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BackgroundThe e-cigarette market has rapidly evolved, with a shift towards higher nicotine concentration and salt-based products, such asJUUL; however, the implications for youth vaping remain unclear.MethodsRepeat cross-sectional online surveys were conducted in 2017, 2018 and 2019, with national samples of youth aged 16–19 years recruited from commercial panels in Canada (n=12 018), England (n=11 362) and the USA (n=12 110). Regression models examined differences between countries and over time in the types of e-cigarette products used (design and nicotine content), reasons for using brands and differences in patterns of use, sociodemographics and dependence symptoms by brand/nicotine content.ResultsIn 2019, the use of pod- or cartridge-style e-cigarettes was greater in Canada and the USA than England, withSmokandJUULthe leading brands in all countries. In 2019, youth vapers in England were less likely to report using e-cigarettes with ≥2% nicotine (12.8%) compared with Canada (40.5%; adjusted OR (AOR)=4.96; 95% CI 3.51 to 7.01) and the USA (37.0%; AOR=3.99, 95% CI 2.79 to 5.71) and less likely to report using nicotine salt-based products (12.3%) compared with Canada (27.1%; AOR=2.77, 95% CI 1.93 to 3.99) and the USA (21.9%; AOR=2.00, 95% CI 1.36 to 2.95). In 2019, self-reported use of products with higher nicotine concentration was associated with significantly greater frequency of vaping, urges to vape and perceived vaping addiction (pConclusionsThe use of high-nicotine salt-based products is associated with greater symptoms of dependence, includingJUULand other higher-nicotine brands. Greater use of high-nicotine salt-based products may account for recent increases in the frequency of vaping among youth in Canada and the USA.

Purpose The tobacco and nicotine market is diversifying. Implications for public health will depend on trends in use, including overall use, and who is using these products. This study examined differences over time (2017–2019), across countries (Canada, England, the United States (US)), and by smoking and vaping, in use of other tobacco/nicotine products and overall use. Methods The study includes online repeat cross-sectional surveys of youth aged 16–19 years in Canada (N = 11,714), England (N = 11,170), US (N = 11,838) in 2017, 2018, and 2019. Past 30-day use of tobacco/nicotine products (any, cigarette, e-cigarette, other combusted [cigars/cigarillos/waterpipe], other non-combusted [smokeless tobacco/nicotine replacement therapies) were examined by country, year, and, for other combusted and non-combusted products, past 30-day cigarette smoking and vaping. Use of emerging products (IQOS, nicotine pouches) was explored in 2018–2019. Results From 2017 to 2019, use of any product increased in Canada (17.1%–23.2%, AOR = 1.07 [95% CI = 1.04–1.09]) and the US (18.0%–24.0%, AOR = 1.06 [1.04–1.09]) but not England (20.8%–21.7%, AOR = 1.01 [.99–1.03]). Use of other combusted products (cigars/cigarillos/waterpipe) showed little change (Canada: 8.1%–7.8%; England: 6.3%–7.3%; US: 8.6%–8.5%; p ≥ .151). Use of other non-combusted products (smokeless/nicotine replacement therapies) increased in all countries (Canada: 1.5%–3.2%, AOR = 1.02 [1.01–1.02]; England: 1.4%–2.6%, AOR = 1.02 [1.01–1.03]; US: 3.3%–4.9%, AOR = 1.02 [1.01–1.02]). Vaping increased in all countries (Canada: 8.4%–17.8%; England: 8.7%–12.6%; United States: 11.1%–18.5%; all p Conclusions Youth past 30-day tobacco and nicotine product use increased from 2017 to 2019 in Canada and the United States, largely due to increases in vaping and other non-combusted products. “Other” tobacco/nicotine products were used predominantly by youth who smoked cigarettes and/or vaped.

ObjectiveThe current study examined indicators of dependence among youth cigarette smokers and e-cigarette users in Canada, England and the USA, including changes between 2017 and 2019.MethodsData are from repeated cross-sectional online surveys conducted in 2017, 2018 and 2019 with national samples of youth aged 16–19 years, in Canada (n=12 018), England (n=11 362) and the USA (n=12 110). Measures included perceived addiction to cigarettes/e-cigarettes, frequency of experiencing strong urges to smoke/use an e-cigarette, plans to quit smoking/using e-cigarettes and past attempts to quit. Logistic regression models were fitted to examine differences between countries and changes over time.ResultsThe proportion of ever-users who vaped frequently was significantly higher in 2019 compared with 2017 for all outcomes in each country. Between 2017 and 2019, the proportion of past 30-day vapers reporting strong urges to vape on most days or more often increased in each country (Canada: 35.3%, adjusted OR (AOR) 1.69, 95% CI 1.20 to 2.38; England: 32.8%, AOR 1.55, 1.08 to 2.23; USA: 46.1%, AOR 1.88, 1.41 to 2.50), along with perceptions of being ‘a little’ or ‘very addicted’ to e-cigarettes (Canada: 48.3%, AOR 1.99, 1.44 to 2.75; England: 40.1%, AOR 1.44, 1.03 to 2.01; USA: 53.1%, AOR 1.99, 1.50 to 2.63). Indicators of dependence among smokers were consistently greater than e-cigarette users, although differences had narrowed by 2019, particularly in Canada and the USA.ConclusionsPrevalence of dependence symptoms among young e-cigarette users increased between 2017 and 2019, more so in Canada and the USA compared with England. Dependence symptom prevalence was lower for e-cigarettes than smoking; however, the gap has narrowed over time.

