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Introduction Heated tobacco products (HTPs) and nicotine vaping products (NVPs) both are legal consumer products in the Republic of Korea. Little is known about perceptions of harmfulness of HTPs and NVPs relative to cigarettes in South Korea among adults who smoke, and how exposure to marketing may be associated with harmfulness perceptions. Methods This study used data from the 2020 International Tobacco Control (ITC) Korea Survey, and included 3713 adult (aged 19 years) cigarette smokers who were: 1) exclusive smokers (n=1845); 2) dual HTP + cigarette consumers (n=1130); 3) dual NVP + cigarette consumers (n=224); and 4) triple consumers (all three products, n=514). Weighted multinomial regression models were conducted to estimate smokers’ perceptions of harmfulness of HTPs and NVPs compared to cigarettes, NVPs to HTPs, and self-reported exposure to HTP/NVP advertising. Analyses compared the perceptions of harmfulness between the four different consumer groups, and tested whether exposure to HTP/NVP advertising was associated with perceptions of lower relative harm. Results Among all respondents, 27.5% believe that HTPs are less harmful than cigarettes and 23.4% believe that NVPs are less harmful than cigarettes. Exclusive cigarettes smokers were significantly less likely to perceive that HTPs and NVPs are less harmful than cigarettes compared to dual HTP + cigarette consumers, dual NVP + cigarette consumers, and triple consumers (all p

Several nicotine vaping product (NVP) device types are available to consumers, and many people who smoke report vaping to help them quit. This study included data from the Wave 3 (2020) ITC Smoking and Vaping Survey in the US, Canada, and England and included 2324 adults who were smoking cigarettes and vaping at least weekly. Device types currently used most often (disposables, cartridges/pods, or tank systems) were assessed using weighted descriptive statistics. Multivariable regression analyses were used to compare differences between respondents who reported vaping to quit smoking (‘yes’ vs. ‘no/don’t know’) by device type, overall and by country. Overall, 71.3% of respondents reported vaping to help them quit smoking, with no country differences (p = 0.12). Those using tanks (78.7%, p

Objective: The objective of the current investigation was to examine associations between symptomatic COVID-19 history, neurocognitive function, and psychiatric symptoms using cognitive task performance, functional brain imaging, and a prospective population survey. Methods: Study 1 was a laboratory study conducted between 3 May 2022 and 16 Nov 2022 involving 120 fully vaccinated community dwelling adults between 18 and 84 years of age (Mage = 31.96 (SD = 20.71), 63.3% female). In this cross-sectional study we examined the association between symptomatic COVID-19 infection history and performance on three computer tasks assessing cognitive function (Flanker interference, delay discounting and simple reaction time) and measured oxygen saturation within the prefrontal cortex using functional near infrared spectroscopy (fNIRS). Study 2 was a 2-wave population survey undertaken between 28 September 2021 and 21 March 2022, examining the prospective relationship between symptomatic COVID-19 and self-reported symptoms of cognitive dysfunction, depressive symptoms, anxiety symptoms, and agitation at 6-month follow up. The sample (N = 2,002, Mage = 37.0, SD = 10.4; 60.8% female) was collected using a quota process to ensure equal numbers of vaccinated and unvaccinated individuals. Structural equation modelling with latent variables was performed on the population-level data, evaluating the fit of the proposed mediational model of symptomatic COVID-19 to psychiatric symptoms through cognitive dysfunction. Results: Findings from Study 1 revealed significant effects of symptomatic COVID-19 history on Flanker interference and delay discounting. Effects on flanker performance were significantly stronger among older adult women (effect: 9.603, SE = 4.452, t = 2.157, p = .033), and were accompanied by task-related changes cerebral oxygenation at the right superior frontal gyrus (F (1, 143.1) = 4.729, p = .031). Additionally, those with a symptomatic COVID-19 infection history showed evidence of amplified delay discounting (coefficient = 0.4554, SE = 0.2208, t = 2.0629, p = .041). In Study 2, baseline symptomatic COVID-19 history was associated with self-reported cognitive dysfunction and a latent variable reflecting psychiatric symptoms of anxiety, depression and agitation at follow-up. Mediational analyses revealed evidence of cognitive mediation of clinically significant psychiatric outcomes: depression (indirect effect = 0.077, SE = 0.026, p = .003) and generalized anxiety (indirect effect = 0.060, SE = 0.021, p = .004). Conclusions: Converging findings from laboratory and population survey data support the conclusion that symptomatic COVID-19 infection is associated with task-related, functional imaging and self-reported indices of cognitive dysfunction as well as psychiatric symptoms. In some cases, these findings appear to be more amplified among women than men, and among older women than younger.

