Associations Between Noticing Nicotine Vaping Product Health Warning Labels, Harm Perceptions, and Use Among Adult Vapers, Current and Former Smokers. Findings From the 2018 ITC Four Country Smoking and Vaping Survey.

BACKGROUND: The number of countries mandating a nicotine addiction warning label ("warnings") on nicotine vaping products (NVPs) has been increasing. This study examined associations between noticing NVP warnings, perceptions of NVPs, and intentions to use NVPs. AIM AND METHODS: Cross-sectional analysis of 12 619 adult NVP users, cigarette smokers, concurrent users of both cigarettes and NVPs, and quitters who participated in the 2018 International Tobacco Control (ITC) Project Four Country Smoking and Vaping Survey (England, Australia, Canada, USA). Logistic regression analyses examined associations between noticing warnings in the past 30 days and perceptions of nicotine harm, NVP harm relative to cigarettes, and NVP addictiveness relative to cigarettes. Associations were also explored between noticing warnings and intentions to use NVPs. RESULTS: Noticing warnings was higher among NVP users (18.8%) than nonusers (2.1%). Noticing warnings was associated with perceiving nicotine to pose little or no harm to health among NVP users, but there was no association among nonusers. There was little evidence of an association between noticing warnings and perceptions of NVP harms relative to smoking among NVP users and non-users. Noticing warnings was associated with perceiving NVPs as less addictive than cigarettes among nonusers but not NVP users. Among exclusive smokers, noticing warnings was associated with intending to start using NVPs. Among NVP users, there was little evidence of an association between noticing warnings and intentions to continue using/stopping NVPs. CONCLUSIONS: Noticing NVP warnings was not associated with increased NVP and nicotine harm perceptions or decreased intentions to use NVPs among adult smokers and vapers. IMPLICATIONS: Our findings suggest that noticing NVP warnings may not influence NVP risk perceptions or deter NVP use among adult smokers and vapers. Future research should investigate the impact of warnings on youth and adults who have never smoked or vaped.

Changes in responses to nicotine vaping product warnings and leaflets in England compared with Canada, the US and Australia: findings from the 2016-2018 ITC Four Country Smoking and Vaping Surveys.

BACKGROUND AND AIMS: In May 2017, black-and-white text nicotine addiction warning labels ('warnings') and health and safety leaflets ('leaflets') became mandatory for nicotine vaping products (NVPs) in England, in accordance with the European Union's Tobacco Products Directive. We compared changes over time in noticing warnings and leaflets, recall of warnings about nicotine and concerns about using NVP due to noticing warnings in England, compared with Canada, the US and Australia, where no warnings and leaflets were mandated. DESIGN: 19 005 adult (aged 18+) NVP users, smokers and quitters of cigarettes and NVP from the 2016 and 2018 International Tobacco Control Four Country Smoking and Vaping Surveys in England, Canada, the US and Australia, recruited via probability and non-probability sampling. FINDINGS: Noticing warnings increased in England from 4.9% (2016) to 9.4% (2018) (adjusted OR/AOR=1.64, 95% CI=1.15-2.36); this change was larger than changes in Canada (AOR=2.51, 95% CI=1.71-3.69) and the US (AOR=2.22, 95% CI=1.45-3.39). Recall of a nicotine warning increased in England from 86% (2016) to 94.9% (2018) (AOR=5.50, 95% CI=1.57-19.27) but not significantly elsewhere. Noticing leaflets increased in England from 14.6% (2016) to 19.1% (2018) (AOR=1.42, 95% CI=1.15-1.74); this change was larger than in Canada (AOR=1.42, 95% CI=1.12-1.79), the US (AOR=1.55, 95% CI=1.17-2.06) and Australia (AOR=1.51, 95% CI=1.02-2.22). Among those noticing warnings, concern about NVP use did not change significantly between 2016 and 2018 (all countries p>0.081). CONCLUSIONS: Introduction of mandatory NVP warnings and leaflets in England was associated with small increases in noticing them but not with changes in concerns about NVP use.

Does having one or more smoking friends mediate the transition from e-cigarette use to cigarette smoking: a longitudinal study of Canadian youth.

