The impact of vaping and regulatory environment on cigarette demand: behavioral economic perspective across four countries.

Government regulations of nicotine vaping products (NVP) have evolved rapidly during the past decade. The impact of NVP regulatory environment and vaping on cigarette demand is unknown. The current study aims to investigate whether or not respondents' reported cigarette demand, as measured by a hypothetical cigarette purchase task, varies with (1) smoking status, (2) vaping status or (3) NVP regulatory environment (country used as proxy). Cross-sectional survey data from wave 1 of the International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey (2016). Australia, Canada, England and the United States. A total of 10 316 adult smokers. A hypothetical purchase task asked smokers to estimate how many cigarettes they would purchase for consumption in a single day across multiple cigarette prices. Responses were used to derive measures of cigarette demand. Overall sensitivity of cigarette consumption to price increases was quantified to index cigarette demand elasticity, whereas estimated consumption when cigarettes are free was used to index cigarette demand intensity. A majority of the non-daily smokers had previously smoked daily (72.3%); daily vapers were more likely to be former daily smokers (89.9%) compared to non-daily vapers (70.1%) and non-vapers (69.2%) (P < 0.001). The smoking status × vaping status interaction was significant for cigarette demand intensity (F = 4.93; P = 0.007) and elasticity (F = 7.30; P = 0.001): among non-daily smokers, vapers reported greater intensity but lower elasticity (i.e. greater demand) relative to non-vapers (Ps < 0.05). Among daily smokers, daily vapers reported greater intensity relative to non-vapers (P = 0.005), but vaping status did not impact elasticity (Ps > 0.38). Intensity was higher in Australia compared with all other countries (Ps < 0.001), but elasticity did not vary by country (F = 2.15; P = 0.09). In a hypothetical purchase task, non-daily smokers showed lower price elasticity if they used e-cigarettes than if they did not, while there was no clear difference in elasticity between e-cigarette users and non-users among daily smokers or according to regulatory environment of their country with regard to e-cigarettes.

Heckman BW ，Fong GT ，Borland R ，Hitchman S ，O'Connor RJ ，Bickel WK ，Stein JS ，Yong HH ，Nahhas GJ ，Pope DA ，Shang C ，Cheng KW ，Levy DT ，Cummings KM ... -  《-》

Indicators of cigarette smoking dependence and relapse in former smokers who vape compared with those who do not: findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey.

It has been proposed that many smokers switch to vaping because their nicotine addiction makes this their only viable route out of smoking. We compared indicators of prior and current cigarette smoking dependence and of relapse in former smokers who were daily users of nicotine vaping products ('vapers') or who were not vaping at the time of survey ('non-vapers'). Cross-sectional survey-based comparison between vaping and non-vaping former smokers, including a weighted logistic regression of vaping status onto predictor variables, adjusting for covariates specified below. United States, Canada, Australia and England. A total of 1070 people aged 18+ years from the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Wave 1 Survey who reported having ever been daily smokers but who stopped less than 2 years ago and who were currently vapers or non-vapers. Dependent variable was current vaping status. Predictor variables were self-reported: (1) smoking within 5 minutes of waking and usual daily cigarette consumption, both assessed retrospectively; (2) current perceived addiction to smoking, urges to smoke and confidence in staying quit. Covariates: country, sample sources, sex, age group, ethnicity, income, education, current nicotine replacement therapy use and time since quitting. Vapers were more likely than non-vapers to report: (1) having smoked within 5 minutes of waking [34.3 versus 15.9%, adjusted odds ratio (aOR) = 3.74, 95% confidence interval (CI) = 1.99, 7.03), χ2  = 16.92, P < 0.001]; having smoked > 10 cigarettes/day (74.4 versus 47.2%, aOR = 4.39, 95% CI = 2.22, 8.68), χ2  = 18.18, P < 0.001); (2) perceiving themselves to be still very addicted to smoking (41.3 versus 26.2%, aOR = 2.89, 95% CI = 1.58, 5.30, χ2  = 11.87, P < 0.001) and feeling extremely confident about staying quit (62.1 versus 36.6%, aOR = 3.22, 95% CI = 1.86, 5.59, χ2  = 17.36, P < 0.001). Vapers were not more likely to report any urges to smoke than non-vapers (27.7 versus 38.8%, aOR = 0.86, 95% CI = 0.44, 1.65, χ2  = 0.21, P = 0.643). While former smokers who currently vape nicotine daily report higher levels of cigarette smoking dependence pre- and post-cessation compared with former smokers who are current non-vapers, they report greater confidence in staying quit and similar strength of urges to smoke.

McNeill A ，Driezen P ，Hitchman SC ，Cummings KM ，Fong GT ，Borland R ... -  《-》

Characteristics of nicotine vaping products used by participants in the 2016 ITC Four Country Smoking and Vaping Survey.

