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BACKGROUND: Use of nicotine vaping products (NVPs) to replace smoking is often influenced by perceived harmfulness of these products relative to smoking. This study aimed to identify factors that conjointly influenced NVP relative harm perception among smokers and ex-smokers. METHODS: Data (n=11,838) from adult smokers and ex-smokers (quit

Introduction Although the United States has seen a rapid increase in tobacco minimum legal sales age (MLSA) laws set to age 21, there is wide variation across high-income countries and less is known about policy support outside of the United States. We examined the prevalence of support for tobacco MLSA 21 laws as well as associations by sociodemographic, smoking, and household characteristics among current and former adult smokers. Methods In this cross-sectional analysis, we used the 2018 International Tobacco Control Four Country Smoking and Vaping Survey to examine support for MLSA 21 laws among 12 904 respondents from Australia, Canada, England, and United States. Results Support for raising the legal age of purchasing cigarettes/tobacco to 21 ranged from 62.2% in the United States to 70.8% in Canada. Endorsement also varied by age, such that 40.6% of 18–20 years old supported the policy compared with 69.3% of those aged ≥60 years. In the adjusted regression model, there was also higher support among respondents who were female than male, non-white than white, those who did not allow smoking in the household than those that did, and those who had children in the household than those that did not. There were no differences by household income, education, or smoking status. Conclusions Most current and former smokers, including a sizable minority of those aged ≤20 years, support raising the legal age of purchasing cigarettes/tobacco to 21. Implications There was strong support for MLSA 21 laws among smokers and former smokers across Australia, Canada, England, and the United States, providing evidence for the increasing public support of the passage of these laws beyond the United States.

Introduction To test whether urges to smoke and perceived addiction to smoking have independent predictive value for quit attempts and short-term quit success over and above the Heaviness of Smoking Index (HSI). Aims and Methods Data were from the International Tobacco Control Four Country Smoking and Vaping Wave 1 (2016) and Wave 2 (2018) surveys. About 3661 daily smokers (daily vapers excluded) provided data in both waves. A series of multivariable logistic regression models assessed the association of each dependence measure on odds of making a quit attempt and at least 1-month smoking abstinence. Results Of the 3661 participants, 1594 (43.5%) reported a quit attempt. Of those who reported a quit attempt, 546 (34.9%) reported short-term quit success. Fully adjusted models showed that making quit attempts was associated with lower HSI (adjusted odds ratio [aOR] = 0.81, 95% confidence interval [CI] = 0.73 to 0.90, p < .001), stronger urges to smoke (aOR = 1.08, 95% CI = 1.04 to 1.20, p = .002), and higher perceived addiction to smoking (aOR = 0.52, 95% CI = 0.32 to 0.84, p = .008). Lower HSI (aOR = 0.57, 95% CI = 0.40 to 0.87, p < .001), weaker urges to smoke (aOR = 0.85, 95% CI = 0.76 to 0.95, p = .006), and lower perceived addiction to smoking (aOR = 0.55, 95% CI = 0.32 to 0.91, p = .021) were associated with greater odds of short-term quit success. In both cases, overall R2 was around 0.5. Conclusions The two additional dependence measures were complementary to HSI adding explanatory power to smoking cessation models, but variance explained remains small. Implications Strength of urges to smoke and perceived addiction to smoking may significantly improve prediction of cessation attempts and short-term quit success over and above routinely assessed demographic variables and the HSI. Stratification of analyses by age group is recommended because the relationship between dependence measures and outcomes differs significantly for younger (aged 18–39) compared to older (aged older than 40) participants. Even with the addition of these extra measures of dependence, the overall variance explained in predicting smoking cessation outcomes remains very low. These measures can only be thought of as assessing some aspects of dependence. Current understanding of the factors that ultimately determine quit success remains limited.

Introduction There is limited research on the role of flavors in nicotine vaping products (NVPs) in relation to smoking. We examined patterns of flavor use in NVPs in relation to progression toward quitting. Aims and Methods Data come from 886 concurrent users of NVPs (at least weekly) and cigarettes who were first surveyed in 2016 and then successfully recontacted in 2018 as part of the ITC 4CV Surveys conducted in Australia, Canada, England, and the United States. Participants were asked about their main vaping flavor categorized as: (1) tobacco or unflavored, (2) menthol or mint flavored, and (3) “sweet” flavors (eg, fruit or candy). We examined whether flavor was associated with progression toward quitting smoking between survey years. Results Overall, 11.1% of baseline concurrent users quit smoking by 2018. Compared with users of tobacco flavors, those vaping “sweet” flavors were more likely to quit smoking between surveys (13.8% vs. 9.6%; adjusted odds ratio [aOR] = 1.61, 95% confidence interval [CI] 1.01–2.58, p < .05), but those using menthol flavors were no more likely to quit smoking (8.3% vs. 9.6%, aOR = 0.87, 95% CI 0.43–1.47, p = .69). Among those who had quit smoking in 2018, 52.0% were still vaping, which was lower than the 65.8% among continuing smokers (aOR = 0.60, 95% CI 0.39–0.92, p = .02). Sweet flavor users were no more likely to continue vaping compared with tobacco flavor users, either for those continuing smoking or those having quit smoking by 2018. There was a net shift away from tobacco flavor among those who continued to vape at follow-up. Conclusions Use of fruit and other sweet flavored e-liquids is positively related to smokers’ transition away from cigarettes. Implications With multiple jurisdictions considering limiting or banning the sale of flavored NVPs, it is important to consider how such policies may impact smokers using NVPs to transition away from cigarette smoking. Our results indicate that vapers who used sweet flavors were more likely to transition away from cigarette smoking and quit cigarette use, at least in the short term, compared with those who used tobacco or unflavored NVPs. Randomized clinical trials are needed to establish if the observed association between use of flavored e-liquids and smoking cessation is due to self-selection or is truly causal.

Background Cleaner nicotine delivery devices, such as nicotine vaping products (NVPs), could expose smokers to less harm than combustible cigarettes. While use of NVPs is increasing, it is unknown how harm reduction attitudes are related to intention to use these or other “clean nicotine” products and how smokers would prefer to use them. Methods A sample of 1,538 Australian smokers participated in an online survey. Questions covered use NVPs and nicotine replacement therapy (NRT), and attitudes towards a hypothetical “clean nicotine” product and tobacco harm reduction. Results Lifetime use of NVPs was reported by 21% of participants, while 42% reported that they would probably or definitely use NVPs as a cessation aid in the future. Around three-quarters expressed interest in using a hypothetical clean nicotine product as a short-term cessation aid (75.7%), a long-term substitute for cigarettes (72.4%), or as a partial replacement for cigarettes (74.9%). However, despite this interest, 52% endorsed the statement that using nicotine products long-term was undesirable because it maintained nicotine addiction. A binary logistic regression showed that interest in using the hypothetical “clean nicotine” product was associated with higher education, moderate nicotine dependence, support of tobacco harm reduction, and previous use of NRT and NVPs. Conclusion Most smokers were interested in the use of a hypothetical clean nicotine product that is as addictive as combustible cigarettes but much less harmful. However, many of the participants who were interested in the use of a hypothetical clean nicotine product also endorsed statements that long-term addiction to nicotine is undesirable. These seemingly contradictory findings have implications for communication with smokers about tobacco harm reduction approaches with non-smoked nicotine products.

