Factors associated with quit attempts and smoking cessation in Brazil: findings from the International Tobacco Control Brazil Survey.

OBJECTIVES: This study aimed to identify factors associated with attempting to quit and successful smoking cessation in a population-based sample of Brazilian smokers. STUDY DESIGN: This is a prospective cohort study. METHODS: Data came from the first two waves of the International Tobacco Control Brazil Survey, conducted in 2009 and 2012/2013 in three cities: Rio de Janeiro, São Paulo, and Porto Alegre. Data were collected from 488 adults (aged ≥18 years) who smoked at Wave 1 and who were resurveyed at Wave 2. Crude and adjusted relative risks for two outcomes (making a quit attempt between Wave 1 and Wave 2 and successfully quitting by Wave 2) were estimated. Multivariable multilevel logistic regression models were used, whereby variables were added to the models in a series of blocks. RESULTS: Nearly two-thirds (65.6%) of smokers attempted to quit between waves, and 23.4% had quit at Wave 2. Intention to quit smoking at Wave 1 was the only variable associated with attempt to quit by Wave 2 (odds ratio [OR] = 2.85; 95% confidence interval [CI] 1.64-4.94; P < 0.001). Smokers of higher socio-economic status (OR high versus low = 1.80; 95% CI 1.05-3.10; P = 0.03) and lower nicotine dependence (OR low Heaviness of Smoking Index [HSI] versus high HSI = 1.94; 95% CI 1.10-3.43; P = 0.02) were more likely to successfully quit. The presence of another adult smoker at home was negatively related to successful quitting (OR = 0.50; 95% CI 0.26-0.94; P = 0.03). CONCLUSIONS: These results are generally consistent with prior research and have potential to inform governmental interventions to promote tobacco cessation, particularly among disadvantaged groups.

Reported exposure to E-cigarette advertising and promotion in different regulatory environments: Findings from the International Tobacco Control Four Country (ITC-4C) Survey.

Electronic cigarette (e-cigarette) advertising regulations differ across countries. This study examines how differences in e-cigarette advertising regulations influence exposure to e-cigarette advertising, and perceptions about what participants had seen and read about e-cigarettes. Data come from the ITC Four Country Survey (Canada [CA], United States [US], Australia [AU] and United Kingdom [UK]) carried out between August 2013 and March 2015 (n = 3460). In 2014, AU and CA had laws prohibiting the retail sale of e-cigarettes containing nicotine while the US and UK had no restrictions, although a voluntary agreement restricting advertising in the UK was introduced during fieldwork. Smokers and ex-smokers were asked whether in the last six months they had noticed e-cigarettes advertisements and received free samples/special offers (promotion), and about their perceptions (positive or otherwise) of what they had seen or read about e-cigarettes. Data were analyzed in 2017. US and UK participants were more likely to report that they had noticed e-cigarette advertisements and received promotions compared to CA or AU participants. For TV and radio advertisements, reported exposure was higher in US compared to UK. For all types of advertisements, reported exposure was higher in CA than AU. Overall, nearly half of AU (44.0%) and UK (47.8%) participants perceived everything they had seen and read about e-cigarettes to be positive, with no significant differences between AU and UK. Participants in countries with permissive e-cigarette advertising restrictions and less restrictive e-cigarette regulations were more likely to notice advertisements than participants in countries with more restrictive e-cigarette regulations.

A cross-sectional study on levels of secondhand smoke in restaurants and bars in five cities in China.

OBJECTIVES: To assess indoor secondhand smoke (SHS) exposure in restaurants and bars via PM(2.5) level measurements in five cities in China. METHODS: The study was conducted from July to September in 2007 in Beijing, Xi'an, Wuhan, Kunming and Guiyang. PM(2.5) concentrations were measured in 404 restaurants and bars using portable aerosol monitors. The occupant density and the active smoker density were calculated for each venue sampled. RESULTS: Among the 404 surveyed venues, 23 had complete smoking bans, nine had partial smoking bans and 313 (77.5%) had smoking observed during sampling. The geometric mean of indoor PM(2.5) levels in venues with smoking observed was 208 µg/m(3) and 99 µg/m(3) in venues without smoking observed. When outdoor PM(2.5) levels were adjusted, indoor PM(2.5) levels in venues with smoking observed were consistently significantly higher than those in venues without smoking observed (F=80.49, p<0.001). Indoor PM(2.5) levels were positively correlated with outdoor PM(2.5) levels (partial ρ=0.37 p<0.001) and active smoker density (partial ρ=0.34, p<0.001). CONCLUSIONS: Consistent with findings in other countries, PM(2.5) levels in smoking places are significantly higher than those in smoke-free places and are strongly related to the number and density of active smokers. These findings document the high levels of SHS in hospitality venues in China and point to the urgent need for comprehensive smoke-free laws in China to protect the public from SHS hazards, as called for in Article 8 of the Framework Convention on Tobacco Control, which was ratified by China in 2005.

