Smokers In Australia Research Articles

The Latrobe Smoking Support Service: A quantitative study of participants in a regional area.

More than 70% of current smokers in Australia have a definite plan to stop smoking and around half of them try to quit every year. Latrobe Community Health Service (LCHS) was commissioned by Gippsland Primary Health Network to establish Latrobe Smoking Support Service (LSSS) to break down barriers to accessing services and increase support for smoking cessation. This research aims to assess the feasibility of an ongoing smoking cessation support service and determine the effect the LSSS has on client smoking behavior. Quantitative data were collected for the LSSS situated at LCHS during the period from September 2021 to March 2022. A new client survey, a returning client survey, and a 6-week follow-up survey were conducted by Clinic staff. The consent forms were obtained from the clients. A total of 117 clients attended the LSSS at least once, and a further 315 returning client sessions were conducted. The data analysis was undertaken by means of various descriptive and inferential statistical techniques, such as multiple linear regression analysis. The research findings demonstrate the strong positive effect of the LSSS in helping clients to change their smoking behavior. Results of multiple regression analysis highlight the significant role of behavioral intervention strategies in the LSSS's success. A combination of both nicotine replacement therapy (NRT) and counseling was a key contributor to the project's success. This research proposed and tested the model of a smoking cessation support service that combines a comprehensive mix of services for smokers including free NRT, free counseling, and ongoing support of counselors or/and nurse practitioners.

Efficacy of mindfulness and goal setting interventions for increasing resilience and reducing smoking in lower socio-economic groups: randomised controlled trial protocol

BackgroundSmoking and resulting health problems disproportionately impact low socioeconomic status (SES) individuals. Building resilience presents an approach to ‘closing the gap’. Mindfulness-based interventions and setting realistic goals are preferred in low socioeconomic communities. We aim to test if these interventions, delivered online and consolidated with peer support offered via ex-smokers, are successful in promoting smoking cessation and resilience. Our conceptualisation of resilience encompasses the inner capacity/skills and external resources (e.g., social support) which smokers utilise to bounce back from adversity. We include a process evaluation of barriers/facilitators to interventions and cost-effectiveness analysis (from health system perspective).MethodsWe plan a four-arm parallel 12-month RCT with a 6-month follow-up to test the efficacy of three group-based interventions each followed by peer support. Arm 1: mindfulness-integrated cognitive behavioural therapy; Arm 2: mindfulness training; Arm 3: setting realistic goals; Arm 4: active control group directed to quit services. All interventions will be administered online. Participants are adult smokers in Australia (N = 812) who have an average weekly household income less than $457AUD or receive welfare benefits. Group-based interventions will occur over 6 months, followed by 6 months of forum-based peer support. Primary outcome: self-reported 14-day period prevalence of smoking abstinence at 6 months, with remote biochemical verification of saliva cotinine (< 30 ng/mL). Secondary outcomes include: internal resilience (Connor-Davidson Resilience Scale-25); external resilience (ENRICHD social support tool); quality adjusted life years (EQ-5D-5L); self-efficacy for smoking abstinence (Smoking-Abstinence Self-Efficacy Questionnaire); motivation to quit smoking (Biener and Abrams Contemplation Ladder); nicotine dependence (Fagerstrom Test for Nicotine Dependency); equanimity (Equanimity Scale-16); stress (Perceived Stress Scale-10); goal assessment/attainment (Problems and Goals Assessment Scale).DiscussionThis study is the first to compare resilience interventions for low SES smokers which have been identified by them as acceptable. Our various repeated measures and process evaluation will facilitate exploration of mechanisms of impact. We intervene within the novel framework of the Psychosocial Model of Resilience, applying a promising paradigm to address a critical and inequitable public health problem.Trial registration Australian New Zealand Clinical Trials Registry ID: ACTRN12621000445875, registered 19 April 2021 (https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381007&isReview=true). The Universal Trial Number is U1111-1261–8951

Is smoking reduction and cessation associated with increased e-cigarette use? Findings from a nationally representative sample of adult smokers in Australia

