Timea R. Partos

How much unsuccessful quitting activity is going on among adult smokers? Data from the International Tobacco Control Four Country cohort survey

AIMS To document accurately the amount of quitting, length of quit attempts and prevalence of plans and serious thought about quitting among smokers. DESIGN We used longitudinal data from 7 waves of the International Tobacco Control Policy Evaluation Four Country Survey (ITC-4). We considered point-prevalence data and cumulative prevalence over the 7 years of the study. We also derived annual estimates of quit activity from reports of quit attempts starting only within more recent time-frames, to control for biased recall. SETTING Australia, Canada, the United Kingdom and the United States. PARTICIPANTS A total of 21,613 smokers recruited across seven waves. MEASUREMENTS Reported life-time quit attempts, annual quit attempts, length of attempts, time since last attempt started, frequency of aborted attempts, plans to quit and serious thought about quitting. FINDINGS Around 40.1% (95% CI: 39.6-40.6) of smokers report attempts to quit in a given year and report an average of 2.1 attempts. Based on free recall, this translates to an average annual quit attempt rate of 0.82 attempts per smoker. Estimates derived only from the preceding month to adjust for recall bias indicate an annual rate of approximately one attempt per smoker. There is a high prevalence of quit-related activity, with more than a third of smokers reporting thoughts or actions related to quitting in a given month. More than half the surveyed smokers eventually succeeded in quitting for at least 1 month, and a majority of these for over 6 months. CONCLUSIONS Smokers think a great deal about stopping and make many unsuccessful quit attempts. Many have been able to last for extended periods and yet they still relapsed. More attention needs to be focused on translating quit-related activity into long-term abstinence.

Cigarette packet warning labels can prevent relapse: findings from the International Tobacco Control 4-Country policy evaluation cohort study

Objectives To investigate the links between health warning labels (WLs) on cigarette packets and relapse among recently quit smokers. Design Prospective longitudinal cohort survey. Setting Australia, Canada, the UK and the USA. Participants 1936 recent ex-smokers (44.4% male) from one of the first six waves (2002–2007) of the International Tobacco Control 4-Country policy evaluation survey, who were followed up in the next wave. Main outcome measures Whether participants had relapsed at follow-up (approximately 1 year later). Results In multivariate analysis, very frequent noticing of WLs among ex-smokers was associated with greater relapse 1 year later (OR: 1.52, 95% CI 1.11 to 2.09, p<0.01), but this effect disappeared after controlling for urges to smoke and self-efficacy (OR: 1.29, 95% CI 0.92 to 1.80, p=0.135). In contrast, reporting that WLs make staying quit ‘a lot’ more likely (compared with ‘not at all’ likely) was associated with a lower likelihood of relapse 1 year later (OR: 0.65, 95% CI 0.49 to 0.86, p<0.01) and this effect remained robust across all models tested, increasing in some. Conclusions This study provides the first longitudinal evidence that health warnings can help ex-smokers stay quit. Once the authors control for greater exposure to cigarettes, which is understandably predictive of relapse, WL effects are positive. However, it may be that ex-smokers need to actively use the health consequences that WLs highlight to remind them of their reasons for quitting, rather than it being something that happens automatically. Ex-smokers should be encouraged to use pack warnings to counter urges to resume smoking. Novel warnings may be more likely to facilitate this.

Australian smokers’ support for plain or standardised packs before and after implementation: findings from the ITC Four Country Survey

