International Tobacco Control Research Articles

Electronic nicotine delivery system flavors, devices, and brands used by adults in the United States who smoke and formerly smoked in 2022: Findings from the United States International Tobacco Control Four Country Smoking and Vaping Survey

ObjectiveThis study estimated prevalence of current electronic nicotine delivery systems (ENDS) used by US adults who smoked cigarettes or formerly smoked in 2022 and assessed ENDS flavors, devices, and brands used most often. MethodsData are from the 2022 US ITC Smoking and Vaping Survey. Respondents were recruited from a web panel of a nationally representative sample of US adults ages 18+ who smoked, formerly smoked, and/or vaped ENDS. Using weighted data, we estimated prevalence of current vaping among adults who smoke or formerly smoked (N = 2,016). Among the subset who vaped (n = 554), we assessed flavors and devices used most often. Using unweighted data, we assessed the frequency (count) of reported brands used most often. ResultsIn 2022, 22.0 % of US adults who smoked or formerly smoked were vaping at least monthly. A significantly higher proportion of adults who formerly smoked and/or were younger (18–39) were vaping than adults who were smoking and/or were older (40+) (both p < 0.001). Tank devices were used most often (34.7 %), followed by disposables (27.4 %), pre-filled pods/cartridges (23.0 %), and refillable pods/cartridges (14.9 %). The five most commonly used flavors were fruit (33.9 %), tobacco (20.1 %), menthol (12.2 %), candy/sweets (10.8 %), and mixed ice flavors (10.0 %). The top 5 brands were JUUL, Smok, Vuse, Geekvape, and Blu. ConclusionsIn 2022, a majority of adults who smoked cigarettes or who had quit smoking used a variety of flavors and devices that go beyond the choices that FDA currently has authorized for sale.

Impacts of revised smoke-free regulations under the 2020 Japan Health Promotion Act on cigarette smoking and heated tobacco product use in indoor public places and homes: findings from 2018 to 2021 International Tobacco Control (ITC) Japan Surveys

BackgroundIn April 2020, Japan’s revised Health Promotion Act (HPA) banned cigarette smoking and heated tobacco products (HTP) use in indoor public places but exempted small establishments and permitted smoking-designated/HTP-designated rooms....

Widening the price gap: the effect of the Netherlands' 2020 tax increase on tobacco prices.

The public health impact of a tobacco tax increase depends on the extent to which the industry passes the increase onto consumers, also known as tax-pass through. In 2020, the Netherlands announced tax increases aimed to increase the retail price by €1 per 20 factory-made cigarettes and €2.50 per 50 grams of roll-your-own tobacco. This study examines the pass-through rate after the tax increase, and whether this differed by type of tobacco and brand segment. Self-reported prices of 117 tobacco brand varieties (cigarettes=72, roll-your-own=45) pre- and post-tax increase were extracted from the 2020 International Tobacco Control (ITC) Netherlands Surveys (n=2959 respondents). We calculated the tax pass-through rate per variant, examining differences between type of tobacco and brand segments. On average, cigarette prices increased by €1.12 (SD=0.49) (112% of €1) and roll-your-own prices by €2.53 (SD=0.60) (101% of €2.50). Evidence of differential shifting across segments was found, with evidence of overshifting in non-discount varieties. The average price of discount varieties increased with €0.20 less than non-discount varieties. Similarly, the net-of-tax price decreased in discount varieties (cigarettes=-€0.02; roll-your-own=-€0.05), but increased in non-discount varieties (cigarettes= +€0.14; roll-your-own= +€0.20). Despite the large tax increase, the industry increased prices in line or above the required level. Through differential shifting, the price gap between discount and non-discount varieties has widened, which may reduce the public health impact of the tax increase. Measures aimed at reducing price variability should be strengthened in taxation policy, such as the European Tobacco Tax Directive. We found that the industry used differential shifting after a significant tobacco tax increase in the Netherlands. Prices increased more than required in higher-priced products, but not in lower-priced products. This pattern was found both for factory-made cigarettes and roll-your-own tobacco. Through differential shifting, the industry undermines the potential public health impact of tobacco tax increases, by offering a relatively cheaper alternative, which discourages people to quit or reduce consumption. The revision of the European Tobacco Tax Directive (TTD) provides an opportunity to address the widening price gap - both between and within product segments - across the European Union.

