Estimating demand for alternatives to cigarettes with online purchase tasks

OBJECTIVES

To explore how advertising affects demand for cigarettes and potential substitutes, including snus, dissolvable tobacco, and medicinal nicotine.

METHODS

A Web-based experiment randomized 1062 smokers to see advertisements for alternative nicotine products or soft drinks, then complete a series of purchase tasks, which were used to estimate demand elasticity, peak consumption, and cross-price elasticity (CPE) for tobacco products.

RESULTS

Lower demand elasticity and greater peak consumption were seen for cigarettes compared to all alternative products (p < .05). CPE did not differ across the alternative products (p ≤ .03). Seeing relevant advertisements was not significantly related to demand.

CONCLUSIONS

These findings suggest significantly lower demand for alternative nicotine sources among smokers than previously revealed.

Abstract C15: Differences in the characteristics of those receiving smoking cessation advice

Clinical practice guidelines recommend that healthcare providers assess the tobacco use status of their patients and advise those that smoke to quit. Studies show that advice to stop smoking delivered by a doctor is associated with a 2-fold increase in smoking cessation. However, not all smokers who are seen by a doctor get advised to stop smoking. This study describes the characteristics of smokers who received advice to stop smoking when they were seen by a health care provider. Based upon previous studies, we hypothesized that older smokers with poorer self-reported health, and greater nicotine addiction would be more likely to report receiving advice to stop smoking when seen by a health provider. Data for this analysis are from the International Tobacco Control (ITC) US adult smoker cohort (N=6,669) survey conducted annually from 2002-2011. Participants who reported having visited a healthcare provider within the past year of survey were eligible for inclusion. Trends in the prevalence of participants reporting cessation advice and quit assistance were assessed. Repeated measures logistic regression using generalized estimating equations (GEE) was used to model receipt of counseling. Predictors of receipt of advice to stop smoking included demographic characteristics (age, gender, race/ethnicity, education, and household income), heaviness of smoking (a measure of nicotine dependence), previous quit attempts, and self-reported health status. Over 60% of respondents reported having been seen by a healthcare provider, with over 60% receiving advice to stop smoking. Those who received advice to stop smoking were more likely to be older, report ‘fair’ or ‘poor’ health, and to have reported a quit attempt since their previous interview. Among those who received advice to quit, less than one third received a referral or quit prescription, and less than one half received a stop smoking pamphlet from their healthcare provider. Results indicate that not all smokers get advice to stop smoking when seen by their doctor and those who do appear to be older and less healthy, and more receptive to a quitting message based upon past quit attempts. These data suggest that health care providers may be profiling their patients in terms of those who are in need of cessation counseling rather than uniformly providing this advice to all patients. Among those who received advice to stop smoking the majority received no other type of assistance suggesting that delivery of cessation services to smokers is inadequate.

Citation Format: Monica E. Cornelius, K Michael Cummings. Differences in the characteristics of those receiving smoking cessation advice. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr C15.

Abstract C16: Effects of cessation counseling types on quit attempts and intentions

Smoking cessation assistance programs aid smokers in quitting. While cessation programs have shown some effectiveness, many smokers do not utilize them. The combination of nicotine addiction, access to cheaper products and a general lack of access to smoking cessation tools present difficulties to smokers. Direct counseling from a healthcare provider has been shown to aid in smokers thinking about quitting their smoking; however greater assistance is often needed beyond the recommendation to quit. The purpose of this study was to examine the effect different types of cessation counseling on (1) quit attempts and (2) intention to quit within the next month. We hypothesized that advice + quit assistance from a healthcare provider would be associated with making a quit attempt and intending to quit within the next month when compared with advice alone. This paper presents data from the first eight waves of the International Tobacco Control (ITC) US adult smoker survey from 2002-2011 (N=6669). Participants who visited a healthcare provider within the past year of survey were eligible for inclusion. The levels of healthcare provider counseling included no advice, advice only, and advice + quit assistance. Repeated measures logistic regression, using generalized estimating equations (GEE) was used to model (1) whether participants made a quit attempt and (2) intention to quit within the next month. Models were controlled for age, sex, daily smoking, time-in-sample, wave, education, income, and region, as well as cessation counseling. Over 60% of participants indicated having seen a healthcare provider, with over 60% receiving advice to quit. Among those who reported receiving advice to quit, less than one third received a referral or quit prescription and less than one half received a pamphlet from their healthcare provider. Those receiving advice + quit assistance were almost twice as likely to have attempted to quit as those who received advice only. Participants receiving assistance were more likely to intend to quit within the next month. Not all smokers get advice to stop smoking when seen by their doctor and even fewer get offered assistance beyond the recommendation to stop smoking. This study shows that those who received both advice and assistance were more likely to report making a quit attempt or at least report a greater intention to stop smoking in the future.

