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A growing body of evidence shows smoking is a risk factor for coronavirus disease (COVID-19). We examined the associations of quitting-related behaviors with perceived susceptibility to and severity of COVID-19 in smokers. We conducted a telephone survey of 659 community-based adult smokers (81.7% male) in Hong Kong, where there was no lockdown. Exposure variables were perceptions that smoking can increase the risk of contracting COVID-19 (perceived susceptibility) and its severity if infected (perceived severity). Outcome variables were quit attempts, smoking reduction since the outbreak of the pandemic, and intention to quit within 30 days. Covariates included sex, age, education, heaviness of smoking, psychological distress, and perceived danger of COVID-19. High perceived susceptibility and severity were reported by 23.9% and 41.7% of participants, respectively. High perceived susceptibility was associated with quit attempts (prevalence ratio (PR) 2.22, 95% CI 1.41–3.49), smoking reduction (PR 1.75, 95% CI 1.21–2.51), and intention to quit (PR 2.31, 95% CI 1.40–3.84). Perceived severity of COVID-19 was associated with quit attempts (PR 1.64, 95% CI 1.01–2.67) but not with smoking reduction or intention to quit. To conclude, the perceived susceptibility to and severity of COVID-19 in smokers were associated with quitting-related behaviors in current smokers, which may have important implications for smoking cessation amid the pandemic.

BACKGROUND AND AIMS Proactive brief cessation advice by a lay counsellor combined with a referral to a smoking cessation service (active referral) is effective in increasing service use and quitting in community smokers. We compared the effect of two modified approaches to referrals on the cessation outcomes in community smokers. DESIGN Three-arm cluster-randomized trial. SETTING General community in Hong Kong. PARTICIPANTS Daily cigarette smokers (n = 1163; 77.7% male). INTERVENTIONS Participants were randomized to receive on-site active referral (OSR, n = 395), where lay counsellors helped participants make appointments with a smoking cessation service of their choice plus tailored reminders; mobile text messaging referral (TMR, n = 385), where participants were encouraged to use a smoking cessation service via text messages; or brief cessation advice only (control, n = 383). MEASUREMENTS The primary outcome was a self-reported 7-day point-prevalence abstinence at 6 months post-treatment initiation. Secondary outcomes included 7-day point-prevalence abstinence at 3 and 18 months, biochemically validated abstinence, smoking reduction and the use of cessation services at 3, 6 and 18 months. FINDINGS Using intention-to-treat analysis, the OSR (17.7%) and TMR (17.1%) groups had significantly higher self-reported abstinence than the control (12.0%) group at 6 months [odds ratio (OR) for OSR versus control = 1.58, 95% confidence interval (CI) = 1.06-2.36; OR for TMR versus control = 1.52, 95% CI = 1.01-2.28; both P

ObjectiveTo understand Hong Kong waterpipe smoking (WPS) sales and promotion, including strategies to avoid policy enforcement, from the perspective of WPS venue staff.MethodsQualitative interviews and observations were guided by interpretive description. 20 WPS venue staff who were responsible for preparing and serving waterpipes to patrons and had worked at the bar for at least 3 months were recruited. In-depth semistructured interviews with WPS venue staff were conducted, in addition to covert and participant observations in 10 WPS venues in Hong Kong. Interpretive description involving constant comparative analysis of qualitative data was adopted to facilitate an inductive analytic approach to generate findings.ResultsTwo primary themes emerged from analyses of interview and observation data: strategies to avoid law enforcement, and perceived health and safety concerns linked to working and smoking in waterpipe venues. The findings suggest that many Hong Kong venues may be failing to comply with tobacco control policies and developing strategies to circumvent law enforcement. Moreover, waterpipe preparation, allowance of WPS and burning of charcoal in indoor areas were perceived as negatively affecting the health and safety of staff and customers.ConclusionsThe study provides preliminary evidence indicating the ineffectiveness of current tobacco control policy on WPS. Due to its risks to health and safety, and the need to sustain tobacco control efforts for their intended purpose, waterpipe-specific regulations and stricter surveillance on waterpipe sales and promotion are urgently required.

Summary Background Many smokers do not use existing free or low-cost smoking cessation services, cost-effective interventions to increase use are needed. Methods We did a 2-armed cluster randomised controlled trial (cRCT) in Hong Kong, China, to evaluate the effectiveness of active referral plus a small financial incentive on abstinence. Chinese adult smokers who smoked at least 1 cigarette per day were proactively recruited from 70 community sites (clusters). Random allocation was concealed until the recruitment started. The intervention group received an offer of active referral to cessation services at baseline plus an incentive (HK$300/US$38) after using any cessation services within 3 months. The control group received general brief cessation advice. The primary outcomes were biochemically validated abstinence at 3 and 6 months. Operating costs in real-world implementation was calculated. Trial Registry: ClinicalTrials.gov NCT03565796 . Findings Between June and September 2018, 1093 participants were randomly assigned to the intervention (n=563) and control (n=530) groups. By intention-to-treat, the intervention group showed higher validated abstinence than the control group at 3 months (8.4% vs. 4.5%, risk ratio [RR] 1.88, 95% CI 1.01-3.51, P=0.046) and 6 months (7.5% vs. 4.5%, RR 1.72, 95% CI 1.01-2.93, P=0.046). Average cost per validated abstinence was lower in the intervention (US$ 421) than control (US$ 548) group. Interpretation This cRCT has first shown that a simple, brief, and low-cost intervention with active referral plus a small monetary incentive was effective in increasing smoking abstinence and smoking cessation service use in community smokers. Funding Hong Kong Council on Smoking and Health.