AimsE-cigarettes may benefit public health if they are effective for smoking cessation. Evidence suggests that the frequency of e-cigarette use is likely an important predicator of smoking cessation success, so we examined the associations between frequency of e-cigarette use and smoking reduction and cessation in an Australian population sample of past year adult smokers. MethodsData from the 2019 National Drug Strategy Household Survey were used (N = 22,015). The sample was restricted to 3868 adults who had smoked within the past year. The outcome was self-reported smoking status and smoking reduction, adjusted for key potential confounders. ResultsCompared with no current e-cigarette use, daily e-cigarette users reported an increased likelihood for smoking reduction among current daily smokers (RRR = 2.83; 95% CI = 1.53, 5.22) and were more likely to report quitting smoking among past year smokers (RRR = 2.16; 95% CI = 1.30, 3.58). Smoking reduction and cessation for occasional e-cigarette use were not significantly different from no e-cigarette use. ConclusionsDaily, but not occasional, e-cigarette users were more likely to quit or reduce smoking cigarettes than Australian smokers who did not use e-cigarettes.

Do post-quitting experiences predict smoking relapse among former smokers in Australia and the United Kingdom? Findings from the International Tobacco Control Surveys.

Many smokers attempt to stop smoking every year, but the vast majority of quit attempts fail. This study examined prospectively the association between post-quitting experiences and smoking relapse among ex-smokers in Australia and the United Kingdom. Data came from 584 adult ex-smokers from Australia and the United Kingdom who participated in Wave 9 of the International Tobacco Control Four Country Survey and successfully followed up a year later (Wave 10). Binary logistic regression was used to examine whether baseline post-quitting experiences predicted relapse back to smoking at follow-up. Ex-smokers who perceived their stress coping ability had gotten worse since quitting were more likely to relapse back to smoking compared to their counterparts who reported no change (odds ratio=5.77, 95% confidence interval=1.64, 20.31, P < 0.01). Ex-smokers who reported their homes had become fresher and cleaner post quitting were less likely to relapse compared to those who did not notice any change (odds ratio=0.34, 95% confidence interval=0.13, 0.93, P < 0.05). Perceived changes in life enjoyment, negative affect control, social confidence, work performance, leisure time and financial situation did not independently predict relapse. No country differences were found. The study showed that ex-smokers' relapse risk was elevated if they perceived any negative impact of quitting on their stress coping whereas relapse risk was reduced if they perceived any positive impact of quitting on the home (e.g. fresher and cleaner). Helping ex-smokers to develop alternative stress coping strategies and highlighting the positive impacts of quitting smoking on the homes may help protect against smoking relapse.

Evaluating the impact of plain packaging among Canadian smokers: findings from the 2018 and 2020 ITC Smoking and Vaping Surveys

BackgroundIn February 2020, Canada implemented plain packaging without any changes to the size and content of health warning labels (HWLs), which were last updated in 2012 (pictorial HWLs on 75%...

What kind of smoking identity following quitting would elevate smokers relapse risk?

BackgroundResearch 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. MethodsData 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. ResultsBaseline self-reported smoker identity independently predicted smoking relapse at 12-month follow-up (p < .01). Compared with the subgroup who identified themselves as smokers trying to quit, those who identified themselves as smokers who had chosen to no longer smoke (OR = 0.01, 95% CI = 0.01–0.25, p < .001), ex-smokers (OR = 0.05, CI = 0.01–0.25, p < .001) or non-smokers (OR = 0.07, CI = 0.02–0.37, p < .001) were less likely to relapse at follow-up. No cross-country differences were found. ConclusionsFollowing quitting, smokers who maintained a smoker identity with a firm choice to no longer smoke or adopted a non-smoker or ex-smoker identity were less likely to relapse than those who failed to do so, suggesting that a clear rule/commitment to not smoke and/or a shift to a non-smoking identity may be protective of relapse.

Smokers who do not quit: Can the precaution adoption process model help identify hard-core smokers?

AbstractIntroductionHard-core smokers have been identified as a potential public health challenge. The trans-theoretical model lacks the specificity to identify hard-core smokers. The precaution adoption process model (PAPM) is a stage-based behaviour change model which includes ‘no intent to quit’ as a distinct stage and so may be useful in identifying hard-core smokers.AimsThe aim of this study was to apply the PAPM to a community based sample of smokers to determine whether it provides a useful approach to identifying hard-core smokers.MethodsWe surveyed smokers in Australia who were recruited through social media and an online data collection agency.ResultsThe sample included 336 current smokers, 11.9% were in Stage 4 of the PAPM – i.e. had decided not to quit. Stage 4 smokers are more resistant to quitting and marked by their similarities to hard-core smokers. This is further amplified when addressing Stage 4 smokers with no previous quit attempt.ConclusionsStage 4 smokers with no previous quit attempts are aligned with a hard-core smoker profile with higher levels of nicotine dependence, greater cigarette consumption and low socio-economic status. Further research is required to determine if PAPM is a valid predictive model for identifying hard-core smokers in clinical practice.

Smoker perceptions of health warnings on cigarette packaging and cigarette sticks: A four-country study.

INTRODUCTIONInnovations in tobacco control interventions are required to ensure continued reductions in global tobacco use, and to minimise attributable morbidity and mortality. We therefore aimed to investigate the perceived effectiveness of current cigarette packaging warnings and the potential effectiveness of cigarette-stick warnings across four countries.METHODSAn online survey was distributed to adult smokers in Australia, Canada, the United Kingdom, and the United States. Participants rated (using a 5-point Likert scale) and commented on the effectiveness of current cigarette packaging warnings and text warnings on eight cigarette sticks that prompted smokers to quit. Ratings were analysed using proportional odds logistic regression, and comments were analysed using content analysis.RESULTSParticipants (N=678, mean age=44.3 years) from all four countries perceived cigarette packaging warnings as being minimally effective in prompting smokers to quit, citing desensitisation and irrelevance of the warnings, with US participants particularly critical of the text-only warnings. Compared to packaging warnings, the cigarette-stick warnings describing the financial costs of smoking and the effect of smoking on others, were the highest rated in all four countries (OR=3.42, 95% CI: 2.75–4.25, p<0.001 and OR=2.85, 95% CI: 2.29–3.55, p<0.001, respectively) and cited as strong messages to reduce smoking. Half of the participants either ‘agreed’ or ‘strongly agreed’ to the use of cigarette-stick warnings.CONCLUSIONSThe findings of this study suggest that cigarette packaging warnings may experience a loss of effectiveness over time, eventually resulting in minimal impact on smoker behaviour. Health and non-health focused warnings and messages on individual cigarette sticks represent a novel and potentially effective method for reducing tobacco use. This would complement tobacco control interventions currently employed, resulting in public health benefits.

Discussions between health professionals and smokers about nicotine vaping products: results from the 2016 ITC Four Country Smoking and Vaping Survey.

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. Cross-sectional study using multivariable logistic regression analyses on weighted data from the 2016 ITC Four Country Smoking and Vaping Survey (ITC 4CV1). Four countries with varying regulations governing the sale and marketing of NVPs: 'most restrictive' (Australia), 'restrictive' (Canada) or 'less restrictive' (England and United States). 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). 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. 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. 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.

Correlates of electronic cigarette use in the general population and among smokers in Australia – Findings from a nationally representative survey

AimsIn Australia, sales of nicotine containing electronic cigarettes (also known as e-cigarette) are banned unless approved as a therapeutic good. The aims of this study were to estimate the prevalence of e-cigarette use and its correlates in Australia using a nationally representative survey. MethodWe analysed data from the largest drug use survey in Australia (the National Drug Strategy Household Survey [NDSHS]; N = 22,354). ResultsWe estimated that 227,000 Australians (1.2% of the population) were current e-cigarettes users, and 97,000 (0.5%) used them daily. Individuals who were male, younger, had higher level of psychological distress, and smoked were more likely to use electronic cigarettes. Among smokers, an intention to quit and reduction in smoking was associated with experimentation and daily use of e-cigarette, but not with occasional use. Recent quitting was associated with daily use. ConclusionOverall, the prevalence of e-cigarette use was low in 2016 in Australia. Smoking status was the strongest correlates of e-cigarette use. Patterns of vaping were differentialy associated with an intention to quit smoking, smoking reduction and recent quitting. Some smokers may attempt to use e-cigarettes to cut-down their tobacco use, and those who vaped daily were mostly likely to be recent quitters.

