Neurocognitive and psychiatric symptoms following infection with COVID-19: Evidence from laboratory and population studies.

Objective: The objective of the current investigation was to examine associations between symptomatic COVID-19 history, neurocognitive function, and psychiatric symptoms using cognitive task performance, functional brain imaging, and a prospective population survey. Methods: Study 1 was a laboratory study conducted between 3 May 2022 and 16 Nov 2022 involving 120 fully vaccinated community dwelling adults between 18 and 84 years of age (Mage = 31.96 (SD = 20.71), 63.3% female). In this cross-sectional study we examined the association between symptomatic COVID-19 infection history and performance on three computer tasks assessing cognitive function (Flanker interference, delay discounting and simple reaction time) and measured oxygen saturation within the prefrontal cortex using functional near infrared spectroscopy (fNIRS). Study 2 was a 2-wave population survey undertaken between 28 September 2021 and 21 March 2022, examining the prospective relationship between symptomatic COVID-19 and self-reported symptoms of cognitive dysfunction, depressive symptoms, anxiety symptoms, and agitation at 6-month follow up. The sample (N = 2,002, M age = 37.0, SD = 10.4; 60.8% female) was collected using a quota process to ensure equal numbers of vaccinated and unvaccinated individuals. Structural equation modelling with latent variables was performed on the population-level data, evaluating the fit of the proposed mediational model of symptomatic COVID-19 to psychiatric symptoms through cognitive dysfunction. Results: Findings from Study 1 revealed significant effects of symptomatic COVID-19 history on Flanker interference and delay discounting. Effects on flanker performance were significantly stronger among older adult women (effect: 9.603, SE = 4.452, t = 2.157, p = .033), and were accompanied by task-related changes cerebral oxygenation at the right superior frontal gyrus (F (1, 143.1) = 4.729, p = .031). Additionally, those with a symptomatic COVID-19 infection history showed evidence of amplified delay discounting (coefficient = 0.4554, SE = 0.2208, t = 2.0629, p = .041). In Study 2, baseline symptomatic COVID-19 history was associated with self-reported cognitive dysfunction and a latent variable reflecting psychiatric symptoms of anxiety, depression and agitation at follow-up. Mediational analyses revealed evidence of cognitive mediation of clinically significant psychiatric outcomes: depression (indirect effect = 0.077, SE = 0.026, p = .003) and generalized anxiety (indirect effect = 0.060, SE = 0.021, p = .004). Conclusions: Converging findings from laboratory and population survey data support the conclusion that symptomatic COVID-19 infection is associated with task-related, functional imaging and self-reported indices of cognitive dysfunction as well as psychiatric symptoms. In some cases, these findings appear to be more amplified among women than men, and among older women than younger.

Evaluating the impact of plain packaging among Canadian smokers: findings from the 2018 and 2020 ITC Smoking and Vaping Surveys.

BACKGROUND: In February 2020, Canada implemented plain packaging without any changes to the size and content of health warning labels (HWLs), which were last updated in 2012 (pictorial HWLs on 75% of the pack front and back). This pre-post evaluation study assessed the impact of plain packaging in Canada on: (1) pack appeal; (2) HWL effectiveness; and (3) support for plain packaging. Additionally, a quasi-experimental design was used to assess the Canadian results relative to two comparator countries: Australia, where plain packaging (with new larger HWLs) was implemented in 2012, and the United States (USA), where plain packaging has not been implemented and the same text warnings have appeared on cigarette packs since 1985. METHODS: Data are from adult smokers who participated in the 2018 and/or 2020 International Tobacco Control Smoking and Vaping Surveys in Canada (n=4600), Australia (n=1834) and the USA (n=3046). Online surveys were conducted before (February to July 2018) and after (February to June 2020) the implementation of plain packaging in Canada. Adjusted regression analyses were conducted on weighted data. RESULTS: Plain packaging was associated with a significant increase in the percentage of Canadian smokers who did not like the look of their cigarette pack (2018: 28.6% vs 2020: 44.7%, p<0.001), whereas no change in pack appeal was observed among smokers in Australia and the USA over the same period. Plain packaging was not associated with changes in HWL effectiveness in Canada. Support for plain packaging increased significantly among Canadian smokers (2018: 25.6% vs 2020: 33.7%, p<0.001). CONCLUSIONS: Plain packaging in Canada substantially reduced pack appeal and increased support for the policy among adult smokers; however, there was no increase in the effectiveness of Canada's 8-year-old HWLs. The impact of plain packaging on health warning effectiveness may depend on the design of the warnings and length of time since implementation.

Social cognitive predictors of vaccination status, uptake and mitigation behaviors in the Canadian COVID-19 Experiences survey.

