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Introduction: In line with historical tobacco industry marketing claims, many consumers perceive cigarettes with filters as less harmful than cigarette without filters. However, scientific evidence indicates that cigarette filters do not reduce the risks associated with smoking. We examined opposition to banning the sale of cigarettes with filters, beliefs about whether removing filters makes cigarettes much more harmful, and whether this belief is associated with opposition to banning filters among adults who smoke cigarettes from four high-income countries., Methods: Data are from 2,980 adults who smoke cigarettes and participated in the 2022 ITC Smoking and Vaping Survey in Australia, Canada, England, and the United States (US). Weighted descriptives estimated opposition to a cigarette filter ban and the belief that removing filters makes cigarettes 'much more', 'a little more', 'not more' harmful, or 'don't know'. Adjusted regression analyses examined the association between opposition to banning filters (vs. support/don't know) and the belief that removing filters would make cigarettes much more harmful (vs. otherwise)., Results: Across all counties, 69.3% opposed banning filters, 11.5% of respondents supported banning filters, and 19.1% did not know (main effect for country differences: p=0.001). Country differences remained significant after adjusting for covariates (p=0.047), with adults who smoke in Australia and the US being significantly more likely to oppose a filter ban than those in England. Canada did not differ significantly from any of the countries. Nearly half (45.9%) believe that removing filters would make cigarettes much more harmful, 28.6% reported a little more harmful, 15.3% were unsure, and 10.2% reported not more harmful (country differences: p=0.002). Country differences were no longer significant after adjustment (p=0.18). Believing that removing filters makes cigarettes much more harmful was strongly associated with opposing a filter ban (78.5%) (vs. otherwise: 62.1%, p<0.001)., Conclusions: Across all four countries, three-quarters of adults who smoke erroneously believe that removing filters would make cigarettes more harmful, and believing that doing so would make cigarettes much more harmful was the strongest predictor of opposing a filter ban., Implications: More than 90% of manufactured cigarettes worldwide contain filters. Contrary to marketing claims by the tobacco industry, cigarette filters do not offer any health protection from cigarette smoke; however, three-quarters of adults who smoke erroneously believe that cigarettes with filters are much less harmful than cigarettes without filters. To protect public health and the environment, the World Health Organization has recommended that policymakers consider banning cigarette filters as they are unnecessary single use plastics., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: The public health impact of a tobacco tax increase depends on the extent to which the industry passes the increase onto consumers, also known as tax-pass through. In 2020, the Netherlands announced tax increases aimed to increase the retail price by €1 per 20 factory-made cigarettes and €2.50 per 50 grams of roll-your-own tobacco. This study examines the pass-through rate after the tax increase, and whether this differed by type of tobacco and brand segment., Methods: Self-reported prices of 117 tobacco brand varieties (cigarettes=72, roll-your-own=45) pre- and post-tax increase were extracted from the 2020 International Tobacco Control (ITC) Netherlands Surveys (n=2959 respondents). We calculated the tax pass-through rate per variant, examining differences between type of tobacco and brand segments., Results: On average, cigarette prices increased by €1.12 (SD=0.49) (112% of €1) and roll-your-own prices by €2.53 (SD=0.60) (101% of €2.50). Evidence of differential shifting across segments was found, with evidence of overshifting in non-discount varieties. The average price of discount varieties increased with €0.20 less than non-discount varieties. Similarly, the net-of-tax price decreased in discount varieties (cigarettes=-€0.02; roll-your-own=-€0.05), but increased in non-discount varieties (cigarettes= +€0.14; roll-your-own= +€0.20)., Conclusions: Despite the large tax increase, the industry increased prices in line or above the required level. Through differential shifting, the price gap between discount and non-discount varieties has widened, which may reduce the public health impact of the tax increase. Measures aimed at reducing price variability should be strengthened in taxation policy, such as the European Tobacco Tax Directive., Implications: We found that the industry used differential shifting after a significant tobacco tax increase in the Netherlands. Prices increased more than required in higher-priced products, but not in lower-priced products. This pattern was found both for factory-made cigarettes and roll-your-own tobacco. Through differential shifting, the industry undermines the potential public health impact of tobacco tax increases, by offering a relatively cheaper alternative, which discourages people to quit or reduce consumption. The revision of the European Tobacco Tax Directive (TTD) provides an opportunity to address the widening price gap - both between and within product segments - across the European Union., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

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., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Background: Prior work established a measure of tobacco dependence (TD) among adults that can be used to compare TD across different tobacco products. We extend this approach to develop a common, cross-product metric for TD among youth., Methods: One thousand one hundred and forty-eight youth aged 12-17 who used a tobacco product in the past 30 days were identified from 13 651 youth respondents in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study., Findings: Analyses confirmed a single primary latent construct underlying responses to TD indicators for all mutually exclusive tobacco product user groups. Differential Item Functioning analyses supported the use of 8 of 10 TD indicators for comparisons across groups. With TD levels anchored at 0.0 (standard deviation [SD] = 1.0) among cigarette only (n = 265) use group, mean TD scores were more than a full SD lower for e-cigarette only (n = 150) use group (mean = -1.09; SD = 0.64). Other single product use group (cigar, hookah, pipe, or smokeless; n = 262) on average had lower TD (mean = -0.60; SD = 0.84), and the group with the use of multiple tobacco products (n = 471) experienced similar levels of TD (mean = 0.14; SD = 0.78) as the cigarette only use group. Concurrent validity was established with product use frequency among all user groups. A subset of five TD items comprised a common metric permitting comparisons between youth and adults., Conclusion: The PATH Study Youth Wave 1 Interview provided psychometrically valid measures of TD that enable future regulatory investigations of TD across tobacco products and comparisons between youth and adult tobacco product use group., Implications: A measure of tobacco dependence (TD) has been established previously among adults to compare TD across tobacco products. This study established the validity of a similar, cross-product measure of TD among youth. Findings suggest a single latent TD construct underlying this measure, concurrent validity of the scale with product use frequency across different types of tobacco users, and a subset of common items that can be used to compare TD between youth and adults who use tobacco., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The 2020 European Union (EU) menthol cigarette ban increased quitting among pre-ban menthol smokers in the Netherlands, but some reported continuing to smoke menthol cigarettes. This study examined three possible explanations for post-ban menthol use-(i) illicit purchasing, (ii) use of flavour accessories and (iii) use of non-menthol replacement brands marketed for menthol smokers., Methods: Data were from the ITC Netherlands Cohort Surveys among adult smokers before the menthol ban (Wave 1: February-March 2020, N = 2067) and after the ban (Wave 2: September-November 2020, N = 1752; Wave 3: June-July 2021, N = 1721). Bivariate, logistic regression and generalized estimating equation model analyses were conducted on weighted data., Results: Illicit purchasing remained low from pre-ban (2.4%, 95% CI: 1.8-3.2, Wave 1) to post-ban (1.7%, 1.2-2.5%, Wave 3), with no difference between menthol and non-menthol smokers from Wave 1 to Wave 3. About 4.4% of post-ban menthol smokers last purchased their usual brand outside of the EU and 3.6% from the internet; 42.5% of post-ban menthol smokers and 4.4% of smokers overall reported using flavour accessories, with greater odds among those aged 25-39 years vs. 55+ (aOR = 3.16, P = 0.002). Approximately 70% of post-ban smokers who reported using a menthol brand were actually using a non-menthol replacement brand., Conclusions: There was no increase in illicit purchasing or of smuggling outside the EU among menthol and non-menthol smokers in the Netherlands 1 year after the EU menthol cigarette ban. Use of flavour accessories and non-menthol replacement brands best explain post-ban menthol use, suggesting the need to ban accessories and ensure industry compliance., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Public Health Association.)

