Do Australians use the prescription pathway when using nicotine vaping products to quit smoking?

BACKGROUND: In Australia, nicotine vaping products (NVPs) are only legally available to those with a prescription from a doctor. We investigated the proportion of people using NVPs to quit smoking who had a prescription, and whether this increased following regulatory changes in 2021 that strengthened the prescription requirement. METHODS: Australian data from the 2018, 2020 and 2022 International Tobacco Control (ITC) Project Survey were analysed using GEE models with Poisson regressions to analyze differences between years. Data from participants who reported making a quit attempt in the previous two years and reported use of NVPs on their last quit attempt were included (480 observations across 418 individuals). Participants reported whether they had a prescription for NVPs on their last quit attempt. In 2022, they were also asked whether they sourced their prescription from their usual medical practice. RESULTS: Among those using NVPs for a quit attempt, use with a prescription increased significantly from 2020 to 2022 (IRR = 0.35 (0.17-0.73), p = .005) but was still low at 16.5 % (95 % CI 11.4-23.1). In 2022, among the small number who reported getting a prescription for NVPs, 27 % reported getting it from their regular practice; the remainder from a specialist online doctor service. CONCLUSION: There was a modest increase in obtaining a prescription among those who used NVPs for their last quit attempt after regulations were strengthened, however most NVP use for quitting was without a prescription.

A qualitative study of using nicotine products for smoking cessation after discharge from residential drug and alcohol treatment in Australia.

INTRODUCTION: Tobacco smoking is highly prevalent among alcohol and other drugs (AOD) service clients and, despite interest in quitting, abstinence is rarely sustained. Nicotine products may assist after discharge from residential treatment services, but little is known about client receptivity to them. This study examined AOD withdrawal service clients' experiences of two types of nicotine products for smoking cessation post-discharge, combination nicotine replacement therapy (cNRT) and nicotine vaping products (NVP). METHODS: We held semi-structured telephone interviews with 31 Australian AOD service clients in a clinical trial of a 12-week smoking cessation intervention using Quitline support plus cNRT or NVP delivered post-discharge from a smoke-free residential service. We asked about health and social factors, nicotine cravings, Quitline experience, and barriers and facilitators to cNRT or NVP, then thematically analysed data. RESULTS: cNRT and NVP were described by participants as feasible and acceptable for smoking cessation. For most participants, cost limited cNRT access post study, as did difficulty navigating NVP prescription access. Quitline support was valued, but not consistently used, with participants noting low assistance with NVP-facilitated cessation. Participants considered both cessation methods acceptable and socially supported, and sought information on decreasing nicotine use via NVP. DISCUSSION AND CONCLUSIONS: AOD service clients highly valued receiving cNRT or NVP with behavioural support for smoking reduction or abstinence. Both interventions were acceptable to service clients. Findings suggest a potential need to examine both whether NVP use should be permitted in this context, and guidance on the individual suitability of cNRT or NVP.

'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.

Does alcohol consumption elevate smoking relapse risk of people who used to smoke? Differences by duration of smoking abstinence.

BACKGROUND: Past research indicates dual users of tobacco and alcohol find it harder to quit smoking and may be more likely to relapse. This study investigated whether post-quit alcohol use predicted smoking relapse among ex-smokers, and whether this relationship varied by length of smoking abstinence. METHOD: The study included 1064 ex-smokers (18+ years) from Canada (n = 340), US (n = 314), England (n = 261), and Australia (n = 149) who participated in the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping Survey, and we conducted analyses using multivariable logistic regression. We assessed alcohol consumption in 2018 using AUDIT-C and coded as never/low, moderate or heavy level and used alcohol consumption to predict smoking status in 2020. RESULTS: Overall 26 % and 21 % of ex-smokers consumed alcohol at a moderate and heavy level, respectively. Compared to never/low alcohol consumption, risk of smoking relapse among those who consumed alcohol at a moderate level was significantly lower within the first year of abstinence (OR = 0.34, 95 % CI = 0.14-0.81, p = 0.015) but higher thereafter (OR = 2.44, 95 % CI = 1.13-5.23, p = 0.023). The pattern of results was similar for those who consumed alcohol at a heavy level. CONCLUSIONS: Overall, baseline alcohol consumption of ex-smokers did not predict their smoking relapse risk. As expected, risk differed by smoking abstinence duration. However, the pattern was unexpected among the short-term quitters as the subgroup who drank moderately/heavily had lower relapse risk than their counterparts who never drink or at low level, underscoring the need to replicate this unexpected finding.