BACKGROUND: Increased electronic cigarette (e-cigarette) use among young people is often attributed to industry marketing practices; however, the effectiveness of regulations that limit e-cigarette advertising and promotions has yet to be examined. New federal legislation that liberalized the Canadian e-cigarette market in May 2018, along with differences in provincial regulations, provides an opportunity to examine the impact of regulatory restrictions on e-cigarette marketing. METHODS: Repeat cross-sectional surveys of 12 004 16- to 19-year-olds in Canada, completed online in 2017, 2018, and 2019. Logistic regression models were used to examine differences over time in exposure to e-cigarette marketing and e-cigarette use, including between provinces with differing strengths of marketing restrictions. RESULTS: The percentage of youth surveyed who reported noticing e-cigarette promotions often or very often approximately doubled between 2017 and 2019 (13.6% vs 26.0%; adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.97–2.56). Overall exposure to marketing was generally more prevalent in provinces with fewer regulatory restrictions. Respondents who reported noticing marketing often or very often were more likely to report vaping in the past 30 days (AOR = 1.41, 95% CI = 1.23–1.62), past week (AOR = 1.44, 95% CI = 1.22–1.70), and ≥20 days in the past month (AOR = 1.42, 95% CI = 1.11–1.81, P = .005). Provinces with low restrictions on marketing had higher prevalence of vaping in the past 30 days (AOR = 1.50, 95% CI = 1.25–1.80, P < .001), and in the past week (AOR = 1.65, 95% CI = 1.33–2.05, P < .001). CONCLUSIONS: Exposure to marketing and the prevalence of vaping increased among Canadian youth after the liberalization of the e-cigarette market in 2018. Comprehensive provincial restrictions on e-cigarette marketing were associated with lower levels of exposure to marketing and lower prevalence of e-cigarette use.

Objective To examine the sources of vaping products reported by adolescents, and the characteristics of adolescents who reported purchasing a vaping product in the past year in the United States (US), Canada (CA), and England (EN). Methods Data were from the 2017 ITC Youth Tobacco and Vaping Survey, a web-based survey of 12,128 respondents aged 16–19 years recruited from commercial panels in the US, CA, and EN. Respondents who have vaped in the past 12 months were asked whether they had purchased a vaping product, and from where (vape shop, online, retail), as well as whether anyone refused to sell them a vaping product because of their age. Respondents who reported vaping in the past 30 days were asked where they had obtained their vaping product from a social and/or commercial source. Results Only about 7.5% of respondents reported having purchased a vaping product in the past year. Among those who had vaped in the past year, 32.6% reported having purchased a vaping product in the past year. Purchasing prevalence was significantly higher among US respondents compared to those from CA and EN; purchase prevalence was also higher among Canadian adolescents than respondents from England. The most commonly reported purchase location for vaping products in all counties was vape shops. Among past 30-day vapers, 42.5% reported getting their vaping products only from social sources, 41.4% only from commercial sources, and 13.4% from both types of sources. Purchasing a vaping product in the past year was associated with being male, of legal age to buy tobacco and vaping products, and greater frequency of smoking and vaping in the past 30 days. Conclusions Most adolescents have not purchased a vaping product, but among those who had, vape shops were the mostly commonly reported location for buying a vaping product. Purchasing of a vape product was more commonly reported by those who vape more frequently and by those of legal age to buy a vaping product.

Background The contribution of beverages to overall diet is of increasing interest to researchers and policymakers, particularly in terms of consumption of drinks high in added sugars; however, few tools to assess beverage intake have been developed and evaluated. This study aimed to evaluate the relative validity of a new online Beverage Frequency Questionnaire (BFQ) among young adults in Canada. Methods A cross-sectional relative validation study was conducted among young adults aged 16–30 years (n = 50). Participants completed a 17-item BFQ, a 7-day food record (7dFR), and a single-item measure of sugary drink intake. Pearson correlations and paired t-tests were used to evaluate correlation and agreement between the measures for 17 individual beverage categories, total drink consumption, total alcoholic beverage consumption, and two definitions of drinks with excess sugars. Cognitive interviews were conducted to examine participant interpretation and comprehensiveness of the BFQ. Results Estimates of beverage intake based on the BFQ and the 7dFR were highly correlated, specifically for the total number and volume of beverages consumed, total alcoholic beverage consumption, sugary drink intake, and each of the 17 beverage categories with 3 exceptions: coffee or tea with sugar or cream, specialty coffees, and hard alcohol with caloric mix. Paired t-tests between the BFQ and the 7dFR indicated that the average reported volume was significantly different only for sweetened fruit drinks. The single-item measure of sugary beverage intake was not significantly correlated with the 7dFR. Cognitive interviewing demonstrated high comprehension levels, and confirmed the appropriateness of the BFQ beverage categories and sizes. Conclusions Overall, the results suggest that the BFQ performed well relative to a 7dFR and had high usability among this study population, indicating its promise for collecting population-level data on beverage intake, including sugar-sweetened beverages, which are known indicators of diet and health. Electronic supplementary material The online version of this article (10.1186/s12937-018-0380-8) contains supplementary material, which is available to authorized users.

The economic valuation of ecosystem services in part reflects the desire to use conventional economic tools (markets and economic instruments) to conserve ecosystem services. However, for regulating and supporting ecosystem services that depend on ecosystem structure and function, estimation of economic value requires estimates of the current level of underlying ecological functions first. This primary step is in principle, the job of environmental scientists, not economists. Here, we provide a coarse-level quantitative assessment of the relationship between the research effort expended by environmental scientists (on the biophysical values) and economists (on the monetary values) on 15 different regulating and supporting services in 32 ecosystem types using peer-reviewed article hits retrieved from bibliographic databases as a measure of research effort. We find a positive, moderately strong (r = 0.69) correlation between research efforts in the two domains, a result that, while encouraging, is likely to reflect serendipity rather than the deliberate design of integrated environmental science-economics research programs. Our results suggest that compared to environmental science research effort economic valuation is devoted to a smaller, less diverse set of ecosystem services but a broader, more diverse, set of ecosystem types. The two domains differed more with respect to the ecosystem services that are the major focus of research effort than they did with respect to the ecosystem types of principal research interest. For example, carbon sequestration, erosion regulation, and nutrient cycling receive more relative research effort in the environmental sciences; air quality regulation in economic valuations. For both domains, cultivated areas, wetlands, and urban/semi-urban ecosystem types received relatively large research effort, while arctic and mountain tundra, cave and subterranean, cryosphere, intertidal/littoral zone, and kelp forest ecosystem types received negligible research effort. We suggest ways and means by which the field of sustainability science may be improved by the design and implementation of a searchable database of environmental science and economic valuation literature as well as a global ecosystem service research network and repository that explicitly links research on the estimation and prediction of biophysical ecosystem functions with that of the social sciences and other knowledge systems. These suggestions would, at least in principle, facilitate a more efficient research agenda between economists and environmental scientists and aid management, regulatory and judicial decision-makers.