Objective: The ITC EUREST-PLUS Spain Survey is a longitudinal study of a representative sample of Spanish adult (≥18 years old) smokers. This protocol describes the methods of the 2021 follow-up survey. Method: The ITC EUREST-PLUS Survey, a prospective cohort study of a representative sample of smokers in six European countries, was conducted in 2016 (baseline) and 2018 (waves 1 and 2). The 2021 ITC EUREST-PLUS Spain Survey is a continuation of the Spanish cohort with a new interview in 2021 (wave 3). Lost participants were replaced with new smokers recruited using the same multi-stage sampling design. This latest follow-up aims to examine current patterns and transitions of tobacco use and to evaluate the impact of new tobacco-related policies. Comments: The ITC EUREST-PLUS Spain Survey will provide recent information about the impact of tobacco control policies on smoking behaviour. Resumen: Objetivo: La encuesta ITC EUREST-PLUS España es un estudio longitudinal de una muestra representativa de fumadores adultos (≥18 años) españoles. Este protocolo describe los métodos de la encuesta de seguimiento de 2021. Método: La encuesta ITC EUREST-PLUS, un estudio de cohortes prospectivo de una muestra representativa de fumadores en seis países europeos, se realizó en 2016 y 2018 (olas 1 y 2). La encuesta ITC EUREST-PLUS España de 2021 es una continuación de la cohorte española con una nueva entrevista en 2021 (ola 3). Se sustituyeron las pérdidas con nuevos fumadores reclutados usando el mismo diseño muestral multietápico. Este último seguimiento pretende examinar los patrones actuales y las transiciones del uso de tabaco, y evaluar el impacto de nuevas políticas relacionadas con el tabaco. Comentarios: La encuesta ITC EUREST-PLUS España de 2021 proporcionará información reciente sobre el impacto de las políticas de control del tabaco en el consumo de tabaco.

Introduction China has more than 300 million current smokers. There is a controversy over smokers’ risk of COVID-19 infection. Smoking is a risk factor for COVID-19 disease progression, and the outbreak of COVID-19 may change people’s smoking behaviors. This study assessed people’s attitudes towards ‘smoking and COVID-19’ and changes of smoking behaviors before and after the outbreak of COVID-19. Material and Methods A cross-sectional web survey of 11009 adults in China was conducted between 7 May and 3 August 2020. Attitudes towards ‘smoking and COVID-19’ were compared among non-smokers (n=8837), ex-smokers (n=399) and current smokers (n=1773), and changes in smoking behaviors before and after the outbreak of COVID-19 were assessed among current smokers. Results Fewer current smokers (26.2%) agreed with the statement that ‘Current smokers are more likely than ex-smokers or non-smokers to contract COVID-19’ compared with non-smokers (53%) or ex-smokers (41.4%); fewer current smokers (55.9%) agreed with the statement ‘If contracted, current smokers are more likely than ex-smokers or non-smokers to risk disease progression’ compared with nonsmokers (75.5%) or ex-smokers (68.7%). There were no changes in cigarettes smoked per day (mean ± SD: 13.3 ± 9.55 vs 13.4 ± 9.69, p=0.414), percentage of daily smokers (70.8% vs 71.1%, p=0.882) and percentage of smokers with motivation to quit (intend to quit within the next 6 months, 9.4% vs 10.9%, p=0.148) before and after the outbreak of COVID-19. Conclusions The survey found that fewer current smokers agreed that smoking is a risk-factor for COVID-19 compared with non-smokers or ex-smokers. Among current smokers, there were no changes in their cigarette consumption and motivation to quit before and after the outbreak of COVID-19. More efforts are needed to educate smokers about the health risks of smoking, as well as efforts to promote their motivation to quit.

