1. SRNT Preconference, Florence, Italy, March 2017
How regulation may have affected vaping and smoking: Findings from the ITC project Ron Borland PhD Nigel Gray Distinguished Fellow in Cancer Prevention, Cancer Council Victoria On behalf of all ITC-4 Country team
SRNT Preconference, Florence, Italy, March 2017

2. Off-label meds: No recommendations made
This ITC research organization/research support slide should be in all ITC presentations this year. This is current as of Jan 2017 (version date = Sept 9, 2016). We will update if necessary (e.g., if additional countries come onboard).
There is a space in the bottom left for your institution’s logo.
Funding: See logos
COI: None
Off-label meds: No recommendations made

3. Policy evaluation Policies affect whole populations
Yet until recently there have been few systematic efforts to evaluate their effects
ITC study has been the first large-scale attempt to provide as strong as possible evidence base for virtually any policy that has, or is likely to have modest and/or delayed effects
c/f price

4. Demonstrating policy impacts
Has there been any change in the target behaviour or its determinants?
Do the patterns of change differ from comparable jurisdictions which did not implement the policy, or implemented a different policy?
Are there any other plausible by-country differences that could explain observed differences?

5. ITC Project
Aim to evaluate policies and mass disseminated interventions
Follows cohorts of smokers in different countries
Common methodology
Assesses mediational pathways
Embedded natural experiments
Demonstrate differential effects when policy introduced

6. Vaping and its effects on smoking
Patterns of use
Prevalence of use
Use to try to quit smoking
Intensity/patterns of use
Where used
Relevant beliefs and attitudes
Acceptability
Harmfulness
Enjoyment/Satisfaction (users only)
Future intentions: to use or not use

7. Results – Trends in EC use (ITC data)
USA: 18.6% is the cohort and 30.2% is the replenishment sample (web)
The use of ECs among smokers has increased dramatically between survey waves in all four countries
However, EC prevalence in recent years ( ) is lower in the two countries with strict regulation—Australia (0.6% in 2010 and 11.6% in 2014) and Canada (1.3% in 2010 and 8.3% in 2013)—than in the two countries with liberal EC environments—the UK (4.5% in 2010 and 27% in 2014) and US (5.6% in 2010 and 27.7% in 2015)

8. Current levels of use (Summary of 3 slides presented)
Canadian use has accelarated towards UK and US
Up to around half of all nicotine users
Australian use has increased, but less
Most use is not daily, indeed most is less than weekly (ie is not part of any regular pattern), so can be treated as experimental
Dual daily users smoke less

9. Patterns of use Most vaping is not daily use
Especially in Aust, much is occasional
Dual use is higher than sole use
Not a lot of dual daily use
Daily users more likely to be using nicotine and more likely to be ex-smokers

10. Where bought (slide summary)
Canada mainly vape shops
Australia: Internet
UK and US more coonventional stores
Differences sizeable but not overwhelming

11. Quitting activity and vaping
data
Separating out those who only reported use of e-cigarette (vaping)
Assessed outcome
quit for at least 1 month
Yong et al, NTR, 2017

12. US & UK (liberal policy) AU & CA (restrictive policy)
Effectiveness of using e-cig for quitting: Outcome=Sustained abstinence 1m or more (No meds/ecig as ref)
US & UK (liberal policy)
N=757 (n=805)
AU & CA (restrictive policy)
N=1042 (n=1235)
Help at last quit attempt n
% quit OR
95%CI
No meds or
no e-cigarette
308
58.4
ref
555
56.2
E-cigarette only
145
73.2
1.95 ** 50
31.5
0.36 **
NRT only
69.7
1.64
286
59.6
1.15
Varenicline or
bupropion only
100
74.4
2.07 *
222
68.5
1.69 **
Combination help 98
67.9
1.51
114
56.4
1.01
Don’t Know or No info 10
68.4
1.54 8
45.1
0.64
Previous work we have done suggests that the 3 individual measures of Light beliefs can be combined into a scale as they are reasonably correlated with each other and the resulting scale has acceptable internal reliability. For the purpose of this presentation, I will only be presenting the results for the combined scale although we have done parallel analyses using the individual items and found the pattern of results was very similar.
From Yong et al, NTR, 2017

13. Possible reasons Use of inferior products
In low reg countries, tank systems were associated with better outcomes
Not enough data in restricted countries
Less use of nicotine in high reg countries
Reduced regular supplies
Less social supports

14. Results – Trends in EC use at last quit attempt
CA and US: Wave 9
UK and AU, Wave 9 and 10
At LQA in 2013, more smokers used an EC in the UK than in Canada and Australia (P<0.001). The US had much lower use of an EC at LQA in 2015 (11%) compared to Australia (19.8%) and the UK (54.7%) in 2014 which could represent methodological or EC marketing differences
By Wave 10 (2014), 54.7% of UK smokers reported any-use of EC at their last quit attempt (34.5% used an EC only) compared to 19.8% of Australian smokers (11.0% EC only, P<0.001) which reflects different regulatory environments

15. Quitting
Around half used vaping on last quit attempt (less in Australia)
Around half used tank systems (less in US)
Among daily vapers few younger smokers have quit smoking, but among older smokers around half have.

16. Perceived harmfulness
Belief that vaping is a lot less harmful than smoking has declined where we have prior data and is now similar at around 20% in all 4 ITC-4 countries

17. Summary After a period of divergence Canada has caught up in use
Countries appear to be converging again
Canada has caught up in use
Role of authorities ignoring vape shops
The nature of the market appears to be having some effects on purchase patterns and what devices are used
Beliefs about harm have become more distorted
But perhaps not affecting behaviour much

18. Summary (cont)
Very high levels of dual use, especially occassional use, more so among young
Among daily vapers dual daily use declines with age
Older more likely to use to quit

19. Reminder of limitations
Data presented largely preliminary
Earlier established data is mainly of historical interest
Given rapid changes
Use these data to focus on patterns not as precise estimates

20. Conclusions Vaping appears to be here to stay
Public policy is having a smaller effect than we might expect
But some may have huge consequences
Lack of enforcement = approval
Current vaping not good enough to kill off smoking, especially in those where quitting is less urgent (young)
Can we push more to quit with improved policies?

21. Contact: Ron.Borland@cancervic.org.au
Thank you
My work has focussed on population-level behaviour change to improve future health
Frustrated both be a general neglect of theory in population health, at least in part because of the obvious limitations of existing theories
Ideas which I have come to from trying to work in an integrated way on tobacco and to a lesser extent on sun protection, I was pointed to strongly parallel developments within experimental psychology: eg Strack and Deutsch
Contact: