Trends and socioeconomic differences in policy triggers for thinking about quitting smoking: Findings from the International Tobacco Control (ITC) Europe Surveys

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

BACKGROUND

The cost of tobacco is one of the most reported reasons to quit smoking. The Netherlands increased tobacco taxes twice in the span of nine months: a €1 increase per pack in April 2020, and a €0.12 increase per pack in January 2021. This study examines to what extent people report to think about quitting due to the upcoming tax increase(s), as well as how it relates to their age, income or educational level. Additionally, we examined whether thinking about quitting was associated with quit intention and quit behaviour, and whether these associations were different for the two tax increases.

METHODS

Longitudinal data from the International Tobacco Control (ITC) Netherlands Surveys, Cohort 2 were used (N = 5919 observations; wave 1 (February - March 2020): n = 2051; wave 2 (September - November 2020): n = 1919; wave 3 (June - July 2021): n = 1949). Generalised Estimating Equation (GEE) regressions were fit to test the associations between thinking about quitting due to the tax increase and post-tax increases in quit intention, serious quit attempts, and quitting smoking (≤ 1 cigarette a month), as well as sociodemographic variables.

RESULTS

Circa half of the people who smoke reported thinking about quitting smoking due to the upcoming tax increase (Wave 1 = 51.3% (n = 1052); Wave 2 = 47.3% (n = 849)). Individuals who reported thinking about quitting smoking due to upcoming tax increase(s) were more likely to have increased their quit intention (aOR: 2.00, p ≤ .001) or have carried out a serious quit attempt (aOR:1.48, p ≤ .001) post-tax increase. More people attempted to quit smoking between wave 2 and 3 (post 2021 increase) than between wave 1 and 2 (post 2020 increase). We did not find an interaction effect between wave and thinking about quitting for quit intention, quit attempts, and quitting smoking.

CONCLUSIONS

Tax increases stimulate people to think about quitting. Thinking about quitting due to an upcoming tax increase was associated with more positive quit intention and serious quit attempts.

Motivations to Change Smoking Behaviors Between 2007 and 2019 in Australia: A Repeated Cross-sectional Study

INTRODUCTION

In 2010, Australian tobacco excise (administered federally) increased by 25%, and by 12.5% annually from 2013 to 2020, with additional increases on roll-your-own (RYO) tobacco between 2017 and 2020. We estimated past year changes in smoking behavior among Australian adults who smoked (daily and non-daily) in the past year, and the association between consumer characteristics and stated motivations to change/attempt to change smoking behavior between 2007 and 2019.

METHODS

Logistic regression analysis of combined data from national representative triennial cross-sectional surveys in Australia (N = 22 977).

RESULTS

The main motivation cited for changing smoking behavior switched from health-related from 2007 to 2010 to cost-related from 2013 to 2019. Among those who quit between one and 12 months ago, living in a lower socioeconomic area (odds ratio (OR) = 1.61, 95% CI = 1.18% to -2.18%), was associated with reporting the cost of smoking motivated them to quit. Among those who reduced their smoking, smoking daily and >20 cigarettes/day vs. non-daily smoking (OR = 2.11, 95% CI = 1.60% to 2.78%), having high/very high psychological distress (OR = 1.33, 95% CI = 1.12% to 1.59%), and alcohol consumption (ORdaily drinking = 1.38, 95% CI = 1.05% to 1.81%) was associated with cost as a motivation. Exclusive (OR = 0.65, 95% CI = 0.53% to 0.80%) and non-exclusive (OR = 0.77, 95% CI = 0.65% to 0.91%) RYO use was associated with being less likely to report the cost of tobacco as motivation for cutting down.

CONCLUSIONS

The cost of smoking became the most cited motivator to change smoking behavior (eg, quitting and cutting down), particularly for those who lived in low socioeconomic areas, smoked more cigarettes per day, drank alcohol, and had high/very high psychological distress.

IMPLICATIONS

A change in the main federal tobacco control intervention implemented in Australia from mass-media campaigns to tobacco tax increases has likely led to cost, rather than health, being the main motivation cited for changing smoking behavior in Australia since 2013. Further monitoring is needed to ensure the harmonization in tax rates for RYO and factory-made cigarettes has effectively reduced the price difference between these products because the lower cost of RYO may have reduced the effectiveness of tax increases as a motivator to change smoking behavior.

Impact of population tobacco control interventions on socioeconomic inequalities in smoking: a systematic review and appraisal of future research directions

BACKGROUND

While price increases and targeted cessation support have been found to reduce inequalities in smoking by socioeconomic status (SES), evidence on other measures is mixed. We aimed to update the most recent (2014) previous review by identifying and appraising evidence published since 2013 on the equity impact of population tobacco control measures.

