not associated with changes in HWL effectiveness in Canada. Support for plain packaging increased significantly among Canadian smokers (2018: 25.6% vs 2020: 33.7%, p<0.001). Conclusions Plain packaging in Canada substantially reduced pack appeal and increased support for the policy among adult smokers; however, there was no increase in the effectiveness of Canada’s 8-year-old HWLs. The impact of plain packaging on health warning effectiveness may depend on the design of the warnings and length of time since implementation.
... The weighting methods are described in detail elsewhere. 27 For RQ1, we included all current smokers (both daily and non-daily) and recent quitters (ie, quit for less than 2 years) (weighted n=11 844). The numbers of participants by country were Canada: 2146, USA: 1604, England: 2750 and Australia: 1041. ...
Article
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Background Filter ventilation creates sensations of ‘lightness’ or ‘smoothness’ and is also highly effective for controlling machine-tested yields of tar, nicotine and carbon monoxide. Nearly all factory-made cigarettes (FMC) now have filter ventilation in countries such as Australia, Canada, the UK and the USA. Research conducted before ‘light’ and ‘mild’ labelling was banned found low smoker awareness of filter ventilation and its effects. This study explores current levels of awareness of filter ventilation and current understanding of its effects in these four countries. Methods We used data from the 2018 wave of the ITC Four Country Smoking and Vaping Survey with samples from USA, England, Canada and Australia. Analyses were conducted initially on a weighted sample of 11 844, and subsequently on 7541 daily FMC smokers. Findings Only 40.3% of all respondents reported being aware of filter ventilation. Among daily FMC smokers, only 9.4% believed their cigarettes had filter ventilation. Believing that their usual cigarettes are smoother was positively associated with believing they are also less harmful. Both these beliefs independently predict believing their cigarettes are ventilated (smoother OR=1.97 (95% CI 1.50 to 2.59) and less harmful OR=2.41 (95% CI 1.66 to 3.49) in relation to those believing each characteristic is average. Interpretation Awareness of filter ventilation is currently low, despite decades of public ‘education efforts around the misleading nature of ‘light’ and ‘mild” descriptors. Few smokers realise that their cigarettes almost certainly are vented. Smokers who believed their cigarettes have filter ventilation were more likely to believe they were both smoother and less harmful. Awareness of the technology appears to be insufficient to prevent smokers being deceived by it. Filter ventilation is inherently misleading to smokers and it is time to ban it.
... Data were collected online, and respondents were remunerated. Methodological details are described elsewhere [21][22][23][24][25] and available online (http://www. itcproject. ...
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Objective To evaluate the impact of menthol cigarette bans in seven Canadian provinces between 2016 and 2018. Methods Longitudinal data from the Canadian arm of the 2016 and 2018 ITC Four Country Smoking and Vaping Survey. 1098 non-menthol and 138 menthol smokers were surveyed pre-menthol and post-menthol cigarette bans. Multivariate logistic regression models examined associations between pre-post ban changes in smoking behaviour, including differences between menthol and non-menthol smokers in quit attempts and quitting. Results At follow-up, 59.1% of pre-ban menthol smokers switched to non-menthol cigarettes; 21.5% quit smoking and 19.5% still smoked menthols, primarily purchased from First Nations reserves. Menthol smokers were more likely than non-menthol smokers to make a quit attempt (adjusted OR (aOR)=1.61, 95% CI 1.03 to 2.51), and to remain quit (aOR=2.30, 95% CI 1.06 to 5.01). Menthol smokers did not differ significantly from non-menthol smokers in quit success (aOR=1.72, 95% CI 0.98 to 3.01); however, daily menthol smokers were more likely than daily non-menthol smokers to quit (aOR=2.21, 95% CI 1.15 to 4.24), and daily menthol smokers who quit before the ban were more likely than daily non-menthol smokers to remain quit (aOR=2.81, 95% CI 1.15 to 6.85). Conclusions Although menthol smokers were most likely to switch to non-menthol cigarettes, the menthol ban was also significantly associated with higher rates of quit attempts and quit success among menthol smokers compared with non-menthol smokers, and may have helped to prevent relapse among menthol smokers who had quit smoking before the ban. Results confirm and extend evaluation of Ontario’s menthol ban across provinces covering 83% of the Canadian population.
Article
Objective We examined the relationship in Australia from 2007 to 2020 between tobacco tax increases and use of cost-minimising behaviours (CMBs) when purchasing tobacco and: (1) tobacco expenditure and (2) smoking cessation attempts and quit success. Methods We used data collected from adults who smoked factory-made and/or roll-your-own (RYO) cigarettes in nine waves (2007–2020) of the International Tobacco Control Policy Evaluation Project Australia Survey (N sample =4975, N observations =10 474). CMBs included buying RYO tobacco, cartons, large-sized packs, economy packs, or tax avoidance/evasion, smoking reduction and e-cigarette use. Logistic regression, fit using generalised estimating equations, estimated the CMB-outcome association for quit attempts and quit success at the next wave follow-up (N subsample =2984, N observations =6843). Results Over half of respondents used a CMB for tobacco purchase (P-CMB) at baseline (57.1% in 2007–2008), increasing to 76.8% (2018) post-tax increases. Participating in any P-CMB was associated with having higher weekly tobacco expenditure. Engaging in any P-CMB was negatively associated with attempting to quit (aOR=0.82, 95% CI 0.69–0.98). Purchasing RYO tobacco or cartons was associated with making no quit attempts (aOR=0.66, 95% CI 0.52–0.83; aOR=0.72, 95% CI 0.59–0.89, respectively). Among respondents smoking cigarettes who made quit attempts, there were no significant associations between all P-CMBs and quit success. Neither smoking reduction nor vaping were significantly associated with quit attempts. Conclusion P - CMBs are associated with reduced smoking cessation. Reducing opportunities for industry to promote purchasing-related CMB options, such as by standardising pack sizes and reducing the price differential between RYO and manufactured cigarettes could increase the effectiveness of tax increases.