Future nicotine use preferences of current cigarette smokers: Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey.

INTRODUCTION: Consumer preferences should be important factors that are considered when developing health policies and interventions. This paper examines the prevalence of, and factors associated with, consumer preferences regarding smoking behaviour 1 to 2 years in the future. METHODS: At least weekly cigarette smokers in the 2020 wave of the International Tobacco Control Four Country Smoking and Vaping Survey (USA, Canada, England and Australia) (N = 8642) were asked if they preferred to continue to smoke or to quit with or without an alternative nicotine product (ANP) over the next 1-2 years. RESULTS: Country-specific weighted data showed 21.5% preferred to continue smoking and 8.0% were uncertain, leaving 70.6% preferring to quit: 13.7% using an ANP and 56.9% completely quitting nicotine. Apart from interest in quitting, the main predictors of preferring to quit were history of vaping, being aged 55 and over, smoking weekly, worrying about smoking harms, regretting starting and believing vaping is less harmful relative to smoking. Among those preferring to quit, preferring to use ANPs in future was very strongly associated with current vaping (especially daily), being younger, living in England, reporting strong urges to smoke, believing vaping is much less harmful than smoking, and not strongly regretting starting to smoke, and not wanting to quit. DISCUSSION AND CONCLUSIONS: A significant minority of smokers preferred not to quit, at least in the next year or two. Both interest in quitting and preference for ANPs over complete cessation were associated with similar covariates, including interest in vaping.

Support for nicotine reduction in cigarettes: findings from the 2016 and 2020 ITC Four Country Smoking and Vaping Surveys.

INTRODUCTION: The USA and New Zealand have sought to establish a product standard to set a maximum nicotine level for cigarettes to reduce their addictiveness. This study examined support for very low nicotine cigarettes (VLNCs) in Australia, Canada, England and the USA between 2016 and 2020. METHODS: Repeated cross-sectional data were analysed from participants who currently smoke, formerly smoked or vaped and/or currently vape in the 2016 (n=11 150) and/or 2020 (n=5432) International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. Respondents were asked if they would support a law that reduces the amount of nicotine in cigarettes to make them less addictive. Adjusted and weighted logistic regression analyses estimated the prevalence and predictors of support, such as country, age, sex, education, income, race and smoking/vaping status for VLNCs (support vs oppose/do not know). RESULTS: A majority of respondents supported a VLNC law, with support highest in Canada (69%; 2016 and 2020 combined), followed by England (61%), Australia (60%) and the USA (58%). Overall, support decreased from 62% in 2016 to 59% in 2020 (p=0.004), which did not differ by country. Levels of support differed by smoking/vaping status, where those who exclusively smoked daily showed the lowest level of support (59%) and those who exclusively vaped non-daily had the highest level of support (72%). CONCLUSION: More than half of respondents in all four countries-including those who smoked daily-supported a hypothetical VLNC standard to render cigarettes less addictive. It is important to examine if support is sustained after policies are implemented.

Associations between smokers' knowledge of causes of smoking harm and related beliefs and behaviors: Findings from the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey.

