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BackgroundPopulation studies in mostly high-income countries have shown that pictorial health warnings (PHWs) are much more effective than text-only warnings. This is the first quasi-experimental evaluation of the introduction of PHWs in Africa, comparing the change from text-only to PHWs in Kenya to the unchanged text-only health warning in Zambia.MethodsData were from International Tobacco Control (ITC) Surveys in Kenya (n=1495), and Zambia (n=1628), cohort surveys of nationally representative samples of adult smokers in each country. The ITC Kenya Survey was conducted in 2012 and 2018 (2 years after the 2016 introduction of three PHWs). The ITC Zambia Survey was conducted in 2012 and 2014 with no change to the single text-only warning. Validated indicators of health warning effectiveness (HWIs) (salience: noticing, reading; cognitive reactions: thinking about health risks, thinking about quitting; and behavioural reactions: avoiding warnings; forgoing a cigarette because of the warnings), and a summary measure—the Labels Impact Index (LII)—measured changes in warning impact between the two countries.ResultsPHWs implemented in Kenya led to a significant increase in all HWIs and the LII, compared with the text-only warning in Zambia. The failure to implement PHWs in Zambia led to a substantial missed opportunity to increase warning effectiveness (eg, an estimated additional 168 392 smokers in Zambia would have noticed the warnings).ConclusionsThe introduction of PHWs in Kenya substantially increased the effectiveness of warnings. These results provide strong empirical support for 34 African countries that still have text-only warnings, of which 31 are Parties of the Framework Convention on Tobacco Control and are thus obligated to implement PHWs.

Introduction Involuntary exposure to secondhand smoke most frequently occurs at home, which is problematic for residents of multiunit housing (MUH). The primary objective of this study was to estimate the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their homes but lived in buildings where smoking is allowed. Methods We used data from Wave 9 of the International Tobacco Control Four Country Survey. We estimated 1) the prevalence of complete smoking bans among smokers living in single-family homes vs MUH in the United States (n = 3,208), Canada (n = 1,592), and the United Kingdom (n = 1,403) from 2013 to 2015; 2) the extent of secondhand smoke incursions into the homes of MUH smokers who banned smoking in their units but lived in buildings that allow smoking; and 3) MUH smokers' preferences for complete smoking bans in MUH. Weighted multivariable logistic regression estimated the country-specific adjusted prevalence of all outcomes. Results Overall, 53.0% of smokers living in single-family homes completely banned smoking in their homes, compared with 44.8% of smokers in MUH. Across all 3 countries, only 27.8% of MUH smokers reported that smoking was completely prohibited in their building. A similar percentage of MUH smokers who banned smoking in their home but lived in buildings allowing smoking reported a secondhand smoke incursion into their home in the United States (29.9%; 95% CI, 20.4%-41.5%), Canada (38.4%; 95% CI, 26.7%-51.6%), and the United Kingdom (24.7%; 95% CI, 15.7%-36.7%). Across all 3 countries, 36.1% (95% CI, 33.4%-38.9%) of smokers in MUH reported they preferred a complete smoking ban in all building areas. Conclusion A need remains to educate MUH operators and residents about the benefits of comprehensive smoke-free policies.

Comprehensive smoke-free policies such as those called for by the WHO FCTC are the only way to protect the public effectively from the harms of secondhand smoke (SHS), yet Japan has been slow to implement this important health measure. This study examines baseline levels of smoking and SHS exposure in public places and support for smoking bans in Japan prior to the implementation of the 2018 national smoke-free law. Data are from the International Tobacco Control (ITC) Japan Wave 1 Survey (Feb&ndash, Mar 2018), a web survey of adult cigarette smokers, heated tobacco product users, dual users, and non-users (total N = 4684). Measures included prevalence of smoking (whether respondents noticed people smoking inside restaurants and bars at their last visit, and workplaces in the last month), and support for complete smoking bans in these venues. Smoking prevalence in each venue was high overall in 2018 (49% of workplaces, 55% of restaurants, and 83% of bars), even higher than in China, the country with the greatest toll of SHS. Support for complete smoking bans was very high overall (81% for workplaces, 78% for restaurants, and 65% for bars). Non-users were less likely to be exposed to SHS and had higher support for smoking bans than tobacco users. These findings point to the ineffectiveness of partial smoke-free laws in Japan and reinforce the call for comprehensive smoke-free laws, which even smokers would support at higher levels than in many other ITC countries.