Article
Background and Aims Nicotine vaping products (NVPs) can potentially help adult tobacco users quit smoking. This study evaluated how adult consumers compare the costs between NVPs and cigarettes. Method We used data from the US arm of the 2016–2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) surveys to perform a multinomial logit model with two‐way fixed effects to measure how perceived cost comparisons are associated with NVP and cigarette taxes, use patterns, NVP device types and individual sociodemographic factors. Results Higher cigarette taxes are associated with a greater likelihood of perceiving NVPs and cigarettes as costing the same for the overall population and among people who exclusively smoke, and a lower likelihood of perceiving NVPs as more expensive among people who exclusively vape, compared with lower cigarette taxes. Pre‐filled cartridge and tank users are more likely to perceive NVPs as less expensive than cigarettes, compared with people who use other types of NVPs. The associations between taxes and perceived cost comparison were more pronounced among males, younger and low‐income populations. Conclusions Higher cigarette taxes are associated with perceived financial incentives for nicotine vaping products (NVPs) over cigarettes, whereas NVP taxes are not associated with perceived cost comparison between NVPs and cigarettes.
Article
Introduction Consumer preferences should be important factors that are considered when developing health policies and interventions. This paper examines the prevalence of, and factors associated with, consumer preferences regarding smoking behaviour 1 to 2 years in the future. Methods At least weekly cigarette smokers in the 2020 wave of the International Tobacco Control Four Country Smoking and Vaping Survey (USA, Canada, England and Australia) ( N = 8642) were asked if they preferred to continue to smoke or to quit with or without an alternative nicotine product (ANP) over the next 1–2 years. Results Country‐specific weighted data showed 21.5% preferred to continue smoking and 8.0% were uncertain, leaving 70.6% preferring to quit: 13.7% using an ANP and 56.9% completely quitting nicotine. Apart from interest in quitting, the main predictors of preferring to quit were history of vaping, being aged 55 and over, smoking weekly, worrying about smoking harms, regretting starting and believing vaping is less harmful relative to smoking. Among those preferring to quit, preferring to use ANPs in future was very strongly associated with current vaping (especially daily), being younger, living in England, reporting strong urges to smoke, believing vaping is much less harmful than smoking, and not strongly regretting starting to smoke, and not wanting to quit. Discussion and Conclusions A significant minority of smokers preferred not to quit, at least in the next year or two. Both interest in quitting and preference for ANPs over complete cessation were associated with similar covariates, including interest in vaping.
Article
Objective We examined Australian tobacco purchasing trends, the average self-reported price paid within each purchase type and the association between type of tobacco product purchased and participant characteristics, including quit intentions, between 2007 and 2020. Methods We analysed data collected from adults who smoked factory-made and/or roll-your-own (RYO) cigarettes in nine waves (2007–2020) of the International Tobacco Control Policy Evaluation Project Australia Survey (n sample =5452, n observations =11 534). The main outcome measures were type of tobacco products purchased: RYO, carton, pack or pouch size and brand segment. Logistic regression, fit using generalised estimating equations, was estimated the association between the outcome and participant characteristics. Results The reported price-minimising purchasing patterns increased from 2007 to 2020: any RYO (23.8–43.9%), large-sized pack (2007: 24.0% to 2016: 34.3%); shifting from large-sized to small-sized packs (2020: 37.7%), and economy brand (2007: 37.2% to 2020: 59.3%); shifting from large (2007: 55.8%) to small economy packs (2014: 15.3% to 2020: 48.1%). Individuals with a lower income, a higher nicotine dependence level and no quit intention were more likely to purchase RYO and large-sized packs. Conclusion RYO, large-sized packs and products with a low upfront cost (eg, small RYO pouches and small-sized economy brand packs) may appeal to people on low incomes. Australia’s diverse tobacco pack and pouch sizes allow the tobacco industry to influence tobacco purchases. Standardising pack and pouch sizes may reduce some price-related marketing and especially benefit people who have a low income, are highly addicted and have no quit intention.
Article
Background: This study examined the association between alcohol consumption and smoking cessation behaviour of adults who smoke in four countries. Methods: Data came from 4275 adults (≥18 years) who smoked tobacco ≥ monthly and participated in the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping Surveys (Australia: n = 720; Canada: n = 1250; US: n = 1011; England: n = 1294). The 2018 Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) survey data coded into three levels ('never/low', 'moderate' or 'heavy' consumption) were analysed using multivariable logistic regression models to predict any smoking cessation attempts and successful cessation by 2020 survey, and whether this differed by gender and country. Results: Compared to never/low alcohol consumers, only those who drink heavily were less likely to have made a quit smoking attempt (40.4 % vs. 43.8 %; AOR = 0.69, 95 % CI = 0.57-0.83, p < .001). The association differed by gender and country (3-way interaction, p < .001), with females who drink heavily being less likely to attempt to quit smoking in England (AOR = 0.27, 95 % CI = 0.15-0.49, p < .001) and Australia (AOR = 0.38, 95 % CI = 0.19-0.77, p = .008), but for males, those who drink moderately (AOR = 2.18, 95 % CI = 1.17-4.06, p = .014) or heavily (AOR = 2.61, 95 % CI = 1.45-4.68, p = .001) were more likely to make a quit attempt in England only. Alcohol consumption did not predict quit success. Conclusion: Heavy alcohol use among adults who smoke appears to only undermine the likelihood of trying to quit smoking with some variation by gender and country of residence, but not their chances of succeeding if they tried.
