Background and aims
Social norms towards smoking are a key concept in tobacco control policy and research. However, the influence and strength of different types of social norms on youth smoking ...uptake is unclear. This study aimed to examine, quantify and compare evidence of the longitudinal associations between different types of social norms towards smoking and youth smoking uptake (initiation and escalation).
Methods
Systematic review searching four databases (MEDLINE, EMBASE, PsycInfo, CINAHL) from January 1998 to October 2020. Evidence synthesis via narrative review, meta‐analysis pooling unadjusted associations (initiation only, due to heterogeneity in escalation outcomes) and meta‐regression comparing effect sizes by norm type and study characteristics. Studies included observational prospective cohort studies using survey methodology with youth aged ≤24 years. Measurements included longitudinal associations between descriptive norms (perceived smoking behaviour) and injunctive norms (perceived approval/disapproval of smoking) among social network(s) and subsequent smoking initiation or escalation.
Results
Thirty articles were identified. In the narrative review, smoking initiation (but not escalation) was consistently predicted by two norms: parental and close friend smoking. Associations between smoking uptake and other descriptive norms (smoking among siblings, family/household, partner, peers, adults) and all injunctive norms (perceived approval of smoking among parents, siblings, close friends/peers, partner, teachers, people important to you, the public) were less consistent or inconclusive. In the meta‐analysis pooling unadjusted associations, 17 articles were included (n = 27 767). Smoking initiation was predicted by the following descriptive norms: smoking among parents Odds Ratio (OR) = 1.88, 95% Confidence Interval (CI) = 1.56–2.28, close friends (OR = 2.53, 95% CI = 1.99–3.23), siblings (OR = 2.44, 95% CI = 1.93–3.08), family/household (OR = 1.55, 95% CI = 1.36–1.76) and adults (OR = 1.34, 95% CI = 1.02–1.75), but not peers (OR = 1.14, 95% CI = 0.92–1.42). Smoking initiation was also predicted by two injunctive norms, perceived approval of smoking among parents (OR = 1.74, 95% CI = 1.27–2.38) and the public (OR = 4.57, 95% CI = 3.21–6.49), but not close friends/peers (OR = 2.36, 95% CI = 0.86–6.53) or people important to the individual (OR = 1.24, 95% CI = 0.98–1.58).
Conclusions
In this systematic review (narrative and meta‐analysis), descriptive norms of parents’ and close friends’ smoking behaviour appeared to be consistent predictors of youth smoking initiation, more so than the descriptive norms of more distal social networks and injunctive norms.
To determine whether in countries with high gender empowerment the female-to-male smoking prevalence ratio is also higher.
Bivariate and multiple regression analyses were performed to explore the ...relation between the United Nations Development Programme's gender empowerment measure (GEM) and the female-to-male smoking prevalence ratio (calculated from the 2008 WHO global tobacco control report). Because a country's progression through the various stages of the tobacco epidemic and its gender smoking ratio (GSR) are thought to be influenced by its level of development, we explored this correlation as well, with economic development defined in terms of gross national income (GNI) per capita and income inequality (Gini coefficient).
The GSR was significantly and positively correlated with the GEM (r=0.680; P<0.001). In addition, the GEM was the strongest predictor of the GSR (β, adjusted: 0.47; P<0.0001) after controlling for GNI per capita and for Gini coefficient.
Whether progress towards gender empowerment can take place without a corresponding increase in smoking among women remains to be seen. Strong tobacco control measures are needed in countries where women are being increasingly empowered.
Aims
To use a unique longitudinal data set to assess the association between e‐cigarette use while smoking with smoking cessation attempts, cessation and substantial reduction, taking into account ...frequency of use and key potential confounders.
Design
Web‐based survey, baseline November/December 2012, 1‐year follow‐up in December 2013.
Setting
Great Britain.
Participants
National general population sample of 4064 adult smokers, with 1759 (43%) followed‐up.
Measurements
Main outcome measures were cessation attempt, cessation and substantial reduction (≥50% from baseline to follow‐up) of cigarettes per day (CPD). In logistic regression models, cessation attempt in the last year (analysis n = 1473) and smoking status (n = 1656) at follow‐up were regressed on to baseline e‐cigarette use (none, non‐daily, daily) while adjusting for baseline socio‐demographics, dependence and nicotine replacement (NRT) use. Substantial reduction (n = 1042) was regressed on to follow‐up e‐cigarette use while adjusting for baseline socio‐demographics and dependence and follow‐up NRT use.