Background Polytobacco product use is increasingly popular, but little is known about the prevalence, trend, and factors of such use particularly in non-western countries. Method A representative sample of 1139 current cigarette smokers aged 15+ (84.1% male) were telephone interviewed in Tobacco Control Policy-related Surveys in 2015–2017. Information collected included poly-tobacco use (PTU), smoking and socio-demographic characteristics. Associations of current PTU with related factors were analyzed using logistic regression with adjustment for confounders. Prevalence was weighted by age and sex of current cigarette users in the general population. Results Eighty-four point one percent (95% CI 81.4–86.6%) were exclusive cigarette smokers. Fifteen point nine percent (13.4–18.6%) were current polytobacco product users, 12.3% (10.2–14.8%) used one tobacco product and 2.52% (1.59–3.97%) used two tobacco products in addition to cigarette. Cigarette use with cigar was more common (6.28%, 4.75–8.27%), and the least used product with cigarette was e-cigarette (1.05%, 0.44–2.50%). The changes in overall prevalence of PTU by number of products use varied in 3 years. Current PTU was associated with being male (AOR 2.01, 95% CI 1.12–3.61), younger age (AORs range from 1.34–4.65, P for trend < .001) and less ready to quit (2.08, 1.09–3.97). Conclusions Prevalence of PTU increased slowly by year, one tobacco product use with cigarette was more common. The most used tobacco product with cigarette was cigar. Being male, younger and less ready to quit were associated with current PTU.

BackgroundPoly-tobacco product use is increasingly popular, but little is known about the patterns, trends of concomitant use, and risk factors particularly in non-western countries.MethodA representative sample of 1139 current cigarette smokers aged 15+ (84.1% male) were telephone interviewed in Tobacco Control Policy-related Surveys in 2015-2017. Information collected included poly-tobacco use (PTU), smoking and socio-demographic characteristics. Associations of current PTU with related risk factors were analyzed using logistic regression with adjustment for confounders. Prevalence was weighted by age and sex of current cigarette users in the general population.Results 15.9% (95% CI 13.4-18.6%) were current poly-users, 12.3% (10.2-14.8%) used one tobacco product and 2.52% (1.59-3.97%) used two tobacco products in addition to cigarette. The co-use of cigarette with cigar was more common and the least co-use product was e-cigarette with cigarette. By age group, proportion of co-use of cigarette with waterpipe was highest in young poly-users, older age used more cigar and self-rolling cigarette in addition to cigarette. Prevalence of two products use with cigarette was low. Trends of concomitant use were varied. Current PTU was associated with being male (AOR 2.01, 95% CI 1.12-3.61), younger age (AORs range from 1.34-4.65, P for trend < .001) and less ready to quit (2.08, 1.09-3.97). ConclusionsPrevalence of PTU increased slowly by year, co-use of one tobacco product with cigarette was more common. Being male, younger and less ready to quit were associated with current PTU. [236/250 words]

IntroductionHeated tobacco products (HTPs) are increasingly popular worldwide, but whether they aid or undermine cigarette abstinence remains uncertain. We examined the predictors of HTP initiation and the prospective association of HTP use with cigarette abstinence in community-based smokers in Hong Kong.DesignSecondary analysis of a randomised clinical trial aimed to evaluate the effectiveness of brief advice and referral for smoking cessation. The interventions were not related to HTP use.Participants and settings1213 carbon monoxide-verified daily cigarette smokers with intentions to quit or reduce smoking proactively recruited from community sites throughout Hong KongMain exposureCurrent (past 7 day) use of HTP at baseline.Main outcomeSelf-reported 7-day point-prevalence cigarette abstinence at 6 months (exclusive use of HTP permitted).ResultsAt baseline, 201 (16.6%) and 60 (4.9%) were ever and current HTP users, respectively. During the 6-month follow-up period, 110 of 1012 (10.9%) never users at baseline initiated HTPs. Younger age and higher education significantly predicted initiation. After adjusting for sociodemographic, smoking-related and quitting-related factors, current HTP use at baseline was not associated with cigarette abstinence at 6 months (adjusted prevalence ratio (aPR) 1.08, 95% CI 0.63 to 1.85). The results were similar in persistent users from baseline to 1-month/3-month follow-up (vs non-users; aPR 1.14, 95% CI 0.57 to 2.29). Use of smoking cessation service between baseline and 3-month follow-up significantly predicted cigarette abstinence (aPR 1.70, 95% CI 1.26 to 2.30).ConclusionHTP use was not associated with cigarette abstinence at 6 months in a community-based cohort of smokers with intentions to quit or reduce smoking.Trial registration detailsClinicalTrials.gov, NCT03565796.

