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Objectives. To examine the impact of US restrictions implemented in February 2020 prohibiting flavors other than menthol and tobacco in cartridge-based e-cigarettes. Methods. We analyzed 5 cross-sectional waves of the International Tobacco Control Policy Evaluation Project Youth Tobacco and Vaping Surveys, conducted online with youths aged 16 to 19 years in the United States, Canada, and England, for differences in usual e-cigarette flavor, device, and brand reported by past-30-day vapers (n = 9512) before (2017, 2018, 2019), during (February 2020), and after (August 2020) implementation of US flavor restrictions. Results. In August 2020, 78.7% of vapers in the United States reported using a flavor prohibited in cartridges or pods, versus 86.3% in Canada (adjusted odds ratio [AOR] = 1.73; 95% CI = 1.25, 1.40) and 79.8% in England (AOR = 1.10; 95% CI = 0.78, 1.55). Disposable e-cigarettes (exempt from flavor restrictions) increased to a greater extent among vapers in the United States (13.2% to 36.8%) versus Canada (7.7% to 14.2%; AOR = 2.01; 95% CI = 1.33, 3.04) and England (10.8% to 16.4%; AOR = 2.33; 95% CI = 1.52, 3.57). Puff Bar (disposable) emerged as the most popular brand in the United States. Conclusions. Usual flavors used by youth vapers in the United States were unchanged after 2020 restrictions on cartridge-based e-cigarettes. Youths used brands and devices exempt from the restrictions. (Am J Public Health. 2022;112(7):1014–1024. https://doi.org/10.2105/AJPH.2022.306780 )

Introduction Little is known about the international impact of E-cigarette or Vaping-Associated Lung Injury (‘EVALI’) on youth perceptions of vaping harms. Methods Repeat cross-sectional online surveys of youth aged 16–19 years in England, Canada, and the United States before (2017, 2018), during (2019 August/September), and after (2020 February/March, 2020 August) the ‘EVALI’ outbreak (N = 63380). Logistic regressions assessed trends, country differences, and associations between exposure to negative news stories about vaping and vaping harm perceptions. Results Exposure to negative news stories increased between 2017 and February–March 2020 in England (12.6% to 34.2%), Canada (16.7% to 56.9%), and the United States (18.0% to 64.6%), accelerating during (2019) and immediately after (February–March 2020) the outbreak (p < .001) before returning to 2019 levels by August 2020. Similarly, the accurate perception that vaping is less harmful than smoking declined between 2017 and February–March 2020 in England (77.3% to 62.2%), Canada (66.3% to 43.3%), and the United States (61.3% to 34.0%), again accelerating during and immediately after the outbreak (p < .001). The perception that vaping takes less than a year to harm users’ health and worry that vaping will damage health also doubled over this period (p ≤ .001). Time trends were most pronounced in the United States. Exposure to negative news stories predicted the perception that vaping takes less than a year to harm health (Adjusted Odds Ratio = 1.55, 1.48-1.61) and worry that vaping will damage health (Adjusted Odds Ratio = 1.32, 1.18-1.48). Conclusions Between 2017 and February–March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. Effects were seen in all countries but were most pronounced in the United States. Implications This is the first study examining changes in exposure to news stories about vaping, and perceptions of vaping harms, among youth in England, Canada, and the United States before, during, and after ‘EVALI’. Between 2017 and February–March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. By August 2020, exposure to negative news stories returned to 2019 levels, while perceptions of harm were sustained. Exposure to negative news stories also predicted two of the three harm perception measures. Overall, findings suggest that ‘EVALI’ may have exacerbated youth’s perceptions of vaping harms internationally.

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.

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.

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.

