Brian V. Fix

Effectiveness of stop-smoking medications: findings from the International Tobacco Control (ITC) Four Country Survey

AIM To evaluate the population effectiveness of stop-smoking medications while accounting for potential recall bias by controlling for quit attempt recency. DESIGN Prospective cohort survey. SETTING United Kingdom, Canada, Australia and the United States. PARTICIPANTS A total of 7436 adult smokers (18+ years) selected via random digit dialling and interviewed as part of the International Tobacco Control Four Country Survey (ITC-4) between 2002 and 2009. Primary analyses utilized the subset of respondents who participated in 2006 or later (n = 2550). MEASUREMENTS Continuous abstinence from smoking for 1 month/6 months. FINDINGS Among participants who recalled making a quit attempt within 1 month of interview, those who reported using varenicline, bupropion or nicotine patch were more likely to maintain 6-month continuous abstinence from smoking compared to those who attempted to quit without medication [adjusted odds ratio (OR) 5.84, 95% confidence interval (CI) (2.12-16.12), 3.94 (0.87-17.80), 4.09 (1.72-9.74), respectively]; there were no clear effects for oral NRT use. Those who did not use any medication when attempting to quit tended to be younger, to be racial/ethnic minorities, to have lower incomes and to believe that medications do not make quitting easier. CONCLUSIONS Consistent with evidence from randomized controlled trials, smokers in the United Kingdom, Canada, Australia and the United States are more likely to succeed in quit attempts if they use varenicline, bupropion or nicotine patch. Previous population studies that failed to find an effect failed to control adequately for important sources of bias.

Usage Patterns of Stop Smoking Medications in Australia, Canada, the United Kingdom, and the United States: Findings from the 2006–2008 International Tobacco Control (ITC) Four Country Survey

Varenicline is a new prescription stop smoking medication (SSM) that has been available in the United States since August 1, 2006, in the United Kingdom and other European Union countries since December 5, 2006, in Canada since April 12, 2007, and in Australia since January 1, 2008. There are few population-based studies that have examined use rates of varenicline and other stop smoking medications. We report data from the ITC Four Country survey conducted with smokers in the US, UK, Canada, and Australia who reported an attempt to quit smoking in past year in the 2006 survey (n = 4,022 participants), 2007 (n = 3,790 participants), and 2008 surveys (n = 2,735 participants) Respondents reported use of various stop smoking medications to quit smoking at each survey wave, along with demographic and smoker characteristics. The self-reported use of any stop smoking medication has increased significantly over the 3 year period in all 4 countries, with the sharpest increase occurring in the United States. Varenicline has become the second most used stop smoking medication, behind NRT, in all 4 countries since being introduced. Between 2006 and 2008, varenicline use rates increased from 0.4% to 21.7% in the US, 0.0% to 14.8% in Canada, 0.0% to 14.5% in Australia, and 0.0% to 4.4% in the UK. In contrast, use of NRT and bupropion remained constant in each country. Males and non-whites were significantly less likely to report using any SSM, while more educated smokers were significantly more likely to use any SSM, including varenicline. Our findings suggest that the introduction of varenicline led to an increase in the number of smokers who used evidence-based treatment during their quit attempts, rather than simply gaining market share at the expense of other medications. From a public health perspective, messages regarding increased success rates among medication users and the relative safety of stop smoking medications should be disseminated widely so as to reach all smokers of all socioeconomic classifications equally.

Smokers' reactions to reduced ignition propensity cigarettes

Background: On 28 June 2004, New York State (NY) became the first jurisdiction to require cigarettes to meet a reduced ignition propensity (RIP) standard. This law resulted in cigarette manufacturers modifying nearly all of their brands sold in NY. However, the same cigarette brands sold in other states were not modified to meet the RIP standard. Objectives: This paper examines relationships between the RIP law and smokers’ awareness of changes in the performance of their cigarettes (that is, going out more frequently, change in taste), and smoking behaviour. Methods: Data for this analysis come from a nationwide survey of 2088 adult smokers (> 18 years of age) conducted in the USA between July and December 2004. 143 of the smokers included in the survey were residents of NY while the remainder were from other states (n  =  1945). Survey participants were asked whether their cigarettes “ever go out between puffs” and whether they had noticed any change in the taste of their cigarettes in the past 12 months. Results: NY smokers were three times more likely than smokers in other states to report that their cigarettes often went out between puffs (17.3% v 5.6%). However, NY smokers appeared no more likely to report noticing differences in cigarette taste, an intention to quit smoking, or to have made quit attempts. Conclusions: A significant minority of smokers in NY reported noticing changes in the performance of their cigarettes following the RIP law, as would be expected. However, the RIP law appears to have had no impact on the smoking habits of New Yorkers, countering arguments made by cigarette manufacturers that the law would impact consumer acceptability.