Background Plain packaging (PP) for tobacco products was fully implemented in Australia on 1 December 2012 along with larger graphic health warnings. Using longitudinal data from the Australian arm of the ITC Four Country Survey, we examined attitudes to the new packs before and after implementation, predictors of attitudinal change, and the relationship between support and quitting activity. Methods A population-based cohort study design, with some cross-sectional analyses. Surveys of Australian smokers assessed attitudes to PP at four time points prior to implementation (from 2007 to 2012) and one post-implementation wave collected (early/mid-2013). Results Trend analysis showed a slight rise in opposition to PP among smokers in the waves leading up to their implementation, but no change in support. Support for PP increased significantly after implementation (28.2% pre vs 49% post), such that post-PP more smokers were supportive than opposed (49% vs 34.7%). Multivariate analysis showed support either before or after implementation was predicted by belief in greater adverse health impacts of smoking, desire to quit and lower addiction. Among those not supportive before implementation, having no clear opinion about PP (versus being opposed) prior to the changes also predicted support post-implementation. Support for PP was prospectively associated with higher levels of quitting activity. Conclusions Since implementation of PP along with larger warnings, support among Australian smokers has increased. Support is related to lower addiction, stronger beliefs in the negative health impacts of smoking, and higher levels of quitting activity.

Smoking-related thoughts and microbehaviours, and their predictive power for quitting

Background Negative attitudes to smoking are well-established predictors of intentions to quit and quit behaviours, but less attention has been given to whether quitting is influenced by smoking-related thoughts and microbehaviours that reflect a concern about smoking. Objectives This paper aimed to describe the occurrence of smoking-related thoughts and microbehaviours among Chinese smokers, and to examine their predictive power for making quit attempts and sustained abstinence. Methods The data came from the first three waves of the International Tobacco Control China Survey. Four measures of recent thoughts about smoking and two microbehaviour measures (collectively referred to as microindicators) were examined. Results Most smokers (around three-quarters) reported thinking about harms of smoking to themselves or to others at least occasionally, and an increasing minority reported the two microbehaviours of prematurely butting out cigarettes and forgoing them. All microindicators were positively related to subsequent quit attempts in individual predictor analyses, but only serious thoughts about quitting and butting out cigarettes had independent relationships. Overall, there was no clear relationship between these microindicators and sustained abstinence. Conclusions There was a moderately high level of occurrence of recent smoking-related thoughts and microbehaviours among the Chinese adult smokers in the six cities studied. Like in the West, microindicators of concern about smoking were positively associated with subsequent quit attempts, but unlike in the West, they were largely unrelated to sustained abstinence.

Tobacco industry strategies undermine government tax policy: evidence from commercial data

Objective Taxation equitably reduces smoking, the leading cause of health inequalities. The tobacco industry (TI) can, however, undermine the public health gains realised from tobacco taxation through its pricing strategies. This study aims to examine contemporary TI pricing strategies in the UK and implications for tobacco tax policy. Design Review of commercial literature and longitudinal analysis of tobacco sales and price data. Setting A high-income country with comprehensive tobacco control policies and high tobacco taxes (UK). Participants 2009 to 2015 Nielsen Scantrak electronic point of sale systems data. Main outcome measures Tobacco segmentation; monthly prices, sales volumes of and net revenue from roll-your-own (RYO) and factory-made (FM) cigarettes by segment; use of price-marking and pack sizes. Results The literature review and sales data concurred that both RYO and FM cigarettes were segmented by price. Despite regular tax increases, average real prices for the cheapest FM and RYO segments remained steady from 2013 while volumes grew. Low prices were maintained through reductions in the size of packs and price-marking. Each year, at the point the budget is implemented, the TI drops its revenue by up to 18 pence per pack, absorbing the tax increases (undershifting). Undershifting is most marked for the cheapest segments. Conclusions The TI currently uses a variety of strategies to keep tobacco cheap. The implementation of standardised packaging will prevent small pack sizes and price-marking but further changes in tax policy are needed to minimise the TI’s attempts to prevent sudden price increases.

