'Quitlink': Outcomes of a randomised controlled trial of peer researcher facilitated referral to a tailored quitline tobacco treatment for people receiving mental health services.

OBJECTIVE: The aim of this study was to test the effectiveness of a tailored quitline tobacco treatment ('Quitlink') among people receiving support for mental health conditions. METHODS: We employed a prospective, cluster-randomised, open, blinded endpoint design to compare a control condition to our 'Quitlink' intervention. Both conditions received a brief intervention delivered by a peer researcher. Control participants received no further intervention. Quitlink participants were referred to a tailored 8-week quitline intervention delivered by dedicated Quitline counsellors plus combination nicotine replacement therapy. The primary outcome was self-reported 6 months continuous abstinence from end of treatment (8 months from baseline). Secondary outcomes included additional smoking outcomes, mental health symptoms, substance use and quality of life. A within-trial economic evaluation was conducted. RESULTS: In total, 110 participants were recruited over 26 months and 91 had confirmed outcomes at 8 months post baseline. There was a difference in self-reported prolonged abstinence at 8-month follow-up between Quitlink (16%, n = 6) and control (2%, n = 1) conditions, which was not statistically significant (OR = 8.33 [0.52, 132.09] p = 0.131 available case). There was a significant difference in favour of the Quitlink condition on 7-day point prevalence at 2 months (OR = 8.06 [1.27, 51.00] p = 0.027 available case). Quitlink costs AU$9231 per additional quit achieved. CONCLUSION: The Quitlink intervention did not result in significantly higher rates of prolonged abstinence at 8 months post baseline. However, engagement rates and satisfaction with the 'Quitlink' intervention were high. While underpowered, the Quitlink intervention shows promise. A powered trial to determine its effectiveness for improving long-term cessation is warranted.

The need for a personalized, core digital resource to facilitate health self-management.

High quality healthcare is becoming increasingly unaffordable and inaccessible. To reverse this trend, people need to self-manage as much of their health as possible. They need to take appropriate preventive actions and use health services in a timely and efficient manner. Yet health self-management is challenging in an increasingly complex environment that involves competing demands and sometimes contradictory advice as well as increasingly fragmented delivery of health services. Digital tools have added a new dimension to healthcare and hold the potential to help bridge these challenges. Unfortunately, much of the potential benefit of digital resources is not being realized, partly because of difficulties people face in identifying appropriate and effective resources in a haystack of mainly unevaluated and often poorly conceived resources. Underuse and failure to maintain use of resources found to be effective also retards progress. Furthermore, people need more help to understand their needs and establish priorities around their health self-management. We argue that these needs can be met with a person-centered, digital self-management core resource that supports people to better understand their needs and priorities and has links to find the resources they need to manage their health, alone or by judicious use of health services.

Trends in alcohol expenditure in Australia from 1984 to 2015-2016: An exploratory study.

INTRODUCTION: Excessive alcohol use is associated with non-communicable diseases and social problems, such as work absence, financial problems and family violence. Expenditure and expenditure shares on alcohol are valuable measures to monitor financial activities on this risk behaviour. The aim of this paper is to report trends in alcohol expenditure in Australia over the last two decades. METHODS: Data are from six waves of Australian Household Expenditure Surveys from 1984 to 2015-2016. We explored trends of alcohol expenditure among Australians and in different socio-demographic groups in the last 30 years. We further examined changes of expenditure on different on- and off-premises beverages over time. RESULTS: Absolute alcohol expenditure has remained the same between the 1980s and 2016, after accounting for inflation. However, a declining trend in relative alcohol expenditure as a proportion of total household expenditure was found across nearly all demographic groups (e.g., sex, age, employment, household income), except for women aged 45-54, who showed an increasing trend of alcohol expenditure after 1998-1999. DISCUSSION AND CONCLUSIONS: The current study shows declines in relative alcohol expenditure, which may reflect declines in alcohol's relative importance within the elements of the person's lifestyle they need to pay for and/or increased awareness of alcohol's health and social harms. Further longitudinal analysis should explore additional predictors of household expenditure on alcohol. Results suggest that current bi-annual indexation increases in alcohol tax should account for increases in income to ensure the effectiveness of pricing. Moreover, attention is needed to address drinking among middle-aged females.