Introduction Positive perceptions of electronic cigarettes (e-cigarettes) relative to combustible cigarettes (CCs) may erode support for endgame policies on CCs through smoking renormalization (increasing public acceptance of smoking). We investigated the associations between perceptions of e-cigarettes relative to CCs and support for endgame policies on CCs in Hong Kong. Methods Adult respondents (N=2004) were surveyed using landline random digit dialing in 2015. Perceived relative harm and relative addictiveness of e-cigarettes were combined as an overall perception of e-cigarettes relative to CCs with 5 levels and we analyzed individually ‘neutral/positive/mixed/unknown’ perceptions against the ‘negative’ perception. Five individual items with dichotomous responses assessed the support for endgame policies on CCs. Support for banning the sale/use of CCs (yes/no) was also assessed. Multivariable regressions yielded adjusted odds ratios (AORs) of supporting endgame policies (individual policy items, all 5 policy items, at least 1 policy item, banning the sale/use of CCs) in relation to perceptions of e-cigarettes relative to CCs, adjusting for age, education attainment, marital status, CC smoking status and ever e-cigarette use. Results Support for individual endgame policy items (from 51.8% to 80.0%), banning the sale (63.8%) and use (67.5%) of CCs were generally high. Few respondents perceived e-cigarettes as more harmful (16.6%) or more addictive (9.3%) than CCs. Positive perceptions of e-cigarettes (24.0%) were associated with less support for ‘ban CC sales in 10 years if there is a product providing nicotine not made from tobacco’ (AOR=0.62, 95% CI: 0.40–0.97), ‘ban CC use when it’s prevalence falls below 5%’ (AOR=0.66, 95% CI: 0.44–0.98) and ‘banning the sale of CCs’ (AOR=0.63, 95% CI: 0.42–0.94). Conclusions Positive perceptions of e-cigarettes relative to CCs were associated with less support for endgame policies on CCs in Hong Kong. Public health actions are needed to disseminate evidence-based knowledge of e-cigarettes.

Background Monetary incentive is often used to increase response rate in smokers’ survey, but such effect of prepaid and promised incentives in a follow-up survey is unknown. We compared the effect of different incentive schemes on the consent and retention rates in a follow-up survey of adult cigarette smokers. Methods This was a randomized controlled trial (RCT) in Hong Kong, China. Smokers who completed a non-incentivized baseline telephone smoking survey were invited to a 3-month follow-up, with randomization into (1) the control group (no incentive), (2) a promised HK$100 (US$12.8) incentive upon completion, (3) a promised HK$200 (US$25.6) incentive upon completion, or (4) a prepaid HK$100 incentive plus another promised HK$100 incentive (“mixed incentive”). Crude risk ratios from log-binomial regression models were used to assess if the 3 incentive schemes predicted higher rates of consent at baseline or retention at 3-month than no incentive. Results In total, 1246 smokers were enrolled. The overall consent and retention rates were 37.1 and 23.0%, respectively. Both rates generally increased with the incentive amount and offer of prepaid incentive. The mixed incentive scheme marginally increased the retention rate versus no incentive (26.8% vs 20.3%; risk ratio (RR) = 1.32; 95% CI: 1.00–1.76; P = 0.053), but not the consent rate (RR = 1.13; 95% CI: 0.93–1.38; P = 0.22). Among the consented participants, approximately 50% in the mixed incentive group received the mailed prepaid incentive, who achieved a higher retention rate than the group without incentives (82.8% vs 56.1%; RR = 1.48; 95% CI: 1.21–1.80; P

Summary Background Mobile instant messaging apps offer a modern way to deliver personalised smoking cessation support through real-time, interactive messaging (chat). In this trial, we aimed to assess the effect of chat-based instant messaging support integrated with brief interventions on smoking cessation in a cohort of smokers proactively recruited from the community. Methods In this two-arm, pragmatic, cluster-randomised controlled trial, we recruited participants aged 18 years or older who smoked at least one cigarette per day from 68 community sites in Hong Kong, China. Community sites were computer randomised (1:1) to the intervention group, in which participants received chat-based instant messaging support for 3 months, offers of referral to external smoking cessation services, and brief advice, or to the control group, in which participants received brief advice alone. The chat-based intervention included personalised behavioural support and promoted use of smoking cessation services. Masking of participants and the research team was not possible, but outcome assessors were masked to group assignment. The primary outcome was smoking abstinence validated by exhaled carbon monoxide concentrations lower than 4 parts per million and salivary cotinine concentrations lower than 10 ng/mL at 6 months after treatment initiation (3 months after the end of treatment). The primary analysis was by intention to treat and accounted for potential clustering effect by use of generalised estimating equation models. This trial is registered with ClinicalTrials.gov , number NCT03182790 . Findings Between June 18 and Sept 30, 2017, 1185 participants were randomly assigned to either the intervention (n=591) or control (n=594) groups. At the 6-month follow-up (77% of participants retained), the proportion of validated abstinence was significantly higher in the intervention group than in the control group (48 [8%] of 591 in intervention vs 30 [5%] of 594 in control group, unadjusted odds ratio 1·68, 95% CI 1·03–2·74; p=0·040). Engagement in the chat-based support in the intervention group was low (17%), but strongly predicted abstinence with or without use of external smoking cessation services. Interpretation Chat-based instant messaging support integrated with brief cessation interventions increased smoking abstinence and could complement existing smoking cessation services. Funding Hong Kong Council on Smoking and Health.

