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Introduction Non-combustible nicotine products (NCNPs), such as heated tobacco products (HTPs) and nicotine vaping products (NVPs) have gained a significant nicotine market share in South Korea. This descriptive study examined patterns of regular cigarette and NCNP use among South Korean adults. Methods Data were from the 2020 International Tobacco Control Korea Survey and included 4016 adults (aged ≥19 years) in the Republic of Korea who were regularly (at least weekly) using at least one NCNP (NVP/HTP, n=2117) and/ or smoked cigarettes (n=3763) at the time of the survey. Weighted descriptive estimates were computed to assess respondents’ nicotine product use among all respondents (exclusive, dual, or triple use). Thereafter, we identified sociodemographic characteristics associated with NCNP use (n=2117). Results Among Korean adults who were smoking cigarettes, 83.1% (95% CI: 81.6– 84.6) did so exclusively, and 16.9% (95% CI: 15.4–18.4) smoked cigarettes and used NCNPs. Among those who used HTPs (n=1877), 14.9% (95% CI: 11.5–18.4) did so exclusively, 59.6% used HTPs and smoked cigarettes (95% CI: 55.4–63.1), 4.2% used HTPs and vaped (95% CI: 11.5–18.4), and 21.6 % (95% CI: 18.9–24.2) used all three products. Of adults who used HTPs and smoked cigarettes, 86.6% smoked daily. Among those who vaped (n=865), 13.3% did so exclusively (95% CI: 9.4–17.1), 55.6% (95% CI: 49.6–61.5) vaped and smoked cigarettes, 5.1% (95% CI: 1.7–8.6) used HTPs and vaped, and 26.1% (95% CI: 22.1–30.1) used all three products. Of adults who vaped and smoked cigarettes, 82.4% (95% CI: 77.1–87.7) smoked daily. Conclusions Cigarettes remain the most commonly used nicotine product in South Korea, and among adults using heated tobacco and/or vaping products, the majority were also smoking. Research is urgently needed to assess whether adults who are using an NCNP are doing so to quit, or rather to complement their cigarette smoking.

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. Material and 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.

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.

Objective Since iQOS was introduced in Japan in 2014, the heated tobacco product (HTP) market has expanded in Japan and globally. Tobacco advertising, promotion, and sponsorship (TAPS) restrictions in Japan are self-regulated by the industry, and no forms of TAPS are banned under national law. This study examines awareness of cigarette and HTP marketing, and support for TAPS bans in Japan. Methods Data are from the International Tobacco Control (ITC) Japan Wave 1 (2018) Survey, a web-based survey of adult cigarette smokers, dual users of cigarettes and HTPs, and non-smokers/non-HTP users (n=4,684). Measures included noticing cigarette and HTP advertising in the last 6 months; and support for bans on cigarette and HTP POS displays, cigarette advertising, and price promotions in stores. Weighted logistic regression models examined exposure to cigarette and HTP marketing and support for TAPS bans among HTP users (n=555 dual users and n=207 HTP-only users) and HTP non-users (n=3,306 cigarette smokers and n=616 non-smokers). Results Retail stores were the most common source of cigarette and HTP advertising with higher exposure among HTP users compared to non-users (58% vs. 48% for cigarette advertising; 57% vs. 31% for HTP advertising). At least 1 in 5 HTP users and non-users noticed HTPs and cigarettes advertised on TV, in newspapers/magazines, and on posters/billboards. With a few exceptions, more HTP users noticed HTP advertising than non-users, whereas there were few differences in exposure to cigarette advertising. Non-users had stronger support for TAPS bans than HTP users: POS display bans for HTPs (74% vs. 47%) and cigarettes (65% vs. 49%); bans on cigarette advertising in stores (69% vs. 53%); and price promotions (76% vs. 65%). Conclusions TAPS restrictions are not effective for reducing exposure to HTP and cigarette advertising in Japan. Findings suggest that the public would support a comprehensive TAPS ban.