Background: Framework Convention on Tobacco Control (FCTC) 2030 Program (2017-2021) was launched to accelerate World Health Organization (WHO) FCTC implementation in 15 low- and middle-income countries (LMICs). We evaluated the Program in six domains: Governance; Smoke-Free Policies; Taxation; Packaging and Health Warnings; Tobacco Advertising, Promotion, and Sponsorship (TAPS) bans; and International and Regional Cooperation., Aims and Methods: Following a mixed-methods design, we surveyed (June-September 2020) FCTC focal persons in 14 of the 15 countries, to understand the Program's financial and technical inputs and progress made in each of the six domains. The data were coded in terms of inputs (financial = 1, technical = 1, or both = 2) and progress (none = 1, some = 2, partial = 3, or strong = 4) and a correlation was computed between the inputs and progress scores for each domain. We conducted semi-structured interviews with key stakeholders in five countries. We triangulated between the survey and interview findings., Results: FCTC 2030 offered substantial financial and technical inputs, responsive to country needs, across all six domains. There was a high positive correlation between technical inputs and progress in five of the six domains, ranging from r = 0.61 for taxation (p < .05) to r = 0.91 and for smoke-free policies (p < .001). The interviews indicated that the Program provided timely and relevant evidence and created opportunities for influencing tobacco control debates., Conclusions: The FCTC 2030 Program might have led to variable, but significant progress in advancing FCTC implementation in the 15 countries. As expected, much of the progress was in augmenting existing structures and resources for FCTC implementation. The resulting advances are likely to lead to further progress in FCTC policy implementation., Implications: What this study adds: In many LMICs, WHO FCTC policies are not in place; and even when enshrined in law, they are poorly enforced. It is not clear how financial and technical assistance to high tobacco-burden LMICs can most effectively accelerate the implementation of WHO FCTC policies and offer value for money. Bespoke and responsive assistance, both financial and technical, to LMICs aimed at accelerating the implementation of WHO FCTC policies are likely to lead to progress in tobacco control., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: Cigarette gifting is commonly practiced in China and has contributed to the social acceptability and high prevalence of cigarette smoking in the country. As a result, nonsmokers in China are particularly susceptible to smoking. While previous studies have examined cigarette gifting behaviors among smokers, little is known about cigarette gifting among nonsmokers., Aims and Methods: This study aimed to examine the percentage and correlates of giving and receiving cigarettes as gifts among adult nonsmokers in China. We analyzed nonsmokers (N = 1813) aged ≥18 years using data from the International Tobacco Control China Wave 5 Survey. Descriptive statistics summarized the characteristics of those who gave and received cigarettes as gifts. Multivariable logistic regression models were used to identify factors associated with the two behaviors., Results: Among nonsmokers, 9.9% reported giving cigarettes as gifts to family or friends in the last 6 months. A higher level of knowledge about smoking harms was associated with lower adjusted odds of gifting cigarettes. Nonsmokers aged 25-39 years, with middle income, positive attitude toward cigarette gifts, exposure to anti-smoking information, and exposure to smoking promotion, and those who reported receiving cigarettes as gifts from family or friends were more likely to give cigarettes as gifts. A total of 6.6% of nonsmokers reported receiving cigarettes as gifts in the last 6 months. High education, neutral or positive attitude toward cigarette gifts, exposure to anti-smoking information, exposure to smoking promotion, and having smoking friends were associated with receiving cigarettes as gifts., Conclusions: It is concerning that Chinese cultural norms that support cigarette gifting have extended to giving nonsmokers cigarettes as gifts. Effective anti-smoking messages are needed. Changing the norms around cigarette gifting and increasing knowledge about smoking harms should help reduce cigarette gifting among nonsmokers., Implications: Easy access to cigarettes received as gifts, along with the wide acceptance of smoking in China, places Chinese nonsmokers in a risky position. More educational campaigns targeting nonsmokers to proactively prevent them from smoking are called for. The ineffectiveness of existing anti-smoking information highlights the need for more effective anti-smoking messages. That attitude toward cigarette gifts is the strongest predictor of giving cigarettes as gifts suggests the need for interventions to reverse the positive attitude about cigarette gifting to decrease the popularity of this activity., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Little is known about smoking cessation among gender minority populations compared to cisgender individuals (whose gender matches their sex assigned at birth). We examined differences between smokers from gender minority populations, cis-women, and cis-men in the heaviness of smoking, quit intentions, use of cessation assistance, quit attempts (ever tried and number), and triggers for thinking about quitting., Aims and Methods: We used cross-sectional data from the 2020 International Tobacco Control Netherlands Survey. Among smoking respondents, we distinguished (1) cis-women (female sex, identified as women, and having feminine gender roles; n = 670), (2) cis-men (male sex, identified as men, and having masculine gender roles; n = 897), and (3) gender minorities (individuals who were intersex, who identified as nonbinary, genderqueer, had a sex/gender identity not listed, whose gender roles were not feminine or masculine, or whose gender identity and/or roles were not congruent with sex assigned at birth; n = 220)., Results: Although gender minorities did not differ from cis-women and cis-men in the heaviness of smoking, plans to quit smoking, and quit attempts, they were significantly more likely to use cessation assistance (20% in the past 6 months) than cis-women (12%) and cis-men (9%). Gender minorities were also significantly more likely to report several triggers for thinking about quitting smoking, for example, quit advice from a doctor, an anti-smoking message/campaign, and the availability of a telephone helpline., Conclusion: Despite equal levels of quit attempts and heaviness of smoking, gender minority smokers make more use of smoking assistance, and respond stronger to triggers for thinking about quitting smoking., Implications: Smoking cessation counselors should be sensitive to the stressors that individuals from any minority population face, such as stigmatization, discrimination, and loneliness, and should educate their smoking clients on effective coping mechanisms to prevent relapse into smoking after they experience these stressors. Developing tailored smoking cessation programs or campaigns specifically for gender minority populations can also be useful. Based on the results of our subgroup analyses, programs or campaigns for younger gender minority smokers could focus on the availability of telephone helplines and on how friends and family think about their smoking behavior., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: Cigarette affordability, the price of tobacco relative to consumer income, is a key determinant of tobacco consumption., Aims and Methods: This study examined trends over 12 years in individualized factory-made cigarette affordability in the Netherlands, and whether these trends differed by sex, age, and education. Data from 10 waves (2008-2020) of the International Tobacco Control Netherlands Surveys were used to estimate individualized affordability, measured as the percentage of income required to buy 100 cigarette packs (Relative Income Price [RIP]), using self-reported prices and income. The higher the RIP, the less affordable cigarettes are. Generalized estimating equation regression models assessed trends in individualized affordability over time and by sex, age, and education., Results: Affordability decreased significantly between 2008 and 2020, with RIP increasing from 1.89% (2008) to 2.64% (2020) (p ≤ .001), except for 2008-2010, no significant year-on-year changes in affordability were found. Lower affordability was found among subgroups who have a lower income level: Females (vs. males), 18-24 and 25-39-year-olds (vs. 55 years and over) and low or moderate-educated individuals (vs. highly educated). Interactions between wave and education (p = .007) were found, but not with sex (p = .653) or age (p = .295). A decreasing linear trend in affordability was found for moderately (p = .041) and high-educated (p = .025), but not for low-educated individuals (p = .149)., Conclusions: Cigarettes in the Netherlands have become less affordable between 2008 and 2020, yet this was mostly because of the decrease in affordability between 2008 and 2010. There is a need for more significant increases in tax to further decrease affordability., Implications: Our findings suggest that cigarettes have become less affordable in the Netherlands between 2008 and 2020. But, this appears to be the result of a steep decrease in affordability between 2008 and 2010. Affordability was lower among groups who have on average lower incomes (females, young adults, and low- and moderate-educated individuals), and differences in trends across education levels could be explained by per capita income changes. Our individualized measure indicated lower affordability than published aggregate affordability estimations. Future tax increases should be large enough to result in a lower affordability., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: We examined the differential impact of the 2012 Canadian GWL policy changes on key indicators of warning label impact and quit intentions using national cohorts of Canadian and U.S. adults who smoke., Aims and Methods: We used data from all waves of the International Tobacco Control surveys (2002-2020) in Canada and the United States. Our key measures were quit intentions and an index of warning label effectiveness (salience, cognitive and behavioral reactions). We estimated overall policy impact by comparing Canada (treatment group) with the United States (control group) using controlled interrupted time series (CITS) regression models, with interactions to examine whether policy impact varied by sex, education, and income., Results: The CITS model showed a statistically significant increase in the warning label effectiveness in Canada post-policy, compared to the United States (β = 0.84, 95% CI 0.35,1.33). Similarly, the odds of quit intentions were relatively higher among adults who smoked in Canada compared to the United States (OR = 1.89, 95% CI 1.51,2.36) post-policy. The three-way interaction model showed that these associations were greater among adults from low socioeconomic status (SES) groups than in high SES groups., Conclusions: The 2012 change in the Canadian GWL policy was associated with stronger cognitive and behavioral responses to GWLs and higher odds of quit intentions among adults who smoked in Canada when compared to the United States, specifically among individuals from low SES groups, suggesting a positive equity impact. Our findings affirm the need for countries to implement or enhance GWLs, in line with the WHO Framework Convention on Tobacco Control (FCTC)., Implications: The evidence on the potential health equity benefit of GWL policies is mixed. To further understand the influence of GWL policies on tobacco use disparities, more systematic research using pre/post-policy designs with control groups is needed. Using a CITS model, we aimed to strengthen the available evidence on the causal influence of this tobacco control approach. Our findings show that the 2012 GWL policy change had a greater impact on adults who smoked from low SES groups than it did on adults who smoked from high SES groups, indicating a potentially positive equity impact and confirming the need for countries to implement or maximize the size of GWLs, as recommended by the WHO FCTC., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

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., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Background: Effectiveness of tobacco taxation can be undermined through smokers applying price-minimizing behaviours rather than quitting or reducing consumption. Common price-minimizing strategies are buying cheaper tobacco [discount brands or roll-your-own (RYO) tobacco], bulk buying and cross-border purchasing. This study analyses trends in and factors associated with such behaviours in four European countries from 2006 to 2020., Methods: Data came from adult smokers participating in the International Tobacco Control (ITC) Surveys conducted between 2006 and 2020 in England (9 waves, n = 768-4149), France (4 waves, n = 1415-1735), Germany (5 waves, n = 513-1515) and the Netherlands (10 waves, n = 1191-2177). Country-specific generalized estimating equation regression models were fit to assess trends in smoking RYO tobacco, discount brands, bulk buying and cross-border purchasing within the European Union., Results: Buying discount brands or RYO tobacco was the most common strategy in all countries, except France. Except for buying discount brands, estimates of price-minimizing behaviours were highest in France (2019: RYO = 27.2%, discount brands = 17.3%, bulk buying = 34.1%, cross-border purchasing = 34.2%), and lowest in Germany (2018: RYO = 18.6%, discount brands = 43.7%, bulk buying = 8.0%, cross-border purchasing = 9.8%). Direction and magnitude of trends differed by country, and behaviour. Young smokers were less likely to buy in bulk. Low-income and low-education smokers were more likely to purchase RYO tobacco or discount brands. The association with discount brands was not found for French low-income smokers., Conclusions: Smoking cheaper tobacco is the most prevalent price-minimizing strategy in three countries (England, Germany and Netherlands), and more prevalent among low-income individuals. Harmonizing prices across products and countries would reduce switching to cheaper tobacco., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Public Health Association.)