Citation Format: Monica E. Cornelius, K. Michael Cummings. Effects of cessation counseling types on quit attempts and intentions. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr C16.

Abstract CN04-01: Reducing lung cancer mortality by 50% in the next decade: Is it feasible?

Lung cancer deaths are finally declining in the United States after a nearly century long rise. After a steep increase in cigarette use rates over the first half of the 20th century, smoking prevalence rates started declining from their peak in 1964 and the number of lung cancer deaths followed about 30 years later. Today, less than 20% of adults are current smokers, although there is significant variation from state to state and smoking behavior today, in contrast to 50 years ago, is largely concentrated among the poor and less educated members of society and also among individuals with mental health and substance abuse diagnoses. While some predictions have cigarette consumption dropping to near trivial levels in the US over the next 50 years, others have suggested the rate of decline might be much slower than predicted as the ratio of former to ever smokers has stalled. In other words, while fewer young people are taking up smoking, smoking cessation rates among adult smokers have not changed much in the past decade. While having fewer young people take up smoking means less lung cancer in the long run, in the next decade it means that lung cancer mortality rates will be higher than they might otherwise have to be. This presentation asks the question: Is it feasible to lower lung cancer mortality by 50% in the next decade? The answer to this question is yes, if we want it to make it happen. This presentation describes two complimentary strategies to more rapidly reduce lung cancer mortality in the United States over the next decade. The first strategy includes policies that could realistically be implemented in the next few years to dramatically accelerate a reduction in cigarette consumption. The second strategy focuses on ways to promote lung cancer screening among high risk current and former smokers to change the typical prognosis of lung cancer from one of death sentence to one where lung cancer is detected early enough for cure and improved management. Quite simply, maximizing these two intervention strategies will almost assuredly do more to reduce deaths from lung cancer over the next decade than could possibly be hoped for by investing in high risk biomedical research to try to improve current treatment outcomes, and most likely at a small fraction of the cost.

Citation Format: K. Michael Cummings. Reducing lung cancer mortality by 50% in the next decade: Is it feasible? [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr CN04-01.

Automated tobacco assessment and cessation support for cancer patients

BACKGROUND

Tobacco assessment and cessation support are not routinely included in cancer care. An automated tobacco assessment and cessation program was developed to increase the delivery of tobacco cessation support for cancer patients.

METHODS

A structured tobacco assessment was incorporated into the electronic health record at Roswell Park Cancer Institute to identify tobacco use in cancer patients at diagnosis and during follow-up. All patients who reported tobacco use within the past 30 days were automatically referred to a dedicated cessation program that provided cessation counseling. Data were analyzed for referral accuracy and interest in cessation support.

RESULTS

Between October 2010 and December 2012, 11,868 patients were screened for tobacco use, and 2765 were identified as tobacco users and were referred to the cessation service. In referred patients, 1381 of those patients received only a mailed invitation to contact the cessation service, and 1384 received a mailing as well as telephone contact attempts from the cessation service. In the 1126 (81.4%) patients contacted by telephone, 51 (4.5%) reported no tobacco use within the past 30 days, 35 (3.1%) were medically unable to participate, and 30 (2.7%) declined participation. Of the 1381 patients who received only a mailed invitation, 16 (1.2%) contacted the cessation program for assistance. Three questions at initial consult and follow-up generated over 98% of referrals. Tobacco assessment frequency every 4 weeks delayed referral in < 1% of patients.