Background Intentions to quit is the strongest predictor of a future quit attempt. Therefore, identifying factors that are positively or negatively related to quit intentions is important to health care providers and researchers to develop effective smoking session services. Brazil has been a global leader in many tobacco control domains but has recognized the need to strengthen its cessation services. This study examined the factors associated with quit intentions among Brazilian smokers. Methods Data were analyzed from Wave 3 (2016-17) of the International Tobacco Control (ITC) Brazil Survey, a longitudinal cohort survey of representative samples of adult smokers in Rio de Janeiro, São Paulo, and Porto Alegre (N=1,216). Main outcome was having a quit intention. Results Having a quit intention within the next 6 months in Brazil was 49%, the highest of 25 ITC countries. 43% had made quit attempts in the past year. The following variables were positively associated with intentions to quit: being older (55+years; OR=3.07,p=0.04), having low (OR=2.51,p=0.03) or moderate (OR=2.53,p=0.01) income, attempting to quit in the past year (OR=3.20,p< .0001), believing that quitting is beneficial (OR=5.09, p< .0001), worrying about future health consequences of smoking (OR=3.26,p=0.01), and reporting that smoking is not enjoyable (OR=1.98,p=0.001). Gender, education, and nicotine dependence were unrelated to quit intentions. 67% of smokers who had seen a health care professional in the past year reported being given advice to quit. 79% of smokers wanted the government to do more to help smokers quit. Conclusions Quit intentions are high in Brazil, and predictors of intentions are similar to those of many ITC countries (high-income and low-and middle-income countries). The vast majority of Brazilian smokers want the government to do more to help them quit. These findings support the need to strengthen cessation services to meet the growing demand of smokers who want to quit.

Background China's health warnings do not meet the FCTC Article 11 guidelines. They are small (< 35% of the pack) and do not include pictorial images, which research has shown to have greater impact. Four rounds of warnings have been implemented between 1992-2016. This study examines warning impact over 9 years (2006-15), including the third round (April 2012), which increased font size while maintaining overall warning size and replaced the English text with Chinese on the back. Methods Data are from Waves 1-5 (2006-15) of the International Tobacco Control (ITC) China Survey, a cohort survey of 800 adult smokers in each of five cities, adding five rural areas at Wave 5 (2013-15) (total N=8000). GEE logistic regression models tested changes in key indicators of warning impact over time. Results Over 9 years, there has been little change in impact of the Chinese warnings. Indeed, the percentage of smokers who noticed warnings 'often' actually DECREASED from 51% (2006) to 38% (2013-15) ( p < .001), and fewer than one-third of smokers reported cognitions or behaviours related to quitting because of the warnings. The April 2012 revision did not improve any of the warning impact indicators. Warning noticing/salience did not differ between cities and rural areas, but rural smokers were more likely to think 'a lot' about harms of smoking (17% vs 11%, p < .001) and about quitting (14% vs 6%, p < .001) because of the warnings. Conclusions China's text-only warnings continue to be extremely weak. The minor changes in 2012 did not increase warning impact. Global evidence is clear that large pictorial warnings depicting specific harms of cigarettes would greatly enhance warning impact in China, including increasing knowledge and motivation to quit among the 300M Chinese smokers. These benefits would be especially important for the large rural population, where there are fewer other sources of health information.

