Introduction Multiple occurrences in the United States may have impacted trajectories (i.e., transitions over time) in the use of electronic nicotine delivery systems (ENDS) and cigarette smoking in the population over time. We examine youths' trajectories in ENDS use and adults' trajectories in cigarette smoking across two periods: 2014-2016-2017; 2019-2021-2022.Methods We analyzed longitudinal Population Assessment of Tobacco and Health (PATH) Study data from youth ages 12-17 in 2014 (N = 9,582), youth ages 12-17 in 2019 (N = 7,325), adults who smoked cigarettes in 2014 (N = 8,999), and adults who smoked cigarettes in 2019 (N = 5,800). We evaluated trajectories in ENDS use among youth and trajectories in cigarette smoking among adults, each across two periods: 2014-2016-2017; 2019-2021-2022.Results Among youth, rates of progression from less frequent to frequent ENDS use were 23 and 35% across two periods: 2014-2016-2017; 2019-2021-2022, respectively; rates of maintaining frequent ENDS use were 13 and 51% across two periods: 2014-2016-2017; 2019-2021-2022, respectively. Among adults who smoked cigarettes and used ENDS frequently, 23 and 42% discontinued smoking across two periods: 2014-2016-2017; 2019-2021-2022, respectively.Conclusions Across the period 2019-2021-2022, the number of youths in 2019 who used ENDS frequently in 2022 was 1.6 million, while the number of adults who smoked cigarettes in 2019 who used ENDS frequently in 2019, and stopped smoking cigarettes in 2022, was 1.6 million. The population-level impact of ENDS in the US appears greater since the significant evolution in the ENDS market, including the rise in popularity of salt-based nicotine ENDS, the coronavirus disease 2019 (COVID-19) pandemic, and various tobacco control policies.

INTRODUCTION:Misperceptions about nicotine product harms may influence product use and switching behaviors. METHODS:Data were from the 2020 International Tobacco Control (ITC) Malaysia Survey, a nationally representative survey of 1047 adults aged ≥ 18 who smoked cigarettes at least monthly and had smoked ≥ 100 cigarettes (n = 1047). Respondents reported awareness of HTPs and ECs and perceived harmfulness relative to cigarettes. For regression analyses, perceived harmfulness vs cigarettes were categorized as less harmful, equally/more harmful, or don't know; for HTP-EC comparisons, categories were HTP more harmful, equally/EC more harmful, or don't know. RESULTS:Overall, 53.4% respondents had heard of HTPs, with lower awareness among women, ethnic minorities, and those with lower educational attainment. Among those aware of HTPs, 39.7% perceived HTPs as less harmful and 38.9% as equally harmful as cigarettes. Ethnic minority respondents were more likely to perceive HTPs as equally/more harmful than cigarettes or to report don't know, while those with secondary or lower education had lower odds of reporting don't know. Among adults aware of ECs, 46.4% perceived ECs as less harmful than cigarettes, while 29.7% and 14.1% perceived them as equally or more harmful. Respondent aged ≥ 40 had higher odds of perceiving ECs as equally/more harmful than cigarettes or reporting don't know. When comparing HTPs and ECs directly, 49.5% perceived them as equally harmful and 25.3% perceived HTPs as more harmful than ECs, while respondents aged ≥ 40 were more likely to report don't know. CONCLUSION:Perceptions of harm varied across products and sociodemographic groups, indicating gaps in understanding nicotine product harms.