The growing market for caffeinated energy drinks (CEDs) has caused concern about excessive caffeine intake and potential adverse effects, particularly among young people. The current study examined patterns of CED consumption among youth and young adults in Canada, using data from a national online survey conducted in October 2014. Data from a non-probability sample of 2040 respondents aged 12–24 from a consumer panel was weighted to national proportions; measures of CED consumption were estimated, including prevalence, excessive daily consumption, and context for use (locations and reasons). Separate logistic regression models for two outcomes, past-week consumption and “ever” exceeding two energy drinks in a day (as per common guidance), were conducted to examine associations with demographic variables (sex, age, geographic region, race/ethnicity, and language). Overall, 73.6% of respondents reported “ever” consuming energy drinks; 15.6% had done so in the past week. Any consumption of energy drinks in the past week was more prevalent among males, Aboriginal respondents (vs. white only or mixed/other), and residents of British Columbia. Among “ever-consumers,” 16.0% reported ever consuming more than two energy drinks in a day. Exceeding two in a day was more prevalent among older respondents (young adults aged 18–24), aboriginal respondents (vs. white only), and British Columbia residents. While the majority of youth and young adults had consumed energy drinks, about half were “experimental” consumers (i.e., consumed ≤ 5 drinks in their lifetime). Approximately one in six consumers had exceeded the usual guidance for maximum daily consumption, potentially increasing their risk of experiencing adverse effects., Highlights • Most (73.6%) Canadian youth and young adults (age 12–24) surveyed had consumed CEDs. • Half of ever-consumers (and most youth) had consumed ≤ 5 CEDs in their lifetime. • Past-week CED prevalence was 15.6%, highest among males, Aboriginals, BC residents. • 16.0% of ever-consumers reported exceeding two CEDs in a day (guidance for maximum). • Excess consumption was more prevalent among age 18–24, Aboriginals, BC residents.

Objective To examine differences in vaping and smoking prevalence among adolescents in Canada, England, and the United States. Design Repeat cross sectional surveys. Setting Online surveys in Canada, England, and the US. Participants National samples of 16 to 19 year olds in 2017 and 2018, recruited from commercial panels in Canada (n=7891), England (n=7897), and the US (n=8140). Main outcome measures Prevalence of vaping and smoking was assessed for use ever, in the past 30 days, in the past week, and on 15 days or more in the past month. Use of JUUL (a nicotine salt based electronic cigarette with high nicotine concentration) and usual vaping brands were also assessed. Logistic regression models examined differences in vaping and smoking between countries and over time. Results The prevalence of vaping in the past 30 days, in the past week, and on 15 days or more in the past month increased in Canada and the US between 2017 and 2018 (P Conclusions Between 2017 and 2018, among 16 to 19 year olds the prevalence of vaping increased in Canada and the US, as did smoking in Canada, with little change in England. The rapidly evolving vaping market and emergence of nicotine salt based products warrant close monitoring.

The current study examined prevalence and correlates of electronic cigarette (e-cigarette) use in the Canadian population, using data from the nationally representative 2013 Canadian Tobacco, Alcohol and Drugs Survey (n=14,565). Sociodemographic correlates of e-cigarette use (ever, and in the past 30 days) were examined using logistic regression models. Overall, 8.5% of Canadians aged 15 and older reported having ever tried an e-cigarette; 1.8% had used one in the past 30 days. E-cigarette use was particularly high among smokers and young people. Overall, prevalence did not differ between males and females, for ever (P=0.24) or past 30-day use (P=0.30). Smoking status was the strongest correlate of e-cigarette use (ever and in the past 30 days, P

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

The current study assessed youth and young adults' perceptions and attitudes toward caffeine and energy drinks (EDs). An online survey was conducted with 2036 panelists aged 12-24, about caffeine and ED knowledge, caffeine perceptions, and perceptions of ED safety. Few respondents (2.1%) could state Health Canada's recommended limit for caffeine intake, although most participants (64.9%) correctly stated the maximum number of EDs that should be consumed per day. When shown four beverages, only 17.5% correctly identified the beverage with the most caffeine. Overall, young people generally have low levels of knowledge about caffeine amounts and intake from caffeinated beverages.Cette étude visait à évaluer les perceptions et les attitudes des adolescents et des jeunes adultes à l’égard de la caféine et des boissons énergisantes. Un sondage en ligne a été mené auprès de 2 036 participants de 12 à 24 ans afin de savoir quelles étaient leurs connaissances sur la caféine et les boissons énergisantes ainsi que leurs perceptions concernant la caféine et l’innocuité des boissons énergisantes. Peu de répondants (2,1 %) ont été en mesure de préciser l’apport maximal en caféine recommandé par Santé Canada, bien que la plupart (64,9 %) aient indiqué sans se tromper le nombre maximal de boissons énergisantes pouvant être consommé quotidiennement. Seulement 17,5 % des répondants ont su repérer, parmi quatre boissons présentées, celle qui contenait le plus de caféine. Dans l’ensemble, les jeunes ont généralement une faible connaissance des quantités de caféine contenues dans les boissons et de l’apport en caféine provenant des boissons caféinées.