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Introduction: This study examined individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies (NRTs) relative to combustible cigarettes (CCs). Methods: Data analyzed came from 8,642 adults (18+ years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n=1213), Canada (n=2633), England (n=3057), and United States (US, n=1739). Respondents were asked: "Compared to smoking cigarettes, how harmful do you think nicotine replacement products are?" Responses were dichotomised into "much less" vs. otherwise for analysis using multivariable logistic regression models, complemented by decision-tree analysis to identify conjoint factors. Results: Percentages believing that NRTs are much less harmful than CCs were 29.7% (95% CI:26.2-33.5%) in Australia, 27.4% (95% CI=25.1-29.8%) in England, 26.4% (95% CI=24.4-28.4%) in Canada and 21.7% (95% CI=19.2-24.3%) in the US. Across all countries, believing nicotine is not at all/slightly harmful to health (aOR=1.53-2.27), endorsing nicotine vaping products as less harmful than CCs (much less harmful: aOR=7.24-14.27; somewhat less harmful: aOR=1.97-3.23), and possessing higher knowledge of smoking harms (aOR=1.23-1.88) were individual factors associated with increased odds of believing NRTs are much less harmful than CCs. With some country variations, these nicotine-related measures also interacted with each other and socio-demographic variables to serve as conjoint factors associated with the likelihood of accurate NRT relative harm belief. Conclusions: Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors.What this study adds:This study demonstrates that despite past efforts to educate people who smoke about the harms of NRTs relative to combustible cigarettes, misperceptions around the relative harmfulness of NRTs remain substantial. In all four studied countries, subgroups of people who smoke regularly who are misinformed about the relative harmfulness of NRTs and who may be reluctant to use NRTs for smoking cessation can be reliably identified for corrective interventions based on their understanding of the harms related to nicotine, nicotine vaping products and smoking along with socio-demographic markers. The identified subgroup information can be used to prioritize and inform the development of effective interventions to specifically address the gaps in knowledge and understanding of the various subgroups identified. Our results suggest these may need to be tailored for each country.
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This study examined differences in quit attempts, 1-month quit success, and vaping status at follow-up among a cohort of 3709 daily smokers with and without depression, anxiety, and regular alcohol use who participated in both the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys. At baseline, a survey with validated screening tools was used to classify respondents as having no, or one or more of the following: 1) depression, 2) anxiety, and 3) regular alcohol use. Multivariable adjusted regression analyses were used to examine whether baseline (2018) self-report conditions were associated with quit attempts; quit success; and vaping status by follow-up (2020). Results showed that respondents who reported depressive symptoms were more likely than those without to have made a quit attempt (aOR = 1.32, 95% CI:1.03–1.70, p = 0.03), but were less likely to have quit (aOR = 0.55, 95% CI:0.34–0.89, p = 0.01). There were no differences in quit attempts or quit success between those with and without self-reported anxiety diagnoses or regular alcohol use. Among successful quitters, respondents with baseline depressive symptoms and self-reported anxiety diagnoses were more likely than those without to report vaping at follow-up (aOR = 2.58, 95% CI:1.16–5.74, p = 0.02, and aOR = 3.35 95% CI:1.14–9.87, p = 0.03). In summary, it appears that smokers with depression are motivated to quit smoking but were less likely to manage to stay quit, and more likely to be vaping if successfully quit. As smoking rates are higher among people with mental health conditions, it is crucial for healthcare professionals to identify these vulnerable groups and offer tailored smoking cessation support and continued support during their quit attempt.
Article
Introduction Novel ‘tobacco-free’ oral nicotine products (ONP) are not combusted, easy to conceal, available in flavors, and do not contain tobacco leaf. Since 2016, ONP sales have increased, and may be gaining popularity among youth. This study aims to examine trends in prevalence and correlates of ONP use among US youth. Methods Data from participants 16–19-years in the US ITC Youth Tobacco and Vaping Survey were analyzed cross-sectionally from Aug 2019, Feb 2020, Aug 2020, Feb 2021, and Aug 2021. Weighted descriptive statistics and logistic regressions were used to describe use and correlates of ONPs. Results From Aug 2019 to Aug 2021, ONP use significantly increased from 3.5% in Aug-19 to 4.1% in Aug-21. ONP use was most prevalent among those 18 years, male, and non-Hispanic White. Those who used cigarettes (aOR: 2.18, 95%CI: 19.37, 40.88), nicotine vaping products (NVPs; aOR: 4.27, 95%CI: 3.02, 6.04), and smokeless tobacco (SLT; aOR: 28.14, 95%CI: 19.37, 40.88) in the past 30-days were more likely to report recent use of ONPs. Conclusions Although ONPs are less popular among US youth when compared to cigarettes, NVPs, and SLTs, their prevalence of use significantly increased. ONP users are more likely to be a user of other nicotine products, but the availability of flavors and easy to conceal design may be appealing to those who may not use nicotine products. Researchers should continue to observe behaviors associated with ONP use to inform the need for future regulatory efforts.