Background Little is known about the risk and addiction perceptions of e-cigarettes among Asian populations. We examined e-cigarette perceptions among young adults in Hong Kong and the association between the perceptions and e-cigarette use patterns. Methods An online survey was administered to a convenience sample of Hong Kong residents aged 18–35 (N = 1186). Measures of e-cigarette perceptions included perceived harm and addictiveness of e-cigarettes, perceived harm of secondhand e-cigarette aerosol, and perceived popularity of e-cigarette use among peers. Separate multinomial logistic regression models were conducted to examine the associations between the four perceptions and former and current use of e-cigarettes relative to never use, controlling for demographics and current cigarette smoking status. Interactions of e-cigarette perceptions and current cigarette smoking were assessed in all models. Among current e-cigarette users, bivariate exact logistic regression models were used to examine the relationships between each of the perceptions and frequent e-cigarette use (≥3 days in past 30-day vs. 1–2 days). Among participants who had never used e-cigarettes, separate multivariable logistic regression models were conducted to examine the associations between e-cigarette perceptions and susceptibility to e-cigarette use. Results Overall, 97.2% of participants were aware of e-cigarettes, and 16.1% had tried e-cigarettes (11.3% former users; 4.8% current users). Young adults perceived e-cigarettes (and aerosol) as less harmful, less addictive, and less popular than cigarettes. Current cigarette smokers reported significantly lower perceived harmfulness and addictiveness of e-cigarettes, lower perceived harmfulness of e-cigarette aerosol, and higher perceived popularity than nonsmokers. The lower degree of harm and addiction perceptions, and higher levels of popularity perceptions were associated with greater odds of e-cigarette use, and these relationships were generally stronger among nonsmokers compared to current cigarette smokers. E-cigarette perceptions were not associated with frequent e-cigarette use. Perceiving e-cigarettes (and aerosol) as less harmful and less addictive were associated with greater susceptibility to e-cigarette use. Compared to nonsmokers, current smokers were more likely to report e-cigarette use and susceptibility. Conclusions Continued monitoring of e-cigarette use and perceptions is needed. Educational programs should emphasize the potential harmful and addictive properties of e-cigarettes and the risks of secondhand exposure to e-cigarette aerosol. Electronic supplementary material The online version of this article (10.1186/s12889-019-7464-z) contains supplementary material, which is available to authorized users.

Background Large amount of financial incentive was effective to increase tobacco abstinence, but the effect of small amount is unknown. Purpose We evaluated if a small amount of cash incentive (HK$500/US$64) increased abstinence, quit attempt, and use of cessation aids. Methods A three-armed, block randomized controlled trial recruited 1143 adult daily smokers who participated in the Hong Kong “Quit to Win” Contest. Biochemically validated quitters of the early-informed (n = 379, notified about the incentive at 1-week and 1-month follow-up) and the late-informed incentive group (n = 385, notified at 3-month follow-up) received the incentive at 3 months. The validated quitters of the control group (n = 379) received the incentive at 6 months without prior notification. All subjects received brief advice, a self-help education card and a 12-page booklet. The outcomes were self-reported 7-day point prevalence of abstinence, quit attempt (intentional abstinence for at least 24 h) and use of cessation aids at 3-month follow-up. Results By intention-to-treat, the early-informed group at 3-month follow-up reported a higher rate of quit attempt (no smoking for at least 24 h) than the other 2 groups (44.1% vs. 37.4%, Odds ratio (OR) = 1.32, 95% CI 1.03–1.69, p = 0.03), but they had similar abstinence (9.2% vs. 9.7%, OR = 0.95, 95% CI 0.62, 1.45). The early- and late-informed group showed similar quitting outcomes. The early-informed group reported more quit attempts by reading self-help materials than the other 2 groups (31.4% vs. 25.3%, OR = 1.56, 95% CI 1.12–2.18, p Conclusions The small cash incentive with early notification increased quit attempt by “self-directed help” but not abstinence. Future financial incentive-based programmes with a larger incentive, accessible quitting resources and encouragement of using existing smoking cessation services are needed.

Background Most smokers do not use smoking cessation (SC) services although it increases successful quits. Passive referral providing SC information to smokers is commonly used in SC studies. Little was known about active referral in the community setting. This study aims to motivate community smokers to quit by brief SC advice using a validated AWARD model (Ask, Warn, Advise, Refer and Do-it-again) that adjunct with active referral of smokers to various SC services in Hong Kong. Methods/Design This is a single-blinded, parallel three-armed cluster randomized controlled trial (RCT) with two treatment groups of (1) brief SC advice using the AWARD model, active referral to SC services plus a referral card and a health warning leaflet (active referral group) and (2) brief SC advice using AWARD model and health warning leaflet (brief advice group) and a control group receives general very brief advice with a self-help booklet. A total of 1291 smokers will be recruited from 66 clusters (recruitment sessions) with 22 will be allocated to each of the two intervention and one control groups. SC ambassadors will be trained for delivering the interventions and conducting telephone follow-up. The primary outcomes are self-reported 7-days point prevalence (PP) abstinence at 3 and 6 months follow-up. Intention-to-treat principle and multi-level regressions will be used for data analysis. Discussion This is the first RCT on assessing a model combining brief advice and active referral to SC services among community smokers. The results will inform the practices of SC services and intervention studies. Trial registration NCT02539875 (ClinicalTrials.gov registry; registered retrospectively on 22 July 2015)

IntroductionEvidence-based smoking cessation treatments are effective but underutilised, accentuating the need for novel approaches to increase use. This trial investigates the effects of active referral combined with a financial incentive to use smoking cessation services on smoking abstinence among community smokers.Methods and analysisThis ongoing study is a two-arm, assessor-blinded, pragmatic, cluster randomised controlled trial with follow‐ups at 1, 2, 3 and 6 months after randomisation. We aim to enrol 1134 daily smokers from 70 community sites (clusters) in Hong Kong. All participants receive Ask, Warn, Advise, Refer, Do-it-again (AWARD) guided advice and a self-help booklet at baseline. Additionally, participants in the intervention group receive an offer of referral to smoking cessation services at baseline and a small financial incentive (HK$300≈US$38) contingent on using any of such services within 3 months. The primary outcomes are bioverified abstinence (exhaled carbon monoxide Ethics and disseminationThis protocol has been approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (IRB reference number: UW 18-318). The results of this trial will be submitted for publication in peer-reviewed journals, and the key findings will be presented at national and international conferences.Trial registration numberClinicalTrials.gov Registry NCT03565796.

