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.

Intentions to Quit, Quit Attempts, and the Use of Cessation Aids Among Malaysian Adult Smokers: Findings From the 2020 International Tobacco Control (ITC) Malaysia Survey.

This study examined quitting behavior and use of cessation aids (CAs) among Malaysian adult smokers aged ≥18 years (n = 1,047). Data were from the 2020 International Tobacco Control (ITC) Malaysia Survey were analyzed. A total of 79.9% of Malaysian smokers attempted to quit in the past 12 months and 85.2% intended to quit in the next 6 months. The most common CAs were e-cigarettes (ECs) (61.4%), medication/nicotine replacement therapies (NRTs; 51.0%), and printed materials (36.7%); the least common CA was infoline/quitline services (8.1%). Multivariable logistic regression analysis was performed to examine the association between sociodemographic variables and CAs use. Male smokers were more likely to use infoline/quitline services (adjusted odds ratio [aOR] = 3.27; P = .034). Malay smokers were more likely to use infoline/quitline services (aOR = 3.36; P = .002), ECs (aOR = 1.90; P = .004), printed materials (aOR = 1.79; P = .009), and in-person services (aOR = 1.75; P = .043). Most Malaysian smokers wanted to quit smoking. Furthermore, ECs were the most popular CAs, highlighting the need to assess the effectiveness of ECs for quitting smoking in Malaysia.

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.

ITC EUREST-PLUS Spain: protocol of a prospective longitudinal study of smokers in Spain / ITC EUREST-PLUS España: protocolo de un estudio longitudinal prospectivo de fumadores en España

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.(AU)

Objetivo: La encuesta ITC EUREST-PLUS España es un estudio longitudinal de una muestra representativa de fumadores adultos (≥18 años) españoles. Este protocolo describe los métodos de la encuesta de seguimiento de 2021. Método: La encuesta ITC EUREST-PLUS, un estudio de cohortes prospectivo de una muestra representativa de fumadores en seis países europeos, se realizó en 2016 y 2018 (olas 1 y 2). La encuesta ITC EUREST-PLUS España de 2021 es una continuación de la cohorte española con una nueva entrevista en 2021 (ola 3). Se sustituyeron las pérdidas con nuevos fumadores reclutados usando el mismo diseño muestral multietápico. Este último seguimiento pretende examinar los patrones actuales y las transiciones del uso de tabaco, y evaluar el impacto de nuevas políticas relacionadas con el tabaco. Comentarios: La encuesta ITC EUREST-PLUS España de 2021 proporcionará información reciente sobre el impacto de las políticas de control del tabaco en el consumo de tabaco.(AU)

Factors Associated with Quit Intentions among Adult Smokers in South Korea: Findings from the 2020 ITC Korea Survey.

Background: South Korea has made substantial progress on tobacco control, but cigarette smoking prevalence is still high. Previous studies were conducted before the use of nicotine vaping products (NVPs) or heated tobacco products (HTPs) became popular. Thus, whether the concurrent use of NVPs or HTPs affects quit intentions among Korean smokers remains a question that needs to be explored. This study aims to identify predictors of quit intentions among cigarette-only smokers and concurrent users of cigarettes and NVPs or HTPs. Methods: Data were from the 2020 International Tobacco Control Korea Survey. Included in the analysis were 3778 adult cigarette smokers: 1900 at-least-weekly exclusive smokers and 1878 at-least-weekly concurrent smokers and HTP or NVP users. Bivariate and multivariable logistic regression analyses were conducted. Results: Quit intentions were reported by 66.4% of respondents. Factors significantly associated with quit intentions included younger age, having a spouse/partner, lower nicotine dependence, reporting a past quit attempt, regretting starting smoking, believing that smoking had damaged health, worrying that smoking will damage future health, and perceiving health benefits of quitting. Current use of NVPs or HTPs was not significantly associated with quit intentions. Conclusions: This study contributes the following to current literature: intrinsic health-related beliefs were more important than societal norms in shaping quit intentions. These findings should be considered in shaping future smoking cessation policies, such as reinforcing education programs that emphasize the benefits of quitting for personal health reasons, lowering nicotine dependence, and encouraging multiple quit attempts and successful quitting.

Are smoking restrictions at public venues and psychosocial beliefs associated with intentions to quit smoking among smokers in Malaysia?

