Prevalence and perceptions of flavour capsule cigarettes among adults who smoke in Brazil, Japan, Republic of Korea, Malaysia and Mexico: findings from the ITC surveys.

INTRODUCTION: The global market of flavour capsule cigarettes (FCCs) has grown significantly over the past decade; however, prevalence data exist for only a few countries. This study examined prevalence and perceptions of FCCs among adults who smoke across five countries. METHODS: Cross-sectional data among adults who smoked cigarettes came from the International Tobacco Control Policy Evaluation Project Surveys-Brazil (2016/2017), Japan (2021), Republic of Korea (2021), Malaysia (2020) and Mexico (2021). FCCs use was measured based on reporting one's usual/current brand or favourite variety has flavour capsule(s). Perceptions of the harmfulness of one's usual brand versus other brands were compared between those who used capsules versus no capsules. Adjusted logistic regression models examined correlates of FCC use. RESULTS: There were substantial differences in the prevalence of FCC use among adults who smoke across the five countries: Mexico (50.3% in 2021), Republic of Korea (31.8% in 2021), Malaysia (26.5% in 2020), Japan (21.6% in 2021) and Brazil (6.7% in 2016/2017). Correlates of FCC use varied across countries. Capsule use was positively associated with being female in Japan and Mexico, younger age in Japan, Republic of Korea and Malaysia, high education in Brazil, Japan and Mexico, non-daily smoking in Republic of Korea, and having plans to quit in Japan and Republic of Korea. There was no consistent pattern of consumer perceptions of brand harmfulness. CONCLUSION: Our study documented the high prevalence of FCCs in some countries, pointing to the need to develop and implement regulatory strategies to control these attractive products.

Prevalence of menthol cigarette use among adults who smoke from the United States by census division and demographic subgroup, 2002-2020: findings from the International Tobacco Control (ITC) project.

BACKGROUND: Targeted marketing of menthol cigarettes in the US influences disparities in the prevalence of menthol smoking. There has been no analysis of sub-national data documenting differences in use across demographic subgroups. This study estimated trends in the prevalence of menthol use among adults who smoke in the nine US census divisions by sex, age, and race/ethnicity from 2002 to 2020. METHODS: Data from 12 waves of the US ITC Survey were used to estimate the prevalence of menthol cigarette use across census divisions and demographic subgroups using multilevel regression and post-stratification (n = 12,020). Multilevel logistic regression was used to predict the prevalence of menthol cigarette use in 72 cross-classified groups of adults who smoke defined by sex, age, race/ethnicity, and socioeconomic status; division-level effects were fit with a random intercept. Predicted prevalence was weighted by the total number of adults who smoke in each cross-classified group and aggregated to divisions within demographic subgroup. Estimates were validated against the Tobacco Use Supplement to the Current Population Survey (TUS-CPS). RESULTS: Overall modeled prevalence of menthol cigarette use was similar to TUS-CPS estimates. Prevalence among adults who smoke increased in each division from 2002 to 2020. By 2020, prevalence was highest in the Middle (46.3%) and South Atlantic (42.7%) and lowest in the Pacific (25.9%) and Mountain (24.2%) divisions. Prevalence was higher among adults aged 18-29 (vs. 50+) and females (vs. males). Prevalence among non-Hispanic Black people exceeded 80% in the Middle Atlantic, East North Central, West North Central, and South Atlantic in all years and varied most among Hispanic people in 2020 (Pacific: 26.5%, New England: 55.1%). CONCLUSIONS: Significant geographic variation in the prevalence of menthol cigarette use among adults who smoke suggests the proposed US Food and Drug Administration (FDA) menthol cigarette ban will exert differential public health benefits and challenges across geographic and demographic subgroups.

Prevalence and reasons for use of heated tobacco products among Malaysian adults who smoked: Findings from the 2020 International Tobacco Control Malaysia Survey.