PURPOSE: Studies have shown consistent associations between youth e-cigarette use and subsequent smoking uptake. However, it remains unclear why, as limited evidence exists regarding the mechanisms underlying these associations. Our study investigated whether having one or more smoking friends mediated the association between e-cigarette use and cigarette smoking onset among a longitudinal sample of Canadian youth who were never smokers at baseline. METHODS: A longitudinal sample of youth that participated in three waves of the COMPASS study (2015-2016 to 2017-2018) was identified (N = 5,535). The product of coefficients method was used to assess whether having one or more smoking friends mediated the association between: (1) past 30-day e-cigarette use and cigarette smoking onset and (2) past 30-day e-cigarette use and subsequent dual use of e-cigarettes and cigarettes. RESULTS: Having one or more smoking friends did not mediate the association between (1) past 30-day e-cigarette use and cigarette smoking onset (ß = 0.38, 95% CI - 0.12, 0.89) or (2) past 30-day e-cigarette use and subsequent dual use (ß = 0.46, 95% CI - 0.16, 1.07). Post hoc tests indicated that smoking friends significantly predicted past 30-day e-cigarette use and cigarette smoking at wave 3 (aOR 1.68 and 2.29, respectively). CONCLUSION: Having smoking friends did not explain the association between e-cigarette use and smoking uptake despite being a common risk factor for both e-cigarette use and cigarette smoking. Prevention efforts should consider how best to incorporate effective programming to address these social influences.

Evaluating the impact of introducing standardized packaging with larger health-warning labels in England: findings from adult smokers within the EUREST-PLUS ITC Europe Surveys.

BACKGROUND: The European (EU) Tobacco Product Directive (TPD) was implemented in May 2016 to regulate the design and labelling of cigarettes and roll-your-own tobacco. At the same time, the UK introduced standardized packaging measures, whereas Germany, Greece, Hungary, Poland, Romania and Spain did not. This study examines the impact of introducing standardized packaging in England using a quasi-experimental design. METHODS: Data from adult smokers in Waves 1 (2016; N=9547) and 2 (2018; N=9724) from the International Tobacco Control Policy Evaluation surveys (England) and EUREST-PLUS surveys (Germany, Greece, Hungary, Poland, Romania and Spain) were used. Generalized estimating equations were used to estimate changes in pack/brand appeal, salience of health-warning labels (HWLs) and perceived relative harm of different brands in England (where larger HWLs and standardized packaging were implemented), vs. each EU country (where only larger HWLs were implemented). RESULTS: There was an increase in the percentage of respondents from Germany, Hungary and Poland reporting they did not like the look of the pack (4.7%, 9.6%, and 14.2%, respectively), but the largest increase was in England (41.0%). Moreover, there was a statistically significant increase in the salience of HWLs in Hungary, Poland and Romania (17.0%, 13.9%, and 15.3%, respectively), but the largest increase was in England (27.6%). Few differences were observed in cross-country comparisons of the perceived relative harm of different brands. CONCLUSIONS: Findings suggest that standardized packaging reduces pack appeal and enhances the salience of HWLs over and above the effects of larger HWLs. Findings provide additional evidence and support for incorporating standardized packaging into the EU TPD.

Effectiveness of tobacco warning labels before and after implementation of the European Tobacco Products Directive-findings from the longitudinal EUREST-PLUS ITC Europe surveys.

BACKGROUND: Tobacco product packaging is a key part of marketing efforts to make tobacco use appealing. In contrast, large, prominent health warnings are intended to inform individuals about the risks of smoking. In the European Union, since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) requires tobacco product packages to carry combined health warnings consisting of a picture, a text warning and information on stop smoking services, covering 65% of the front and back of the packages. METHODS: Key measures of warning label effectiveness (salience, cognitive reactions and behavioural reaction) before and after implementation of the TPD2, determinants of warning labels' effectiveness and country differences were examined in a longitudinal sample of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal Generalized Estimating Equations (GEE) models. RESULTS: In the pooled sample, the warning labels' effectiveness increased significantly over time in terms of salience (adjusted OR = 1.18; 95% CI: 1.03-1.35), while cognitive and behavioural reactions did not show clear increases. Generally, among women, more highly educated smokers and less addicted smokers, the effectiveness of warning labels tended to be higher. CONCLUSION: We found an increase in salience, but no clear increases for cognitive and behavioural reactions to the new warning labels as required by the TPD2. While it is likely that our study underestimated the impact of the new pictorial warning labels, it provides evidence that health messages on tobacco packaging are more salient when supported by large pictures.