BackgroundIn February 2020, the US Food and Drug Administration (FDA) prioritised enforcement efforts against flavoured prefilled cartridge/pod electronic nicotine delivery systems (ENDS), with the exception of tobacco and menthol. This study examined changes between prepriority enforcement (2018) and early postenforcement (February–June 2020) among adults on: ENDS flavours and devices used most often; location of last purchase of fruit/other-flavoured cartridges (covered under the enforcement priority); and smoking and vaping.MethodsPrevalence estimates came from 1608 adult frequent (≥weekly) ENDS users (current smokers (n=1072), ex-smokers (n=536)) who participated in the 2018 and/or 2020 US ITC Smoking and Vaping Surveys. Transitions between flavours/devices and changes in smoking/vaping were assessed among baseline respondents who were followed up in 2020 (n=360). Respondents self-reported the ENDS device (disposable, cartridge/pod or tank) and the flavor that they used most often: (1) tobacco flavors (tobacco/tobacco-menthol mix) or unflavored; (2) menthol/mint; (3) fruit/other flavors.ResultsCompared to 2018, in the first 5 months of the 2020 enforcement priority, there were significant increases in the prevalence of fruit/other-flavoured cartridges (7.9% to 12.4%,p=0.026) and menthol/mint cartridges (7.1% to 13.0%, pConclusionsBetween 2018 and the early phase of the FDA’s 2020 enforcement priority, prevalence of menthol/mint and fruit/other-flavoured cartridges increased among adults. Half of vapers using cartridge flavours covered in the enforcement switched to other flavours and/or devices that were exempt, with the exception of disposables. The extent to which more comprehensive restrictions may be problematic for adults who prefer a range of ENDS flavours remains uncertain.

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.

IntroductionHeated tobacco products (HTPs), such as IQOS, have been introduced in a growing number of international markets. However, little is known about perceptions of HTP products among youth.MethodsData are from wave 1 of the International Tobacco Control Youth Tobacco and E-cigarette Survey (2017), a web-based cohort survey of people aged 16–19 years from Canada, England and the USA. Respondents (n=12 064) were shown an image of IQOS and asked about their awareness, interest in trying and susceptibility to trying the product. Youth awareness, interest in trying and susceptibility to trying IQOS were analysed using descriptive statistics, and logistic regression models were used to examine correlates of these outcomes.ResultsOverall, 7.0% of youth reported awareness of IQOS (England=5.6%, Canada=6.4% and USA=9.1%) and 38.6% expressed interest in trying the product (England=41.8%, Canada=33.0% and USA=40.9%). Within each country, all key outcomes varied by smoking status: greater proportions of youth who were currently smoking or had a history of smoking reported being aware of, interested in trying and susceptible to trying IQOS. Interest and susceptibility to trying IQOS were associated with male sex, current tobacco use and current e-cigarette use. Across all countries, susceptibility to trying IQOS (25.1%) was higher than for tobacco cigarettes (19.3%), but lower than for e-cigarettes (29.1%).ConclusionsAwareness of HTPs, such as IQOS, is emerging among youth in Canada, England and the USA. Interest in trying these products is very high among smokers, but also present among non-smokers.

INTRODUCTION: More than 100 countries have implemented pictorial health warnings on cigarette packages. However, few studies have compared how consumers from different geographic and cultural contexts respond to health warning content. The current study compares perceptions of warnings among adult smokers and youth in seven countries, to examine the efficacy of different health warning themes and images. METHODS: Between 2010 and 2012, online and face-to-face surveys were conducted with ~500 adult smokers and ~500 youth (age 16–18) smokers and nonsmokers in each of Mexico, United States, China, Germany, India, Bangladesh, and Republic of Korea (total N = 8182). Respondents were randomized to view and rate sets of 5–7 health warnings (each set for a different health effect); each set included a text-only warning and various types (ie, themes) of pictorial warnings, including graphic health effects, “lived experience,” symbolic images, and personal testimonials. Mixed-effects models were utilized to examine perceived effectiveness of warning themes, and between-country differences in responses. RESULTS: Overall, pictorial warnings were rated as more effective than text-only warnings (p < .001). Among pictorial themes, “graphic” health effects were rated as more effective than warnings depicting “lived experience” (p < .001) or “symbolic” images (p < .001). Pictorial warnings with personal testimonials were rated as more effective than the same images with didactic text (p < .001). While the magnitude of differences between warning themes varied across countries, the pattern of findings was generally consistent. CONCLUSIONS: The findings support the efficacy of graphic pictorial warnings across diverse geographic and cultural contexts, and support sharing health warning images across jurisdictions. IMPLICATIONS: Although over 100 countries have implemented pictorial health warnings on cigarette packages, there is little research on the most effective types of message content across geographic and cultural contexts. The current study examined perceived effectiveness of text and pictorial health warnings featuring different message content—graphic health effects, “lived experience,” personal testimonials, and symbolic imagery—among more than 8000 adults and youth in Mexico, United States, China, Germany, India, Bangladesh, and Korea. Across countries, “graphic” pictorial messages were rated as most effective. Consistencies across countries in rating message content suggests there may be “globally effective” themes and styles for designing effective health warnings.