Background: Vaccine hesitancy and inconsistent mitigation behavior performance have been significant challenges throughout the COVID-19 pandemic. In Canada, despite relatively high vaccine availability and uptake, willingness to accept booster shots and maintain mitigation behaviors in the post-acute phase of COVID-19 remain uncertain. The aim of the Canadian COVID-19 Experiences Project (CCEP) is threefold: 1) to identify social-cognitive and neurocognitive predictors of mitigation behaviors, 2) to identify optimal communication strategies to promote vaccination and mitigation behaviors, and 3) to examine brain health outcomes of SARS-CoV-2 infection and examine their longevity. Methods: The CCEP is comprised of two components: a conventional population survey (Study 1) and a functionally interconnected laboratory study (Study 2). Study 1 will involve 6 waves of data collection. Wave 1, completed between 28 September and 21 October 2021, recruited 1,958 vaccine-hesitant (49.8%) and fully vaccinated (50.2%) adults using quota sampling to ensure maximum statistical power. Measures included a variety of social cognitive (e.g., beliefs, intentions) and neurocognitive (e.g., delay discounting) measures, followed by an opportunity to view and rate a set of professionally produced COVID-19 public service announcement (PSA) videos for perceived efficacy. Study 2 employs the same survey items and PSAs but coupled with lab-based eye tracking and functional near-infrared spectroscopy (fNIRS) to directly quantify neural indicators of attention capture and self-reflection in a smaller community sample. In the final phase of the project, subjective impressions and neural indicators of PSA efficacy will be compared and used to inform recommendations for construction of COVID-19 PSAs into the post-acute phase of the pandemic. Discussion: The CCEP provides a framework for evaluating effective COVID-19 communication strategies by levering conventional population surveys and the latest eye-tracking and brain imaging metrics. The CCEP will also yield important information about the brain health impacts of SARS-CoV-2 in the general population, in relation to current and future virus variants as they emerge.

Cigarette gifting is pervasive in China. As the Chinese are increasingly aware of harm from smoking cigarettes, e-cigarettes, often promoted as less harmful alternatives to cigarettes, may be viewed as appropriate gifts. This study is the first using population-based survey data to examine receiving and giving e-cigarettes as gifts in China. We analyzed 9,274 adults from Wave 5 of the International Tobacco Control China Survey, which was completed in July 2015. We found that the prevalence of receiving e-cigarettes as gifts was 1.3% among all respondents and 5.3% among urban smokers; the prevalence of giving e-cigarettes as gifts was 0.5% among all respondents and 1.2% among urban smokers. These prevalence estimates were very low among nonsmokers and rural respondents. Further analysis on urban smokers (N = 3,312) found that those aged 40–54 and 55+, those with high education levels, heavy smokers, and those who perceived e-cigarettes as equally/more harmful than cigarettes were more likely to receive e-cigarette gifts; and those who ever used e-cigarettes were significantly more likely to both receive and give e-cigarette gifts. Urban smokers with positive attitude about cigarette gifting were also more likely to give e-cigarette gifts to others, but those aged 55+ were less likely to gift e-cigarettes. Findings of this study indicate that the Chinese may perceive e-cigarettes as appropriate gifts for smokers, especially heavy smokers. Precautions should be taken to prevent e-cigarettes from becoming a gift choice for nonsmokers. Health campaigns designed to combat the social acceptance of cigarette gifting may also help reduce e-cigarette gifting.

Objective Before 2018, Japan did not have a national smoke-free law covering indoor public places, workplaces, or public transport as recommended by the WHO FCTC. A national smoking ban was passed in July 2018, to be implemented in stages leading up to the 2020 Olympics; however, the law is still not comprehensive. This study examines baseline levels of smoking in public places and support for smoke-free laws in Japan prior to the 2018 smoke-free law. The results will also be compared to findings from other ITC countries to demonstrate the need for stronger smoke-free legislation. Methods Data are from the International Tobacco Control (ITC) Japan Wave 1 Survey (Feb-Mar 2018), a web survey of adult cigarette smokers, HTP users, dual users, and non-users (total N=4,684). Measures included prevalence of smoking (whether respondents noticed people smoking inside restaurants, bars, and workplaces); smoking rules inside these venues; and support for complete smoking bans in these venues. Results The majority of indoor workplaces in 2018 (52%) had a complete smoking ban; however, restaurants and bars were more likely to have a partial ban or no rules. As a result, smoking prevalence in public places was extremely high overall – even higher than in China, the country with the greatest toll of SHS. Almost half of all workplaces (49%), over half of restaurants (55%) and the majority of bars (83%) had smoking in 2018, although non-users were less likely to be exposed to SHS. Support for complete smoking bans was also high overall (81% for workplaces, 78% for restaurants, and 65% for bars), and was higher among non-users. Conclusions These findings demonstrate the weak impact of partial smoke-free laws in Japan thus far and strong support for a comprehensive national law without exceptions to protect the public from the harms of tobacco smoke.