Does perceived vaping addiction predict subsequent vaping cessation behaviour among adults who use nicotine vaping products regularly?

BackgroundThis study aimed to investigate whether perceived vaping addiction is a predictor of quitting nicotine vaping product (NVP) use among adults who have ever smoked and currently vape exclusively or predominantly in four countries: Australia, Canada, the US, and England. MethodData analysed (n = 574) came from participants (aged 18 + ) who completed the International Tobacco Control (ITC) Four Country Smoking and Vaping survey in 2018 and again in 2020. Baseline inclusion criteria were: (1) currently not smoking or non-daily smoking; and (2) using NVPs daily/weekly for a period of at least 4 months. Association of self-reported baseline levels of perceived vaping addiction with making any attempts to quit vaping and successful attempts reported at follow-up were examined using logistic regression models, controlling for potential sociodemographic and smoking/vaping-related confounders. ResultsParticipants who perceived themselves as being addicted to vaping were less likely to attempt to quit vaping than those who perceived themselves as not addicted. Among those who tried, those who perceived themselves being addicted were also less likely to succeed than those who perceived themselves as not addicted. No significant country differences in associations were observed for both outcomes. ConclusionsPerceived vaping addiction was shown to have predictive utility for vaping cessation behaviours, possibly acting as an indicator of task difficulty, and thus may serve as a useful screening tool for identifying NVP users who may benefit from tailored cessation support programs if they want to stop using these products.

Does Self-Reported smoking cessation fatigue predict making quit attempts and sustained abstinence among adults who smoke Regularly?

BackgroundQuitting smoking is difficult and many people who smoke experience cessation fatigue (CF) as a result of multiple failed attempts. This study examined the association of CF with making and sustaining a smoking quit attempt. MethodsData analysed were 4,139 adults (aged 18 years or older) who smoked daily or weekly and participated in the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping Surveys (ITC 4CV) conducted in Australia, Canada, England, and the US. CF was assessed at baseline using a single question: “To what extent are you tired of trying to quit smoking?” with response options: “Not at all tired”; “Slightly tired”; “Moderately tired”; “Very tired”; or “Extremely tired”. We used binary logistic regression models to test the hypothesis that baseline CF would predict lower odds of both making a quit attempt and sustaining abstinence for a month or longer at follow-up adjusted for socio-demographic and smoking/vaping-related covariates. ResultsPersons who currently smoked and reported at least some CF were more likely to make a quit attempt, but less likely to sustain abstinence for at least one month, than those who reported no CF. These associations were independent of socio-demographic variables, and they did not differ by country. ConclusionContrary to expectation, CF was positively associated with making a quit attempt and non-linearly associated with lower rates of sustained abstinence at follow-up. While these findings should be replicated, they suggest that people with CF may benefit from targeted support to remain abstinent after a quit attempt.

Expansion of Smoke-Free Laws in Public Places and Support for Smoke-Free in Malaysia: Findings from the 2020 ITC Malaysia Survey.

Smoke-free laws (SFL) are more effective with public support. This study investigated the smoking prevalence, public perceptions of smoking rules, and support for comprehensive SFL among 1047 people who smoke (PWS) and 206 people who do not smoke (PNS) aged ≥18 in the 2020 International Tobacco Control Malaysia Survey. Smoking prevalence was highest in nighttime entertainment venues (85.7%), non-air-conditioned eateries (49.7%), and indoor workplaces (34.6%). Respondents reported that smoking was banned in most indoor workplaces (81.7% PNS, 69.2% PWS), air-conditioned eateries (84.7% PNS, 75.7% PWS), and non-air-conditioned eateries (81.2% PNS, 78.7% PWS), but much less so in nighttime entertainment venues (30.1% PNS, 24.6% PWS). Support for comprehensive SFL in public venues was highest among PNS (≥84.9%) but still substantial among PWS (≥49.9%). PWS under 40, Malay, married, and aware of smoking rules supported SFL more. Robust SFL enforcement is essential in Malaysia to reduce secondhand smoke exposure in public places.