The regulatory environment for nicotine vaping products (NVPs) varies widely across countries and this will probably affect the devices used, nicotine content and usage, and hence the ability of NVPs to substitute for cigarettes. We aimed to describe the types of NVPs used by current vapers in four countries with varying regulatory and enforcement approaches toward the marketing and sale of NVPs. Data are from wave 1 (July-November 2016) of the ITC Four Country Smoking and Vaping Survey (4CV1), conducted among a cohort of current and former smokers, and current NVP users (n = 5147 adults; ≥ 18 years) in Australia (AU), Canada (CA), England (EN) and the United States (US) reporting either current daily, weekly or occasional NVP use. Devices were described by type, brand, voltage variability and refill capacity. Refill solutions were described by flavour and nicotine content. Descriptive statistics and bivariate analyses were conducted on the overall sample and stratified by country. A multinomial logistic regression examined factors associated with device preference across the whole sample. The types of NVPs used differed by pattern of use and country. Exclusive, daily vapers were more likely to use refillable pen-shaped devices [odds ratio (OR) = 10.0] or refillable box-shaped devices (OR = 5.4) than disposable cigalike devices, when compared with other (non-daily/dual) users. Nearly all respondents reported using flavoured NVPs, fruit (28.3%) being the most common flavour. Refillable devices were the most popular: refillable box-shaped devices were more commonly reported by vapers in AU (36.8%) and US (31.4%), whereas in EN (47.4%) and CA (29.7%), vapers more often reported using refillable pen-style devices. Most users also reported that their products contained nicotine, even in CA (87.8%) and AU (91.2%), where vaping products containing nicotine were technically illegal. In Australia, Canada, England and the United States in 2016, refillable nicotine vaping products were the most common type of nicotine vaping products used by daily vapers. Most daily vapers reported using flavoured e-liquids/refills (with variance across countries) and most reported using products that contain nicotine, even where vaping products with nicotine were banned.

O'Connor RJ ，Fix BV ，McNeill A ，Goniewicz ML ，Bansal-Travers M ，Heckman BW ，Cummings KM ，Hitchman S ，Borland R ，Hammond D ，Levy D ，Gravely S ，Fong GT ... -  《-》

Exposure to and perceptions of health warning labels on nicotine vaping products: findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey.

The presence and content of health warning labels (HWLs) on nicotine vaping products (NVPs), such as electronic cigarettes, varies by country and manufacturer. We compared proportions of people who report (i) noticing HWLs on NVPs and (ii) feeling concerned having noticed HWLs, by country and by smoking or vaping status. We also examined recall of HWL content and whether this varies by country. Cross-sectional survey. Australia (AU), Canada (CA), England (EN) and the United States (US). At the time of data collection, HWLs on NVPs were only mandatory in EN. A total of 11 561 respondents from the following samples in the 2016 International Tobacco Control Four Country Project: (1) re-contacted smokers and quitters who had participated in the previous wave of the project; (2) newly recruited current smokers and recent quitters; and (3) newly recruited current vapers from CA, EN and US. Outcomes included: (1) having noticed HWLs on NVPs, (2) feeling concerned having noticed HWLs, and (3) recall of HWL message content. Compared with respondents in EN, respondents in CA were more likely to report having noticed HWLs [odds ratio (OR) = 1.58, P = 0.02], whereas respondents in AU (OR = 0.76, P = 1.00) and the US (OR = 1.54, P = 0.09) were not significantly more or less likely to report having noticed HWLs. Compared with concurrent smokers and vapers, daily smokers, non-daily smokers and quitters were less likely to report having noticed HWLs (ORs = 0.21, 0.33 and 0.19, respectively, all P < 0.001). There were no significant differences in reports of noticing HWLs when comparing concurrent smokers and vapers with daily (OR = 1.62, P = 0.91) or non-daily (OR = 1.15, P = 1.00) vapers. There were no significant differences by country in reporting that HWLs made them concerned about using NVPs. Daily vapers were less likely to report feeling concerned than concurrent users (OR = 0.11, P = 0.017). Among those who reported reading HWLs (n = 688), there was little evidence of differences in recall of the HWL content. Respondents in England, where health warning labels on nicotine vaping products are mandatory, were not significantly more likely to report having noticed such warnings than those in Australia, Canada and the United States where warnings are not mandatory.

McDermott MS ，Li G ，McNeill A ，Hammond D ，Thrasher JF ，O'Connor RJ ，Cummings KM ，Borland R ，Fong GT ，Hitchman SC ... -  《-》

Differences in norms towards the use of nicotine vaping products among adult smokers, former smokers and nicotine vaping product users: cross-sectional findings from the 2016 ITC Four Country Smoking and Vaping Survey.

To examine whether norms towards nicotine vaping product (NVP) use varied between Australia, Canada, England and the United States and by socio-demographics, smoking and NVP status. Cross-sectional data from the 2016 ITC Four Country Smoking and Vaping Survey. Four countries with distinct regulatory policies relating to the sale and advertising of NVPs: Australia (most restrictive), Canada (restrictive), England and the United States (least restrictive). A total of 10900 adult (age 18+) current smokers, former smokers, or at least weekly NVP users. Respondents were from Australia (n = 1366), Canada (n = 3309), England (n = 3835) and the United States (n = 2390). Questions permitted the categorization of respondents as current smokers, former smokers, NVP users and socio-demographic categories (sex, age, country, ethnicity, income and education). Further questions were asked regarding the frequency of exposure to NVPs in public, whether they had a partner or close friends who vaped and whether they believed society or those considered important to them approved of NVPs. Adjusting for relevant covariates, compared with Australian respondents, those in England, Canada and the United States were more likely to report frequent exposure to NVPs in public (83.1%, 57.3% and 48.3%, respectively, compared to 19.8% in Australia; P < 0.0001), having a partner who vaped (13.8%, 7.1% and 7.7%, respectively, compared to 2.1% in Australia; P < 0.0001) and having close friend(s) who vaped (31.7%, 25.3%, 20.9%, respectively, compared to 10.0% in Australia; P < 0.0001). Compared with Australian respondents, respondents from England were more likely to report that society (27.6% compared to 12.3% in Australia; P < 0.0001) and people important to them approved of NVP use (28.9% compared to 14.3% in Australia; P < 0.0001). Norms towards nicotine vaping product (NVP) use appear to vary among countries with different regulatory contexts regarding sales and advertising.

Aleyan S ，East K ，McNeill A ，Cummings KM ，Fong GT ，Yong HH ，Thrasher JF ，Borland R ，Hitchman SC ... -  《-》