Estimating the Cost-Effectiveness of Lung Cancer Screening with Low-Dose Computed Tomography for High-Risk Smokers in Australia.

Health economic evaluations of lung cancer screening with low-dose computed tomography (LDCT) that are underpinned by clinical outcomes are relatively few. We assessed the cost-effectiveness of LDCT lung screening in Australia by applying Australian cost and survival data to the outcomes observed in the U.S. National LungScreening Trial (NLST), in which a 20% lung cancer mortality benefit was demonstrated for three rounds of annual screening among high-risk smokers age 55 to 74 years. Screening-related costs were estimated from Medicare Benefits Schedule reimbursement rates (2015), lung cancer diagnosis and treatment costs from a 2012 Australian hospital-based study, lung cancer survival rates from the New South Wales Cancer Registry (2005-2009), and other-cause mortality from Australian life tables weighted by smoking status. The health utility outcomes, screening participation rates, and lung cancer rates were those observed in the NLST. Incremental cost effectiveness ratios (ICER) were calculated for a 10-year time horizon. The cost-effectiveness of LDCT lung screening wasestimated at AU$138,000 (80% confidence interval: AU$84,700-AU$353,000)/life-year gained and AU$233,000 (80% confidence interval: AU$128,000-AU$1,110,000)/quality-adjusted life year (QALY) gained. The ICER was more favorable when LDCT screening impact on all-cause mortality was considered, even when the costs of incidental findings were also estimated in sensitivity analyses: AU$157,000/QALY gained. This can be compared to an indicative willingness-to-pay threshold in Australia of AU$30,000 to AU$50,000/QALY. LDCT lung screening using NLST selection and implementation criteria is unlikely to be cost-effective in Australia. Future economic evaluations should consider alternative screening eligibility criteria, intervals, nodule management, the impact and cost of new therapies, investigationsof incidental findings, and incorporation of smoking cessation interventions.

A Qualitative Study of Attitudes towards Smoking and Anti-Smoking Measures among Korean Male Smokers in Australia

The study aims to explore how Korean male smokers living in Australia talk and feel about smoking and how they have understood and experienced tobacco control policies in Australia—including price increase, display ban, plain packaging, and graphic warning labels. A qualitative study was conducted based on in-depth face-to-face interviews with 8 Korean male smokers aged 23–40 years living in Canberra. Participants discussed social and cultural conditions in Korea under which smoking is practiced and maintained. Smoking as a means of socialising and relaxation were consistently discussed as the main reasons for continued smoking which was deeply embedded in their everyday lives as habit or part of routines. The health risks of smoking were not among the immediate or ultimate considerations influencing participants. Participants commented that price increases had affected them most but other measures had little impact on their smoking behaviours, although they acknowledged their potentials in deterring younger people. Future anti-smoking interventions in Korea should address the significant social and cultural determinants of smoking and acknowledge smokers’ own understanding of their smoking and anti-smoking measures. Appreciating smokers’ diverse representations of their own smoking and their attitudes towards health and anti-smoking measures would increase acceptance of policies and the probability that they will be successful, leading to positive outcomes.

Path analysis of warning label effects on negative emotions and quit attempts: A longitudinal study of smokers in Australia, Canada, Mexico, and the US

BackgroundCigarette pack health warning labels can elicit negative emotions among smokers, yet little is known about how these negative emotions influence behavior change. ObjectiveGuided 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. MethodsWe 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. ResultsSmokers 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. ConclusionNegative emotions elicited by warnings encourage behavior change, promoting attention to warnings and behavioral responses that positively predict quit attempts.

Does Reactance against Cigarette Warning Labels Matter? Warning Label Responses and Downstream Smoking Cessation amongst Adult Smokers in Australia, Canada, Mexico and the United States.