The Malaysian government reinforced smoking restrictions at public venues to protect nonsmokers from secondhand smoke (SHS) exposure. This study examined whether smokers' reports about smoking restrictions and psychosocial beliefs were associated with quit intentions among Malaysian smokers. Data from 1047 cigarette smokers (103 females and 944 males) aged 18 and older from the 2020 International Tobacco Control (ITC) Malaysia Wave 1 Survey were analyzed with bivariate and multivariable logistic regression models. Most Malaysian smokers (85.2%) reported having quit intentions. Smoking was completely restricted in 34.8% of the nighttime venues, 85.3% of air-conditioned (AC) food and beverage (F&B) venues (restaurants, food courts, coffee shops), 87.3% of non-AC F&B, and 69.4% of indoor workplaces. Smokers who visited nighttime entertainment venues where smoking was fully restricted were less likely to have quit intentions. There was no significant association found with quit intentions for smokers who visited AC and non-AC F&B venues and indoor workplaces where smoking was fully restricted. All five psychosocial beliefs assessed, age, and education were positively associated with quit intentions. Malaysian smokers are interested in quitting and psychosocial beliefs were positively associated with quit intentions. There is a need for the Malaysian government to implement and reinforce comprehensive smoking restrictions in all public venues and indoor workplaces to protect nonsmokers from SHS exposure and to encourage smokers to think about quitting, which may influence their quit intentions.

Methods of the 2020 (Wave 1) International Tobacco Control (ITC) Malaysia survey.

The ITC Malaysia Project is part of the 31-country ITC Project, of which the central objective is to evaluate the impact of tobacco control policies of the WHO Framework Convention on Tobacco Control (FCTC). This article describes the methods used in the 2020 International Tobacco Control (ITC) Malaysia (MYS1) Survey. Adult smokers and non-smokers aged ≥18 years in Malaysia were recruited by a commercial survey firm from its online panel. Survey weights, accounting for smoking status, sex, age, education, and region of residence, were calibrated to the Malaysian 2019 National Health and Morbidity Survey. The survey questions were identical or functionally similar to those used in other ITC countries. Questions included demographic measures, patterns of use, quit history, intentions to quit, risk perceptions, beliefs and attitudes about cigarettes, e-cigarettes, and heated tobacco products. Questions also assessed measures assessing the impact of tobacco demand-reduction domains of the FCTC: price/tax (Article 6), smoke-free laws (Article 8), health warnings (Article 11), education, communication and public awareness (Article 12), advertising, promotion, and sponsorship restrictions (Article 13), and support for cessation (Article 14). The total sample size was 1253 (1047 cigarette smokers and 206 non-smokers). Response rate was 11.3%, but importantly, the cooperation rate was 95.3%. The 2020 ITC MYS1 Survey findings will provide evidence on current tobacco control policies and evidence needed by Malaysian government regulatory agencies to develop new or strengthen existing tobacco control efforts that could help achieve Malaysia's endgame, i.e. a tobacco-free nation by 2040.

E-cigarette prevalence among Malaysian adults and types and flavors of e-cigarette products used by cigarette smokers who vape: Findings from the 2020 ITC Malaysia Survey.

INTRODUCTION: E-cigarettes (ECs) have become increasingly common in many countries, including Malaysia. The prevalence of EC use increased in Malaysia from 0.8% in 2011 to 4.9% in 2019. Three quarters of Malaysian EC users also smoke combustible cigarettes, and the prevalence of EC use among Malaysian smokers in 2014 was consistent with the prevalence of use among smokers from Canada and the US in 2016. The purpose of this study was to estimate the prevalence of EC use among Malaysian adults aged ≥18 years in 2020 and the types of EC products and flavors used by cigarette smokers who also used ECs at least monthly. METHODS: Data came from 1253 adults aged ≥18 years who participated in the 2020 International Tobacco Control Malaysia Wave 1 Survey. Weighted descriptive statistics were used to estimate the prevalence of adults who reported ever using ECs and the prevalence who used ECs either monthly, weekly, or daily. The types of EC products and flavors used were compared by frequency of EC use among current smokers who used ECs at least monthly (n=459). RESULTS: Overall, 5.4% (95% CI: 3.7-7.5) of Malaysian adults reported using ECs on a daily basis in 2020. Among current cigarette smokers who used ECs daily, 81.0% (95% CI: 72.5-87.7) used nicotine in their ECs, 46.2% (95% CI: 37.8-54.7) used pre-filled ECs, and 60.4% (95% CI: 51.9-68.6) reported being somewhat/very addicted to ECs. The most common EC flavors were fruit, coffee, and menthol/ mint. CONCLUSIONS: Continued surveillance of EC use is necessary to monitor EC use in non-tobacco using populations while longitudinal research is needed to determine the extent to which ECs are, or are not, related to quitting smoking.