INTRODUCTION: There have been rapid expansions in heated tobacco products (HTPs) outside of Japan and the Republic of Korea. In November 2018, HTPs were first introduced in Malaysia and since then, no studies have been conducted on Malaysians' use of HTPs. This study is the first to examine the prevalence of HTP use and reasons for use among Malaysian adults who smoked cigarettes. METHODS: Data came from the 2020 ITC Malaysia Survey, a web-based survey of a nationally representative sample of adults who smoked (n=1047) aged 18 and older. They were asked on ever heard of, ever used, and currently using HTPs, and their reasons for using HTPs. RESULTS: Overall, 25.4% (n= 324; 95% CI:22.3%-28.7%) of Malaysians who smoked reported ever used HTPs with 6.7% (n=85; 95% CI:22.3%-28.7%) were using them daily and 8.1% (n=110; 95% CI:6.4% -10.2%) were using HTPs non-daily. Most of them (57.2%) who dual use were of aged 25-39 and 97.3% were males. Among those who smoked daily, almost half (49.3%) were also using HTP daily. Among those who used HTPs daily and non-daily, curiosity (84.2%, 95% CI:78.4%-90.0%), taste (83.2%, 95% CI:77.3%-89.1%), and appealing technology (78.5%, 95% CI:71.3%-85.6%) were the most reported reasons. Among those who used HTPs daily, curiosity was the top reason (87.9%, 95% CI:78.9%-93.4%), while among non-daily, taste good was the top reason (81.9%, 95% CI:71.9%-88.8%). CONCLUSIONS: The very high use of HTPs among Malaysians who smoked requires continued public health surveillance that can inform the regulation of these novel tobacco products.

Distribution of legal retail cannabis stores in Canada by neighbourhood deprivation.

OBJECTIVES: In legal cannabis markets, the distribution of retail stores has the potential to influence transitions from illegal to legal sources as well as consumer patterns of use. The current study examined the distribution of legal cannabis stores in Canada according to level of neighbourhood deprivation. METHODS: Postal code data for all legal cannabis stores in Canada were collected from government websites from October 2018 to September 2021. This data was linked to the Institut National de Santé Publique du Québec measures for material and social neighbourhood deprivation. Descriptive data are reported, including differences across provinces with different retail systems. RESULTS: At the national level, there were approximately 8.0 retail cannabis stores per 100,000 individuals age 15+ in September 2021. The distribution of stores was closely aligned with the expected distribution across levels of material deprivation: for example, 19.5% of stores were located in neighbourhoods with the lowest level of material deprivation versus 19.1% in the highest level. More cannabis stores were located in the 'most socially deprived' or 'socially deprived' neighbourhoods (37.2% and 22.1%, respectively), characterized by a higher proportion of residents who live alone, are unmarried, or in single-parent families. The distribution of stores in provinces and territories were generally consistent with national patterns with a few exceptions. CONCLUSION: In the first 3 years following cannabis legalization in Canada, retail cannabis stores were evenly distributed across materially deprived neighbourhoods but were more common in socially deprived neighbourhoods. Future monitoring of retail store locations is required as the legal retail market evolves in Canada.

How do users compare the costs between nicotine vaping products and cigarettes? Findings from the 2016-2020 International Tobacco Control United States surveys.

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

Evaluation of the effectiveness of the Indian government's policies to strengthen health warning labels on smokeless tobacco products: findings from the 2010-2019 Tobacco Control Project India Surveys.

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

Cannabis-related arrests and convictions in Canada: Differences by race/ethnicity, individual socioeconomic factors, and neighborhood deprivation.