Emerging infectious diseases like COVID-19 will remain a concern for the foreseeable future, and determinants of vaccination and other mitigation behaviors are therefore critical to understand. Using data from the first two waves of the Canadian COVID-19 Experiences Survey (CCES; N = 1,958; 66.56 % female), we examined social cognitive predictors of vaccination status, transition to acceptance and mitigation behaviors in a population-representative sample. Findings indicated that all social cognitive variables were strong predictors of mitigation behavior performance at each wave, particularly among unvaccinated individuals. Among those who were vaccine hesitant at baseline, most social cognitive variables predicted transition to fully vaccinated status at follow-up. After controlling for demographic factors and geographic region, greater odds of transitioning from unvaccinated at CCES Wave 1 to fully vaccinated at CCES Wave 2 was predicted most strongly by a perception that one's valued peers were taking up the vaccine (e.g., dynamic norms (OR = 2.13 (CI: 1.54,2.93)), perceived effectiveness of the vaccine (OR = 3.71 (CI: 2.43,5.66)), favorable attitudes toward the vaccine (OR = 2.80 (CI: 1.99,3.95)), greater perceived severity of COVID-19 (OR = 2.02 (CI: 1.42,2.86)), and stronger behavioral intention to become vaccinated (OR = 2.99 (CI: 2.16,4.14)). As a group, social cognitive variables improved prediction of COVID-19 mitigation behaviors (masking, distancing, hand hygiene) by a factor of 5 compared to demographic factors, and improved prediction of vaccination status by a factor of nearly 20. Social cognitive processes appear to be important leverage points for health communications to encourage COVID-19 vaccination and other mitigation behaviors, particularly among initially hesitant members of the general population.

Le déploiement de la surveillance épidémiologique automatisée du COVID-19 : une analyse comparée de la Corée du Sud et du Canada.

Governments across the world have deployed various surveillance devices to curb the COVID-19 pandemic. Based on literature research on two contrasting cases, South Korea and Canada, this study shows the influence of national context on deploying automated epidemiological surveillance of COVID-19. Beside highlighting food for thought regarding government management of a possible new health crisis, the study shows that civil society can contribute to informing public debate by bringing governments to be transparent in terms of automated epidemiological surveillance. In conclusion, the study stresses the importance of debating surveillance issues outside of health crisis periods to avoid possible excesses caused by the urgent need for action.

Partout dans le monde, divers dispositifs de surveillance ont été déployés par les gouvernements pour freiner la pandémie du COVID­19. À partir d'une recherche documentaire portant sur deux cas contrastés, la Corée du Sud et le Canada, la présente étude montre l'influence du contexte national sur le déploiement d'une surveillance épidémiologique automatisée du COVID­19. En plus de faire ressortir des pistes de réflexion quant à la gestion gouvernementale d'une éventuelle autre crise sanitaire, l'étude indique que la société civile peut contribuer à éclairer le débat public en amenant les gouvernements à être transparents en matière de surveillance épidémiologique automatisée. L'étude conclut sur l'importance de débattre des enjeux de surveillance en dehors des périodes de crise sanitaire pour éviter de possibles dérives causées par l'urgence d'agir.

Brain and behavior in health communication: The Canadian COVID-19 Experiences Project.

Background: Vaccine hesitancy and inconsistent mitigation behavior performance have been significant challenges throughout the COVID-19 pandemic. In Canada, despite relatively high vaccine availability and uptake, willingness to accept booster shots and maintain mitigation behaviors in the post-acute phase of COVID-19 remain uncertain. The aim of the Canadian COVID-19 Experiences Project (CCEP) is threefold: 1) to identify social-cognitive and neurocognitive predictors of mitigation behaviors, 2) to identify optimal communication strategies to promote vaccination and mitigation behaviors, and 3) to examine brain health outcomes of SARS-CoV-2 infection and examine their longevity. Methods: The CCEP is comprised of two components: a conventional population survey (Study 1) and a functionally interconnected laboratory study (Study 2). Study 1 will involve 6 waves of data collection. Wave 1, completed between 28 September and 21 October 2021, recruited 1,958 vaccine-hesitant (49.8%) and fully vaccinated (50.2%) adults using quota sampling to ensure maximum statistical power. Measures included a variety of social cognitive (e.g., beliefs, intentions) and neurocognitive (e.g., delay discounting) measures, followed by an opportunity to view and rate a set of professionally produced COVID-19 public service announcement (PSA) videos for perceived efficacy. Study 2 employs the same survey items and PSAs but coupled with lab-based eye tracking and functional near-infrared spectroscopy (fNIRS) to directly quantify neural indicators of attention capture and self-reflection in a smaller community sample. In the final phase of the project, subjective impressions and neural indicators of PSA efficacy will be compared and used to inform recommendations for construction of COVID-19 PSAs into the post-acute phase of the pandemic. Discussion: The CCEP provides a framework for evaluating effective COVID-19 communication strategies by levering conventional population surveys and the latest eye-tracking and brain imaging metrics. The CCEP will also yield important information about the brain health impacts of SARS-CoV-2 in the general population, in relation to current and future virus variants as they emerge.

