Andrew Hyland

Electronic Nicotine Delivery Systems: International Tobacco Control Four-Country Survey

BACKGROUND Electronic nicotine delivery systems (ENDS) initially emerged in 2003 and have since become widely available globally, particularly over the Internet. PURPOSE Data on ENDS usage patterns are limited. The current paper examines patterns of ENDS awareness, use, and product-associated beliefs among current and former smokers in four countries. METHODS Data come from Wave 8 of the International Tobacco Control Four-Country Survey, collected July 2010 to June 2011 and analyzed through June 2012. Respondents included 5939 current and former smokers in Canada (n=1581); the U.S. (n=1520); the United Kingdom (UK; n=1325); and Australia (n=1513). RESULTS Overall, 46.6% were aware of ENDS (U.S.: 73%, UK: 54%, Canada: 40%, Australia: 20%); 7.6% had tried ENDS (16% of those aware of ENDS); and 2.9% were current users (39% of triers). Awareness of ENDS was higher among younger, non-minority smokers with higher incomes who were heavier smokers. Prevalence of trying ENDS was higher among younger, nondaily smokers with a high income and among those who perceived ENDS as less harmful than traditional cigarettes. Current use was higher among both nondaily and heavy (≥20 cigarettes per day) smokers. In all, 79.8% reported using ENDS because they were considered less harmful than traditional cigarettes; 75.4% stated that they used ENDS to help them reduce their smoking; and 85.1% reported using ENDS to help them quit smoking. CONCLUSIONS Awareness of ENDS is high, especially in countries where they are legal (i.e., the U.S. and UK). Because trial was associated with nondaily smoking and a desire to quit smoking, ENDS may have the potential to serve as a cessation aid.

Reductions in tobacco smoke pollution and increases in support for smoke-free public places following the implementation of comprehensive smoke-free workplace legislation in the Republic of Ireland: findings from the ITC Ireland/UK Survey

Objective: To evaluate the psychosocial and behavioural impact of the first ever national level comprehensive workplace smoke-free law, implemented in Ireland in March 2004. Design: Quasi-experimental prospective cohort survey: parallel cohort telephone surveys of national representative samples of adult smokers in Ireland (n  =  769) and the UK (n  =  416), surveyed before the law (December 2003 to January 2004) and 8–9 months after the law (December 2004 to January 2005). Main outcome measures: Respondents’ reports of smoking in key public venues, support for total bans in those key venues, and behavioural changes due to the law. Results: The Irish law led to dramatic declines in reported smoking in all venues, including workplaces (62% to 14%), restaurants (85% to 3%), and bars/pubs (98% to 5%). Support for total bans among Irish smokers increased in all venues, including workplaces (43% to 67%), restaurants (45% to 77%), and bars/pubs (13% to 46%). Overall, 83% of Irish smokers reported that the smoke-free law was a “good” or “very good” thing. The proportion of Irish homes with smoking bans also increased. Approximately 46% of Irish smokers reported that the law had made them more likely to quit. Among Irish smokers who had quit at post-legislation, 80% reported that the law had helped them quit and 88% reported that the law helped them stay quit. Conclusion: The Ireland smoke-free law stands as a positive example of how a population-level policy intervention can achieve its public health goals while achieving a high level of acceptance among smokers. These findings support initiatives in many countries toward implementing smoke-free legislation, particularly those who have ratified the Framework Convention on Tobacco Control, which calls for legislation to reduce tobacco smoke pollution.

Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry

Objective: To compare the quality and funding source of studies concluding a negative economic impact of smoke-free policies in the hospitality industry to studies concluding no such negative impact. Data sources: Researchers sought all studies produced before 31 August 2002. Articles published in scientific journals were located with Medline, Science Citation Index, Social Sciences Citation Index, Current Contents, PsychInfo, Econlit, and Healthstar. Unpublished studies were located from tobacco company websites and through internet searches. Study selection: 97 studies that made statements about economic impact were included. 93% of the studies located met the selection criteria as determined by consensus between multiple reviewers. Data extraction: Findings and characteristics of studies (apart from funding source) were classified independently by two researchers. A third assessor blind to both the objective of the present study and to funding source also classified each study. Data synthesis: In studies concluding a negative impact, the odds of using a subjective outcome measure was 4.0 times (95% confidence interval (CI) 1.4 to 9.6; p = 0.007) and the odds of not being peer reviewed was 20 times (95% CI 2.6 to 166.7; p = 0.004) that of studies concluding no such negative impact. All of the studies concluding a negative impact were supported by the tobacco industry. 94% of the tobacco industry supported studies concluded a negative economic impact compared to none of the non-industry supported studies. Conclusion: All of the best designed studies report no impact or a positive impact of smoke-free restaurant and bar laws on sales or employment. Policymakers can act to protect workers and patrons from the toxins in secondhand smoke confident in rejecting industry claims that there will be an adverse economic impact.