Introduction: Using a quasiexperimental design, we compared the impact of the 2000 Canadian introduction of graphic warning labels (GWLs) on differences in smoking prevalence by sex and education, to the United States, where no GWLs were introduced., Methods: We pooled 1999-2004 data from the Canadian Tobacco Use Monitoring Survey and the U.S. Behavioral Risk Factor Surveillance System. We used a difference-in-difference (DD) model to assess the impact of Canadian policy introduction on smoking prevalence, and a difference-in-difference-in-difference (DDD) model to examine differences in the policy impact by sex and education, comparing Canada (the treatment group) with the United States (the control group)., Results: From 1999 to 2004, smoking prevalence decreased from 23.7% to 18.6% in Canada, and from 21.7% to 20.0% in the United States. Results from the DD regression models showed that Canadian respondents reported lower odds of being a current smoker compared to the U.S. respondents following the 2000 introduction of GWLs (OR = 0.84, 95% CI = 0.74-0.94). The DDD model showed that the impact of the Canadian GWLs versus the United States did not differ by sex or education., Conclusions: The 2000 Canadian GWL policy reduced smoking prevalence overall, with similar reductions for males and females and across education levels. The impact of the Canadian GWLs in reducing smoking prevalence did not reduce differences by sex or education. Although beneficial for all smokers, GWLs may not serve to decrease existing disparities, especially those by socioeconomic status., Implications: Existing evidence shows that GWL implementation is associated with reductions in smoking prevalence. But there is limited evidence from past evaluation studies on whether the impact of GWLs on smoking prevalence differs by sociodemographic subgroup. Our findings confirm existing studies that the 2000 implementation of GWLs in Canada was significantly associated with an overall reduction in smoking prevalence in Canada compared to the United States. However, our study improves existing evidence by showing that the impact of the Canadian GWLs on smoking prevalence did not differ by sex or education, and thus did not reduce existing smoking disparities by educational levels., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: This study examined whether smokers' harm perceptions of nicotine replacement therapy (NRT) and nicotine vaping products (NVPs) relative to cigarettes predicted their subsequent use as smoking cessation aids during their last quit attempt (LQA)., Aims and Methods: We analyzed data from 1,315 current daily smokers (10+ cigarettes per day) who were recruited at Wave 1 (2016), and who reported making a quit attempt by Wave 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the United States. We used multinomial logistic regression models to examine prospective associations between harm perceptions of (a) NRT and (b) NVPs and their use at LQA, controlling for socio-demographic and other potential confounders., Results: Smokers who perceive that (a) NRT and (b) NVPs are much less harmful than cigarettes were more likely to subsequently use the respective product as an aid than using no aid or other aids during LQA (adjusted relative risk ratio [aRRR] = 3.79, 95%CI = 2.16-6.66; and aRRR = 2.11, 95%CI = 1.29-3.45, respectively) compared to smokers who perceive these products as equally or more harmful. Additionally, those who perceive NVPs as much less harmful than cigarettes were less likely to use NRT as a quit aid (aRRR = 0.34, 95%CI = 0.20-0.60). No country variations for these associations were found., Conclusions: This study found that smokers' perceptions of the harmfulness of (a) NRT and (b) NVPs relative to cigarettes predicted the respective product use when trying to quit smoking. Corrective education targeting misperceptions of nicotine products' relative harmfulness may facilitate their use for smoking cessation., Implications: Nicotine replacement therapy and nicotine vaping products are two commonly used smoking cessation aids. This study demonstrates that misperceptions of the harms of nicotine products relative to cigarettes influence their use for smoking cessation. Believing that nicotine vaping products are much less harmful than cigarette smoking may lead some smokers to prefer these products over nicotine replacement therapy to aid smoking cessation. Education targeting misperceptions of nicotine products' harmfulness relative to cigarettes may enable smokers to make informed choices about which are appropriate to aid smoking cessation., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Background: The number of countries mandating a nicotine addiction warning label ("warnings") on nicotine vaping products (NVPs) has been increasing. This study examined associations between noticing NVP warnings, perceptions of NVPs, and intentions to use NVPs., Aim and Methods: Cross-sectional analysis of 12 619 adult NVP users, cigarette smokers, concurrent users of both cigarettes and NVPs, and quitters who participated in the 2018 International Tobacco Control (ITC) Project Four Country Smoking and Vaping Survey (England, Australia, Canada, USA). Logistic regression analyses examined associations between noticing warnings in the past 30 days and perceptions of nicotine harm, NVP harm relative to cigarettes, and NVP addictiveness relative to cigarettes. Associations were also explored between noticing warnings and intentions to use NVPs., Results: Noticing warnings was higher among NVP users (18.8%) than nonusers (2.1%). Noticing warnings was associated with perceiving nicotine to pose little or no harm to health among NVP users, but there was no association among nonusers. There was little evidence of an association between noticing warnings and perceptions of NVP harms relative to smoking among NVP users and non-users. Noticing warnings was associated with perceiving NVPs as less addictive than cigarettes among nonusers but not NVP users. Among exclusive smokers, noticing warnings was associated with intending to start using NVPs. Among NVP users, there was little evidence of an association between noticing warnings and intentions to continue using/stopping NVPs., Conclusions: Noticing NVP warnings was not associated with increased NVP and nicotine harm perceptions or decreased intentions to use NVPs among adult smokers and vapers., Implications: Our findings suggest that noticing NVP warnings may not influence NVP risk perceptions or deter NVP use among adult smokers and vapers. Future research should investigate the impact of warnings on youth and adults who have never smoked or vaped., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Macroeconomic studies have shown that young individuals who smoke, and have a low socioeconomic status respond more strongly to price increases. Most of this evidence stems from research on factory-made (FM) cigarettes. With the rising popularity of roll-your-own (RYO) tobacco, there is a need for studies on cigarette demand that distinguish between both., Aims and Methods: This study examined whether individual demand differed for FM and RYO tobacco, and across age, and socioeconomic (income and education) groups. Purchase tasks for FM and RYO cigarettes were included in the 2020 International Tobacco Control (ITC) Netherlands Survey. Adults who smoke daily (n = 1620) stated how many cigarettes they would smoke in 24 hours across eight prices. Four demand indices were derived: intensity (consumption at zero costs), alpha (rate of change in elasticity), Pmax (turning point elasticity), and breakpoint (lowest price where consumption equals zero). The indices were tested for subgroup differences., Results: Individuals who smoke RYO tobacco indicated higher intensity, and greater alpha than individuals who smoke FM cigarettes. Participants aged 25-39 had lower Pmax, and 18-24 year olds displayed higher breakpoints. Participants with low income displayed higher intensity, and lower Pmax than other income groups. No associations were found with education., Conclusions: Individuals who smoke RYO tobacco indicated higher price sensitivity than those smoking FM cigarettes, supporting the need to harmonize tobacco taxation. Taxation may be especially beneficial to reducing consumption among individuals with a low income or smoke RYO tobacco. Substantially higher prices are needed in the Netherlands to achieve the desired results., Implications: Individuals who smoke daily were willing to pay substantially higher prices than the current market prices, indicating the room and need for much higher taxation levels. Demand for RYO tobacco was more sensitive to price changes than demand for FM cigarettes. Taxation should be raised at equivalent rates for FM and RYO cigarettes. Taxation appears to be especially effective in reducing consumption among people who smoke RYO tobacco and low-income individuals. It remains important to combine increased taxation with other tobacco control measures., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: Heated tobacco products (HTP) have diversified global tobacco markets, and user characteristics remain understudied. This study evaluated sociodemographic characteristics, nicotine-related perceptions, and behaviors of current HTP users within a sample of adult (18+ years) nicotine users across four countries., Aims and Methods: Data were from current smokers or nicotine vaping product (NVP; known as "e-cigarettes") users from Canada, England, the United States, and Australia (n = 11 421) who participated in the 2018 ITC Four Country Smoking and Vaping Survey. Current (at-least-monthly) HTP users were characterized (n = 441), and weighted multivariable logistic regressions examined correlates of HTP use., Results: Compared to nonusers, current HTP users were younger (mean age: 44.4 vs 31.0 years; p < .001) and had higher socioeconomic status (p < .001). A majority of current HTP users used HTPs nondaily (daily: 40.3% vs nondaily: 59.7%). Most HTP users concurrently used both cigarettes and NVPs (90.5%). Among concurrent cigarette-HTP-NVP users, 36.2% used all three products daily. Use of other combusted tobacco products (cigars, cigarillos, pipe, waterpipe/hookah), cannabis, and binge drinking were each associated with current HTP use. HTP use was more common among smokers intending to quit within 6 months or reporting a quit attempt in the past 18 months, and vapers who had experienced negative side effects., Conclusion: HTP users in this sample tended to be younger and more affluent. Most reported concurrent use of multiple nicotine products and other substances. Those cigarette smokers who used HTPs appeared more interested in smoking cessation, while some characteristics of concurrent HTP-NVP users were suggestive of dissatisfaction with NVPs., Implications: Few studies have scrutinized characteristics of HTP early adopters in emerging markets. Our results indicate that in 2018, characteristics of established nicotine users who adopted HTP use in four high-income