Introduction JUUL has emerged as the leading brand in a rapidly evolving electronic cigarette (e-cigarette) market. JUUL is distinctive for its novel nicotine delivery method that results in high nicotine concentrations, as well as its sleek, discreet design. This study examined national estimates of JUUL among youth in the United States, including whether JUUL users report different patterns of use compared to users of other e-cigarettes. Methods Data were analyzed from the US arm of the International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and E-cigarette Survey, an online survey conducted in July–August 2017 with youth aged 16–19 years recruited from consumer panels (n = 4086). Results Overall, 14.2% of respondents had used an e-cigarette in the past 30 days. JUUL was the second-most popular brand reported by past-30-day e-cigarette users (9.7%). Compared to e-cigarette users of other brands, JUUL users were significantly older (adjusted odds ratio [aOR] = 2.50, 95% confidence interval [CI] = 1.56 to 4.01) and reported a greater number of computers in the household (a socioeconomic status proxy; aOR = 1.55, 95% CI = 1.22 to 1.96), with no differences by sex, race/ethnicity, or student status. Controlling for sociodemographic variables, JUUL users were more likely than other e-cigarette users to have ever tried to quit e-cigarettes (aOR = 2.65, 95% CI = 1.12 to 6.30), with no differences observed by smoking status, frequency of e-cigarette use, urges to use e-cigarettes, or perceived addiction to e-cigarettes. Conclusions JUUL was among the most popular e-cigarette brands among youth, and there were few differences in sociodemographic profile or patterns of use between users of JUUL and other e-cigarette brands. Implications This study examined national estimates of JUUL e-cigarette use among youth in the United States, during the early phase of JUUL’s popularity. JUUL was among the most popular e-cigarette brands among youth, and there were few differences in sociodemographic profile or patterns of use between JUUL and other e-cigarette brands. The findings help to characterize the rapid rise of this new product category within the rapidly evolving e-cigarette market at a time when the US Food and Drug Administration and public health community are seeking to understand JUUL and its appeal among young people.

E-cigarettes remain a contentious topic in public health, with debates focussing on their benefits as a smoking cessation aid1–3 versus potential increases in nicotine use among non-smoking young people.4 Accordingly, the public health impact of e-cigarettes will be determined by who is using them and for what purpose. To date, most studies exploring the prevalence of vaping have been conducted among either youth5–10 or adults,11–13 with little evidence on overall populations of vapers. Specifically, evidence is lacking regarding the relative contribution of youth and adults, smokers and never smokers, and how these groups have contributed to overall increases in vaping at the population level. Evidence is also required to evaluate the impact of e-cigarette policies on patterns of vaping among these different groups. Canada represents an interesting case study given recent shifts in the regulatory framework for e-cigarettes.14 Prior to May 2018, e-cigarettes containing nicotine could not be sold or marketed without approval; although no products were approved for legal sale, they were widely available.15 In May 2018, the Tobacco and Vaping Products Act (TVPA) permitted the sale of nicotine-containing e-cigarettes, as well as wider advertising and promotion of e-cigarettes, which increased retail accessibility and the presence of international brands.14 Studies have highlighted increases in youth vaping following implementation of the TVPA,5 6 although there are few estimates on changes in vaping at the population level in Canada. This study uses data from nationally representative surveys to examine how smoking and vaping evolved at the population level in Canada following the implementation of the TVPA. Data are from the 2019 Canadian Tobacco and Nicotine Survey (CTNS),16 a national monitoring survey in Canada. Briefly, the CTNS is a probability-based sample of the general population of Canada aged 15 years or older (n=8600) …

The current study examined the efficacy of health warnings on caffeinated energy drinks (CEDs). Participants aged 12–24 years (n = 2040) completed an online survey where they were asked to recall any existing warning statements on CED products and were randomized to one of 29 experimental warning conditions. Regression models were fitted to examine differences between conditions in product appeal, perceived safety and message recall. Overall, fewer than 30% of participants were able to accurately describe an existing CED product warning. Experimental findings indicated that exposure to CEDs with warning labels resulted in greater recall. Warnings on the back of CED cans featuring large font, a border, and a ‘caution’ heading resulted in significantly greater recall (P