Reasons for using e-cigarettes and support for e-cigarette regulations: Findings from the 2020 ITC Malaysia Survey.

INTRODUCTION: Malaysia has the largest e-cigarette (EC) market in Southeast Asia, and it has been estimated that 17% of adult daily cigarette smokers also used ECs on a daily basis in 2020. However, few studies have examined the reasons people use ECs in Malaysia. This cross-sectional study of adult cigarette smokers from Malaysia assessed reasons for EC use and their support for key proposed EC regulations. METHODS: Data are from the 2020 International Tobacco Control (ITC) Malaysia Wave 1 Survey of adult (aged ≥18 years) smokers who reported that they used ECs at least monthly (N=459 out of 1047 smokers). Weighted analyses were conducted on EC users' reasons for using ECs and their support for various EC regulations. RESULTS: Smokers who used ECs at least monthly were more likely to be male, aged 25-39 years, of Malay ethnicity, married, more highly educated, and living in Peninsular Malaysia. Smokers who used ECs daily reported using ECs to reduce the number of cigarettes smoked (91.3%), pleasant taste (90.1%), to quit smoking (87.9%), and enjoyment (87.5%). Smokers who used ECs less than daily reported using ECs for their pleasant taste (weekly 89.4%, monthly 87.5%), curiosity (weekly 79.5%, monthly 88.8%), being offered EC by someone (weekly 76.3%, monthly 81.6%), and to reduce the number of cigarettes smoked (weekly 76.2%, monthly 77.6%). Smokers who also used ECs were most likely to support EC regulations requiring a minimum purchasing age (88.3%) and limiting nicotine concentration (79.6%), and least likely to support regulations banning EC fruit and candy flavors (27.1%). CONCLUSIONS: The most prevalent reasons for using ECs in Malaysia are comparable to those of other ITC countries, including Canada, US, England, and Australia. An understanding of use patterns of ECs, especially their interaction with cigarettes, are important in developing evidence-based regulations in Malaysia.

Who Are More Likely to Have Quit Intentions among Malaysian Adult Smokers? Findings from the 2020 ITC Malaysia Survey.

Increasing quitting among smokers is essential to reduce the population burden of smoking-related diseases. Smokers' intentions to quit smoking are among the strongest predictors of future quit attempts. It is therefore important to understand factors associated with intentions to quit, and this is particularly important in low- and middle-income countries, where there have been few studies on quit intentions. The present study was conducted to identify factors associated with quit intentions among smokers in Malaysia. Data came from the 2020 International Tobacco Control (ITC) Malaysia Survey, a self-administered online survey of 1047 adult (18+) Malaysian smokers. Smokers who reported that they planned to quit smoking in the next month, within the next six months, or sometime beyond six months were classified as having intentions to quit smoking. Factors associated with quit intentions were examined by using multivariable logistic regression. Most smokers (85.2%) intended to quit smoking. Smokers were more likely to have quit intentions if they were of Malay ethnicity vs. other ethnicities (adjusted odds ratio (AOR) = 1.82, 95% confidence interval (CI) = 1.03-3.20), of moderate (AOR = 2.11, 95% CI = 1.12-3.99) or high level of education vs. low level of education (AOR = 1.97, 95% CI = 1.04-3.75), if they had ever tried to quit smoking vs. no quit attempt (AOR = 8.81, 95% CI = 5.09-15.27), if they received advice to quit from a healthcare provider vs. not receiving any quit advice (AOR = 3.78, 95% CI = 1.62-8.83), and if they reported worrying about future health because of smoking (AOR = 3.11, 95% CI = 1.35-7.15 (a little worried/moderately worried vs. not worried); AOR = 7.35, 95% CI = 2.47-21.83 (very worried vs. not worried)). The factors associated with intentions to quit smoking among Malaysian smokers were consistent with those identified in other countries. A better understanding of the factors influencing intentions to quit can strengthen existing cessation programs and guide the development of more effective smoking-cessation programs in Malaysia.