ObjectiveSome researchers have raised concerns that pictorial health warning labels (HWLs) on cigarette packages may lead to message rejection and reduced effectiveness of HWL messages. This study aimed to determine how state reactance (i.e., negative affect due to perceived manipulation) in response to both pictorial and text-only HWLs is associated with other types of HWL responses and with subsequent cessation attempts.MethodsSurvey data were collected every 4 months between September 2013 and 2014 from online panels of adult smokers in Australia, Canada, Mexico, and the US were analyzed. Participants with at least one wave of follow-up were included in the analysis (n = 4,072 smokers; 7,459 observations). Surveys assessed psychological and behavioral responses to HWLs (i.e., attention to HWLs, cognitive elaboration of risks due to HWLs, avoiding HWLs, and forgoing cigarettes because of HWLs) and cessation attempts. Participants then viewed specific HWLs from their countries and were queried about affective state reactance. Logistic and linear Generalized Estimating Equation (GEE) models regressed each of the psychological and behavioral HWL responses on reactance, while controlling for socio-demographic and smoking-related variables. Logistic GEE models also regressed having attempted to quit by the subsequent survey on reactance, each of the psychological and behavioral HWL responses (analyzed separately), adjustment variables. Data from all countries were initially pooled, with interactions between country and reactance assessed; when interactions were statistically significant, country-stratified models were estimated.ResultsInteractions between country and reactance were found in all models that regressed psychological and behavioral HWL responses on study variables. In the US, stronger reactance was associated with more frequent reading of HWLs and thinking about health risks. Smokers from all four countries with stronger reactance reported greater likelihood of avoiding warnings and forgoing cigarettes due to warnings, although the association appeared stronger in the US. Both stronger HWLs responses and reactance were positively associated with subsequent cessation attempts, with no significant interaction between country and reactance.ConclusionsReactance towards HWLs does not appear to interfere with quitting, which is consistent with its being an indicator of concern, not a systematic effort to avoid HWL message engagement.

Influences of Self-Efficacy, Response Efficacy, and Reactance on Responses to Cigarette Health Warnings: A Longitudinal Study of Adult Smokers in Australia and Canada

ABSTRACTGuided 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.

Impact of the introduction of standardised packaging on smokers' brand awareness and identification in Australia.

The introduction of standardised packaging (SP) in Australia in December 2012 has heightened interest in how image and branding might affect smoking. This paper tests the hypothesis that brand awareness and identification among smokers will decline after the introduction of SP. Longitudinal study of three waves of smokers in Australia, conducted between October 2011-February 2012 (pre-SP) (n = 1104), February-May 2013 (post-SP1) (n = 1093) and August-December 2014 (post-SP2) (n = 1090). We explored the extent of changes in two variables, brand awareness (noticing others with the brand of cigarettes you smoke) and brand identification (perceiving something in common among smokers of your brand), and examined change in a number of other measures of brand appeal, brand characteristics and determinants of brand choice. Brand awareness 'at least sometimes' reduced from 45.3% pre-SP to 26.9% at post-SP2 [odds ratio (OR) 0.35 (0.27-0.45)]. Brand identification also decreased from 18.2% to 12.7% [OR 0.62 (0.42-0.91)]. Significant decline was also found in measures of perceived brand prestige [OR 0.51 (0.39-0.66)] and choice of brand for health reasons [OR 0.45 (0.32-0.63)]. Liking the look of the pack was strongly associated with brand identification, but only post-SP (P = 0.02 for interaction across the three waves). The introduction of SP of tobacco products in Australia has been associated with reductions in brand awareness and identification, and changes in related measures. The findings support the notion that SP has reduced the capacity for smokers to use pack branding to create and communicate a desired identity. [Balmford J, Borland R, Yong H-H. Impact of the introduction of standardised packaging on smokers' brand awareness and identification in Australia. Drug Alcohol Rev 2015;00:000-000].

Electronic nicotine devices considered through an equity lens.