Article
Background We examined the differential impact of the 2012 Canadian GWL policy changes on key indicators of warning label impact and quit intentions using national cohorts of Canadian and US adults who smoke. Methods We used data from all waves of the International Tobacco Control surveys (2002-2020) in Canada and the US. Our key measures were quit intentions and an index of warning label effectiveness (salience, cognitive and behavioral reactions). We estimated overall policy impact by comparing Canada (treatment group) with the US (control group) using controlled interrupted time series (CITS) regression models, with interactions to examine whether policy impact varied by sex, education, and income. Results The CITS model showed a statistically significant increase in the warning label effectiveness in Canada post-policy, compared to the US (β= 0.84, 95% CI 0.35,1.33). Similarly, the odds of quit intentions were relatively higher among adults who smoked in Canada compared to the US (OR= 1.89, 95% CI 1.51,2.36) post-policy. The three-way interaction model showed that these associations were greater among adults from low socioeconomic status (SES) groups than in high SES groups. Discussion The 2012 change in the Canadian GWL policy was associated with stronger cognitive and behavioral responses to GWLs and higher odds of quit intentions among adults who smoked in Canada when compared to the US, specifically among individuals from low SES groups, suggesting a positive equity impact. Our findings affirm the need for countries to implement or enhance GWLs, in line with the WHO Framework Convention on Tobacco Control. Implications The evidence on the potential health equity benefit of GWL policies is mixed. To further understand the influence of GWL policies on tobacco use disparities, more systematic research using pre/post policy designs with control groups is needed. Using a controlled interrupted time series model, we aimed to strengthen the available evidence on the causal influence of this tobacco control approach. Our findings show that the 2012 GWL policy change had a greater impact on adults who smoked from low SES groups than it did on adults who smoked from high SES groups, indicating a potentially positive equity impact and confirming the need for countries to implement or maximize the size of GWLs, as recommended by the WHO Framework Convention on Tobacco Control.
Article
Background and aims: Most population studies that evaluate the relationship between nicotine vaping and cigarette cessation focus on limited segments of the smoker population. We evaluated vaping uptake and smoking cessation considering differences in smokers' plans to quit. Design: Longitudinal ITC Four Country Smoking and Vaping Surveys conducted in 2016, 2018, and 2020. Setting: US, Canada, England, Australia. Participants: Adult daily cigarette smokers who had not vaped in the past 6 months at baseline and had participated in two or more consecutive waves of the ITC Four Country Smoking and Vaping Surveys (n= 2,815). Measurements: Plans to quit cigarette smoking at baseline (within 6 months, beyond 6 months, not planning to quit) and at follow-up (within 6 months versus not within 6 months); cigarette smoking cessation at follow-up (smoking less than monthly [including complete cessation] versus daily/weekly/monthly smoking); inter-wave vaping uptake (none, only nondaily vaping, any daily vaping). Generalized estimating equations were used to evaluate whether inter-wave vaping uptake was associated with smoking cessation at follow-up, and with planning to quit at follow-up, each stratified by plans to quit smoking at baseline. Findings: Overall, 12.7% of smokers quit smoking. Smokers not initially planning to quit within 6 months experienced higher odds of smoking cessation when they took up daily vaping (32.4%) versus no vaping (6.8%; adjusted odds ratio [AOR]=8.58, 95% confidence interval [CI]:5.06-14.54). Among smokers planning to quit, smoking cessation rates were similar between those who did and did not take up daily vaping (25.1% vs. 16.8%; AOR=1.91, 95%CI:0.91-4.00), though we could not account for potential use of cessation aids. Daily vaping uptake was associated with planning to quit smoking at follow-up among those initially not planning to quit (AOR=6.32, 95%CI:4.17-9.59). Conclusions: Uptake of nicotine vaping appears to be strongly associated with cigarette smoking cessation among smokers with no initial plans to quit smoking. Excluding smokers not planning to quit from studies on vaping and smoking cessation may underestimate potential benefit of daily vaping for daily smokers.
Article
Aims: To examine whether poly-use of cigarettes and other smoked products (poly-smoking) is predictive of quit attempts and quit success. Design: A prospective multi-country cohort design. Setting: Australia, Canada, England and the US. Participants: 3983 adult daily cigarette smokers were surveyed in 2016 (Wave 1 of data collection) and were recontacted in 2018 (Wave 2) (i.e., Wave 1-Wave 2 cohort) in the International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys; and 3736 smokers were surveyed in 2018 and recontacted in 2020 (Wave 3) (i.e., Wave 2-Wave 3 cohort). Measurements: Participants were asked about their cigarette smoking and use of cigars, cigarillos, pipes, and waterpipes. Outcomes were quit attempts between two survey waves and success, defined as having quit smoking all the combustible tobacco at the subsequent survey for 1 month or more. Findings: Levels of poly-smoking were 12.7% in the Wave 1-Wave 2 cohort and 10.5% for the Wave 2-Wave 3 cohort. Compared with cigarette-only smokers, poly-smokers were more likely to attempt between Waves 1 and 2 (54.9% vs. 42.7%, adjusted odds ratio (aOR)=1.37, 95% confidence interval [CI] 1.08-1.74, p<0.01), but not between Waves 2 and 3 (43.8% vs. 40.1%, aOR=0.94, 95%CI 0.72-1.22). Poly-smoking predicted reduced likelihood of success in both cohorts among attempters and the overall samples. Between Waves 2 and 3 there were significantly more transitions to non-daily smoking among the poly-smokers (12.4% vs. 5.3%, 2 =40.4, p<0.001). Conclusions: There is a consistent association between poly-smoking (use of cigarettes along with other smoked products) and reduced quit success for combustible tobacco, but it is likely due to increased likelihood of transitioning to non-daily use rather than complete cessation.
