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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.

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.

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.

ObjectiveTo evaluate heated tobacco product (HTP) awareness, trial and current use among adult cigarette smokers and vaping product users in four countries with varying regulations governing HTP sales.DesignData came from Wave 2 of the ITC Four Country Smoking and Vaping Survey, collected from February to July 2018. Respondents were current and former smokers and/or users of vaping products (18 years or older) from Canada (CA; n=3778), England (EN; n=4848), the USA (US; n=2846) and Australia (AU; n=1515). At the time of the survey, only Canada and England permitted the sale of contemporary HTPs (eg, IQOS).ResultsOverall, 30.2% of respondents reported being aware of HTPs (CA=30.4%; EN=31.0%; US=30.2%; AU=27.4%; p=0.346), 2.4% had ever tried HTPs (CA=3.3%; EN=2.4%; US=2.0%; AU=0.9%; p=0.001) and 0.9% currently used HTPs at least monthly (CA=0.8%; EN=1.2%; US=0.7%; AU=0.2%; p<0.001). Trial and current use were higher among those who concurrently smoked and vaped (at least monthly) versus other nicotine use categories (trial: 10.9% v. 1.2%–2.0%, p<0.001; current use: 8.4% v. 0.1%–1.0%, p<0.001). In multivariable analyses, HTP awareness did not differ across countries, whereas odds of trial and current use were lower where HTPs were unavailable. Odds of HTP trial did not differ by regulatory environment when restricting analysis to HTP-aware concurrent smokers–vapers.ConclusionApproximately one third of respondents were aware of HTPs, even in the USA and Australia, where contemporary HTPs were not yet on the market. Trial and use were uncommon, except among concurrent smokers–vapers. Restrictions on availability may have limited HTP use generally, but less so for concurrent smokers–vapers.

BACKGROUND AND AIMS: In May 2017, black-and-white text nicotine addiction warning labels ('warnings') and health and safety leaflets ('leaflets') became mandatory for nicotine vaping products (NVPs) in England, in accordance with the European Union's Tobacco Products Directive. We compared changes over time in noticing warnings and leaflets, recall of warnings about nicotine and concerns about using NVP due to noticing warnings in England, compared with Canada, the US and Australia, where no warnings and leaflets were mandated. DESIGN: 19 005 adult (aged 18+) NVP users, smokers and quitters of cigarettes and NVP from the 2016 and 2018 International Tobacco Control Four Country Smoking and Vaping Surveys in England, Canada, the US and Australia, recruited via probability and non-probability sampling. FINDINGS: Noticing warnings increased in England from 4.9% (2016) to 9.4% (2018) (adjusted OR/AOR=1.64, 95% CI=1.15-2.36); this change was larger than changes in Canada (AOR=2.51, 95% CI=1.71-3.69) and the US (AOR=2.22, 95% CI=1.45-3.39). Recall of a nicotine warning increased in England from 86% (2016) to 94.9% (2018) (AOR=5.50, 95% CI=1.57-19.27) but not significantly elsewhere. Noticing leaflets increased in England from 14.6% (2016) to 19.1% (2018) (AOR=1.42, 95% CI=1.15-1.74); this change was larger than in Canada (AOR=1.42, 95% CI=1.12-1.79), the US (AOR=1.55, 95% CI=1.17-2.06) and Australia (AOR=1.51, 95% CI=1.02-2.22). Among those noticing warnings, concern about NVP use did not change significantly between 2016 and 2018 (all countries p>0.081). CONCLUSIONS: Introduction of mandatory NVP warnings and leaflets in England was associated with small increases in noticing them but not with changes in concerns about NVP use.

STUDY OBJECTIVES: To compare the prices paid for nicotine vaping products (NVPs) and supplies among current NVP users to prices paid for cigarettes among current smokers. DATA: The 2016 International Tobacco Control Four Country Vaping and Smoking Survey (4CV1). Key measures included: (1) self-reported prices paid for reusable NVPs (eg, rechargeable devices with cartridges and tank system devices with e-liquids) in the 3-month period prior to the survey among current NVP users, (2) prices paid for disposable NVPs, cartridges and e-liquids purchased in the last 30 days among current NVP users and (3) self-reported prices paid for cigarettes among current smokers. RESULTS: Disposable NVP price was higher than the price of a comparable unit for combustible cigarettes in England (EN), USA and Canada (CA). Prefilled cartridge price was higher than the price of a comparable unit of cigarettes in USA and CA, but lower in EN and Australia. E-liquid price was consistently lower than the price of a comparable unit of cigarettes across four countries. For start-up costs, price of a rechargeable device is approximately 3-5 times higher than a pack of cigarettes in four countries. CONCLUSION: NVP prices were generally higher than prices of combustible cigarettes, especially the high upfront NVP devices. The high upfront costs of purchasing a reusable NVP may discourage some smokers from switching to vaping. However, the average lower costs of cartridges and e-liquids relative to a package of cigarettes make switching to a NVP an attractive alternative to smoking in the long term so long as smokers switch completely to vaping.