Risk factors associated with smoking behaviour in recreational venues: findings from the International Tobacco Control (ITC) China Survey.

OBJECTIVE: To explore the determinants of smoking behaviour in recreational venues and to provide scientific bases for establishing smoke-free measures applying to these locations. METHODS: The International Tobacco Control (ITC) China Survey--a face-to-face cross-sectional survey of representative adult smokers from six cities (Shenyang, Beijing, Shanghai, Guangzhou, Changsha and Yinchuan)--was conducted between April and August 2006. A total of 4815 smokers were selected using multistage sampling methods, and final analyses were conducted on 2875 smokers who reported patronising recreational venues at least once in the last six months. Multivariate logistic regression models were used to identify factors influencing the smoking behaviour within recreational settings. Outcome measure Whether a smoker reported smoking in recreational venues during the last 6 months. RESULTS: 84% subjects reported smoking in recreational venues. Analyses showed that smoke-free laws had been exempted, 32.0% of the patrons reporting bans on smoking in these locations. The following factors were significant predictors of smoking in recreational venues: absence of bans on smoking, support for non-bans, being aged 18-24 years, positive smoking-related attitudes, low number of health effects reported and not living in Beijing. CONCLUSIONS: The findings point to the importance of informing Chinese smokers about the active smoking and passive smoking harmfulness in both building support for smoke-free laws and in reducing smokers' desire to smoke within recreational venues. They also point to the importance of good enforcement of smoke-free laws when implemented. Such strategies could also serve to de-normalise smoking in China, a key strategy for reducing smoking in general.

Support for smoke-free policies among smokers and non-smokers in six cities in China: ITC China Survey.

OBJECTIVE: To examine levels of support for comprehensive smoke-free policies in six large Chinese cities. METHODS: Data from Wave 1 of the International Tobacco Control (ITC) China Survey (April-August 2006) were analysed. The ITC China Survey employed a multistage sampling design in Beijing, Shenyang, Shanghai, Changsha, Guangzhou and Yinchuan (none of which has comprehensive smoke-free policies in place). Face-to-face interviews were conducted with 4815 smokers and 1270 non-smokers. Multivariate logistic regression models were used to identify factors associated with support for comprehensive smoke-free policies. RESULTS: About one in two Chinese urban smokers and four in five non-smokers believed that secondhand smoke (SHS) causes lung cancer. The majority of respondents supported comprehensive smoke-free policies in hospitals, schools and public transport vehicles while support for smoke-free workplaces, restaurants and bars was lower. Levels of support were generally comparable between smokers and non-smokers. Support for comprehensive smoke-free policies was positively associated with knowledge about the harm of SHS. Respondents who worked in a smoke-free worksite or who frequented smoke-free indoor entertainment places were more likely to support comprehensive smoking restriction in bars and restaurants. CONCLUSION: Considerable support for smoke-free policies exists in these six large cities in China. Greater public education about the dangers of SHS may further increase support. Experiencing the benefits of smoke-free indoor entertainment places and/or workplaces increases support for these policies and suggests that some initial smoke-free policy implementation may hasten the diffusion of these public health policies.

Beliefs about the relative harm of "light" and "low tar" cigarettes: findings from the International Tobacco Control (ITC) China Survey.