Trends in market share of leading cigarette brands in the USA: national survey on drug use and health 2002–2013

Objectives The main objective of this study is to examine trends in market share for leading cigarette brands, both before (2002–2008) and after (2009–2013) Food and Drug Administration (FDA) regulation of tobacco products. Design Data come from the annual National Survey on Drug Use and Health from 2002 through 2013. Descriptive statistics, cross tabulations, and logistic regression were employed. Data were weighted to the US population and adjusted for cigarette consumption. Our analysis is restricted to 164 343 current cigarette smokers who were at least 12 years of age or older, had smoked at least one cigarette in the 30 days prior to the survey, and reported a usual cigarette brand at the time of the survey. Results Over 12 years, 14 brands comprised over 77% of the cigarette market. Marlboro consistently held over 38% of the market. Newport held the second highest market share, and increased from 7.2% in 2002 to 10.9% by 2013. Market share of Pall Mall grew by over 400% (1.7% in 2002 vs 8.9% in 2013), likely aided by the 2009 Federal excise tax increase. No clear associations of changes in market share with the implementation of FDAs regulatory authority over tobacco in 2009 were noted. Conclusions Tracking market share trends offers clues about brand marketing changing preferences of consumers. Rapidly growing cigarette brands should be monitored to determine if specific marketing practices or design changes are drivers, as these could represent public health concerns. Monitoring trends in cigarette market share could inform regulatory decision-making efforts related to marketing and advertising.

A novel approach to estimating the prevalence of untaxed cigarettes in the USA: findings from the 2009 and 2010 international tobacco control surveys

Background Increases in tobacco taxes are effective in reducing tobacco consumption, but because of the addictive nature of cigarettes, smokers often seek out less expensive sources of cigarettes. The objective of this study is to estimate the prevalence of cigarette packs that are untaxed by the state in which the participant resides in a sample of US smokers at two time points. Methods Data for this study were taken from the 2009 and 2010 waves of the International Tobacco Control United States Survey. Members of this nationally representative cohort of smokers were invited to send us an unopened pack of their usual brand of cigarettes. Results In 2009, 318 packs were received from 401 eligible participants (79%). In 2010, 366 packs were received from 491 eligible participants (75%). In total, 20% of the packs in 2009 and 21% in 2010 were classified as untaxed by the participants state of residence. The prevalence of untaxed cigarettes was higher in states with higher-excise taxes. Smokers who do not have a plan to quit were significantly more likely to have sent back a pack that was classified as untaxed by the participants state of residence. Conclusions One in five packs were untaxed with rates higher in states with higher-excise taxes. It is unclear whether these estimates differ from the actual prevalence of cigarettes that are untaxed by a smokers state of residence. Harmonisation of excise tax rates across all 50 US states might be one method of reducing or eliminating the incentive to avoid or evade these taxes.

The impact of reduced ignition propensity cigarette regulation on smoking behaviour in a cohort of Ontario smokers

This study examined the degree to which legislation intended to reduce the incidence of cigarette-caused fires influenced the behaviours of a cohort of smokers in Ontario. A random digit dialled telephone survey of adult smokers residing in Ontario was conducted in 2005, ending 1 month prior to the reduced ignition propensity (RIP) regulations implementation date. A follow-up survey was conducted one year later. Of the baseline participants, 73.0% (n=435) completed the follow-up survey. The frequency of fire risk behaviours was similar across both surveys. At baseline, only 3.7% of smokers interviewed reported that their cigarettes went out on their own ‘often’ while smoking. Following the implementation of the reduced ignition propensity legislation, this increased significantly to 14.7%. Results suggest that the proportion of Ontario smokers who reported engaging in behaviour such as leaving a cigarette burning unattended and smoking in bed actually declined, although these declines were not statistically significant across all measures of fire risk.

Sex Differences Among College Students in Awareness of the Human Papillomavirus Vaccine and Vaccine Options

Abstract Objectives: To explore awareness of human papillomavirus (HPV) and use of HPV vaccines (Gardasil and Cervarix) by college students. Participants: The sample was composed of 817 undergraduates at 2 northeastern US universities; they participated between February and May 2010. Methods: Students were provided with a link to an anonymous, self-administered, Web-based survey comprised of 76 questions. The survey included questions about health behaviors, awareness, and knowledge of HPV and the 2 HPV vaccines, and vaccine uptake. Results: Results indicate high levels of awareness of HPV as well as marked sex differences related to vaccine awareness and uptake. Both sexes are largely unaware of Cervarix and the differences between Cervarix and Gardasil. Conclusion: The study affirms the importance of a clinicians recommendation for HPV vaccination. Public health messaging should become more inclusive of adolescent and young adult males. College students’ awareness of HPV vaccine options mirrors Gardasils market dominance in the United States.

