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Introduction To examine whether perceived injunctive and descriptive social norms towards cigarette and nicotine vaping product (NVP) use predicted subsequent trying NVPs and attempts to quit cigarette smoking amongst current smokers and whether associations varied across countries. Aims and Methods Three waves of longitudinal cohort data from the International Tobacco Control Four Country Smoking and Vaping Survey were collected between 2016 and 2020 from 2290 adult smokers in Canada, Australia, England, and the United States who had never used NVPs at baseline (either wave 1 or wave 2) and followed up at the subsequent wave (wave 2 or wave 3, respectively) were analyzed using Generalized Estimating Equations. Results Of the injunctive and descriptive norm measures for smoking and NVP use, NVP initiation was only independently predicted by the injunctive interpersonal norm for NVP use, with perceived approval of NVP use by important others predicting higher odds of trying NVPs (AOR = 1.65, 95% CI = 1.20 to 2.27). This predictive effect was independent of baseline quit intention with no country variations found. By contrast, making cigarette smoking quit attempts were independently predicted by both injunctive and descriptive interpersonal norms with perceived disapproval of smoking by important others (AOR = 1.65, 95% CI = 1.38 to 1.99) and close friends using NVPs (AOR = 1.37, 95% CI = 1.04 to 1.79), both associated with higher odds of smoking quit attempts. Conclusions Adult smokers who perceive NVP use as normative, either because such behavior is socially approved or common within their close social networks, appear more inclined to try NVPs or make smoking quit attempts than smokers who do not. Implications Social norms can shape a person’s behavior and result in behavior change. This study shows that initiation of NVP use behavior among smokers can be reliably predicted by their perception of whether NVP use is acceptable to those important to them within their close social networks. Similarly, any attempts to stop cigarette smoking can be predicted by their perception of how acceptable cigarette smoking is among those who are important to them and whether any of their close friends use NVPs. Changing social norms towards cigarette smoking and NVP use could therefore be incorporated into smoking cessation interventions to help smokers to quit and/or switch to NVP use.

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.

Introduction 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). Aims and 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 United States. 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. Conclusions 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 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.

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.

ObjectivesTo explore how cigarette packet branding and colours influence young male smokers’ perceptions of tobacco brands in Cambodia.DesignMixed-methods study.SettingWorksites, living accommodations, a university and public locations in Phnom Penh, Cambodia.Participants147 male Cambodian smokers (18–24 years).InterventionsParticipants were shown mock-up pictures of different cigarette packet branding and colour variations and asked to respond to close-ended and short-response questions.Outcome measuresBrand recognition, appeal and harm perceptions of cigarette packet branding and colours.ResultsWhen shown three packets with brand names removed, 98.6% of participants recognised packet one as Mevius brand, 21.1% recognised packet two as Marlboro and 38.8% recognised packet three as 555. For the three fully-branded and three matching plain packets, most participants selected a fully-branded packet as the most appealing taste (83.0%) and most appealing to youth (81.7%). Participants described their chosen brand as appealing due to beliefs about its superior taste/quality, reduced harm and symbolic attitudes surrounding tobacco brands and smokers of different brands in a social status hierarchy. When shown six different colours of unbranded packets, participants selected the blue packet (51.0%) as the most appealing for taste, the white packet as the least harmful (25.2%), and the red (15.0%) and black (12.9%) packets as the most harmful to health. They described their associations of packet colours with abstract imagery concerning smoking-related harms and their future well-being.ConclusionsFindings suggest that packet branding and colours influence young male smokers’ recognition, appeal and harm perceptions of tobacco brands in Cambodia and remain an influential marketing tool for tobacco companies where advertising is banned. Consequently, Cambodia and other low and middle-income countries in Southeast Asia should implement plain packaging.

To examine whether perceived injunctive and descriptive social norms towards cigarette and nicotine vaping product (NVP) use predicted subsequent trying NVPs and attempts to quit cigarette smoking amongst current smokers, and whether associations varied across countries.Three waves of longitudinal cohort data from the International Tobacco Control Four Country Smoking and Vaping Survey collected between 2016 and 2020 from 2,290 adult smokers in Canada, Australia, England, and the United States who had never used NVPs at baseline (either Wave 1 or Wave 2) and followed up at the subsequent wave (Wave 2 or Wave 3, respectively) were analysed using Generalised Estimating Equations.Of the injunctive and descriptive norm measures for smoking and NVP use, NVP initiation was only independently predicted by the injunctive interpersonal norm for NVP use, with perceived approval of NVP use by important others predicting higher odds of trying NVPs (AOR=1.65, 95% CI=1.20-2.27). This predictive effect was independent of baseline quit intention with no country variations found. By contrast, making cigarette smoking quit attempts was independently predicted by both injunctive and descriptive interpersonal norms with perceived disapproval of smoking by important others (AOR=1.65, 95% CI=1.38-1.99) and close friends using NVPs (AOR=1.37, 95% CI=1.04-1.79), both associated with higher odds of smoking quit attempts.Adult smokers who perceive NVP use as normative, either because such behaviour is socially approved or common within their close social networks, appear more inclined to try NVPs or make smoking quit attempts than smokers who do not.What this study adds: Social norms can shape a person's behaviour and result in behaviour change. This study shows that initiation of NVP use behaviour among smokers can be reliably predicted by their perception of whether NVP use is acceptable to those important to them within their close social networks. Similarly, any attempts to stop cigarette smoking can be predicted by their perception of how acceptable cigarette smoking is among those who are important to them and whether any of their close friends use NVPs. Changing social norms towards cigarette smoking and NVP use could therefore be incorporated into smoking cessation interventions to help smokers to quit and/or switch to NVP use.

To measure the prevalence and changes in smokers' discussions with health professionals (HPs) about nicotine vaping products (NVPs) and HPs' recommendations about NVPs between 2016 and 2020, and their associations with tobacco product use transitions.Cohort study using multinomial logistic regression analyses on data from waves 1 (2016), 2 (2018) and 3 (2020) from the International Tobacco Control Four Country Smoking and Vaping Surveys.Four countries with varying NVP regulatory environments: 'most restrictive' (Australia), 'somewhat restrictive' (Canada) and 'less restrictive' (England and the United States).Adult exclusive daily smokers who did not report NVP use at the time of their baseline survey and had visited a HP in the last 12-24 months. Prevalence data came from 4125, 4503 and 4277 respondents, respectively, for each year. Longitudinal data were from 4859 respondents who participated in at least two consecutive surveys.Prevalence of self-reported discussions with HPs and recommendations from HPs about NVPs. Longitudinal transitions from smoking to vaping (either exclusively or concurrently with smoking) and quitting (regardless of NVP uptake).The prevalence of NVP discussions was low among countries with varying regulatory environments and study waves (range = 1.4-6.2%). In 2020, a low percentage of smokers who discussed NVPs with a HP reported that their HPs recommended they use NVPs in the United States (14.7%), Australia (20.2%), Canada (25.7%), with a higher percentage in England (55.7%) where clinical guidelines for smoking cessation include NVPs. Compared with 12.0% of smokers who reported no discussion, 37.0% of those whose HPs recommended NVPs transitioned to vaping at follow-up. Transition to quitting was 9.6% with HPs' recommendation of NVPs versus 13.5% without discussion, a non-significant difference.In Australia, Canada, England and the United States between 2016 and 2020, health professionals' discussions with smokers about nicotine vaping products (NVPs) were infrequent. NVP discussions were associated with NVP uptake, but not with quitting smoking.

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 provided 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-month 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.

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.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.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.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.

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.