Novel approaches to engage community smokers in smoking cessation are needed as smokers typically lack motivation to quit or use evidence-based tobacco dependence treatment. Mobile instant messaging apps (e.g., WhatsApp, Facebook Messenger) are widely used but under-studied as a mobile health modality for delivering smoking cessation support. This paper presents the rationale and study design of a trial which aims to evaluate the effectiveness of a chat-based intervention using mobile instant messaging combined with brief interventions for community smokers.This is a two-arm, parallel, accessor-blinded, pragmatic cluster-randomized controlled trial on an estimated 1172 daily cigarette smokers aged ≥18 years proactively recruited from 68 community sites (cluster) throughout Hong Kong. Subjects in intervention group received three months of chat-based, instant messaging support guided by acceptance and commitment therapy and other behavioural change techniques, integrated with brief advice and active referral to a smoking cessation service using the AWARD (Ask, Warn, Advise, Refer, Do-it-again) intervention model. Control group received brief advice to quit plus a self-help booklet at baseline. Outcomes were assessed at 1-, 2-, 3- and 6-month after baseline. The primary outcome is abstinence validated by exhaled carbon monoxide (4 ppm) and salivary cotinine (10 ng/mL) at 6-month after baseline. Primary analyses will be based on intention-to-treat.This is the first trial examining the effectiveness of a chat-based cessation support programme combined with brief interventions in promoting abstinence. The intervention model can be adapted for other behavioural change treatments and more advanced digital smoking cessation intervention.

Actively referring smokers to smoking cessation (SC) services could increase quitting and is scalable for the population. The objective of this study is to compare 2 different intensities of SC active referral for smokers in the community of Hong Kong. This is a single-blind, parallel 3-armed cluster randomized controlled trial (cRCT) consisting of high-intensity SC active referral (HAR Group), low-intensity SC referral by text messaging on promoting SC services use (Text Group) and a control group receives general very brief advice. Biochemically validated daily smokers will be proactively recruited in the community from 68 clusters (recruitment sessions). The primary outcome is self-reported 7-days point prevalence abstinence (PPA) at the 3- and 6- month follow-ups. Secondary outcomes are SC service use, smoking reduction rate (SRR, daily cigarette consumption reduced by ≥50%; excluding quitters) and biochemically validated quit rate (exhaled CO

Electronic cigarettes (e-cigarettes) have gained popularity rapidly in the Western world but data in the East are scarce. We examined the awareness and ever use of e-cigarettes, and reasons for e-cigarette use in a probability sample of adults in Hong Kong.Cross-sectional data were collected in 2014 from Chinese adults aged 15-65 in Hong Kong (819 never smokers, 800 former smokers, 800 current smokers) via computer-assisted telephone interviews (response rate: 73.8%). Analysis was limited to a subset of 809 respondents (i.e., 357 never smokers, 269 former smokers, 183 current smokers) who were randomly selected to answer questions on e-cigarettes. Chi-square analyses compared e-cigarette awareness and ever use by gender, age, education, and cigarette smoking status. Multivariable logistic regression examined if e-cigarette awareness was associated with demographic variables and cigarette smoking status.75.4% of adults had heard of e-cigarettes, and 2.3% reported having used e-cigarettes. Greater awareness was associated with male gender and higher education. Ever use of e-cigarettes was higher among males (3.6%, p=.03), younger adults (aged 15-29, 5.2%, p=.002), and current cigarette smokers (11.8%, p.001). Common reasons for using e-cigarettes were curiosity (47.4%), the stylish product design (25.8%), and quitting smoking (13.6%).Awareness of e-cigarettes was widespread in Hong Kong. Although the use of e-cigarettes was low, its relation with younger age and current smoking is of concern. Health surveillance of e-cigarette use is needed. Interventions should target young adults and cigarette smokers, and address the marketing messages, especially the effect of e-cigarettes on smoking cessation.

The present trial examined the effectiveness of brief interventions for smokers who joined the Hong Kong Quit to Win Contest to quit smoking. A block randomized controlled trial allocated 1003 adult daily smokers to three groups: (i) The TEL group (n = 338) received a 5-min nurse-led telephone counselling; (ii) The SMS group (n = 335) received eight text messages through mobile phone and (iii) The CONTROL group (n = 330) did not receive the above interventions. Participants with biochemically verified abstinence at 6-month follow-up could receive cash incentive. The primary outcome was the self-reported 7-day point prevalence (PP) of tobacco abstinence at 6-month follow-up. The abstinence rate in the TEL, SMS and CONTROL group was 22.2, 20.6 and 20.3%, respectively (P for TEL versus CONTROL = 0.32; P for SMS versus CONTROL = 0.40). When abstinence at 2-, 6- and 12-month follow-up was modelled simultaneously, the TEL group had a higher abstinence than the CONTROL group (Adjusted OR = 1.38, 95% CI = 1.01-1.88, P = 0 .04). In the Quit to Win Contest, the brief telephone counselling might have increased abstinence, but the text messages had no significant effect. Further studies on intensive intervention and interactive messaging services are warranted.