One of the biggest challenges facing the tobacco control community today is how to address the high rates of smoking by groups experiencing social and/or economic disadvantage. For example, half of all smokers in Australia are the most socio-economically disadvantaged members of society 1. This pattern is evident in most high-income countries where smoking rates are high among people with a mental illness or drug addiction, who are unemployed or homeless and who are in the lowest socio-economic groups 2. These social groups have been exposed to the same levels and types of tobacco control measures as the rest of the population yet, unlike the rest of the population, cessation rates are low and smoking remains widespread. It is increasingly acknowledged that different treatment approaches may be required, including tobacco harm reduction 3. Hall et al., in this issue of the Journal, present arguments to show that banning electronic (e-) cigarettes is likely to increase inequity and challenge ethical principles 4. They argue that e-cigarettes could be an effective tobacco harm reduction strategy and they present two alternative pathways for the retailing of e-cigarettes—‘levelling up’ to allow e-cigarettes to be sold like tobacco cigarettes or ‘levelling down’ to impose the same restrictions on tobacco cigarettes as apply to e-cigarettes 4. Research on e-cigarettes is in its infancy and, as with most tobacco research, has been focused on the general population. Given that many smokers are from disadvantaged groups, it is important to consider whether e-cigarettes have a differential impact on smokers from these groups 2. However, only limited data are available. A large-scale study in the United States found that smokers with mental illness were more likely to try e-cigarettes, be current users and be interested in future use than those without a mental illness 5. Using e-cigarettes to ‘try to quit smoking’ or ‘as a safer alternative to tobacco cigarettes’ were two of the three most common reasons for using them, with ‘just because’ reported as the most common reason. This mirrors our unpublished data with 369 socio-economically disadvantaged smokers from Australian community welfare services, which show high awareness and use of e-cigarettes and the perception that they are safe. The results suggest that people who are disadvantaged or with a mental illness are more open to the idea of using e-cigarettes, whether it is as a quitting aid, for harm reduction or ‘just because’. With limited evidence, and no government and tobacco control sanctioned awareness campaigns for e-cigarettes, the question arises—from where are people getting information about the safety and efficacy of e-cigarettes? One explanation is manufacturers marketing e-cigarettes as a treatment for mental health conditions 5. No doubt the tobacco control community need to ‘catch up’ in handling electronic cigarette public education, particularly among more vulnerable groups that are currently being targeted by manufacturers. Similar targeting is occurring among prisoners in the United States 6. There are only two small trials of e-cigarettes for smoking cessation or reduction with disadvantaged smokers. A pilot study of 14 smokers with schizophrenia who were not interested in quitting showed that e-cigarette use reduced tobacco cigarette consumption significantly over a 12-month period with no negative effects 7. A secondary analysis of the smoking outcomes data of a randomized trial of e-cigarettes compared with nicotine patches and placebo with a subsample of 86 participants with mental illness found no significant differences between groups in cessation rates, but higher reduction of cigarettes smoked and greater acceptability and treatment compliance in the group receiving the e-cigarettes 8. Treatment compliance and retention is an important issue generally in tobacco dependence treatment with reports of nicotine replacement therapy (NRT) compliance often low, particularly among socio-economically disadvantaged groups. If e-cigarettes are a more acceptable form of nicotine substitution for smokers in disadvantaged groups, they may result in higher cessation and reduction outcomes among groups notoriously difficult to change 9. Applying the ‘levelling down’ approach outlined by Hall et al. may introduce the public health benefits of e-cigarettes to groups of smokers who are only exposed to the extreme forms of tobacco-related harms. The Hall et al. paper raises important policy and ethical issues about the availability of e-cigarettes. The idea of tobacco harm reduction is central, and no one could benefit more from tobacco harm reduction than socio-economic groups who experience tobacco-related harm at disproportionately high rates. Further debate and research on e-cigarettes must be conducted through an equity lens to ensure that those at highest risk of harm are most likely to gain benefits. None. B.B. is supported by a National Health and Medical Research Council (NHMRC) Career Development Fellowship and a University of Newcastle, Faculty of Health and Medicine, Gladys M. Brawn Career Development Award.