METHODS

Systematic searching of 10 electronic databases and hand-searching of four key journals identified 68 primary research articles published since 2013 that sought to examine the equity impact of population tobacco control measures in high-income countries with a negative socioeconomic gradient in smoking. Reported equity impacts were categorised as positive (greater impact among lower SES), neutral (no difference by SES), negative (greater impact among higher SES) or mixed/unclear.

RESULTS

There was substantial growth in research seeking to evaluate the equity impact of tobacco control interventions, but the majority of new studies showed mixed/unclear results. Findings for price increases and targeted cessation support continue to suggest an equity-positive impact, but limitations in the available evidence make further assessment difficult. Substantial differences in the context, scale and implementation of tobacco control policies make straightforward comparison of findings from the previous 2014 and current reviews problematic.

CONCLUSION

Researchers need to adopt more sophisticated, multidisciplinary approaches in evaluating the equity impact of tobacco control measures-developing robust measures of equity effect and using frameworks that take account of context, existing systems/processes and the likely mechanisms of action. Socioeconomic differences in intervention impact within low-income and middle-income countries require evaluation.

Dependence, plans to quit, quitting self-efficacy and past cessation behaviours among menthol and other flavoured cigarette users in Europe: The EUREST-PLUS ITC Europe Surveys

INTRODUCTION

This study characterises smoking and cessation-related behaviours among menthol and other flavoured cigarette users in Europe prior to the implementation of the European Tobacco Products Directive (TPD) ban on the sale of flavoured cigarettes.

METHODS

An analysis of cross-sectional data from the 2016 EUREST-PLUS ITC Europe Surveys was conducted among a sample of 10760 adult smokers from eight European Union Member States. Respondents were classified as menthol, other flavoured, unflavoured, or no usual flavour cigarette users and compared on smoking and cessation behaviours and characteristics. Data were analysed in SPSS Complex Samples Package using bivariate and multivariate regression analyses adjusted for sociodemographic characteristics, dependence, and country.

RESULTS

In bivariate analyses, cigarette flavour was significantly associated with all outcomes (p<0.001). After adjusting for sociodemographic characteristics, these associations attenuated but remained significant and in the same direction for dependence, self-efficacy, plans to quit, past quit attempts, and ever e-cigarette use. In fully adjusted models, compared to smokers of non-flavoured cigarettes, menthol smokers were less likely to smoke daily (AOR=0.47, 95% CI: 0.32-0.71), smoke within 30 min of waking (0.52,0.43-0.64), consider themselves addicted (0.74,0.59-0.94), and more likely to have ever used e-cigarettes (1.26,1.00-1.57); other flavoured cigarette smokers were less likely to smoke daily (0.33,0.15-0.77), and have higher self-efficacy (1.82,1.20-2.77); no usual flavour smokers were less likely to smoke daily (0.34,0.22-0.51), smoke within 30 min of waking (0.66,0.55-0.80), consider themselves addicted (0.65,0.52-0.78), have ever made a quit attempt (0.69,0.58-0.84), have ever used e-cigarettes (0.66,0.54-0.82), and had higher self-efficacy (1.46,1.19-1.80).

CONCLUSIONS

Smokers of different cigarette flavours in Europe differ on smoking and cessation characteristics. The lower dependence of menthol cigarette smokers could lead to greater success rates if quit attempts are made, however cross-country differences in smoking behaviours and quitting intentions could lead to the TPD ban on cigarette flavours having differential impact if not accompanied by additional measures, such as smoking cessation support.

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

INTRODUCTION

Innovations 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.

METHODS

An 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.

RESULTS

Participants (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.

CONCLUSIONS

The 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.

Smoking and urinary cotinine by socioeconomic status in the Heinz Nixdorf Recall Study

Background

Associations of socioeconomic status (SES) and smoking-related diseases depend on uniform validity of self-reported smoking habits in different SES groups. We investigated the influence of SES on validity of self-reported smoking status by means of urinary cotinine.

Methods

We determined total urinary cotinine in the baseline population of the Heinz Nixdorf Recall Study. Participants with cotinine>200 µg/L were potential current smokers. We defined upper and lower 20% of the gender-specific distribution of the International Socio-Economic Index (ISEI) as high and low SES, respectively, else as intermediate. We analysed the association of self-reported smoking status and cotinine by ISEI and additional SES measures, stratified by gender. In self-reported non-smokers, we estimated age-adjusted ORs with 95% CI to detect differences by SES in the validity of self-reported smoking status.

Results

In 2004 men and 1887 women, 78% and 80%, respectively, reported to be non-smokers. Median cotinine concentrations were 2 µg/L in non-smokers, and 3651 µg/L in male and 3127 µg/L in female smokers. Based on cotinine in non-smokers, 2.0 % of men (n = 32) and 1.8 % of women (n = 27) were potential smokers, with lower proportions in the subgroup of never-smokers (men: 0.7%, women: 0.5%). The validity of self-reported smoking status did not substantially differ by SES. Tendencies for increased underreporting were indicated for women with low ISEI (OR 1.35; 95% CI 0.54 to 3.39) and men in blue-collar jobs (OR 1.39; 95% CI 0.67 to 2.87).