Background Menthol and other flavorings are appealing to young people. They mask the adverse effects of cigarette smoke, such as throat irritation, and are marketed as less harmful to appeal to health-concerned smokers. In March 2012, Brazil banned all flavors in tobacco products, including menthol, but the ban has not been implemented due to industry legal challenges. This is the first study in Brazil to examine menthol use and beliefs about menthols (particularly harm perceptions). Such research can increase an understanding of menthol use to inform/support regulatory action in Brazil and other countries. Methods Data were from Wave 3 (2016-17) of the International Tobacco Control (ITC) Brazil Survey, a cohort survey of adult smokers and non-smokers in Rio de Janeiro, São Paulo, and Porto Alegre. This study analyzed responses from 1216 smokers on prevalence and predictors of menthol use, beliefs about harmfulness, and support for banning additives. Results In 2016-17, 7.8% of smokers with a regular cigarette brand reported that they smoked menthols (lowest of 10 ITC LMICs). 12.5% of smokers erroneously believed that menthol cigarettes are less harmful than regular cigarettes (lowest of 7 ITC middle-income countries); 33.4% believed menthols are smoother on the throat and chest (lowest of 4 LMICs). 59.6% of smokers support a complete ban on all additives including flavorings (3rd highest among 14 ITC countries). Conclusions These findings support Brazil's effort to ban all additives including menthol: menthol prevalence is comparatively low, erroneous beliefs that menthols are less harmful is low, and support for an additive ban is high. Brazilian media reporting of the risks of additives in the context of the tobacco industry injunction may have raised public awareness of the harms of additives and support for the ban. Also, the 2014 ban on advertising at points of sale may have reduced exposure to marketing of menthols.

Background In 2000, Brazil implemented a comprehensive ban on tobacco advertising (except point-of-sale), promotion, and sponsorship, including sponsorship by tobacco brands of national sporting and arts events, then in 2005 adding international sport events. However, a loophole in the law permits company names for sponsorship. This study examines whether this loophole has been exploited by the industry via Brazilians' awareness of tobacco company sponsorship of sporting and arts events between 2009 and 2016-17. Methods Data were from Waves 1 to 3 (2009, 2012-13, 2016-17) of the International Tobacco Control (ITC) Brazil Survey - a cohort survey of approximately 1200 adult smokers and 600 non-smokers in Rio de Janeiro, São Paulo, and Porto Alegre. At all three waves, respondents were asked whether they had seen or heard about (1) sport or sporting events and/or (2) music, theatre, art or fashion events sponsored by or connected with cigarette companies. At Waves 2 and 3, tobacco company name recognition was tested by asking respondents whether the following are tobacco companies: Souza Cruz, Nestle, and Pirelle. Data were analyzed using GEE logistic regression models. Results Awareness of a sport or sporting event sponsored by a cigarette company decreased between 2009 and 2016-17 among both smokers (from 8.7% to 4.7%; p=0.004) and non-smokers (from 11.8% to 5.7%; p=0.008). Awareness of an arts event sponsored by a tobacco company decreased among smokers (from 6.3% to 1.4%; p< .001), but not significantly among non-smokers (from 6.1% to 3.8%; p=0.235). Over 93% of smokers and non-smokers correctly stated that Souza Cruz is a tobacco company and over 98% correctly stated that Nestle and Pirelle are not. Conclusions Although Brazil has not specifically banned tobacco company sponsorship, public awareness of tobacco company sponsorship has decreased over 7 years, possibly suggesting that the industry has not (yet) taken advantage of the loophole.