Background E-cigarettes have become increasingly popular. We examined perceptions of e-cigarettes, and their associations with e-cigarette use, frequency of use, and use susceptibility among young adults in Hong Kong. Methods An online survey was administered to 1,186 Hong Kong residents aged 18-35 in 2016-17. On a 0-10 visual scale, participants rated the perceived harm of e-cigarettes, perceived harm of secondhand exposure to e-cigarette aerosols, and perceived addictiveness. An overall perception score was calculated by averaging the values of non-missing perception items. Multinomial logistic regression examined the relationship of the overall perception score with former and current e-cigarette use relative to never use, controlling for age, gender, education, place of birth, current cigarette smoking, and perceived popularity of e-cigarettes among peers. Bivariate exact logistic regression assessed the association between perceptions and frequency of e-cigarette use (“≥3 days” vs. “1-2 days” in past 30-day) among current users. Multivariate logistic regression assessed the relationship between perceptions and e-cigarette susceptibility among never users. Results 97.2% of participants were aware of e-cigarettes, and 16.1% had ever used e-cigarettes (11.3% former users; 4.8% current users). Of current e-cigarette users, 63.2% reported infrequent use. Among never users, 34.0% were susceptible to e-cigarette use. E-cigarettes were perceived as less harmful and less addictive than cigarettes, particularly among current cigarette smokers. Low overall perception score was associated with former and current e-cigarette use, frequent use, and use susceptibility. Current cigarette smoking and perceived higher popularity of e-cigarettes were also related to e-cigarette use. Current cigarette smoking was associated with e-cigarette susceptibility. Conclusions Continued surveillance on e-cigarette use is needed. Interventions must address the conceptions about e-cigarettes. Health communication messages emphasizing the harmful and addictive nature of e-cigarette use and secondhand exposure to e-cigarette aerosols, and health warning labels on e-cigarette packages may help reduce e-cigarette use in young people.

Background Point-of-sale (POS) tobacco displays can promote smoking and purchase of tobacco in current and former smokers, but no studies have examined such effect in never smoking adults. We investigated the correlates of frequent exposure to, and responses and attitudes towards POS tobacco displays in never smokers in Hong Kong, China. Methods We included 1,833 never smokers aged 15+ years from two random telephone surveys in 2015 (n=932) and 2016 (n=901). All respondents reported how often they noticed POS tobacco displays in the past 30 days (often, sometimes, not noticing), whether they perceived displays as attractive, felt encouraged to smoke by them, perceived them as advertisements, and supported the banning displays. Risk ratio (RR) adjusting for socio-demographic characteristics was used to examine factors associated with often noticing the display and other responses. Results Young adults aged 15-29 years (vs 60+) were more likely to report often noticing POS displays (RR = 2.39, 95% CI 1.47-3.91). Those with primary education or below (vs tertiary) reported less often noticing (RR = 0.41, 95% CI 0.23-0.73), but more perceiving displays as attractive (RR = 2.52, 95% CI 1.51-4.22). Often noticing displays (vs not noticing) was associated with perceiving them as attractive (RR = 1.90, 95% CI 1.32-2.75), and being encouraged to smoke (RR = 4.05, 95% CI 0.98-16.85). Sometimes (RR = 0.89, 95% CI 0.80-0.997) or often noticing (RR=0.86, 95% CI 0.77-0.97) displays were associated with lower support for banning displays. Conclusions In never smokers, younger adults were more exposed to POS tobacco displays and those with low education level were more attracted by them. Frequent exposure could induce never smokers to smoke, and reduce their support for banning displays. To eliminate the advertising and normalization of POS tobacco displays in the retail environment, the ban on tobacco advertisements should include those displays simultaneously.