Article
Background Little is known about population-level differences between adults who exclusively smoke cigarettes and those who smoke cigarettes and also use cannabis (co-consumers). Thus, this study describes differences on sociodemographic, cigarette-dependence, health and behavioral variables, and risk perceptions associated with smoking cannabis. Methods This cross-sectional study included 6941 respondents from the 2020 ITC Four Country Smoking and Vaping Survey (US, Canada, Australia, England). Adult daily cigarette smokers were included and categorized as: cigarette-only smokers (never used cannabis/previously used cannabis, but not in the past 12 months, n=4857); occasional co-consumers (cannabis use in the past 12 months, but <weekly use, n=739); or regular co-consumers (use cannabis ≥weekly, n=1345). All outcomes were self-reported. Regression models were conducted on weighted data. Results Overall, 19.9% of respondents reported regular cannabis co-use and 10.1% reported occasional co-use. Regular co-use was highest in Canada (27.2%), followed by the US (24.4%), England (12.7%) and Australia (12.3%). Compared to cigarette-only smokers, regular co-consumers were more likely to be male and report chest/breathing problems (p<0.001). All co-consumers were more likely to be younger, have lower income, be experiencing financial stress, reside in Canada, have depressive symptoms, use alcohol more frequently and binge drink, use other tobacco/nicotine products, and perceive smoking cannabis as low health risk and less harmful than smoking cigarettes (all p<0.001). Cigarette dependence measures were similar between co-consumers and cigarette-only smokers (all p≥0.05). Conclusions Although there were no differences on cigarette dependence measures between daily cigarette smokers who do and do not use cannabis, there are several other risk factors that may affect tobacco use and abstinence among co-consumers (e.g., greater depression, high-risk alcohol consumption). Thus, tobacco cessation treatment may require multi-pronged strategies to address other health behaviors. Continued surveillance is needed to determine the nature and health implications of co-use considering changing policies, markets, and products.
Article
Introduction Tobacco-free oral nicotine products are an emerging class of noncombustible nicotine products. Oral nicotine product sales have increased since 2016, although little research has investigated consumer awareness, use, or correlates of oral nicotine product use. The purpose of this analysis was to assess the prevalence and correlates of oral nicotine product awareness and use. Methods This paper is a cross-sectional analysis of 2,507 U.S. participants from Wave 3 (February–June 2020) of the International Tobacco Control Four Country Smoking and Vaping Survey, a population-based survey of current and former cigarette smokers and nicotine vaping product users in the U.S. Oral nicotine product awareness and use prevalence were compared with those of heated tobacco products. Analyses conducted in late 2021 assessed the correlates of oral nicotine product awareness and use such as demographic characteristics, tobacco use (cigarettes, nicotine vaping products, smokeless tobacco), and tobacco quit attempts. Results Almost 1 in 5 respondents claimed to have heard of oral nicotine products, 3.0% reported ever use, and 0.9% were current users, all of which were lower than for heated tobacco products. Ever use of oral nicotine products was more common among younger adults (e.g., aged 18–24 years), males, and current users of smokeless tobacco. Oral nicotine product prevalence was higher among those who reported having made attempts to stop smoking or vaping. Conclusions Oral nicotine product use was low among current and former smokers and nicotine vaping product users. Oral nicotine product users were demographically similar to use among individuals who smoke/vape and also use smokeless tobacco. Future studies are needed to understand emerging oral nicotine products, particularly whether they are being used as product supplements (dual use), replacements (switching), or cessation aids (quitting).
Article
Introduction There is mixed evidence as to whether nicotine vaping products (NVPs) can help adults who smoke transition away from cigarettes. This study investigated if self-reported attempts to quit smoking and smoking cessation, over a period of either 18 or 24 months, differed between respondents who initiated nicotine vaping versus those who did not. Outcome comparisons were made between those who: (1) initiated vaping vs. those who did not; (2) initiated daily or non-daily vaping vs. those who did not; and (3) initiated daily or non-daily vaping between surveys and continued to vape at follow-up (daily or non-daily) vs. those who did not initiate vaping. Methods This cohort study included 3516 respondents from the ITC Four Country Smoking and Vaping Surveys (Australia, Canada, England, United Sates), recruited at Wave 1 (2016) or 2 (2018) and followed up at Wave 2 (18 months) and/or 3 (2020, 24 months). Adults who smoked daily at baseline and did not have a history of regular vaping were included. Initiation of vaping was defined as beginning to vape at least monthly between surveys. Respondents indicated whether they made an attempt to quit smoking between surveys. Smoking cessation was defined as those who self-reported no longer smoking cigarettes at follow-up. Results Relative to those who did not initiate vaping, initiation of any daily vaping between surveys was associated with a greater likelihood of smokers making a cigarette quit attempt (p < 0.001) and quitting smoking (p < 0.001). Among smokers who attempted to quit smoking, initiation of daily vaping was associated with a greater likelihood of being abstinent from smoking at follow-up (p = 0.001). Respondents who initiated vaping between surveys and were vaping daily at follow up were significantly more likely to have attempted to quit smoking (p < 0.001) and to have quit smoking (p < 0.001) than those who did not initiate vaping. Respondents who initiated non-daily vaping did not differ significantly from those who did not initiate vaping on any of the outcome measures. Conclusions Daily NVP use was associated with increased attempts to quit smoking and abstinence from smoking cigarettes. These findings are consistent with the concept that complete cigarette substitution may be more likely to be achieved when smokers vape nicotine daily.