CONCLUSIONS

An automated electronic health record-based tobacco assessment and cessation referral program can identify substantial numbers of smokers who are receptive to enrollment in a cessation support service.

Brief, instructional smokeless tobacco use among cigarette smokers who do not intend to quit: a pilot randomized clinical trial

INTRODUCTION

Low-nitrosamine smokeless tobacco (SLT) may have efficacy for smoking reduction and cessation, but its public health impact depends on how smokers use it.

METHODS

This pilot study explored brief, instructional low-nitrosamine SLT use among smokers unmotivated to quit. Participants (N = 57) were randomized to either a free 2-week supply of Camel Snus group or a no-supply group. Of those randomized to use Camel Snus, half were told to use it to cope with smoking restrictions (Snus to Cope), and the remaining half were advised to use it to reduce smoking (Snus to Reduce). Participants were assessed before, during, and immediately after the intervention.

RESULTS

Many Snus to Cope and Snus to Reduce participants reported daily use of Camel Snus, although the amount of use was low. Snus to Cope (18.4%) and Snus to Reduce (37.6%) participants reported a decline in number of cigarettes used per day, which was not reported by the control participants (p < .001). Intention to quit smoking and intention to quit all tobacco use (ps < .001) increased to a greater extent among Snus to Cope and Snus to Reduce participants than among control participants.

CONCLUSIONS

This study replicates previous work that shows that low-nitrosamine SLT use can lead to reduced smoking and increased intention to quit, and it adds direct evidence to suggest that the function of low-nitrosamine SLT use-either to cope with smoking restrictions or to reduce smoking-can have a differential impact on smoking behavior. Overall, the results highlight the importance of messaging and, more specifically, marketing of low-nitrosamine SLT to smokers.

Trends in the use of premium and discount cigarette brands: findings from the ITC US Surveys (2002-2011)

OBJECTIVE

The purpose of this paper was to examine trends in the use of premium and discount cigarette brands and determine correlates of type of brand used and brand switching.

METHODS

Data from the International Tobacco Control (ITC) US adult smoker cohort survey were analysed. The total study sample included 6669 adult cigarette smokers recruited and followed from 2002 to 2011 over eight different survey waves. Each survey wave included an average of 1700 smokers per survey with replenishment of those lost to follow-up.

RESULTS

Over the eight survey waves, a total of 260 different cigarette brands were reported by smokers, of which 17% were classified as premium and 83% as discount brands. Marlboro, Newport, and Camel were the most popular premium brands reported by smokers in our sample over all eight survey waves. The percentage of smokers using discount brands increased between 2002 and 2011, with a marked increase in brand switching from premium to discount cigarettes observed after 2009 corresponding to the $0.61 increase in the federal excise tax on cigarettes. Cigarette brand preferences varied by age group and income levels with younger, higher income smokers more likely to report smoking premium brand cigarettes, while older, middle and lower income, heavier smokers were more likely to report using discount brands.

CONCLUSIONS

Our data suggest that demographic and smoking trends favour the continued growth of low priced cigarette brands. From a tobacco control perspective, the findings from this study suggest that governments should consider enacting stronger minimum pricing laws in order to keep the base price of cigarettes high, since aggressive price marketing will likely continue to be used by manufacturers to compete for the shrinking pool of remaining smokers in the population.

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 participant's 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 participant's 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 smoker's 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.

Relationship of cigarette-related perceptions to cigarette design features: findings from the 2009 ITC U.S. Survey

INTRODUCTION

Many governments around the world have banned the use of misleading cigarette descriptors such as "light" and "mild" because the cigarettes so labeled were found not to reduce smokers' health risks. However, underlying cigarette design features, which are retained in many brands, likely contribute to ongoing belief that these cigarettes are less harmful by producing perceptions of lightness/smoothness through lighter taste and reduced harshness and irritation.