Tobacco companies are utilizing similar strategies to advertise and promote their products in developing countries as they have used successfully for over 50 years in developed countries. The present study describes how adult smokers, smokeless tobacco users, and non-users of tobacco from the Tobacco Control Project (TCP) India Pilot Survey, conducted in 2006, responded to questions regarding their perceptions and observations of pro-tobacco advertising and promotion and beliefs about tobacco use. Analyses found that 74% (n = 562) of respondents reported seeing some form of pro-tobacco advertising in the last six months, with no differences observed between smokers (74%), smokeless tobacco users (74%), and nonsmokers (73%). More than half of respondents reported seeing pro-tobacco advertising on store windows or inside shops. Overall, this study found that a significant percentage of tobacco users and non-users in India report seeing some form of pro-tobacco advertising and promotion messages. Additional analyses found that smokers were more likely to perceive tobacco use as harmful to their health compared with smokeless tobacco users and non-users (p < 0.01). The findings from this study reiterate the need for stronger legislation and strict enforcement of bans on direct and indirect advertising and promotion of tobacco products in India.

Background The harmful effects of smoking are well documented. Moreover, public knowledge and beliefs about the health risks of smoking and secondhand smoke exposure have increased substantially over the past several decades. Methods The aim of this study is to examine the association between the awareness of the health risks of smoking and secondhand smoke exposure with the desire to quit smoking. The Wave 1 (2016) ITC 6 European Country (6E) Survey within the framework of EUREST-PLUS Project covered both urban and rural areas of the country's 13 geographical regions. The survey sample consisted of 1,000 individuals smokers aged 18 and older in Greece, one of the six ITC 6E countries. Results The majority of Greek smokers agreed that smoking causes lung cancer (95.4%), heart diseases (94.4%), throat cancer (87.9%), bronchitis (87.7%) and mouth cancer (84.8%), however, 51.7% smokers disagreed that smoking could cause blindness, tuberculosis (37.8%), impotence (33.8%), stroke (24%) and heart attacks to non-smokers (27.3%). Chi-square and spearman correlation coefficient were fitted to investigate the association between the awareness of the effects of smoking and the desire to quit. The percentages of the awareness regarding blindness and stroke were less among smokers who reported moderate difficulty to completely quit (p

Background China's health warnings do not meet the FCTC Article 11 guidelines. They are small (< 35% of the pack) and do not include pictorial images, which research has shown to have greater impact. Four rounds of warnings have been implemented between 1992-2016. This study examines warning impact over 9 years (2006-15), including the third round (April 2012), which increased font size while maintaining overall warning size and replaced the English text with Chinese on the back. Methods Data are from Waves 1-5 (2006-15) of the International Tobacco Control (ITC) China Survey, a cohort survey of 800 adult smokers in each of five cities, adding five rural areas at Wave 5 (2013-15) (total N=8000). GEE logistic regression models tested changes in key indicators of warning impact over time. Results Over 9 years, there has been little change in impact of the Chinese warnings. Indeed, the percentage of smokers who noticed warnings 'often' actually DECREASED from 51% (2006) to 38% (2013-15) ( p < .001), and fewer than one-third of smokers reported cognitions or behaviours related to quitting because of the warnings. The April 2012 revision did not improve any of the warning impact indicators. Warning noticing/salience did not differ between cities and rural areas, but rural smokers were more likely to think 'a lot' about harms of smoking (17% vs 11%, p < .001) and about quitting (14% vs 6%, p < .001) because of the warnings. Conclusions China's text-only warnings continue to be extremely weak. The minor changes in 2012 did not increase warning impact. Global evidence is clear that large pictorial warnings depicting specific harms of cigarettes would greatly enhance warning impact in China, including increasing knowledge and motivation to quit among the 300M Chinese smokers. These benefits would be especially important for the large rural population, where there are fewer other sources of health information.