BACKGROUND: Caffeine is a widely consumed stimulant, and caffeine-containing products are increasingly available on the market. Few tools are available to capture caffeine intake, particularly among young adults. To estimate caffeine consumption in the previous 24 hours, the 24-Hour Caffeine Intake Recall (CIR-24) was modeled after the Automated Self-Administered 24-Hour Dietary Assessment Tool, using a brand-specific database of caffeine-containing foods, beverages, and supplements. OBJECTIVE: To evaluate the accuracy of the CIR-24 compared with caffeine concentration biomarkers in urine and a caffeinated beverage intake frequency screener (CBQ) designed to assess usual intake among a young adult population in Canada. DESIGN/PARTICIPANTS: In all, 79 young adults, aged 18 to 29 years, provided 24-hour urine samples and completed the CIR-24 and CBQ. MAIN OUTCOME MEASURES: Excretion for caffeine and eight caffeine metabolites were quantified from urine samples using high-performance liquid chromatography-polarity switching electrospray ionization-tandem quadrupole mass spectrometry with stable isotope-labeled internal standards. STATISTICAL ANALYSES PERFORMED: Pearson correlations and weighted κ coefficients were calculated for the self-report tools and caffeine biomarkers. RESULTS: The CIR-24 was significantly positively associated with all caffeine biomarkers (r(p)=0.28 to 0.52, κ=0.39 to 0.59), and the CBQ was significantly positively associated with all but one biomarker (r(p)=0.21 to 0.40, κ=0.32 to 0.45). The CIR-24 yielded a higher mean intake of caffeine than the CBQ. There was strong linear correlation between the CIR-24 and CBQ (r(p)=0.60, P

INTRODUCTION: Studies examining cigarette package pictorial health warning label (HWL) content have primarily used designs that do not allow determination of effectiveness after repeated, naturalistic exposure. This research aimed to determine the predictive and external validity of a pre-market evaluation study of pictorial HWLs. METHODS: Data were analyzed from: (1) a pre-market convenience sample of 544 adult smokers who participated in field experiments in Mexico City before pictorial HWL implementation (September 2010); and (2) a post-market population-based representative sample of 1765 adult smokers in the Mexican administration of the International Tobacco Control Policy Evaluation Survey after pictorial HWL implementation. Participants in both samples rated six HWLs that appeared on cigarette packs, and also ranked HWLs with four different themes. Mixed effects models were estimated for each sample to assess ratings of relative effectiveness for the six HWLs, and to assess which HWL themes were ranked as the most effective. RESULTS: Pre- and post-market data showed similar relative ratings across the six HWLs, with the least and most effective HWLs consistently differentiated from other HWLs. Models predicting rankings of HWL themes in post-market sample indicated: (1) pictorial HWLs were ranked as more effective than text-only HWLs; (2) HWLs with both graphic and "lived experience" content outperformed symbolic content; and, (3) testimonial content significantly outperformed didactic content. Pre-market data showed a similar pattern of results, but with fewer statistically significant findings. CONCLUSIONS: The study suggests well-designed pre-market studies can have predictive and external validity, helping regulators select HWL content.

Introduction In 2000, Quebec began reimbursing stop-smoking medications (SSMs) through their provincial public drug insurance plan. Several other Canadian provinces have since begun offering SSM subsidies. Clinical trials indicate that SSMs can increase quit success; however, little evidence exists on patterns of use in “real-world” settings and impact on population quit rates. This study examines Canadian trends in SSM use and quit success over time, comparing provinces with differing subsidization policies. Methods Secondary analyses were conducted in 2014 using nationally representative Canadian Tobacco Use Monitoring Survey data, 2004–2012, for current and former smokers who made a quit attempt in the past 2 years (N=26,094). Regression models tested for differences in SSM use and quit success in provinces with differing SSM coverage (i.e., none, partial, or comprehensive). Results Smokers were more likely to use nicotine replacement therapy (NRT) in jurisdictions with comprehensive SSM coverage versus jurisdictions with partial (OR=1.39, 95% CI=1.22, 1.59) or no coverage (OR=1.43, 95% CI=1.21, 1.68). Prescription medication use was more likely in provinces with partial (versus no) coverage (OR=1.27, 95% CI=1.01, 1.59). Overall, smokers who attempted to quit were more likely to remain abstinent in jurisdictions with comprehensive versus partial (OR=1.20, 95% CI=1.12, 1.28) or no coverage (OR=1.23, 95% CI=1.00, 1.50). An interaction between coverage and cigarettes per day was observed, suggesting potentially greater impact of comprehensive coverage among heavier smokers. Conclusions Comprehensive subsidization policies are associated with modest increases in NRT use and quit success, but do not appear to impact prescription SSM use.

OBJECTIVES: Caffeinated energy drinks have become increasingly popular among young people, raising concern about possible adverse effects, including increased alcohol consumption and related risk behaviours. The current study examined consumption of caffeinated energy drinks and use of energy drinks with alcohol, as well as associations with socio-demographic and behavioural characteristics, among a sample of secondary school students in Ontario. METHODS: Survey data from 23,610 grade 9–12 students at 43 purposefully sampled Ontario secondary schools participating in the baseline wave (2012/13) of the COMPASS study were analyzed using generalized linear mixed-effects models. Outcomes were any energy drink use, frequency of use, and use of alcohol mixed with energy drinks; covariates were age, sex, race, spending money, bodymass index (BMI), weight-related efforts and alcohol use. Two-way interactions between sex and other covariates were tested. RESULTS: Nearly one in five students (18.2%) reported consuming energy drinks in a usual week. Use of energy drinks was associated (p < 0.01) with all socio-demographic variables examined and was more common among students who were male, off-reserve Aboriginal, had some spending money, had a BMI outside of “healthy” range, were trying to lose weight, and/or reported a higher intensity of alcohol use. Interactions with sex were observed for age, spending money and weight-related efforts. Use of energy drinks mixed with alcohol in the previous 12 months was reported by 17.3% of the sample, and was associated with race, spending money, and more frequent binge drinking. CONCLUSION: Regular use of energy drinks was common among this sample of students and strongly linked to alcohol consumption.