METHODS

Participants (N = 320) were recruited from the International Tobacco Control U.S. Survey conducted in 2009 and 2010, when they answered questions about smoking behavior, attitudes and beliefs about tobacco products, and key mediators and moderators of tobacco use behaviors. Participants also submitted an unopened pack of their usual brand of cigarettes for analysis using established methods.

RESULTS

Own-brand filter ventilation level (M 29%, range 0%-71%) was consistently associated with perceived lightness (p < .001) and smoothness (p = .005) of own brand. Those whose brand bore a light/mild label (55% of participants) were more likely to report their cigarettes were lighter [71.9% vs. 41.9%; χ(2)(2) = 38.1, p < .001] and smoother than other brands [75.5% vs. 68.7%; χ(2)(2) = 7.8, p = .020].

CONCLUSION

Product design features, particularly filter ventilation, influence smokers' beliefs about product attributes such as lightness and smoothness, independent of package labels. Regulation of cigarette design features such as filter ventilation should be considered as a complement to removal of misleading terms in order to reduce smokers' misperceptions regarding product risks.

Addressing tobacco use in patients with cancer: a survey of American Society of Clinical Oncology members

PURPOSE

Assessing tobacco use and providing cessation support is recommended by the American Society for Clinical Oncology (ASCO). The purpose of this study was to evaluate practice patterns and perceptions of tobacco use and barriers to providing cessation support for patients with cancer.

METHODS

In 2012, an online survey was sent to 18,502 full ASCO members asking about their practice patterns regarding tobacco assessment, cessation support, perceptions of tobacco use, and barriers to providing cessation support for patients with cancer. Responses from 1,197 ASCO members are reported.

RESULTS

At initial visit, most respondents routinely ask patients about tobacco use (90%), ask patients to quit (80%), and advise patients to stop using tobacco (84%). However, only 44% routinely discuss medication options with patients, and only 39% provide cessation support. Tobacco assessments decrease at follow-up assessments. Most respondents (87%) agree or strongly agree that smoking affects cancer outcomes, and 86% believe cessation should be a standard part of clinical cancer care. However, only 29% report adequate training in tobacco cessation interventions. Inability to get patients to quit (72%) and patient resistance to treatment (74%) are dominant barriers to cessation intervention, but only 8% describe cessation as a waste of time.

CONCLUSION

Among ASCO members who responded to an online survey about their practice patterns regarding tobacco, most believe that tobacco cessation is important and frequently assess tobacco at initial visit, but few provide cessation support. Interventions are needed to increase access to tobacco cessation support for patients with cancer.

Tobacco and lung cancer: risks, trends, and outcomes in patients with cancer

Tobacco use, primarily associated with cigarette smoking, is the largest preventable cause of cancer mortality, responsible for approximately one-third of all cancer deaths. Approximately 85% of lung cancers result from smoking, with an additional fraction caused by secondhand smoke exposure in nonsmokers. The risk of lung cancer is dose dependent, but can be dramatically reduced with tobacco cessation, especially if the person discontinues smoking early in life. The increase in lung cancer incidence in different countries around in the world parallels changes in cigarette consumption. Lung cancer risks are not reduced by switching to filters or low-tar/low-nicotine cigarettes. In patients with cancer, continued tobacco use after diagnosis is associated with poor therapeutic outcomes including increased treatment-related toxicity, increased risk of second primary cancer, decreased quality of life, and decreased survival. Tobacco cessation in patients with cancer may improve cancer treatment outcomes, but cessation support is often not provided by oncologists. Reducing the health related effects of tobacco requires coordinated efforts to reduce exposure to tobacco, accurately assess tobacco use in clinical settings, and increase access to tobacco cessation support. Lung cancer screening and coordinated international tobacco control efforts offer the promise to dramatically reduce lung cancer mortality in the coming decades.