BACKGROUND: Many smokers in Western countries perceive "light" or "low tar" cigarettes as less harmful and less addictive than "regular" or "full flavoured" cigarettes. However, there is little research on whether similar perceptions exist among smokers in low and middle incomes, including China. OBJECTIVE: To characterise beliefs about "light" and "low tar" cigarettes among adult urban smokers in China. METHODS: We analysed data from Wave 1 of the ITC China Survey, a face-to-face household survey of 4732 adult Chinese smokers randomly selected from six cities in China in 2006. Households were sampled using a stratified multistage design. FINDINGS: Half (50.0%) of smokers in our sample reported having ever tried a cigarette described as "light," "mild" or "low tar". The majority of smokers in our sample (71%) believed that "light" and/or "low tar" cigarettes are less harmful compared to "full flavoured" cigarettes. By far the strongest predictor of the belief that "light" and/or "low tar" cigarettes are less harmful was the belief that "light" and/or "low tar" cigarettes feel smoother on the respiratory system (p<0.001, OR=53.87, 95% CI 41.28 to 70.31). CONCLUSION: Misperceptions about "light" and/or "low tar" cigarettes were strongly related to the belief that these cigarettes are smoother on the respiratory system. Future tobacco control policies should go beyond eliminating labelling and marketing that promotes "light" and "low tar" cigarettes by regulation of product characteristics (for example, additives, filter vents) that reinforce perceptions that "light" and "low tar" cigarettes are smoother on the respiratory system and therefore less harmful.

A cross-sectional study on levels of second-hand smoke in restaurants and bars in five cities in China.

OBJECTIVES: To assess indoor second-hand smoke (SHS) exposure in restaurants and bars via PM(2.5) (fine particles 2.5 µm in diameter and smaller) level measurements in five cities in China. METHODS: The study was conducted from July to September in 2007 in Beijing, Xi'an, Wuhan, Kunming and Guiyang. Portable aerosol monitors were used to measure PM(2.5) concentrations in 404 restaurants and bars. The occupant density and the active smoker density were calculated for each venue sampled. RESULTS: Among the 404 surveyed venues, 23 had complete smoking bans, 9 had partial smoking bans and 313 (77.5%) were observed to have allowed smoking during sampling. The geometric mean of indoor PM(2.5) levels in venues with smoking observed was 208 µg/m(3) and 99 µg/m(3) in venues without observed smoking. When outdoor PM(2.5) levels were adjusted, indoor PM(2.5) levels in venues with smoking observed were consistently significantly higher than in venues without smoking observed (F=80.49, p<0.001). Indoor PM(2.5) levels were positively correlated with outdoor PM(2.5) levels (partial rho=0.37 p<0.001) and active smoker density (partial rho=0.34, p<0.001). CONCLUSIONS: Consistent with findings in other countries, PM(2.5) levels in smoking places are significantly higher than those in smoke-free places and are strongly related to the number and density of active smokers. These findings document the high levels of SHS in hospitality venues in China and point to the urgent need for comprehensive smoke-free laws in China to protect the public from SHS hazards, as called for in Article 8 of the Framework Convention on Tobacco Control, which was ratified by China in 2005.

Teaching reasoning.

Twentieth-century psychologists have been pessimistic about teaching reasoning, prevailing opinion suggesting that people may possess only domain-specific rules, rather than abstract rules; this would mean that training a rule in one domain would not produce generalization to other domains. Alternatively, it was thought that people might possess abstract rules (such as logical ones) but that these are induced developmentally through self-discovery methods and cannot be trained. Research suggests a much more optimistic view: even brief formal training in inferential rules may enhance their use for reasoning about everyday life events. Previous theorists may have been mistaken about trainability, in part because they misidentified the kind of rules that people use naturally.

Does the availability of single cigarettes promote or inhibit cigarette consumption? Perceptions, prevalence and correlates of single cigarette use among adult Mexican smokers.