Differences in cigarette smoking quit attempts and cessation between adults who did and did not take up nicotine vaping: Findings from the ITC four country smoking and vaping surveys.

INTRODUCTION: There is mixed evidence as to whether nicotine vaping products (NVPs) can help adults who smoke transition away from cigarettes. This study investigated if self-reported attempts to quit smoking and smoking cessation, over a period of either 18 or 24 months, differed between respondents who initiated nicotine vaping versus those who did not. Outcome comparisons were made between those who: (1) initiated vaping vs. those who did not; (2) initiated daily or non-daily vaping vs. those who did not; and (3) initiated daily or non-daily vaping between surveys and continued to vape at follow-up (daily or non-daily) vs. those who did not initiate vaping. METHODS: This cohort study included 3516 respondents from the ITC Four Country Smoking and Vaping Surveys (Australia, Canada, England, United Sates), recruited at Wave 1 (2016) or 2 (2018) and followed up at Wave 2 (18 months) and/or 3 (2020, 24 months). Adults who smoked daily at baseline and did not have a history of regular vaping were included. Initiation of vaping was defined as beginning to vape at least monthly between surveys. Respondents indicated whether they made an attempt to quit smoking between surveys. Smoking cessation was defined as those who self-reported no longer smoking cigarettes at follow-up. RESULTS: Relative to those who did not initiate vaping, initiation of any daily vaping between surveys was associated with a greater likelihood of smokers making a cigarette quit attempt (p < 0.001) and quitting smoking (p < 0.001). Among smokers who attempted to quit smoking, initiation of daily vaping was associated with a greater likelihood of being abstinent from smoking at follow-up (p = 0.001). Respondents who initiated vaping between surveys and were vaping daily at follow up were significantly more likely to have attempted to quit smoking (p < 0.001) and to have quit smoking (p < 0.001) than those who did not initiate vaping. Respondents who initiated non-daily vaping did not differ significantly from those who did not initiate vaping on any of the outcome measures. CONCLUSIONS: Daily NVP use was associated with increased attempts to quit smoking and abstinence from smoking cigarettes. These findings are consistent with the concept that complete cigarette substitution may be more likely to be achieved when smokers vape nicotine daily.

Methods of the 2020 (Wave 1) International Tobacco Control (ITC) Korea Survey.

This article presents methods used in the 2020 International TC Korea Wave 1 (KRA1) Survey. To date, three cohorts of Korean respondents have participated in the larger ITC Korea Project (cohort 1: 2005-2014, cohort 2: 2016, and cohort 3: 2020-present). The overall objectives of the ITC KRA1 Survey were to examine the use of cigarettes, heated tobacco products (HTPs), e-cigarettes (ECs); whether HTPs might help smokers quit; and the effectiveness of tobacco control policies, such as large graphic warnings, high cigarette taxes, and smoking bans in public places. The KRA1 Survey measures were identical or functionally similar to those of the ITC Japan Survey and, to a lesser extent, those of other ITC countries. Key measures assessed sociodemographic characteristics of respondents; the use of combustible cigarettes, e-cigarettes, and heated tobacco products; and measures assessing policies of the WHO Framework Convention on Tobacco Control, including price and tax (Article 6), smoke-free laws (Article 8), health warnings (Article 11), education, communication and public awareness (Article 12), advertising, promotion, and sponsorship restrictions (Article 13), and support for cessation (Article 14). Adult tobacco and/or nicotine users aged ≥19 years in South Korea were recruited by a commercial survey firm from its online panel. Overall, 4794 respondents completed the KRA1 Survey. The cooperation rate was 97.4% and the response rate was 15.2%. The cohort design permits assessment of transitions in products used among users in South Korea and evaluations of the impact of policies on tobacco and/or nicotine products used and transitions in use.

Exposure to Negative News Stories About Vaping, and Harm Perceptions of Vaping, Among Youth in England, Canada, and the United States Before and After the Outbreak of E-cigarette or Vaping-Associated Lung Injury ('EVALI').