Conclusion

Validity of self-reported smoking status in this elderly German cohort was high and did not depend on SES.

Does free or lower cost smoking cessation medication stimulate quitting? Findings from the International Tobacco Control (ITC) Netherlands and UK Surveys

OBJECTIVE

To investigate whether mentioning free or lower cost smoking cessation medication as a trigger for thinking about quitting is related to higher medication use, more quit attempts and quit success, and whether these associations are modified by education and income.

METHODS

Data were derived from the 2013 and 2014 surveys of the International Tobacco Control Netherlands (n=1164) and UK (n=768) cohort. Logistic regression analyses were used to assess associations between mentioning in 2013 that free/lower cost smoking cessation medication was a trigger for thinking about quitting smoking and the use of medication, quit attempts and smoking cessation in 2014.

RESULTS

37.0% of smokers in the UK and 24.9% of smokers in the Netherlands mentioned free/lower cost medication as a trigger for thinking about quitting. Smokers who mentioned this trigger were more likely to have used cessation medication during a quit attempt both in the UK (OR=4.19, p<0.001) and in the Netherlands (OR=2.14, p=0.033). The association between mentioning free/lower cost medication as a trigger for thinking about quitting and actual quit attempts was significant in the UK (OR=1.45, p=0.030), but not in the Netherlands (OR=1.10, p=0.587). There was no significant association with quit success. Associations did not differ across income and education groups.

CONCLUSION

Free/lower cost smoking cessation medication may increase the use of cessation medication and stimulate quit attempts among smokers with low, moderate and high education and income.

Quitting activity and use of cessation assistance reported by smokers in eight European countries: Findings from the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

There is clear evidence that the use of cessation aids significantly increases the likelihood of successful smoking cessation. The aim of this study was to examine quitting activity and use of cessation aids among smokers from various European countries. Subgroup differences were also examined for sex, income, education, and age in each country.

METHODS

Cross-sectional data were collected in 2016 from 10,683 smokers in eight European countries participating in the ITC Project: England (n=3,536), Germany (n=1,003), Greece (n=1,000), Hungary (n=1,000), the Netherlands (n=1,136), Poland (n=1,006), Romania (n=1,001), and Spain (n=1,001). We measured quitting activity, including quit attempts in the previous 12 months and intention to quit, use of cessation aids (i.e., medication, quitlines, internet, local services, and e-cigarettes), and whether respondents had received advice about quitting and e-cigarettes from health professionals.

RESULTS

Quit attempts were most common in England (46.3%) and least common in Hungary (10.4%). Quit intention was highest in England and lowest in Greece. Use of e-cigarettes to quit was highest in England (51.6%) and lowest in Spain (5.0%). Use of cessation aids was generally low across all countries; in particular this was true for quitlines, internet-based support, and local services. Receiving health professional advice to quit was highest in Romania (56.5%), and lowest in Poland (20.8%); few smokers received advice about e-cigarettes from health professionals. No clear differences were found for sex and income groups. Across countries, smokers with lower education reported less quitting activity.

CONCLUSIONS

Quitting activity and use of cessation methods were low in most countries. Greater quit attempts and use of cessation aids were found in England, where large investments in tobacco control and smoking cessation have been made. Health professionals are important for motivating smokers to quit and promoting the effectiveness of various methods, but overall, few smokers get advice to quit.

Cross-country comparison of smokers' reasons for thinking about quitting over time: findings from the International Tobacco Control Four Country Survey (ITC-4C), 2002-2015

OBJECTIVE

To explore between-country differences and within-country trends over time in smokers' reasons for thinking about quitting and the relationship between reasons and making a quit attempt.

METHODS

Participants were nationally representative samples of adult smokers from the UK (N=4717), Canada (N=4884), the USA (N=6703) and Australia (N=4482), surveyed as part of the International Tobacco Control Four Country Survey between 2002 and 2015. Generalised estimating equations were used to evaluate differences among countries in smokers' reasons for thinking about quitting and their association with making a quit attempt at follow-up wave.

RESULTS

Smokers' concern for personal health was consistently the most frequently endorsed reason for thinking about quitting in each country and across waves, and was most strongly associated with making a quit attempt. UK smokers were less likely than their counterparts to endorse health concerns, but were more likely to endorse medication and quitline availability reasons. Canadian smokers endorsed the most reasons, and smokers in the USA and Australia increased in number of reasons endorsed over the course of the study period. Endorsement of health warnings, and perhaps price, appears to peak in the year or so after the change is introduced, whereas other responses were not immediately linked to policy changes.

CONCLUSIONS

Differences in reasons for thinking about quitting exist among smokers in countries with different histories of tobacco control policies. Health concern is consistently the most common reason for quitting and the strongest predictor of future attempts.