Background The harms of thirdhand smoking (THS) are being discovered, but limited studies investigated people's knowledge on these harms, especially in Asian population. Knowledge on harms of THS may increase support on tobacco control, as shown in the case of recognizing harms of secondhand smoking. We examined the association between knowledge on harms of THS and support on smokefree policies. Methods In the Tobacco Control Policy-related Survey 2015 using random digit dialing, 902 of 1834 never smoking Hong Kong citizens aged 15+ were randomly selected to report their knowledge on harms of THS and support on smokefree policies. Respondents were asked if they agreed "THS increases risk of respiratory diseases in children". Respondents also indicated their support on an overall extension of smokefree zones and banning smoking in 8 different public areas. Adjusted odds ratios (AORs) from separate logistic regressions showed the associations between knowledge on harms of THS and support on smokefree policies in never smokers, adjusting for socio-demographic characteristics Results Overall 81.0% respondents agreed "THS increases risk of respiratory diseases in children". Knowing harms of THS was associated with greater support on an overall extension of smokefree zones (AOR 2.13, 95% CI 1.32-3.45) and banning smoking in 7 out of 8 different public areas (AOR 1.86-3.42). The strongest association was found for public transport stops or waiting areas (3.42, 1.59-7.37), followed by outside seating of bars (2.91, 1.87-4.53) and all public areas in housing estates (2.75, 1.63-4.65). Conclusions Knowledge on harms of THS was associated with greater support on smokefree policies. Future prospective studies should be conducted to investigate whether increasing never smokers' knowledge on harms of THS could raise their support on smokefree policies. Ban smoking in the outside seating of restaurants Ban smoking in the outside seating of bars Ban smoking in busy streets Ban smokers using tobacco while walking on the streets Ban smoking in pedestrian zones Ban smoking in public transport stops or waiting areas Ban smoking in areas within 3 meters of office buildings Ban smoking in all public areas in housing estates THS increases risk of respiratory diseases in children Disagree or Don't know (%) 63.5 42.7 79.2 63.5 83.3 89.6 73.7 76.0 Agree (%) 78.0 66.3 86.6 77.1 87.1 96.5 85.1 89.6 Crude OR (95% CI) 2.04 (1.30-3.19) ** 2.63 (1.71-4.05) *** 1.70 (1.00-2.90) 1.94 (1.24-3.03) ** 1.35 (0.76-2.40) 3.23 (1.52-6.88) ** 2.04 (1.24-3.35) ** 2.71 (1.61-4.56) *** Adjusted OR (95% CI) 2.13 (1.35-3.34) ** 2.91 (1.87-4.53) *** 1.86 (1.08-3.20) * 2.19 (1.38-3.47) ** 1.43 (0.80-2.58) 3.42 (1.59-7.37) ** 2.11 (1.27-3.50) ** 2.75 (1.63-4.65) *** [THS harms knowledge & support on smokefree policy]

Introduction Never smokers’ responses to tobacco control policy are often overshadowed by the opposition from smokers and tobacco industry during policy advocacy and legislation. Very few studies have examined never smokers’ exposure to point-of-sale (POS) tobacco displays and their effects. Therefore, we investigated the exposure, pro-smoking responses due to and attitudes towards such displays in never smokers in Hong Kong. Methods We conducted two-stage, randomized cross-sectional telephone-based surveys in 2015 and 2016 of 1833 never-smoking adults. They were asked how often they noticed POS displays in the past 30 days (often, sometimes, never), whether they found POS displays attractive, felt encouraged to smoke, perceived POS displays as advertisements, and if they supported banning them. The distributions of the outcomes were analyzed by descriptive statistics with weighting to the general population. Risk ratios (RR) from Poisson regression models adjusted for sociodemographic characteristics were used to analyze the associations. Results Our results showed that, in never smokers, the younger were more likely to often notice POS displays (RR=0.80, 95% CI: 0.72–0.89, p

Background Youth smoking continues to be a significant global public health concern. To ensure healthier lives for youths, healthcare professionals need to increase awareness among the youth of the health risks and addictive nature of smoking, strengthen their ability to resist negative peer influence and curiosity, and help those who smoked to quit. The Smoke-free Teens Programme was launched in 2012 to equip youngsters with up-to-date information about smoking and global trends in tobacco control and to encourage them to play a pioneering role in tobacco control. This paper describes the process and outcomes of this programme for youths in Hong Kong. Methods The Smoke-free Teens Programme contained three major components: (i) a 2-day-1-night training camp; (ii) creative activities to promote smoke-free messages in schools and the community; and (iii) an award presentation ceremony to recognize the efforts of outstanding Smoke-free Teens in establishing a smoke-free culture. All secondary school students or teenagers aged 14 to 18 years from secondary schools, youth centres and uniform groups were invited to join the programme. The outcome measures were changes in (1) knowledge about smoking hazards; (2) attitudes towards smoking, tobacco control, and smoking cessation; and (3) practices for promoting smoking cessation. Results A total of 856 teenagers were recruited during the study period (July 2014 to March 2017). The results showed statistically significant changes in participants’ knowledge about smoking hazards, attitudes towards tobacco control, and practice for promoting smoking cessation. Conclusions The Smoke-free Teens Programme demonstrated effectiveness in equipping youngsters with up-to-date information about smoking and global trends in tobacco control and in encouraging them to play a pioneering role in tobacco control. The trained Smoke-free Teens not only promoted the smoke-free messages among their schoolmates, friends, and families, but also gathered community support for a smoke-free Hong Kong. The programme has been instrumental in fostering a new batch of Smoke-free Teens to advocate smoke-free culture and protect public health. Trial registration Clinicaltrials.gov ID NCT03291132 (retrospectively registered on September 19, 2017).

Objectives: To investigate the effects of ever use of electronic cigarettes (ECs), many of which lack nicotine, on abstinence from convention cigarettes among Hong Kong adult smokers. Methods: We collected data from 956 daily smokers in 2014–2015 regarding ever EC use and smoking behaviors at baseline, any and past 30-day EC use at the 3-month follow-up. Outcomes measured at 6 months included past 7-day point prevalence abstinence (PPA), biochemically validated quitting, smoking reduction (≥50% from baseline) and cessation attempt. Logistic regression yielded adjusted odds ratios (AOR) for quitting in relation to EC use, adjusting for socio-demographic characteristics and smoking profile. Complete case, missing observation as smoking and propensity score analyses were conducted. Results: By complete case, ever EC use at baseline did not predict self-reported PPA (AOR 0.99, 95% CI 0.57–1.73), biochemically validated quitting (AOR 1.22, 95% CI 0.64–2.34), cessation attempt (AOR 0.74, 95% CI 0.48–1.14), or smoking reduction (AOR 0.89, 95% CI 0.54–1.47). EC use during the first 3 months did not predict quitting (AOR 1.02, 95% CI 0.22–4.71). Similar results were observed for missing observations as smoking and propensity score analyses. Conclusions: Any use of ECs, many of which lack nicotine, did not predict smoking abstinence among Hong Kong adult smokers.