INTRODUCTION: Little is known about the international impact of E-cigarette or Vaping-Associated Lung Injury ('EVALI') on youth perceptions of vaping harms. METHODS: Repeat cross-sectional online surveys of youth aged 16-19 years in England, Canada, and the United States before (2017, 2018), during (2019 August/September), and after (2020 February/March, 2020 August) the 'EVALI' outbreak (N = 63380). Logistic regressions assessed trends, country differences, and associations between exposure to negative news stories about vaping and vaping harm perceptions. RESULTS: Exposure to negative news stories increased between 2017 and February-March 2020 in England (12.6% to 34.2%), Canada (16.7% to 56.9%), and the United States (18.0% to 64.6%), accelerating during (2019) and immediately after (February-March 2020) the outbreak (p < .001) before returning to 2019 levels by August 2020. Similarly, the accurate perception that vaping is less harmful than smoking declined between 2017 and February-March 2020 in England (77.3% to 62.2%), Canada (66.3% to 43.3%), and the United States (61.3% to 34.0%), again accelerating during and immediately after the outbreak (p < .001). The perception that vaping takes less than a year to harm users' health and worry that vaping will damage health also doubled over this period (p ≤ .001). Time trends were most pronounced in the United States. Exposure to negative news stories predicted the perception that vaping takes less than a year to harm health (Adjusted Odds Ratio = 1.55, 1.48-1.61) and worry that vaping will damage health (Adjusted Odds Ratio = 1.32, 1.18-1.48). CONCLUSIONS: Between 2017 and February-March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after 'EVALI'. Effects were seen in all countries but were most pronounced in the United States. IMPLICATIONS: This is the first study examining changes in exposure to news stories about vaping, and perceptions of vaping harms, among youth in England, Canada, and the United States before, during, and after 'EVALI'. Between 2017 and February-March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after 'EVALI'. By August 2020, exposure to negative news stories returned to 2019 levels, while perceptions of harm were sustained. Exposure to negative news stories also predicted two of the three harm perception measures. Overall, findings suggest that 'EVALI' may have exacerbated youth's perceptions of vaping harms internationally.

Responses to potential nicotine vaping product flavor restrictions among regular vapers using non-tobacco flavors: Findings from the 2020 ITC Smoking and Vaping Survey in Canada, England and the United States.

INTRODUCTION: Some jurisdictions have implemented nicotine vaping product (NVP) flavor restrictions because of concerns about rising adolescent use. However, little is known how these restrictions may impact adult vapers. This study describes the level of support and predictive behavioral responses to a hypothetical NVP ban on non-tobacco flavors among regular adult vapers who only use flavors that would be banned. METHODS: Data came from 851 regular vapers (all current or ex-smokers) participating in the 2020 ITC Four Country Smoking and Vaping Survey in Canada, England, and the United States (US). A random sample of respondents in each country received and completed the questions about flavor bans: (1) do you support or oppose a ban on all non-tobacco flavors; and (2) what would you do if all flavors were banned, with the exception of tobacco in the US, and tobacco and menthol in Canada and England. Those who used tobacco-flavored or unflavored NVPs were excluded from all analyses, and additionally, vapers of menthol flavor in Canada and England were excluded from Aim 2. RESULTS: Overall, 53.6% of vapers were strongly opposed to flavor bans, 28.2% were opposed, 9.3% were in support, 3.6% were in strong support, and 5.2% did not know. Predicted behavioral responses were: 28.8% would continue vaping an available flavor, 28.3% would find a way to get their banned flavor(s), 17.1% would stop vaping and smoke instead, 12.9% said that they would stop vaping and not smoke, and 12.9% do not know what they would do. Responses to a potential flavor ban largely varied by smoking and vaping status, and by the level of support of a flavor restriction policy. CONCLUSIONS: At this time, it is not clear what net population-level consequences would occur if non-tobacco flavored NVPs were prohibited. While a majority of vapers in this study opposed this policy, and many vapers would not be willing to switch to available flavors, there was considerable variability in predicted behavioral responses.

Smokers' cognitive and behavioural reactions during the early phase of the COVID-19 pandemic: Findings from the 2020 ITC Four Country Smoking and Vaping Survey.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Self-Reported Quit Aids and Assistance Used By Smokers At Their Most Recent Quit Attempt: Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey.