Article
Evidence of the impact of COVID-19 and mandatory stay-at-home orders on cigarette smoking is mixed. In the United States, household tobacco purchases increased in early 2020, but it is unclear whether this was associated with increased smoking. Using individual-level, longitudinal data from a representative cohort of US smokers (n=3046), this study tested whether (1) carton purchases of cigarettes increased in early 2020 relative to the same calendar period in 2018, (2) more smokers permitted smoking inside their homes, and (3) smokers increased the number of cigarettes they smoked per day. Weighted multivariable logistic regression tested whether trends in carton purchasing and smoke-free homes differed in 2020 compared to 2018 while weighted multivariable linear regression tested whether trends in cigarette consumption differed in 2020 compared to 2018. Overall, 24.0% of US smokers last purchased cigarettes by the carton in early 2018; this increased to 28.8% in early 2020 (p = 0.007). Average daily cigarette consumption and the percentage of smokers reporting that smoking was not allowed inside their homes did not differ between 2018 and 2020 (p = 0.92 and p = 0.054, respectively). Overall, these findings suggest that COVID-19 mitigation measures implemented in the spring of 2020 had limited impact on the smoking behavior of US adult smokers.
Article
Background: The number of countries mandating a nicotine addiction warning label ('warnings') on nicotine vaping products (NVPs) has been increasing. This study examined associations between noticing NVP warnings, perceptions of NVPs, and intentions to use NVPs. Methods: Cross-sectional analysis of 12,619 adult NVP users, cigarette smokers, concurrent users of both cigarettes and NVPs, and quitters who participated in the 2018 International Tobacco Control (ITC) Project Four Country Smoking and Vaping Survey (England, Australia, Canada, US). Logistic regression analyses examined associations between noticing warnings in the past 30 days and perceptions of nicotine harm, NVP harm relative to cigarettes, and NVP addictiveness relative to cigarettes. Associations were also explored between noticing warnings and intentions to use NVPs. Results: Noticing warnings was higher among NVP users (18.8%) than non-users (2.1%). Noticing warnings was associated with perceiving nicotine to pose little or no harm to health among NVP users, but there was no association among non-users. There was little evidence of an association between noticing warnings and perceptions of NVP harms relative to smoking among NVP users and non-users. Noticing warnings was associated with perceiving NVPs as less addictive than cigarettes among non-users but not NVP users. Among exclusive smokers, noticing warnings was associated with intending to start using NVPs. Among NVP users, there was little evidence of an association between noticing warnings and intentions to continue using/stopping NVPs. Conclusions: Noticing NVP warnings was not associated with increased NVP and nicotine harm perceptions or decreased intentions to use NVPs among adult smokers and vapers.
Article
Smoking rates are disproportionately high among people living with HIV. Smokers living with HIV (SLWH) are also largely unaware of the HIV-specific deleterious effects of smoking and often lack motivation and confidence in their ability to quit tobacco. To address these issues, we developed the Wellness Intervention for Smokers Living with HIV (WISH). WISH is grounded in the Information-Motivation-Behavioral Skills (IMB) Model and is designed for all SLWH, regardless of their initial motivation to quit. It follows evidence-based, best practice guidelines for nicotine dependence treatment, but is innovative in its use of a comprehensive wellness approach that addresses smoking within the context of HIV self-management including treatment adherence and engagement, stress management, substance use, and other personally relevant health behavior goals. The described randomized trial will enroll SLWH who are receiving care at Veterans Affairs (VA) medical centers and compare WISH's impact on smoking behavior to standard care services offered through the National VA Quitline and SmokefreeVET texting program. It will also assess intervention impact on markers of immune status and mortality risk. If effective, WISH could be disseminated to Veterans nationwide and could serve as a model for designing quitline interventions for other smokers who are ambivalent about quitting. The current paper outlines the rationale and methodology of the WISH trial, one of a series of studies recently funded by the National Cancer Institute to advance understanding of how to better promote smoking cessation among SLWH.