INTRODUCTION:A growing number of US states have legalised adult 'recreational' cannabis. Restrictions on advertising and promotions are a key component of cannabis regulations in legal markets; however, there is little evidence on the impact of restrictions. This study examines differences in cannabis marketing exposure by the strength of marketing restrictions among US states with legal recreational sales. METHODS:Data are from the International Cannabis Policy Study: repeated cross-sectional surveys conducted annually (2018-2023) with 99,132 respondents aged 16-65. The 'strength' of marketing restrictions was measured using regulatory documents in 20 states with legal recreational cannabis sales. Adjusted mixed effects logistic regression models were fitted to analyse differences in past-12 month noticing of cannabis marketing by the strength of marketing restrictions overall and within specific marketing channels. RESULTS:People in states with low and moderate strength marketing restrictions reported similar exposure to cannabis marketing (61.4% and 61.8%, respectively). Compared to those with moderate strength restrictions, people in states with the highest strength restrictions reported the lowest exposure (53.4%: p = 0.037), with no significant differences for states with low strength restrictions (p = 0.067). Comprehensive restrictions on marketing via billboards and posters, and at sports events were associated with reductions in reported exposure to these channels. Cannabis marketing exposure was highest among people below the minimum legal age (16-20 years old; 63.0%: p < 0.001). DISCUSSION AND CONCLUSIONS:Stronger regulations may reduce exposure to marketing in states with recreational cannabis markets; however, existing regulations appear to be inadequate to prevent advertising and promotions from reaching young people.

BACKGROUND:Some countries are exploring policies that might help lower cigarette smoking prevalence to below 5% by 2030. This study assesses support for three policies among adults who smoke: (1) ending smoked tobacco sales within 10 years; (2) limiting cigarette nicotine content to make them less addictive; and (3) restricting smoked tobacco sales for life to anyone currently under 18 (Smoke-Free Generation, SFG). METHODS:Data were from the 2022 International Tobacco Control Four Country Smoking and Vaping Survey, including 2723 adults who smoked at least monthly in Australia, Canada, England and the USA. We estimated the weighted prevalence of support and used logistic regression to assess whether support (vs no support) differed by sociodemographic variables (country, gender, age, race/ethnicity, education, income). RESULTS:Support was 27.1% for ending smoked tobacco sales within 10 years, 53.5% for limiting the nicotine content of cigarettes and 51.7% for an SFG law. US adults had consistently lower odds of support compared with those in Canada and England (all policies: p<0.01). Women and white individuals had lower odds of supporting an end to smoked tobacco sales (adjusted OR (aOR): 0.63, p=0.02; 0.68, p=0.03) and an SFG law (aOR: 0.72, p=0.04; 0.66, p=0.01). Women (aOR: 1.41, p<0.01) were more supportive of nicotine reduction. Individuals with moderate (aOR vs high: 1.34, p=0.03) and low (aOR: 1.41, p=0.03) education, and those with financial difficulties (aOR: 1.36, p=0.04) showed higher support for an SFG law. No differences in support were observed by age in the pooled data. CONCLUSIONS:Support for policies to reduce the use of commercial cigarettes was moderate-to-high among adults who smoke, although it varied significantly by country, gender and income. Tailored communication strategies could help increase support and promote policy adoption.

INTRODUCTION:E-cigarettes are an increasingly popular method of smoking cessation assistance; however, there is little research on whether this has affected the number of smokers who quit using "any" evidence-based cessation aid. This study examined trends in the use of cessation aids, including e-cigarettes and other evidence-based methods. AIMS AND METHODS:Data were cross-sectional surveys in 2016, 2018, and 2020 from the International Tobacco Control Four Country Smoking and Vaping Survey conducted in Canada, United States (US), England, and Australia. Respondents were adults (≥18) recruited by commercial panel firms who currently smoked, and/or quit smoking in the past 12 months. Respondents were asked about use of e-cigarettes, nicotine replacement therapies, prescription medications, quitlines, and counseling services during their last quit attempt (LQA). Generalized estimating equation regression models that were analyzed separately by country examined use of cessation assistance among 14 536 observations (Canada = 4880; US = 2917; England = 4846; and Australia = 1898). RESULTS:E-cigarettes (29.9%) and nicotine replacement therapy (29.8%) were popular methods of cessation assistance at LQA. Using e-cigarettes at LQA increased in Australia (2016 = 11.1%; 2020 = 25.1%; p=.002) and England (2016 = 37.1%; 2018 = 46.7%; p=.002), with no significant change in Canada or the US. Across all countries, there was little change over time in the overall use of evidence-based cessation assistance. Nearly half of respondents used some form of cessation assistance excluding e-cigarettes. Approximately two-thirds used "any" form of evidence-based cessation including e-cigarettes at LQA, which decreased in Canada (2016 = 64.0%, 2020 = 58.9%; p=.010). CONCLUSIONS:While e-cigarettes are a popular cessation aid, use of other evidence-based cessation assistance has remained comparatively stable among adults that tried to quit smoking. IMPLICATIONS:The findings indicated that e-cigarettes are a popular cessation method among adults trying to quit smoking. Despite differences in e-cigarette use and regulatory environments in the four countries, rates of evidence-based cessation assistance were similar across countries and over time. E-cigarettes can be an effective method for stopping smoking; however, the current study suggests few, if any, changes in the proportion of adults who smoke using any evidence-based form of cessation assistance, despite changes in the use of e-cigarettes as a quit aid.