BACKGROUND: Although evidence shows that co-use of cigarettes and cannabis is common, there is little research examining if co-use patterns vary depending on the regulatory environment for cannabis. This study examined patterns of co-use and perceptions of relative harm among cigarette smokers in four countries with different histories, and at different stages of cannabis legalization. METHODS: Data are from the 2018 International Tobacco Control 4CV Survey and included 10,035 adult cigarette smokers from Canada, United States (US), Australia, and England. At the time of the survey, Canada and the US had relatively more permissive cannabis regulations compared to Australia and England. RESULTS: Among this sample of 10,035 cigarette smokers, Canada had the highest rate of cannabis co-use in the last 12 months (36.3%), followed by the US (29.1%), England (21.6%), and Australia (21.4%). Among past 12 month co-users (n=3,134), the US (40.2%) and Canada (35.2%) had the highest rates of daily cannabis use, followed by smokers in England (26.3%) and Australia (21.7%); Australian co-users had the highest rate of infrequent (

Background and aimsIn May 2017, black-and-white text nicotine addiction warning labels (‘warnings’) and health and safety leaflets (‘leaflets’) became mandatory for nicotine vaping products (NVPs) in England, in accordance with the European Union’s Tobacco Products Directive. We compared changes over time in noticing warnings and leaflets, recall of warnings about nicotine and concerns about using NVP due to noticing warnings in England, compared with Canada, the US and Australia, where no warnings and leaflets were mandated.Design19 005 adult (aged 18+) NVP users, smokers and quitters of cigarettes and NVP from the 2016 and 2018 International Tobacco Control Four Country Smoking and Vaping Surveys in England, Canada, the US and Australia, recruited via probability and non-probability sampling.FindingsNoticing warnings increased in England from 4.9% (2016) to 9.4% (2018) (adjusted OR/AOR=1.64, 95% CI=1.15–2.36); this change was larger than changes in Canada (AOR=2.51, 95% CI=1.71–3.69) and the US (AOR=2.22, 95% CI=1.45–3.39). Recall of a nicotine warning increased in England from 86% (2016) to 94.9% (2018) (AOR=5.50, 95% CI=1.57–19.27) but not significantly elsewhere. Noticing leaflets increased in England from 14.6% (2016) to 19.1% (2018) (AOR=1.42, 95% CI=1.15–1.74); this change was larger than in Canada (AOR=1.42, 95% CI=1.12–1.79), the US (AOR=1.55, 95% CI=1.17–2.06) and Australia (AOR=1.51, 95% CI=1.02–2.22). Among those noticing warnings, concern about NVP use did not change significantly between 2016 and 2018 (all countries p>0.081).ConclusionsIntroduction of mandatory NVP warnings and leaflets in England was associated with small increases in noticing them but not with changes in concerns about NVP use.

Background: Filter ventilation creates impressions of ‘lightness’ and controls machine-tested yields of tar and nicotine. Virtually all factory made cigarettes now have filter ventilation in Australia, Canada, the UK and the US. Previous research, conducted before ‘light’ and ‘mild’ labelling was banned, found low awareness of filter ventilation. This study explores current levels of awareness and understandings. Methods: We used data from the 2018 wave of the ITC Four Country Smoking and Vaping Survey with samples from USA, England, Canada and Australia. Analyses were conducted initially on a weighted sample of 11,844, and subsequently on 7,541 daily factory made cigarette (FMC) smokers. Findings: Only 38.5% of all respondents reported being aware of filter ventilation. Among daily FMC smokers, only 9.4% believed their cigarettes had filter ventilation. Respondents who believed their usual cigarettes had filter ventilation were more likely to believe their usual cigarettes were both less harmful (18.2% vs 8.8%, p

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.

BackgroundThe 2018 National Academies of Sciences, Engineering, and Medicine Report found substantial evidence that electronic cigarette use (vaping) by youth is strongly associated with an increased risk of ever using cigarettes (smoking) and moderately associated with progressing to more established smoking. However, the Report also noted that recent increases in vaping have been associated with declining rates of youth smoking. This paper examines the temporal relationship between vaping and youth smoking using multiple data sets to explore the question of whether vaping promotes smoking initiation in the USA.MethodsUsing publicly available, nationally representative data on smoking and vaping among youth and young adults, we conducted a trend line analysis of deviations from long-term trends in smoking starting from when vaping became more prevalent.ResultsThere was a substantial increase in youth vaping prevalence beginning in about 2014. Time trend analyses showed that the decline in past 30-day smoking prevalence accelerated by two to four times after 2014. Indicators of more established smoking rates, including the proportion of daily smokers among past 30-day smokers, also decreased more rapidly as vaping became more prevalent.ConclusionsThe inverse relationship between vaping and smoking was robust across different data sets for both youth and young adults and for current and more established smoking. While trying electronic cigarettes may causally increase smoking among some youth, the aggregate effect at the population level appears to be negligible given the reduction in smoking initiation during the period of vaping’s ascendance.

Background This study examined the prevalence and correlates of (1) perceived social acceptability of personal vaporizer (PV)/e-cigarette use, and (2) reported vaping in public and private places, in the UK and Australia with different regulatory environments for PVs. Methods Data analyzed come from 2849 smokers and recent ex-smokers in the UK and Australia who participated in the 2014 wave of the International Tobacco Control Survey. Results UK respondents were more likely to think vaping is socially acceptable than Australians (56.4% vs. 27.9%; p

Introduction The demand for alternative nicotine/tobacco products is not well established. This paper uses a behavioral economic approach to test whether smokers have differential demand for conventional factory-made, electronic, and very low nicotine content cigarettes (FMCs/ECs/VLNCs) and uses the prospective cohort design to test the predictive validity of demand indices on subsequent use of commercially available FMCs and ECs.Methods Daily smokers (>= 16 years) from the Netherlands completed an online survey in April 2014 (N = 1215). Purchase tasks were completed for FMCs, ECs, and VLNCs. Participants indicated the number of cigarettes they would consume in 24 h, across a range of prices (0-30 euro). The relationship between consumption and price was quantified into four indices of demand (intensity, Pmax, breakpoint, and essential value). A follow-up survey in July 2015 measured FMC and EC use.Results At baseline, greater demand was observed for FMCs relative to ECs and VLNCs across all demand indices, with no difference between ECs and VLNCs. At follow-up, greater baseline FMC demand (intensity, essential value) was associated with lower quit rates and higher relapse. EC demand (Pmax, breakpoint, essential value) was positively associated with any EC use between survey waves, past 30 day EC use, and EC purchase between waves.Conclusions Smokers valued FMCs more than ECs or VLNCs, and FMCs were less sensitive to price increases. Demand indices predicted use of commercially available products over a 15 month period. To serve as viable substitutes for FMCs, ECs and VLNCs will need to be priced lower than FMCs.Implications Purchase tasks can be adapted for novel nicotine/tobacco products as a means to efficiently quantify demand and predict use. Among current daily smokers, the demand for ECs and VLNCs is lower than FMCs.