The value of compassionate support to address smoking: A qualitative study with people who experience severe mental illness.

Introduction: People experiencing severe mental illness (SMI) smoke at much higher rates than the general population and require additional support. Engagement with existing evidence-based interventions such as quitlines and nicotine replacement therapy (NRT) may be improved by mental health peer worker involvement and tailored support. This paper reports on a qualitative study nested within a peer researcher-facilitated tobacco treatment trial that included brief advice plus, for those in the intervention group, tailored quitline callback counseling and combination NRT. It contextualizes participant life experience and reflection on trial participation and offers insights for future interventions. Methods: Qualitative semi-structured interviews were conducted with 29 participants in a randomized controlled trial (intervention group n = 15, control group n = 14) following their 2-month (post-recruitment) follow-up assessments, which marked the end of the "Quitlink" intervention for those in the intervention group. Interviews explored the experience of getting help to address smoking (before and during the trial), perceptions of main trial components including assistance from peer researchers and tailored quitline counseling, the role of NRT, and other support received. A general inductive approach to analysis was applied. Results: We identified four main themes: (1) the long and complex journey of quitting smoking in the context of disrupted lives; (2) factors affecting quitting (desire to quit, psychological and social barriers, and facilitators and reasons for quitting); (3) the perceived benefits of a tailored approach for people with mental ill-health including the invitation to quit and practical resources; and (4) the importance of compassionate delivery of support, beginning with the peer researchers and extended by quitline counselors for intervention participants. Subthemes were identified within each of these overarching main themes. Discussion: The findings underscore the enormity of the challenges that our targeted population face and the considerations needed for providing tobacco treatment to people who experience SMI. The data suggest that a tailored tobacco treatment intervention has the potential to assist people on a journey to quitting, and that compassionate support encapsulating a recovery-oriented approach is highly valued. Clinical trial registration: The Quitlink trial was registered with ANZCTR (www.anzctr.org.au): ACTRN12619000244101 prior to the accrual of the first participant and updated regularly as per registry guidelines.

Effectiveness, safety and cost-effectiveness of vaporized nicotine products versus nicotine replacement therapy for tobacco smoking cessation in a low-socioeconomic status Australian population: a study protocol for a randomized controlled trial.

BACKGROUND: In Australia, tobacco smoking rates have declined but inequalities remain with significantly higher smoking prevalence among low-socioeconomic populations. Clinical trial data suggest vaporized nicotine products (VNPs) aid smoking cessation. Most VNP trials have used refillable tank systems, but newer generation (pod) devices now comprise the largest market share yet have limited clinical trial evidence on safety and effectiveness. This study evaluates the effectiveness, safety and cost-effectiveness of VNPs (pod and tank device) compared with nicotine replacement therapy ([NRT]-gum or lozenge) for smoking cessation. METHODS: This is a two-arm, open-label, superiority, parallel group, randomized controlled trial (RCT) with allocation concealment and blinded outcome assessment. The RCT is conducted at the National Drug and Alcohol Research Centre at the University of New South Wales, Sydney, Australia. Participants are people who smoke daily, are interested in quitting and receive a government pension or allowance (N = 1058). Participants will be randomized (1:1 ratio) to receive 8 weeks of free: VNPs, with pod (40 mg/mL nicotine salt) and tank device (18 mg/mL freebase nicotine) in mixed flavours; or NRT (gum or lozenge; 4 mg). All participants will receive daily text message behavioural support for 5 weeks. Assessments will be undertaken by telephone at baseline, with three follow-up calls (two check-in calls within the first month and final follow-up at 7 months post randomization) to ascertain smoking status, treatment adherence and adverse events. The primary outcome is 6-month continuous abstinence verified by carbon monoxide breath test of ≤5ppm at 7-month follow-up. Safety and cost-effectiveness of VNPs versus NRT will also be evaluated. DISCUSSION: Further data are required to strengthen certainty of evidence for VNPs aiding smoking cessation, particularly for newer generation pod devices. To our knowledge, this trial is the first to offer choice of VNPs and no comparative effectiveness trial data exists for new pod devices. If effective, the findings can inform wider implementation of VNPs to aid smoking cessation in a priority group. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621000076875. Registered on 29 January 2021.  https://www.anzctr.org.au.