BACKGROUND: Single cigarette use and its implications have rarely been studied among adults. OBJECTIVE: To assess perceptions, prevalence and correlates of single cigarette purchase behaviour and its relation to harm reduction. DESIGN: Focus group transcripts and cross-sectional data were analysed. SETTING AND PARTICIPANTS: Focus groups among convenience samples of adult smokers in two Mexican cities and a population-based sample of 1079 adult smokers from the International Tobacco Control Policy Evaluation Project in four Mexican cities. MAIN OUTCOME MEASURES: Purchase of single cigarettes last time cigarettes were bought, frequency of purchasing single cigarettes in the previous month and intention to quit in the next 6 months. RESULTS: Focus group data indicated that smokers bought single cigarettes as a harm reduction strategy. Survey data indicated that 38% of participants purchased single cigarettes in the last month and 10% purchased them the last time they bought cigarettes, with more frequent consumption among young adults and those with lower income. Purchasing single cigarettes was independently associated with the frequency of using single cigarettes to reduce consumption and, less consistently, with the frequency of being cued to smoke after seeing single cigarettes for sale. Using single cigarettes to reduce consumption was positively associated with quit intention, whereas being cued to smoke by single cigarettes was negatively associated with quit intention. CONCLUSIONS: Study results suggest that some adult Mexican smokers purchase single cigarettes as a method to limit, cut down on and even quit smoking. Nevertheless, promotion of the availability of single cigarettes as a harm reduction strategy could provide additional smoking cues that undermine quit attempts and promote youth smoking.

Reported awareness of tobacco advertising and promotion in China compared to Thailand, Australia and the USA.

BACKGROUND: China currently does not have comprehensive laws or regulations on tobacco advertising and promotion, although it ratified the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in October 2005 and promised to ban all tobacco advertising by January 2011. Much effort is needed to monitor the current situation of tobacco advertising and promotion in China. OBJECTIVE: This study aims to examine levels of awareness of tobacco advertising and promotion among smokers in China as compared to other countries with different levels of restrictions. METHODS: One developing country (Thailand) and two developed countries (Australia and the USA) were selected for comparison. All four countries are part of the International Tobacco Control (ITC) Policy Evaluation Survey project. Between 2005 and 2006, parallel ITC surveys were conducted among adult smokers (at least smoked weekly) in China (n = 4763), Thailand (n = 2000), Australia (n = 1767) and the USA (n = 1780). Unprompted and prompted recall of noticing tobacco advertising and promotion were measured. RESULTS: Chinese respondents reported noticing tobacco advertisements in a range of channels and venues, with highest exposure levels on television (34.5%), billboards (33.4%) and in stores (29.2%). A quarter of respondents noticed tobacco sponsorships, and a high level of awareness of promotion was reported. Cross-country comparison reveals that overall reported awareness was significantly higher in China than in Thailand (particularly) and Australia, but lower than in the USA. CONCLUSIONS: There is a big gap between China and the better-performing countries such as Thailand and Australia regarding tobacco promotion restrictions. China needs to do more, including enhanced policy and more robust enforcement.

Impact of graphic and text warnings on cigarette packs: findings from four countries over five years.

OBJECTIVES: To examine the impact of health warnings on smokers by comparing the short-term impact of new graphic (2006) Australian warnings with: (i) earlier (2003) United Kingdom larger text-based warnings; (ii) and Canadian graphic warnings (late 2000); and also to extend our understanding of warning wear-out. METHODS: The International Tobacco Control Policy Evaluation Survey (ITC Project) follows prospective cohorts (with replenishment) of adult smokers annually (five waves: 2002-2006), in Canada, United States, UK and Australia (around 2000 per country per wave; total n = 17 773). Measures were of pack warning salience (reading and noticing); cognitive responses (thoughts of harm and quitting); and two behavioural responses: forgoing cigarettes and avoiding the warnings. RESULTS: All four indicators of impact increased markedly among Australian smokers following the introduction of graphic warnings. Controlling for date of introduction, they stimulated more cognitive responses than the UK (text-only) changes, and were avoided more, did not significantly increase forgoing cigarettes, but were read and noticed less. The findings also extend previous work showing partial wear-out of both graphic and text-only warnings, but the Canadian warnings have more sustained effects than UK ones. CONCLUSIONS: Australia's new health warnings increased reactions that are prospectively predictive of cessation activity. Warning size increases warning effectiveness and graphic warnings may be superior to text-based warnings. While there is partial wear-out in the initial impact associated with all warnings, stronger warnings tend to sustain their effects for longer. These findings support arguments for governments to exceed minimum FCTC requirements on warnings.

Levels and correlates of awareness of tobacco promotional activities among adult smokers in Malaysia and Thailand: findings from the International Tobacco Control Southeast Asia (ITC-SEA) Survey.