Objectives:Among Canadian adults who currently or formerly smoked cigarettes, we examined: consultations with healthcare providers (HPs) in the last two years; among those, the proportion who received any smoking cessation advice and the type of support recommended; and whether receiving cessation advice varied by social determinants of health (SDH) and health conditions. Methods:Data are from the 2022 Canada International Tobacco Control Survey (online; August-December 2022). Eligible respondents included 1163 adults who smoked daily for at least two years or quit smoking in the last two years, but previously smoked daily. SDH and health variables included: sociodemographics, financial insecurity, depression/anxiety, lung disease, and alcohol use. Results:Almost half consulted an HP (48.7 %); among those, 51.0% received cessation advice: 46.8 % were advised to use nicotine replacement therapy, 32.0 % varenicline, 14.0 % bupropion, 13.3 % a quitline, 14.5 % a smoking cessation program, and 2.6 % an e-cigarette. Adults with heart disease were more likely to receive advice to quit [odds ratio (OR) 2.74, 95 % confidence interval (CI):1.26,5.98)]. Among adults who were smoking, those who had no interest in quitting (OR 0.25, 95 % CI: 0.09,0.68) or reported that they wanted to quit a little/somewhat (OR 0.42, 95 % CI: 0.22,0.80) were less likely to receive advice compared to those who wanted to quit smoking a lot. There were no significant differences by SDH, mental health, lung disease, or alcohol use. Conclusion:The low rate of smoking cessation advice from HPs underscores the need for systematic engagement across clinical settings to encourage quitting smoking and offer evidence-based methods to support cessation.

OBJECTIVE:To assess the prevalence and associated factors of smoke-free homes (SFHs) among Spanish adults who smoke across three cohort waves, and to identify determinants of SFH adoption during follow-up (2016-2021). METHODS:The International Tobacco Control EUREST-PLUS Spain Survey is a nationally representative cohort of ∼1000 adults (≥18 years) who smoke surveyed in 2016, 2018, and 2021. First, we conducted repeated cross-sectional analysis to estimate the prevalence of SFHs at each wave. Second, we estimated incidence and risk ratios (RR) with 95 % confidence intervals (CI) for SFH adoption during the follow-up using adjusted generalised linear models. Independent variables included sociodemographics, smoking characteristics, and beliefs about second-hand smoke harms. RESULTS:SFH prevalence was 13.1 % in 2016, 19.0 % in 2018, and 31.5 % in 2021 (p trend <0.001). Quitting smoking (RR = 2.66; 95 % CI: 2.10, 3.36), remaining in any stage other than precontemplation (RR = 1.76; 1.13, 2.73) and progressing beyond precontemplation stage (RR = 2.59; 1.99, 3.37) were determinants of SFH adoption. Maintaining moderate or high nicotine dependence (RR = 0.46; 0.30, 0.69) was inversely associated with SFH adoption. CONCLUSIONS:SFH prevalence among Spanish adults who smoke increased in 2016-2021. Initiatives promoting SFHs should encourage progression through the stages of change towards cessation and provide tailored support for individuals with high nicotine dependence.