Costs of vaping: evidence from ITC Four Country Smoking and Vaping Survey.

STUDY OBJECTIVES: To compare the prices paid for nicotine vaping products (NVPs) and supplies among current NVP users to prices paid for cigarettes among current smokers. DATA: The 2016 International Tobacco Control Four Country Vaping and Smoking Survey (4CV1). Key measures included: (1) self-reported prices paid for reusable NVPs (eg, rechargeable devices with cartridges and tank system devices with e-liquids) in the 3-month period prior to the survey among current NVP users, (2) prices paid for disposable NVPs, cartridges and e-liquids purchased in the last 30 days among current NVP users and (3) self-reported prices paid for cigarettes among current smokers. RESULTS: Disposable NVP price was higher than the price of a comparable unit for combustible cigarettes in England (EN), USA and Canada (CA). Prefilled cartridge price was higher than the price of a comparable unit of cigarettes in USA and CA, but lower in EN and Australia. E-liquid price was consistently lower than the price of a comparable unit of cigarettes across four countries. For start-up costs, price of a rechargeable device is approximately 3-5 times higher than a pack of cigarettes in four countries. CONCLUSION: NVP prices were generally higher than prices of combustible cigarettes, especially the high upfront NVP devices. The high upfront costs of purchasing a reusable NVP may discourage some smokers from switching to vaping. However, the average lower costs of cartridges and e-liquids relative to a package of cigarettes make switching to a NVP an attractive alternative to smoking in the long term so long as smokers switch completely to vaping.

Nicotine replacement treatment, e-cigarettes and an online behavioural intervention to reduce relapse in recent ex-smokers: a multinational four-arm RCT.

BACKGROUND: Relapse remains an unresolved issue in smoking cessation. Extended stop smoking medication use can help, but uptake is low and several behavioural relapse prevention interventions have been found to be ineffective. However, opportunistic 'emergency' use of fast-acting nicotine replacement treatment or electronic cigarettes may be more attractive and effective, and an online behavioural Structured Planning and Prompting Protocol has shown promise. The present trial aimed to evaluate the clinical effectiveness and cost-effectiveness of these two interventions. DESIGN: A randomised controlled trial. SETTING: English stop smoking services and Australian quitlines, Australian social media and St Vincent's Hospital Melbourne, Fitzroy, VIC. PARTICIPANTS: Ex-smokers abstinent for at least 4 weeks, with some participants in Australia also recruited from 1 week post quit date. The planned sample size was 1400, but the trial was curtailed when 235 participants were recruited. INTERVENTIONS: Participants were randomised in permuted blocks of random sizes to (1) oral nicotine replacement treatment/electronic cigarettes to use if at risk of relapse, plus static text messages (n = 60), (2) the Structured Planning and Prompting Protocol and interactive text messages (n = 57), (3) oral nicotine replacement treatment/electronic cigarettes plus the Structured Planning and Prompting Protocol with interactive text messages (n = 58) or (4) usual care plus static text messages (n = 59). OUTCOME MEASURES: Owing to delays in study set-up and recruitment issues, the study was curtailed and the primary outcome was revised. The original objective was to determine whether or not the two interventions, together or separately, reduced relapse rates at 12 months compared with usual care. The revised primary objective was to determine whether or not number of interventions received (i.e. none, one or two) affects relapse rate at 6 months (not biochemically validated because of study curtailment). Relapse was defined as smoking on at least 7 consecutive days, or any smoking in the last month at final follow-up for both the original and curtailed outcomes. Participants with missing outcome data were included as smokers. Secondary outcomes included sustained abstinence (i.e. no more than five cigarettes smoked over the 6 months), nicotine product preferences (e.g. electronic cigarettes or nicotine replacement treatment) and Structured Planning and Prompting Protocol coping strategies used. Two substudies assessed reactions to interventions quantitatively and qualitatively. The trial statistician remained blinded until analysis was complete. RESULTS: The 6-month relapse rates were 60.0%, 43.5% and 49.2% in the usual-care arm, one-intervention arm and the two-intervention arm, respectively (p = 0.11). Sustained abstinence rates were 41.7%, 54.8% and 50.9%, respectively (p = 0.17). Electronic cigarettes were chosen more frequently than nicotine replacement treatment in Australia (71.1% vs. 29.0%; p = 0.001), but not in England (54.0% vs. 46.0%; p = 0.57). Of participants allocated to nicotine products, 23.1% were using them daily at 6 months. The online intervention received positive ratings from 63% of participants at 6 months, but the majority of participants (72%) completed one assessment only. Coping strategies taught in the Structured Planning and Prompting Protocol were used with similar frequency in all study arms, suggesting that these are strategies people had already acquired. Only one participant used the interactive texting, and interactive and static messages received virtually identical ratings. LIMITATIONS: The inability to recruit sufficient participants resulted in a lack of power to detect clinically relevant differences. Self-reported abstinence was not biochemically validated in the curtailed trial, and the ecological momentary assessment substudy was perceived by some as an intervention. CONCLUSIONS: Recruiting recent ex-smokers into an interventional study proved problematic. Both interventions were well received and safe. Combining the interventions did not surpass the effects of each intervention alone. There was a trend in favour of single interventions reducing relapse, but it did not reach significance and there are reasons to interpret the trend with caution. FUTURE WORK: Further studies of both interventions are warranted, using simpler study designs. TRIAL REGISTRATION: Current Controlled Trials ISRCTN11111428. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 68. See the NIHR Journals Library website for further project information. Funding was also provided by the National Health and Medical Research Council, Canberra, ACT, Australia (NHMRC APP1095880). Public Health England provided the funds to purchase the nicotine products in England.