AIMS To estimate predictors of time to smoking relapse and test if prediction varied by quit duration. DESIGN Longitudinal cohort data from the International Tobacco Control Four-Country survey with annual follow up collected between 2002 and 2015. SETTING Canada, United States, United Kingdom and Australia. PARTICIPANTS A total of 9171 eligible adult smokers who had made at least one quit attempt during the study period. MEASUREMENTS Time to relapse was the main outcome. Predictor variables included pre-quit baseline measures of nicotine dependence, smoking and quitting-related motivations, quitting capacity and social influence, and also two post-quit measures, use of stop-smoking medications and quit duration (1-7 days, 8-14 days, 15-31 days, 1-3 months, 3-6 months, 6-12 months, 1-2 years and 2+ years), along with socio-demographics. FINDINGS All factors were predictive of relapse within the first 6 months of quitting but only wanting to quit, quit intentions and number of friends who smoke were still predictive of relapse in the 6-12-month period of quitting [hazard ratios (HR) = 1.20, P < 0.05; 1.13, P < 0.05; and 1.21, P

Cigarette pack health warning labels can elicit negative emotions among smokers, yet little is known about how these negative emotions influence behavior change.Guided by psychological theories emphasizing the role of emotions on risk concern and behavior change, we investigated whether smokers who reported stronger negative emotional responses when viewing warnings reported stronger responses to warnings in daily life and were more likely to try to quit at follow-up.We analyzed data from 5439 adult smokers from Australia, Canada, Mexico, and the US, who were surveyed every four months from September 2012 to September 2014. Participants were shown warnings already implemented on packs in their country and reported negative emotional responses (i.e., fear, disgust, worry), which were averaged (range = 1 to 9). Country-stratified logistic and linear generalized estimating equations were used to analyze the effect of negative emotional responses on self-reported responses to warnings in daily life (i.e., attention, risk concern, avoidance of warnings, forgoing planned cigarettes) and quit attempts at follow-up. Models were adjusted for socio-demographic and smoking-related characteristics, survey wave, and the number of prior surveys answered.Smokers who reported stronger negative emotions were more likely to make quit attempts at follow-up (Adjusted ORs ranged from 1.09 [95% CI 1.04 to 1.14] to 1.17 [95% CI 1.12 to 1.23]; p .001) than those who reported lower negative emotions. This relationship was mediated through attention to warnings and behavioral responses to warnings. There was no significant interaction of negative emotions with self-efficacy or nicotine dependence.Negative emotions elicited by warnings encourage behavior change, promoting attention to warnings and behavioral responses that positively predict quit attempts.

Introduction Smoking is a key modifiable risk factor in multiple sclerosis (MS). MS healthcare providers have a central role informing people of the deleterious effects of smoking on MS progression and promote smoking cessation, yet there is limited information about smoking cessation and support provided by these providers. This study aimed to gain an understanding of MS healthcare providers current practices, barriers and facilitators related to providing smoking cessation support for people with MS. Methods A total of 13 MS nurses and 6 neurologists working in public and private MS clinics across Australia were recruited through professional networks and MS organisations. Telephone interviews were conducted, transcribed and evaluated using framework analysis. Results MS nurses and neurologists reported that they routinely assess smoking status of people with MS at initial appointments and less regularly also at follow-up appointments. Clinicians considered it important to provide information about smoking impact on MS health outcomes and advise to cease smoking, but the content and delivery varies. Beyond this, some clinicians offer referral for smoking cessation support, while others stated this was not their responsibility, especially in light of competing priorities. Many were unsure about referral pathways and options, requiring more information, training and resources. Conclusion Results of this research indicate that there is potential to improve support for MS clinicians to promote smoking cessation among people with MS. Smoking cessation support may include tailored patient resources, clinician training and stronger collaboration with smoking cessation service providers.

Nicotine vaping products (NVPs) have evolved rapidly, and some vapers have difficulty reporting about their NVP. NVP knowledge may be important for providing accurate survey data, understanding the potential risks of NVP use, and assessing legal and regulated products. This paper examines current vapers who responded “don’t know” (DK) regarding their NVP features. Data are from adult daily/weekly vapers in Waves Two (2018, n = 4192) and Three (2020, n = 3894) of the ITC Four Country Smoking and Vaping Survey. Analyses assessed DK responses for NVP features (e.g., type/appearance, nicotine) and consumption. A DK index score was computed based on the percent of all features with DK responses, which was tested for associations with demographics, smoking/vaping status, NVP features, purchase location, and knowledge of NVP relative risks. NVP description and appearance were easily identified, but DK was more common for features such as nicotine content (7.3–9.2%) and tank/cartridge volume capacity (26.6–30.0%). DK responses often differed by vaping/smoking status, NVP type/appearance, purchase location, and country. Vapers who are younger, use box-shaped NVPs, purchase online, and exclusive daily vapers were associated with lower DK index scores. Higher DK index scores were associated with poorer knowledge of relative health risks of NVP use. The diversity of the NVP market and wide variation in how products are used makes it challenging to capture information from users about device features, such as nicotine content and capacity, in population surveys.

IntroductionUS tobacco control policies to reduce cigarette use have been effective, but their impact has been relatively slow. This study considers a strategy of switching cigarette smokers to e-cigarette use (‘vaping’) in the USA to accelerate tobacco control progress.MethodsA Status Quo Scenario, developed to project smoking rates and health outcomes in the absence of vaping, is compared with Substitution models, whereby cigarette use is largely replaced by vaping over a 10-year period. We test an Optimistic and a Pessimistic Scenario, differing in terms of the relative harms of e-cigarettes compared with cigarettes and the impact on overall initiation, cessation and switching. Projected mortality outcomes by age and sex under the Status Quo and E-Cigarette Substitution Scenarios are compared from 2016 to 2100 to determine public health impacts.FindingsCompared with the Status Quo, replacement of cigarette by e-cigarette use over a 10-year period yields 6.6 million fewer premature deaths with 86.7 million fewer life years lost in the Optimistic Scenario. Under the Pessimistic Scenario, 1.6 million premature deaths are averted with 20.8 million fewer life years lost. The largest gains are among younger cohorts, with a 0.5 gain in average life expectancy projected for the age 15 years cohort in 2016.ConclusionsThe tobacco control community has been divided regarding the role of e-cigarettes in tobacco control. Our projections show that a strategy of replacing cigarette smoking with vaping would yield substantial life year gains, even under pessimistic assumptions regarding cessation, initiation and relative harm.

Health warning labels (HWLs) on cigarette packs in Australia, Canada, Mexico, and the United States include varying information about toxic cigarette smoke constituents and smoking-related health risks. HWL information changed more recently in Australia, Canada, and Mexico than in the United States.To investigate whether smokers' knowledge of toxic constituents and perceived smoking-related risks increased after adding this information to HWLs and how knowledge of toxic constituents is associated with perceptions of smoking-related risks.Data come from a longitudinal, online cohort of 4,621 adult smokers surveyed every 4 months from September 2012 (Wave 1) to January 2014 (Wave 5) in Australia, Canada, and Mexico, with the United States being surveyed from Waves 2 to 5. Generalized estimating equation models estimated the association between perceived smoking-related risk at follow-up and prior wave knowledge of toxic constituents, adjusting for attention to HWLs, sociodemographics, and smoking-related characteristics.Between 2012 and 2014, knowledge of toxic constituents increased in Australia, Canada, and Mexico ( p.001), but not in the United States. Higher levels of both attention to HWLs and knowledge of toxic constituents were associated with a higher perceived risk of smoking-related conditions at follow-up across all countries except for the United States.Our results suggest that information about toxic constituents on prominent HWLs not only increases smoker's knowledge of toxic constituents, but that it may also reinforce the effects of HWL messages about specific, smoking-related health outcomes.