AIM: To examine the impact of tobacco advertising policy on adult smokers' awareness of tobacco promotion in two developing countries--Malaysia and Thailand. METHODS: Data from 2004 Malaysian and 2000 Thai adult smokers who participated in the baseline wave of the International Tobacco Control Southeast Asia survey (ITC-SEA). Respondents were asked in a face-to-face interview conducted between January and March 2005 to indicate their levels of awareness of tobacco advertising and promotional activities in the last six months. RESULTS: Unprompted awareness of any tobacco marketing activities was very low in Thailand (20%) but significantly higher in Malaysia (53%; OR = 5.6, 95% CI: 3.5 to 8.9, p<0.001). When prompted about specific locations, Thai adult smokers reported very low recall of tobacco advertising where it was banned, being highest around point of sale, particularly street vendors (7.5%). In contrast, Malaysian adult smokers reported significantly higher levels of awareness of tobacco advertising in all locations (range = 17.7% noticing in disco lounges to 59.3% on posters) including where they are notionally banned (for example, billboards). CONCLUSIONS: These findings demonstrate that comprehensive tobacco advertising legislation when well implemented can lead to dramatic decline in awareness of tobacco promotion, thus supporting strong implementation of Article 13 of the Framework Convention on Tobacco Control.

What happened to smokers' beliefs about light cigarettes when "light/mild" brand descriptors were banned in the UK? Findings from the International Tobacco Control (ITC) Four Country Survey.

AIM: This paper examines how beliefs of smokers in the UK were affected by the removal of "light" and "mild" brand descriptors, which came into effect on 30 September 2003 for Member States of the European Union (EU). PARTICIPANTS: The data come from the first four waves (2002-2005) of the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey, an annual cohort telephone survey of adult smokers in Canada, USA, UK and Australia (15 450 individual cases). DESIGN: The UK ban on misleading descriptors occurred around the second wave of data collection in the ITC survey, permitting us to compare beliefs about light cigarettes among adult smokers in the UK before and after the ban, with beliefs in the three other ITC countries unaffected by the ban. RESULTS: There was a substantial decline in reported beliefs about the benefits of light cigarettes in the UK following the policy change and an associated public information campaign, but by 2005 (ie, wave 4), these beliefs rebounded slightly and the change in beliefs was no greater than in the USA, where there was no policy change. CONCLUSIONS: The findings reveal that high levels of misperceptions about light cigarettes existed among smokers in all four countries before and after the EU ban took effect. We cannot conclude that the policy of removing some aspects of misleading labels has been effective in changing beliefs about light cigarettes. Efforts to correct decades of consumer misperceptions about light cigarettes must extend beyond simply removing "light" and "mild" brand descriptors.

A longitudinal study into the reciprocal effects of identities and smoking behaviour: Findings from the ITC Netherlands Survey.

OBJECTIVE: Although it has been found that identity constructs related to smoking are associated with changes in smoking behaviour, the direction of causal associations is as yet unclear. This study aims to clarify the nature and direction of these associations. METHODS: In this longitudinal study we examined the reciprocal relations between identity constructs (i.e., smoker self-identity, quitter self-identity and smoker group-identity), intention to quit and smoking and quitting behaviour among a sample of 1036 smokers and ex-smokers, using cross-lagged structural equation modelling. Moreover, we tested whether these relations differed by socio-economic status (SES). RESULTS: Identity and smoking behaviour were reciprocally related in that in intention to quit and smoking behaviour consistently predicted identity change, and identity predicted (changes in) intentions to quit and smoking behaviour. Behaviour appears more important for identity change than identity for behaviour change. Furthermore, quitter self-identity appears more important than smoker self- and group-identity. Relationships did not differ significantly between SES-groups. The findings were replicated using a cross-validation sample. CONCLUSION: Results imply that changing smoking behaviour may be a vehicle to change smoking-related identity. Moreover, strengthening identification with quitting is more crucial for quit success than decreasing smoker identities. The finding that behaviour may be more important for identity than vice versa, if replicated, may call for additions to identity theories.

Building the evidence base for effective tobacco control policies: the International Tobacco Control Policy Evaluation Project (the ITC Project).