The impact of tobacco tax increases on cost-minimising behaviours and subsequent smoking cessation in Australia: an analysis of the International Tobacco Control Policy Evaluation Project

ObjectiveWe examined the relationship in Australia from 2007 to 2020 between tobacco tax increases and use of cost-minimising behaviours (CMBs) when purchasing tobacco and: (1) tobacco expenditure and (2) smoking...

Tax increases as an incentive to quit smoking: is thinking about quitting due to a tobacco tax increase associated with post-tax increase smoking cessation?

BackgroundThe cost of tobacco is one of the most reported reasons to quit smoking. The Netherlands increased tobacco taxes twice in the span of nine months: a €1 increase per pack in April 2020, and a €0.12 increase per pack in January 2021. This study examines to what extent people report to think about quitting due to the upcoming tax increase(s), as well as how it relates to their age, income or educational level. Additionally, we examined whether thinking about quitting was associated with quit intention and quit behaviour, and whether these associations were different for the two tax increases.MethodsLongitudinal data from the International Tobacco Control (ITC) Netherlands Surveys, Cohort 2 were used (N = 5919 observations; wave 1 (February – March 2020): n = 2051; wave 2 (September – November 2020): n = 1919; wave 3 (June – July 2021): n = 1949). Generalised Estimating Equation (GEE) regressions were fit to test the associations between thinking about quitting due to the tax increase and post-tax increases in quit intention, serious quit attempts, and quitting smoking (≤ 1 cigarette a month), as well as sociodemographic variables.ResultsCirca half of the people who smoke reported thinking about quitting smoking due to the upcoming tax increase (Wave 1 = 51.3% (n = 1052); Wave 2 = 47.3% (n = 849)). Individuals who reported thinking about quitting smoking due to upcoming tax increase(s) were more likely to have increased their quit intention (aOR: 2.00, p ≤ .001) or have carried out a serious quit attempt (aOR:1.48, p ≤ .001) post-tax increase. More people attempted to quit smoking between wave 2 and 3 (post 2021 increase) than between wave 1 and 2 (post 2020 increase). We did not find an interaction effect between wave and thinking about quitting for quit intention, quit attempts, and quitting smoking.ConclusionsTax increases stimulate people to think about quitting. Thinking about quitting due to an upcoming tax increase was associated with more positive quit intention and serious quit attempts.

Use of disposable e-cigarettes among youth who vape in Canada, England and the United States: Repeat cross-sectional surveys, 2017-2023.

To measure changes over time (between 2017 and 2023) in disposable e-cigarette use and popular brands among youth in Canada, England and the United States (US) who vaped. Nine waves of repeat cross-sectional data from the International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Survey. Online surveys conducted in Canada, England and the US between 2017 and 2023. Youth aged 16 to 19 years who had vaped in the past 30 days (n = 19710). Usual type (disposable, cartridge/pod, tank) and brand of e-cigarette used; covariates sex at birth, age, race/ethnicity, cigarette smoking status, vaping on ≥20 of the past 30 days. In 2017, the majority of youth who vaped in the past 30 days reported using refillable tank e-cigarettes, whereas disposable e-cigarettes were the least commonly used product type in Canada (10.0%), England (8.6%) and the US (14.4%). Cartridge/pods overtook tank devices in Canada and the US by 2020; however, by 2023, disposables were the leading type of e-cigarette used by youth who vaped in all three countries (Canada = 58.5%; England = 83.2%; US = 67.3%). The shift to disposables occurred among all socio-demographic groups, with few differences by vaping and smoking status. The percentage of youth who vaped that reported 'no usual' brand also decreased substantially from 2017 (29% to 42%) to 2023 (11% to 17%). The rise of disposable e-cigarettes appeared to be driven primarily by individual brands in the US (Puff Bar in 2020/2021, Elf Bar in 2022/2023) and England (Elf Bar in 2022/2023). The e-cigarette market has evolved rapidly with notable shifts in the types of e-cigarettes used by youth who vape in Canada, England and the United States. Although the timing differed across countries, major shifts in device types appear to be driven by individual brands and were often accompanied by increases in vaping prevalence among youth.