INTRODUCTION: This study retrospectively describes smoking cessation aids, cessation services, and other types of assistance used by current and ex-smokers at their last quit attempt in four high-income countries. AIMS AND METHODS: Data are from the Wave 3 (2020) International Tobacco Control Four Country Smoking and Vaping Survey in Australia, Canada, England, and the United States (US). Eligible respondents were daily smokers or past-daily recent ex-smokers who made a quit attempt/quit smoking in the last 24-months, resulting in 3614 respondents. Self-reported quit aids/assistance included: nicotine vaping products (NVPs), nicotine replacement therapy (NRT), other pharmacological therapies (OPT: varenicline/bupropion/cytisine), tobacco (noncombustible: heated tobacco product/smokeless tobacco), cessation services (quitline/counseling/doctor), other cessation support (e.g., mobile apps/website/pamphlets, etc.), or no aid. RESULTS: Among all respondents, at last quit attempt, 28.8% used NRT, 28.0% used an NVP, 12.0% used OPT, 7.8% used a cessation service, 1.7% used a tobacco product, 16.5% other cessation support, and 38.6% used no aid/assistance. Slightly more than half of all smokers and ex-smokers (57.2%) reported using any type of pharmacotherapy (NRT or OPT) and/or an NVP, half-used NRT and/or an NVP (49.9%), and 38.4% used any type of pharmacotherapy (NRT and/or OPT). A quarter of smokers/ex-smokers used a combination of aids. NVPs and NRT were the most prevalent types of cessation aids used in all four countries; however, NRT was more commonly used in Australia relative to NVPs, and in England, NVPs were more commonly used than NRT. The use of NVPs or NRT was more evenly distributed in Canada and the US. CONCLUSIONS: It appears that many smokers are still trying to quit unassisted, rather than utilizing cessation aids or other forms of assistance. Of those who did use assistance, NRT and NVPs were the most common method, which appears to suggest that nicotine substitution is important for smokers when trying to quit smoking. IMPLICATIONS: Clinical practice guidelines in a number of countries state that the most effective smoking cessation method is a combination of pharmacotherapy and face-to-face behavioral support by a health professional. Most quit attempts however are made unassisted, particularly without the use of government-approved cessation medications. This study found that about two in five daily smokers used approved cessation medications (nicotine replacement therapy (NRT) or other approved pharmacotherapies, such as varenicline). Notably, nicotine substitution in the form of either NRT and nicotine vaping products (NVPs) were the most common method of cessation assistance (used by one in two respondents), but the proportion using NRT and/or NVPs varied by country. Few smokers who attempted to quit utilized cessation services such as stop-smoking programs/counseling or quitlines, despite that these types of support are effective in helping smokers manage withdrawals and cravings. Primary healthcare professionals should ask their patients about smoking and offer them evidence-based treatment, as well as be prepared to provide smokers with a referral to trained cessation counselors, particularly when it comes to tailoring intensive treatment programs for regular daily smokers. Additionally, healthcare providers should be prepared to discuss the use of NVPs, particularly if smokers are seeking advice about NVPs, wanting to try/or already using an NVP to quit smoking, have failed repeatedly to quit with other cessation methods, and/or if they do not want to give up tobacco/nicotine use completely.

Changes in Smoking and Vaping over 18 Months among Smokers and Recent Ex-Smokers: Longitudinal Findings from the 2016 and 2018 ITC Four Country Smoking and Vaping Surveys.

This descriptive study of smokers (smoked at least monthly) and recent ex-smokers (quit for ≤2 years) examined transitions over an 18 month period in their smoking and vaping behaviors. Data are from Waves 1 (W1: 2016) and 2 (W2: 2018) of the ITC Four Country Smoking and Vaping Survey, a cohort study of adult (≥18+) smokers, concurrent users (smoke and vape), and recent ex-smokers from Australia, Canada, England, and the United States (US). Respondents (N = 5016) were classified according to their smoking and vaping status, which resulted in eight subgroups: (1) exclusive daily smokers (2) exclusive non-daily smokers; (3-6) concurrent users (subdivided into four groups by each combination of daily/non-daily smoking and daily/non-daily vaping); (7) ex-smokers who vape; (8) ex-smokers not vaping. The analyses focused first on describing changes between groups from W1 to W2. Second, transition outcomes were assessed based on changes in smoking and vaping between W1 and W2. Transitions focused on smoking were: no change in smoking (continued smoking at the same frequency); decreased smoking; increased smoking; discontinued smoking; relapsed (ex-smokers at W1 who were smoking at W2). Transitions focused on vaping were: initiated vaping; switched from smoking to vaping. Overall, this study found that the vast majority of smokers were smoking 18 months later. Non-daily smokers were more likely than daily smokers to have discontinued smoking (p < 0.0001) and to have switched to exclusive vaping (p = 0.034). Exclusive non-daily smokers were more likely than exclusive daily smokers to have initiated vaping (p = 0.04). Among all W1 daily smokers, there were no differences in discontinued smoking between daily smokers who vaped (concurrent users) and exclusive daily smokers; however, concurrent users were more likely than exclusive daily smokers to have decreased to non-daily smoking (p < 0.001) or to have switched to vaping by W2 (p < 0.001). Among all W1 non-daily smokers, there were no significant differences in increased smoking or discontinued smoking between concurrent users or exclusive smokers. Most ex-smokers remained abstinent from smoking, and there was no difference in relapse back to smoking between those who vaped and those who did not.

The Association of E-cigarette Flavors With Satisfaction, Enjoyment, and Trying to Quit or Stay Abstinent From Smoking Among Regular Adult Vapers From Canada and the United States: Findings From the 2018 ITC Four Country Smoking and Vaping Survey.