BACKGROUND: Most smokers know that smoking is harmful to health, but less is known about their understanding of what causes the harms. The primary aim was to examine smokers' perceptions of the relative contributions to smoking-related morbidity from combustion products, nicotine, other substances present in unburned tobacco, and additives. A secondary aim was to evaluate the association of these perceptions with nicotine vaping product use intentions, and quitting motivation/intentions. METHODS: Participants were current smokers and recent ex-smokers from Australia, Canada, England and the United States (N = 12,904, including 8511 daily smokers), surveyed in the 2018 International Tobacco Control Four Country Smoking and Vaping Survey. Respondents reported on how much they thought combustion products, nicotine, chemicals in the tobacco and additives in cigarettes contribute to smoking-related morbidity (none/very little; some but less than half; around half; more than half; all or nearly all of it; don't know). RESULTS: Overall, 4% of participants provided estimates for all four component causes that fell within the ranges classified correct, with younger respondents and those from England most likely to be correct. Respondents who rated combustion as clearly more important than nicotine in causing harm (25%) were the least likely to be smoking daily and more likely to have quit and/or to be vaping. Among daily smokers, all four cause estimates were independently related to overall health worry and extent of wanting to quit, but the relative rating of combustion compared to nicotine did not add to prediction. Those who answered 'don't know' to the sources of harm questions and those suggesting very little harm were consistently least interested in quitting. CONCLUSIONS: Most smokers' knowledge of specific causes of harm is currently inadequate and could impact their informed decision-making ability.

Self-reported depression and anxiety and healthcare professional interactions regarding smoking cessation and nicotine vaping: Findings from 2018 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Survey.

INTRODUCTION: People with mental health conditions are disproportionately affected by smoking-related diseases and death. The aim of this study was to assess whether health professional (HP) interactions regarding smoking cessation and nicotine vaping products (NVPs) differ by mental health condition. METHODS: The cross-sectional 2018 International Tobacco Control Four Country (Australia, Canada, England, United States) Smoking and Vaping Survey data included 11040 adults currently smoking or recently quit. Adjusted weighted logistic regressions examined associations between mental health (self-reported current depression and/or anxiety) and visiting a HP in last 18 months; receiving advice to quit smoking; discussing NVPs with a HP; and receiving a recommendation to use NVPs. RESULTS: Overall, 16.1% self-reported depression and anxiety, 7.6% depression only, and 6.6% anxiety only. Compared with respondents with no depression/anxiety, those with depression (84.7%, AOR=2.65; 95% CI: 2.17-3.27), anxiety (82.2%, AOR=2.08; 95% CI: 1.70-2.57), and depression and anxiety (87.6%, AOR=3.74; 95% CI: 3.19-4.40) were more likely to have visited a HP. Among those who had visited a HP, 47.9% received advice to quit smoking, which was more likely among respondents with depression (AOR=1.58; 95% CI: 1.34-1.86), and NVP discussions were more likely among those with depression and anxiety (AOR=1.63; 95% CI: 1.29-2.06). Of the 6.1% who discussed NVPs, 33.5% received a recommendation to use them, with no difference by mental health. CONCLUSIONS: People with anxiety and/or depression who smoke were more likely to visit a HP than those without, but only those with depression were more likely to receive cessation advice, and only those with depression and anxiety were more likely to discuss NVPs. There are missed opportunities for HPs to deliver cessation advice. NVP discussions and receiving a positive recommendation to use them were rare overall.

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.

Individual and Conjoint Factors Associated With Beliefs About the Harmfulness of Nicotine Replacement Therapies Relative to Combustible Cigarettes Among People Who Smoke: Findings From the 2020 ITC Four Country Smoking and Vaping Survey.

INTRODUCTION: This study examined individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies (NRTs) relative to combustible cigarettes (CCs). AIMS AND METHODS: Data analyzed came from 8642 adults (≥18 years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n = 1213), Canada (n = 2633), England (n = 3057), and United States (n = 1739). Respondents were asked: "Compared to smoking cigarettes, how harmful do you think nicotine replacement products are?" Responses were dichotomized into "much less" versus otherwise for analysis using multivariable logistic regression models, complemented by decision-tree analysis to identify conjoint factors. RESULTS: Percentages believing that NRTs are much less harmful than CCs were 29.7% (95% CI = 26.2% to 33.5%) in Australia, 27.4% (95% CI = 25.1% to 29.8%) in England, 26.4% (95% CI = 24.4% to 28.4%) in Canada, and 21.7% (95% CI = 19.2% to 24.3%) in the United States. Across all countries, believing nicotine is not at all/slightly harmful to health (aOR = 1.53-2.27), endorsing nicotine vaping products (NVPs) as less harmful than CCs (much less harmful: aOR = 7.24-14.27; somewhat less harmful: aOR = 1.97-3.23), and possessing higher knowledge of smoking harms (aOR = 1.23-1.88) were individual factors associated with increased odds of believing NRTs are much less harmful than CCs. With some country variations, these nicotine-related measures also interacted with each other and sociodemographic variables to serve as conjoint factors associated with the likelihood of accurate NRT relative harm belief. CONCLUSIONS: Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors. IMPLICATIONS: This study demonstrates that despite past efforts to educate people who smoke about the harms of NRTs relative to CCs, misperceptions around the relative harmfulness of NRTs remain substantial. In all four studied countries, subgroups of people who smoke regularly who are misinformed about the relative harmfulness of NRTs, and who may be reluctant to use NRTs for smoking cessation can be reliably identified for corrective interventions based on their understanding of the harms related to nicotine, NVPs and smoking along with sociodemographic markers. The identified subgroup information can be used to prioritize and inform the development of effective interventions to specifically address the gaps in knowledge and understanding of the various subgroups identified. Our results suggest these may need to be tailored for each country.