Article
Introduction: Heated tobacco products (HTP) have diversified global tobacco markets, and user characteristics remain understudied. This study evaluated sociodemographic characteristics, nicotine-related perceptions and behaviors of current HTP users within a sample of adult (18+ years) nicotine users across four countries. Methods: Data were from current smokers or nicotine vaping product (NVP; known as "e-cigarettes") users from Canada, England, the United States and Australia (n=11,421) who participated in the 2018 ITC Four Country Smoking and Vaping Survey. Current (at-least-monthly) HTP users were characterized (n=441), and weighted multivariable logistic regressions examined correlates of HTP use. Results: Compared to non-users, current HTP users were younger (mean age: 44.4 vs 31.0 years; p<0.001) and had higher socioeconomic status (p<0.001). A majority of current HTP users used HTPs non-daily (daily: 40.3% vs non-daily: 59.7%). Most HTP users concurrently used both cigarettes and NVPs (90.5%). Among concurrent cigarette-HTP-NVP users, 36.2% used all three products daily. Use of other combusted tobacco products (cigars, cigarillos, pipe, waterpipe/hookah), cannabis, and binge drinking were each associated with current HTP use. HTP use was more common among smokers intending to quit within 6 months or reporting a quit attempt in the past 18 months, and vapers who had experienced negative side effects. Conclusion: HTP users in this sample tended to be younger and more affluent. Most reported concurrent use of multiple nicotine products and other substances. Those cigarette smokers who used HTPs appeared more interested in smoking cessation, while some characteristics of concurrent HTP-NVP users were suggestive of dissatisfaction with NVPs. Implications: Few studies have scrutinized characteristics of HTP early-adopters in emerging markets. Our results indicate that in 2018, characteristics of established nicotine users who adopted HTP use in four high-income Western countries mirror those of HTP users in East Asian markets (South Korea and Japan) where HTPs are popular. HTP users reported high levels of concurrent use of non-cigarette combusted tobacco products (e.g., cigars, pipe tobacco). These findings point to the need for future longitudinal studies of HTP use given the implications of those use patterns on the harm reduction potential of HTPs. HTP user characteristics may yield important information to consider in regulation of these products.
Article
Introduction Concurrent use (co-use) of tobacco and cannabis may impede successful cigarette smoking cessation. This study examined whether changes in cannabis use frequency were associated with smoking cessation. Methods Nationally representative samples of adult cigarette smokers from Canada (n=1455), the United States (n=892), England (n=1416), and Australia (n=717) were surveyed in 2016 and 2018. In each year, smokers reported how often they used cannabis in the previous 12 months. Reports were compared to determine whether cannabis use increased, remained unchanged, or decreased. Smoking cessation outcomes, measured in 2018, were (1) any attempt to quit in the previous year, (2) currently quit, and (3) currently quit for at least 6 months. Weighted multivariable logistic regression estimated the association between changes in cannabis use and cessation outcomes. Results Cigarette smokers who increased their frequency of cannabis use were significantly less likely to be currently quit than non-cannabis using smokers (adjusted odds ratio (aOR) = 0.52, 95% CI: 0.31, 0.86); they were also less likely to have quit for at least 6 months (aOR = 0.30; 95% CI: 0.15, 0.62). Conclusions Smokers who increase their frequency of cannabis use have poorer smoking cessation outcomes compared to non-cannabis using smokers. It will be important to monitor the impact of cannabis legalization on patterns of cannabis use, and whether this influences cigarette smoking cessation rates.
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Background Noncigarette tobacco products are evolving rapidly, with increasing popularity in the United States. Methods We present prevalence estimates for 12 types of tobacco products, using data from 45,971 adult and youth participants (≥12 years of age) from Wave 1 (September 2013 through December 2014) of the Population Assessment of Tobacco and Health (PATH) Study, a large, nationally representative, longitudinal study of tobacco use and health in the United States. Participants were asked about their use of cigarettes, e-cigarettes, traditional cigars, cigarillos, filtered cigars, pipe tobacco, hookah, snus pouches, other smokeless tobacco, dissolvable tobacco, bidis, and kreteks. Estimates of the prevalence of use for each product were determined according to use category (e.g., current use or use in the previous 30 days) and demographic subgroup, and the prevalence of multiple-product use was explored. Results More than a quarter (27.6%) of adults were current users of at least one type of tobacco product in 2013 and 2014, although the prevalence varied depending on use category. A total of 8.9% of youths had used a tobacco product in the previous 30 days; 1.6% of youths were daily users. Approximately 40% of tobacco users, adults and youths alike, used multiple tobacco products; cigarettes plus e-cigarettes was the most common combination. Young adults (18 to 24 years of age), male adults and youths, members of racial minorities, and members of sexual minorities generally had higher use of tobacco than their counterparts. Conclusions During this study, 28% of U.S. adults were current users of tobacco, and 9% of youths had used tobacco in the previous 30 days. Use of multiple products was common among tobacco users. These findings will serve as baseline data to examine between-person differences and within-person changes over time in the use of tobacco products. (Funded by the National Institute on Drug Abuse and the Food and Drug Administration.)
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Introduction: The rapid rise in electronic cigarettes (ECs) globally has stimulated much debate about the relative risk and public health impact of this new emerging product category as compared to conventional cigarettes. The sale and marketing of ECs containing nicotine are banned in many countries (e.g., Australia) but are allowed in others (e.g., UK). This study examined prevalence and correlates of the belief that ECs are a lot less harmful than conventional cigarettes under the different regulatory environments in Australia (i.e., more restrictive) and the UK (i.e., less restrictive). Methods: Australian and UK data from the 2013 survey of the International Tobacco Control Four-Country project were analysed. Results: More UK than Australian respondents (58.5% versus 35.2%) believed that ECs are a lot less harmful than conventional cigarettes but more respondents in Australia than in the UK selected “Don’t Know” (36.5% versus 17.1%). The proportion that responded “A little less, equally or more harmful” did not differ between countries. Correlates of the belief that ECs are “A lot less harmful” differed between countries, while correlates of “Don’t Know” response did not differ. Conclusions: Consistent with the less restrictive regulatory environment affecting the sale and marketing of ECs, smokers and recent ex-smokers in the UK were more likely to believe ECs were less harmful relative to conventional cigarettes compared to those in Australia.