Stop smoking services help people to stop smoking over a short period of time. However, nearly three-quarters of quitters return to smoking (i.e. relapse) within 1 year. Effective relapse prevention strategies are needed. Traditional behavioural relapse prevention strategies (e.g. teaching techniques to resist having a cigarette) have not proved effective. However, an earlier study showed that an online programme guiding smokers in stopping smoking and remaining abstinent reduced relapse between 1 week and 6 months. Long-term use of stop smoking medications (e.g. nicotine replacement treatment) can also help, but most successful quitters do not continue to use them. Nicotine mouth spray, lozenges or electronic cigarettes that can quickly help relieve urges to smoke and that ex-smokers can use 'in emergencies' could be a more attractive option. We planned to test these two interventions, on their own and together, in 1400 participants who had quit ≥ 4 weeks previously and who were recruited from English stop smoking services and Australian quitlines. We would then compare these participants with the participants following usual care (i.e. access to stop smoking medications used during the quit attempt for up to 3 months). Owing to delays in study set-up and difficulties in recruiting, the study recruited only 234 participants (n = 131 in Australia and n = 103 in England). We studied participants' reactions to the two interventions and to their combination, and how clinically effective the interventions were. Both interventions were rated positively by most participants. Among the participants in Australia, electronic cigarettes were more popular than medical nicotine products. In England, both products were equally popular. Participants in the online intervention group appreciated the advice on coping strategies, but they rarely completed repeat assessments. In addition, participants who were not in this group used the strategies just as much. There were hints that the interventions may be helpful in preventing relapse. There is an indication that the two interventions combined did not do any better than each on its own, but this requires replication in a larger study. Although the interventions show promise, the small number of participants recruited means that we are unable to make strong conclusions. The study identified areas for future work.

Identifying smoker subgroups with high versus low smoking cessation attempt probability: A decision tree analysis approach.

BACKGROUND: Regression-based research has successfully identified independent predictors of smoking cessation, both its initiation and maintenance. However, it is unclear how these various independent predictors interact with each other and conjointly influence smoking behaviour. As a proof-of-concept, this study used decision tree analysis (DTA) to identify the characteristics of smoker subgroups with high versus low smoking cessation initiation probability based on the conjoint effects of four predictor variables, and determine any variations by socio-economic status (SES). METHODS: Data come from the Australian arm of the ITC project, a longitudinal cohort study of adult smokers followed up approximately annually. Reported wanting to quit smoking, worries about smoking negative health impact, quitting self-efficacy and quit intentions assessed in 2005 were used as predictors and reported quit attempts at the 2006 follow-up survey were used as the outcome for the initial model calibration and validation analyses (n = 1475), and further cross-validated using the 2012-2013 data (n = 787). RESULTS: DTA revealed that while all four predictor variables conjointly contributed to the identification of subgroups with high versus low smoking cessation initiation probability, quit intention was the most important predictor common across all SES strata. The relative importance of the other predictors showed differences by SES. CONCLUSIONS: Modifiable characteristics of smoker subgroups associated with making a quit attempt and any variations by SES can be successfully identified using a decision tree analysis approach, to provide insights as to who might benefit from targeted intervention, thus, underscoring the value of this approach to complement the conventional regression-based approach.