OBJECTIVES: Many countries, including Canada, are considering nutrition policies that seek to improve dietary behaviour and related health outcomes. The current study examined support for policy measures among youth and young adults in Canada. METHODS: Participants aged 16–30 years were recruited for online surveys using in-person intercept sampling in five Canadian cities as part of the Canada Food Study conducted in October–December, 2016 (n = 2729). Items included support for 21 specific policies in seven key areas: menu labelling, food package symbols and warnings, school policies, taxation and subsidies, zoning restrictions, marketing bans, and food formulation. Linear regression models examined support by age, sex, city, race/ethnicity, parental status, body mass index (BMI), and health literacy. RESULTS: Very high levels of support were observed for menu labelling in restaurants and schools, as well as food package symbols and warnings. Taxation, zoning restrictions (e.g., fast food and convenience stores near schools), and bans on marketing to children received relatively lower levels of support. In general, policy support increased with age for all 21 policies (p

BACKGROUND: The influence of e-cigarette use on smoking initiation is a highly controversial issue, with limited longitudinal data available for examining temporal associations. We examined e-cigarette use and its association with cigarette-smoking initiation at 1-year follow-up within a large cohort of Canadian secondary school students. METHODS: We analyzed data from students in grades 9–12 who participated in 2 waves of COMPASS, a cohort study of purposefully sampled secondary schools in Ontario and Alberta, Canada, at baseline (2013/14) and 1-year follow-up (2014/15). We assessed cigarette smoking and e-cigarette use at baseline and follow-up using self-completed surveys. We used generalized linear mixed-effects models to examine correlates of past 30-day e-cigarette use at baseline and smoking initiation between waves within the longitudinal sample. RESULTS: Past 30-day e-cigarette use increased from 2013/14 to 2014/15 (7.2% v. 9.7%, p INTERPRETATION: E-cigarette use was strongly associated with cigarette smoking behaviour, including smoking initiation at follow-up. The causal nature of this association remains unclear, because common factors underlying the use of both e-cigarettes and conventional cigarettes may also account for the temporal order of initiation.

Cigarette package health warnings can be an important and low-cost means of communicating the health risks of smoking. We examined whether viewing health warnings in an experimental study influenced beliefs about the health effects of smoking, by conducting surveys with ~500 adult male smokers and ~500 male and female youth (age 16–18) in Beijing, China (n = 1070), Mumbai area, India (n = 1012), Dhaka, Bangladesh (n = 1018), and Republic of Korea (n = 1362). Each respondent was randomly assigned to view and rate pictorial health warnings for 2 of 15 different health effects, after which they reported beliefs about whether smoking caused 12 health effects. Respondents who viewed relevant health warnings (vs. other warnings) were significantly more likely to believe that smoking caused that particular health effect, for several health effects in each sample. Approximately three-quarters of respondents in China (Beijing), Bangladesh (Dhaka), and Korea (which had general, text-only warnings) thought that cigarette packages should display more health information, compared to approximately half of respondents in the Mumbai area, India (which had detailed pictorial warnings). Pictorial health warnings that convey the risk of specific health effects from smoking can increase beliefs and knowledge about the health consequences of smoking, particularly for health effects that are lesser-known.

In Canada, energy drinks and energy shots are currently classified and regulated differently (food and drugs versus natural health products, respectively), on the assumption that they are used and perceived differently. The current study examined potential differences in use and perceptions of energy drinks and shots.An online survey was conducted in 2015 using a national commercial online panel of youth and young adults aged 12-24 years (n=2,040 retained for analysis in 2016). Participants were randomized to view an image of an energy shot or drink, and were asked about 14 potential reasons for using the product. Past consumption of each product was also assessed. Chi-square and t-tests were conducted to examine differences in use and perceptions between products.Overall, 15.6% of respondents reported using both energy shots and drinks. Of all respondents,1% had tried only energy shots, whereas 58.0% had tried only energy drinks. For each product, the most commonly reported reasons for use were "to stay awake" and "to increase concentration or alertness." Out of 14 potential reasons for use, respondents were significantly more likely to endorse seven of the reasons for energy drinks rather than shots; however, the magnitude of these differences was modest and the ordering of the reasons for use of each product was comparable.Despite differences in prevalence of ever-use of energy shots and drinks, consumption patterns and perceived reasons for using the products are similar. The findings provide little support for regulating energy shots differently than energy drinks.

Background: Globally, smokeless tobacco use is disproportionately concentrated in low-income and middle-income countries like India and Bangladesh. Objectives: The current study examined comparative patterns of use and perceptions of harm for different smokeless tobacco products among adults and youth in Navi Mumbai, India, and Dhaka, Bangladesh. Methods: Face-to-face interviews were conducted on tablets with adult (19 years and older) smokeless tobacco users and youth (16–18 years) users and non-users in Navi Mumbai (n = 1002), and Dhaka (n = 1081). Results: A majority (88.9%) of smokeless tobacco users reported daily use. Approximately one-fifth (20.4%) of the sample were mixed-users (used both smoked and smokeless tobacco), of which about half (54.4%) reported that they primarily used smokeless over smoked forms like cigarettes or bidis. The proportion of users planning to quit was higher in India than in Bangladesh (75.7% vs. 49.8%, p < 0.001). Gutkha was the most commonly used smokeless product in India, and pan masala in Bangladesh. Among users in Bangladesh, the most commonly reported reason for using their usual product was the belief that it was “less harmful” than other types. Perceptions of harm also differed with respect to a respondent's usual product. Bangladeshi respondents reported more negative attitudes toward smokeless tobacco compared to Indian respondents. Conclusions: The findings highlight the high daily use of smokeless tobacco, and the high prevalence of false beliefs about its harms. This set of findings reinforces the need to implement effective tobacco control strategies in low and middle-income countries like India and Bangladesh.