Evaluation of a dedicated institutional tobacco cessation service for thoracic clinic cancer patients

1603

Background: Tobacco use by cancer patients is associated with poor therapeutic outcomes including increased toxicity, decreased quality of life, and decreased survival. Though recommendations provide for tobacco assessment and cessation for cancer patients, few oncologists provide cessation support. Presented are data from universal tobacco assessment and cessation program for patients presenting at a thoracic oncology clinic in a NCI Designated Comprehensive Cancer Center. Methods: A standard set of evidence based tobacco assessment questions were incorporated into an automated electronic medical record based system delivered by nursing at initial consult and at follow-up. Patients eligible for tobacco cessation support (i.e. patients self-reporting tobacco use within 30 days) were automatically referred to a dedicated tobacco cessation service. All referred patients are sent a standardized packet of cessation materials with telephone-based follow-up by trained cessation counselors. Results: A total of 980 new thoracic clinic patients were referred to the cessation service from January 2011 and October 2012. Two-thirds of the patients referred (n=728) referred into the system were current smokers and the remainder had quit in the 30 days prior to assessment. Among the 788 patients with contact attempts by the cessation service, 81.2% (n=640) were successfully contacted and only 2.5% (n=20) refused the offer of cessation support. At first contact, 75.6% (n=484) of patients reported continued current tobacco use. Follow-up calls were placed for 53.1% (n=340) of those who participated in the first contact an average of 39 days after the first successful contact. The follow-up had a 93.2% (n=317) participation rate which revealed that 33.3% (n=106) reported not smoking, an 8.9% increase since the first cessation service telephone call. Conclusions: Data demonstrate that an automated tobacco assessment and cessation service for thoracic oncology patients can effectively generate a large mandatory referral base with high patient interest in cessation, and that cessation support can be implemented and maintained in high risk cancer patients.

Addressing tobacco use and cessation in cancer patients: Practices, perceptions, and barriers reported by oncology providers

1561

Background: Tobacco use is associated with adverse outcomes in cancer patients, but there are limited data on tobacco cessation support by oncology providers. Methods: Duplicate surveys were sent to the membership of the International Association for the Study of Lung Cancer (IASLC) and the American Society of Clinical Oncology (ASCO) asking about tobacco assessment and cessation practices, perceptions of tobacco use by cancer patients, and barriers to implementing tobacco cessation. The results of 1,507 responses from IASLC and 1,197 responses from ASCO are reported. Results: At initial consult, most respondents asked about tobacco use (90% in both surveys), asked if smokers would quit tobacco use (79-80%), advised patients to stop smoking (81-82%). Most respondents felt that tobacco affects cancer outcomes (87-92%) and that tobacco cessation should be a standard part of clinical care (86-90%). However, few discussed medication options (40-44%) or actively provided smoking cessation assistance (39% in both surveys). Fewer respondents asked about tobacco use at follow-up and few reported adequate tobacco cessation training (29-33%). Dominant barriers to providing cessation interventions included patient resistance to cessation treatment (67-74%) and inability to get patients to quit tobacco use (58-72%), but very few believed tobacco cessation was a waste of time (8-12%). Lack of time, reimbursement, lack of training, and lack of resources were reported as barriers in less than 50% of respondents. Conclusions: Oncology providers feel tobacco affects cancer outcomes and cessation should be a standard part of clinical care. Most assess tobacco use, but few discuss medication options or provide active cessation support. Efforts are needed to improve cessation methods in cancer patients and to improve access to tobacco cessation support for cancer patients.