Support for banning sale of smoked tobacco products among adults who smoke: findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2018–2022)

BackgroundMany people continue to smoke despite strong policies to deter use, thus stronger regulatory measures may be required. In four high-income countries, we examined whether people who smoke would support...

Reasons for using e-cigarettes among adults who smoke: comparing the findings from the 2016 and 2020 ITC Korea Surveys

IntroductionDual use of e-cigarettes and cigarettes is a growing usage pattern in adults, but little is known about the motivations underlying this trend. We investigated the reasons for e-cigarette use...

Estimating own-price and cross-price elasticity of cigarette consumption by price tiers in Bangladesh

ObjectivesThe overall price elasticity of cigarette consumption in Bangladesh has been studied extensively. The estimates of price elasticity by price tiers are not available in the existing literature.MethodsUsing cohort data...

Associations between vaping and self-reported respiratory symptoms in young people in Canada, England and the US

BackgroundPrevalence of youth nicotine vaping has increased, heightening concerns around negative health effects. This study aimed to compare self-reported respiratory symptoms among youth by vaping behaviours.MethodsParticipants (n = 39,214) aged 16–19 from the 2020 and 2021 International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Surveys (Canada, England, US). Weighted multivariable logistic regression assessed associations between reporting any of five respiratory symptoms in the past week (shortness of breath, wheezing, chest pain, phlegm, cough) and: past 30-day smoking and/or vaping; lifetime/current vaping. Among past-30-day vapers (n = 4644), we assessed associations between symptoms and vaping frequency, use of nicotine salts, usual flavour and device type(s).ResultsOverall, 27.8% reported experiencing any of the five respiratory symptoms. Compared with youth who had only vaped, those who had only smoked had similar odds of symptoms [adjusted odds ratio, OR (95% confidence interval, CI): 0.97 (0.85–1.10)], those who both smoked and vaped had higher odds [1.26 (1.12–1.42)], and those who had done neither, lower odds [0.67 (0.61–0.72)]. Compared with those who had never vaped, past use, experimentation and current regular or occasional use were all associated with higher odds. Reporting usually using nicotine salts was associated with higher odds of symptoms [1.43 (1.22–1.68)] than non-salt but was often uncertain. Compared with tobacco flavour (including with menthol), menthol/mint and sweets flavours were associated with similar odds; fruit [1.44 (1.07–1.93)], multiple [1.76 (1.30–2.39)] and ‘other’ [2.14 (1.45–3.16)] flavours with higher odds. All device types were associated with similar odds.ConclusionsAmong youth, vaping was associated with increased reporting of past-week respiratory symptoms. Among those who vaped, some flavour types and potentially nicotine salts were associated with respiratory symptoms.

Prevalence and perceptions of flavour capsule cigarettes among adults who smoke in Brazil, Japan, Republic of Korea, Malaysia and Mexico: findings from the ITC surveys

IntroductionThe global market of flavour capsule cigarettes (FCCs) has grown significantly over the past decade; however, prevalence data exist for only a few countries. This study examined prevalence and perceptions...