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.

A critique of the Australian National Health and Medical Research Council CEO statement on electronic cigarettes.

This paper critically analyses a statement by Australia's National Health and Medical Research Council (NHMRC) on e-cigarettes in May 2022 that will be used to guide national policy. We reviewed the evidence and the conclusions drawn in the NHMRC Statement. In our view, the Statement is not a balanced reflection of the benefits and risks of vaping because it exaggerates the risks of vaping and fails to compare them to the far greater risks of smoking; it uncritically accepts evidence of harms from e-cigarettes while adopting a highly sceptical attitude towards evidence of their benefits; it incorrectly claims that the association between adolescent vaping and subsequent smoking is causal; and it understates the evidence of the benefits of e-cigarettes in assisting smokers to quit. The Statement dismisses the evidence that vaping is probably already having a positive net public health effect and misapplies the precautionary principle. Several sources of evidence supporting our assessment were published after the NHMRC Statement's publication and are also referenced. The NHMRC Statement on e-cigarettes does not present a balanced assessment of the available scientific literature and fails to meet the standard expected of a leading national scientific body.

Perceived Health and Capacity to Cope With Stress in Recent Ex-smokers: Impact of Vaping Versus Quitting All Nicotine.

INTRODUCTION: Little is known about the continued use of nicotine following smoking cessation on perceived well-being in comparison to complete cessation of nicotine use. AIMS AND METHODS: To explore aspects of perceived well-being and coping among recent ex-smokers as a function of vaping status. Ever-daily smokers in the International Tobacco Control 4 country smoking and vaping surveys in 2016 (w1 N = 883) and 2018 (w2 N = 1088). Cross-sectional associations and longitudinal samples for those who quit between waves and those who quit at w1 and maintained abstinence to w2. Main outcome measures were: Past 30 days of depression symptoms, perceived stress, stress management since quitting, and change in perceived day-to-day health. RESULTS: In the cross-sectional analyses vapers were more likely to report both improved stress management (aOR = 1.71, 95% CI 1.23-2.36) and perceived day-to-day health (aOR = 1.65, 95% CI 1.26-2.16) than nicotine abstainers. In the longitudinal analyses, smokers who switched to vaping between waves (n = 372) were more likely to report depression symptoms at w2 (aOR = 2.00, 95% CI 1.09-3.65) but reported improved perceived health (aOR = 1.92, 95% CI 1.16-3.20). For the past daily smokers who remained quit between waves (n = 382), vapers were more likely to report improved stress management relative to abstainers (RRR = 5.05. 95% CI 1.19-21.40). There were no other significant differences between vapers and nicotine abstainers. CONCLUSIONS: There is little evidence to support the view that perceptions of well-being deteriorate in vapers compared to complete nicotine abstainers in the immediate years after smoking cessation. IMPLICATIONS: This study could find no conclusive evidence that the continued use of nicotine via e-cigarettes was detrimental to health compared to completely stopping nicotine intake altogether. Our results would suggest that continuing to use nicotine may even result in some benefits in the short term such as improved stress management, however further longitudinal studies are required to examine if these effects are restricted to the early post-quitting phase and whether other positive or negative effects on psychosocial health emerge in the future.