Background The electronic cigarette or e-cigarette (vapour device) is a consumer product undergoing rapid growth, and governments have been adopting regulations on the sale of the devices and their nicotine liquids. Competing claims about vapour devices have ignited a contentious debate in the public health community. What claims have been taken up in the state arena, and how have they possibly influenced regulatory outcomes? Methods This study utilized Narrative Policy Framework to analyze the claims made about vapour devices in legislation recommendation reports from Queensland Australia, Canada, and the European Union, and the 2016 deeming rule legislation from the United States, and examined the claims and the regulatory outcomes in these jurisdictions. Results The vast majority of claims in the policy documents represented vapour devices as a threat: an unsafe product harming the health of vapour device users, a gateway product promoting youth tobacco uptake, and a quasi-tobacco product impeding tobacco control. The opportunity for vapour devices to promote cessation or reduce exposure to toxins was very rarely presented, and these positive claims were not discussed at all in two of the four documents studied. Conclusion The dominant claims of vapour devices as a public health threat have supported regulations that have limited their potential as a harm reduction strategy. Future policy debates should evaluate the opportunities for vapour devices to decrease the health and social burdens of the tobacco epidemic.

Objective: To assess whether social, economic and demographic measures are associated with initiating and sustaining quit attempts in a national sample of Aboriginal and Torres Strait Islander smokers. Methods: We analysed data from 759 adults who reported smoking at least weekly in the Talking About The Smokes baseline survey (April 2012 – October 2013) and completed a follow up survey a year later (August 2013 – August 2014). Results: Almost none of the standard baseline socioeconomic indicators predicted making or sustaining quit attempts. However, becoming employed was associated with making quit attempts (OR 1.88) and both becoming employed (OR 3.03) and moving to purchase a home (OR 2.34) were both positively associated with sustaining abstinence of one month or more. More smokers who had insufficient money for food or essentials because of money spent on cigarettes had made a quit attempt (OR 1.47) and sustained abstinence of one month or more (OR 1.74). Conclusions and implications: Disadvantage does not seem to have pervasive negative effects on quitting. We should be more optimistic in our tobacco control activities with the most disadvantaged among Aboriginal and Torres Strait Islander smokers. Increasing personal empowerment (e.g. getting a job) may lead to at least short-term improvements in quitting. Refereed/Peer-reviewed

Background and aims Little is known about the factors associated with retention in smoking cessation trials, especially for low-socioeconomic status (low-SES) smokers. This study examined the factors associated with retention of low-SES smokers in the Australian Financial Interventions for Smoking Cessation Among Low-Income Smokers (FISCALS) trial. Design A two-group parallel block randomised open-label trial with allocation concealment. Setting Australia. The study was conducted primarily by telephone-based interviews with nicotine replacement therapy delivered via mail. Participants 1047 low-SES smokers interested in quitting smoking were randomised. Measurements Participants completed computer assisted telephone interviews (CATIs) at baseline, 2-month and 8-month follow-up. Smoking-related, substance use, mental or physical health, general psychological constructs, sociodemographic and recruitment sources association with retention at 8-month follow-up were examined using binary logistic regression. Findings 946 participants (90%) completed the 2-month follow-up interview and 880 participants (84%) completed the 8-month follow-up interview. Retention at 8-months was associated with higher motivation to quit (OR: 1.15; 95% CI: 1.04, 1.27 p

This paper provides a brief introduction to CEOS theory, a comprehensive theory for understanding hard to maintain behaviour change. The name CEOS is an acronym for Context, Executive, and Operational Systems theory. Behaviour is theorised to be the result of the moment by moment interaction between internal needs (operational processes) in relation to environmental conditions, and for humans this is augmented by goal-directed, executive action which can transcend immediate contingencies. All behaviour is generated by operational processes. Goal-directed behaviours only triumph over contingency-generated competing behaviours when operational processes have been sufficiently activated to support them. Affective force can be generated around executive system (ES) goals from such things as memories of direct experience, vicarious experience, and emotionally charged communications mediated through stories the person generates. This paper makes some refinements and elaborations of the theory, particularly around the role of feelings, and of the importance of stories and scripts for facilitating executive action. It also sketches out how it reconceptualises a range of issues relevant to behaviour change. CEOS provides a framework for understanding the limitations of both informational and environmental approaches to behaviour change, the need for self-regulatory strategies and for taking into account more basic aspects of human functioning.

Kok et al. (2018) attempt to make the case that fear appeals don't work. They argue that high threat communications generate reactance which precludes effective action unless self-efficacy is high,...

Introduction and aims: To investigate relationships between smoking-related behaviours and knowledge of the disease risks of smoking and the causes of smoking harms, using a four-way division of “component causes”: nicotine, other substances found in unburned tobacco, combustion products of tobacco, and additives. Design and methods: The data were collected using an on-line survey in Australia with 1047 participants in three groups; young non-smokers (18 to 25), young smokers (18 to 25) and older smokers (26 and above). Results: Most participants agreed that cancer and heart disease are major risks of smoking but only a quarter accurately quantified the mortality risk of lifetime daily smoking. Very few (2 of 1047) correctly estimated the relative contributions of all four component causes. Post-hoc analyses reinterpreting responses as expressions of relative concern about combustion products and nicotine showed that 29% of participants rated combustion products above nicotine. We delineated six relative concern segments, most of which had distinctive patterns of beliefs and actions. However, higher levels of concern about combustion products were only weakly positively associated with harm reducing beliefs and actions.Discussion and conclusions: Most smokers do not appear to understand the risks of smoking and their causes well enough to be able to think systematically about the courses of action open to them to reduce their health risk. To facilitate informed decision-making, tobacco control communicators may need to better balance the dual aims of creating fear/negative affect about smoking and imparting knowledge about the health harms and their mechanisms.

BACKGROUND: This paper describes the methods of the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey, conducted in 2016 in Australia (AU), Canada (CA), England (EN), and the United States (US). METHODS: The respondents were cigarette smokers, former smokers (quit within the previous two years), and at-least-weekly vapers, aged 18 and older. Eligible cohort members from the ITC Four Country Survey (4C) were retained. New respondents were sampled by commercial firms from their panels. Where possible, ages 18–24 and vapers were over-sampled. Data were collected online, and respondents were remunerated. Survey weights were calibrated to benchmarks from nationally representative surveys. RESULTS: Response rates by country for new recruits once invited ranged from 15.2% to 49.6%; cooperation rates were above 90%. Retention rates from the 4C cohort ranged from 35.7% to 44.2%. Sample sizes for smokers/former smokers were 1504 in AU, 3006 in CA, 3773 in EN, and 2239 in the US. Sample sizes for additional vapers were 727 in CA, 551 in EN, and 494 in the US. CONCLUSION: The ITC 4CV Survey design and data collection methods allow analyses to examine prospectively the use of cigarettes and NVPs in jurisdictions with different regulatory policies. The effects on the sampling designs and response quality of recruiting the respondents from commercial panels are mitigated by the use of demographic and geographic quotas in sampling; by quality control measures; and by the construction of survey weights taking into account smoking/vaping status, sex, age, education, and geography.

