ITC EUREST-PLUS Spain: protocol of a prospective longitudinal study of smokers in Spain

Objective: The ITC EUREST-PLUS Spain Survey is a longitudinal study of a representative sample of Spanish adult (≥18 years old) smokers. This protocol describes the methods of the 2021 follow-up survey. Method: The ITC EUREST-PLUS Survey, a prospective cohort study of a representative sample of smokers in six European countries, was conducted in 2016 (baseline) and 2018 (waves 1 and 2). The 2021 ITC EUREST-PLUS Spain Survey is a continuation of the Spanish cohort with a new interview in 2021 (wave 3). Lost participants were replaced with new smokers recruited using the same multi-stage sampling design. This latest follow-up aims to examine current patterns and transitions of tobacco use and to evaluate the impact of new tobacco-related policies. Comments: The ITC EUREST-PLUS Spain Survey will provide recent information about the impact of tobacco control policies on smoking behaviour

Depression symptoms and quitting among a nationally representative sample of smokers from Africa

Background There are mixed reports as to whether depression is associated with quitting among smokers, but almost all of these studies have been conducted in high income countries (HICs); nothing is known about this association in low- and middle-income countries (LMICs) including African countries. This is the first population-based study in Africa to examine the relationship between depression symptoms and key cessation variables—quit intentions and quit attempts. Methods Data were analyzed from the International Tobacco Control (ITC) Kenya Wave 1 (2012) and Zambia Wave 2 (2014) surveys of nationally representative samples of adult smokers (N=2,055). This study examined the relation between five symptoms of depression and quit intentions and quit attempts. Logistic regression analyses adjusted for sex, age, location, smoking status, and time-in-sample. Results 40% of Kenyan smokers and 51% of Zambian smokers had “ever” tried to quit smoking;17% of Kenyan and 27% of Zambian smokers planned to quit smoking within the next 6 months. Quit attempts were positively associated with 4 depressive symptoms: having a poor appetite (OR=2.43; 95% CI 1.61-3.67), not being able to control important things of life (OR=1.69; 95% CI 1.15-2.48), feeling sad (OR=1.59; 95% CI 1.15-2.19), and feeling that people disliked them (OR=1.39; 95% CI 1.05-2.85). Intending to quit was positively associated with 1 symptom—having a poor appetite (OR=1.76; 95% CI 1.22-2.54). Moreover, being hopeful about the future was positively associated with both quit attempts (OR=1.50; 95% CI 1.17-1.90) and intending to quit (OR=1.41; 95% CI 1.06-1.87). There were no significant differences between Zambia and Kenya. Conclusions In both Kenya and Zambia, depression symptoms were positively associated with quit attempts and quit intentions, consistent with findings from high-income ITC countries (Canada, United Kingdom, USA, Australia), suggesting that this association between depression and quit attempts/intentions is considerably broader than being limited to HICs

Low knowledge among Zambian smokers and the need for large pictorial health warnings: findings from the ITC Zambia Wave 2 survey

Background Many studies have shown that pictorial health warnings (PHWs) are more effective in increasing knowledge about the many harms of cigarettes. Zambia currently has a single text-only English warning covering less than 3% of pack. This study is the first to assess health knowledge and the effectiveness of warnings in Zambia. Methods Data were from 1,171 smokers in the International Tobacco Control (ITC) Zambia Wave 2 Survey (2014), a longitudinal survey of a nationally representative sample of Zambian adults. Key variables analyzed were knowledge of specific harms of smoking and validated indicators of warning effectiveness. Results Knowledge among Zambian smokers was very low compared to other ITC countries: only 45% knew that smoking causes stroke (2 nd lowest among 20 ITC countries), heart disease (74%--3 rd lowest among 14 ITC countries), and lung cancer (79%--lowest among 12 ITC countries). The Zambian text-only warning was very ineffective: 58% of Zambian smokers reported “never” or “hardly ever” noticing the warning; only 24% reported closely reading the warning. 75% reported that warning “never” stopped them from smoking; 70% reported that warning did not make them more likely to think about health risks; 66% reported that warning “never” made them think about quitting. When shown the warning, 55% of smokers were not able to easily read it. And yet 71% thought the packs should have more health information and 86% wanted the government to do more about harms of tobacco use. Conclusions Knowledge of tobacco-related harms is very poor among Zambian smokers and the single-text only warning provides no help, particularly among the many low literacy smokers in Zambia. There is a clear need for Zambia to implement pictorial health warnings, as they are obligated to do as a Party to the FCTC and as other African countries - Mauritius and Kenya - have already done successfully