Racialized individuals were disproportionately impacted by cannabis prohibition in Canada; however, the role of socioeconomic factors and neighborhood deprivation are not well understood. The current study examined race/ethnicity, individual socioeconomic factors, and neighborhood deprivation in relation to arrests and convictions for cannabis-related offenses. Repeat cross-sectional data were analyzed from two waves of the International Cannabis Policy Study (ICPS), a web-based survey conducted in 2019 (n = 12,226) and 2020 (n = 12,815) in Canada among those aged 16 to 65. Respondents were recruited through commercial online panels. Respondents' postal codes were linked to the INSPQ deprivation index. Multinomial regression models examined the association between race/ethnicity, individual socioeconomic factors, neighborhood deprivation, and lifetime arrests or convictions for cannabis offenses. Overall, 4.4% of respondents reported a lifetime arrest or conviction for a cannabis-related offense. Black and Indigenous individuals had more than three times the odds of conviction than White individuals (AOR = 3.90, 95% CI = 2.07-7.35, p = <0.01; AOR = 3.24, 95% CI = 1.78-5.90, p = <0.01, respectively). Differences were still statistically significant after adjusting for cannabis use and socioeconomic factors; however, after adjusting for neighborhood deprivation, only the difference for Black individuals remained. Neighborhood deprivation was associated with cannabis-related convictions: the odds of a conviction among the "most privileged" and "privileged" neighborhoods were approximately half of those in the "most deprived" neighborhoods (AOR = 0.50, 95% CI = 0.29-0.86, p = 0.01; AOR = 0.50, 95% CI = 0.27-0.92, p = 0.03, respectively). Arrests and convictions for cannabis-related offenses were disproportionately higher among racialized individuals and those living in the most marginalized neighborhoods. Future research should examine whether inequities change following the legalization of recreational cannabis in Canada.

Trend over time on knowledge of the health effects of cigarette smoking and smokeless tobacco use in Bangladesh: Findings from the International Tobacco Control Policy Evaluation Bangladesh Surveys.

INTRODUCTION: Cigarette smoking and smokeless tobacco (ST) use are prevalent in Bangladesh. This longitudinal study examined how knowledge of the health effects of smoking and ST use in Bangladesh has changed overtime with the country's acceleration of tobacco control efforts. METHODS: Data were analysed from the International Tobacco Control Survey, a nationally representative longitudinal study of users and non-users of tobacco (aged 15 and older) in Bangladesh, across four waves conducted in 2009 (n = 4378), 2010 (n = 4359), 2012 (n = 4223) and 2015 (n = 4242). Generalised estimating equations assessed the level of knowledge about harms of tobacco use across four waves. Multivariable logistic regressions assessed whether knowledge of health effects from cigarette smoking and ST use in 2015 differed by user group. RESULTS: In 2015 survey, most tobacco users were aware that cigarette smoking causes stroke (92%), lung cancer (97%), pulmonary tuberculosis (97%) and ST use causes mouth cancer (97%) and difficulty in opening mouth (80%). There were significant increases in the total knowledge score of smoking related health harm from 2010 to 2012 (mean difference = 0.640; 95% confidence interval [CI] 0.537, 0.742) and 2012 to 2015 (mean difference = 0.555; 95% CI 0.465, 0.645). Participants had greater odds of awareness for ST health effects from 2010 to 2015. DISCUSSION AND CONCLUSIONS: The results suggest that increasing efforts of awareness policy interventions is having a positive effect on tobacco-related knowledge in Bangladesh. These policy initiatives should be continued to identify optimal methods to facilitate behaviour change and improve cessation of smoking and ST use.

Illicit purchasing and use of flavour accessories after the European Union menthol cigarette ban: findings from the 2020-21 ITC Netherlands Surveys.