Background: Our study evaluated the short-term impact of introducing European Union's tobacco pictorial health warnings (PHWs).Methods: Longitudinal data were collected at two time-points from adult smokers, participating in the International Tobacco Control (ITC) surveys, conducted in the Netherlands, Australia, Canada, the United Kingdom and the United States. In the Netherlands, textual health warnings (THWs) were replaced by PHWs between both time-points. Health warning policies did not change in the other countries. Data from continuing smokers were used (N = 3,487) and analyzed using Generalized Estimating Equations.Results: Between both time-points, only Dutch smokers showed increases in noticing health warnings (beta = 0.712, p Conclusions: Results suggest that introducing the European PHWs was effective in provoking changes closely related to health warnings, but there was no direct impact on variables more closely related to smoking cessation.

This study evaluated compliance with the comprehensive smoke-free law in public indoor places introduced in Shanghai in March 2017. Observations and PM2.5 monitoring over 30 min intervals in 8 types of the venue were conducted three times: within a month before implementation and 3- and 12-months post implementation. Observations of evidence of smoking decreased from 66.2% before legislation to 52.8% three months after (p = 0.002) and 49.7% one year after (p &lt, 0.001). The density of lit cigarettes also reduced significantly after implementation (p &lt, 0.001). When adjusting for outdoor, indoor PM2.5 levels were significantly lower after the legislation, but only by a small amount (three months later: &minus, 0.27, p = 0.08, one year later: &minus, 0.12, p = 0.03). Evidence of compliance was weakest in farmer&rsquo, s markets and bars, and smoking in male toilets did not change significantly. The reduction in smoking was affected by the management performance of their obligations. The comprehensive smoke-free law led to modest reductions in smoking and PM2.5 levels as a result, but from levels suggesting quite high levels of pre-compliance. However, compliance was limited in some areas, suggesting more effort is required on management to gain better compliance in some places like farmer&rsquo, s markets, bars, and toilets.

Study objectivesTo compare the prices paid for nicotine vaping products (NVPs) and supplies among current NVP users to prices paid for cigarettes among current smokers.DataThe 2016 International Tobacco Control Four Country Vaping and Smoking Survey (4CV1). Key measures included: (1) self-reported prices paid for reusable NVPs (eg, rechargeable devices with cartridges and tank system devices with e-liquids) in the 3-month period prior to the survey among current NVP users, (2) prices paid for disposable NVPs, cartridges and e-liquids purchased in the last 30 days among current NVP users and (3) self-reported prices paid for cigarettes among current smokers.ResultsDisposable NVP price was higher than the price of a comparable unit for combustible cigarettes in England (EN), USA and Canada (CA). Prefilled cartridge price was higher than the price of a comparable unit of cigarettes in USA and CA, but lower in EN and Australia. E-liquid price was consistently lower than the price of a comparable unit of cigarettes across four countries. For start-up costs, price of a rechargeable device is approximately 3–5 times higher than a pack of cigarettes in four countries.ConclusionNVP prices were generally higher than prices of combustible cigarettes, especially the high upfront NVP devices. The high upfront costs of purchasing a reusable NVP may discourage some smokers from switching to vaping. However, the average lower costs of cartridges and e-liquids relative to a package of cigarettes make switching to a NVP an attractive alternative to smoking in the long term so long as smokers switch completely to vaping.

Aims: This paper presents updated prevalence estimates of awareness, ever-use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing. Design, Setting, Participants and Measurements: A cross-sectional analysis of adult (≥ 18 years) current smokers and ex-smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013–17. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs), not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs), not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand; (3) less restrictive policies (LRPs), legal to be sold and marketed with regulations: England, the Netherlands, Republic of Korea, United States; and (4) no regulatory policies (NRPs), Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country-specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily versus non-daily). Findings: NVP awareness and use were lowest in NRP countries. Generally, ever- and current use of NVPs were lower in MRP countries (ever-use = 7.1–48.9%; current use = 0.3–3.5%) relative to LRP countries (ever-use = 38.9–66.6%; current use = 5.5–17.2%) and RP countries (ever-use = 10.0–62.4%; current use = 1.4–15.5%). NVP use was highest among high-income countries, followed by upper–middle-income countries, and then by lower–middle-income countries. Conclusions: With a few exceptions, awareness and use of nicotine vaping products varied by the strength of national regulations governing nicotine vaping product sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in nicotine vaping products in these countries where smoking populations are predominantly poorer. The higher awareness and use of nicotine vaping products in high income countries with moderately (e.g. Canada, New Zealand) and less (e.g. England, United States) restrictive policies, is likely due to the greater availability and affordability of nicotine vaping products.

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.

This study examines whether having health conditions or concerns related to smoking is associated with use of vaping products. Data came from the 2016 wave of the International Tobacco Control Four Country Smoking and Vaping Survey. Smokers and recent quitters (n = 11,344) were asked whether they had a medical diagnosis for nine health conditions (i.e., depression, anxiety, alcohol problems, severe obesity, chronic pain, diabetes, heart disease, cancer, and chronic lung disease) and concerns about past and future health effects of smoking, and their vaping activities. Respondents with depression and alcohol problems were more likely to be current vapers both daily (Adjusted odds ratio, AOR = 1.42, 95% confidence interval, CI 1.09&ndash, 1.85, p &lt, 0.05 for depression, and AOR = 1.52, 95% CI 1.02&ndash, 2.27, p &lt, 0.05 for alcohol) and monthly (AOR = 1.32, 95% CI 1.11&ndash, 1.57 for depression, p &lt, 0.01, and AOR = 1.43, 95% CI 1.06&ndash, 1.90, p &lt, 0.05 for alcohol). Vaping was more likely at monthly level for those with severe obesity (AOR = 1.77, 95% CI 1.29&ndash, 2.43, p &lt, 0.001), cancer (AOR = 5.19, 95% CI 2.20&ndash, 12.24, p &lt, 0.001), and concerns about future effects of smoking (AOR = 1.83, 95% CI 1.47&ndash, 2.28, p &lt, 0.001). Positive associations were also found between chronic pain and concerns about past health effects of smoking and daily vaping. Only having heart disease was, in this case negatively, associated with use of vaping products on their last quit attempt (AOR = 0.72, 95% CI 0.43&ndash, 0.91, p &lt, 0.05). Self-reported health condition or reduced health associated with smoking is not systematically leading to increased vaping or increased likelihood of using vaping as a quitting strategy.