Western countries mirror those of HTP users in East Asian markets (South Korea and Japan) where HTPs are popular. HTP users reported high levels of concurrent use of noncigarette-combusted tobacco products (e.g., cigars, pipe tobacco). These findings point to the need for future longitudinal studies of HTP use given the implications of those use patterns on the harm reduction potential of HTPs. HTP user characteristics may yield important information to consider in regulation of these products., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Exposure to secondhand smoke (SHS) poses serious and extensive health and economic-related consequences to European society and worldwide. Smoking bans are a key measure to reducing SHS exposure but have been implemented with varying levels of success. We assessed changes in the prevalence of self-reported SHS exposure and smoking behavior in public places among smokers in six European countries and the influence of the country's type of smoking ban (partial or total ban) on such exposure and smoking behavior., Aims and Methods: The EUREST-PLUS ITC Europe Surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, and Spain in 2016 (Wave 1, n = 6011) and 2018 (Wave 2, n = 6027). We used generalized estimating equations models to assess changes between Waves 1 and 2 and to test the interaction between the type of smoking ban and (1) self-reported SHS exposure, (2) self-reported smoking in several public places., Results: A significant decrease in self-reported SHS exposure was observed in workplaces, from 19.1% in 2016 to 14.0% in 2018 (-5.1%; 95% CI: -8.0%; -2.2%). Self-reported smoking did not change significantly inside bars (22.7% in Wave 2), restaurants (13.2% in Wave 2) and discos/nightclubs (34.0% in W2). SHS exposure in public places was significantly less likely (adjusted odds ratio = 0.35; 95% CI: 0.26-0.47) in the countries with total bans as compared to those countries with partial bans., Conclusion: The inverse association between smoking in public places and smoking bans indicates an opportunity for strengthening smoke-free legislation and protecting bystanders from exposure to SHS in public places., Implications: Prevalence of smokers engaging in and being exposed to smoking in public places varied by type of smoke-free legislation across six European Union countries in our study; those with total smoke bans reported significantly less exposure to SHS than those with partial or no bans. Our results indicate room for improvement, not only to decrease the prevalence of exposure to SHS in Europe but also to diminish the variability between countries through common, more restrictive smoke-free legislation, and importantly, strong and sustained enforcement., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Concurrent use of tobacco and cannabis may impede successful cigarette smoking cessation. This study examined whether changes in cannabis use frequency were associated with smoking cessation., Aims and Methods: Nationally representative samples of adult cigarette smokers from Canada (n = 1455), the United States (n = 892), England (n = 1416), and Australia (n = 717) were surveyed in 2016 and 2018. In each year, smokers reported how often they used cannabis in the previous 12 months. Reports were compared to determine whether cannabis use increased, remained unchanged, or decreased. Smoking cessation outcomes, measured in 2018, were (1) any attempt to quit in the previous year, (2) currently quit, and (3) currently quit for at least 6 months. Weighted multivariable logistic regression estimated the association between changes in cannabis use and cessation outcomes., Results: Cigarette smokers who increased their frequency of cannabis use were significantly less likely to be currently quit than noncannabis-using smokers (adjusted odds ratio (aOR) = 0.52, 95% CI = 0.31% to 0.86%); they were also less likely to have quit for at least 6 months (aOR = 0.30; 95% CI = 0.15% to 0.62%)., Conclusions: Smokers who increase their frequency of cannabis use have poorer smoking cessation outcomes compared to noncannabis-using smokers. It will be important to monitor the impact of cannabis legalization on patterns of cannabis use, and whether this influences cigarette smoking cessation rates., Implications: Cigarette smokers who start using cannabis may be less likely to quit cigarettes compared with smokers who do not use cannabis at all. If smokers who also use cannabis are more likely to continue smoking, it is important to monitor these trends and understand the impact, if any, on smoking cessation in jurisdictions that have legalized cannabis for nonmedical use., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: This study retrospectively describes smoking cessation aids, cessation services, and other types of assistance used by current and ex-smokers at their last quit attempt in four high-income countries., Aims and Methods: Data are from the Wave 3 (2020) International Tobacco Control Four Country Smoking and Vaping Survey in Australia, Canada, England, and the United States (US). Eligible respondents were daily smokers or past-daily recent ex-smokers who made a quit attempt/quit smoking in the last 24-months, resulting in 3614 respondents. Self-reported quit aids/assistance included: nicotine vaping products (NVPs), nicotine replacement therapy (NRT), other pharmacological therapies (OPT: varenicline/bupropion/cytisine), tobacco (noncombustible: heated tobacco product/smokeless tobacco), cessation services (quitline/counseling/doctor), other cessation support (e.g., mobile apps/website/pamphlets, etc.), or no aid., Results: Among all respondents, at last quit attempt, 28.8% used NRT, 28.0% used an NVP, 12.0% used OPT, 7.8% used a cessation service, 1.7% used a tobacco product, 16.5% other cessation support, and 38.6% used no aid/assistance. Slightly more than half of all smokers and ex-smokers (57.2%) reported using any type of pharmacotherapy (NRT or OPT) and/or an NVP, half-used NRT and/or an NVP (49.9%), and 38.4% used any type of pharmacotherapy (NRT and/or OPT). A quarter of smokers/ex-smokers used a combination of aids. NVPs and NRT were the most prevalent types of cessation aids used in all four countries; however, NRT was more commonly used in Australia relative to NVPs, and in England, NVPs were more commonly used than NRT. The use of NVPs or NRT was more evenly distributed in Canada and the US., Conclusions: It appears that many smokers are still trying to quit unassisted, rather than utilizing cessation aids or other forms of assistance. Of those who did use assistance, NRT and NVPs were the most common method, which appears to suggest that nicotine substitution is important for smokers when trying to quit smoking., Implications: Clinical practice guidelines in a number of countries state that the most effective smoking cessation method is a combination of pharmacotherapy and face-to-face behavioral support by a health professional. Most quit attempts however are made unassisted, particularly without the use of government-approved cessation medications. This study found that about two in five daily smokers used approved cessation medications (nicotine replacement therapy (NRT) or other approved pharmacotherapies, such as varenicline). Notably, nicotine substitution in the form of either NRT and nicotine vaping products (NVPs) were the most common method of cessation assistance (used by one in two respondents), but the proportion using NRT and/or NVPs varied by country. Few smokers who attempted to quit utilized cessation services such as stop-smoking programs/counseling or quitlines, despite that these types of support are effective in helping smokers manage withdrawals and cravings. Primary healthcare professionals should ask their patients about smoking and offer them evidence-based treatment, as well as be prepared to provide smokers with a referral to trained cessation counselors, particularly when it comes to tailoring intensive treatment programs for regular daily smokers. Additionally, healthcare providers should be prepared to discuss the use of NVPs, particularly if smokers are seeking advice about NVPs, wanting to try/or already using an NVP to quit smoking, have failed repeatedly to quit with other cessation methods, and/or if they do not want to give up tobacco/nicotine use completely., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: There is limited research on the role of flavors in nicotine vaping products (NVPs) in relation to smoking. We examined patterns of flavor use in NVPs in relation to progression toward quitting., Aims and Methods: Data come from 886 concurrent users of NVPs (at least weekly) and cigarettes who were first surveyed in 2016 and then successfully recontacted in 2018 as part of the ITC 4CV Surveys conducted in Australia, Canada, England, and the United States. Participants were asked about their main vaping flavor categorized as: (1) tobacco or unflavored, (2) menthol or mint flavored, and (3) "sweet" flavors (eg, fruit or candy). We examined whether flavor was associated with progression toward quitting smoking between survey years., Results: Overall, 11.1% of baseline concurrent users quit smoking by 2018. Compared with users of tobacco flavors, those vaping "sweet" flavors were more likely to quit smoking between surveys (13.8% vs. 9.6%; adjusted odds ratio [aOR] = 1.61, 95% confidence interval [CI] 1.01-2.58, p < .05), but those using menthol flavors were no more likely to quit smoking (8.3% vs. 9.6%, aOR = 0.87, 95% CI 0.43-1.47, p = .69). Among those who had quit smoking in 2018, 52.0% were still vaping, which was lower than the 65.8% among continuing smokers (aOR = 0.60, 95% CI 0.39-0.92, p = .02). Sweet flavor users were no more likely to continue vaping compared with tobacco flavor users, either for those continuing smoking or those having quit smoking by 2018. There was a net shift away from tobacco flavor among those who continued to vape at follow-up., Conclusions: Use of fruit and other sweet flavored e-liquids is positively related to smokers' transition away from cigarettes., Implications: With multiple jurisdictions considering limiting or banning the sale of flavored NVPs, it is important to consider how such policies may impact smokers using NVPs to transition away from cigarette smoking. Our results indicate that vapers who used sweet flavors were more likely to transition away from cigarette smoking and quit cigarette use, at least in the short term, compared with those who used tobacco or unflavored NVPs. Randomized clinical trials are needed to establish if the observed association between use of flavored e-liquids and smoking cessation is due to self-selection or is truly causal., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: This study explores patterns of use of non-cigarette tobacco and nicotine products among adult cigarette smokers and recent ex-smokers. Along with cigarette smoking status we explore differences as a function of countries with different product regulations, gender, and age., Methods: Data came from the ITC Four Country Smoking and Vaping Wave 3 Survey conducted between February-June 2020. The analytic sample consisted of 9112 current cigarette smokers (at least monthly) and 1184 recent ex-smokers (quit cigarettes ≤ 2 years) from Australia, Canada, England, and the United States. Respondents were asked about their cigarette smoking and current use of the following non-cigarette products: combustible tobacco (cigars, cigarillos, pipe, waterpipe); noncombustible tobacco (smokeless tobacco, and heated tobacco products [HTPs]); and non-tobacco nicotine products (nicotine vaping products [NVPs], nicotine replacement therapy [NRT], and nicotine pouches)., Results: Overall, NVPs (13.7%) and NRT (10.9%) were the most reported nicotine products used, followed by cigars (5.3%), cigarillos (4.2%), and HTPs (3.5%). More than 21% current and recent ex-smokers of cigarettes reported using a non-tobacco nicotine product and noncombustible product, with respondents in England reporting the highest levels of use (>26%). Males, younger respondents, and current non-daily cigarette smokers were more likely to use non-cigarette nicotine products. Notably, 11.6% of ex-cigarette smokers were using other combustible tobacco., Conclusion: Considerable percentages of current cigarette smokers and ex-smokers use non-cigarette nicotine products, and there are unexpectedly high levels of use of other combustible products by those recent ex-smokers of cigarettes which is concerning and has important implications for definitions of smoking cessation., Implications: The tobacco product market has evolved to include new products which add to existing non-cigarette tobacco products creating a much more diverse nicotine market. This brief report provides a snapshot of use of various combustible and noncombustible nicotine-containing products among current cigarette smokers and recent ex-smokers in four western countries. Our results indicate that use of non-cigarette tobacco and nicotine products among these cigarette smokers and recent ex-smokers is not low, particularly among males, younger and non-daily cigarette smokers. Use of other combustible tobacco among respondents that recently quit cigarette smoking is concerning and has important implications for definitions of smoking cessation. Increased emphasis on researching non-cigarette nicotine product use is warranted in tobacco control generally and smoking cessation in particular., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: This study examined in youth (12-17 years), young adults (18-24 years), and adults (25+ years): (1) the prevalence of the first menthol cigarette and menthol/mint cigar use among new tobacco users; (2) association between the first menthol/mint use, subsequent tobacco use, and nicotine dependence ~1 year later compared with the first non-menthol/mint use., Aims and Methods: Longitudinal analysis of data from Waves 1 to 4 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2017; 10 086 youth and 21 281 adults). Main outcome measures were past 12-month and past 30-day cigarette and cigar use, and nicotine dependence., Results: Youth and young adult new cigarette users are more likely to smoke a menthol cigarette or indicate that they do not know the flavor compared with adults aged 25+. A greater proportion of adults aged 25+ first used menthol/mint-flavored cigars (13.4%) compared with youth (8.5%) and young adults (7.4%). Among young adults, first use of a menthol cigarette is associated with past 12-month use of cigarettes at the subsequent wave and first use of any menthol/mint-flavored cigars is associated with past 30-day use of these products at the subsequent wave in both youth and young adults. In youth and adults, there were no significant relationships between first use of a menthol/mint cigarette or cigar and nicotine dependence scores at a subsequent wave in multivariable analyses., Conclusions: The first use of menthol/mint cigarettes and cigars is associated with subsequent cigarette and cigar use in young people aged 12-24., Implications: This study examined the relationship between initiation with menthol cigarettes and menthol/mint cigars, subsequent tobacco use, and nicotine dependence in US youth, young adults, and adults who participated in Waves 1-4 of the Population Assessment of Tobacco and Health study. New use of menthol cigarettes was associated with greater past 12-month cigarette use in young adults and new use of menthol/mint-flavored cigars was associated with greater past 30-day cigar use in youth and young adults compared with non-menthol use. Initiation with menthol/mint cigarette and cigar products may lead to subsequent use of those products., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Little is known about why males are more likely to use electronic cigarettes (ECs) compared with females. This study examined gender differences in reasons for vaping and characteristics of EC used (device type, device capacity, e-liquid nicotine strength, and flavor)., Methods: Data were obtained from 3938 current (≥18 years) at-least-weekly EC users who participated in Wave 2 (2018) ITC Four Country Smoking and Vaping Survey in Canada, the United States, England, and Australia., Results: Of the sample, 54% were male. The most commonly cited reasons for vaping in females were "less harmful to others" (85.8%) and in males were "less harmful than cigarettes" (85.5%), with females being more likely to cite "less harmful to others" (adjusted odds ratio [aOR] = 1.64, p = .001) and "help cut down on cigarettes" (aOR = 1.60, p = .001) than males. Significant gender differences were found in EC device type used (χ  2 = 35.05, p = .043). Females were less likely to report using e-liquids containing >20 mg/mL of nicotine, and tank devices with >2 mL capacity (aOR = 0.41, p < .001 and aOR = 0.65, p = .026, respectively) than males. There was no significant gender difference in use of flavored e-liquids, with fruit being the most common flavor for both males (54.5%) and females (50.2%)., Conclusion: There were some gender differences in reasons for vaping and characteristics of the product used. Monitoring of gender differences in patterns of EC use would be useful to inform outreach activities and interventions for EC use., Implications: Our findings provide some evidence of gender differences in reasons for vaping and characteristics of EC used. The most common reason for vaping reported by females was "less harmful to others," which may reflect greater concern by female vapers about the adverse effects of secondhand smoke compared with male vapers. Gender differences might be considered when designing gender-sensitive smoking cessation policies. Regarding characteristics of EC products used, we found gender differences in preferences for e-liquid nicotine strength and device capacity. Further studies should examine whether the observed gender differences in EC use reasons and product characteristics are predictive of smoking cessation. Furthermore, studies monitoring gender-based marketing of ECs may be considered., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: To test whether urges to smoke and perceived addiction to smoking have independent predictive value for quit attempts and short-term quit success over and above the Heaviness of Smoking Index (HSI)., Aims and Methods: Data were from the International Tobacco Control Four Country Smoking and Vaping Wave 1 (2016) and Wave 2 (2018) surveys. About 3661 daily smokers (daily vapers excluded) provided data in both waves. A series of multivariable logistic regression models assessed the association of each dependence measure on odds of making a quit attempt and at least 1-month smoking abstinence., Results: Of the 3661 participants, 1594 (43.5%) reported a quit attempt. Of those who reported a quit attempt, 546 (34.9%) reported short-term quit success. Fully adjusted models showed that making quit attempts was associated with lower HSI (adjusted odds ratio [aOR] = 0.81, 95% confidence interval [CI] = 0.73 to 0.90, p < .001), stronger urges to smoke (aOR = 1.08, 95% CI = 1.04 to 1.20, p = .002), and higher perceived addiction to smoking (aOR = 0.52, 95% CI = 0.32 to 0.84, p = .008). Lower HSI (aOR = 0.57, 95% CI = 0.40 to 0.87, p < .001), weaker urges to smoke (aOR = 0.85, 95% CI = 0.76 to 0.95, p = .006), and lower perceived addiction to smoking (aOR = 0.55, 95% CI = 0.32 to 0.91, p = .021) were associated with greater odds of short-term quit success. In both cases, overall R2 was around 0.5., Conclusions: The two additional dependence measures were complementary to HSI adding explanatory power to smoking cessation models, but variance explained remains small., Implications: Strength of urges to smoke and perceived addiction to smoking may significantly improve prediction of cessation attempts and short-term quit success over and above routinely assessed demographic variables and the HSI. Stratification of analyses by age group is recommended because the relationship between dependence measures and outcomes differs significantly for younger (aged 18-39) compared to older (aged older than 40) participants. Even with the addition of these extra measures of dependence, the overall variance explained in predicting smoking cessation outcomes remains very low. These measures can only be thought of as assessing some aspects of dependence. Current understanding of the factors that ultimately determine quit success remains limited., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To assess trends in daily smokers' social norms and opinions of smoking between 2002 and 2015 in Canada, the United States, the United Kingdom, and Australia., Method: Data were from wave 1 (2002) to wave 9 (2013-2015) of the longitudinal International Tobacco Control Four Country Survey (Canada, the United States, the United Kingdom, Australia), involving 23 831 adult daily smokers. Generalized estimating equation logistic regression models, adjusted for demographics and survey design effects, assessed associations of wave and country with outcomes: (A) over half of five closest friends smoke, (B) agreeing that people important to you believe you should not smoke, (C) agreeing that society disapproves of smoking, and (D) negative opinion of smoking., Results: Between 2002 and 2015, adjusting for covariates, (A) over half of five closest friends smoke did not change (56% vs. 55%; adjusted odds ratio [AOR] = 0.95 [95% Confidence Interval = 0.85-1.07]), (B) agreeing that people important to you believe you should not smoke generally decreased (89% vs. 82%; AOR = 0.54 [0.46-0.64]) despite an increase around 2006-2007, (C) agreeing that society disapproves of smoking increased between 2002 and 2006-2007 (83% vs. 87%; AOR = 1.38 [1.24-1.54]) then decreased until 2013-2015 (78%; AOR = 0.74 [0.63-0.88]), and (D) negative opinion of smoking decreased between 2002 and 2010-2011 (54% vs. 49%; AOR = 0.83 [0.75-0.91]) despite an increase around 2005-2006 and at the final wave (2013-2015). Except friend smoking, Canada had the