BACKGROUND: The 2020 European Union (EU) menthol cigarette ban increased quitting among pre-ban menthol smokers in the Netherlands, but some reported continuing to smoke menthol cigarettes. This study examined three possible explanations for post-ban menthol use-(i) illicit purchasing, (ii) use of flavour accessories and (iii) use of non-menthol replacement brands marketed for menthol smokers. METHODS: Data were from the ITC Netherlands Cohort Surveys among adult smokers before the menthol ban (Wave 1: February-March 2020, N = 2067) and after the ban (Wave 2: September-November 2020, N = 1752; Wave 3: June-July 2021, N = 1721). Bivariate, logistic regression and generalized estimating equation model analyses were conducted on weighted data. RESULTS: Illicit purchasing remained low from pre-ban (2.4%, 95% CI: 1.8-3.2, Wave 1) to post-ban (1.7%, 1.2-2.5%, Wave 3), with no difference between menthol and non-menthol smokers from Wave 1 to Wave 3. About 4.4% of post-ban menthol smokers last purchased their usual brand outside of the EU and 3.6% from the internet; 42.5% of post-ban menthol smokers and 4.4% of smokers overall reported using flavour accessories, with greater odds among those aged 25-39 years vs. 55+ (aOR = 3.16, P = 0.002). Approximately 70% of post-ban smokers who reported using a menthol brand were actually using a non-menthol replacement brand. CONCLUSIONS: There was no increase in illicit purchasing or of smuggling outside the EU among menthol and non-menthol smokers in the Netherlands 1 year after the EU menthol cigarette ban. Use of flavour accessories and non-menthol replacement brands best explain post-ban menthol use, suggesting the need to ban accessories and ensure industry compliance.

Tobacco purchasing in Australia during regular tax increases: findings from the International Tobacco Control Policy Evaluation Project.

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

Proximity to Legal Cannabis Stores in Canada and Use of Cannabis Sources in the First Three Years of Legalization, 2019-2021.

OBJECTIVE: The accessibility of legal cannabis in Canada may influence how consumers source their cannabis. The aims of this study were to examine (a) the distance between respondents' homes and legal retail stores, (b) the cannabis sources used in the past 12 months, and (c) the association between cannabis sources used and distance to legal retail stores. METHOD: Data were analyzed from Canadian respondents participating in the International Cannabis Policy Study from 2019 to 2021. Respondents were 15,311 past-12-month cannabis consumers of legal age to purchase cannabis. Weighted logistic regression models examined cannabis sources used and their association with the Euclidean distance to the nearest legal store, province of residence, and year (n = 12,928). RESULTS: Respondents lived closer to a legal retail store in 2021 (1.5 km) versus 2019 (6.8 km) as the number of retail stores increased. Respondents in 2020 and 2021 had higher odds of obtaining cannabis from legal sources (e.g., legal stores: 47.9% and 60.0% vs. 38.6%, respectively, adjusted odds ratio [AOR] range: 1.41-2.42) and lower odds of obtaining cannabis from illegal sources versus 2019 (e.g., dealers: 22.6% and 19.9% vs. 29.1%, respectively, AOR range: 0.65-0.54). Respondents who lived closest to legal stores had higher odds of sourcing from legal stores and lower odds of sourcing from legal websites or growing their own cannabis. CONCLUSIONS: Legal cannabis stores are increasingly accessible to people living in Canada 3 years after legalization. Household proximity to a legal cannabis store was associated with sourcing cannabis from legal retail stores, but only among those who live very close (<3 km). Findings suggest that proximity to legal cannabis stores may aid uptake of the legal market, yet there may be diminishing returns after a certain point.

Support for pictorial health warning labels on cigarette packages in the United States among adults who currently smoke or quit smoking: Findings from the ITC US Smoking and Vaping Surveys.

INTRODUCTION: In March 2020, the US Food and Drug Administration (FDA) finalized new pictorial health warnings (PHWs), covering 50% of the front and back of the pack; however, legal challenges from cigarette manufacturers have prevented the new warnings from being implemented. About 70% of adults in the general US population support PHWs. This study assessed support for PHWs in 2016, 2018 and 2020 among US adults (aged ≥18 years) who currently smoke or formerly smoked cigarettes. We also assessed factors related to support. METHODS: Respondents included adults who currently or formerly smoked cigarettes and participated in at least one wave of the US ITC Smoking and Vaping Surveys: Wave 1 (2016, n=2557); Wave 2 (2018, n=2685); and Wave 3 (2020, n=1112). We assessed changes in support for PHWs between 2016 and 2020, and assessed factors related to support (support vs oppose/don't know). Analyses were conducted on weighted data. RESULTS: Overall, 38.0% of respondents supported PHWs in 2016, with a significant increase to 44.7% in 2018 (p<0.001), and leveling off to 45.0% in 2020 (2018 vs 2020, p=0.91). Support was highest among former smokers and lowest among daily smokers in all three survey years. Support for PHWs at all survey years was significantly higher among those who formerly smoked, were younger (aged 18-39 vs ≥40 years), those who identified as Black (vs White), and planned to quit smoking (vs not planning to quit). There were no differences by income level, education level, or sex. CONCLUSIONS: Nearly half of US adults who smoke cigarettes or quit smoking supported PHWs in 2020, with support being higher among younger adults, ethnic minorities, and those who formerly smoked. Support increased between 2016 and 2018, but not between 2018 and 2020. Similar to other studies, fewer current and former smokers supported PHWs compared to the US adult general population.