Countries have adopted various regulations to limit youth exposure to vaping product advertising. This study aims to examine youth exposure to and perceptions of vaping ads in Canada, England, and the US, three countries with varying vaping product advertising regulations. Data were analyzed from the 2017 ITC Youth Tobacco and Vaping Survey, an online survey of youth aged 16 to 19 years from a consumer panel (n = 12,064). The survey assessed vaping product ad exposure in the prior month, including channels, perceived appeal, and perceived target audience. Most young people reported some vaping product ad exposure in the past 30 days (Canada = 74%, England = 83%, US = 81%). Among those exposed to vaping product ads, more than one-third found them appealing (Canada = 36%, England = 38%, US = 43%). Stores that sell cigarettes were the most common venue for vaping ad exposure, although it was less common in Canada (46%) than in England (60%) or the US (60%), both of which had less restrictive regulatory environments. Ad exposure through websites or social media did not differ by country (Canada = 38%, England = 40%, US = 41%). Compared to those who never smoked or used vaping products, youth who reported smoking and/or vaping were more likely to report ad exposure through most channels. More than one-third of youth perceived that vaping product ads target non-smokers (Canada = 47%, England = 36%, US = 48%). Our study suggests most youth are exposed to vaping product ads, which may promote product use. Except for online channels, cross-country differences in the channels of ad exposure may reflect contrasting regulatory environments.

In 2012, Health Canada transitioned caffeinated energy drinks from Natural Health Product to Food and Drug classification and regulations, implementing temporary guidelines with requirements such as caffeine content limits, mandatory cautionary labelling, and restrictions on health claims. “Energy shots” often contain as much or more caffeine compared to energy drinks and have been associated with a similar number of adverse health events. However, current requirements for energy drinks do not apply to energy shots, which remain classified as “natural health products” on the basis that they are “not consumed or perceived as foods” in the same way as energy drinks. An online survey was conducted with Canadian youth and young adults aged 12–24 years ( N = 2040) in October 2014 to examine perceptions of energy shots. Respondents viewed an image of a popular energy shot and were asked which term best described it, with six randomly-ordered options. The vast majority (78.8%) perceived the energy shot as an “energy drink” (vs. “supplement”, “vitamin drink”, “natural health product”, “soft drink” or “food product”). Given consumer perceptions and the similarity in product constituents, there is little basis for regulating energy shots differently from energy drinks; these products should be subject to similar labelling and health warning requirements.

Introduction: In 2010, the U.S. Food and Drug Administration (FDA) developed 36 proposed health warnings for cigarette packages, from which 9 were subsequently selected for imple- mentation. The current study aimed to evaluate the perceived effi cacy of the 36 proposed FDA warnings. Methods: Web-based surveys were conducted with 783 adult smokers and 510 youth in United States. Participants were randomized to view and rate two sets of 6 - 7 warnings, each set corresponding to one of nine health effect statements required under the Tobacco Control Act. Warnings included all 36 FDA- proposed warnings and additional warnings for comparison. Results: Youth and adults rated individual warnings similarly; in all cases where differences were found, youth perceived warnings as more effective. Comparisons on specifi c elements indicated that warnings were perceived as more effective if they were: full color (vs. black and white), featured real people (vs. comic book style), contained graphic images (vs. nongraphic), and included a telephone " quitline " number or personal infor- mation. Few sociodemographic differences were observed in overall perceived effectiveness: younger respondents, non- White respondents, and smokers intending to quit rated warnings higher. Conclusions: Seven of the nine health warnings selected by the FDA for implementation were among the proposed warnings rated as most effective in the current study. However, the warning(s) added for comparison were rated higher than the FDA-selected warning for fi ve of the nine sets, suggesting some warnings could be improved for greater impact. The fi ndings support the inclusion of a telephone " quitline " number and reinforce the importance of depicting " real " people and health effects.

Pictorial health warnings on cigarette packages are a prominent and effective means of communicating the risks of smoking; however, there is little research on effective types of message content and socio-demographic effects. This study tested message themes and content of pictorial warnings in Mexico.Face-to-face surveys were conducted with 544 adult smokers and 528 youth in Mexico City. Participants were randomized to view 5-7 warnings for two of 15 different health effects. Warnings for each health effect included a text-only warning and pictorial warnings with various themes: "graphic" health effects, "lived experience", symbolic images, and testimonials.Pictorial health warnings were rated as more effective than text-only warnings. Pictorial warnings featuring "graphic" depictions of disease were significantly more effective than symbolic images or experiences of human suffering. Adding testimonial information to warnings increased perceived effectiveness. Adults who were female, older, had lower education, and intended to quit smoking rated warnings as more effective, although the magnitude of these differences was modest. Few interactions were observed between socio-demographics and message theme.Graphic depictions of disease were perceived by youth and adults as the most effective warning theme. Perceptions of warnings were generally similar across socio-demographic groups.

INTRODUCTION: Our aim was to investigate the association between socioeconomic position (income and education) and abrupt versus gradual method of smoking cessation. METHODS: The analysis used data (n = 5,629) from Waves 1 through 6 (2002-2008) of the International Tobacco Control Four-Country Survey, a prospective study of a cohort of smokers in the United States, Canada, the United Kingdom, and Australia. RESULTS: Logistic regression analyses using generalized estimating equations showed that higher income (p < .001) and higher education (p = .011) were associated with a higher probability of abrupt versus gradual quitting. The odds of adopting abrupt versus gradual quitting were about 40% higher among respondents with high income ($60,000 and more in the United States/Canada/Australia and £30,000 and more in the United Kingdom) compared with those with low income (less than $30,000 in the United States/Canada/Australia; £15,000 and less in the United Kingdom). Similarly, the odds of abrupt versus gradual quitting were about 30% higher among respondents with a high level of education (university degree) compared with those with a low level of education (high school diploma or lower). DISCUSSION: Higher socioeconomic position is associated with a higher probability of quitting abruptly rather than gradually reducing smoking before quitting.