OBJECTIVE: To compare exposure to and use of certain cigarette and vaping product marketing among adult smokers and vapers in four countries with contrasting regulations-Australia (AU), Canada, England and the USA. DATA SOURCES: Adult smokers and vapers (n=12 294) from the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Survey (4CV1). ANALYSIS: Self-reported exposure to cigarette and vaping product advertising through point-of-sale, websites/social media, emails/texts, as well as exposure to and use of price offers were assessed for country differences using logistic regression models adjusted for multiple covariates. RESULTS: Reported exposure to cigarette advertising exposure at point-of-sale was higher in the USA (52.1%) than in AU, Canada and England (10.5%-18.5%). Exposure to cigarette advertising on websites/social media and emails/texts was low overall (1.5%-10.4%). Reported exposure to vaping ads at point-of-sale was higher in England (49.3%) and USA (45.9%) than in Canada (32.5%), but vaping ad exposure on websites/social media in Canada (15.1%) was similar with England (18.4%) and the USA (12.1%). Exposure to vaping ads via emails/texts was low overall (3.1%-9.9%). Exposure to, and use of, cigarette price offers was highest in the USA (34.0 % and 17.8 %, respectively), but the use rate among those exposed was highest in AU (64.9%). Exposure to, and use of, price offers for vaping products was higher in the USA (42.3 % and 21.7 %) than in AU, Canada and England (25.9%-31.5 % and 7.4%-10.3 %). CONCLUSIONS: Patterns of cigarette and vaping product marketing exposure generally reflected country-specific policies, except for online vaping ads. Implications for research and policy are discussed.

BACKGROUND: The 2018 National Academies of Sciences, Engineering, and Medicine Report found substantial evidence that electronic cigarette use (vaping) by youth is strongly associated with an increased risk of ever using cigarettes (smoking) and moderately associated with progressing to more established smoking. However, the Report also noted that recent increases in vaping have been associated with declining rates of youth smoking. This paper examines the temporal relationship between vaping and youth smoking using multiple data sets to explore the question of whether vaping promotes smoking initiation in the USA. METHODS: Using publicly available, nationally representative data on smoking and vaping among youth and young adults, we conducted a trend line analysis of deviations from long-term trends in smoking starting from when vaping became more prevalent. RESULTS: There was a substantial increase in youth vaping prevalence beginning in about 2014. Time trend analyses showed that the decline in past 30-day smoking prevalence accelerated by two to four times after 2014. Indicators of more established smoking rates, including the proportion of daily smokers among past 30-day smokers, also decreased more rapidly as vaping became more prevalent. CONCLUSIONS: The inverse relationship between vaping and smoking was robust across different data sets for both youth and young adults and for current and more established smoking. While trying electronic cigarettes may causally increase smoking among some youth, the aggregate effect at the population level appears to be negligible given the reduction in smoking initiation during the period of vaping's ascendance.

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.

BACKGROUND: Over 350 million smokers live in China, and this represents nearly one-third of the smoking population of the world. Smoking cessation is critically needed to help reduce the harms and burden caused by smoking-related diseases. It is therefore important to identify the determinants of quitting and of quit intentions among smokers in China. Such knowledge would have potential to guide future tobacco control policies and programs that could increase quit rates in China. OBJECTIVE: To identify the correlates of intentions to quit smoking among a representative sample of adult smokers in six cities in China. METHODS: Data from wave 1 (2006) of the International Tobacco Control (ITC) Policy Evaluation Project China Survey, a face-to-face survey of adult Chinese smokers in six cities: Beijing, Shenyang, Shanghai, Changsha, Guangzhou and Yinchuan, was analysed. Households were sampled using a stratified multistage design. About 800 smokers were surveyed in each selected city (total n=4815). RESULTS: Past quit attempts, duration of past attempts, Heaviness of Smoking Index (HSI), outcome expectancy of quitting, worry about future health and overall opinion of smoking were found to be independently associated with intentions to quit smoking, but demographic characteristics were not. CONCLUSIONS: The determinants of quit intentions among smokers in China are fairly similar to those found among smokers in Western countries, despite the fact that interest in quitting is considerably lower among Chinese smokers. Identifying the determinants of quit intentions provides possibilities for shaping effective policies and programs for increasing quitting among smokers in China.

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.