Prevalence of depressive symptoms and cannabis use among adult cigarette smokers in Canada: cross-sectional findings from the 2020 International Tobacco Control Policy Evaluation Project Canada Smoking and Vaping Survey.

BACKGROUND: Tobacco smoking and cannabis use are independently associated with depression, and evidence suggests that people who use both tobacco and cannabis (co-consumers) are more likely to report mental health problems, greater nicotine dependence and alcohol misuse than those who use either product exclusively. We examined prevalence of cannabis use and depressive symptoms among Canadian adults who smoke cigarettes and tested whether co-consumers of cannabis and tobacco were more likely to report depressive symptoms than cigarette-only smokers; we also tested whether cigarette-only smokers and co-consumers differed on cigarette dependence measures, motivation to quit smoking and risky alcohol use by the presence or absence of depressive symptoms. METHODS: We analyzed cross-sectional data from adult (age ≥ 18 yr) current (≥ monthly) cigarette smokers from the Canadian arm of the 2020 International Tobacco Control Policy Evaluation Project Four Country Smoking and Vaping Survey. Canadian respondents were recruited from Leger's online probability panel across all 10 provinces. We estimated weighted percentages for depressive symptoms and cannabis use among all respondents and tested whether co-consumers (≥ monthly use of cannabis and cigarettes) were more likely to report depressive symptoms than cigarette-only smokers. Weighted multivariable regression models were used to identify differences between co-consumers and cigarette-only smokers with and without depressive symptoms. RESULTS: A total of 2843 current smokers were included in the study. The prevalence of past-year, past-30-day and daily cannabis use was 44.0%, 33.2% and 16.1%, respectively (30.4% reported using cannabis at least monthly). Among all respondents, 30.0% screened positive for depressive symptoms, with co-consumers being more likely to report depressive symptoms (36.5%) than those who did not report current cannabis use (27.4%, p < 0.001). Depressive symptoms were associated with planning to quit smoking (p = 0.01), having made multiple attempts to quit smoking (p < 0.001), the perception of being very addicted to cigarettes (p < 0.001) and strong urges to smoke (p = 0.001), whereas cannabis use was not (all p ≥ 0.05). Cannabis use was associated with high-risk alcohol consumption (p < 0.001), whereas depressive symptoms were not (p = 0.1). INTERPRETATION: Co-consumers were more likely to report depressive symptoms and high-risk alcohol consumption; however, only depression, and not cannabis use, was associated with greater motivation to quit smoking and greater perceived dependence on cigarettes. A deeper understanding of how cannabis, alcohol use and depression interact among people who smoke cigarettes is needed, as well as how these factors affect cessation activity over time.

ITC EUREST-PLUS Spain: protocol of a prospective longitudinal study of smokers in Spain.