Protocol for an Economic Evaluation of the Quitlink Randomized Controlled Trial for Accessible Smoking Cessation Support for People With Severe Mental Illness.

Introduction: Smoking is a major cause of disease burden and reduced quality of life for people with severe mental illness (SMI). It places significant resource pressure on health systems and financial stress on smokers with SMI (SSMI). Telephone-based smoking cessation interventions have been shown to be cost effective in general populations. However, evidence suggests that SSMI are less likely to be referred to quitlines, and little is known about the effectiveness and cost effectiveness of such interventions that specifically target SSMI. The Quitlink randomized controlled trial for accessible smoking cessation support for SSMI aims to bridge this gap. This paper describes the protocol for evaluating the cost effectiveness of Quitlink. Methods: Quitlink will be implemented in the Australian setting, utilizing the existing mental health peer workforce to link SSMI to a tailored quitline service. The effectiveness of Quitlink will be evaluated in a clustered randomized controlled trial. A cost-effectiveness evaluation will be conducted alongside the Quitlink clustered randomized controlled trial (RCT) with incremental cost-effectiveness ratios (ICERs) calculated for the cost (AUD) per successful quit and quality adjusted life year (QALY) gained at 8 months compared with usual care from both health care system and limited societal perspectives. Financial implications for study participants will also be investigated. A modeled cost-effectiveness analysis will also be conducted to estimate future costs and benefits associated with any treatment effect observed during the trial. Results will be extrapolated to estimate the cost effectiveness of rolling out Quitlink nationally. Sensitivity analyses will be undertaken to assess the impact on results from plausible variations in all modeled variables. Discussion: SSMI require additional support to quit. Quitlink utilizes existing peer worker and quitline workforces and tailors quitline support specifically to provide that increased cessation support. Given Quitlink engages these existing skilled workforces, it is hypothesized that, if found to be effective, it will also be found to be both cost effective and scalable. This protocol describes the economic evaluation of Quitlink that will assess these hypotheses. Ethics and dissemination: Full ethics clearances have been received for the methods described below from the University of Newcastle (Australia) Human Research Ethics Committee (H-2018-0192) and St Vincent's Hospital, Melbourne (HREC/18/SVHM/154). The trial has been registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12619000244101). Participant consent is sought both to participate in the study and to have the study data linked to routine health administrative data on publicly subsidized health service and pharmaceutical use, specifically the Medicare Benefits and Pharmaceutical Benefits Schemes (MBS/PBS). Trial findings (including economic evaluation) will be published in peer reviewed journals and presented at international conferences. Collected data and analyses will be made available in accordance with journal policies and study ethics approvals. Results will be presented to relevant government authorities with an interest in cost effectiveness of these types of interventions.

Socioeconomic patterns of smoking cessation behavior in low and middle-income countries: Emerging evidence from the Global Adult Tobacco Surveys and International Tobacco Control Surveys.

INTRODUCTION: Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs. METHODS: Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008-2011) and the International Tobacco Control Surveys (2009-2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country. RESULTS: Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10). CONCLUSION: Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes.

Differences in norms towards the use of nicotine vaping products among adult smokers, former smokers and nicotine vaping product users: cross-sectional findings from the 2016 ITC Four Country Smoking and Vaping Survey.