BACKGROUND AND AIMS:Many vaping products feature bright colors and novel brand names and flavor descriptors, which may appeal to youth. We measured the strength of the associations between e-liquid packaging design (branded, white standardized or white standardized limiting brand and flavor descriptors) and perceived peer interest in trying the e-liquids among youth. DESIGN:A between-subjects online experiment. SETTING:The Action on Smoking and Health Smokefree Great Britain (GB) Youth 2021 online survey. PARTICIPANTS:Participants included 1628 youth aged 11-18, 51.9% female, 71.8% socioeconomic status ABC1 (the three highest Market Research Society grades). MEASUREMENTS:Participants were randomized to view a set of three images of e-liquids from one of three packaging conditions: (1) fully branded (control), (2) white standardized with usual brand names and flavor descriptors or (3) white standardized with coded brand names and limited flavor descriptors. Participants were asked which e-liquid they thought people their age would be most interested in trying and could select a product, 'none of these', or 'do not know'. Multinomial logistic regression models were used to test associations between selecting 'none of these' ('no interest') versus any product ('interest') or 'do not know' and packaging condition. Analyses were adjusted for sex, age, socioeconomic status, vaping status and smoking status. FINDINGS:Compared with fully branded packaging (22.7%; reference category), youth had higher odds of reporting no perceived peer interest in trying e-liquids in standardized packs with brand codes and limited flavor descriptors [30.3%, adjusted odds ratio (AOR) = 2.07, 95% confidence interval (CI) = 1.53-2.79], but not standardized packs with usual descriptors (23.1%, AOR = 1.21, 95% CI = 0.89-1.65). Youth had higher odds of reporting no perceived peer interest in e-liquids in white standardized packs with brand codes and limited flavor descriptors (30.3%, AOR = 1.87, 95% CI = 1.29-2.16, P < 0.001) compared with standardized packs with usual descriptors (23.1%; reference category). CONCLUSION:Standardized e-liquid packaging that limits flavor and brand descriptors may reduce the youth appeal of e-liquids.

BACKGROUND:Smokeless tobacco (SLT) packaging in India had a single symbolic (a scorpion) health warning label (HWL) in 2009 covering 40% of the front surface. In 2011, it was replaced with four pictorial images. In 2016, HWLs were enlarged to 85% on the front and back. This study aimed to assess the effectiveness of the old (symbolic and smaller images) and larger HWLs. METHODS:Data were from the Tobacco Control Project India Survey and included respondents who used SLT in Wave 1 (2010-2011, n=5911), Wave 2 (2012-2013, n=5613) and Wave 3 (2018-2019, n=5636). Using a repeated-measures design, weighted logistic regression models assessed whether there were changes in seven HWL effectiveness measures within the domains of awareness, salience, cognitive and behavioural responses. A cohort design was employed to test whether HWL effectiveness in Waves 1 and 2 was associated with quitting SLT in Waves 2 and 3, respectively. RESULTS:The 2011 HWL revision did not result in any significant changes in HWL effectiveness. There was no significant change in HWL awareness and salience after larger HWLs were introduced in 2016, but respondents were more likely to consider SLT health risks (Wave 2=17.9%, Wave 3=33.6%, p<0.001) and quitting SLT (Wave 2=18.9%, Wave 3=36.5, p<0.001). There was no change in HWLs stopping SLT use (Wave 2=36.6%, Wave 3=35.2%, p=0.829); however, respondents were more likely to avoid looking at HWLs (Wave 2=10.1%, Wave 3=40.2%, p<0.001). Effectiveness of older, symbolic and smaller pictorial HWLs was not associated with quitting SLT. DISCUSSION:There was no significant change in HWL effectiveness following the revision from a symbolic to a pictorial image, but enlarging pictorial images resulted in some improved cognitive and behavioural effects. Results suggested wear-out of HWL salience and that the effectiveness of warnings depends on both their design and time since implementation.