OBJECTIVE: The ITC EUREST-PLUS Spain Survey is a longitudinal study of a representative sample of Spanish adult (≥18 years old) smokers. This protocol describes the methods of the 2021 follow-up survey. METHOD: The ITC EUREST-PLUS Survey, a prospective cohort study of a representative sample of smokers in six European countries, was conducted in 2016 (baseline) and 2018 (waves 1 and 2). The 2021 ITC EUREST-PLUS Spain Survey is a continuation of the Spanish cohort with a new interview in 2021 (wave 3). Lost participants were replaced with new smokers recruited using the same multi-stage sampling design. This latest follow-up aims to examine current patterns and transitions of tobacco use and to evaluate the impact of new tobacco-related policies. COMMENTS: The ITC EUREST-PLUS Spain Survey will provide recent information about the impact of tobacco control policies on smoking behaviour.

Patterns of problematic cannabis use in Canada pre- and post-legalisation: Differences by neighbourhood deprivation, individual socioeconomic factors and race/ethnicity.

INTRODUCTION: The legalisation of cannabis in Canada in 2018, and subsequent increase in prevalence of use, has generated interest in understanding potential changes in problematic patterns of use, including by socio-demographic factors such as race/ethnicity and neighbourhood deprivation level. METHODS: This study used repeat cross-sectional data from three waves of the International Cannabis Policy Study web-based survey. Data were collected from respondents aged 16-65 prior to cannabis legalisation in 2018 (n = 8704), and post-legalisation in 2019 (n = 12,236) and 2020 (n = 12,815). Respondents' postal codes were linked to the INSPQ neighbourhood deprivation index. Multinomial regression models examined differences in problematic use by socio-demographic and socio-economic factors and over time. RESULTS: No evidence of a change in the proportion of those aged 16-65 in Canada whose cannabis use would be classified as 'high risk' was noted from before cannabis legalisation (2018 = 1.5%) to 12 or 24 months after legalisation (2019 = 1.5%, 2020 = 1.6%; F = 0.17, p = 0.96). Problematic use differed by socio-demographic factors. For example, consumers from the most materially deprived neighbourhoods were more likely to experience 'moderate' vs 'low risk' compared to those living outside deprived neighbourhoods (p < 0.01 for all). Results were mixed for race/ethnicity and comparisons for high risk were limited by small sample sizes for some groups. Differences across subgroups were consistent from 2018 to 2020. DISCUSSION AND CONCLUSIONS: The risk of problematic cannabis use does not appear to have increased in the 2 years following cannabis legalisation in Canada. Disparities in problematic use persisted, with some racial minority and marginalised groups experiencing higher risk.

Association of Fully Branded and Standardized e-Cigarette Packaging With Interest in Trying Products Among Youths and Adults in Great Britain.

Importance: e-Cigarette vaping among youths and adults has increased in Great Britain. The design of e-cigarette packaging may appeal to youths. Regulations that reduce the appeal of e-cigarettes to youths may deter adult smokers from trying e-cigarettes to help them quit smoking. Objective: To examine the association of fully branded and standardized e-cigarette packaging with interest in trying products among youths and adults in Great Britain. Design, Setting, and Participants: In this survey study comprising 2 surveys, the online Action on Smoking and Health Smokefree Great Britain survey collected data between March 25 and April 16, 2021, from a representative sample of 2469 youths (aged 11-18 years) and between February 18 and March 18, 2021, from a representative sample of 12 046 adults (aged ≥18 years). Interventions: A between-individuals experimental design was used to examine participants' perceptions of e-cigarette packs that were digitally altered to remove brand imagery and color. Participants were randomly assigned to view a set of 3 e-cigarette packs from 1 of 3 different packaging conditions: (1) fully branded packs (control), (2) white standardized packs with brand name, or (3) green standardized packs with brand name. Main Outcomes and Measures: Youth participants were asked which product people their age would be most interested in trying, while adult participants were asked which product they would be most interested in trying. All participants could respond "no interest" or "don't know." Logistic regression models tested whether reporting no interest in trying the e-cigarettes differed between the pack conditions. Results: This study included 2469 youths (1286 female youths [52.1%]; mean [SD] age, 15.0 [2.3] years) and 12 046 adults (6412 female [53.2%]; mean [SD] age, 49.9 [17.4] years). Youths had higher odds of reporting no interest among people their age in trying the e-cigarettes packaged in green (292 of 815 [35.8%]; adjusted odds ratio [AOR], 1.37; 95% CI, 1.10-1.71; P = .005) but not white (264 of 826 [32.0%]; AOR, 1.16; 95% CI, 0.93-1.44; P = .20) standardized packaging compared with the fully branded packaging (238 of 828 [28.7%]). Adults had lower odds of reporting no interest in trying e-cigarettes in green standardized packaging (3505 of 4040 [86.8%]; AOR, 0.85; 95% CI, 0.73-0.99; P = .046) but not white packaging (3532 of 4006 [88.2%]; AOR, 1.05; 95% CI, 0.89-1.23; P = .59) compared with branded packaging (3526 of 4000 [88.1%]). Youths who had never vaped (275 of 699 [39.3%]; AOR, 1.34; 95% CI, 1.07-1.69; P = .01) and youths who had never smoked (271 of 676 [40.1%]; AOR, 1.38; 95% CI, 1.10-1.75; P = .006) were more likely to report no interest in trying e-cigarettes in green packaging compared with branded packaging (224 of 688 [32.6%] never vaping; 216 of 662 [32.6%] never smoking). There were no significant differences by vaping or smoking status among adults. Conclusions and Relevance: The findings of this survey study suggest that standardized packaging measures may reduce the appeal of e-cigarettes among youths without reducing their appeal among adults.