ObjectiveTo examine the potential links between activity spaces, the food retail environment and food shopping behaviours for the population of young, urban adults.DesignParticipants took part in the Canada Food Study, which collected information on demographics, food behaviour, diet and health, as well as an additional smartphone study that included a seven-day period of logging GPS (global positioning system) location and food purchases. Using a time-weighted, continuous representation of participant activity spaces generated from GPS trajectory data, the locations of food purchases and a geocoded food retail data set, negative binomial regression models were used to explore what types of food retailers participants were exposed to and where food purchases were made.SettingToronto, Montreal, Vancouver, Edmonton and Halifax, Canada.SubjectsYoung adults aged 16–30 years (n496). These participants were a subset of the larger Canada Food Study.ResultsDemographics, household food shopper status and city of residence were significantly associated with different levels of exposure to various types of food retailers. Food shopping behaviours were also statistically significantly associated with demographics, the activity space-based food environment, self-reported health and city of residence.ConclusionsThe study confirms that food behaviours are related to activity space-based food environment measures, which provide a more comprehensive accounting of food retail exposure than home-based measures. In addition, exposure to food retail and food purchasing behaviours of an understudied population are described.

Objective To examine exposure to energy drink marketing among youth and young adults, and test perceptions of energy drink advertisements (ads) regarding target audience age and promoting energy drink use during sports. Design A between-group experiment randomly assigned respondents to view one of four energy drink ads (sport-themed or control) and assessed perceptions of the ad. Regression models examined marketing exposure and perceptions. Setting Online survey (2014). Subjects Canadians aged 12–24 years (n 2040) from a commercial panel. Results Overall, 83 % reported ever seeing energy drink ads through at least one channel, including on television (60 %), posters/signs in stores (49 %) and online (44 %). Across experimental conditions, most respondents (70·1 %) thought the ad they viewed targeted people their age or younger, including 42·2 % of those aged 12–14 years. Two sport-themed ads were more likely to be perceived as targeting a younger audience (adjusted OR (95 % CI): ‘X Games’ 36·5 %, 4·16 (3·00, 5·77); ‘snowboard’ 19·2 %, 1·50 (1·06, 2·13)) v. control (13·3 %). Participants were more likely to believe an ad promoted energy drink use during sports if they viewed any sport-themed ad (‘X Games’ 69·9 %, 8·29 (6·24, 11·02); ‘snowboard’ 76·7 %, 11·85 (8·82, 15·92); ‘gym’ 66·8 %, 7·29 (5·52, 9·64)) v. control (22·0 %). Greater reported exposure to energy drink marketing was associated with perceiving study ads as promoting energy drink use during sports. Conclusions Energy drink marketing has a high reach among young people. Ads for energy drinks were perceived as targeting youth and promoting use during sports. Such ads may be perceived as making physical performance claims, counter to Canadian regulations.

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.

The objective of the current study was to evaluate young Canadians&rsquo, exposure to caffeinated energy drink marketing and educational messages that warn about the potential health risks of energy drinks. An online survey was conducted in 2015 with youth and young adults aged 12&ndash, 24 years recruited from a national online panel (n = 2023). Respondents were asked about their exposure to energy drink marketing and educational messages that warn about the potential health risks of energy drinks. Regression models were fitted to examine correlates of exposure to marketing and to educational messages. Over 80% of respondents reported ever seeing energy drink marketing through at least one channel, most commonly television (58.8%), posters or signs in a convenience or grocery store (48.5%), and online ads (45.7%). The mean number of marketing channels selected was 3.4 (SD = 2.9) out of ten. Respondents aged 18&ndash, 19 (vs. 12&ndash, 14 and 15&ndash, 17) and 20&ndash, 24 (vs. 12&ndash, 17) reported significantly more channels of exposure to marketing. Overall, 32% of respondents reporting ever seeing an educational message about energy drinks. The most frequently reported sources of exposure were at school (16.2%), online (15.0%), and on television (12.6%). Respondents aged 18&ndash, 14, 15&ndash, 17 and 20&ndash, 24) and 20&ndash, 24 (vs. 15&ndash, 17) were significantly more likely to report having seen an educational message. Exposure to energy drink marketing was common among youth and young adults and was significantly more prevalent than exposure to educational messages that warn about the potential health risks of energy drinks. A comprehensive policy approach, including enforcing responsible marketing and increasing education surrounding the risks of consuming energy drinks, may be an effective approach in promoting lower-risk consumption of CEDs.