Findings
Compared with non‐use, daily e‐cigarette use at baseline was associated with increased cessation attempts odds ratio (OR) = 2.11, 95% confidence interval (CI) = 1.24–3.58, P = 0.006, but not with cessation at follow‐up (OR = 0.62, 95% CI = 0.28–1.37, P = 0.24). Non‐daily use was not associated with cessation attempts or cessation. Daily e‐cigarette use at follow‐up was associated with increased odds of substantial reduction (OR = 2.49, 95% CI = 1.14–5.45, P = 0.02), non‐daily use was not.
Conclusions
Daily use of e‐cigarettes while smoking appears to be associated with subsequent increases in rates of attempting to stop smoking and reducing smoking, but not with smoking cessation. Non‐daily use of e‐cigarettes while smoking does not appear to be associated with cessation attempts, cessation or reduced smoking.
Highlights • A cohort of smokers and ex-smokers was followed over a period of two years. • Perceived harm of electronic cigarettes relative to cigarettes increased over time. • Smoking cessation ...ande-cigarette use predicted subsequent perceived relative harm. • Perceived relative harm predicted subsequent use of e-cigarettes in non-users.
E-cigarettes can be categorized into two basic types, (1) cigalikes, that are disposable or use pre-filled cartridges and (2) tanks, that can be refilled with liquids. The aims of this study were to ...examine: (1) predictors of using the two e-cigarette types, and (2) the association between type used, frequency of use (daily vs. non-daily vs. no use), and quitting.
Online longitudinal survey of smokers in Great Britain was first conducted in November 2012. Of 4064 respondents meeting inclusion criteria at baseline, this study included (N = 1643) current smokers followed-up 1 year later. Type and frequency of e-cigarette use were measured at follow-up.
At follow-up, 64% reported no e-cigarette use, 27% used cigalikes, and 9% used tanks. Among e-cigarette users at follow-up, respondents most likely to use tanks versus cigalikes included: 40-54 versus 18-24 year olds and those with low versus moderate/high education. Compared to no e-cigarette use at follow-up, non-daily cigalike users were less likely to have quit smoking since baseline (P = .0002), daily cigalike or non-daily tank users were no more or less likely to have quit (P = .3644 and P = .4216, respectively), and daily tank users were more likely to have quit (P = .0012).
Whether e-cigarette use is associated with quitting depends on type and frequency of use. Compared with respondents not using e-cigarettes, daily tank users were more likely, and non-daily cigalike users were less likely, to have quit. Tanks were more likely to be used by older respondents and respondents with lower education.
Electronic cigarette (e-cigarette) use is associated with smoking initiation among young people; however, it is also possible that smoking is associated with e-cigarette initiation. This study ...explores these associations among young people in Great Britain.
A longitudinal survey of 1,152 11- to 18-year-olds was conducted with baseline in April 2016 and follow-up between August and October 2016. Logistic regression models and causal mediation analyses assessed whether (1) ever e-cigarette use and escalation were associated with smoking initiation (ever smoking at follow-up) among baseline never smokers (n = 923), and (2) ever smoking and escalation were associated with e-cigarette initiation (ever e-cigarette use at follow-up) among baseline never e-cigarette users (n = 1,020).
At baseline, 19.8% were ever smokers and 11.4% were ever e-cigarette users. Respondents who were ever e-cigarette users (vs. never users, 53% vs. 8%, odds ratio OR = 11.89, 95% confidence interval CI = 3.56–39.72) and escalated their e-cigarette use (vs. did not, 41% vs. 8%, OR = 7.89, 95% CI = 3.06–20.38) were more likely to initiate smoking. Respondents who were ever smokers (vs. never smokers, 32% vs. 4%, OR = 3.54, 95% CI = 1.68–7.45) and escalated their smoking (vs. did not, 34% vs. 6%, OR = 5.79, 95% CI = 2.55–13.15) were more likely to initiate e-cigarette use. There was a direct effect of ever e-cigarette use on smoking initiation (OR = 1.34, 95% CI = 1.05–1.72), and ever smoking on e-cigarette initiation (OR = 1.08, 95% CI = 1.01–1.17); e-cigarette and smoking escalation, respectively, did not mediate these effects.
Among young people in Great Britain, ever e-cigarette use is associated with smoking initiation, and ever smoking is associated with e-cigarette initiation.
COVID-19 is primarily a respiratory illness, and smoking adversely impacts the respiratory and immune systems; this confluence may therefore incentivize smokers to quit. The present study, conducted ...in four high-income countries during the first global wave of COVID-19, examined the association between COVID-19 and: (1) thoughts about quitting smoking; (2) changes in smoking (quit attempt, reduced or increased smoking, or no change); and (3) factors related to a positive change (making a quit attempt or reducing smoking) based on an adapted framework of the Health Belief Model.