greatest, and the United Kingdom the lowest, antismoking social norms and opinions., Conclusions: Except friend smoking and opinion of smoking, daily smokers' social norms became less antismoking between 2002 and 2015 despite increases around 2006-2007. Several potential explanations are discussed yet remain undetermined., Implications: Increasingly comprehensive tobacco control policies alongside decreasing smoking prevalence in Canada, the United States, the United Kingdom, and Australia have led to the assumption that smoking has become denormalized in these countries. Absent from the literature is any formal assessment of social norms towards smoking over time. Contrary to our hypotheses, this study found that the injunctive social norms of daily smokers became less antismoking between 2002 and 2015, despite increases around 2006-2007. There was no change over time in the proportion of daily smokers who report that over half of their five closest friends smoke., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: Although the United States has seen a rapid increase in tobacco minimum legal sales age (MLSA) laws set to age 21, there is wide variation across high-income countries and less is known about policy support outside of the United States. We examined the prevalence of support for tobacco MLSA 21 laws as well as associations by sociodemographic, smoking, and household characteristics among current and former adult smokers., Methods: In this cross-sectional analysis, we used the 2018 International Tobacco Control Four Country Smoking and Vaping Survey to examine support for MLSA 21 laws among 12 904 respondents from Australia, Canada, England, and United States., Results: Support for raising the legal age of purchasing cigarettes/tobacco to 21 ranged from 62.2% in the United States to 70.8% in Canada. Endorsement also varied by age, such that 40.6% of 18-20 years old supported the policy compared with 69.3% of those aged ≥60 years. In the adjusted regression model, there was also higher support among respondents who were female than male, non-white than white, those who did not allow smoking in the household than those that did, and those who had children in the household than those that did not. There were no differences by household income, education, or smoking status., Conclusions: Most current and former smokers, including a sizable minority of those aged ≤20 years, support raising the legal age of purchasing cigarettes/tobacco to 21., Implications: There was strong support for MLSA 21 laws among smokers and former smokers across Australia, Canada, England, and the United States, providing evidence for the increasing public support of the passage of these laws beyond the United States., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)

Aims: This study examined whether nontobacco flavors are more commonly used by vapers (e-cigarette users) compared with tobacco flavor, described which flavors are most popular, and tested whether flavors are associated with: vaping satisfaction relative to smoking, level of enjoyment with vaping, reasons for using e-cigarettes, and making an attempt to quit smoking by smokers., Methods: This cross-sectional study included 1603 adults from Canada and the United States who vaped at least weekly, and were either current smokers (concurrent users) or former smokers (exclusive vapers). Respondents were categorized into one of seven flavors they used most in the last month: tobacco, tobacco-menthol, unflavored, or one of the nontobacco flavors: menthol/mint, fruit, candy, or "other" (eg, coffee)., Results: Vapers use a wide range of flavors, with 63.1% using a nontobacco flavor. The most common flavor categories were fruit (29.4%) and tobacco (28.7%), followed by mint/menthol (14.4%) and candy (13.5%). Vapers using candy (41.0%, p < .0001) or fruit flavors (26.0%, p = .01) found vaping more satisfying (compared with smoking) than vapers using tobacco flavor (15.5%) and rated vaping as very/extremely enjoyable (fruit: 50.9%; candy: 60.9%) than those using tobacco flavor (39.4%). Among concurrent users, those using fruit (74.6%, p = .04) or candy flavors (81.1%, p = .003) were more likely than tobacco flavor users (63.5%) to vape in order to quit smoking. Flavor category was not associated with the likelihood of a quit attempt (p = .46). Among exclusive vapers, tobacco and nontobacco flavors were popular; however, those using tobacco (99.0%) were more likely than those using candy (72.8%, p = .002) or unflavored (42.5%, p = .005) to vape in order to stay quit., Conclusions: A majority of regular vapers in Canada and the US use nontobacco flavors. Greater satisfaction and enjoyment with vaping are higher among fruit and candy flavor users. While it does not appear that certain flavors are associated with a greater propensity to attempt to quit smoking among concurrent users, nontobacco flavors are popular among former smokers who are exclusively vaping. Future research should determine the likely impact of flavor bans on those who are vaping to quit smoking or to stay quit., Implications: Recent concerns about the attractiveness of e-cigarette flavors among youth have resulted in flavor restrictions in some jurisdictions of the United States and Canada. However, little is known about the possible consequences for current and former smokers if they no longer have access to their preferred flavors. This study shows that a variety of nontobacco flavors, especially fruit, are popular among adult vapers, particularly among those who have quit smoking and are now exclusively vaping. Limiting access to flavors may therefore reduce the appeal of e-cigarettes among adults who are trying to quit smoking or stay quit., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Background: The 2016 European Tobacco Products Directive (TPD) required Member States (MS) to implement new regulations for electronic cigarettes (ECs). We conducted a longitudinal study to assess changes over 2 years in smokers' support for EC policies and identify predictors of support in seven European countries after TPD implementation., Methods: Prospective cohort surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, Spain and England in 2016 (n = 9547; just after TPD) and 2018 (n = 10 287; 2 years after TPD). Multivariable logistic regression models employing generalized estimating equations assessed changes in support for four EC policies, and tested for country differences and strength of key predictors of support., Results: Banning EC use in smoke-free places was supported by 53.1% in 2016 and 54.6% in 2018 with a significant increase in Greece (51.7-66.0%) and a decrease in Spain (60.1-48.6%). Restricting EC/e-liquid nicotine content was supported by 52.2 and 47.4% in 2016 and 2018, respectively, with a significant decrease in England (54.2-46.5%) and Romania (52.5-41.0%). An EC promotion ban was supported by 41.1 and 40.2%. A flavour ban was supported by 33.3% and 32.3% with a significant increase in Hungary (34.3-43.3%). Support was generally higher in Poland, Hungary and Greece vs. England. Support was lower among dual and EC-only users, and low-income smokers., Conclusions: Smokers in all countries strongly supported banning EC use in smoke-free places and restricting nicotine content after TPD implementation, with no clear trends for changes in policy support., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: Advertising, promotion and sponsorship of electronic cigarettes (ECAPS) have increased in recent years. Since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) prohibits ECAPS in various advertising channels, including media that have cross-border effects. The objective of this study was to investigate changes in exposure to ECAPS in a cohort of smokers from six European Union member states after implementation of TPD2., Methods: Self-reported exposure to ECAPS overall and in various media and localities was examined over two International Tobacco Control Policy Evaluation survey waves (2016 and 2018) in a cohort of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal generalized estimating equations models., Results: Self-reported ECAPS exposure at both timepoints varied between countries and across examined advertising channels. Overall, there was a significant increase in ECAPS exposure [adjusted odds ratio (aOR): 1.25, 95% CI: 1.09-1.44]. Between waves, no consistent patterns of change in ECAPS exposure across countries and different media were observed. Generally, ECAPS exposure tended to decline in some channels regulated by TPD2, particularly on television and radio, while exposure tended to increase in some unregulated channels, such as at points of sale., Conclusions: The findings suggest that the TPD2 was generally effective in reducing ECAPS in regulated channels. Nonetheless, further research is warranted to evaluate its role in reducing ECAPS exposure, possibly by triangulation with additional sources of data., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: The European Tobacco Products Directive (TPD), which went into effect in May 2016, regulates packaging design and labelling of cigarettes and roll-your-own (RYO) tobacco. The aim of the current study was to examine whether smokers and recent quitters in six European Union (EU) countries (Germany, Greece, Hungary, Poland, Romania and Spain) reported noticing TPD-related changes to packaging, and correlates of noticing these changes., Methods: Cross-sectional data from the Wave 2 of the ITC 6 European Country Survey in 2018 after implementation of the TPD. Bivariate analyses included adult smokers (n = 5597) and recent quitters (n = 412). Adjusted logistic regression analyses were restricted to the subset of current smokers (n = 5597) and conducted using SAS-callable SUDAAN., Results: Over half of smokers (58.2%) and 30% of quitters noticed at least one of five types of TPD-related pack changes. Over one-quarter of all respondents noticed changes to health warnings (30.0%), standardized openings (27.7%), minimum pack unit size (27.9%), and the removal of tar, nicotine and carbon monoxide information (26.7%) on packaging. Cross-country differences were observed across all measures, with noticing all pack changes markedly lower in Spain than the other countries. Correlates of noticing specific pack changes included sociodemographic characteristics, smoking behaviours and related to packaging., Conclusions: This is one of the first cross-country studies to examine the extent to which TPD changes to cigarette and RYO tobacco packaging are being noticed by smokers and recent quitters. Findings indicate that the majority of smokers noticed at least one type of pack change, but this varied across countries and sub-populations., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: There is currently no comprehensive legislation protecting non-smokers and children from second-hand smoke (SHS) exposure in private cars at the European Union (EU) level. This study aims to assess smokers' support for smoke-free cars legislation in six EU