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.

ObjectivesTo examine trends in smoking prevalence in key venues (workplaces, restaurants, bars) and in public support for comprehensive smoke-free laws, with comparisons between cities and rural areas in China.DesignData are from Waves 3–5 (2009–2015) of the International Tobacco Control (ITC) China Survey, a cohort survey of smokers and non-smokers. Logistic regression analyses employing generalised estimating equations assessed changes in smoking prevalence and support for smoke-free laws over time; specific tests assessed whether partial smoking bans implemented in three cities between Waves 3 and 4 had greater impact.SettingFace-to-face surveys were conducted in seven cities (Beijing, Changsha, Guangzhou, Kunming, Shanghai, Shenyang and Yinchuan) and five rural areas (Changzhi, Huzhou, Tongren, Yichun and Xining).ParticipantsIn each survey location at each wave, a representative sample of approximately 800 smokers and 200 non-smokers (aged 18+) were selected using a multistage cluster sampling design.Main outcome measuresPrevalence of smoking (whether respondents noticed smoking inside restaurants, bars and workplaces); smoking rules inside these venues; and support for complete smoking bans in these venues.ResultsAlthough smoking prevalence decreased and support increased over time, neither trend was greater in cities that implemented partial smoke-free laws. Smoking was higher in rural than urban workplaces (62% vs 44%, pConclusionsPartial laws have had no effect on reducing SHS in China. There is an urgent need for comprehensive smoke-free laws to protect the public from exposure to deadly tobacco smoke in both urban and rural areas. The high support among Chinese smokers for such a law demonstrates that public support is not a barrier for action.

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 2009, after many delays and changes, India introduced a single pictorial health warning label (HWL) on smokeless tobacco (SLT) packing—a symbolic image of a scorpion covering 40% of the front surface. In 2011, the scorpion was replaced with 4 graphic images. This paper tested the effectiveness of SLT HWLs in India and whether the 2011 change from symbolic to graphic images increased their effectiveness. Methods Data were from a cohort of 4733 adult SLT users (age15+) of the Tobacco Control Project (TCP) India Survey from 4 states. The surveys included key indicators of health warning effectiveness, including warning salience, and cognitive, emotional, and behavioral responses to the warnings. Results The HWL change from symbolic to graphic did not result in significant increases on any of the HWL outcome indicators. A substantial minority of SLT users were unaware that SLT packages contained HWLs (27% at both waves). Noticing the warnings was also remarkably low at both waves (W1 = 34.3%, W2 = 28.1%). These effects carried over to the cognitive and behavioural measures, where among those who noticed HWLs, about one-third reported forgoing SLT at least once because of the HWLs, and fewer than 20% reported that HWLs made them think about SLT risks or about quitting SLT. Even fewer reported avoiding HWLs (8.1 to 11.6%). Among those who quit using SLT by post-policy, awareness that SLT packaging contained HWLs was significantly greater at post-policy (86.8%) compared to pre-policy (77.8%, p = 0.02). Quitters were also significantly more aware of the post-policy HWLs compared to those who continued to use SLT (p

Awareness of the health risks of smoking is an important factor in predicting smoking-related behaviour; however, little is known about the knowledge of health risks in low-income countries such as India. The present study examined beliefs about the harms of smoking and the impact of health knowledge on intentions to quit among a sample of 249 current smokers in both urban and rural areas in two states (Maharashtra and Bihar) from the 2006 TCP India Pilot Survey, conducted by the ITC Project. The overall awareness among smokers in India of the specific health risks of smoking was very low compared to other ITC countries, and only 10% of respondents reported that they had plans to quit in the next six months. In addition, smokers with higher knowledge were significantly more likely to have plans to quit smoking. For example, 26.2% of respondents who believed that smoking cause CHD and only 5.5% who did not believe that smoking causes CHD had intentions to quit (χ2 = 16.348, p < 0.001). Important differences were also found according to socioeconomic factors and state: higher levels of knowledge were found in Maharashtra than in Bihar, in urban compared to rural areas, among males, and among smokers with higher education. These findings highlight the need to increase awareness about the health risks of smoking in India, particularly in rural areas, where levels of education and health knowledge are lower.