AIMS: This study examined whether nontobacco flavors are more commonly used by vapers (e-cigarette users) compared with tobacco flavor, described which flavors are most popular, and tested whether flavors are associated with: vaping satisfaction relative to smoking, level of enjoyment with vaping, reasons for using e-cigarettes, and making an attempt to quit smoking by smokers. METHODS: This cross-sectional study included 1603 adults from Canada and the United States who vaped at least weekly, and were either current smokers (concurrent users) or former smokers (exclusive vapers). Respondents were categorized into one of seven flavors they used most in the last month: tobacco, tobacco-menthol, unflavored, or one of the nontobacco flavors: menthol/mint, fruit, candy, or "other" (eg, coffee). RESULTS: Vapers use a wide range of flavors, with 63.1% using a nontobacco flavor. The most common flavor categories were fruit (29.4%) and tobacco (28.7%), followed by mint/menthol (14.4%) and candy (13.5%). Vapers using candy (41.0%, p < .0001) or fruit flavors (26.0%, p = .01) found vaping more satisfying (compared with smoking) than vapers using tobacco flavor (15.5%) and rated vaping as very/extremely enjoyable (fruit: 50.9%; candy: 60.9%) than those using tobacco flavor (39.4%). Among concurrent users, those using fruit (74.6%, p = .04) or candy flavors (81.1%, p = .003) were more likely than tobacco flavor users (63.5%) to vape in order to quit smoking. Flavor category was not associated with the likelihood of a quit attempt (p = .46). Among exclusive vapers, tobacco and nontobacco flavors were popular; however, those using tobacco (99.0%) were more likely than those using candy (72.8%, p = .002) or unflavored (42.5%, p = .005) to vape in order to stay quit. CONCLUSIONS: A majority of regular vapers in Canada and the US use nontobacco flavors. Greater satisfaction and enjoyment with vaping are higher among fruit and candy flavor users. While it does not appear that certain flavors are associated with a greater propensity to attempt to quit smoking among concurrent users, nontobacco flavors are popular among former smokers who are exclusively vaping. Future research should determine the likely impact of flavor bans on those who are vaping to quit smoking or to stay quit. IMPLICATIONS: Recent concerns about the attractiveness of e-cigarette flavors among youth have resulted in flavor restrictions in some jurisdictions of the United States and Canada. However, little is known about the possible consequences for current and former smokers if they no longer have access to their preferred flavors. This study shows that a variety of nontobacco flavors, especially fruit, are popular among adult vapers, particularly among those who have quit smoking and are now exclusively vaping. Limiting access to flavors may therefore reduce the appeal of e-cigarettes among adults who are trying to quit smoking or stay quit.

Survey Methods of the 2018 International Tobacco Control (ITC) Japan Survey.

This paper describes the methods of the Wave 1 (2018) International Tobacco Control (ITC) Japan Survey. The respondents were adults aged 20 years and older in one of four user groups: (1) cigarette-only smokers who smoked at least monthly and used heated tobacco products (HTPs) not at all or less than weekly, (2) HTP-only users who used HTPs at least weekly and smoked cigarettes not at all or less than monthly, (3) cigarette-HTP dual users who smoked at least monthly and used HTPs at least weekly, and (4) non-users who had never smoked or who smoked less than monthly and used HTPs less than weekly. Eligible respondents were recruited by a commercial survey firm from its online panel. Respondents were allocated proportionally to sample strata based on demographic, geographic, and user type specifications benchmarked to a national reference. Survey weights, accounting for smoking/HTP use status, sex, age, education, and geography, were calibrated to benchmarks from a nationally representative survey in Japan. Response rate was 45.1% and cooperation rate was 96.3%. The total sample size was 4615 (3288 cigarette smokers, 164 exclusive HTP users, 549 cigarette-HTP dual users, and 614 non-users). The 2018 ITC Japan Survey sampling design and survey data collection methods will allow analyses to examine prospectively the use of cigarettes and HTPs in Japan and factors associated with the use of both products and of transitions between them.

International differences in patterns of cannabis use among adult cigarette smokers: Findings from the 2018 ITC Four Country Smoking and Vaping Survey.

BACKGROUND: Although evidence shows that co-use of cigarettes and cannabis is common, there is little research examining if co-use patterns vary depending on the regulatory environment for cannabis. This study examined patterns of co-use and perceptions of relative harm among cigarette smokers in four countries with different histories, and at different stages of cannabis legalization. METHODS: Data are from the 2018 International Tobacco Control 4CV Survey and included 10035 adult cigarette smokers from Canada, United States (US), Australia, and England. At the time of the survey, Canada and the US had relatively more permissive cannabis regulations compared to Australia and England. RESULTS: Among this sample of 10035 cigarette smokers, Canada had the highest rate of cannabis co-use in the last 12 months (36.3%), followed by the US (29.1%), England (21.6%), and Australia (21.4%). Among past 12 month co-users (n = 3134), the US (40.2%) and Canada (35.2%) had the highest rates of daily cannabis use, followed by smokers in England (26.3%) and Australia (21.7%); Australian co-users had the highest rate of infrequent (

Perceptions of Harmfulness of Heated Tobacco Products Compared to Combustible Cigarettes among Adult Smokers in Japan: Findings from the 2018 ITC Japan Survey.