An analysis of 1771 Canadian adults who smoke or used to smoke cigarettes was conducted using data from the 2022 International Tobacco Control Four Country Smoking and Vaping Survey. Using weighted data, we estimated the prevalence of Canadian adults who tried to quit smoking between 2020 and 2022, and the use of a nicotine vaping product (NVP) and the flavours and devices used most often at their most recent quit attempt. Overall, 36.5% made a quit attempt; of those, 19.4% used an NVP. Those who were younger and quit smoking were more likely to have used an NVP. Prefilled cartridges or pods (36.3%) and fruit flavours (39.5%) were used most frequently.

Nous avons mené une analyse portant sur 1 771 adultes canadiens qui fument ou fumaient des cigarettes en nous fondant sur les données de l’Enquête sur le tabagisme et le vapotage dans quatre pays menée en 2022 par le Projet international d’évaluation de la lutte antitabac. En utilisant des données pondérées, nous avons estimé la prévalence des tentatives d’abandon du tabagisme chez les adultes canadiens entre 2020 et 2022 et nous avons évalué leur utilisation d’un produit de vapotage contenant de la nicotine (PVN), de même que les arômes et les dispositifs le plus souvent utilisés lors de leur tentative d’abandon la plus récente. Dans l’ensemble, 36,5 % des participants ont tenté de cesser de fumer et 19,4 % de ces derniers ont utilisé un PVN. Ceux qui étaient plus jeunes et qui avaient effectivement cessé de fumer étaient plus susceptibles d’avoir utilisé un PVN. Les cartouches ou capsules (pods) préremplies (36,3 %) et les arômes de fruits (39,5 %) étaient les choix les plus populaires.

BACKGROUND:A growing number of US states have legalized adult "recreational" cannabis; however, there is little evidence on the impact of cannabis policies on cannabis marketing exposure to date. The current study examined marketing exposure in the US, including differences between states where cannabis is illegal ('illegal' states), legal for medical use ('medical'), and legal for recreational use ('recreational'). METHODS:Data are from the US component of the International Cannabis Policy Study: national repeat cross-sectional data from surveys conducted with 187,573 respondents aged 16-65 over 6 annual survey waves (2018-2023). Adjusted mixed effects logistic regression (GLIMMIX) models examined differences in self-reported exposure to cannabis marketing ('noticing') by state-level cannabis laws. RESULTS:Self-reported exposure to cannabis marketing differed across policy changes. Noticing cannabis marketing was lowest in illegal states and increased in the first 12-months following medical legalization (35.4 % vs. 39.2 %: AOR=1.16; 95 % CI=1.01-1.33; p = 0.034). Noticing marketing was highest in 'recreational' states, with increases in the first 12-months following legalization (50.0 % vs. 41.1 %: AOR=1.41; 95 % CI=1.34-1.48; p < .001), and additional increases 1-3 years (56.2 %: AOR=1.20; 95 % CI=1.14-1.25; p < .001) and 4 or more years following legalization (63.9 %: AOR=1.21; 95 % CI=1.16-1.27; p < .001). Noticing was highest among people who consume cannabis and younger ages. CONCLUSIONS:Self-reported exposure to cannabis marketing increases following medical and recreational legalization and is disproportionately noticed by underaged people. Cannabis regulations in 'legal' markets should account for marketing, which has been shown to promote cannabis use.

Objective We examined Australian tobacco purchasing trends, the average self-reported price paid within each purchase type and the association between type of tobacco product purchased and participant characteristics, including quit intentions, between 2007 and 2020. Methods We analysed data collected from adults who smoked factory-made and/or roll-your-own (RYO) cigarettes in nine waves (2007–2020) of the International Tobacco Control Policy Evaluation Project Australia Survey (n sample =5452, n observations =11 534). The main outcome measures were type of tobacco products purchased: RYO, carton, pack or pouch size and brand segment. Logistic regression, fit using generalised estimating equations, was estimated the association between the outcome and participant characteristics. Results The reported price-minimising purchasing patterns increased from 2007 to 2020: any RYO (23.8–43.9%), large-sized pack (2007: 24.0% to 2016: 34.3%); shifting from large-sized to small-sized packs (2020: 37.7%), and economy brand (2007: 37.2% to 2020: 59.3%); shifting from large (2007: 55.8%) to small economy packs (2014: 15.3% to 2020: 48.1%). Individuals with a lower income, a higher nicotine dependence level and no quit intention were more likely to purchase RYO and large-sized packs. Conclusion RYO, large-sized packs and products with a low upfront cost (eg, small RYO pouches and small-sized economy brand packs) may appeal to people on low incomes. Australia’s diverse tobacco pack and pouch sizes allow the tobacco industry to influence tobacco purchases. Standardising pack and pouch sizes may reduce some price-related marketing and especially benefit people who have a low income, are highly addicted and have no quit intention.