Background Research in high-income countries shows that exposure to point-of-sale (POS) product displays encourages youth smoking, promotes impulse purchasing, and undermines quitting, and that there is strong public support for POS advertising bans. Brazil banned tobacco advertising, promotion, and sponsorship (TAPS) in most channels in 2000 and POS advertising in 2014. However, public awareness of tobacco promotion remains high in Brazil compared to other countries, and POS product displays are still permitted.This study evaluated the impact of the 2014 Brazil POS advertising ban, and assessed public support for complete bans on in-store advertising and POS displays. Methods Data were from Waves 1-3 of the ITC Brazil Survey, a cohort survey of approximately 1200 adult smokers and 600 non-smokers residing in Rio de Janeiro, São Paulo, and Porto Alegre. Waves 1 and 2 were conducted before the 2014 POS advertising ban (2009 and 2012-13), and Wave 3 was conducted after the ban (2016-17). Data were analyzed using GEE logistic regression models. Results From 2009 (pre-ban) to 2016-17 (post-ban), noticing things that promote smoking decreased among smokers (42.3% to 34.4%, p< .01) and non-smokers (34.0% to 25.8%, p< .05). Following the 2014 POS advertising ban, 19.9% of smokers and 20.0% of non-smokers noticed signs/items with cigarette logos in stores; 61.3% of smokers and 58.5% of non-smokers noticed cigarette displays in stores. There was strong support for complete bans on in-store advertising (74.2% smokers, 87.8% non-smokers) and POS cigarette displays (71.9% smokers, 85.5% non-smokers); and generally no differences in support between cities. Conclusions TAPS bans in Brazil have reduced exposure to tobacco marketing, but POS advertising continues to be visible. These findings demonstrate that Brazil should implement a complete ban on in-store tobacco advertising, including POS displays, and that such a ban would be supported by the majority of smokers and non-smokers.

Background Secondhand smoke (SHS) poses a major public health threat in China, causing over 100,000 deaths/year. China, however, has not yet implemented a national comprehensive smoke-free law, and the few subnational laws are only partial. This study presents trends in selected cities from 2007 to 2015 in: (1) exposure to SHS in key public places (workplaces, restaurants, bars), and (2) smokers' support for comprehensive smoke-free laws, comparing cities and rural areas in 2013-15. Methods Data are from Waves 2 to 5 of the International Tobacco Control (ITC) China Survey (2007-15), a face-to-face cohort survey of 800 smokers in each of five cities (Beijing, Guangzhou, Kunming, Shanghai, Shenyang), plus five rural areas at Wave 5 (2013-15) (total N=8000). GEE logistic regression models tested changes over time. Results At the latest wave (2013-15), the majority of respondents reported being exposed to SHS in public places. Smoking was most prevalent in bars, with little reduction over time across cities (from 93% overall in 2007 to 86% in 2013-15). Smoking in other venues decreased over time, but remained very high in 2013-15 (from 94% to 67% for restaurants; and 75% to 51% for workplaces). In rural areas, smoking prevalence was higher in workplaces (73% vs 56%, p < .001) and lower in bars (73% vs 88%, p < .05) compared to cities; there was no difference in restaurants. Support for complete smoking bans among smokers in cities increased over time for each venue and is higher than nearly all other 20+ ITC countries. Support did not differ between cities and rural locations. Conclusions Partial smoke-free laws in China are failing to protect both urban and rural residents from SHS, demonstrating the urgent need for a comprehensive national smoke-free law, as called for by the FCTC. Such a law would be supported by the majority of the Chinese public.

Background Little is known about the harmfulness perceptions of e-cigarettes (ECs) outside of high-income countries. This study examined reasons for EC use and harmfulness perceptions of ECs compared to regular cigarettes among smokers in Brazil, where 18.3% of smokers and 2.2% of non-smokers have tried ECs. Methods Data were from Waves 2 (2012-13) and 3 (2016-17) of the International Tobacco Control (ITC) Brazil Survey, a cohort survey of 1200 adult smokers and 600 non-smokers in Rio de Janeiro, São Paulo, and Porto Alegre. At Wave 3, EC users (those who used ECs daily, weekly, monthly, and less than monthly; total n=48) were asked why they started and reasons for using ECs. At Waves 2 and 3, smokers who had ever heard of ECs (N=392 at Wave 2; N=859 at Wave 3) were asked whether they thought ECs are more, less, or equally harmful as regular cigarettes. Results Among the 43 smokers who reported using ECs, the most common reasons for using e-cigarettes were: “using ECs is less harmful than smoking to other people” (69.3%), “out of curiosity” (59.4%), “they may not be as bad for your health” (59.0%), and “as a way to help you quit” (57.5%). Between 2012-13 and 2016-17, the percentage of smokers who “don't know” about the relative harmfulness of ECs decreased (41.6% to 28.0%; p< .001) and the percentage who believed that ECs are equally or more harmful than cigarettes increased (22.7% to 35.2%; p< .001). Conclusions Smokers using ECs most commonly use ECs to reduce harm to others, reduce harm to their own health, and to help them to quit smoking. More smokers now have an opinion about the relative harmfulness of ECs, and a greater percentage of smokers now incorrectly believe that ECs are equally or more harmful than cigarettes.