In Japan, the tobacco industry promotes heated tobacco products (HTPs) as a reduced-risk tobacco product. This study examines: (1) smokers' harm perceptions of HTPs relative to combustible cigarettes; (2) differences in relative harm perceptions between exclusive smokers and smokers who use HTPs (concurrent users) and between concurrent users based on frequency of product use; and (3) if smokers who were exposed to HTP advertising hold beliefs that are consistent with marketing messages of lower harmfulness. This cross-sectional study included 2614 adult exclusive cigarette smokers and 986 concurrent users who reported their perceptions of harmfulness of HTPs compared to cigarettes, as well as their exposure to HTP advertising in the last six months. Among all smokers, 47.5% perceive that HTPs are less harmful than cigarettes, 24.6% perceive HTPs to be equally as harmful, 1.8% perceive HTPs as more harmful, and 26.1% did not know. Concurrent users are more likely than exclusive smokers to believe that HTPs are less harmful (62.1% versus 43.8%, p < 0.0001) and less likely to report that they did not know (14.3% versus 29.4%, p < 0.0001). Frequent HTP users are more likely than infrequent users to believe that HTPs are less harmful (71.7% versus 57.1%, p ≤ 0.001). Believing that HTPs are less harmful than cigarettes was associated with noticing HTP advertising on TV (p = 0.0005), in newspapers/magazines (p = 0.0001), on posters/billboards (p < 0.0001), in stores where tobacco (p < 0.0001) or where HTPs (p < 0.0001) are sold, on social media (p < 0.0001), or in bars/pubs (p = 0.04). HTP users were significantly more likely than non-HTP users to believe that HTPs are less harmful than cigarettes, with this belief being more prominent among frequent users. Smokers who have been exposed to HTP advertising were more likely to perceive HTPs as less harmful than cigarettes.

Evaluating the impacts of cannabis legalization: The International Cannabis Policy Study.

An increasing number of jurisdictions have legalized non-medical cannabis use, including Canada in October 2018 and several US states starting in 2012. The policy measures implemented within these regulated markets differ with respect to product standards, labelling and warnings, public education, retail policies, marketing, and price/taxation. The International Cannabis Policy Study (ICPS) seeks to evaluate the impacts of these policy measures as well as the broader population-level impact of cannabis legalization using a quasi-experimental research design. The objective of this paper is to describe the ICPS conceptual framework, methods, and baseline estimates of cannabis use. The ICPS is a prospective cohort survey conducted with national samples of 16-65-year-olds in Canada and the US. Data are collected via an online survey using the Nielsen Consumer Insights Global Panel. Primary survey domains include: prevalence and patterns of cannabis use; purchasing and price; consumption and product types; commercial retail environment; problematic use and risk behaviours; cannabis knowledge and risk perceptions; and policy-relevant outcomes including exposure to health warnings, public educational campaigns, and advertising and promotion. The first annual wave was conducted in Aug-Oct 2018 with 27,169 respondents in three geographic 'conditions': Canada (n = 10,057), US states that had legalized non-medical cannabis (n = 7,398) and US states in which non-medical cannabis was prohibited (n = 9,714). The ICPS indicates substantial differences in cannabis use in jurisdictions with different regulatory frameworks for cannabis. Future waves of the study will examine changes over time in cannabis use and its effects associated with legalization in Canada and additional US states.

Methods of the International Tobacco Control (ITC) EUREST-PLUS ITC Europe Surveys.

BACKGROUND: The EUREST-PLUS ITC Europe surveys aim to evaluate the impact of the European Union's Tobacco Products Directive (EU TPD) implementation within the context of the WHO FCTC. This article describes the methodology of the 2016 (Wave 1) and 2018 (Wave 2) International Tobacco Control 6 European (6E) Country Survey in Germany, Greece, Hungary, Poland, Romania and Spain; the England arm of the 2016 (Wave 1) and 2018 (Wave 2) ITC 4 Country Smoking and Vaping (4CV) Survey; and the 2016 (Wave 10) and 2017 (Wave 11) ITC Netherlands (NL) Survey. All three ITC surveys covering a total of eight countries are prospective cohort studies with nationally representative samples of smokers. METHODS: In the three surveys across the eight countries, the recruited respondents were cigarette smokers who smoked at least monthly, and were aged 18 and older. At each survey wave, eligible cohort members from the previous waves were retained, regardless of smoking status, and dropouts were replaced by a replenishment sample. RESULTS: Retention rates between the two waves of the ITC 6E Survey by country were 70.5% for Germany, 41.3% for Greece, 35.7% for Hungary, 45.6% for Poland, 54.4% for Romania and 71.3% for Spain. The retention rate for England between ITC 4CV1 and ITC 4CV2 was 39.1%; the retention rates for the ITC Netherlands Survey were 76.6% at Wave 10 (2016) and 80.9% at Wave 11 (2017). CONCLUSION: The ITC sampling design and data collection methods in these three ITC surveys allow analyses to examine prospectively the impact of policy environment changes on the use of cigarettes and other tobacco products in each country, to make comparisons across the eight countries.