Increasing access to tobacco cessation support for cancer patients: Results of an institution-wide screening and referral program in an NCI-designated comprehensive cancer center

1566

Background: Guidelines from ASCO and other national organizations recommend assessment of tobacco use and structured tobacco cessation support for cancer patients. However, most oncology providers fail to provide cessation assistance to cancer patients who use tobacco. Reported are results of a systematic approach to assessing tobacco use and delivering cessation support for cancer patients in a comprehensive cancer center. Methods: A standard set of evidence based tobacco assessment questions were incorporated into an automated electronic medical record based system delivered by nursing at initial consult and follow-up. Patients eligible for tobacco cessation support (i.e. patients self-reporting tobacco use within 30 days) were automatically referred to a dedicated tobacco cessation service providing primarily phone based cessation support. Results: Of approximately 11,900 patients screened over 26 months, 2,978 patients were automatically triaged for cessation support. Contact priority was given to newly diagnosed patients in tobacco related disease sites. Using 1.25 full time cessation specialists, 1,531 received only a standard tobacco cessation mailing and no further contacts were attempted by the cessation service. In 1447 patients with attempted phone contact by the cessation service, 1189 (82.2%) were reached within 5 contact attempts. In 1,189 patients contacted, 52 (4.4%) were inappropriate referrals, 245 (20.6%) were in an active quitting phase, 465 (39.1%) were willing to prepare, and only 24 (2.0%) refused any intervention at initial contact. At the most recent follow-up, 44 patients (3.7%) requested no further contact and 90 additional patients (7.6%) were lost to follow-up. In the 1,045 remaining patients, 338 (32.3%) reported quitting tobacco use. Notably, in the 1,531 patients with no phone contact by the cessation service, only 14 proactively contacted the cessation service for assistance. Conclusions: An institution wide program to automate the delivery of tobacco cessation services was feasible with high patient contact rates, low patient refusal, and moderately high tobacco cessation rates.

The quitting rollercoaster: how recent quitting history affects future cessation outcomes (data from the International Tobacco Control 4-country cohort study)

INTRODUCTION

Most smokers have a history of unsuccessful quit attempts. This study used data from 7 waves (2002-2009) of the International Tobacco Control 4-country cohort study to examine the role of smokers' quitting history (e.g., recency, length, and number of previous quit attempts) on their subsequent likelihood of making a quit attempt and achieving at least 6 months of sustained abstinence.

METHODS

Generalized estimating equations were used, allowing for estimation of relationships between variables across repeated observations while controlling for correlations from multiple responses by the same individual (29,682 observations from 13,417 individuals).

RESULTS

The likelihood of a future quit attempt increased independently with recency and number of prior attempts. By contrast, the likelihood of achieving sustained abstinence of at least 6 months was reduced for smokers with a failed quit attempt within the last year (15.1% vs. 27.1% for those without, p < .001). Two or more failed attempts (vs. only one) in the previous year were also associated with a lower likelihood of achieving sustained abstinence (OR: 0.57, 95% CI: 0.38-0.85). Effects persisted after controlling for levels of addiction, self-efficacy to quit, and use of stop-smoking medications.

CONCLUSIONS

There appears to be a subset of smokers who repeatedly attempt but fail to remain abstinent from tobacco. Understanding why repeated attempts might be less successful in the long term is an important research priority because it implies a need to tailor treatment approaches for those who are motivated to quit but persistently relapse back to smoking.

Nicotine replacement therapy distribution to light daily smokers calling a quitline

BACKGROUND

With an increasing prevalence of lighter smokers presenting for cessation assistance, outcome-based recommendations are needed to inform nicotine replacement therapy (NRT) distribution protocols by quitlines.

METHODS

A quasi-experimental design was utilized to compare quit rates based on samples selected from the time period before and after NRT (gum or lozenge) was offered to light daily smokers (1-9 cigarettes) contacting the New York State Smokers' Quitline. Outcome measures included self-reported 7- and 30-day abstinence rates, numbers of daily cigarettes among continuing smokers, and cost per quit analyses.

RESULTS

Among responders to the follow-up survey, quit rates were higher for those given NRT compared with those not offered NRT at both 7 (33.0% vs. 27.2%; Relative Risk [RR] = 2.25 [95% CI: 1.15, 4.40; p < .05]) and 30 days (28.0% vs. 21.9%; RR = 2.63 [95% CI: 1.25, 5.54; p < .05]). Similar results were obtained based on intent-to-treat analyses for both 7 (13.4% vs. 11.3%; RR = 1.92 [95% CI: 1.08, 3.39; p < .05]) and 30 days (11.4% vs. 9.1%; RR = 2.29 [95% CI: 1.20, 4.40; p < .05]). Among continuing smokers, the mean number of cigarettes smoked per day increased from enrollment to follow-up in both groups, but less so in those receiving NRT. The additional cost associated with providing a 2-week free supply of nicotine replacement to smokers was $52 for gum and $74 for lozenge.