Most smoking cessation (SC) clinics are costly, passive, and underused.To compare the SC effect of a combined intervention involving brief, model-guided SC advice plus active referral to SC services (active referral group) with those of brief, model-guided SC advice only (brief advice group) and general SC advice only (control group).A single-blind, 3-arm, pragmatic cluster randomized clinical trial was conducted including 1226 adult daily smokers in the general Hong Kong community proactively recruited to participate in the Quit-to-Win Contest held in 2015. The study was conducted from June 20 to September 24, 2015. Participants were randomly allocated to the active referral (n = 402), brief advice (n = 416), and control (n = 408) groups. Intention-to-treat analysis was used.Brief telephone counseling was offered to the active referral and brief advice groups at 1 and 2 months. Interventions were delivered by SC ambassadors who had undergone a short training period.The primary outcome was the self-reported past 7-day point prevalence of abstinence (PPA) at 6 months. The secondary outcomes were carbon monoxide level-validated abstinence, smoking reduction, and SC service use.Participants included 991 (80.8%) men; mean (SD) age was 42.0 (14.8) years. The response rate was 68.2% at 3 and 72.3% at 6 months. The corresponding PPAs were 18.9% and 17.2% in the active referral group-higher than in the brief advice (8.9% and 9.4%; both P ≤ .001) or control (14.0% and 11.5%; P = .03 at 6 months) groups. Compared with the other 2 groups, the active referral group had significantly higher validated abstinence rates (10.2% at 3 months and 9.0% at 6 months, all P .05) with odds ratios of 2.84 (95% CI, 1.57-5.15) and 2.61 (95% CI, 1.46-4.68) at 3 months, and 1.85 (95% CI, 1.06-3.23) and 1.81 (95% CI, 1.04-3.16) at 6 months in the brief advice and control groups, respectively. The SC service use rate was significantly higher in the active referral group (25.1%) than in either brief advice (2.4%) or control (3.4%) groups at 6 months (P .001).An intervention involving brief advice and active referral delivered to smokers in the community by volunteers can increase quitting in places where SC services are available but underused.clinicaltrials.gov Identifier: NCT02539875.

Smoking cessation counseling by healthcare professionals is effective, but very few healthcare professionals can deliver these interventions in the busy clinical settings. This study aimed to evaluate the effectiveness of a brief smoking cessation advice delivered by briefly-trained youth counselors at the enrolment of an incentive-based smoking cessation campaign. The study design was a cluster 2-arm randomized controlled trial of 831 Chinese adult smokers who were recruited in public areas to participate in the Hong Kong Quit to Win Contest 2010. The intervention group (n = 441) received a 5-min quitting advice from the youth counselors, who were mainly undergraduate nursing students, and a 12-page self-help smoking cessation booklet at the enrolment, while the control group (n = 390) only received the same booklet. Biochemically confirmed quitters at 6-month follow-up could join a lucky draw that offered HK$10,000 (US$1282) cash prize to three winners and HK$4000 gift vouchers to the other 10 winners. Primary outcome was self-reported smoking abstinence at 6-month follow-up. By intention-to-treat, the intervention group had a non-significantly higher self-reported (18.4 versus 13.8%, OR = 1.40, 95% CI 0.96–2.04, p = 0.08) and validated quit rate (9.1 versus 6.7%, OR = 1.40, 95% CI 0.84–2.33, p = 0.20) than the control group at 6-month follow-up. The analysis with multiple imputation for missing data also found similar results. We concluded that the brief on-site advice by trained youth counselors had a modest effect on smoking cessation, but the effect was not significant. Future studies with larger sample size and results from higher participation of the biochemical validation to confirm the effectiveness are warranted.

IntroductionWe investigated heated tobacco products (HTPs) use and associated factors in Chinese adults in Hong Kong where HTPs are not formally marketed yet, and cigarette smoking prevalence was the lowest in the developed world.MethodsA population-based landline telephone survey in 2017 interviewed 5131 (45.2% male; 26.7% aged ≥60) adults to collect information on awareness, intention to use, ever use of HTPs, cigarette smoking status and sociodemographic characteristics. Descriptive statistics were weighted by the age, sex and smoking status of the Hong Kong adult population. Sociodemographics were mutually adjusted in logistic regression to yield adjusted ORs (AORs) for awareness of HTPs, controlling for smoking status.ResultsOverall, 11.3% (95% CI 10.0% to 12.7%) were aware of HTPs and 1.0 % (0.8%–1.2%) had ever used it. Awareness was associated with aged 40–49 years (AOR 1.37, 95% CI 1.01 to 1.87) or 30–39 years (2.03, 1.41–2.91) (vs ≥60 years), born in Hong Kong (1.37, 1.11–1.68) and higher monthly household income (p for trend 0.001). Ever HTP users had higher educational attainment and monthly household income, and more were aged 30–39 and economically active (all pConclusionHigher socioeconomic status was associated with HTP use and intention to use. Public health education on HTPs is needed especially for this high-risk group.