Prevalence of awareness, ever-use and current use of nicotine vaping products (NVPs) among adult current smokers and ex-smokers in 14 countries with differing regulations on sales and marketing of NVPs: cross-sectional findings from the ITC Project.

AIMS: This paper presents updated prevalence estimates of awareness, ever-use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: A cross-sectional analysis of adult (≥ 18 years) current smokers and ex-smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013-17. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs), not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs), not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand; (3) less restrictive policies (LRPs), legal to be sold and marketed with regulations: England, the Netherlands, Republic of Korea, United States; and (4) no regulatory policies (NRPs), Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country-specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily versus non-daily). FINDINGS: NVP awareness and use were lowest in NRP countries. Generally, ever- and current use of NVPs were lower in MRP countries (ever-use = 7.1-48.9%; current use = 0.3-3.5%) relative to LRP countries (ever-use = 38.9-66.6%; current use = 5.5-17.2%) and RP countries (ever-use = 10.0-62.4%; current use = 1.4-15.5%). NVP use was highest among high-income countries, followed by upper-middle-income countries, and then by lower-middle-income countries. CONCLUSIONS: With a few exceptions, awareness and use of nicotine vaping products varied by the strength of national regulations governing nicotine vaping product sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in nicotine vaping products in these countries where smoking populations are predominantly poorer. The higher awareness and use of nicotine vaping products in high income countries with moderately (e.g. Canada, New Zealand) and less (e.g. England, United States) restrictive policies, is likely due to the greater availability and affordability of nicotine vaping products.

The impact of the 2009/2010 enhancement of cigarette health warning labels in Uruguay: longitudinal findings from the International Tobacco Control (ITC) Uruguay Survey.

BACKGROUND: Framework Convention on Tobacco Control (FCTC) Article 11 Guidelines recommend that health warning labels (HWLs) should occupy at least 50% of the package, but the tobacco industry claims that increasing the size would not lead to further benefits. This article reports the first population study to examine the impact of increasing HWL size above 50%. We tested the hypothesis that the 2009/2010 enhancement of the HWLs in Uruguay would be associated with higher levels of effectiveness. METHODS: Data were drawn from a cohort of adult smokers (≥18 years) participating in the International Tobacco Control (ITC) Uruguay Survey. The probability sample cohort was representative of adult smokers in five cities. The surveys included key indicators of HWL effectiveness. Data were collected in 2008/09 (prepolicy: wave 2) and 2010/11 (postpolicy: wave 3). RESULTS: Overall, 1746 smokers participated in the study at wave 2 (n=1379) and wave 3 (n=1411). Following the 2009/2010 HWL changes in Uruguay (from 50% to 80% in size), all indicators of HWL effectiveness increased significantly (noticing HWLs: OR=1.44, p=0.015; reading HWLs: OR=1.42, p=0.002; impact of HWLs on thinking about risks of smoking: OR=1.66, p<0.001; HWLs increasing thinking about quitting: OR=1.76, p<0.001; avoiding looking at the HWLs: OR=2.35, p<0.001; and reports that HWLs stopped smokers from having a cigarette 'many times': OR=3.42, p<0.001). CONCLUSIONS: The 2009/2010 changes to HWLs in Uruguay, including a substantial increment in size, led to increases of key HWL indicators, thus supporting the conclusion that enhancing HWLs beyond minimum guideline recommendations can lead to even higher levels of effectiveness.

Tobacco smoke exposure in public places and workplaces after smoke-free policy implementation: a longitudinal analysis of smoker cohorts in Mexico and Uruguay.

OBJECTIVE: To determine the prevalence, correlates and changes in secondhand smoke (SHS) exposure over the period after comprehensive smoke-free policy implementation in two Latin American countries. METHODS: Data were analysed from population-based representative samples of adult smokers and recent quitters from the 2008 and 2010 waves of the International Tobacco Control Policy Evaluation Survey in Mexico (n = 1766 and 1840, respectively) and Uruguay (n = 1379 and 1411, respectively). Prevalence of SHS exposure was estimated for regulated venues, and generalized estimating equations were used to determine correlates of SHS exposure. RESULTS: Workplace SHS exposure in the last month was similar within and across countries (range: Mexico 20-25%; Uruguay 14-29%). At the most recent restaurant visit, SHS exposure was lower where comprehensive smoke-free policies were implemented (range: Uruguay 6-9%; Mexico City 5-7%) compared with Mexican cities with weaker policies, where exposure remained higher but decreased over time (32-17%). At the most recent bar visit, SHS exposure was common (range: Uruguay 8-36%; Mexico City 23-31%), although highest in jurisdictions with weaker policies (range in other Mexican cities: 74-86%). In Uruguay, males were more likely than females to be exposed to SHS across venues, as were younger compared with older smokers in Mexico. CONCLUSIONS: Comprehensive smoke-free policies are more effective than weaker policies, although compliance in Mexico and Uruguay is not as high as desired.