Patterns of Use of Vaping Products Among Smokers: Findings from the 2016-2018 International Tobacco Control (ITC) New Zealand Surveys.

Alternative nicotine products like e-cigarettes could help achieve an end to the epidemic of ill health and death caused by smoking. However, in-depth information about their use is often limited. Our study investigated patterns of use of e-cigarettes and attitudes and beliefs among smokers and ex-smokers in New Zealand (NZ), a country with an 'endgame' goal for smoked tobacco. Data came from smokers and ex-smokers in Waves 1 and 2 of the International Tobacco Control (ITC) NZ Survey (Wave 1 August 2016-April 2017, 1155 participants; Wave 2, June-December 2018, 1020 participants). Trial, current and daily use of e-cigarettes was common: daily use was 7.9% among smokers and 22.6% among ex-smokers in Wave 2, and increased between surveys. Use was commonest among 18-24 years and ex-smokers, but was similar among Maori and non-Maori participants, and by socio-economic status. Most participants used e-cigarettes to help them quit or reduce their smoking. The most common motivating factor for use was cost and the most common barrier to use cited was that e-cigarettes were less satisfying than smoking. The findings could inform developing interventions in order to maximise the contribution of e-cigarettes to achieving an equitable smoke-free Aotearoa, and to minimise any potential adverse impacts.

Identifying factors associated with quit intentions among smokers from two nationally representative samples in Africa: Findings from the ITC Kenya and Zambia Surveys.

It is well established that intentions to quit smoking is the strongest predictor of future quit attempts. However, most studies on quit intentions have been conducted in high-income countries with very few in low- and middle-income countries particularly in Africa. This is the first population-based study to compare factors associated with quit intentions among smokers in two African countries. Data were from the International Tobacco Control (ITC) Kenya and Zambia Surveys (2012), face-to-face surveys of nationally representative samples of 2291 adult smokers (Kenya = 1103; Zambia = 1188). Multivariate logistic regression analyses were conducted to identify predictors of quit intentions. Most Kenyan (65.1%) and Zambian (69.1%) smokers had quit intentions of which 54.8% planned to quit within the next 6 months. Five factors were significantly associated with quit intentions in both countries: being younger, having tried to quit previously, perceiving that quitting is beneficial to health, worrying about future health consequences of smoking, and being low in nicotine dependence. The predictive strength of these factors did not differ in the two countries. Four additional factors were significant predictors in Zambia only: having a quit attempt lasting six months or more, lower smoking enjoyment, having a negative opinion about smoking, and concern about cigarette expenses. The factors predicting quit intentions were similar to those in other ITC countries including Canada, US, UK, China and Mauritius. These findings highlight the need for stronger tobacco control policies in Kenya and Zambia including increased taxation, greater access to cessation services, and anti-smoking campaigns denormalizing tobacco use.

Cigarette price and other factors associated with brand choice and brand loyalty in Zambia: findings from the ITC Zambia Survey.

OBJECTIVES: Little is known about cigarette pricing and brand loyalty in sub-Saharan Africa. This study examines these issues in Zambia, analysing data from the International Tobacco Control (ITC) Zambia Survey. METHODS: Data from Wave 1 of the ITC Zambia Survey (2012) were analysed for current smokers of factory-made (FM) cigarettes compared with those who smoked both FM and roll-your-own (RYO) cigarettes, using multivariate logistic regression models to identify the predictors of brand loyalty and reasons for brand choice. RESULTS: 75% of FM-only smokers and 64% of FM+RYO smokers reported having a regular brand. Compared with FM-only smokers, FM+RYO smokers were, on average, older (28% vs 20% ≥40 years), low income (64% vs 43%) and had lower education (76% vs 44% < secondary). Mean price across FM brands was ZMW0.50 (US$0.08) per stick. Smokers were significantly less likely to be brand loyal (>1 year) if they were aged 15-17 years (vs 40-54 years) and if they had moderate (vs low) income. Brand choice was predicted mostly by friends, taste and brand popularity. Price was more likely to be a reason for brand loyalty among FM+RYO smokers, among ≥55-year-old smokers and among those who reported being more addicted to cigarettes. CONCLUSIONS: These results in Zambia document the high levels of brand loyalty in a market where price variation is fairly small across cigarette brands. Future research is needed on longitudinal trends to evaluate the effect of tobacco control policies in Zambia.