Availability and use of cheap tobacco in the UK 2002 - 2014: findings from the International Tobacco Control Project

Abstract Introduction Raising tobacco prices is the most effective population-level intervention for reducing smoking, but this is undermined by the availability of cheap tobacco. This study monitors trends in cheap tobacco use among adult smokers in the United Kingdom between 2002 and 2014 via changes in product type, purchase source, and prices paid. Methods Weighted data from 10 waves of the International Tobacco Control policy evaluation study were used. This is a longitudinal cohort study of adult smokers with replenishment; 6169 participants provided 15812 responses. Analyses contrasted (1) product type: roll-your-own (RYO) tobacco, factory-made packs (FM-P), and factory-made cartons (FM-C); (2) purchase source: UK store-based sources (e.g., supermarkets and convenience stores) with non-UK/nonstore sources representing tax avoidance/evasion (e.g., outside the UK, duty free, and informal sellers); and (3) prices paid (inflation-adjusted to 2014 values). Generalized estimating equations tested linear changes over time. Results (1) RYO use increased significantly over time as FM decreased. (2) UK store-based sources constituted approximately 80% of purchases over time, with no significant increases in tax avoidance/evasion. (3) Median RYO prices were less than half that of FM, with FM-C cheaper than FM-P. Non-UK/nonstore sources were cheapest. Price increases of all three product types from UK store-based sources from 2002 to 2014 were statistically significant but not substantial. Wide (and increasing for FM-P) price ranges meant each product type could be purchased in 2014 at prices below their 2002 medians from UK store-based sources. Conclusions Options exist driving UK smokers to minimize their tobacco expenditure; smokers do so largely by purchasing cheap tobacco products from UK stores. Implications The effectiveness of price increases as a deterrent to smoking is being undermined by the availability of cheap tobacco such as roll-your-own tobacco and cartons of packs of factory-made cigarettes. Wide price ranges allowed smokers in 2014 to easily obtain cigarettes at prices comparable to 12 years prior, without resorting to tax avoidance or evasion. UK store-based sources accounted for 80% or more of all tobacco purchases between 2002 and 2014, suggesting little change in tax avoidance or evasion over time. There was a widening price range between the cheapest and most expensive factory-made cigarettes.

You Don't See What I See: Individual Differences in the Perception of Meaning from Visual Stimuli

Everyone has their own unique version of the visual world and there has been growing interest in understanding the way that personality shapes one’s perception. Here, we investigated meaningful visual experiences in relation to the personality dimension of schizotypy. In a novel approach to this issue, a non-clinical sample of subjects (total n = 197) were presented with calibrated images of scenes, cartoons and faces of varying visibility embedded in noise; the spatial properties of the images were constructed to mimic the natural statistics of the environment. In two experiments, subjects were required to indicate what they saw in a large number of unique images, both with and without actual meaningful structure. The first experiment employed an open-ended response paradigm and used a variety of different images in noise; the second experiment only presented a series of faces embedded in noise, and required a forced-choice response from the subjects. The results in all conditions indicated that a high positive schizotypy score was associated with an increased tendency to perceive complex meaning in images comprised purely of random visual noise. Individuals high in positive schizotypy seemed to be employing a looser criterion (response bias) to determine what constituted a ‘meaningful’ image, while also being significantly less sensitive at the task than those low in positive schizotypy. Our results suggest that differences in perceptual performance for individuals high in positive schizotypy are not related to increased suggestibility or susceptibility to instruction, as had previously been suggested. Instead, the observed reductions in sensitivity along with increased response bias toward seeing something that is not there, indirectly implicated subtle neurophysiological differences associated with the personality dimension of schizotypy, that are theoretically pertinent to the continuum of schizophrenia and hallucination-proneness.

Quitting activity and tobacco brand switching: findings from the ITC-4 Country Survey.

Objective: Among Australian smokers, to examine associations between cigarette brand switching, quitting activity and possible causal directions by lagging the relationships in different directions.

Recall bias does impact on retrospective reports of quit attempts: response to Messer and Pierce.