countries., Methods: Data come from the EUREST-PLUS ITC Europe Surveys: Wave 1 (2016, n = 6011) and Wave 2 (2018, n = 6027) conducted in Germany, Greece, Hungary, Poland, Romania and Spain. Support for smoke-free cars carrying pre-school children and non-smokers and voluntary implementation of smoke-free cars were assessed among adult smokers. Generalized estimating equations models were used to assess changes in support between waves., Results: In 2018, 96.3% [95% confidence interval (CI) 95.4-97.0%] of the overall sample supported smoke-free legislation for cars carrying pre-school children, representing an increase of 2.4 percentage points in comparison to 2016. Smoke-free legislation for cars transporting non-smokers was supported by 85.2% (95% CI 83.1-87.1%) of smokers' in 2016 and 90.2% (95% CI 88.6-91.7%) in 2018. Among smokers who owned cars, there was a significant 7.2 percentage points increase in voluntary implementation of smoke-free cars carrying children from 2016 (60.7%, 95% CI 57.2-64.0%) to 2018 (67.9%, 95% CI 65.1-70.5%). All sociodemographic groups of smokers reported support higher than 80% in 2018., Conclusion: The vast majority of smokers in all six EU countries support smoke-free legislation for cars carrying pre-school children and non-smokers. This almost universal support across countries and sociodemographic groups is a clear indicator of a window of opportunity for the introduction of comprehensive legislation to protect non-smokers and children from SHS exposure in cars., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: Tobacco product packaging is a key part of marketing efforts to make tobacco use appealing. In contrast, large, prominent health warnings are intended to inform individuals about the risks of smoking. In the European Union, since May 2016, the Tobacco Products Directive 2014/40/EU (TPD2) requires tobacco product packages to carry combined health warnings consisting of a picture, a text warning and information on stop smoking services, covering 65% of the front and back of the packages., Methods: Key measures of warning label effectiveness (salience, cognitive reactions and behavioural reaction) before and after implementation of the TPD2, determinants of warning labels' effectiveness and country differences were examined in a longitudinal sample of 6011 adult smokers from Germany, Greece, Hungary, Poland, Romania and Spain (EUREST-PLUS Project) using longitudinal Generalized Estimating Equations (GEE) models., Results: In the pooled sample, the warning labels' effectiveness increased significantly over time in terms of salience (adjusted OR = 1.18; 95% CI: 1.03-1.35), while cognitive and behavioural reactions did not show clear increases. Generally, among women, more highly educated smokers and less addicted smokers, the effectiveness of warning labels tended to be higher., Conclusion: We found an increase in salience, but no clear increases for cognitive and behavioural reactions to the new warning labels as required by the TPD2. While it is likely that our study underestimated the impact of the new pictorial warning labels, it provides evidence that health messages on tobacco packaging are more salient when supported by large pictures., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: This study presents perceptions of the harmfulness of electronic cigarettes (e-cigarettes) relative to combustible cigarettes among smokers from six European Union (EU) countries, prior to the implementation of the EU Tobacco Products Directive (TPD), and 2 years post-TPD., Methods: Data were drawn from the EUREST-PLUS ITC Europe Surveys, a cohort study of adult smokers (≥18 years) from Germany, Greece, Hungary, Poland, Romania and Spain. Data were collected in 2016 (pre-TPD: N = 6011) and 2018 (post-TPD: N = 6027). Weighted generalized estimating equations were used to estimate perceptions of the harmfulness of e-cigarettes compared to combustible cigarettes (less harmful, equally harmful, more harmful or 'don't know')., Results: In 2016, among respondents who were aware of e-cigarettes (72.2%), 28.6% reported that they perceived e-cigarettes to be less harmful than cigarettes (range 22.0% in Spain to 34.1% in Hungary). In 2018, 72.2% of respondents were aware of e-cigarettes, of whom 28.4% reported perceiving that e-cigarettes are less harmful. The majority of respondents perceived e-cigarettes to be equally or more harmful than cigarettes in both 2016 (58.5%) and 2018 (61.8%, P > 0.05). Overall, there were no significant changes in the perceptions that e-cigarettes are less, equally or more harmful than cigarettes, but 'don't know' responses significantly decreased from 12.9% to 9.8% (P = 0.036). The only significant change within countries was a decrease in 'don't know' responses in Spain (19.3-9.4%, P = .001)., Conclusions: The majority of respondents in these six EU countries perceived e-cigarettes to be equally or more harmful than combustible cigarettes., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association.)

Background: The emergence of new types of tobacco and tobacco-related products on the European Union (EU) market has precipitated the possibility for both poly-tobacco use and transitions between products. In the EU, the regulatory environment has shifted with the implementation of the European Tobacco Products Directive (TPD) in May 2016, which may influence consumer transitions between products., Methods: The aim of this paper was to examine trends and transitions in tobacco products from 2016 to 2018 -before and after implementation of the TPD in the EU. Data come from Wave 1 (pre-TPD) and Wave 2 (post-TPD) of the EUREST-PLUS ITC Six European Country Survey, a cohort study of adults who at the time of recruitment were smokers from six EU countries- Germany, Greece, Hungary, Poland, Romania, and Spain. D (N = 3195). Bivariate and logistic regression analyses of weighted data was conducted using SAS-callable SUDAAN., Results: Overall, among those who smoked factory-made cigarettes (FM) only at Wave 1, 4.3% switched to roll-your-own tobacco (RYO) only. Among RYO only users at Wave 1, 17.0% switched to FM only, however compared to all other countries, respondents from Hungary had the highest percentage of FM only users at Wave 1 switch to RYO only at Wave 2 (18.0%)., Conclusions: The most prominent transition overall was from smoking RYO exclusively at Wave 1 to smoking FM tobacco exclusively at Wave 2, however this varied across countries. As the tobacco control regulatory environment of the EU develops, it is important to continue to monitor transitions between types of products, as well as trends in cessation., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

The European Tobacco Products Directive (TPD) introduced a ban on characterizing flavours in cigarettes (2016), including menthol (2020). The longitudinal data analysis of the EUREST-PLUS International Tobacco Control (ITC) Project Europe Surveys (n = 16 534; Wave 1 in 2016 and Wave 2 in 2018) found significant but small declines in the weighted prevalence of menthol (by 0.94%; P = 0.041) and other flavoured cigarette use (by 1.32%; P < 0.001) following the 2016 TPD. The declines tended to be driven primarily by the menthol and flavoured cigarette (MFC) smokers switching to unflavoured tobacco. Cigarette consumption declined between waves, but there were no statistically significant difference in decline between MFC and unflavoured tobacco smokers on smoking and cessation behaviours between the waves., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: The EUREST-PLUS ITC Europe surveys aim to evaluate the impact of the European Union's Tobacco Products Directive (EU TPD) implementation within the context of the WHO FCTC. This article describes the methodology of the 2016 (Wave 1) and 2018 (Wave 2) International Tobacco Control 6 European (6E) Country Survey in Germany, Greece, Hungary, Poland, Romania and Spain; the England arm of the 2016 (Wave 1) and 2018 (Wave 2) ITC 4 Country Smoking and Vaping (4CV) Survey; and the 2016 (Wave 10) and 2017 (Wave 11) ITC Netherlands (NL) Survey. All three ITC surveys covering a total of eight countries are prospective cohort studies with nationally representative samples of smokers., Methods: In the three surveys across the eight countries, the recruited respondents were cigarette smokers who smoked at least monthly, and were aged 18 and older. At each survey wave, eligible cohort members from the previous waves were retained, regardless of smoking status, and dropouts were replaced by a replenishment sample., Results: Retention rates between the two waves of the ITC 6E Survey by country were 70.5% for Germany, 41.3% for Greece, 35.7% for Hungary, 45.6% for Poland, 54.4% for Romania and 71.3% for Spain. The retention rate for England between ITC 4CV1 and ITC 4CV2 was 39.1%; the retention rates for the ITC Netherlands Survey were 76.6% at Wave 10 (2016) and 80.9% at Wave 11 (2017)., Conclusion: The ITC sampling design and data collection methods in these three ITC surveys allow analyses to examine prospectively the impact of policy environment changes on the use of cigarettes and other tobacco products in each country, to make comparisons across the eight countries., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: The study assessed awareness and use of heated tobacco products (HTPs) and factors that influenced these issues among cigarette smokers from six European countries in 2016 (Wave 1) and 2018 (Wave 2)., Methods: A survey was conducted among a nationally representative sample of cigarette smokers aged 18 years or older from Germany, Greece, Hungary, Poland, Romania and Spain in 2016 (N = 6011) and 2018 (N = 6027; 53% of smokers from the previous wave were retained, regardless of smoking status and dropouts were replaced by a replenishment sample of smokers). Data were collected through face-to-face interviews. Estimates were produced using weighted data. The study presents the cross-sectional results., Results: Awareness of HTPs increased from 8% to 17% between the two waves. At Wave 1, 1.1% of the smokers declared having used HTPs at least once during their lifetime; and at Wave 2, this increased to 1.9% (around 1% or less in four countries, except for Greece and Romania where it was around 4%). Factors associated with HTPs use among those who had ever heard about these products at Wave 1 were country of residence, being a daily cigarette smoker and ever use of electronic cigarettes. At Wave 2, ever use of HTPs was significantly higher among those who had tried to quit smoking combustible cigarettes in the last 12 months, had tried electronic cigarettes during lifetime and perceived HTPs as less dangerous than combustible cigarettes; the country of residence was also associated with HTPs use., Conclusion: This study offers insights into the behaviours and perceptions of European adult smokers regarding HTPs, an important emerging issue in the field of tobacco control., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: We examined quit attempts, use of cessation