Background While smoke-free policies in most European countries are established for public places, private areas are mainly not regulated and may represent an important source of second-hand smoke exposure. We aimed to describe and characterise smoking rules in homes and cars of smokers from 6 European countries. Methods We used data from the first wave (2016) of the International Tobacco Control (ITC) 6 European Country Survey, part of the EUREST-PLUS Project, in representative national samples of adult (18+ years) smokers in Germany, Greece, Hungary, Poland, Romania and Spain (1000 in each country). We analysed questions about smoking rules in smokers' homes and cars with children and differentiated among: no rules, partial (allowed in some rooms or under special circumstances) and total ban (smoke-free homes and cars). We computed the prevalence (%) of homes and cars according to the rules, and used Poisson regression models to identify factors associated with total smoking ban. We incorporated weights from the complex sample design. Results In homes, more smokers opted for partial ban rather than for a total ban. The highest and lowest proportions of smoke-free homes were found in Hungary (35.5%) and Spain (13.1%), respectively, while partial ban prevalence ranged from 41.3% (Spain) to 49.9% (Greece). The proportion of smoke-free cars with children was overall higher compared to homes, ranging from 51.8% (Greece) to 67.7% (Germany). Having moderate or high level of education, presence of children, smoking less than 10 cigarettes per day and having previous attempts to quit smoking were positively associated with total smoking ban in homes and cars. Conclusions European smokers tend to opt for partial smoking ban at homes and for total ban in cars with children. Prevalence of smoke-free homes is relatively low and further legal and educational enforcement is needed to promote smoke-free environments. Funding: EC Horizon2020 HCO-6-2015 (EUREST-PLUS No. 681109).

Background Menthol and other flavorings are appealing to young people. They mask the adverse effects of cigarette smoke, such as throat irritation, and are marketed as less harmful to appeal to health-concerned smokers. In March 2012, Brazil banned all flavors in tobacco products, including menthol, but the ban has not been implemented due to industry legal challenges. This is the first study in Brazil to examine menthol use and beliefs about menthols (particularly harm perceptions). Such research can increase an understanding of menthol use to inform/support regulatory action in Brazil and other countries. Methods Data were from Wave 3 (2016-17) of the International Tobacco Control (ITC) Brazil Survey, a cohort survey of adult smokers and non-smokers in Rio de Janeiro, São Paulo, and Porto Alegre. This study analyzed responses from 1216 smokers on prevalence and predictors of menthol use, beliefs about harmfulness, and support for banning additives. Results In 2016-17, 7.8% of smokers with a regular cigarette brand reported that they smoked menthols (lowest of 10 ITC LMICs). 12.5% of smokers erroneously believed that menthol cigarettes are less harmful than regular cigarettes (lowest of 7 ITC middle-income countries); 33.4% believed menthols are smoother on the throat and chest (lowest of 4 LMICs). 59.6% of smokers support a complete ban on all additives including flavorings (3rd highest among 14 ITC countries). Conclusions These findings support Brazil's effort to ban all additives including menthol: menthol prevalence is comparatively low, erroneous beliefs that menthols are less harmful is low, and support for an additive ban is high. Brazilian media reporting of the risks of additives in the context of the tobacco industry injunction may have raised public awareness of the harms of additives and support for the ban. Also, the 2014 ban on advertising at points of sale may have reduced exposure to marketing of menthols.

Background Secondhand smoke (SHS) poses a major public health threat in China, causing over 100,000 deaths/year. China, however, has not yet implemented a national comprehensive smoke-free law, and the few subnational laws are only partial. This study presents trends in selected cities from 2007 to 2015 in: (1) exposure to SHS in key public places (workplaces, restaurants, bars), and (2) smokers' support for comprehensive smoke-free laws, comparing cities and rural areas in 2013-15. Methods Data are from Waves 2 to 5 of the International Tobacco Control (ITC) China Survey (2007-15), a face-to-face cohort survey of 800 smokers in each of five cities (Beijing, Guangzhou, Kunming, Shanghai, Shenyang), plus five rural areas at Wave 5 (2013-15) (total N=8000). GEE logistic regression models tested changes over time. Results At the latest wave (2013-15), the majority of respondents reported being exposed to SHS in public places. Smoking was most prevalent in bars, with little reduction over time across cities (from 93% overall in 2007 to 86% in 2013-15). Smoking in other venues decreased over time, but remained very high in 2013-15 (from 94% to 67% for restaurants; and 75% to 51% for workplaces). In rural areas, smoking prevalence was higher in workplaces (73% vs 56%, p < .001) and lower in bars (73% vs 88%, p < .05) compared to cities; there was no difference in restaurants. Support for complete smoking bans among smokers in cities increased over time for each venue and is higher than nearly all other 20+ ITC countries. Support did not differ between cities and rural locations. Conclusions Partial smoke-free laws in China are failing to protect both urban and rural residents from SHS, demonstrating the urgent need for a comprehensive national smoke-free law, as called for by the FCTC. Such a law would be supported by the majority of the Chinese public.