Time to First Cigarette in the Morning as an Index of Ability to Quit Smoking: Implications for Nicotine Dependence

An inability to maintain abstinence is a key indicator of tobacco dependence. Unfortunately, little evidence exists regarding the ability of the major tobacco dependence measures to predict smoking cessation outcome. This paper used data from four placebo-controlled smoking cessation trials and one international epidemiological study to determine relations between cessation success and the Fagerström Test for Nicotine Dependence (FTND), the Heaviness of Smoking Index, the Nicotine Dependence Syndrome Scale, and the Wisconsin Inventory of Smoking Dependence Motives. Results showed that much of the predictive validity of the FTND could be attributed to its first item, time to first cigarette in the morning, and this item had greater validity than any other single measure. Thus the time-to-first-cigarette item appears to tap a pattern of heavy, uninterrupted, and automatic smoking and may be a good single-item measure of nicotine dependence.

Individual-level predictors of cessation behaviours among participants in the International Tobacco Control (ITC) Four Country Survey

Background: The International Tobacco Control (ITC) Four Country Survey (ITC-4) is a prospective cohort study designed to evaluate the psychosocial and behavioural impact of national-level tobacco control policies enacted in the Australia, Canada, the UK, and the USA. Wave 1 of ITC-4 survey was conducted between October 2002 and December 2002. Wave 2 survey was conducted between May 2003 and August 2003. Objective: To test for individual-level predictors of smoking cessation behaviours (that is, quit attempts and smoking cessation) among cigarette smokers in the ITC Four Country Study measured between Wave 1 and Wave 2. This set of predictors will serve as the base for evaluating the added effect of tobacco control policies and other factors. Methods: Respondents included in this study are 6682 adult current smokers in the Wave 1 main survey who completed the Wave 2 follow-up (1665 were in Canada, 1329 were in the USA, 1837 were in the UK and 1851 were in Australia). Results: Factors predictive of making a quit attempt included intention to quit, making a quit attempt in the previous year, longer duration of past quit attempts, less nicotine dependence, more negative attitudes about smoking, and younger age. Lower levels of nicotine dependence were the main factor that predicted future cessation among those that made a quit attempt. Conclusion: Intention to quit and other cognitive variables were associated with quit attempts, but not cessation. Behavioural variables related to task difficulty, including measures of dependence, predicted both making attempts and their success. Predictors of making quit attempts and cessation were similar for each of the four countries, but there were some differences in predictors of success.

Predictors of cessation in a cohort of current and former smokers followed over 13 years

The present study attempted to identify predictors of smoking cessation in a cohort of cigarette smokers followed over 13 years. Data are reported on 6,603 persons who resided in one of 20 U.S. communities involved in the National Cancer Institutes Community Intervention Trial for Smoking Cessation (COMMIT) study, were current smokers in the COMMIT trial in 1988, and completed detailed tobacco use telephone surveys in 1988, 1993, and 2001. A person was classified as a former smoker if at the time of follow-up he or she reported not smoking for at least 6 months prior to the interview. Reasons and methods for quitting also were assessed in 1993 and 2001. Among smokers in 1988, 24% had stopped smoking by 1993 and 42% were not smoking by 2001. The most frequently cited reasons for quitting were health and cost reasons, while assisted methods to quit were more common in more recent years. Measures of nicotine dependence were much more strongly associated with cessation than measures of motivation. Other predictors included male gender, older age, higher income, and less frequent alcohol consumption, although the gender effect no longer existed when cessation from cigarettes as well as other tobacco products was considered as the outcome. The present study shows that nicotine dependence is a major factor predicting long-term cessation in smokers. This finding has implications for tobacco control policy and treatment approaches.