Background Large-scale international sporting events such as the Olympic Games provide opportunities for hosting nations to promote smoke-free environments. The Olympics have been tobacco-free since 1998, but there have been few studies on the effectiveness of smoke-free Olympic policies. This study evaluated the effectiveness of smoke-free policies at the 2016 Rio Olympics, which were supported by Brazil's 2014 comprehensive smoke-free law, and measured public support for smoke-free Olympic venues. Methods Data were from Waves 2-3 of the ITC Brazil Survey, a cohort survey of approximately 1200 adult smokers and 600 non-smokers in Rio de Janeiro, São Paulo, and Porto Alegre. Wave 2 (2012-13), conducted before the 2014 smoke-free law and 2016 Olympics provided the pre-policy data, and Wave 3 (2016-17) provided the post-policy data. Analyses employed GEE logistic regression models. Results Of 1826 respondents surveyed in 2016-17, 116 (9.9%) smokers and 57 (14.8%) non-smokers attended the Olympics. The vast majority who attended at least one indoor event reported that smoking was banned inside venues (97.5% smokers, 93.0% non-smokers); and noticed no-smoking signs inside venues (82.2% smokers, 73.1% non-smokers). Only 10.7% of smokers and 7.2% of non-smokers noticed people smoking inside venues; 5.8% of smokers said they personally smoked at an indoor venue. Following the 2014 smoking ban and 2016 Olympics, support for the indoor smoking ban in Olympic venues increased among smokers (79.2% to 93.3%, p< .001) and non-smokers (86.4% to 94.1%, p< .001). Conclusions There was strong implementation of and high compliance with Brazil's comprehensive smoking ban at the 2016 Rio Olympics. Smoke-free Olympic venues were widely supported by the public before the Games, and increased after the Games. It would be beneficial for the upcoming 2020 Tokyo Olympics organizers to consult with Rio Olympics organizers to maximize the effectiveness of any efforts to make the Tokyo Olympics smoke-free.

Background Uruguay has implemented strong tobacco control policies over the years which has resulted in decreased tobacco consumption. However, there is little information about flavored cigarettes and on electronic cigarettes (ECs). EC sales are banned in Uruguay. The purpose of this study is to evaluate consumption of these products. Methods Data is from the International Tobacco Control (ITC) Uruguay Wave 5 smokers aged 18 and older in five cities. The sample size was 1,428 smokers. Results The minimum age of onset of smoking was 5 years old and 96% of smokers started smoking before the age of 25. Two out of three (68.6%) smokers chose their cigarette brand because of the taste. 72.5% have tried flavored (menthol) cigarettes, and1.3% currently smoking menthol brands. Younger age (94% aged 18-24) and smokers with higher education (84% high, 74% medium, 61% low) have tried menthol cigarettes associated with. Awareness of ECs was 56% among the smokers, but it is higher among smokers aged 18-24 (62%) and smokers with higher education (81%). Among the smokers who had heard of e-cigarettes. 12.8% had tried once (higher under age 24 (24%) and higher among smokers with high education level (20%)). Among the smokers, 1.3% using EC daily and 1.9% using EC weekly. Conclusions Taste is a very important factor for Uruguayan smokers. Almost all young smokers have tried menthol cigarettes. ECs use is also on the rise, mainly among young peopleand people with higher education. There is a need for monitoring flavored cigarettes and EC consumptionto defining new regulations for them.