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.

Characterisation of vaping liquids used in vaping devices across four countries: results from an analysis of selected vaping liquids reported by users in the 2016 ITC Four Country Smoking and Vaping Survey.

OBJECTIVES: This study presents an analysis of vaping products (VPs) purchased in the USA, Canada, England and Australia and assesses whether differences in regulations were associated with differences in the chemical composition of the VPs. METHODS: April-September 2017, a total of 234 VP refill liquids and prefilled cartridges were purchased in convenience samples of retail locations in each country. Products were chosen from brands and styles most commonly reported by current VP users in the 2016 ITC Four Country Smoking and Vaping Survey. All products were tested for nicotine, tobacco-specific nitrosamines (TSNAs), minor tobacco alkaloids, organic acids and flavouring chemicals. RESULTS: Consistent with the laws in Canada and Australia at the time of product purchase, nicotine was not detected in any of the VPs (n=10 in Canada; n=15 in Australia). US liquids (n=54) had a mean nicotine concentration of 16.2 mg/mL, (range=0.0-58.6) and English liquids (n=166) had a mean concentration of 11.9 mg/mL ((range=0.0-31.2) F(3244)=12.32, p<0.001). About 5% of English samples exceeded the UK's 20 mg/mL nicotine limit. Substantial country differences were observed in levels ofTSNAs, with the USA being higher than elsewhere. Of all products tested, 18.8% contained at least one organic acid. Liquids purchased in England contained far more identifiable flavouring chemicals than those in the other countries. CONCLUSIONS: VP composition, particularly with respect to nicotine and flavouring, varies by country, likely reflecting both marketplace preferences and country-specific regulations. There are differences between nicotine levels claimed on the package and actual levels, particularly in England.

Do Social Norms for Cigarette Smoking and Nicotine Vaping Product Use Predict Trying Nicotine Vaping Products and Attempts to Quit Cigarette Smoking Amongst Adult Smokers? Findings From the 2016-2020 International Tobacco Control Four Country Smoking and Vaping Surveys.

INTRODUCTION: To examine whether perceived injunctive and descriptive social norms towards cigarette and nicotine vaping product (NVP) use predicted subsequent trying NVPs and attempts to quit cigarette smoking amongst current smokers and whether associations varied across countries. AIMS AND METHODS: Three waves of longitudinal cohort data from the International Tobacco Control Four Country Smoking and Vaping Survey were collected between 2016 and 2020 from 2290 adult smokers in Canada, Australia, England, and the United States who had never used NVPs at baseline (either wave 1 or wave 2) and followed up at the subsequent wave (wave 2 or wave 3, respectively) were analyzed using Generalized Estimating Equations. RESULTS: Of the injunctive and descriptive norm measures for smoking and NVP use, NVP initiation was only independently predicted by the injunctive interpersonal norm for NVP use, with perceived approval of NVP use by important others predicting higher odds of trying NVPs (AOR = 1.65, 95% CI = 1.20 to 2.27). This predictive effect was independent of baseline quit intention with no country variations found. By contrast, making cigarette smoking quit attempts were independently predicted by both injunctive and descriptive interpersonal norms with perceived disapproval of smoking by important others (AOR = 1.65, 95% CI = 1.38 to 1.99) and close friends using NVPs (AOR = 1.37, 95% CI = 1.04 to 1.79), both associated with higher odds of smoking quit attempts. CONCLUSIONS: Adult smokers who perceive NVP use as normative, either because such behavior is socially approved or common within their close social networks, appear more inclined to try NVPs or make smoking quit attempts than smokers who do not. IMPLICATIONS: Social norms can shape a person's behavior and result in behavior change. This study shows that initiation of NVP use behavior among smokers can be reliably predicted by their perception of whether NVP use is acceptable to those important to them within their close social networks. Similarly, any attempts to stop cigarette smoking can be predicted by their perception of how acceptable cigarette smoking is among those who are important to them and whether any of their close friends use NVPs. Changing social norms towards cigarette smoking and NVP use could therefore be incorporated into smoking cessation interventions to help smokers to quit and/or switch to NVP use.