AIMS: To examine whether norms towards nicotine vaping product (NVP) use varied between Australia, Canada, England and the United States and by socio-demographics, smoking and NVP status. DESIGN: Cross-sectional data from the 2016 ITC Four Country Smoking and Vaping Survey. SETTING: Four countries with distinct regulatory policies relating to the sale and advertising of NVPs: Australia (most restrictive), Canada (restrictive), England and the United States (least restrictive). PARTICIPANTS: A total of 10900 adult (age 18+) current smokers, former smokers, or at least weekly NVP users. Respondents were from Australia (n = 1366), Canada (n = 3309), England (n = 3835) and the United States (n = 2390). MEASUREMENTS: Questions permitted the categorization of respondents as current smokers, former smokers, NVP users and socio-demographic categories (sex, age, country, ethnicity, income and education). Further questions were asked regarding the frequency of exposure to NVPs in public, whether they had a partner or close friends who vaped and whether they believed society or those considered important to them approved of NVPs. FINDINGS: Adjusting for relevant covariates, compared with Australian respondents, those in England, Canada and the United States were more likely to report frequent exposure to NVPs in public (83.1%, 57.3% and 48.3%, respectively, compared to 19.8% in Australia; P < 0.0001), having a partner who vaped (13.8%, 7.1% and 7.7%, respectively, compared to 2.1% in Australia; P < 0.0001) and having close friend(s) who vaped (31.7%, 25.3%, 20.9%, respectively, compared to 10.0% in Australia; P < 0.0001). Compared with Australian respondents, respondents from England were more likely to report that society (27.6% compared to 12.3% in Australia; P < 0.0001) and people important to them approved of NVP use (28.9% compared to 14.3% in Australia; P < 0.0001). CONCLUSIONS: Norms towards nicotine vaping product (NVP) use appear to vary among countries with different regulatory contexts regarding sales and advertising.

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.

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.

Prices, use restrictions and electronic cigarette use-evidence from wave 1 (2016) US data of the ITC Four Country Smoking and Vaping Survey.

AIMS: To determine if there are associations between changes in the explicit (i.e. price) and implicit (i.e. use restrictions in public places) costs of cigarettes and nicotine vaping products (NVPs) and their use patterns in the United States. METHODS: Data came from wave 1 (2016) US data of the ITC Four Country Smoking and Vaping Survey (ITC US 4CV1) and Nielsen Scanner Track database. A multiple logistic regression model was applied to estimate the likelihoods of NVP use (vaping at least monthly), cigarette/NVP concurrent use (vaping and smoking at least monthly) and switch from cigarettes to NVPs (had quit smoking < 24 months and currently vape) among ever smokers, conditioning upon cigarette/NVP prices, use restrictions and socio-demographics. RESULTS: Living in places where vaping is allowed in smoke-free areas was significantly associated with an increase in the likelihood of vaping [marginal effect (ME) = 0.17; P < 0.05] and the concurrent use of cigarettes and NVPs (ME = 0.11; P < 0.05). Higher NVP prices were associated with decreased likelihood of NVP use, concurrent use, and complete switch (P > 0.05). Higher cigarette prices were associated with greater likelihood of cigarette and NVP concurrent use (P > 0.05). Working in places where vaping is banned is associated with lower likelihood of vaping and NVP and cigarette concurrent use (P > 0.05). CONCLUSIONS: Higher prices for nicotine vaping products (NVPs) and vaping restrictions in public places are associated with less NVP use and less concurrent use of vaping and smoking. Public policies that increase prices for vaping devices and supplies (i.e. regulations, taxes) and restrict where vaping is allowed are likely to suppress vaping.

Behavioral Economic Purchase Tasks to Estimate Demand for Novel Nicotine/tobacco Products and Prospectively Predict Future Use: Evidence From The Netherlands.

INTRODUCTION: The demand for alternative nicotine/tobacco products is not well established. This paper uses a behavioral economic approach to test whether smokers have differential demand for conventional factory-made, electronic, and very low nicotine content cigarettes (FMCs/ECs/VLNCs) and uses the prospective cohort design to test the predictive validity of demand indices on subsequent use of commercially available FMCs and ECs. METHODS: Daily smokers (≥16 years) from the Netherlands completed an online survey in April 2014 (N = 1215). Purchase tasks were completed for FMCs, ECs, and VLNCs. Participants indicated the number of cigarettes they would consume in 24 h, across a range of prices (0-30 euro). The relationship between consumption and price was quantified into four indices of demand (intensity, Pmax, breakpoint, and essential value). A follow-up survey in July 2015 measured FMC and EC use. RESULTS: At baseline, greater demand was observed for FMCs relative to ECs and VLNCs across all demand indices, with no difference between ECs and VLNCs. At follow-up, greater baseline FMC demand (intensity, essential value) was associated with lower quit rates and higher relapse. EC demand (Pmax, breakpoint, essential value) was positively associated with any EC use between survey waves, past 30 day EC use, and EC purchase between waves. CONCLUSIONS: Smokers valued FMCs more than ECs or VLNCs, and FMCs were less sensitive to price increases. Demand indices predicted use of commercially available products over a 15 month period. To serve as viable substitutes for FMCs, ECs and VLNCs will need to be priced lower than FMCs. IMPLICATIONS: Purchase tasks can be adapted for novel nicotine/tobacco products as a means to efficiently quantify demand and predict use. Among current daily smokers, the demand for ECs and VLNCs is lower than FMCs.