The Framework Convention on Tobacco Control (FCTC) is a seminal event in tobacco control and in global health. Scientific evidence guided the creation of the FCTC, and as the treaty moves into its implementation phase, scientific evidence can be used to guide the formulation of evidence-based tobacco control policies. The International Tobacco Control Policy Evaluation Project (ITC Project) is a transdisciplinary international collaboration of tobacco control researchers who have created research studies to evaluate and understand the psychosocial and behavioural impact of FCTC policies as they are implemented in participating ITC countries, which together are inhabited by over 45% of the world's smokers. This introduction to the ITC Project supplement of Tobacco Control presents a brief outline of the ITC Project, including a summary of key findings to date. The overall conceptual model and methodology of the ITC Project--involving representative national cohort surveys created from a common conceptual model, with common methods and measures across countries--may hold promise as a useful paradigm in efforts to evaluate and understand the impact of population-based interventions in other important domains of health, such as obesity.

Socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: results from the 2002 International Tobacco Control (ITC) Four Country Survey.

BACKGROUND: Socioeconomic status is strongly associated with smoking prevalence and social class differences contribute substantially to social inequalities in mortality. This research investigated socioeconomic and country variations in smokers' knowledge that smoking causes heart disease, stroke, impotence and lung cancer, that smoke contains cyanide, mercury, arsenic and carbon monoxide, and whether nicotine causes most of the cancer. METHODS: Data were from the International Tobacco Control (ITC) Four Country Survey, a cohort survey of over 9000 adult smokers from four countries: the United States, Canada, the United Kingdom, and Australia. Data were collected via telephone interviews in 2002. RESULTS: Higher education and income were associated with higher awareness. For example, the odds of knowing that smoking causes heart disease, stroke and lung cancer were respectively 71%, 34% and 83% larger for respondents with high versus low income. The odds of knowing that smoke contains cyanide, mercury, arsenic and carbon monoxide were respectively 66%, 26%, 44% and 108% larger for respondents with a university degree than those with a high school diploma or lower level of education. Results also revealed that awareness of harms of smoking was generally the highest in Canada and the lowest in the UK. CONCLUSIONS: Lower socioeconomic status was associated with lower awareness of the harms of smoking and misunderstanding around nicotine. There is a need to improve knowledge of the dangers of smoking among the disadvantaged segments of the population.

Socioeconomic variations in nicotine dependence, self-efficacy, and intention to quit across four countries: findings from the International Tobacco Control (ITC) Four Country Survey.

OBJECTIVE: To examine the effect of socioeconomic status (SES) on nicotine dependence, self-efficacy, and intention to quit. DESIGN SETTING AND PARTICIPANTS: Data were from the first wave (2002) of the International Tobacco Control (ITC) Four Country Survey (ITC-4), a panel study of over 2000 adult smokers from each of four countries: the United States, Canada, the United Kingdom, and Australia. Data were collected via telephone interviews. MAIN OUTCOME MEASURES: Nicotine dependence, intention to quit, and self-efficacy to quit smoking were the main outcome measures used in this study. RESULTS: Lower levels of education were associated with higher nicotine dependence. The effect of lower income on higher heaviness of smoking index (HIS) scores was significant in Canada, the UK, and Australia. Respondents with low education had 35% larger odds of low self-efficacy than those with high education. Respondents with low education had 40% larger odds of having no intention to quit than those with high education. Respondents with low income had 23% larger odds of having no intention to quit than those with high income. Country was not a moderator of the association of SES with self-efficacy and intention to quit. CONCLUSION: To the extent that lower SES smokers are more addicted, they are likely to need more intensive support if they are to be successful in their attempts to quit. Given their lower incomes, this places a special responsibility on government to provide or subsidise such services. This should include access to the widest possible range of effective pharmacotherapies complemented with evidence based counselling and support.

Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey.