Non-cigarette combustible tobacco use and its associations with subsequent cessation of smoking among daily cigarette smokers: findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2016-20).

AIMS: To examine whether polyuse of cigarettes and other smoked products (polysmoking) is predictive of quit attempts and quit success. DESIGN: A prospective multi-country cohort design. SETTING: Australia, Canada, England and the United States. PARTICIPANTS: A total of 3983 adult daily cigarette smokers were surveyed in 2016 (wave 1 of data collection) and were re-contacted in 2018 (wave 2) (i.e. waves 1-2 cohort) in the International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) surveys; and 3736 smokers were surveyed in 2018 and re-contacted in 2020 (wave 3) (i.e. waves 2-3 cohort). MEASUREMENTS: Participants were asked about their cigarette smoking and use of cigars, cigarillos, pipes and waterpipes. Outcomes were quit attempts between two survey waves and success, defined as having quit smoking all the combustible tobacco at the subsequent survey for 1 month or more. FINDINGS: Levels of polysmoking were 12.7% in the waves 1-2 cohort and 10.5% for the waves 2-3 cohort. Compared with cigarette-only smokers, polysmokers were more likely to attempt to quit between waves 1 and 2 [54.9 versus 42.7%, adjusted odds ratio (aOR) = 1.37, 95% confidence interval (CI) = 1.08-1.74, P < 0.01], but not between waves 2 and 3 (43.8 versus 40.1%, aOR = 0.94, 95% CI = 0.72-1.22). Polysmoking predicted reduced likelihood of success in both cohorts among attempters and the overall samples. Between waves 2 and 3 there were significantly more transitions to non-daily smoking among the polysmokers (12.4 versus 5.3%, χ2 = 40.4, P < 0.001). CONCLUSIONS: There is a consistent association between polysmoking (use of cigarettes together with other smoked products) and reduced quit success for combustible tobacco, but it is probably due to increased likelihood of transitioning to non-daily use rather than complete cessation.

The Australia Smoking and Vaping Model: The Potential Impact of Increasing Access to Nicotine Vaping Products.

BACKGROUND: We model the potential impact of relaxing current nicotine vaping product (NVP) restrictions on public health in Australia. AIMS AND METHODS: A Restricted NVP Scenario was first developed to project current smoking and vaping rates, where a U.S. smoking model was calibrated to recent Australian trends. To model less restrictive NVP policies, a Permissive NVP Scenario applied rates of switching from smoking to vaping, initiation into NVP and cigarette use, and cessation from smoking and vaping based on U.S. trends. The model measures vaping risk relative to the excess mortality rate of smoking. The public health impacts are measured as the difference between smoking- and vaping-attributable deaths (SVADs) and life years lost (LYLs) in the Restricted and Permissive NVP Scenarios. Sensitivity analysis is conducted regarding the NVP excess risk and other factors. RESULTS: Assuming an NVP excess risk of 5% that of smoking, 104.2 thousand SVADs (7.7% reduction) and 2.05 million LYLs (17.3% reduction) are averted during 2017-2080 in the Permissive NVP Scenario compared to the Restricted NVP Scenario. Assuming 40% NVP excess risk, 70 thousand SVADs and 1.2 million LYLs are averted. The impact is sensitive to the rate at which smokers switch to NVPs and quit smoking, and relatively insensitive to the smoking initiation and NVP initiation and cessation rates. CONCLUSIONS: The model suggests the potential for public health gains to be achieved by relaxing NVP access regulations. However, the model would benefit from better information regarding the impact of NVPs on smoking under a relaxation of current restrictions. IMPLICATIONS: Australia has implemented a strong array of cigarette-oriented policies, but has restricted access to NVPs. The Smoking and Vaping Model offers a framework for modeling hypothetical policy scenarios. The Australian model shows the potential for public health gains by maintaining cigarette-oriented policies while relaxing the current restrictive NVP policy. Modeling results under a permissive NVP policy are particularly sensitive to the estimated rates of smoking cessation and switching to vaping, which are not well established and will likely depend on past and future cigarette-oriented policies and the specific NVP policies implemented in Australia.