Background and aims The regulatory environment for nicotine vaping products (NVPs) varies widely across countries and this will probably affect the devices used, nicotine content and usage, and hence the ability of NVPs to substitute for cigarettes. We aimed to describe the types of NVPs used by current vapers in four countries with varying regulatory and enforcement approaches toward the marketing and sale of NVPs. Methods Data are from wave 1 (July-November 2016) of the ITC Four Country Smoking and Vaping Survey (4CV1), conducted among a cohort of current and former smokers, and current NVP users (n = 5147 adults; ≥ 18 years) in Australia (AU), Canada (CA), England (EN) and the United States (US) reporting either current daily, weekly or occasional NVP use. Devices were described by type, brand, voltage variability and refill capacity. Refill solutions were described by flavour and nicotine content. Descriptive statistics and bivariate analyses were conducted on the overall sample and stratified by country. A multinomial logistic regression examined factors associated with device preference across the whole sample. Results The types of NVPs used differed by pattern of use and country. Exclusive, daily vapers were more likely to use refillable pen-shaped devices [odds ratio (OR) = 10.0] or refillable box-shaped devices (OR = 5.4) than disposable cigalike devices, when compared with other (non-daily/dual) users. Nearly all respondents reported using flavoured NVPs, fruit (28.3%) being the most common flavour. Refillable devices were the most popular: refillable box-shaped devices were more commonly reported by vapers in AU (36.8%) and US (31.4%), whereas in EN (47.4%) and CA (29.7%), vapers more often reported using refillable pen-style devices. Most users also reported that their products contained nicotine, even in CA (87.8%) and AU (91.2%), where vaping products containing nicotine were technically illegal. Conclusions In Australia, Canada, England and the United States in 2016, refillable nicotine vaping products were the most common type of nicotine vaping products used by daily vapers. Most daily vapers reported using flavoured e-liquids/refills (with variance across countries) and most reported using products that contain nicotine, even where vaping products with nicotine were banned.

Aims To determine whether a simple combination of level of smoking and level of vaping results in a useful typology for characterizing smoking and vaping behaviours. Methods Cross-sectional data from adults (≥ 18 years) in the 2016 wave 1 ITC Four Country Smoking and Vaping Survey in the United States (n = 2291), England (n = 3591), Australia (n = 1376) and Canada (n = 2784) were used. Participants who either smoked, vaped or concurrently used both at least monthly were included and divided into eight groups based on use frequency of each product (daily, non-daily, no current use). This resulted in four concurrent use groups (predominant smokers, dual daily users, predominant vapers and concurrent non-daily users). These groups were compared with each other and with the four exclusive use groups, on socio-demographics, nicotine dependence, beliefs and attitudes about both products, and quit-related measures using data weighted to reference population surveys in each country. Results Of the sample, 10.8% were concurrent users, with daily smokers vaping non-daily (predominant smokers), constituting 51.6% of this group. All eight categories differed from other categories on at least some measures. Concurrent daily nicotine users reported higher levels of indicators of nicotine dependence, and generally more positive attitudes toward both smoking and vaping than concurrent non-daily users. Among daily nicotine users, compared with exclusive daily smokers, reports of interest in quitting were higher in all concurrent use groups. Dual daily users had the most positive attitudes about smoking overall, and saw it as the least denormalized, and at the same time were equally interested in quitting as other concurrent users and were most likely to report intending to continue vaping. Conclusions In Australia, Canada, England and the United States in 2016, daily nicotine users differed considerably from non-daily nicotine users. Among daily nicotine users, dual daily users (those who smoke and vape concurrently) should be treated as a distinct grouping when studying relationships between smoking and vaping. The eight-level typology characterizing concurrent and exclusive use of smoking and vaping should be considered when studying both products.

Aim: This study examines where vapers purchase their vaping refills in countries having different regulations over such devices, Canada (CA), the United States (US), England (EN), and Australia (AU). Methods: Data were available from 1899 current adult daily and weekly vapers who participated in the 2016 (Wave 1) International Tobacco Control Four Country Smoking and Vaping. The outcome was purchase location of vaping supplies (online, vape shop, other). Adjusted odds ratios and 95% confidence intervals were reported for between country comparisons. Results: Overall, 41.4% of current vapers bought their vaping products from vape shops, 27.5% bought them online, and 31.1% from other retail locations. The vast majority of vapers (91.1%) reported using nicotine-containing e-liquids. In AU, vapers were more likely to buy online vs other locations compared to CA (OR = 6.4, 2.3&ndash, 17.9), the US (OR = 4.1, 1.54&ndash, 10.7), and EN (OR = 7.9, 2.9&ndash, 21.8). In the US, they were more likely to buy from vape shops (OR = 3.3, 1.8&ndash, 6.2) or online (OR = 1.9, 1.0&ndash, 3.8) vs other retail locations when compared to those in EN. In CA, vapers were more likely to purchase at vape shops than at other retail locations when compared to vapers in EN (5.9, 3.2&ndash, 10.9) and the US (1.87, 1.0&ndash, 3.1). Conclusions: The regulatory environment and enforcement of such regulations appear to influence the location where vapers buy their vaping products. In AU, banning the retail sale of nicotine vaping products has led vapers to rely mainly on online purchasing sources, whereas the lack of enforcement of the same regulation in CA has allowed specialty vape shops to flourish.

Introduction:There is clear evidence that the use of cessation aids significantly increases the likelihood of successful smoking cessation. The aim of this study was to examine quitting activity and use of cessation aids among smokers from various European countries. Subgroup differences were also examined for sex, income, education, and age in each country.Methods:Cross-sectional data were collected in 2016 from 10683 smokers in eight European countries participating in the ITC Project: England (n=3536), Germany (n=1003), Greece (n=1000), Hungary (n=1000), the Netherlands (n=1136), Poland (n=1006), Romania (n=1001), and Spain (n=1001). We measured quitting activity, including quit attempts in the previous 12 months and intention to quit, use of cessation aids (i.e. medication, quitlines, internet, local services, e-cigarettes), and whether respondents had received advice from health professionals about quitting and e-cigarettes.Results:Quit attempts were most common in England (46.3%) and least common in Hungary (10.4%). Quit intention was highest in England and lowest in Greece. Use of e-cigarettes to quit was highest in England (51.6%) and lowest in Spain (5.0%). Use of cessation aids was generally low across all countries; in particular this was true for quitlines, internetbased support, and local services. Receiving health professional advice to quit was highest in Romania (56.5%), and lowest in Poland (20.8%); few smokers received advice about e-cigarettes from health professionals. No clear differences were found for sex and income groups. Across countries, smokers with lower education reported less quitting activity.Conclusions:Quitting activity and use of cessation methods were low in most countries. Greater quit attempts and use of cessation aids were found in England, where large investments in tobacco control and smoking cessation have been made. Health professionals are important for motivating smokers to quit and promoting the effectiveness of various methods, but overall, few smokers get advice to quit.