BACKGROUND: Health warnings on cigarette packages are among the most common means of communicating the health risks of smoking. However, few studies have evaluated the impact of package warnings on consumer knowledge about tobacco risks. OBJECTIVE: The aim of the current study was to use nationally representative samples of adult smokers from the United States (USA), the United Kingdom (UK), Canada (CAN), and Australia (AUS) from the International Tobacco Control Four Country Survey (ITC-4) to examine variations in smokers' knowledge about tobacco risks and the impact of package warnings. METHODS: A telephone survey was conducted with 9058 adult smokers from the following countries: USA (n = 2138), UK (n = 2401), CAN (n = 2214) and AUS (n = 2305). Respondents were asked to state whether they believed smoking caused heart disease, stroke, impotence, lung cancer in smokers, and lung cancer in non-smokers. Respondents were also asked whether the following chemicals are found in cigarette smoke: cyanide, arsenic and carbon monoxide. FINDINGS: Smokers in the four countries exhibited significant gaps in their knowledge of the risks of smoking. Smokers who noticed the warnings were significantly more likely to endorse health risks, including lung cancer and heart disease. In each instance where labelling policies differed between countries, smokers living in countries with government mandated warnings reported greater health knowledge. For example, in Canada, where package warnings include information about the risks of impotence, smokers were 2.68 (2.41-2.97) times more likely to agree that smoking causes impotence compared to smokers from the other three countries. CONCLUSION: Smokers are not fully informed about the risks of smoking. Warnings that are graphic, larger, and more comprehensive in content are more effective in communicating the health risks of smoking.

Determinants and consequences of smoke-free homes: findings from the International Tobacco Control (ITC) Four Country Survey.

OBJECTIVE: To report on prevalence, trends and determinants of smoke-free home policies in smokers' homes in different countries and to estimate the effects of these policies on smoking cessation. DESIGN: Two waves of the International Tobacco Control (ITC) Four Country Survey (ITC-4), a cohort survey of smokers conducted by telephone. Wave 1 was conducted in October/December 2002 with broadly representative samples of over 2000 adult (>or= 18 years) cigarette smokers in each of the following four countries: Canada, the United States, the United Kingdom, and Australia, 75% of whom were followed up at Wave 2 on average seven months later. KEY MEASURES: Levels of smoking restrictions in homes (both waves). RESULTS: Australian smokers were most likely to live in smoke-free homes and UK smokers least likely (34% v 15% at Wave 1). Levels of smoke-free homes increased between waves. Logistic regressions indicated that the main independent predictors of smokers reporting smoke-free homes or implementation of a smoke-free policy between waves included household factors such as having a child, particularly a young child, and having other non-smoking adults in the household. Positive attitudes to smoke-free public places and/or reported presence of smoke-free public places were independent predictors of having or implementing smoke-free homes, supporting a social diffusion model for smoking restrictions. Intentions to quit at Wave 1 and quitting activity between survey waves were associated with implementing bans between Waves 1 and 2. Presence of bans at Wave 1 was associated with significantly greater proportions of quit attempts, and success among those who tried at Wave 2. There was no significant interaction between the predictive models and country. CONCLUSIONS: Smoke-free public places seem to stimulate adoption of smoke-free homes, a strategy associated with both increased frequency of quit attempts, and of the success of those attempts.

Effects of the 2003 advertising/promotion ban in the United Kingdom on awareness of tobacco marketing: findings from the International Tobacco Control (ITC) Four Country Survey.

BACKGROUND: In February 2003, a comprehensive ban on tobacco promotion came into effect in the United Kingdom, which prohibited tobacco marketing through print and broadcast media, billboards, the internet, direct mail, product placement, promotions, free gifts, coupons and sponsorships. OBJECTIVE: To investigate the impact of the UK's comprehensive ban on tobacco promotion on adult smokers' awareness of tobacco marketing in the UK relative to Canada, the United States and Australia. DESIGN: A total of 6762 adult smokers participated in two waves of a random digit dialled telephone survey across the four countries. Wave 1 was conducted before the UK ban (October-December 2002) and Wave 2 was conducted after the UK ban (May-September 2003). KEY MEASURES: Awareness of a range of forms of tobacco marketing. RESULTS: Levels of tobacco promotion awareness declined significantly among smokers in the UK after implementation of the advertising ban. Declines in awareness were greater in those channels regulated by the new law and change in awareness of tobacco promotions was much greater in the UK than the other three countries not affected by the ban. At least in the short term, there was no evidence that the law resulted in greater exposure to tobacco promotions in the few media channels not covered by the law. Notwithstanding the apparent success of the UK advertising ban and the controls in other countries, 9-22% of smokers in the four countries still reported noticing things that promoted smoking "often or very often" at Wave 2. CONCLUSIONS: The UK policy to ban tobacco advertising and promotion has significantly reduced exposure to pro-tobacco marketing influences. These findings support the effectiveness of comprehensive bans on advertising and promotion, as included in the Framework Convention on Tobacco Control.