Aims To measure the prevalence and correlates of nicotine replacement therapy (NRT) use for reasons other than quitting smoking among smokers in four countries. Design and setting Population-based, cross-sectional telephone survey with nationally representative samples of adult smokers in Canada, the United States, the United Kingdom and Australia, conducted in 2005. Participants A total of 6532 adult daily smokers in Canada (n = 1660), the United States (n = 1664), the United Kingdom (n = 1617) and Australia (n = 1591). Measurements Survey questions included demographics, smoking behaviour, use of NRT and reasons for NRT use, as well as access and availability of NRT. Findings Approximately 17% of smokers surveyed had used NRT in the past year. Among NRT users, approxi- mately one-third used NRT for a reason other than quitting smoking, including temporary abstinence or reducing the number of cigarettes smoked. The prevalence of non-standard NRT use was remarkably consistent across countries. UsingNRTforreasonsotherthanquittingwasassociatedwithhighereducationlevel,heaviersmoking,havingnoquit intentions, having no past-year quit attempts, the type of NRT product used and accessing NRT without a prescription. Conclusions The use of NRT for purposes other than quitting smoking is fairly common and may help to explain the difficulty in detecting significant quitting benefits associated with NRT use in population studies. Tobacco control policies, including the accessibility of NRT, may have important implications for patterns of NRT use.

Although adolescents who overestimate peer smoking prevalence are more likely to smoke, little research has focused on the factors associated with why the majority of adolescents overestimate peer smoking rate. The purpose of this study was to examine demographic, social, environmental and behavioural characteristics related to overestimation of peer smoking prevalence among secondary school students. The current study analysed data collected in two Canadian studies that used the Tobacco Module of the School Health Action, Planning and Evaluation System, a school-based questionnaire. One study surveyed 23 458 students (Grades 9-13) in 29 schools during 2001-02, and the other surveyed 25 452 students in 39 schools in 2003. Results of multiple logistic regression indicate that grade, gender, close friends' smoking, seeing smoking at school, family members' smoking, smoking in the home and smoking status have a clear association with overestimation; school smoking rate and susceptibility to smoking show a tentative relationship and warrant further study. Other factors may also be important for prevalence estimation, and further research is needed to identify these factors. Since adolescents tend to overestimate peer smoking prevalence and perceived prevalence is in turn linked to smoking behaviour, interventions should focus on creating realistic perceptions of smoking prevalence.

OBJECTIVES To examine the impact of a calorie label intervention on cafeteria menus. METHODS Exit surveys were conducted in a university cafeteria. Participants were surveyed at baseline and one week after calorie labels were displayed. We assessed changes in noticing and use of nutrition information, the calorie content of food purchased, and estimated calorie consumption. RESULTS The intervention was associated with significant increases in noticing nutrition information (92.5% vs 39.6%; p < .001), and the use of nutrition information to guide food purchases (28.9% vs 8.8%; p < .001). The calorie content of foods purchased decreased after calorie labels were posted (B = -88.69, p = .013), as did the estimated amount of calories consumed (B = -95.20, p = .006). CONCLUSIONS Findings suggest that displaying calorie amounts on menus can help reduce excess energy intake.

Objective To examine knowledge of recommended daily calorie intake, use of calorie information, and sociodemographic correlates between knowledge and use. Design Population-based, random digit–dialed phone surveys. Participants Canadian adults (n = 1,543) surveyed between October and December, 2012. Main Outcome Measures Knowledge of recommended calorie intake and use of calorie information when purchasing food. Analysis Regression models, adjusting for sociodemographics and diet-related measures. Results Overall, 24% of participants correctly stated their recommended daily calorie intake; the majority (63%) underestimated it, whereas few (4%) overestimated it. Females, younger participants, those with a higher income and more education, and those who consumed fruits and vegetables at least 5 times daily were significantly more likely to state recommended intake correctly. Most respondents (82%) reported considering calories when selecting foods. Respondents considered calories more often if they were female, had a higher income and more education, perceived themselves to be overweight, were actively trying to control their weight, reported a healthier diet, or consumed fruits and vegetables at least 5 times daily. Conclusions and Implications Although most Canadians reported using calorie information to guide their food choices, few knew their daily recommended calorie intake. To promote healthy weights, policy initiatives, including education regarding daily calorie intake and changes to the Nutrition Facts table, may help consumers make better choices about food.

To examine the perceived effectiveness of text and pictorial smokeless tobacco health warnings in India and Bangladesh, including different types of message content.An experimental study was conducted in Navi Mumbai, India (n=1002), and Dhaka, Bangladesh (n=1081). Face-to-face interviews were conducted on tablets with adult (≥19 years) smokeless tobacco users and youth (16-18 years) users and non-users. Respondents viewed warnings depicting five health effects, within one of the four randomly assigned warning label conditions (or message themes): (1) text-only, (2) symbolic pictorial, (3) graphic pictorial or (4) personal testimonial pictorial messages.Text-only warnings were perceived as less effective than all of the pictorial styles (p0.001 for all). Graphic warnings were given higher effectiveness ratings than symbolic or testimonial warnings (p0.001). No differences were observed in levels of agreement with negative attitudes and beliefs across message themes, after respondents had viewed warnings.Pictorial warnings are more effective than text-only messages. Pictorial warnings depicting graphic health effects may have the greatest impact, consistent with research from high-income countries on cigarette warnings.