Messer and Pierce (2013) provide four arguments that they claim collectively bring into question the possibility we raised (Borland, Partos, & Cummings, 2012), which is that differential recall bias might be a partial explanation for the failure of population studies to consistently document beneficial effects of nicotine replacement therapy (NRT). Previously, Pierce et al. (2012), along with others (e.g., Chapman & MacKenzie, 2010), have argued that there is no strong evidence that pharmacotherapy makes a significant contribution to smoking cessation, and this argument rests heavily on there not being marked benefits of use of quit smoking medications when used outside closely controlled clinical contexts. We provide evidence and arguments to refute their criticisms. First they argued that population-based studies have accurately detected differences in quitting as a function of such things as age and addiction level, so the failure to find effects in retrospective population studies (e.g., Gilpin, Messer, & Pierce, 2006) is likely to be real. We agree with the observations for addiction and age, but note that these are characteristics of the people, while mode of quitting is a characteristic of the quit attempt, not of the person. Thus the potential for error works in very different ways. While some fixed or relatively fixed characteristics of a smoker might differentially affect memory, such as aspects of cognitive ability, this is a very different kind of effect to the potential for characteristics of a quit event to affect memory. The magnitude, including duration and amount of activity involved, affects memory, as any introductory textbook on the topic would show. Using aids, something that plausibly makes the quitting event more salient is thus a plausible reason for improved recall. Second, they argue that even though there is more use of medication, there has been a stalling of quitting in the United States and the United Kingdom; thus, this is an evidence that these therapies are not working. We are convinced that there is a stall in quitting rates. The same stalled quitting rates have been documented in Australia (Australian Institute of Health and Welfare, 2011). These surveys also document a massive decline in uptake of smoking that has driven prevalence figures in Australia down to around 15% for daily smokers in 2010. The lack of progress on cessation has occurred even though this was a period when bans on smoking in recreational venues, including bars, became universal; graphic health warnings were added to tobacco packs; unprecedented levels of strong anti-smoking public education campaigns occurred; and just before the last survey, there was a massive tax increase. Use of medications for quitting also rose in a similar fashion to the other countries mentioned (Cooper, Borland, & Yong, 2011). However, we also have population level data that some of these interventions have stimulated quitting in the countries concerned (Borland et al., 2009; Wakefield et al., 2011). Thus, we appear to have a situation where a lot of things have happened that facilitate quitting, many of which also inhibit relapse at least in the short term (Partos et al., 2012; Wakefield et al., 2013), yet there appears to be no marked increase in the proportion of ex-smokers in the community. We do not think the explanation of using the wrong tools for cessation such as NRT offers a credible explanation of the stalled quit rates, especially given the Australian prevalence data and the data that at least some of these interventions retain some potency. This leaves the somewhat frightening possibility that the population has become hardened, and while the interventions are helping to push what progress we are making, it is really not enough to make much progress against a more hardened population of smokers. Third, contrary to Messer and Pierce’s interpretation, our Figure 1 indicates that the level of addiction (measured by Heaviness of Smoking Index) is not the main contributor of reporting more proximal start dates but that the differential effect of stop-smoking medications use is apparent even among the more addicted smokers. The final argument put forward by Messer and Pierce is that because unassisted attempts might be shorter, this is a plausible reason why they occur more recently. They are right that we did not canvass this “plausible” explanation in our paper. However, we think that this explanation is not especially plausible. Doesn’t lasting a shorter period mean being less successful? They have to assume that the argument they are trying to defend (no benefit of assisted quitting) is wrong, to find a potential reason why we might be wrong! To be fair, if the rate of relapse was different at different points in the period post quitting, with medications only having an effect while they are being used, then this may be plausible. This is an area worthy of more investigation, but it should focus on the period immediately after the end of medication use where greater relapse among medication users is most plausible.

Selective impairment of global motion integration, but not global form detection, in schizophrenia and bipolar affective disorder

Recent evidence suggests that schizophrenia is associated with impaired processing of global visual motion, but intact processing of global visual form. This project assessed whether preserved visual form detection in schizophrenia extended beyond low-level pattern discrimination to a naturalistic form-detection task. We assessed both naturalistic form detection and global motion detection in individuals with schizophrenia spectrum disorder, bipolar affective disorder, and healthy controls. Individuals with schizophrenia spectrum disorder and bipolar affective disorder were impaired relative to healthy controls on the global motion task, but not the naturalistic form-detection task. Results indicate that preservation of visual form detection in these disorders extends beyond configural forms to naturalistic object processing.