Who is more likely to have a quit intention in Brazil's major cities? Findings from the ITC Brazil Wave 3 Survey

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

Evaluating the impact of health warnings in Brazil over 7 years (2009 - 2016): findings from the ITC Brazil Wave 1-3 surveys

Background Studies demonstrate that large pictorial warnings (PHWs) on both sides of the pack have greater impact than text-only warnings. For over a decade, Brazil has had 100% pictorial warnings but only on the back of pack. In 2009, Brazil introduced dramatic fear-arousing images. In 2016, Brazil finally added a front warning although text-only and 30%. This study evaluated the 2009 and 2016 changes on key perceptual and behavioural indicators of warning impact. Methods Data were analyzed from Waves 1-3 (2009-2016) of the International Tobacco Control (ITC) Brazil Survey, a longitudinal cohort survey of representative samples of adult smokers in Rio de Janeiro, São Paulo, and Porto Alegre (N=1,719). Key outcomes were 6 validated indicators of warning impact. The 2009 warning revision was implemented 2 months after Wave 1 (2009) and 3 years before Wave 2 (2012-13). The 2016 warning revision (introducing front 30% text warnings) was implemented 3 years after Wave 2 (2012-13) and 8 months before Wave 3 (2016-17). Thus, pre-post evaluations of the two revisions were conducted by testing differences in the impact indicators across the three waves. Results Three indicators of warning effectiveness increased significantly between W1 and W2 (showing greater effectiveness of introducing dramatic fear-arousing images of the 2009 revision) and declined at W3 (showing lack of effectiveness of introducing the front text-only warning): noticing (W1=45%; W2=51%; W3=49%), reading (W1=34%; W2=41%; W3=36%), avoiding labels (W1=43%; W2=45%; W3=34%). The remaining 3 indicators (forgoing smoking, thinking about risks, and thinking about quitting) declined at W2 and W3. Conclusions Introducing dramatic fear-arousing images (2009) increased warning effectiveness, but introducing 30% text-only front warnings (2016) did not. There was also evidence of “wearout” of warning impact. These findings demonstrate the importance of frequent warning revision, and the need for pictorial warnings on the FRONT of the pack, consistent with FCTC Article 11 Guidelines

Prevalence, perceptions and predictors of menthol cigarettes among African smokers: findings from the ITC Kenya and Zambia Surveys

Background Research in high-income countries (HICs) has raised awareness of the harms of menthol cigarettes, providing the foundation for a growing movement in HICs to ban menthol. Menthol masks the harshness of smoke, making it easier for youth to start smoking, and encouraging health-concerned smokers to switch to menthols, incorrectly believing that menthols are less harmful. There are few studies of menthols in LMICs, and almost none in Africa. We conducted the first population study in Africa to assess the prevalence of menthol cigarettes, beliefs about harmfulness of menthols, and predictors of menthol use. Methods Data were from the International Tobacco Control (ITC) Kenya Wave 1 (2012) and Zambia Wave 2 Survey (2014). These are longitudinal surveys of nationally representative samples of adults in each country. This study focuses on 1,449 smokers who answered questions on use, choice, and perceptions of menthol cigarettes (Zambia only). Results Prevalence of menthols was high in Zambia (43%, highest of 24 ITC countries) and Kenya (21%, third-highest). In Zambia, the erroneous belief that menthols are less harmful was high (36%—second-highest), and most common among younger (69%), medium-income (36%), and non-daily smokers (42%). In Zambia, menthol use was associated with: belief that menthol is less harmful (OR=3.68,p=0.01), choosing brand because of taste (OR=2.46,p=0.01), health concerns (OR=3.32,p=0.0001), and price (OR=0.31,p=0.04). In Kenya, menthol use was associated with: choosing brand because of taste (OR=3.49,p=0.0002), price (OR=1.73,p=0.05); health concerns (OR=1.57,p=0.04); and perceiving that quitting is beneficial (OR=1.78,p=0.04). Conclusions Menthol use was high in Zambia and Kenya, and predicted by health concerns. This is alarming because many smokers (in Zambia) incorrectly believe that menthols are less harmful. These findings support the need for African countries to raise awareness of the myth of menthols and to ban menthol and other flavorings to reduce initiation among youth and to encourage smokers to quit