We do not smoke but some of us are more susceptible than others: a multilevel analysis of a sample of Canadian youth in grades 9 to 12.

BACKGROUND: Smoking susceptibility has been found to be a strong predictor of experimental smoking. This paper examined which student- and school-level factors differentiated susceptible never smokers from non-susceptible never smokers among a nationally representative sample of Canadian students in grades 9 to 12. METHODS: Student-level data from the 2008-2009 Canadian Youth Smoking Survey were linked with school-level data from the 2006 Census, and one built environment characteristic (the density of tobacco retailers surrounding schools). These data were examined using multilevel logistic regression analyses. RESULTS: The likelihood of a never smoker being susceptible to smoking significantly varied across schools (p=0.0002). Students in this study were more likely to be susceptible never smokers if they reported low self-esteem, held positive attitudes towards smoking, used alcohol or marijuana, had close friends who smoked, and came from homes without a total ban on smoking. The school location (rural versus urban), the socioeconomic status of the neighbourhood surrounding a school, and the density of tobacco retailers that were located within 1-km radius of each school were not associated with students' smoking susceptibility. CONCLUSION: These findings underscore the continued need to develop school-based tobacco use prevention policies and/or programs that enhance students' self-esteem, address tobacco use misinformation and substance use, and include strategies targeting friends who smoke, and students who come from homes without a total ban on smoking.

Investigating the effectiveness of pictorial health warnings in Mauritius: findings from the ITC Mauritius survey.

INTRODUCTION: Health warnings on tobacco packages are an effective strategy for informing the public about the harms associated with tobacco use. Most studies investigating the effectiveness of pictorial health warnings (PHWs) on cigarette packages are from high-income countries. This study evaluated the impact of PHWs on smokers' perceptions and behavior in Mauritius, the first country in the World Health Organization African region to implement PHWs. METHODS: Data were drawn from 3 waves of a nationally representative cohort of adult smokers from the International Tobacco Control (ITC) Mauritius Survey (n = 668). Wave 1 was conducted in 2009, 6 months prior to the implementation of PHWs. Waves 2 and 3 were conducted 10-12 months and 20-21 months, respectively, postimplementation. Six established indicators of warning effectiveness were used to evaluate the effect of PHWs on smokers' perceptions and behavior. RESULTS: All indicators of warning effectiveness (salience, cognitive, and behavioral reactions) and the Label Impact Index, a weighted combination of 4 indicators, increased significantly between Waves 1 and 2. However, between Waves 2 and 3, there was a significant decline in the proportion of smokers who reported "avoiding looking" at labels. CONCLUSIONS: This study found that implementation of PHWs in Mauritius significantly enhanced the effectiveness of warnings, illustrating their value for other countries, particularly in Africa, at an early stage in tobacco control. The study also demonstrates the importance of revising PHWs to counteract wearout. The introduction of PHWs in Mauritius clearly demonstrates the benefits of employing an evidence-based approach to strengthen tobacco control policies.

Using student and school factors to differentiate adolescent current smokers from experimental smokers in Canada: a multilevel analysis.

OBJECTIVE: In order to understand the factors that differentiate adolescents who have tried smoking from those who have become established smokers, this study examined which student- and school-level factors differentiated current smokers from experimental smokers among a nationally representative sample of Canadian secondary school students. METHOD: Student-level secondary data from the 2008-2009 Canadian Youth Smoking Survey was linked with school-level data from the 2006 Census and one built environment characteristic, and examined using multilevel logistic regression analyses. RESULTS: The current smoking rates varied (P<0.001) across schools. The number of tobacco retailers surrounding the schools was associated with current smoking when adjusting for student characteristics. Additionally, students were more likely to be current smokers if they were: male, in higher grades, believed that smoking can help when they are bored, reported low school connectedness, used marijuana, had a sibling or close friend who smoked, and had no smoking bans at home. CONCLUSIONS: These study findings suggest that school anti-smoking strategies need to target males, increase students' attachment to their school, address tobacco-related beliefs, and include interventions targeting smoking siblings and friends. The government should consider zoning restrictions to limit sales of tobacco products near schools.