Risky cannabis use is associated with varying modes of cannabis consumption: Gender differences among Canadian high school students.

Background: Our objective was to explore associations between indicators of more risky cannabis use (i.e., solitary use, frequent use, and younger age of initiation) and different modes of cannabis use (i.e., smoking, vaping and/or edibles). Methods: Data were gathered from a large sample of Canadian youth in Alberta, British Columbia, Ontario, and Quebec who participated in Year 8 (2019-20) of the COMPASS study, and who reported using cannabis in the past year (n = 4,763). Generalized estimating equations were used to examine associations between risky cannabis use and modes of cannabis use, stratified by gender. Results: Overall, 38% of students reported using multiple modes of cannabis use. Consistent among both males and females, students who used cannabis alone (35%) and at a higher frequency (55%) were more likely to use multiple modes than smoking only. Among females, those who used cannabis alone were more likely to report using edibles only compared to smoking only (aOR=2.27, 95%CI=1.29-3.98). Earlier cannabis use initiation was associated with lower likelihood of vaping cannabis only among males (aOR=0.25; 95%CI = 0.12-0.51), and lower likelihood of using edibles only among females (aOR=0.35; 95%CI = 0.13-0.95), than by smoking only. Conclusions: Our findings suggest that multiple modes of use may be an important indicator or risky cannabis use among youth, given associations with frequency, solitary use, and age of onset.

Trends in youth e-cigarette and cigarette use between 2013 and 2019: insights from repeat cross-sectional data from the COMPASS study.

OBJECTIVES: E-cigarettes are an increasingly popular product among youth in Canada. However, there is a lack of long-term data presenting trends in use. As such, the objective of this study was to examine trends in e-cigarette and cigarette use across various demographic characteristics between 2013 and 2019 among a large sample of secondary school youth in Canada. METHODS: Using repeat cross-sectional data from a non-probability sample of students in grades 9 to 12, this study explored trends in the prevalence of ever and current e-cigarette use and cigarette smoking between 2013-2014 and 2018-2019 in British Columbia, Alberta, Ontario, and Quebec. Trends in ever and current e-cigarette use and cigarette smoking were studied across demographic variables among students in Ontario. RESULTS: The prevalence of e-cigarette ever and current use was variable across province and increased over time, particularly between 2016-2017 and 2018-2019. In contrast, the prevalence of current cigarette smoking was relatively stable over the study period, decreasing significantly in Alberta and Ontario between 2017-2018 and 2018-2019. In Ontario, the prevalence of ever and current e-cigarette use increased among all grades, both genders, and all ethnicities. CONCLUSION: Consistent with data from the United States, the prevalence of e-cigarette use among our large sample of Canadian youth has increased substantially in a short period of time. Surveillance systems should continue to monitor the prevalence of tobacco use among youth. Additional interventions may be necessary to curb e-cigarette use among Canadian youth.

RéSUMé: OBJECTIFS: Les cigarettes électroniques sont de plus en plus populaires auprès des jeunes au Canada. Il manque cependant de données à long terme sur les tendances de leur usage. C'est pourquoi nous avons cherché à examiner les tendances de l'usage des cigarettes électroniques et des cigarettes selon diverses caractéristiques démographiques entre 2013 et 2019 dans un vaste échantillon de jeunes fréquentant l'école secondaire au Canada. MéTHODE: À l'aide de données transversales répétées d'un échantillon non probabiliste d'élèves de la 9e à la 12e année, l'étude a exploré les tendances de la prévalence de l'usage antérieur et actuel des cigarettes électroniques et des cigarettes entre 2013-2014 et 2018-2019 en Colombie-Britannique, en Alberta, en Ontario et au Québec. Les tendances de l'usage antérieur et actuel des cigarettes électroniques et des cigarettes ont été étudiées pour diverses variables démographiques chez les élèves de l'Ontario. RéSULTATS: La prévalence de l'usage antérieur et actuel des cigarettes électroniques varie selon la province et a augmenté avec le temps, particulièrement entre 2016-2017 et 2018-2019. Par contre, la prévalence de l'usage actuel des cigarettes a été relativement stable sur la période de l'étude et a sensiblement diminué en Alberta et en Ontario entre 2017-2018 et 2018-2019. En Ontario, la prévalence de l'usage antérieur et actuel des cigarettes électroniques a augmenté chez les élèves de toutes les années, des deux sexes et de toutes les origines ethniques. CONCLUSION: Comme pour les données des États-Unis, la prévalence de l'usage des cigarettes électroniques dans notre vaste échantillon de jeunes Canadiens a considérablement augmenté sur une courte période. Les systèmes de surveillance devraient continuer à surveiller la prévalence du tabagisme chez les jeunes. Des interventions supplémentaires pourraient être nécessaires pour freiner l'usage des cigarettes électroniques chez les jeunes Canadiens.