Background and Aims: Debate exists about whether health professionals (HPs) should advise smokers to use nicotine vaping products (NVPs) to quit smoking. The objectives were to examine in four countries: (1) the prevalence of HP discussions and recommendations to use an NVP; (2) who initiated NVP discussions; (3) the type of HP advice received about NVPs; and (4) smoker's characteristics related to receiving advice about NVPs. Design: Cross-sectional study using multivariable logistic regression analyses on weighted data from the 2016 ITC Four Country Smoking and Vaping Survey (ITC 4CV1). Setting: Four countries with varying regulations governing the sale and marketing of NVPs: ‘most restrictive’ (Australia), ‘restrictive’ (Canada) or ‘less restrictive’ (England and United States). Participants: A total of 6615 adult smokers who reported having visited an HP in the last year (drawn from the total sample of 12 294 4CV1 respondents, of whom 9398 reported smoking cigarettes daily or weekly). Respondents were from the United States (n = 1518), England (n = 2116), Australia (n = 1046), and Canada (n = 1935). Measurements: Participants’ survey responses indicated if they were current daily or weekly smokers and had visited an HP in the past year. Among those participants, further questions asked participants to report (1) whether NVPs were discussed, (2) who raised the topic, (3) advice received on use of NVPs and (4) advice received on quitting smoking. Findings: Among the 6615 smokers who visited an HP in the last year, 6.8% reported discussing NVPs with an HP and 2.1% of smokers were encouraged to use an NVP (36.1% of those who had a discussion). Compared with Australia (4.3%), discussing NVPs with an HP was more likely in the United States [8.8%, odds ratio (OR) = 2.15, 95% confidence interval (CI) = 1.41–3.29] and Canada (7.8%, OR = 1.87, 95% CI = 1.26–2.78). Smokers in Australia were less likely to discuss NVPs than smokers in England (6.2%), although this was not statistically significant (OR = 1.47, 95% CI = 0.98–2.20). Overall, the prevalence of HPs recommending NVPs was three times more likely in the United States than in Australia (OR = 3.07, 95% CI = 1.45–6.47), and twice as likely in Canada (OR = 2.28, 95% CI = 1.06–4.87) than in Australia. Australia and England did not differ (OR = 1.76, 95% CI = 0.83–3.74). Just over half (54%) of respondents brought up NVPs themselves; there were no significant differences among countries. Conclusions: Discussions in Australia, Canada, England, and the United States between smokers and health professionals about nicotine vaping products appear to be infrequent, regardless of the regulatory environment. A low percentage of health professionals recommended vaping products. This was particularly evident in Australia, which has the most restrictive regulatory environment of the four countries studied.

BACKGROUND: Research has suggested that smokers who quit smoking and continue to identify themselves as a smoker versus a non-smoker are at greater risk of relapse. This study examines the relationship between post-quit smoker identities and relapse risk of former smokers in Australia and the UK comparing those who still identified as a smoker with firm choice to no longer smoke versus those not expressing a firm choice. Cross-country differences were examined. METHODS: Data analysed came from 544 former smokers (quit 1 month or more) who participated in the Australian and UK Waves 9 (2013) and 10 (2014) of the International Tobacco Control (ITC) surveys. Post-quit smoker identities were assessed at baseline and smoking relapse at follow-up. RESULTS: Baseline self-reported smoker identity independently predicted smoking relapse at 12-month follow-up (p

Objective To explore between-country differences and within-country trends over time in smokers' reasons for thinking about quitting and the relationship between reasons and making a quit attempt. Methods Participants were nationally representative samples of adult smokers from the UK (N=4717), Canada (N=4884), the USA (N=6703) and Australia (N=4482), surveyed as part of the International Tobacco Control Four Country Survey between 2002 and 2015. Generalised estimating equations were used to evaluate differences among countries in smokers' reasons for thinking about quitting and their association with making a quit attempt at follow-up wave. Results Smokers' concern for personal health was consistently the most frequently endorsed reason for thinking about quitting in each country and across waves, and was most strongly associated with making a quit attempt. UK smokers were less likely than their counterparts to endorse health concerns, but were more likely to endorse medication and quitline availability reasons. Canadian smokers endorsed the most reasons, and smokers in the USA and Australia increased in number of reasons endorsed over the course of the study period. Endorsement of health warnings, and perhaps price, appears to peak in the year or so after the change is introduced, whereas other responses were not immediately linked to policy changes. Conclusions Differences in reasons for thinking about quitting exist among smokers in countries with different histories of tobacco control policies. Health concern is consistently the most common reason for quitting and the strongest predictor of future attempts.

Introduction The public health impact of vaporized nicotine products (VNPs) such as e-cigarettes is unknown at this time. VNP uptake may encourage or deflect progression to cigarette smoking in those who would not have otherwise smoked, thereby undermining or accelerating reductions in smoking prevalence seen in recent years. Methods The public health impact of VNP use are modeled in terms of how it alters smoking patterns among those who would have otherwise smoked cigarettes and among those who would not have otherwise smoked cigarettes in the absence of VNPs. The model incorporates transitions from trial to established VNP use, transitions to exclusive VNP and dual use, and the effects of cessation at later ages. Public health impact on deaths and life years lost is estimated for a recent birth cohort incorporating evidence-informed parameter estimates. Results Based on current use patterns and conservative assumptions, we project a reduction of 21% in smoking-attributable deaths and of 20% in life years lost as a result of VNP use by the 1997 US birth cohort compared to a scenario without VNPs. In sensitivity analysis, health gains from VNP use are especially sensitive to VNP risks and VNP use rates among those likely to smoke cigarettes. Conclusions Under most plausible scenarios, VNP use generally has a positive public health impact. However, very high VNP use rates could result in net harms. More accurate projections of VNP impacts will require better longitudinal measures of transitions into and out of VNP, cigarette and dual use. Implications Previous models of VNP use do not incorporate whether youth and young adults initiating VNP would have been likely to have been a smoker in the absence of VNPs. This study provides a decision-theoretic model of VNP use in a young cohort that incorporates tendencies toward smoking and shows that, under most plausible scenarios, VNP use yields public health gains. The model makes explicit the type of surveillance information needed to better estimate the effect of new products and thereby inform public policy.

Guided by the extended parallel process model (EPPM) and reactance theory, this study examined the relationship between efficacy beliefs, reactance, and adult smokers’ responses to pictorial health warning labels (HWL) on cigarette packaging, including whether efficacy beliefs or reactance modify the relationship between HWL responses and subsequent smoking cessation behavior. Four waves of data were analyzed from prospective cohorts of smokers in Australia and Canada (n = 7,120 observations) over a period of time after implementation of more prominent, pictorial HWLs. Three types of HWL responses were studied: psychological threat responses (i.e., thinking about risks from smoking), forgoing cigarettes due to HWLs, and avoiding HWLs. The results from Generalized Estimating Equation models indicated that stronger efficacy beliefs and lower trait reactance were significantly associated with greater psychological threat responses to HWLs. Similar results were found for models predicting forgoing behavior, although response efficacy was inversely associated with it. Only response efficacy was significantly associated with avoiding HWLs, showing a positive relationship. Higher self-efficacy and stronger responses to HWLs, no matter the type, were associated with attempting to quit in the follow-up period; reactance was unassociated. No statistically significant interactions were found. These results suggest that stronger efficacy beliefs and lower trait reactance are associated with some stronger responses to fear-arousing HWL responses; however, these HWL responses appear no less likely to lead to cessation attempts among smokers with different levels of self-efficacy to quit, of response efficacy beliefs, or of trait reactance against attempts to control their behavior.