Background In India, it is important to understand the factors that promote intention to quit as quitting is rather uncommon. Data from International Tobacco Control Policy (TCP) Project conducted in four states (Maharashtra, Bihar, Madhya Pradesh and West Bengal) were used to investigate the factors associated with intention to quit tobacco. Methods Data from Wave 1 (Aug 2010-Dec 2011) comprising 8,051 tobacco users and Wave 2 (Aug 2012-Dec 2013) comprising 7,401 users were analysed. Respondents reporting planning to quit using tobacco in the next month, in the next six months, or sometime in the future, were categorized as having an intention to quit. Bivariate analysis and multivariable logistic regression was used to study the relationship between intention to quit and factors associated with intention to quit among tobacco users. All analyses were performed using SPSS V.20.0. Results Intention to quit decreased from 19.6% in Wave 1 to 13.5% in Wave 2. In both waves, education, advice from doctors to quit and exposure to warning messages on tobacco packages were associated with intention to quit tobacco. Exposure to anti-tobacco messages on public transportation vehicles (OR=2.13, CI=1.49-3.08), in restaurants (OR=1.63, CI=1.11-2.40), in bars (OR=1.81, CI=1.07-3.06) and at workplaces (OR=1.73, CI=1.23-2.44) were associated with intention to quit in Wave 1. However, these relationships were not significant in Wave 2. Conclusions Perceptions of individuals leading to intention to quit are rapidly changing over the years. Future tobacco control efforts could emphasize on making warnings more effective that depict the harm of tobacco, taking into consideration, education of individuals. Also, involving doctors to advise patients to quit might increase motivation to quit tobacco use.

Background India's Cigarette and Other Tobacco Products Act (COTPA) of 2003 prescribes a complete ban on all forms of tobacco advertisements, promotions and sponsorships (TAPS) of events by tobacco companies across India. We examined the level of variation and predictors of awareness of TAPS in four Indian states. Methods We used data from the International Tobacco Control Policy (TCP) Survey India from Wave1 (Aug 2010- Dec 2011) and Wave2 (Aug 2012-Dec 2013) consisting of 10,585 and 10,501 respondents, respectively, surveyed from Madhya Pradesh (MP), Bihar (BR), Maharashtra (MH) and West Bengal (WB). Bivariate analysis and multivariable logistic regression was used to investigate associations between sociodemographic factors, states and TAPS awareness. All analyses were performed using SPSS V. 20.0 Results Noticing tobacco advertisements was highest in MH (78.5%) and lowest in WB (50.1%) in Wave 1, while in Wave 2, it was highest in MP (83.5%) and lowest in WB (32.6%). Noticing tobacco promotions and sponsorships was highest in MP (promotions: 35.7%, sponsorships: 14.4%) in Wave 1, while in Wave 2, it was highest in WB (promotions:15.0%, sponsorships:10.8%). Across waves, education was a predictor of noticing tobacco advertisements, promotions and sponsorships. In Wave 1, but not Wave 2, noticing tobacco advertisements (OR:2.11) and promotions (OR:2.02) was highest among the youngest age group (15-17yrs) compared to corresponding oldest age group (55yrs+). Noticing advertisements and sponsorships remained consistent in urban areas across both waves. In Wave 1 tobacco promotions were observed twice as frequently among rural population as compared urban population but the association was reversed in Wave 2. Conclusions Awareness of tobacco marketing varied across the four states of India to observe a greater impact of the tobacco control legislation. This study suggests that even though policies are the same in all states, a coordinated effort is required to implement the law on TAPS ban consistently.