assistance, quitting beliefs and intentions among smokers who participated in the 2018 International Tobacco Control (ITC) Europe Surveys in eight European Union Member States (England, Germany, Greece, Hungary, the Netherlands, Poland, Romania and Spain)., Methods: Cross-sectional data from 11 543 smokers were collected from Wave 2 of the ITC Six European Country (6E) Survey (Germany, Greece, Hungary, Poland, Romania and Spain-2018), the ITC Netherlands Survey (the Netherlands-late 2017) and the Four Countries Smoking and Vaping (4CV1) Survey (England-2018). Logistic regression was used to examine associations between smokers' characteristics and recent quit attempts., Results: Quit attempts in the past 12 months were more frequently reported by respondents in the Netherlands (33.0%) and England (29.3%) and least frequently in Hungary (11.5%), Greece (14.7%), Poland (16.7%) and Germany (16.7%). With the exception of England (35.9%), the majority (56-84%) of recent quit attempts was unaided. Making a quit attempt was associated with younger age, higher education and income, having a smoking-related illness and living in England. In all countries, the majority of continuing smokers did not intend to quit in the next 6 months, had moderate to high levels of nicotine dependence and perceived quitting to be difficult., Conclusions: Apart from England and the Netherlands, smokers made few quit attempts in the past year and had low intentions to quit in the near future. The use of cessation assistance was sub-optimal. There is a need to examine approaches to supporting quitting among the significant proportion of tobacco users in Europe and increase the use of cessation support as part of quit attempts., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: Article 20 of the European Tobacco Product Directive (TPD), which went into effect in May 2016, regulates electronic cigarettes (e-cigarettes) in the European Union (EU). The aim of this study was to evaluate changes in e-cigarette use, design attributes of the products used and awareness of e-cigarette labelling and packaging among smokers from six EU Member States (MS) before and after TPD implementation., Methods: Data come from Wave 1 (2016, pre-TPD) and Wave 2 (2018, post-TPD) of the ITC Six European Country Survey among a sample of smokers and recent quitters who use e-cigarettes from six EU MS. Weighted logistic generalized estimating equations regression models were estimated to test the change in binary outcomes between Waves 1 and 2 using SAS-callable SUDAAN., Results: In 2018, current daily/weekly e-cigarette use among adult smokers was just over 2%, but this varied from the highest in Greece (4%) to lowest in Poland (1.2%). From Waves 1 to 2, there was a significant increase in respondents reporting noticing and reading health and product safety information on leaflets inside e-cigarette packaging (8.39-11.62%, P < 0.001). There were no significant changes between waves of respondents reporting noticing or reading warning labels on e-cigarette packages/vials., Conclusions: e-cigarette use among smokers in these six EU countries is low. Although reported noticing and reading leaflets included in the packaging of e-cigarettes increased significantly from before to after the TPD, there was no significant change in reported noticing and reading of warning labels. Findings indicate the importance of continued monitoring of TPD provisions around e-cigarettes., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: The prevalence of roll-your-own tobacco (RYO) in Europe has been increasing. The aim of this study was to investigate transitions between factory-made (FM) cigarettes and RYO in a longitudinal sample of European smokers, and their perceptions of relative harmfulness and knowledge of health effects., Methods: We used data collected from the EUREST-PLUS ITC 6 European Country (6E) Surveys in 2016 (n = 6011 smokers) and in 2018 (n = 6027) in Germany, Greece, Hungary, Poland, Romania and Spain. A total of 3195 cohort respondents were interviewed in both years. Use of RYO and FM, knowledge of health effects of smoking as well as perceptions about RYO were assessed. We used logistic regression models to explore sociodemographic correlates of transitions from one product to the other, of perceptions and knowledge related to smoking health effects., Results: Approximately 7.4% of exclusive FM smokers transitioned to RYO and 29.5% of exclusive RYO smokers transitioned to FM cigarettes from 2016 to 2018. RYO use in 2018 was more frequent among smokers of low education and income, but none of these factors were associated with transitions. Most RYO smokers perceived RYO as cheaper than FM and 21.7% of them considered RYO to be less harmful than FM. Knowledge of the health effects of smoking was not associated with type of product smoked., Conclusions: RYO is popular among European smokers; its lower cost seems to be a major factor for RYO users; reasons for transitions to and from RYO are less clear and need to be further investigated., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association.)

Background: The European (EU) Tobacco Product Directive (TPD) was implemented in May 2016 to regulate the design and labelling of cigarettes and roll-your-own tobacco. At the same time, the UK introduced standardized packaging measures, whereas Germany, Greece, Hungary, Poland, Romania and Spain did not. This study examines the impact of introducing standardized packaging in England using a quasi-experimental design., Methods: Data from adult smokers in Waves 1 (2016; N=9547) and 2 (2018; N=9724) from the International Tobacco Control Policy Evaluation surveys (England) and EUREST-PLUS surveys (Germany, Greece, Hungary, Poland, Romania and Spain) were used. Generalized estimating equations were used to estimate changes in pack/brand appeal, salience of health-warning labels (HWLs) and perceived relative harm of different brands in England (where larger HWLs and standardized packaging were implemented), vs. each EU country (where only larger HWLs were implemented)., Results: There was an increase in the percentage of respondents from Germany, Hungary and Poland reporting they did not like the look of the pack (4.7%, 9.6%, and 14.2%, respectively), but the largest increase was in England (41.0%). Moreover, there was a statistically significant increase in the salience of HWLs in Hungary, Poland and Romania (17.0%, 13.9%, and 15.3%, respectively), but the largest increase was in England (27.6%). Few differences were observed in cross-country comparisons of the perceived relative harm of different brands., Conclusions: Findings suggest that standardized packaging reduces pack appeal and enhances the salience of HWLs over and above the effects of larger HWLs. Findings provide additional evidence and support for incorporating standardized packaging into the EU TPD., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Background: Social norms have received little attention in relation to electronic cigarettes (EC). The current study examine social norms for EC use and smoking tobacco, and their associations with (i) initiation of EC use, (ii) intention to quit smoking and (iii) attempts to quit smoking., Methods: Cross-sectional and longitudinal data analysis from Waves 1 and 2 of the ITC 6 European Country Survey and corresponding waves from England (the ITC Four Country Smoking and Vaping Survey). Current smokers at baseline, who heard of ECs and provided data at both waves were included (n = 3702). Complex samples logistic regression examined associations between the outcomes and descriptive (seeing EC use in public, close friends using ECs/smoking) and injunctive (public approves of ECs/smoking) norms, adjusting for country, demographics, EC use and heaviness of smoking., Results: In longitudinal analyses, seeing EC use in public at least some days was the only social norm that predicted initiation of EC use between waves (OR = 1.66, 95%CI = 1.08-2.56). In the cross-sectional analysis, having an intention to quit was associated with seeing EC use in public (OR = 1.37, 95%CI = 1.04-1.81) and reporting fewer than three close friends smoke (OR = 0.59, 95%CI = 0.44-0.80). There was no association between any social norm and making a quit attempt between waves., Conclusions: Initiation of EC use is predicted by seeing EC use in public, which was also associated with greater intention to quit smoking. Friends' smoking was associated with lower intention to quit. These findings may allay concerns that increased visibility of ECs is renormalizing smoking amongst current smokers., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Introduction: "Dual use" refers to the concurrent use of tobacco cigarettes (smoking) and electronic cigarettes (e-cigarettes; vaping). Although dual use is common among e-cigarette users, there is little evidence regarding biomarkers of exposure among dual users and how these change under different conditions of product use., Methods: A nonblinded within-subjects crossover experiment was conducted with adult daily dual users (n = 48) in Ontario, Canada. Participants completed three consecutive 7-day periods in which the use of tobacco cigarettes and e-cigarettes was experimentally manipulated, resulting in four study conditions: Dual use, Tobacco cigarette use, E-cigarette use, and No product use. Repeated measures models were used to examine changes in product use and biomarkers of exposure., Results: Compared to dual use, cotinine remained stable when participants exclusively smoked (p = .524), but significantly decreased when they exclusively vaped (p = .027), despite significant increases in e-cigarette consumption (p = .001). Levels of biomarkers of exposure to toxicants, including carbon monoxide (CO), 1-hydroxypyrene (1-HOP), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), were significantly lower when participants exclusively vaped than when they engaged in dual use (CO = -41%, p < .001; 1-HOP = -31%, p = .025; NNAL = -30%, p = .017). Similar findings were observed among participants abstaining from both products as compared to dual use (CO: -26%, p < .001; 1-HOP = -14% [ns]; NNAL = -35%, p = .016). In contrast, levels of biomarkers of exposure increased when participants exclusively smoked as compared to dual use (CO = +21%, p = .029; 1-HOP = +23%, p = .048; NNAL = +8% [ns])., Conclusions: Although dual use may reduce exposure to tobacco smoke constituents to some extent, abstaining from smoking is the most effective way to reduce such exposure., Implications: Public health authorities should clearly communicate the relative risk of e-cigarettes and tobacco cigarettes to the general public, focusing on two salient points: (1) e-cigarettes are not harmless, but they are less harmful than tobacco cigarettes; and (2) using e-cigarettes while smoking may not necessarily reduce health risks; therefore, consumers should stop smoking completely to maximize potential health benefits., (© The Author(s) 2018. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)