The use of vaporized nicotine products (VNPs), especially e-cigarettes and, to a lesser extent, pressurized aerosol nicotine products and heat-not-burn tobacco products, are being adopted increasingly as an alternative to smoking combusted products, primarily cigarettes. Considerable controversy has accompanied their marketing and use. We propose a framework that describes and incorporates patterns of VNP and combustible cigarette use in determining the total amount of toxic exposure effects on population health. We begin by considering toxicity and the outcomes relevant to population health. We then present the framework and define different measures of VNP use; namely, trial and long-term use for exclusive cigarette smokers, exclusive VNP and dual (cigarette and VNP) use. Using a systems thinking framework and decision theory we considered potential pathways for current, former and never users of VNPs. We then consider the evidence to date and the probable impacts of VNP use on public health, the potential effects of different policy approaches and the possible influence of the tobacco industry on VNP and cigarette use.

Aims To determine whether abstinence or relapse on a quit attempt in the previous year is associated with current depressive symptoms. Design Prospective cohort with approximately annual waves. Mixed-effect logistic regressions tested whether time 2 (T2) quitting status was associated with reporting symptoms at T2, and whether time 1 (T1) symptoms moderated this relationship. Setting Waves 5–8 of the Four-Country International Tobacco Control Study: a quasi-experimental cohort study of smokers from Canada, the United States, the United Kingdom and Australia. Participants A total of 6978 smokers who participated in telephone surveys. Measurements T1 and T2 depressive symptoms in the last 4 weeks were assessed with two screening items from the PRIME-MD questionnaire. Quitting status at T2: (1) no attempt since T1; (2) attempted and relapsed; and (3) attempted and abstinent at T2. Findings Compared with no attempt, relapse was associated with reporting T2 symptoms [odds ratio (OR) = 1.46, 95% confidence interval (CI) = 1.33, 1.59]). Associations between T2 quitting status and T2 symptoms were moderated by T1 symptoms. Relapse was associated positively with T2 symptoms for those without T1 symptoms (OR = 1.71, 95% CI = 1.45, 2.03) and those with T1 symptoms (OR = 1.45, 95% CI = 1.23, 1.70). Abstinence was associated positively for those without T1 symptoms (OR = 1.37, 95% CI = 1.10, 1.71) and negatively for those with T1 symptoms (OR = 0.74, 95% CI = 0.59, 0.94). Age moderated these associations significantly. Relapse did not predict T2 symptoms for those aged 18–39 irrespective of T1 symptoms. The negative effect of abstinence on T2 symptoms for those with T1 symptoms was significant only for those aged 18–39 (OR = 0.61, 95% CI = 0.40, 0.94) and 40–55 (OR = 0.58, 95% CI = 0.40, 0.84). The positive effect of abstinence on T2 symptoms for those without T1 symptoms was significant only for those aged more than 55 (OR =1.97, 95% CI = 1.35, 2.87). Conclusions Most people who stop smoking appear to be at no greater risk of developing symptoms of depression than if they had continued smoking. However, people aged more than 55 who stop smoking may be at greater risk of developing symptoms of depression than if they had continued smoking.

BackgroundMuch attention has been directed towards the possible effects of e-cigarette advertisements on adolescent never smokers. However, e-cigarette advertising may also influence perceptions and behaviours of adult smokers. The aim of our study was to examine whether noticing e-cigarette advertisements is associated with current use of e-cigarettes, disapproval of smoking, quit smoking attempts, and quit smoking success.MethodsWe used longitudinal data from two survey waves of the ITC Netherlands Survey among smokers aged 16 years and older (n = 1198). Respondents were asked whether they noticed e-cigarettes being advertised on television, on the radio, and in newspapers or magazines in the previous 6 months.ResultsThere was a significant increase in noticing e-cigarette advertisements between 2013 (13.3%) and 2014 (36.0%), across all media. The largest increase was for television advertisements. There was also a substantial increase in current use of e-cigarettes (from 3.1% to 13.3%), but this was not related to noticing advertisements in traditional media (OR = 0.99, p = 0.937). Noticing advertisements was bivariately associated with more disapproval of smoking (Beta = 0.05, p = 0.019) and with a higher likelihood of attempting to quit smoking (OR = 1.37, p = 0.038), but these associations did not reach significance in multivariate analyses. There was no significant association between noticing advertisements and quit smoking success in either the bivariate or multivariate regression analysis (OR = 0.92, p = 0.807).ConclusionNoticing e-cigarette advertisements increased sharply in the Netherlands between 2013 and 2014 along with increased e-cigarette use, but the two appear unrelated. The advertisements did not seem to have adverse effects on disapproval of smoking and smoking cessation.

Aims To determine whether signs of current depression predict attempts to quit smoking, and short-term abstinence among those who try, and to test moderating effects of gender and cessation support (pharmacological and behavioural). Design Prospective cohort with approximately annual waves. Among smokers at one wave we assessed outcomes at the next wave using mixed-effects logistic regressions. Setting Waves 5–8 of the Four Country International Tobacco Control Study: a quasi-experimental cohort study of smokers from Canada, USA, UK and Australia. Participants A total of 6811 tobacco smokers who participated in telephone surveys. Measurements Three-level depression index: (1) neither low positive affect (LPA) nor negative affect (NA) in the last 4 weeks; (2) LPA and/or NA but not diagnosed with depression in the last 12 months; and (3) diagnosed with depression. Outcomes were quit attempts and 1-month abstinence among attempters. Findings Depression positively predicted quit attempts, but not after controlling for quitting history and motivational variables. Controlling for all covariates, depression consistently negatively predicted abstinence. Cessation support did not moderate this effect. There was a significant interaction with gender for quit attempts (P = 0.018) and abstinence (P = 0.049) after controlling for demographics, but not after all covariates. Depression did not predict abstinence among men. Among women, depressive symptoms [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.49–0.81] and diagnosis (OR = 0.46, 95% CI = 0.34–0.63) negatively predicted abstinence. Conclusions Smokers with depressive symptoms or diagnosis make more quit attempts than their non-depressed counterparts, which may be explained by higher motivation to quit, but they are also more likely to relapse in the first month. These findings are stronger in women than men.

Malaysia introduced graphic health warning labels (GHWLs) on all tobacco packages in 2009. We aimed to examine if implementing GHWLs led to stronger warning reactions (e.g., thinking about the health risks of smoking) and an increase in subsequent quitting activities; and to examine how reactions changed over time since the implementation of the GHWLs in Malaysia and Thailand where GHWL size increased from 50–55% in 2010. Data came from six waves (2005–2014) of the International Tobacco Control Southeast Asia Survey. Between 3,706 and 4,422 smokers were interviewed across these two countries at each survey wave. Measures included salience of warnings, cognitive responses (i.e., thinking about the health risks and being more likely to quit smoking), forgoing cigarettes, and avoiding warnings. The main outcome was subsequent quit attempts. Following the implementation of GHWLs in Malaysia, reactions increased, in some cases to levels similar to the larger Thai warnings, but declined over time. In Thailand, reactions increased following implementation, with no decline for several years, and no clear effect of the small increase in warning size. Reactions, mainly cognitive responses, were consistently predictive of quit attempts in Thailand, but this was only consistently so in Malaysia after the change to GHWLs. In conclusion, GHWLs are responded to more frequently, and generate more quit attempts, but warning wear-out is not consistent in these two countries, perhaps due to differences in other tobacco control efforts.