Prevalence of menthol cigarette use among adults who smoke from the United States by census division and demographic subgroup, 2002–2020: findings from the International Tobacco Control (ITC) project

BackgroundTargeted marketing of menthol cigarettes in the US influences disparities in the prevalence of menthol smoking. There has been no analysis of sub-national data documenting differences in use across demographic subgroups. This study estimated trends in the prevalence of menthol use among adults who smoke in the nine US census divisions by sex, age, and race/ethnicity from 2002 to 2020.MethodsData from 12 waves of the US ITC Survey were used to estimate the prevalence of menthol cigarette use across census divisions and demographic subgroups using multilevel regression and post-stratification (n = 12,020). Multilevel logistic regression was used to predict the prevalence of menthol cigarette use in 72 cross-classified groups of adults who smoke defined by sex, age, race/ethnicity, and socioeconomic status; division-level effects were fit with a random intercept. Predicted prevalence was weighted by the total number of adults who smoke in each cross-classified group and aggregated to divisions within demographic subgroup. Estimates were validated against the Tobacco Use Supplement to the Current Population Survey (TUS-CPS).ResultsOverall modeled prevalence of menthol cigarette use was similar to TUS-CPS estimates. Prevalence among adults who smoke increased in each division from 2002 to 2020. By 2020, prevalence was highest in the Middle (46.3%) and South Atlantic (42.7%) and lowest in the Pacific (25.9%) and Mountain (24.2%) divisions. Prevalence was higher among adults aged 18–29 (vs. 50+) and females (vs. males). Prevalence among non-Hispanic Black people exceeded 80% in the Middle Atlantic, East North Central, West North Central, and South Atlantic in all years and varied most among Hispanic people in 2020 (Pacific: 26.5%, New England: 55.1%).ConclusionsSignificant geographic variation in the prevalence of menthol cigarette use among adults who smoke suggests the proposed US Food and Drug Administration (FDA) menthol cigarette ban will exert differential public health benefits and challenges across geographic and demographic subgroups.

Use of 'Elf Bar' among youth and young adults who currently vape in England: cross-sectional associations with demographics, dependence indicators and reasons for use.

Elf Bar is currently the leading e-cigarette (vape) brand in Great Britain. This study examined youth and young adults' use of Elf Bar, socio-demographic characteristics and dependence indicators and reasons for use over other brands. Cross-sectional survey. Online 2022 International Tobacco Control Project Youth Tobacco and Vaping Survey (N = 1355 16-29-year-olds in England who had vaped in the past 30 days). Currently using Elf Bar most often (versus other brands) and associations with: socio-demographics, owning a vaping device, dependence indicators and reasons for brand choice. Logistic regressions were used. Among 16-29-year-olds who vaped in the past 30 days, 48.4% (n = 732) reported Elf Bar as the brand they used most often. Among 16-17-year-olds, 40.7% used Elf Bar over other brands; this was lower than among 18-19-year-olds (60.1%) and 20-29-year-olds (47.4%) (P ≤ 0.002). Using Elf Bar over other brands was higher among those who were female (55.2 versus 41.5% male), identified as White (53.1 versus 30.9% other/mixed), a student (54.5 versus 44.3% not), did not own a vape (66.7 versus 44.4% who did) and typically vaped 5-8hours after waking (62.7 versus 36.8% within 5min) (P ≤ 0.044). Most who vaped but had never smoked used Elf Bar (64.3%), although use did not significantly differ from those who currently (45.4%), formerly (42.3%) or experimentally (48.7%) smoked (all P ≥ 0.060). Popular reasons for choosing Elf Bar over other brands were better flavour/taste (47.5%), less expensive (28.7%), easier to get (26.1%), smoother to inhale (24.0%) and popularity (23.1%). 'Better for quitting smoking' (10.1%) was least frequently selected reason for choosing Elf Bar over other brands. Elf Bar brand e-cigarettes were used by approximately half of 16-29-year-olds who vaped in England in 2022 and was mainly chosen over other brands for subjective responses (e.g. flavour/taste), rather than for quitting smoking.