BACKGROUND:Spain implemented an extensive outdoor smoking ban during the COVID-19 pandemic in 2020. We examined support for this restriction during and beyond the pandemic among people who currently and formerly smoked. METHODS:Cross-sectional study. The 2021 ITC EUREST-PLUS Spain Survey used a multistage sampling to obtain a representative sample of people who currently or formerly smoked (n=1006). We estimated prevalence ratios (PRs) to examine associations with ban support during and after the pandemic. Analyses accounted for the complex sampling design and were weighted to ensure representativeness. RESULTS:Most people who currently (79.2%) and formerly smoked (94.6%) supported the outdoor smoking ban when a safe interpersonal distance could not be maintained during the pandemic. Support for a permanent ban remained substantial (61.4% and 87.2%, respectively). Those who currently smoke were more likely to support bans during and after the pandemic if they had smoke-free homes (PR=1.11; PR=1.29, respectively), understood secondhand smoke harms to health (PR=1.40; PR=1.65), had tried to quit (PR=1.14; PR=1.30) and self-reported as healthy (PR=1.40; PR=1.47). Those who formerly smoked were more likely to support bans during the pandemic if they had smoke-free homes (PR=1.08) and did not self-report as healthy (PR=0.95); and after the pandemic if they had quit smoking for ≥6 months (PR=1.23) and used alternative tobacco products (PR=1.17). CONCLUSIONS:Most people who currently or formerly smoked in Spain supported the outdoor smoking ban during and after the COVID-19 pandemic. This high acceptance suggests that the pandemic may have created an opportunity to strengthen tobacco control.

ObjectiveWe examined the relationship in Australia from 2007 to 2020 between tobacco tax increases and use of cost-minimising behaviours (CMBs) when purchasing tobacco and: (1) tobacco expenditure and (2) smoking cessation attempts and quit success.MethodsWe used data collected from adults who smoked factory-made and/or roll-your-own (RYO) cigarettes in nine waves (2007–2020) of the International Tobacco Control Policy Evaluation Project Australia Survey (Nsample=4975, Nobservations=10 474). CMBs included buying RYO tobacco, cartons, large-sized packs, economy packs, or tax avoidance/evasion, smoking reduction and e-cigarette use. Logistic regression, fit using generalised estimating equations, estimated the CMB-outcome association for quit attempts and quit success at the next wave follow-up (Nsubsample=2984, Nobservations=6843).ResultsOver half of respondents used a CMB for tobacco purchase (P-CMB) at baseline (57.1% in 2007–2008), increasing to 76.8% (2018) post-tax increases. Participating in any P-CMB was associated with having higher weekly tobacco expenditure. Engaging in any P-CMB was negatively associated with attempting to quit (aOR=0.82, 95% CI 0.69–0.98). Purchasing RYO tobacco or cartons was associated with making no quit attempts (aOR=0.66, 95% CI 0.52–0.83; aOR=0.72, 95% CI 0.59–0.89, respectively). Among respondents smoking cigarettes who made quit attempts, there were no significant associations between all P-CMBs and quit success. Neither smoking reduction nor vaping were significantly associated with quit attempts.ConclusionP-CMBs are associated with reduced smoking cessation. Reducing opportunities for industry to promote purchasing-related CMB options, such as by standardising pack sizes and reducing the price differential between RYO and manufactured cigarettes could increase the effectiveness of tax increases.

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