Trends and predictors of exclusive e-cigarette use, exclusive smoking and dual use among youth in Canada.

BACKGROUND: Few studies have examined predictors of exclusive e-cigarette use, exclusive smoking and dual use among youth. We investigated whether frequency of e-cigarette use and cigarette smoking predicted involvement in different usage groups after a 1- and 2-year follow-up among a sample of Canadian youth. METHODS: A longitudinal sample of youth who participated in three waves of COMPASS [Wave 1 (W1) 2015/16, Wave 2 (W2) 2016-17, Wave 3 (W3) 2017/18] was identified (N = 5,704). Multinomial logistic regression was used to examine whether frequency of e-cigarette use and cigarette smoking at W1 predicted involvement in different usage groups at W2 and W3. Similarly, we examined whether changes in frequency of e-cigarette use and cigarette smoking between W1 and W2 predicted involvement in different usage groups at W3. RESULTS: E-cigarette users reporting use on 4 or more days per month at W1 had greater odds of dual use at W2, compared to non-users (aOR = 11.22, p < 0.0001). Those who reduced their frequency of e-cigarette use between W1 and W2 had lower odds of exclusive e-cigarette use and dual use at W3 (aOR = 0.18 and 0.17 respectively; both p < 0.05). Those who increased their frequency of cigarette smoking between W1 and W2 had higher odds of exclusive smoking and dual use at W3 (aOR = 22.65 and aOR = 9.92 respectively; both p < 0.0001). DISCUSSION: Reductions in frequency of e-cigarette use appeared to have a protective effect of reducing exclusive e-cigarette use and dual use at follow-up. Increases in frequency of cigarette smoking were a significant predictor of exclusive smoking and dual use.

Assessing the strength of secondary school tobacco policies of schools in the COMPASS study and the association to student smoking behaviours.

OBJECTIVES: The school environment is an ideal setting to introduce policies to prevent smoking behaviour. However, there may be variability in the strength of school board and secondary school tobacco policies, which may affect student smoking behaviours. This study assessed the strength of a sample of school board and secondary school tobacco policies and examined the association with student smoking behaviours. METHODS: Tobacco policies from school boards (n = 21/26) and secondary schools (n = 43/81) that participated in the COMPASS study during 2015-2016 were obtained online. A standardized instrument was used to assess the strength of school board and secondary school tobacco policies on four domains. Using the sample of students from schools with identified policies (n = 22,696), separate multilevel regression models examined the association between school policy scores and a student's susceptibility to smoking, ever smoking, current smoking, and perceived support of the school environment. RESULTS: The mean school board tobacco policy score was 13.7/40 and the mean secondary school tobacco policy score was 11.3/40. Students were significantly less likely to report current smoking (OR 0.95, 95% CI 0.91-0.99) and more likely to report a supportive school environment (OR 1.06, 95% CI 1.04-1.08) with each four-unit (i.e., 10%) increase in school tobacco policy score. CONCLUSIONS: The vast majority of school board and secondary school tobacco policies were missing components and therefore could not be considered comprehensive. Stronger school tobacco policies may help to reduce student current smoking behaviours.

Exploring the association between E-cigarette retailer proximity and density to schools and youth E-cigarette use.