Interpersonal communication about pictorial health warnings on cigarette packages: Policy-related influences and relationships with smoking cessation attempts

This study evaluated the relationship between interpersonal communication about cigarette health warning labels (HWLs), psychological responses to HWLs, and smoking cessation attempts. Data were analyzed from online consumer panels of adult smokers in Australia, Canada and Mexico, during implementation of new pictorial health warning labels (HWLs) on cigarette packs. Approximately 1000 adult smokers were surveyed in each country every four months (September 2012, January 2013, May 2013, September 2013, January 2014). Only smokers followed for at least two waves were included in the analytic sample. Participants reported the frequency of talking about HWLs in the last month (in general, with family members, and with friends). For each country, poisson generalized estimating equation (GEE) models were estimated to assess the bivariate and adjusted correlates of talking about HWLs. Logistic GEE models regressed having attempted to quit by the subsequent wave on HWL talk, sociodemographics and psychological responses to HWLs. The frequency of HWL talk gradually decreased in Canada (48%–36%) after new HWLs were implemented; an increase (30%–58%) in Australia corresponded with implementation of new HWLs, after which talking stabilized; and the frequency of HWL talk in Mexico was stable over time, where new HWLs are implemented every six months. Talk about HWLs was an independent predictor of subsequent quit attempts in Canada (AOR = 1.50; 95% CI = 1.11–2.02), Australia (AOR = 1.41; 95% CI = 1.05–1.89), and Mexico (AOR = 1.53; 95% CI = 1.11–2.10), as was cognitive responses to HWLs (Australia AOR = 1.66; 95% CI = 1.22–2.24; Canada AOR = 1.56; 95% CI = 1.15–2.11; Mexico AOR = 1.30; 95% CI = 0.91–1.85). No interaction between talk and cognitive reactions to HWLs were found. These results suggest that interpersonal communication about HWLs influences smoking cessation attempts independent of other established predictors of smoking cessation, including cessation-related HWL responses. Future research should determine ways to catalyze interpersonal communication about HWLs and thereby potentiate HWL effects.

The relation between number of smoking friends, and quit intentions, attempts, and success: findings from the International Tobacco Control (ITC) Four Country Survey.

Smokers who inhabit social contexts with a greater number of smokers may be exposed to more positive norms toward smoking and more cues to smoke. This study examines the relation between number of smoking friends and changes in number of smoking friends, and smoking cessation outcomes. Data were drawn from Wave 1 (2002) and Wave 2 (2003) of the International Tobacco Control (ITC) Project Four Country Survey, a longitudinal cohort survey of nationally representative samples of adult smokers in Australia, Canada, United Kingdom, and United States (N = 6,321). Smokers with fewer smoking friends at Wave 1 were more likely to intend to quit at Wave 1 and were more likely to succeed in their attempts to quit at Wave 2. Compared with smokers who experienced no change in their number of smoking friends, smokers who lost smoking friends were more likely to intend to quit at Wave 2, attempt to quit between Wave 1 and Wave 2, and succeed in their quit attempts at Wave 2. Smokers who inhabit social contexts with a greater number of smokers may be less likely to successfully quit. Quitting may be particularly unlikely among smokers who do not experience a loss in the number of smokers in their social context.

Socioeconomic status and smokers’ number of smoking friends: Findings from the International Tobacco Control (ITC) Four Country Survey

BackgroundSmoking rates are higher among low socioeconomic (SES) groups, and there is evidence that inequalities in smoking are widening over time in many countries. Low SES smokers may be more likely to smoke and less likely to quit because smoking is heavily concentrated in their social contexts. This study investigated whether low SES smokers (1) have more smoking friends, and (2) are more likely to gain and less likely to lose smoking friends over time. Correlates of having more smoking friends and gaining or losing smoking friends were also considered. MethodRespondents included 6321 adult current smokers (at recruitment) from Wave 1 (2002) and Wave 2 (2003) of the International Tobacco Control Project (ITC) Four Country Survey, a nationally representative longitudinal cohort survey of smokers in Australia, Canada, UK, and US. ResultsLow SES smokers reported more smoking friends than moderate and high SES smokers. Low SES smokers were also more likely to gain smoking friends over time compared with high SES smokers. Smokers who were male, younger, and lived with other smokers reported more smoking friends, and were also more likely to gain and less likely to lose smoking friends. Smoking behaviours, such as higher nicotine dependence were related to reporting more smoking friends, but not to losing or gain smoking friends. ConclusionsSmoking is highly concentrated in the social networks of lower SES smokers and this concentration may be increasing over time. Cessation interventions should consider how the structure of low SES smokers’ social networks affects quitting.