Legal sourcing of ten cannabis products in the Canadian cannabis market, 2019-2021: a repeat cross-sectional study.

BACKGROUND: One of the objectives of cannabis legalization in Canada is to transition consumers from the illegal to the legal market. Little is known about how legal sourcing varies across different cannabis product types, provinces, and frequency of cannabis use. METHODS: Data were analyzed from Canadian respondents in the International Cannabis Policy Study, a repeat cross-sectional survey conducted annually from 2019 to 2021. Respondents were 15,311 past 12-month cannabis consumers of legal age to purchase cannabis. Weighted logistic regression models estimated the association between legal sourcing ("all"/ "some"/ "none") of ten cannabis product types, province, and frequency of cannabis use over time. RESULTS: The percentage of consumers who sourced "all" their cannabis products from legal sources in the past 12 months varied by product type, ranging from 49% of solid concentrate consumers to 82% of cannabis drink consumers in 2021. The percentage of consumers sourcing "all" their respective products legally was greater in 2021 than 2020 across all products. Legal sourcing varied by frequency of use: weekly or more frequent consumers were more likely to source "some" (versus "none") of their products legally versus less frequent consumers. Legal sourcing also varied by province, with a lower likelihood of legal sourcing in Québec of products whose legal sale was restricted (e.g., edibles). CONCLUSION: Legal sourcing increased over time, demonstrating progress in the transition to the legal market for all products in the first three years of legalization in Canada. Legal sourcing was highest for drinks and oils and lowest for solid concentrates and hash.

Do cigarette prices near secondary schools vary by area-level socioeconomic status? Findings from a field study in Ontario and Québec, Canada.

OBJECTIVES: To examine, in the context of youth smoking, whether cigarette prices near secondary schools varied by area-level socioeconomic status in Southwestern and Central Ontario, and the greater Montréal region. METHODS: We collected cigarette prices four times between 2016 and 2019 from stores near secondary schools and used mixed-effects and ordinary least squares regressions. RESULTS: We found consistent evidence that cigarette prices near secondary schools were lower in neighbourhoods with lower area-level household income, and that differences were large enough to be meaningful. In Ontario and Québec, our results indicate a Can$0.26 [0.04, 0.47] to Can$0.51 [0.33, 0.69] and Can$0.10 [-0.04, 0.24] to Can$0.37 [0.22, 0.52] difference in prices for a pack of 25 cigarettes between neighbourhoods with a median household income standard deviation below/above the provincial median, respectively. CONCLUSION: Policy changes that limit area-level cigarette price differences without lowering cigarette prices may reduce inequities in youth smoking.

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.