Background China is the world9s largest consumer of tobacco, with hundreds of millions of people exposed daily to secondhand smoke (SHS). Comprehensive smoke-free policies are the only effective way to protect the population from the harms of SHS. China does not have a comprehensive national smoke-free law but some local-level regulations have been implemented. Objective To evaluate local level smoke-free regulations across 7 cities in China by measuring the prevalence of smoking in public places (workplaces, restaurants and bars), and support for smoke-free policies over time. Methods Data were from waves 2 to 4 of the International Tobacco Control (ITC) China Survey (2007–2012), a face-to-face cohort survey of approximately 800 smokers in each of 7 cities in mainland China. Multivariate logistic regression models estimated with generalised estimating equations were used to test the changes in variables over time. Results As of 2012, over three-quarters of respondents were exposed to smoking in bars; more than two-thirds were exposed to smoking in restaurants and more than half were exposed to smoking in indoor workplaces. Small decreases in the prevalence of smoking were found overall from waves 2 to 4 for indoor workplaces, restaurants and bars, although the decline was minimal for bars. Support for complete smoking bans increased over time for each venue, although it was lowest for bars. Conclusions Existing partial smoking bans across China have had minimal impact on reducing smoking in public places. A strongly enforced, comprehensive national smoke-free law is urgently needed in order to achieve greater public health gains.

Background In 2009, China changed its health warnings on cigarette packs from side-only text warnings to two text-only warnings on 30% of the bottom of the front and back of the pack. Also in 2009, Malaysia changed from similar text warnings to pictorial health warnings consistent with Framework Convention on Tobacco Control (FCTC) Article 11 Guidelines. Objective To measure the impact of the change in health warnings in China and to compare the text-only health warnings to the impact of the pictorial health warnings introduced in Malaysia. Methods We measured changes in key indicators of warning effectiveness among a longitudinal cohort sample of smokers from Waves 1 to 3 (2006–2009) of the International Tobacco Control (ITC) China Survey and from Waves 3 to 4 (2008–2009) of the ITC Malaysia Survey. Each cohort consisted of representative samples of adult (≥18 years) smokers from six cities in China (n=6575) and from a national sample in Malaysia (n=2883). Generalised Estimating Equations (GEE) were used to examine the impact of the health warnings on subsequent changes in salience of warnings, cognitive and behavioural outcomes. Findings Compared to Malaysia, the weak text-only warning labels in China led to a significant change in only two of six key indicators of health warning effectiveness: forgoing cigarettes and reading the warning labels. The change to pictorial health warnings in Malaysia led to significant and substantial increases in five of six indicators (noticing, reading, forgoing, avoiding, thinking about quitting). Conclusions The delay in implementing pictorial health warnings in China constitutes a lost opportunity for increasing knowledge and awareness of the harms of cigarettes, and for motivating smokers to quit.

International audience; BACKGROUND: Prior studies have demonstrated that time perspective---the propensity to consider short-versus long-term consequences of one's actions---is a potentially important predictor of health-related behaviors, including smoking. However, most prior studies have been conducted within single high-income countries. The aim of this study was to examine whether time perspective was associated with the likelihood of being a smoker or non-smoker across five countries that vary in smoking behavior and strength of tobacco control policies. METHODS: The data were from the International Tobacco Control (ITC) Surveys in five countries with large probability samples of both smokers (N=10,341) and non-smokers (N=4,955): Scotland, France, Germany, China, and Malaysia. The surveys were conducted between 2005--2008. Survey respondents indicated their smoking status (smoker vs. non-smoker) and time perspective (future oriented vs. not future-oriented) and provided demographic information. RESULTS: Across all five countries, non-smokers were significantly more likely to be future-oriented (66%) than were smokers (57%), chi2(1, N = 15,244) = 120.64, p < .001. This bivariate relationship between time perspective and smoking status held in a multivariate analysis. After controlling for country, age, sex, income, education, and ethnicity (language in France), those who were future-oriented had 36% greater odds of being a non-smoker than a smoker (95% CI: 1.22 to 1.51, p