The US Cigarette Industry: An Economic and Marketing Perspective.

OBJECTIVES: Tobacco company conduct has been a central concern in tobacco control. Nevertheless, the public health community has not taken full advantage of the large economics and marketing literature on market competition in the cigarette industry. METHODS: We conducted an unstructured narrative review of the economics and marketing literature using an antitrust framework that considers: 1) market; definition, 2) market concentration; 3) entry barriers; and 4) firm conduct. RESULTS: Since the 1960s, U.S. cigarette market concentration has increased primarily due to mergers and growth in the Marlboro brand. Entry barriers have included brand proliferation, slotting allowance contracts with retailers and government regulation. While cigarette sales have declined, established firms have used coordinated price increases, predatory pricing and price discrimination to sustain their market power and profits. CONCLUSIONS: Although the major cigarette firms have exercised market power to increase prices and profits, the market could be radically changing, with consumers more likely to use several different types of tobacco products rather than just smoking a single cigarette brand. Better understanding of the interaction between market structure and government regulation can help develop effective policies in this changing tobacco product market.

An Economic Analysis of the Pre-Deeming US Market for Nicotine Vaping Products.

OBJECTIVES: Public health policies are often enacted without adequate consideration of the existing market structure or their impacts on that market structure. This paper provides context for the potential impact of regulations on nicotine vaping products (NVP) use by providing a structural analysis of competition in the US NVP market before FDA regulation. METHODS: A literature review was conducted with the aim of providing a framework for analysis that: 1) defines the market; 2) evaluates market concentration; 3) identifies entry barriers; and 4) examines firm conduct. RESULTS: The NVP market includes retail, internet sellers and vape shops. Although conventional retail became more concentrated after the major cigarette companies entered the NVP market, the vape shop and internet sectors remain substantially less concentrated, producing an overall low market concentration, with few entry barriers and competitive behavior. CONCLUSIONS: The largely unregulated US NVP market has been highly competitive, with a high degree of innovation. However, new FDA deeming regulations as applied to NVPs could make it difficult for smaller companies to remain in the market and could discourage new companies and new product innovations from entering the market.

Factors associated with Quitline and pharmacotherapy utilisation among low-socioeconomic status smokers.

AIMS: To examine factors associated with Quitline and pharmacotherapy utilisation in low socioeconomic status (low-SES) smokers enrolled in a smoking cessation trial. METHODS: Baseline data was used from a large-scale smoking cessation randomised controlled trial (RCT). Logistic regression models were used to examine predictors of treatment utilisation prior to entering the RCT and perceived effectiveness of past and future use. RESULTS: A total of 1047 smokers consented and prior to enrolment 92% had previously tried to quit smoking, 86% had ever used quit support, 83% had used pharmacotherapy at least once and 38% had ever utilised Quitline. For those who had used pharmacotherapies, 71% used NRT, of which 21% had used dual NRT products. In the last 12-months, 27% utilised Quitline and 50% utilised NRT. Ever use of Quitline was negatively associated with self-efficacy to quit (OR: 0.80; 95% CI: 0.68, 0.94 p < .01) and positively associated with being diagnosed with a mental health condition (OR: 1.50; 95% CI: 1.01, 2.25 p < .05). Recent use of NRT was positively associated with mental health condition (OR: 1.39; 95% CI: 1.02, 1.90 p < .05) and negatively associated with alcohol consumption (OR: 0.69; 95% CI: 0.52, 0.92 p < .01). CONCLUSION: Past use of Quitline and pharmacotherapy treatment was associated with self-efficacy to quit, sociodemographic variables, mental health conditions and alcohol consumption. Community-based strategies that target smoking, mental health and drug and alcohol problems may overcome some of the barriers that prevent low-SES populations from engaging with smoking cessation support.