Limited evidence exists examining the association between e-cigarette retailer density and e-cigarette use among youth. This study explored whether e-cigarette retailer proximity and density to schools were associated with youth use of e-cigarettes in 4 Canadian provinces. Between October and December 2017, an online search identified e-cigarette retailers within 500 m, 1000 m, and 1500 m circular buffer zones around high schools (N = 122) that participated in the COMPASS study in 2017-18. Retailer proximity/density data were linked to student-level data (N = 63,400 students). Multilevel regression models examined the association between e-cigarette retailer proximity and density and ever and current e-cigarette use, controlling for relevant covariates. Results indicated the average school had <1 e-cigarette retailer within 500 m, 1000 m, and 1500 m. Significant between-school variability in the likelihood of ever [σ2 µ0 = 0.215 (0.030), p < .0001] and current [σ2 µ0 = 0.258 (0.036), p < .0001] e-cigarette use was found among students. However, after controlling for relevant covariates, e-cigarette retailer proximity and density surrounding a school were not significantly associated with the likelihood of ever or currently using e-cigarettes. These findings suggest that students are accessing e-cigarettes through other sources.

Exploring the Bi-Directional Association between Tobacco and E-Cigarette Use among Youth in Canada.

Research has demonstrated associations between e-cigarette use and tobacco use among youth. However, few studies have examined whether reciprocal relationships exist between e-cigarette and tobacco use. The objective of this study was to examine whether bi-directional associations exist between e-cigarette and tobacco use in a large longitudinal sample of Canadian youth. A longitudinal sample of secondary students (n = 6729) attending 87 schools in Ontario and Alberta, Canada, who completed the COMPASS student questionnaire across three waves (from 2014-2015 to 2016-2017) was identified. Using cross-lagged models, we explored bi-directional associations between current tobacco and e-cigarette use, adjusting for relevant covariates. Our findings showed that current e-cigarette use predicted subsequent tobacco use between Wave 1 (W1) and Wave 2 (W2) of the study (W1-2: OR = 1.54, 95% CI = 1.37-1.74). Similarly, current tobacco use predicted e-cigarette use during earlier waves of the study (W1-2: OR = 1.43, 95% CI = 1.30-1.58). However, these relationships dissipated in later waves, when tobacco use no longer predicted e-cigarette use (W2-3: OR = 1.07, 95 % CI = 0.99-1.16). This study extends prior work that focused mainly on the association between e-cigarette and subsequent tobacco use. Specifically, our findings portray a more complex relationship, where e-cigarette use may influence and be influenced by tobacco use.

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.

Risky business: a longitudinal study examining cigarette smoking initiation among susceptible and non-susceptible e-cigarette users in Canada.

OBJECTIVES: Given that many adolescent e-cigarette users are never-smokers, the possibility that e-cigarettes may act as a gateway to future cigarette smoking has been discussed in various studies. Longitudinal data are needed to explore the pathway between e-cigarette and cigarette use, particularly among different risk groups including susceptible and non-susceptible never-smokers. The objective of this study was to examine whether baseline use of e-cigarettes among a sample of never-smoking youth predicted cigarette smoking initiation over a 2-year period. DESIGN: Longitudinal cohort study. SETTING: 89 high schools across Ontario and Alberta, Canada. PARTICIPANTS: A sample of grade 9-11 never-smoking students at baseline (n=9501) who participated in the COMPASS study over 2 years. PRIMARY AND SECONDARY OUTCOME MEASURES: Participants completed in-class questionnaires that assessed smoking susceptibility and smoking initiation. RESULTS: Among the baseline sample of non-susceptible never-smokers, 45.2% of current e-cigarette users reported trying a cigarette after 2 years compared with 13.5% of non-current e-cigarette users. Among the baseline sample of susceptible never-smokers, 62.4% of current e-cigarette users reported trying a cigarette after 2 years compared with 36.1% of non-current e-cigarette users. Overall, current e-cigarette users were more likely to try a cigarette 2 years later. This association was stronger among the sample of non-susceptible never-smokers (AOR=5.28, 95% CI 2.81 to 9.94; p<0.0001) compared with susceptible never-smokers (AOR=2.78, 95% CI 1.84 to 4.20; p<0.0001). CONCLUSIONS: Findings from this large, longitudinal study support public health concerns that e-cigarette use may contribute to the development of a new population of cigarette smokers. They also support the notion that e-cigarettes are expanding the tobacco market by attracting low-risk youth who would otherwise be unlikely to initiate using cigarettes. Careful consideration will be needed in developing an appropriate regulatory framework that prevents e-cigarette use among youth.