The association between excise taxes and smoking and vaping transitions–Findings from the 2016–2020 ITC United States surveys

BackgroundWhile a growing number of studies examined the effect of e-cigarette (EC) excise taxes on tobacco use behaviors using cross-sectional surveys or sales data, there are currently no studies that evaluate the impact of EC taxes on smoking and vaping transitions. MethodsUsing data from the US arm of the 2016–2020 International Tobacco Control Four Country Smoking and Vaping Survey (ITC 4CV), we employed a multinomial logit model with two-way fixed effects to simultaneously estimate the impacts of cigarette/EC taxes on the change in smoking and vaping frequencies. ResultsOur benchmark model suggests that a 10 % increase in cigarette taxes led to an 11 % reduction in smoking frequencies (p < 0.01), while EC taxes did not have a significant effect on smoking frequencies. ConclusionOur findings suggest that increasing cigarette taxes may serve as an effective means of encouraging people who smoke to cut back on smoking or quit smoking. The impact of increasing EC taxes on smoking transitions is less certain at this time.

Public support for tobacco endgame policies in South Korea: Findings from the 2020 International Tobacco Control Korea Survey

BackgroundStrong public support can increase the likelihood of adopting tobacco control policies. We assessed support for six commercial tobacco endgame policies in South Korea: limiting the nicotine in cigarettes, banning...

Prevalence and reasons for use of heated tobacco products among Malaysian adults who smoked: Findings from the 2020 International Tobacco Control Malaysia Survey

IntroductionThere have been rapid expansions in heated tobacco products (HTPs) outside of Japan and the Republic of Korea. In November 2018, HTPs were first introduced in Malaysia and since then, no studies have been conducted on Malaysians’ use of HTPs. This study is the first to examine the prevalence of HTP use and reasons for use among Malaysian adults who smoked cigarettes. MethodsData came from the 2020 ITC Malaysia Survey, a web-based survey of a nationally representative sample of adults who smoked (n=1047) aged 18 and older. They were asked on ever heard of, ever used, and currently using HTPs, and their reasons for using HTPs. ResultsOverall, 25.4% (n= 324; 95% CI:22.3%−28.7%) of Malaysians who smoked reported ever used HTPs with 6.7% (n=85; 95% CI:22.3%−28.7%) were using them daily and 8.1% (n=110; 95% CI:6.4% −10.2%) were using HTPs non-daily. Most of them (57.2%) who dual use were of aged 25–39 and 97.3% were males. Among those who smoked daily, almost half (49.3%) were also using HTP daily. Among those who used HTPs daily and non-daily, curiosity (84.2%, 95% CI:78.4%−90.0%), taste (83.2%, 95% CI:77.3%−89.1%), and appealing technology (78.5%, 95% CI:71.3%−85.6%) were the most reported reasons. Among those who used HTPs daily, curiosity was the top reason (87.9%, 95% CI:78.9%−93.4%), while among non-daily, taste good was the top reason (81.9%, 95% CI:71.9%−88.8%). ConclusionsThe very high use of HTPs among Malaysians who smoked requires continued public health surveillance that can inform the regulation of these novel tobacco products.

How do users compare the costs between nicotine vaping products and cigarettes? Findings from the 2016-2020 International Tobacco Control United States surveys.

Nicotine vaping products (NVPs) can potentially help adult tobacco users quit smoking. This study evaluated how adult consumers compare the costs between NVPs and cigarettes. We used data from the US arm of the 2016-2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) surveys to perform a multinomial logit model with two-way fixed effects to measure how perceived cost comparisons are associated with NVP and cigarette taxes, use patterns, NVP device types and individual sociodemographic factors. Higher cigarette taxes are associated with a greater likelihood of perceiving NVPs and cigarettes as costing the same for the overall population and among people who exclusively smoke, and a lower likelihood of perceiving NVPs as more expensive among people who exclusively vape, compared with lower cigarette taxes. Pre-filled cartridge and tank users are more likely to perceive NVPs as less expensive than cigarettes, compared with people who use other types of NVPs. The associations between taxes and perceived cost comparison were more pronounced among males, younger and low-income populations. Higher cigarette taxes are associated with perceived financial incentives for nicotine vaping products (NVPs) over cigarettes, whereas NVP taxes are not associated with perceived cost comparison between NVPs and cigarettes.