CONCLUSIONS

This study demonstrates that light daily smokers (1-9 cigarettes) who contact a telephone quitline are interested in using NRT if offered and are able to achieve higher quit rates compared with those not offered NRT.

Electronic nicotine delivery systems: international tobacco control four-country survey

BACKGROUND

Electronic nicotine delivery systems (ENDS) initially emerged in 2003 and have since become widely available globally, particularly over the Internet.

PURPOSE

Data on ENDS usage patterns are limited. The current paper examines patterns of ENDS awareness, use, and product-associated beliefs among current and former smokers in four countries.

METHODS

Data come from Wave 8 of the International Tobacco Control Four-Country Survey, collected July 2010 to June 2011 and analyzed through June 2012. Respondents included 5939 current and former smokers in Canada (n=1581); the U.S. (n=1520); the United Kingdom (UK; n=1325); and Australia (n=1513).

RESULTS

Overall, 46.6% were aware of ENDS (U.S.: 73%, UK: 54%, Canada: 40%, Australia: 20%); 7.6% had tried ENDS (16% of those aware of ENDS); and 2.9% were current users (39% of triers). Awareness of ENDS was higher among younger, non-minority smokers with higher incomes who were heavier smokers. Prevalence of trying ENDS was higher among younger, nondaily smokers with a high income and among those who perceived ENDS as less harmful than traditional cigarettes. Current use was higher among both nondaily and heavy (≥20 cigarettes per day) smokers. In all, 79.8% reported using ENDS because they were considered less harmful than traditional cigarettes; 75.4% stated that they used ENDS to help them reduce their smoking; and 85.1% reported using ENDS to help them quit smoking.

CONCLUSIONS

Awareness of ENDS is high, especially in countries where they are legal (i.e., the U.S. and UK). Because trial was associated with nondaily smoking and a desire to quit smoking, ENDS may have the potential to serve as a cessation aid.

Patterns of cognitive dissonance-reducing beliefs among smokers: a longitudinal analysis from the International Tobacco Control (ITC) Four Country Survey

OBJECTIVE

The purpose of this paper is to assess whether smokers adjust their beliefs in a pattern that is consistent with Cognitive Dissonance Theory. This is accomplished by examining the longitudinal pattern of belief change among smokers as their smoking behaviours change.

METHODS

A telephone survey was conducted of nationally representative samples of adult smokers from Canada, the USA, the UK and Australia from the International Tobacco Control Four Country Survey. Smokers were followed across three waves (October 2002 to December 2004), during which they were asked to report on their smoking-related beliefs and their quitting behaviour.

FINDINGS

Smokers with no history of quitting across the three waves exhibited the highest levels of rationalisations for smoking. When smokers quit smoking, they reported having fewer rationalisations for smoking compared with when they had previously been smoking. However, among those who attempted to quit but then relapsed, there was once again a renewed tendency to rationalise their smoking. This rebound in the use of rationalisations was higher for functional beliefs than for risk-minimising beliefs, as predicted by social psychological theory.

CONCLUSIONS

Smokers are motivated to rationalise their behaviour through the endorsement of more positive beliefs about smoking, and these beliefs change systematically with changes in smoking status. More work is needed to determine if this cognitive dissonance-reducing function has an inhibiting effect on any subsequent intentions to quit.

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.