Electronic Cigarette Use and Understanding Among a National Sample of Australian Aboriginal and Torres Strait Islander Smokers.

INTRODUCTION: Adult daily smoking prevalence in the Aboriginal and Torres Strait Islander population is 2.8 times that of other Australians. There is little data on prevalence of electronic cigarette (e-cigarette) use among Aboriginal and Torres Strait Islander peoples. We measured e-cigarette use and beliefs about their harmfulness in national samples of Aboriginal and Torres Strait Islander smokers and of all Australian smokers. METHODS: The Talking About the Smokes project interviewed a nationally representative quota sample of 1301 Aboriginal and Torres Strait Islander smokers between August 2013 and August 2014. The Australian Wave 9 survey of the long-running International Tobacco Control Project interviewed 1093 smokers between February and May 2013. Estimates for all Australian smokers were standardized to the age and sex distribution of Aboriginal and Torres Strait Islander smokers. RESULTS: Fewer Aboriginal and Torres Strait Islander than all Australian smokers had tried an e-cigarette (21% vs. 30%). This was in part because of more Aboriginal and Torres Strait Islander smokers having not heard of e-cigarettes. Fewer Aboriginal and Torres Strait Islander smokers than all Australian smokers agreed that e-cigarettes are less harmful than conventional cigarettes (22% vs. 50%). CONCLUSIONS: Many Aboriginal and Torres Strait Islander smokers have used e-cigarettes. However, there is considerable misunderstanding about the relative harm of e-cigarettes compared with conventional cigarettes, in part because of the tight regulatory environment in Australia. IMPLICATIONS: The study describes e-cigarette use and understanding in national samples of Aboriginal and Torres Strait Islander smokers and of all Australian smokers. Only small studies have reported on e-cigarette use in this high smoking prevalence population. Fewer Aboriginal and Torres Strait Islander smokers than all Australian smokers had tried an e-cigarette and fewer agreed that e-cigarettes are less harmful than conventional cigarettes. Australian governments, health authorities, health professionals, and e-cigarette regulations should provide clearer messages that e-cigarettes are less harmful.

The impact of vaping and regulatory environment on cigarette demand: behavioral economic perspective across four countries.

BACKGROUND AND AIMS: Government regulations of nicotine vaping products (NVP) have evolved rapidly during the past decade. The impact of NVP regulatory environment and vaping on cigarette demand is unknown. The current study aims to investigate whether or not respondents' reported cigarette demand, as measured by a hypothetical cigarette purchase task, varies with (1) smoking status, (2) vaping status or (3) NVP regulatory environment (country used as proxy). DESIGN: Cross-sectional survey data from wave 1 of the International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey (2016). SETTING: Australia, Canada, England and the United States. PARTICIPANTS: A total of 10 316 adult smokers. MEASUREMENTS: A hypothetical purchase task asked smokers to estimate how many cigarettes they would purchase for consumption in a single day across multiple cigarette prices. Responses were used to derive measures of cigarette demand. Overall sensitivity of cigarette consumption to price increases was quantified to index cigarette demand elasticity, whereas estimated consumption when cigarettes are free was used to index cigarette demand intensity. FINDINGS: A majority of the non-daily smokers had previously smoked daily (72.3%); daily vapers were more likely to be former daily smokers (89.9%) compared to non-daily vapers (70.1%) and non-vapers (69.2%) (P < 0.001). The smoking status × vaping status interaction was significant for cigarette demand intensity (F = 4.93; P = 0.007) and elasticity (F = 7.30; P = 0.001): among non-daily smokers, vapers reported greater intensity but lower elasticity (i.e. greater demand) relative to non-vapers (Ps < 0.05). Among daily smokers, daily vapers reported greater intensity relative to non-vapers (P = 0.005), but vaping status did not impact elasticity (Ps > 0.38). Intensity was higher in Australia compared with all other countries (Ps < 0.001), but elasticity did not vary by country (F = 2.15; P = 0.09). CONCLUSIONS: In a hypothetical purchase task, non-daily smokers showed lower price elasticity if they used e-cigarettes than if they did not, while there was no clear difference in elasticity between e-cigarette users and non-users among daily smokers or according to regulatory environment of their country with regard to e-cigarettes.