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This paper outlines the design features, data collection methods and analytic strategies of the International Tobacco Control (ITC) Four Country Survey, a prospective study of more than 2000 longitudinal respondents per country with yearly replenishments. This survey possesses unique features that sets it apart among surveys on tobacco use and cessation. One of these features is the use of theory-driven conceptual models. In this paper, however, the focus is on the two key statistical features of the survey: longitudinal and "quasi-experimental" designs. Although it is often possible to address the same scientific questions with a cross-sectional or a longitudinal study, the latter has the major advantage of being able to distinguish changes over time within individuals from differences among people at baseline (that is, differences between age and cohort effects). Furthermore, quasi-experiments, where countries not implementing a given new tobacco control policy act as the control group to which the country implementing such a policy will be compared, provide much stronger evidence than observational studies on the effects of national-level tobacco control policies. In summary, application of rigorous research methods enables this survey to be a rich data resource, not only to evaluate policies, but also to gain new insights into the natural history of smoking cessation, through longitudinal analyses of smoker behaviour.
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Tables. Boxes. Figures. Getting Files from the Wiley ftp and Internet Sites. List of Data Sites Provides on Web Site. Preface to the Fourth Edition. Part 1: Basic Concepts. 1. Use of Sample Surveys. 2. The Population and the Sample. Part 2: Major Sampling Designs and Estimation Procedures. 3. Simple Random Sampling. 4. Systematic Sampling. 5. Stratification and Stratified Random Sampling. 6. Stratified Random Sampling: Further Issues. 7. Ratio Estimation. 8. Cluster Sampling: Introduction and Overview. 9. Simple One-Stage Cluster Sampling. 10. Two-Stage Cluster Sampling: Clusters Sampled with Equal Probability. 11. Cluster Sampling in Which Clusters Are Sampled with Unequal Probability: Probability Proportional to Size Sampling. 12. Variance Estimation in Complex Sample Surveys. Part 3: Selected Topics in Sample Survey Methodology. 13. Nonresponse and Missing Data in Sample Surveys. 14. Selected Topics in Sample Design and Estimation Methodology. 15. Telephone Survey Sampling (Michael W. Link and Mansour Fahimi). 16. Constructing the Survey Weights (Paul P. Biemer and Sharon L. Christ). 17. Strategies for Design-Based Analysis of Sample Survey Data. Appendix. Answers to Selected Exercises. Index.
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Electronic nicotine delivery systems (ENDS) initially emerged in 2003 and have since become widely available globally, particularly over the Internet. Data on ENDS usage patterns are limited. The current paper examines patterns of ENDS awareness, use, and product-associated beliefs among current and former smokers in four countries. Data come from Wave 8 of the International Tobacco Control Four-Country Survey, collected July 2010 to June 2011 and analyzed through June 2012. Respondents included 5939 current and former smokers in Canada (n=1581); the U.S. (n=1520); the United Kingdom (UK; n=1325); and Australia (n=1513). Overall, 46.6% were aware of ENDS (U.S.: 73%, UK: 54%, Canada: 40%, Australia: 20%); 7.6% had tried ENDS (16% of those aware of ENDS); and 2.9% were current users (39% of triers). Awareness of ENDS was higher among younger, non-minority smokers with higher incomes who were heavier smokers. Prevalence of trying ENDS was higher among younger, nondaily smokers with a high income and among those who perceived ENDS as less harmful than traditional cigarettes. Current use was higher among both nondaily and heavy (≥20 cigarettes per day) smokers. In all, 79.8% reported using ENDS because they were considered less harmful than traditional cigarettes; 75.4% stated that they used ENDS to help them reduce their smoking; and 85.1% reported using ENDS to help them quit smoking. Awareness of ENDS is high, especially in countries where they are legal (i.e., the U.S. and UK). Because trial was associated with nondaily smoking and a desire to quit smoking, ENDS may have the potential to serve as a cessation aid.
University of Waterloo Waterloo Ontario Canada; Medical University of South Carolina Charleston South Carolina United States; VicHealth Centre for Tobacco Control Carlton Australia; Cancer Control Victoria Melbourne Australia; King's College London London United Kingdom
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Awareness trial and use of electronic cigarettes among adult current smokers and ex-smokers in 14 countries with differing EC regulatory polices: Results from the International Tobacco Control Policy Evaluation Project
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Gravely S., Driezen P., Ouimet J., Quah A. C. K., Cummings K. M., Thompson M. E. et al. Awareness, trial, and use of electronic cigarettes among adult current smokers and exsmokers in 14 countries with differing EC regulatory polices: Results from the International Tobacco Control Policy Evaluation Project. In press.
Methods for Evaluating Tobacco Control Policies
IARC Handbooks of Cancer Prevention. Tobacco Control, vol. 12: Methods for Evaluating Tobacco Control Policies. Lyon, France; 2008.
United States; VicHealth Centre for Tobacco Control
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ITC Project (2011). ITC Four Country Waves 2 to 8 (2003-2011) Technical Report. University of Waterloo, Waterloo, Ontario, Canada; Medical University of South Carolina, Charleston, South Carolina, United States; VicHealth Centre for Tobacco Control, Carlton, Australia; Cancer Control Victoria, Melbourne, Australia; King's College London, London, United Kingdom; University of Stirling, Stirling, United Kingdom; and the Open University, Buckinghamshire, United Kingdom. 2011 (Archived at http://www.webcitation. org/73jHg8tRf on November 6, 2018).