Current status of tobacco policy and control

Behaviors pertaining to tobacco use have changed significantly over the past century. Compared with 1964, smoking prevalence rates have halved from 40% to 20%, and as a result there has been a slow but steady decline in the rates of tobacco-induced diseases such as heart disease and cancer. Growing awareness of the health risks of smoking was aided by the US Surgeon Reports that were issued on a nearly annual basis starting from 1964. Concerns about the hazards of breathing in second-hand smoke further contributed to the declining social acceptance of smoking, which evolved into regulatory actions restricting smoking on buses, planes, retail outlets, restaurants, and bars. Today, 23 states and 493 localities have comprehensive laws restricting indoor smoking. This paper examines public policies that have made a significant impact on smoking and lung cancer rates and discusses potential future research directions to further reduce the diseases caused by smoking.

Longitudinal associations between smoking cessation medications and alcohol consumption among smokers in the International Tobacco Control Four Country survey

BACKGROUND

Available evidence suggests that quitting smoking does not alter alcohol consumption. However, smoking cessation medications may have a direct impact on alcohol consumption independent of any effects on smoking cessation. Using an international longitudinal epidemiological sample of smokers, we evaluated whether smoking cessation medications altered alcohol consumption independent of quitting smoking.

METHODS

Longitudinal data were analyzed from the International Tobacco Control Four Country (ITC-4) Survey between 2007 and 2008, a telephone survey of nationally representative samples of smokers from the United Kingdom, Australia, Canada, and the United States (n = 4,995). Quantity and frequency of alcohol consumption, use of smoking cessation medications (varenicline, nicotine replacement [NRT], and no medications), and smoking behavior were assessed across 2 yearly waves. Controlling for baseline drinking and changes in smoking status, we evaluated whether smoking cessation medications were associated with reduced alcohol consumption.

RESULTS

Varenicline was associated with a reduced likelihood of any drinking compared with nicotine replacement (OR = 0.56; 95% CI = 0.34 to 0.94), and consuming alcohol once a month or more compared to nicotine replacement (OR = 0.43; 95% CI = 0.27 to 0.69) or no medication (OR = 0.63; 95% CI = 0.41 to 0.99). Nicotine replacement was associated with an increased likelihood of consuming alcohol once a month or more compared to no medication (OR = 1.14; 95% CI = 1.03 to 1.25). Smoking cessation medications were not associated with more frequent drinking (once a week or more) or typical quantity consumed per episode. Medication effects on drinking frequency were independent of smoking cessation.

CONCLUSIONS

This epidemiological investigation demonstrated that varenicline was associated with a reduced frequency of alcohol consumption. Continued work should clarify under what conditions nicotine replacement therapies may increase or decrease patterns of alcohol consumption.

Cigarette warning label policy alternatives and smoking-related health disparities

BACKGROUND

Pictorial health warning labels on cigarette packaging have been proposed for the U.S., but their potential influences among populations that suffer tobacco-related health disparities are unknown.

PURPOSE

To evaluate pictorial health warning labels, including moderation of their influences by health literacy and race.

METHODS

From July 2011 to January 2012, field experiments were conducted with 981 adult smokers who were randomized to control (i.e., text-only labels, n=207) and experimental conditions (i.e., pictorial labels, n=774). The experimental condition systematically varied health warning label stimuli by health topic and image type. Linear mixed effects (LME) models estimated the influence of health warning label characteristics and participant characteristics on label ratings. Data were analyzed from January 2012 to April 2012.

RESULTS

Compared to text-only warning labels, pictorial warning labels were rated as more personally relevant (5.7 vs 6.8, p<0.001) and effective (5.4 vs 6.8, p<0.001), and as more credible, but only among participants with low health literacy (7.6 vs 8.2, p<0.001). Within the experimental condition, pictorial health warning labels with graphic imagery had significantly higher ratings of credibility, personal relevance, and effectiveness than imagery of human suffering and symbolic imagery. Significant interactions indicated that labels with graphic imagery produced minimal differences in ratings across racial groups and levels of health literacy, whereas other imagery produced greater group differences.

CONCLUSIONS

Pictorial health warning labels with graphic images have the most-pronounced short-term impacts on adult smokers, including smokers from groups that have in the past been hard to reach.