Tabaquismo en los médicos uruguayos (2011) / Tobacco use in Uruguayan physicians (2011)

El objetivo del presente trabajo es señalar que las políticas de control del tabaco tienen efecto sobre la prevalencia de tabaquismo en general y en los médicos en particular. Pero, además, qué efecto tiene el papel de los médicos en modificar la prevalencia. Para eso se mide la prevalencia de tabaquismo y aspectos vinculados en los médicos, y se los compara con los de la población en general. Finalmente se examina la acción sobre el tabaquismo desarrollada por los médicos hacia sus pacientes

Using Cognitive Interviewing and Behavioral Coding to Determine Measurement Equivalence across Linguistic and Cultural Groups: An Example from the International Tobacco Control Policy Evaluation Project.

The present study aimed to examine and compare results from two questionnaire pretesting methods (i.e., behavioral coding and cognitive interviewing) in order to assess systematic measurement bias in survey questions for adult smokers across six countries (USA, Australia, Uruguay, Mexico, Malaysia and Thailand). Protocol development and translation involved multiple bilingual partners in each linguistic/cultural group. The study was conducted with convenience samples of 20 adult smokers in each country. Behavioral coding and cognitive interviewing methods produced similar conclusions regarding measurement bias for some questions; however, cognitive interviewing was more likely to identify potential response errors than behavioral coding. Coordinated survey qualitative pretesting (or post-survey evaluation) is feasible across cultural groups, and can provide important information on comprehension and comparability. Cognitive interviewing appears a more robust technique than behavioral coding, although combinations of the two might be even better.

ITC "spit and butts" pilot study: the feasibility of collecting saliva and cigarette butt samples from smokers to evaluate policy.

INTRODUCTION: Large-scale epidemiological surveys have frequently relied upon clinic-based sample collection to incorporate biological data, which can be costly and result in nonrepresentative data. Collecting samples in a nonclinical setting (i.e., through postal mail or at the subject's home) offers an alternative option that is minimally invasive and can be incorporated into large population-based studies. OBJECTIVES: (a) To assess the feasibility of collecting biological data from a cohort of smokers in the International Tobacco Control (ITC) study, through the mail and in the home; (b) to examine whether participants are representative of the population under consideration; and (c) to evaluate how the added burden of providing biomarker samples might impact subsequent participation in a follow-up survey. METHODS: Participants were asked to provide a saliva sample and five cigarette butts from cigarettes smoked on a single day, using standardized procedures. Sample collection kits were mailed to a random sample of 400 daily cigarette smokers who were involved in the 2006 annual ITC Four Country (United Kingdom, United States, Canada, and Australia) telephone survey and agreed to participate in sample collection. A random sample of 179 daily smokers who participated in a face-to-face ITC survey in Mexico and Uruguay and agreed to participate in sample collection were also asked to provide samples. RESULTS: Samples were collected from 96% of invited participants in the face-to-face surveys and 52% of participants in the telephone survey. The added burden of the sample collection did not reduce survey retention rates. Participants who initially agreed to participate in the sample collection were more likely to participate in the subsequent survey than participants who were not asked or declined to participate (odds ratio [OR] = 1.28; 95% CI = 1.01-1.62, p = .021). Further, those who provided samples were also more likely to participate in the subsequent survey than those who did not (OR = 2.78; 95% CI = 1.71-4.52, p < .001). DISCUSSION: Collecting saliva and cigarette butt samples from a group of smokers is feasible, yields a representative sample, and the added participant burden does not reduce subsequent survey response rates.

Assessing the impact of cigarette package health warning labels: a cross-country comparison in Brazil, Uruguay and Mexico.

OBJECTIVE: To assess the impact of different health warning labels (HWL). MATERIAL AND METHODS: Data from the International Tobacco Control Survey (ITC Survey) were analyzed from adult smokers in Brazil, Uruguay and Mexico, each of which used a different HWL strategy (pictures of human suffering and diseased organs; abstract pictorial representations of risk; and text-only messages, respectively). Main outcomes were HWL salience and cognitive impact. RESULTS: HWLs in Uruguay (which was the only country with a HWL on the front of the package) had higher salience than either Brazilian or Mexican packs. People at higher levels of educational attainment in Mexico were more likely to read the text-only HWLs whereas education was unassociated with salience in Brazil or Uruguay. Brazilian HWLs had greater cognitive impacts than HWLs in either Uruguay or Mexico. HWLs in Uruguay generated lower cognitive impacts than the text-only HWLs in Mexico. In Brazil, cognitive impacts were strongest among smokers with low educational attainment. CONCLUSIONS: This study suggests that HWLs have the most impact when they are prominent (i.e., front and back of the package) and include emotionally engaging imagery that illustrates negative bodily impacts or human suffering due to smoking.