Evaluation of modified risk claim advertising formats for Camel Snus

Objectives: The US Food and Drug Administration (FDA) has regulatory authority for modified risk tobacco product advertising claims. To guide future regulatory efforts, we investigated how variations in modified risk claim advertisements influence consumer perceptions of product risk claims for Camel Snus. Methods: Young people and adults (15–65), including current, never, and former smokers, were randomised to view one of five Camel Snus print advertisements as part of a web-based survey. Four of the advertisements presented information related to nitrosamine content of snus using four formats: (1) text, (2) a bar chart, (3) a text/testimonial and (4) a bar chart/testimonial. The fifth format, used as a control, was a current advertisement for Camel Snus without the explicit claims made about nitrosamine content. After viewing advertisements for all products, participants were asked which product they would be most interested in trying. Results: Participants exposed to advertisements that contained an explicit reduced risk message agreed the advertising claim for that product posed fewer health risks than cigarettes. However, advertisements containing the reduced risk messages were also viewed as containing less truthful information and respondents were more sceptical of the information presented. Advertisement claim format was not associated with selecting snus over the other tobacco products, nor was it associated with purchase intentions. Conclusion: The results of this research indicate that consumers respond to reduced risk messages, though perhaps not in the direct way anticipated. We found no significant differences by advertisement format (numerical, graphical, testimonial).

Differences in Cigarette Design and Metal Content across Five Countries: Results from the International Tobacco Control (ITC) Project

Objectives The current study examines physical cigarette design characteristics and tobacco metal content of cigarettes obtained from 5 countries to determine how these properties vary for cigarette brands, both within and across countries with different dominant manufacturers. Methods Cigarette packs were collected from International Tobacco Control Policy Evaluation Survey (ITC) participants in the U.S., the U.K., Mauritius, Mexico, and Thailand. Cigarettes were assessed for physical and design properties (eg, ventilation, pressure drop, rod density, weight) by published methods, and for metal content (As, Cd, Ni, Pb) by X-ray fluorescence spectrometry. Results Significant differences in cigarette design and toxic metal concentrations were observed between countries and between manufacturers within countries. Filter ventilation, which is strongly predictive of machine-measured tar and nicotine levels, varied most widely across countries. Ni and Cd were highest in Thailand (2.23ug/g and 1.64ug/g, respectively); As was highest in Mexico (0.29ug/g) and Pb was highest in the U.K. (0.43 ug/g). Conclusions Parties to the FCTC should consider the adoption of uniform product standards related to cigarette design, emissions, and tobacco content that would reduce population health risks.

ITC spit and butts pilot study: The feasibility of collecting saliva and cigarette butt samples from smokers to evaluate policy

INTRODUCTION Large-scale epidemiological surveys have frequently relied upon clinic-based sample collection to incorporate biological data, which can be costly and result in nonrepresentative data. Collecting samples in a nonclinical setting (i.e., through postal mail or at the subjects home) offers an alternative option that is minimally invasive and can be incorporated into large population-based studies. OBJECTIVES (a) To assess the feasibility of collecting biological data from a cohort of smokers in the International Tobacco Control (ITC) study, through the mail and in the home; (b) to examine whether participants are representative of the population under consideration; and (c) to evaluate how the added burden of providing biomarker samples might impact subsequent participation in a follow-up survey. METHODS Participants were asked to provide a saliva sample and five cigarette butts from cigarettes smoked on a single day, using standardized procedures. Sample collection kits were mailed to a random sample of 400 daily cigarette smokers who were involved in the 2006 annual ITC Four Country (United Kingdom, United States, Canada, and Australia) telephone survey and agreed to participate in sample collection. A random sample of 179 daily smokers who participated in a face-to-face ITC survey in Mexico and Uruguay and agreed to participate in sample collection were also asked to provide samples. RESULTS Samples were collected from 96% of invited participants in the face-to-face surveys and 52% of participants in the telephone survey. The added burden of the sample collection did not reduce survey retention rates. Participants who initially agreed to participate in the sample collection were more likely to participate in the subsequent survey than participants who were not asked or declined to participate (odds ratio [OR] = 1.28; 95% CI = 1.01-1.62, p = .021). Further, those who provided samples were also more likely to participate in the subsequent survey than those who did not (OR = 2.78; 95% CI = 1.71-4.52, p < .001). DISCUSSION Collecting saliva and cigarette butt samples from a group of smokers is feasible, yields a representative sample, and the added participant burden does not reduce subsequent survey response rates.