Background Exposure to secondhand smoke (SHS) is a serious global public health problem. Understanding the correlates of SHS exposure could guide the development of evidence based SHS exposure reduction interventions. The purpose of this study is to describe the pattern of and factors associated with SHS exposure among non-smoking adults in Bangladesh. Methods Data come from adult non-smokers who participated in the second wave (2010) of the International Tobacco Control Policy (ITC) Evaluation Bangladesh Survey conducted in all six administrative divisions of Bangladesh. A structured questionnaire gathered information on participants’ demographic characteristics, pattern of SHS exposure, SHS knowledge, and attitudes towards tobacco control. Exposure to SHS at home was defined as non-smokers who lived with at least one smoker in their household and who reported having no home smoking ban. The data were analyzed using chi-square tests and logistic regression procedures. Results The SHS exposure rate at home among the participants (N = 2813) was 43%. Several sociodemographic and attitudinal factors were associated with SHS exposure. Logistic regression analyses identified eight predictors of SHS exposure: being female (OR = 2.35), being aged 15–24 (OR = 2.17), being recruited from Dhaka slums (OR = 5.19) or non-tribal/non-border areas outside Dhaka (OR = 2.19) or tribal/border area (OR = 4.36), having lower education (1–8 years: OR = 2.45; illiterate: OR = 3.00, having higher monthly household income (5000 to

Background: Global Adult Tobacco Survey India 2009-2010 revealed that more than one-third (35%) of adults in India use tobacco in some form: 21% use smokeless tobacco, 9% smoke, and 5% are mixed users (they smoke and use smokeless tobacco), and the quit rate is very low. In an effort to decrease prevalence of tobacco use, it is thus important to understand the factors that are related to intention to quit among Indian tobacco users. Research has shown consistently that intention to quit is a strong predictor of future quitting. The present study reports the factors encouraging quitting tobacco products in India. Subjects and Methods: Cross-sectional data from Wave 1 of the International Tobacco Control Policy Evaluation India Survey conducted in four cities and surrounding rural areas (i.e. Mumbai [Maharashtra], Patna [Bihar], Indore [Madhya Pradesh], and Kolkata [West Bengal]) between August 2010 and December 2011 were analyzed. A total of 8051 tobacco users (15+ years) were randomly sampled from 8586 households: 1255 smokers, 5991 smokeless users, and 805 mixed (smoke and smokeless) users. Validated, standardized questions were asked about current tobacco use, intention to quit, and factors encouraging quitting. Results: Overall, 19.6% of tobacco users intended to quit. Smokers had less intention to quit as compared to smokeless tobacco users whereas mixed users had more intention to quit (odds ratio [OR] =1.48, 95% confidence interval [CI] =1.12-1.97) compared to smokeless tobacco users. Highly educated people were more likely to report intention to quit (OR = 1.82, 95% CI = 1.09-3.02) compared to less educated. Advice by doctors to quit tobacco had a strong impact on intention to quit (OR = 1.68, CI = 1.29-2.15). Tobacco users who were exposed to antitobacco messages at work places (OR = 1.74, CI = 1.23-2.46), at restaurants (OR = 1.65, CI = 1.12-2.43), bars (OR = 1.81, CI = 1.07-3.06), on public transportation (OR = 2.14, CI = 1.49-3.08) and on tobacco packages (OR = 1.77, CI = 1.29-2.14) also expressed greater intention to quit tobacco use. Conclusion: Around one-fifth of tobacco users in India intended to quit tobacco use. Higher education, doctor's advice, and antitobacco messages were positively associated with users' intention to quit tobacco.

Tobacco companies are utilizing similar strategies to advertise and promote their products in developing countries as they have used successfully for over 50years 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