This cross-sectional study included 6870 adult smokers participating in the Wave 3 (2020) ITC Four Country Smoking and Vaping Survey conducted in Australia, Canada, England, and United States (US). These four countries had varying responses to the pandemic by governments and public health, ranging from advising voluntary social distancing to implementing national and subnational staged lockdowns. Considering these varying responses, and the differences in the number of confirmed cases and deaths (greatest in England and the US and lowest in Australia), smoking behaviours related to COVID-19 may have differed between countries. Other factors that may be related to changes in smoking because of COVID-19 were also explored (e.g., sociodemographics, nicotine dependence, perceptions about personal and general risks of smoking on COVID-19). Regression analyses were conducted on weighted data.
Overall, 46.7% of smokers reported thinking about quitting because of COVID-19, which differed by country (p<0.001): England highest (50.9%) and Australia lowest (37.6%). Thinking about quitting smoking because of COVID-19 was more frequent among: females, ethnic minorities, those with financial stress, current vapers, less dependent smokers (non-daily and fewer cigarettes smoked/day), those with greater concern about personal susceptibility of infection, and those who believe COVID-19 is more severe for smokers. Smoking behaviour changes due to COVID-19 were: 1.1% attempted to quit, 14.2% reduced smoking, and 14.6% increased smoking (70.2% reported no change). Positive behaviour change (tried to quit/reduced smoking) was reported by 15.5% of smokers, which differed by country (p = 0.02), where Australia had significantly lower rates than the other three countries. A positive behavioural smoking change was more likely among smokers with: lower dependence, greater concern about personal susceptibility to infection, and believing that COVID-19 is more severe for smokers.
Though nearly half of smokers reported thinking about quitting because of COVID-19, the vast majority did not change their smoking behaviour. Smokers were more likely to try and quit or reduce their smoking if they had greater concern about susceptibility and severity of COVID-19 related to smoking. Smokers in Australia were least likely to reduce or try to quit smoking, which could be related to the significantly lower impact of COVID-19 during the early phase of the pandemic relative to the other countries.
Aim
To describe the methods of the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey, conducted in 2016 in Australia (AU), Canada (CA), England (EN) and the United ...States (US).
Methods
The respondents were cigarette smokers, former smokers (quit within the previous 2 years), and at‐least‐weekly vapers, aged 18 years and older. Eligible cohort members from the ITC Four Country Survey (4C) were retained. New respondents were sampled by commercial firms from their panels. Where possible, ages 18–24 and vapers were oversampled. Data were collected online, and respondents were remunerated. Survey weights were calibrated to benchmarks from nationally representative surveys.
Results
Response rates by country for new recruits once invited ranged from 15.2 to 49.6%. Sample sizes for smokers/former smokers were 1504 in AU, 3006 in CA, 3773 in EN and 2239 in the US. Sample sizes for additional vapers were 727 in CA, 551 in EN and 494 in the US.
Conclusion
The International Tobacco Control Four Country Smoking and Vaping Survey design and data collection methods allow analyses to examine prospectively the use of cigarettes and nicotine vaping products in jurisdictions with different regulatory policies. The effects on the sampling designs and response quality of recruiting the respondents from commercial panels are mitigated by the use of demographic and geographic quotas in sampling; by quality control measures; and by the construction of survey weights taking into account smoking/vaping status, sex, age, education and geography.
BackgroundOne of the most widely available heated tobacco products is IQOS by Philip Morris International. However, there is a lack of independent research exploring IQOS initiation and subsequent ...use among smokers and ex-smokers.AimsTo (1) explore the reasons why smokers and ex-smokers use and continue/discontinue IQOS and (2) consider implications for future research and policy.ParticipantsAdult (18+) current (n=22) and ex-users (n=8) of IQOS who either currently smoked or quit smoking in the last 2 years.MethodsQualitative interview study in London, UK.ResultsSix main factors influenced initiation and use of IQOS: (1) Health—wanting to reduce/quit smoking and perceptions of reduced harm (while understanding IQOS was not risk-free). Branded packaging, absence of pictorial warnings and physical health improvements conveyed reduced harm. (2) Financial—including high start-up costs, but cheaper ongoing costs than smoking. (3) Physical—mixed views on enjoyment and satisfaction. Sensory experiences influenced use including discreetness, cleanliness, reduced smell and tactile similarities relative to combustible cigarettes. (4) Practical—issues of accessibility, shortcomings with maintenance/operation limited ongoing use, whereas use in smoke-free places increased use. (5) Psychological—similarities in rituals and routines, although new practices developed to charge and clean; some liked trailblazing new technology. (6) Social—improved social interactions from using IQOS instead of smoking, but with more limited shared social experiences for some.ConclusionFor some, IQOS facilitated smoking substitution. Factors such as packaging, labelling, risk communication, price and smoke-free policies appear to influence initiation and use.