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

OBJECTIVE: To examine food sources among young people in five major Canadian cities. METHODS: As part of the 2016 Canada Food Study, respondents aged 16–30 were recruited from five Canadian cities (Toronto, Montreal, Halifax, Edmonton, and Vancouver) using in-person intercept sampling and completed an online survey (n = 2840 retained for analysis). Descriptive statistics were used to summarize food preparation and purchase locations. A linear regression model was fitted to examine correlates of the proportion of meals that were ready-to-eat or prepared outside the home. RESULTS: In total, 80% of meals were prepared at home and 20% were prepared outside the home. More than 25% of meals prepared at home were ready-to-eat/box food. Of all meals consumed, 42% were either ready-to-eat/box food prepared at home or prepared outside the home. Food for meals prepared at home was purchased predominantly at grocery stores/supercentres while meals prepared outside the home were purchased predominantly at fast food/quick service/coffee shop outlets. Respondents who were younger, identified as Aboriginal, had obesity, had no children, lived in residence at school, university, or college, and reported poorer cooking skills reported more meals that were ready-to-eat or prepared outside the home. CONCLUSIONS: The current findings indicate that a substantial proportion of meals consumed by young people consist of meals either prepared outside the home or ready-to-eat/box food prepared at home. Dietary recommendations should highlight basic patterns of food preparation and eating, such as limiting ultra-processed food and food prepared outside the home.

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.

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

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.

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.

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.

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.

Plain cigarette packaging, which seeks to remove all brand imagery and standardize the shape and size of cigarette packs, represents a novel policy measure to reduce the appeal of cigarettes. Plain packaging has been studied primarily in high-income countries like Australia and the UK. It is unknown whether the effects of plain packaging may differ in low-and-middle income countries with a shorter history of tobacco regulation, such as Mexico. An experimental study was conducted in Mexico City to examine perceptions of branded and plain cigarette packaging among smoking and non-smoking Mexican adolescents (n = 359). Respondents were randomly assigned to a branded or plain pack condition and rated 12 cigarette packages for appeal, taste, harm to health and smoker-image traits. As a behavioral measure of appeal, respondents were offered (although not given) four cigarette packs (either branded or plain) and asked to select one to keep. The findings indicated that branded packs were perceived to be more appealing (β = 3.40, p < 0.001) and to contain better tasting cigarettes (β = 3.53, p < 0.001), but were not perceived as less harmful than plain packs. Participants rated people who smoke the branded packs as having relatively more positive smoker-image traits overall (β = 2.10, p < 0.001), with particularly strong differences found among non-smokers for the traits ‘glamorous’, ‘stylish’, ‘popular’ and ‘sophisticated’ (p < 0.001). No statistically significant difference was found for the proportion of youth that accepted when offered branded compared with plain packs. These results suggest that plain packaging may reduce brand appeal among Mexican youth, consistent with findings in high-income countries.

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.

Introduction Lower socioeconomic status (SES) groups have higher rates of tobacco use, are less likely to successfully quit, and may also be less likely to intend or attempt to quit. However, results are inconsistent for some outcomes, and little is known about how socioeconomic disparities vary across countries and over time. Methods This study examined the associations between SES and quitting-related behaviors among representative samples of smokers in Canada, the United States, the United Kingdom, and Australia, using data from the first five waves (2002-2006/2007) of the International Tobacco Control Four Country Survey (35,532 observations from 16,458 respondents). Generalized estimating equations modeling was used to examine whether education and income were related to intentions to quit, incidence of quit attempts, and smoking abstinence. Potential differences in the associations over time and across countries were also considered. Results Smokers with higher education were more likely to intend to quit, to make a quit attempt, and to be abstinent for at least 1 and 6 months; smokers with higher income were more likely to intend to quit and to be abstinent for at least 1 month. Some between-country differences were observed: U.K. and U.S. smokers were less likely to intend to quit than Australians and Canadians; and, although U.K. respondents were least likely to attempt to quit, those that did were more likely to be abstinent. Discussion The results suggest that socioeconomic disparities exist at multiple stages in the path to smoking cessation. Potential effects on socioeconomic disparities should be considered when implementing cessation interventions.

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