Rules about smoking and vaping in the home: findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey.

AIMS: To examine rules about smoking and vaping in the home in relation to beliefs about the relative harm of second-hand vapor (SHV) compared with second-hand smoke (SHS) in four countries: Canada, United States, England and Australia. DESIGN: Data were available from 12 294 adults (18+) who participated in the 2016 (wave 1) International Tobacco Control Four Country Smoking and Vaping (ITC 4CV1) Survey. PARTICIPANTS: All participants were current or recent former adult smokers. MEASUREMENTS: Data were analyzed by weighted logistic regression on rules about smoking and vaping in the home; odds ratios and 95% confidence intervals were reported, adjusted for demographic and behavioral variables. FINDINGS: Of all respondents, 37.4% allowed smoking inside their home. Among a subset who were current vapers (n = 6135), 60.4% allowed vaping in their homes. After controlling for demographic and behavioral characteristics, beliefs about the harm of SHV compared with SHS was not associated with allowing smoking in the home, but was associated with allowing vaping in the home [odds ratio (OR) = 2.86 in Canada, OR = 1.82 in the United States and OR = 1.68 in England]. Characteristics that were associated with rules about vaping inside the home included daily vaping (OR = 2.95, 2.04-4.26; OR = 7.00, 4.12-11.87; OR = 5.50, 3.40-8.88; OR = 7.78, 1.90-31.80), living with a spouse who vapes (OR = 2.48, 1.54-3.98; OR = 2.69, 1.42-5.11; OR = 4.67, 2.74-7.95; OR = 21.82, 2.16-220.9) and living with children aged under 18 years (OR = 0.50, 0.37-0.68; OR = 0.89, 0.48-1.65; OR = 0.76, 0.53-1.09; OR = 0.26, = 0.11-0.61) in Canada, the United States, England and Australia, respectively. Similar characteristics were associated with rules about smoking inside the home. CONCLUSIONS: Among current and former smokers in 2016 in Canada, the United States, England and Australia, 37.4% allowed smoking in the home; 60.4% of current vapers allowed vaping. Both concurrent users and exclusive vapers were more likely to allow vaping than smoking inside the home. Allowing vaping inside the home was correlated with the belief that second-hand vapor is less harmful than second-hand smoke.

Where Do Vapers Buy Their Vaping Supplies? Findings from the International Tobacco Control (ITC) 4 Country Smoking and Vaping Survey.

Aim: This study examines where vapers purchase their vaping refills in countries having different regulations over such devices, Canada (CA), the United States (US), England (EN), and Australia (AU). Methods: Data were available from 1899 current adult daily and weekly vapers who participated in the 2016 (Wave 1) International Tobacco Control Four Country Smoking and Vaping. The outcome was purchase location of vaping supplies (online, vape shop, other). Adjusted odds ratios and 95% confidence intervals were reported for between country comparisons. Results: Overall, 41.4% of current vapers bought their vaping products from vape shops, 27.5% bought them online, and 31.1% from other retail locations. The vast majority of vapers (91.1%) reported using nicotine-containing e-liquids. In AU, vapers were more likely to buy online vs other locations compared to CA (OR = 6.4, 2.3⁻17.9), the US (OR = 4.1, 1.54⁻10.7), and EN (OR = 7.9, 2.9⁻21.8). In the US, they were more likely to buy from vape shops (OR = 3.3, 1.8⁻6.2) or online (OR = 1.9, 1.0⁻3.8) vs other retail locations when compared to those in EN. In CA, vapers were more likely to purchase at vape shops than at other retail locations when compared to vapers in EN (5.9, 3.2⁻10.9) and the US (1.87, 1.0⁻3.1). Conclusions: The regulatory environment and enforcement of such regulations appear to influence the location where vapers buy their vaping products. In AU, banning the retail sale of nicotine vaping products has led vapers to rely mainly on online purchasing sources, whereas the lack of enforcement of the same regulation in CA has allowed specialty vape shops to flourish.