The conceptual framework of the International Tobacco Control (ITC) Policy Evaluation Project

This paper describes the conceptual model that underlies the International Tobacco Control Policy Evaluation Project (ITC Project), whose mission is to measure the psychosocial and behavioural impact of key policies of the Framework Convention on Tobacco Control (FCTC) among adult smokers, and in some countries, among adult non-smokers and among youth. The evaluation framework utilises multiple country controls, a longitudinal design, and a pre-specified, theory-driven conceptual model to test hypotheses about the anticipated effects of specific policies. The ITC Project consists of parallel prospective cohort surveys of representative samples of adult smokers currently in nine countries (inhabited by over 45% of the world’s smokers), with other countries being added in the future. Collectively, the ITC Surveys constitute the first-ever international cohort study of tobacco use. The conceptual model of the ITC Project draws on the psychosocial and health communication literature and assumes that tobacco control policies influence tobacco related behaviours through a causal chain of psychological events, with some variables more closely related to the policy itself (policy-specific variables) and other variables that are more downstream from the policy, which have been identified by health behaviour and social psychological theories as being important causal precursors of behaviour (psychosocial mediators). We discuss the objectives of the ITC Project and its potential for building the evidence base for the FCTC.

Determinants and consequences of smoke-free homes: findings from the International Tobacco Control (ITC) Four Country Survey

Objective: To report on prevalence, trends and determinants of smoke-free home policies in smokers’ homes in different countries and to estimate the effects of these policies on smoking cessation. Design: Two waves of the International Tobacco Control (ITC) Four Country Survey (ITC-4), a cohort survey of smokers conducted by telephone. Wave 1 was conducted in October/December 2002 with broadly representative samples of over 2000 adult (⩾ 18 years) cigarette smokers in each of the following four countries: Canada, the United States, the United Kingdom, and Australia, 75% of whom were followed up at Wave 2 on average seven months later. Key measures: Levels of smoking restrictions in homes (both waves). Results: Australian smokers were most likely to live in smoke-free homes and UK smokers least likely (34% v 15% at Wave 1). Levels of smoke-free homes increased between waves. Logistic regressions indicated that the main independent predictors of smokers reporting smoke-free homes or implementation of a smoke-free policy between waves included household factors such as having a child, particularly a young child, and having other non-smoking adults in the household. Positive attitudes to smoke-free public places and/or reported presence of smoke-free public places were independent predictors of having or implementing smoke-free homes, supporting a social diffusion model for smoking restrictions. Intentions to quit at Wave 1 and quitting activity between survey waves were associated with implementing bans between Waves 1 and 2. Presence of bans at Wave 1 was associated with significantly greater proportions of quit attempts, and success among those who tried at Wave 2. There was no significant interaction between the predictive models and country. Conclusions: Smoke-free public places seem to stimulate adoption of smoke-free homes, a strategy associated with both increased frequency of quit attempts, and of the success of those attempts.

Methods of the International Tobacco Control (ITC) Four Country Survey

This paper outlines the design features, data collection methods and analytic strategies of the International Tobacco Control (ITC) Four Country Survey, a prospective study of more than 2000 longitudinal respondents per country with yearly replenishments. This survey possesses unique features that sets it apart among surveys on tobacco use and cessation. One of these features is the use of theory-driven conceptual models. In this paper, however, the focus is on the two key statistical features of the survey: longitudinal and “quasi-experimental” designs. Although it is often possible to address the same scientific questions with a cross-sectional or a longitudinal study, the latter has the major advantage of being able to distinguish changes over time within individuals from differences among people at baseline (that is, differences between age and cohort effects). Furthermore, quasi-experiments, where countries not implementing a given new tobacco control policy act as the control group to which the country implementing such a policy will be compared, provide much stronger evidence than observational studies on the effects of national-level tobacco control policies. In summary, application of rigorous research methods enables this survey to be a rich data resource, not only to evaluate policies, but also to gain new insights into the natural history of smoking cessation, through longitudinal analyses of smoker behaviour.

Declines in Hospital Admissions for Acute Myocardial Infarction in New York State After Implementation of a Comprehensive Smoking Ban

OBJECTIVES Reductions in exposure to environmental tobacco smoke have been shown to attenuate the risk of cardiovascular disease. We examined whether the 2003 implementation of a comprehensive smoking ban in New York State was associated with reduced hospital admissions for acute myocardial infarction and stroke, beyond the effect of moderate, local and statewide smoking restrictions, and independent of secular trends. METHODS We analyzed trends in county-level, age-adjusted, monthly hospital admission rates for acute myocardial infarction and stroke from 1995 to 2004 to identify any association between admission rates and implementation of the smoking ban. We used regression models to adjust for the effects of pre-existing smoking restrictions, seasonal trends in admissions, differences across counties, and secular trends. RESULTS In 2004, there were 3813 fewer hospital admissions for acute myocardial infarction than would have been expected in the absence of the comprehensive smoking ban. Direct health care cost savings of