Purpose The purpose of this study was to examine the use of conventional and alternative tobacco and nicotine products among secondary school students. Methods Respondents were 44,163 grade 9–12 students who participated in Year 2 (2013–2014) of COMPASS, a cohort study of 89 purposefully sampled secondary schools in Ontario and Alberta, Canada. Past-month use of various tobacco and nicotine products was assessed, as well as correlates of use, using a generalized linear mixed effects model. Results Overall, 21.2% of the sample reported past-month use of any tobacco or nicotine product, with 7.2% reporting past-month use of e-cigarettes. E-cigarette users reported significantly greater prevalence of current use for all products. Students who were male, white, had more spending money, and had a history of tobacco use were more likely to report past-month use of e-cigarettes. Conclusions Approximately one fifth of youth reported past-month use of a nicotine product, with e-cigarettes being the third most common product. Overall, the findings suggest a rapidly evolving nicotine market.

Concern over health risks is the most common motivation for quitting smoking. Health warnings on tobacco packages are among the most prominent interventions to convey the health risks of smoking. Face-to-face surveys were conducted in Mexico (n = 1,072), and a web-based survey was conducted in the US (n = 1,449) to examine the efficacy of health warning labels on health beliefs. Respondents were randomly assigned to view two sets of health warnings (each with one text-only warning and 5-6 pictorial warnings) for two different health effects. Respondents were asked whether they believed smoking caused 12 different health effects. Overall, the findings indicate high levels of health knowledge in both countries for some health effects, although significant knowledge gaps remained; for example, less than half of respondents agreed that smoking causes impotence and less than one third agreed that smoking causes gangrene. Mexican respondents endorsed a greater number of correct beliefs about the health effects of smoking than did the U.S. sample. In both countries, viewing related health warning labels increased beliefs about the health risks of smoking, particularly for less well-known health effects such as gangrene, impotence, and stroke.

Health warnings on tobacco products have emerged as a prominent area of tobacco control policy. Regulatory practice has rapidly evolved over the past decade to the point where health warnings on tobacco products continue to set international precedents for their size and comprehensiveness. The current paper provides a general review of current regulatory practices, including physical design features (such as size and location), message content (pictorial vs. text and content themes), and regulatory considerations such as rotation period and other novel practices.

Objectives: Comprehensive tobacco control policies implemented in Canada have succeeded in lowering overall smoking prevalence; however, the extent to which they have impacted socio-economic disparities in tobacco use is not known. This study examined smoking rates and related measures across socio-economic groups over a 7-year period in Canada. Methods: Regression analyses tested associations between smoking-related outcomes (prevalence, frequency, consumption, quit intentions and attempts, quit ratios), education level and time, using data from adults 25 years and older who completed the 1999 to 2006 waves of the Canadian Tobacco Use Monitoring Survey (CTUMS), a repeated cross-sectional survey with nationally representative samples (n=86,971). Results: Between 1999 and 2006, smoking prevalence, daily smoking, and cigarette consumption decreased, while the proportion of smokers who planned to quit increased, as did the proportion of ever-smokers who had quit. However, significant educational differences were observed: Canadians with less education had greater odds of current smoking (prevalence approximately doubled between the most and least educated groups) and daily smoking, and consumed more cigarettes, compared to university graduates. Highly-educated ever-smokers were also more likely to have quit smoking. These disparities remained stable over the time period studied. Intentions and attempts to quit were not consistently associated with education. Conclusions: The decline in smoking among Canadians between 1999 and 2006 represents a major public health achievement. However, considerable smoking-related disparities exist between socio-economic groups, and have changed very little. Therefore, while recent programs and policies have succeeded in reducing overall tobacco use, they have not addressed socio-economic disparities. Key words: Tobacco; smoking; socioeconomic status; Canada

Objective To examine the association of financial stress with interest in quitting smoking, making a quit attempt and quit success. Design and participants The analysis used data from 4984 smokers who participated in waves 4 and 5 (2005‐07)of theInternationalTobaccoControl(ITC)FourCountrySurvey,aprospectivestudyof acohortof smokers in the United States, Canada, the United Kingdom and Australia. Measurement The outcomes were interest in quitting at wave 4, making a quit attempt and quit success at wave 5. The main predictor was financial stress at wave 4: ‘. . . because of a shortage of money, were you unable to pay any important bills on time, such as electricity, telephone or rent bills?’. Additional socio-demographic and smoking-related covariates were also examined. Findings Smokers with financial stress were more likely than others to have an interest in quitting at baseline [odds ratio (OR): 1.63;95%confidenceinterval(CI):1.22‐2.19],butwerelesslikelytohavemadeaquitattemptatfollow-up(OR:0.74; 95% CI: 0.57‐0.96). Among those who made a quit attempt,financial stress was associated with a lower probability of abstinence at follow-up (OR: 0.53; 95% CI: 0.33‐0.87). Conclusions Cessation treatment efforts should consider assessing routinely the financial stress of their clients and providing additional counseling and resources for smokers who experience financial stress. Social policies that provide a safety net for people who might otherwise face severe financial problems, such as not being able to pay for rent or food, may have a favorable impact on cessation rates.

Purpose: To examine lunch sources during the school week among students and the associations with fruits and vegetable (F&V) and sugar-sweetened beverage (SSB) consumption. Methods: Students (n = 23 680) from 43 Ontario, Canada, secondary schools completed a health behaviour survey in the Year 1 COMPASS study. Analysis used generalized linear mixed effects models. Results: The most frequently reported lunch source was home (2.9 days per school week), then the school cafeteria (1.1) and fast-food places or restaurants (FFRs) (0.9). Eating a home lunch was associated with having less spending money, white ethnicity, and females; whereas cafeteria lunch was associated with more spending money, lower school grade, and females. A FFR lunch was associated with males, more spending money, and higher physical activity. Greater frequency of a home lunch was associated with greater F&V consumption. Greater frequency of a FFR lunch was associated with more frequent SSB consumption. Cafeteria lunches were associated with increases in both SSB and F&V. Conclusions: Eating a lunch obtained from outside of the home is a regular behaviour among students. Sources of school-week lunches may have an important influence on dietary intake among youth. These findings reinforce the need for strategies to promote healthier lunch sources and healthier food options.