Assessing the impact of cigarette package health warning labels: a cross-country comparison in Brazil, Uruguay and Mexico / Impacto de advertencias sanitarias del empaquetado de cigarros: un análisis comparativo en Brasil, Uruguay y México

Objective. To assess the impact of different health warning labels (HWL). Material and Methods. Data from the International Tobacco Control Survey (ITC Survey) were analyzed from adult smokers in Brazil, Uruguay and Mexico, each of which used a different HWL strategy (pictures of human suffering and diseased organs; abstract pictorial representations of risk; and text-only messages, respectively). Main outcomes were HWL salience and cognitive impact. Results. HWLs in Uruguay (which was the only country with a HWL on the front of the package) had higher salience than either Brazilian or Mexican packs. People at higher levels of educational attainment in Mexico were more likely to read the text-only HWLs whereas education was unassociated with salience in Brazil or Uruguay. Brazilian HWLs had greater cognitive impacts than HWLs in either Uruguay or Mexico. HWLs in Uruguay generated lower cognitive impacts than the text-only HWLs in Mexico. In Brazil, cognitive impacts were strongest among smokers with low educational attainment. Conclusions. This study suggests that HWLs have the most impact when they are prominent (i.e., front and back of the package) and include emotionally engaging imagery that illustrates negative bodily impacts or human suffering due to smoking.

Objetivo. Evaluar el impacto de diferentes advertencias sanitarias (AS). Material y métodos. Se analizaron datos de la Encuesta Internacional para el Control del Tabaco (ITC Survey), un estudio de fumadores adultos en Brasil, Uruguay y México, tres países con distintas AS (con imágenes de sufrimiento humano y órganos enfermos; con imágenes abstractas del riesgo; mensajes de solo texto, respectivamente). Se analizó prominencia e impacto cognitivo de las AS. Resultados. Las AS de Uruguay (que era el único país con AS en la parte frontal del paquete) tuvieron una mayor prominencia que en Brasil o México. En México, la gente que tenía un nivel de educación mayor eran mas propensos a leer mensajes de advertencia, mientras que educación no se asoció con prominencia en Brasil o Uruguay. Las AS de Brasil tuvieron un mayor impacto cognitivo y conductual que las AS de Uruguay o México. Las AS de Uruguay generaron un menor impacto cognitivo y conductual que las AS de sólo texto en México. En Brasil, los impactos cognitivos fueron los más fuertes entre fumadores con un bajo nivel educacional. Conclusiones. Este estudio sugiere que las AS tienen el mayor impacto cuando son prominentes (por ej. en el frente y la parte trasera del paquete) e incluyen imágenes emocionalmente llamativas que muestran impactos negativos en el cuerpo o sufrimiento humano debido al fumar.

Smoke-free policies and the social acceptability of smoking in Uruguay and Mexico: findings from the International Tobacco Control Policy Evaluation Project.

INTRODUCTION: Little research has been conducted to determine the psychosocial and behavioral impacts of smoke-free policies in middle-income countries. METHODS: Cross-sectional data were analyzed from the 2006 waves of the International Tobacco Control Policy Evaluation. Survey comparing adult smokers in Mexico (n = 1,080), where smoke-free legislation at that time was weak, and Uruguay (n = 1,002), where comprehensive smoke-free legislation was implemented. Analyses aimed to determine whether exposure to smoke-free policies and perceived antismoking social norms were associated with smokers' receiving cues about the bothersome nature of secondhand smoke (SHS), with smokers' reactance against such cues, and with smokers' level of support for smoke-free policies in different venues. RESULTS: In bivariate analyses, Uruguayan smokers were more likely than Mexican smokers to experience verbal anti-SHS cues, lower reactance against anti-SHS cues, stronger antismoking societal norms, and stronger support for 100% smoke-free policies in enclosed workplaces, restaurants, and bars. In multivariate models for both countries, the strength of voluntary smoke-free policies at home was independently associated with support for smoke-free policies across all venues queried, except for in bars among Uruguayans. Perceived strength of familial antismoking norms was consistently associated with all indicators of the social acceptability of smoking in Uruguay but only with the frequency of receiving anti-SHS verbal cues in Mexico. DISCUSSION: These results are generally consistent with previous research indicating that comprehensive smoke-free policies are likely to increase the social unacceptability of smoking and that resistance against such policies is likely to diminish once such policies are in place.