Tobacco use is the largest single preventable cause of death and disease worldwide. Standardised tobacco packaging is an intervention intended to reduce the promotional appeal of packs and can be ...defined as packaging with a uniform colour (and in some cases shape and size) with no logos or branding, apart from health warnings and other government-mandated information, and the brand name in a prescribed uniform font, colour and size. Australia was the first country to implement standardised tobacco packaging between October and December 2012, France implemented standardised tobacco packaging on 1 January 2017 and several other countries are implementing, or intending to implement, standardised tobacco packaging.
To assess the effect of standardised tobacco packaging on tobacco use uptake, cessation and reduction.
We searched MEDLINE, Embase, PsycINFO and six other databases from 1980 to January 2016. We checked bibliographies and contacted study authors to identify additional peer-reviewed studies.
Primary outcomes included changes in tobacco use prevalence incorporating tobacco use uptake, cessation, consumption and relapse prevention. Secondary outcomes covered intermediate outcomes that can be measured and are relevant to tobacco use uptake, cessation or reduction. We considered multiple study designs: randomised controlled trials, quasi-experimental and experimental studies, observational cross-sectional and cohort studies. The review focused on all populations and people of any age; to be included, studies had to be published in peer-reviewed journals. We examined studies that assessed the impact of changes in tobacco packaging such as colour, design, size and type of health warnings on the packs in relation to branded packaging. In experiments, the control condition was branded tobacco packaging but could include variations of standardised packaging.
Screening and data extraction followed standard Cochrane methods. We used different 'Risk of bias' domains for different study types. We have summarised findings narratively.
Fifty-one studies met our inclusion criteria, involving approximately 800,000 participants. The studies included were diverse, including observational studies, between- and within-participant experimental studies, cohort and cross-sectional studies, and time-series analyses. Few studies assessed behavioural outcomes in youth and non-smokers. Five studies assessed the primary outcomes: one observational study assessed smoking prevalence among 700,000 participants until one year after standardised packaging in Australia; four studies assessed consumption in 9394 participants, including a series of Australian national cross-sectional surveys of 8811 current smokers, in addition to three smaller studies. No studies assessed uptake, cessation, or relapse prevention. Two studies assessed quit attempts. Twenty studies examined other behavioural outcomes and 45 studies examined non-behavioural outcomes (e.g. appeal, perceptions of harm). In line with the challenges inherent in evaluating standardised tobacco packaging, a number of methodological imitations were apparent in the included studies and overall we judged most studies to be at high or unclear risk of bias in at least one domain. The one included study assessing the impact of standardised tobacco packaging on smoking prevalence in Australia found a 3.7% reduction in odds when comparing before to after the packaging change, or a 0.5 percentage point drop in smoking prevalence, when adjusting for confounders. Confidence in this finding is limited, due to the nature of the evidence available, and is therefore rated low by GRADE standards. Findings were mixed amongst the four studies assessing consumption, with some studies finding no difference and some studies finding evidence of a decrease; certainty in this outcome was rated very low by GRADE standards due to the limitations in study design. One national study of Australian adult smoker cohorts (5441 participants) found that quit attempts increased from 20.2% prior to the introduction of standardised packaging to 26.6% one year post-implementation. A second study of calls to quitlines provides indirect support for this finding, with a 78% increase observed in the number of calls after the implementation of standardised packaging. Here again, certainty is low. Studies of other behavioural outcomes found evidence of increased avoidance behaviours when using standardised packs, reduced demand for standardised packs and reduced craving. Evidence from studies measuring eye-tracking showed increased visual attention to health warnings on standardised compared to branded packs. Corroborative evidence for the latter finding came from studies assessing non-behavioural outcomes, which in general found greater warning salience when viewing standardised, than branded packs. There was mixed evidence for quitting cognitions, whereas findings with youth generally pointed towards standardised packs being less likely to motivate smoking initiation than branded packs. We found the most consistent evidence for appeal, with standardised packs rating lower than branded packs. Tobacco in standardised packs was also generally perceived as worse-tasting and lower quality than tobacco in branded packs. Standardised packaging also appeared to reduce misperceptions that some cigarettes are less harmful than others, but only when dark colours were used for the uniform colour of the pack.
The available evidence suggests that standardised packaging may reduce smoking prevalence. Only one country had implemented standardised packaging at the time of this review, so evidence comes from one large observational study that provides evidence for this effect. A reduction in smoking behaviour is supported by routinely collected data by the Australian government. Data on the effects of standardised packaging on non-behavioural outcomes (e.g. appeal) are clearer and provide plausible mechanisms of effect consistent with the observed decline in prevalence. As standardised packaging is implemented in different countries, research programmes should be initiated to capture long term effects on tobacco use prevalence, behaviour, and uptake. We did not find any evidence suggesting standardised packaging may increase tobacco use.
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