Article Text

Download PDFPDF
Banning tobacco price promotions, smoking-related beliefs and behaviour: findings from the International Tobacco Control Four Country (ITC 4C) Survey
  1. Sherine El-Toukhy1,
  2. Kelvin Choi1,
  3. Sara C Hitchman2,
  4. Maansi Bansal-Travers3,
  5. James F Thrasher4,
  6. Hua-Hie Yong5,
  7. Richard J O’Connor3,
  8. Ce Shang6
  1. 1 Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland, USA
  2. 2 Department of Addictions, Institute of Psychiatry, Psychology and Neuroscience, King’s College London; UK Centre for Tobacco and Alcohol Studies, London, UK
  3. 3 Department of Health Behavior, Division of Cancer Prevention and Population Sciences, Roswell Park Cancer Institute, New York, New York, USA
  4. 4 Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
  5. 5 The Cancer Council Victoria, Victoria, Australia
  6. 6 Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
  1. Correspondence to Dr Sherine El-Toukhy, Division of Intramural Research, National Institute on Minority Health and Health Disparities, The National Institutes of Health, Building 3, Room 5E11, 9000 Rockville Pike, Bethesda, MD 20892, USA; sherine.el-toukhy{at}


Background Ecological models emphasise multilevel influences on health behaviours. While studies show that exposure to price promotions is associated with smoking behaviour and its antecedents, less is known about whether these associations differ by macro-level factors such as national price promotion policies.

Methods Current and former smokers (N=4698) from the International Tobacco Control Policy Evaluation Project four-country cohort were included in weighted multivariate logistic regression models to examine individual-level associations between exposure to price promotions at waves 7 and 8 (conducted in 2008–2009 and 2010–2011) and beliefs (social and injunctive norms, functional value of smoking, misconceptions around smoking and beliefs of tobacco industry and its regulations) and behaviour at wave 8, stratified by whether countries allow (Australia and USA) or ban (Canada and UK) price promotions.

Results Associations between exposure to price promotions and smoking-related beliefs and behaviour differed by national price promotion policies. In countries that allow price promotions, participants repeatedly exposed to price promotions at waves 7 and 8 were more likely to associate functional values to smoking (ie, calms down when stressed (adjusted OR (AOR) 1.83) and to be current smokers at wave 8 (AOR 1.94). In countries that ban price promotions, participants repeatedly exposed to price promotions were less likely to hold misconceptions around smoking (ie, harsher smoke is more dangerous).

Conclusions Differential associations emerged between exposure to price promotions, smoking-related beliefs and behaviour across countries with and without a price promotions ban. Adopting price promotion bans could ameliorate the associations between exposure to price promotions and smoking beliefs and behaviours.

  • International health
  • Smoking behavior
  • Smoking-related beliefs
  • Tobacco-control policy
  • Tobacco price promotions

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors Drs SE-T and KC conceptualised the study. Dr SE-T ran the analyses and drafted the manuscript. Drs SCH, MB-T, JFT, HHY, RJO and CS provided input on the analysis plan, helped interpret the results and critically reviewed the manuscript. Drs SE-T and KC are responsible for the overall content as guarantors.

  • Funding The data collection for the ITC 4 Country Project is supported by grants R01 CA 100362 and P50 CA111236 (Roswell Park Transdisciplinary Tobacco Use Research Center) and P01 CA138389, R01 CA090955 from the National Cancer Institute of the USA, Robert Wood Johnson Foundation (045734), Canadian Institutes of Health Research (57897, 79551, and 115016), Commonwealth Department of Health and Aging, Canadian Tobacco Control Research Initiative (014578), National Health and Medical Research Council of Australia (265903, 450110, 1005922), Cancer Research UK (C312/A3726, C312/A6465, C321/A11039, C312/A11943). Additional support was provided to Geoffrey T. Fong from a Senior Investigator Award from the Ontario Institute for Cancer Research and a Prevention Scientist Award from the Canadian Cancer Society Research Institute. Drs SE-T and KC’s effort is supported by the Division of Intramural Research, The National Institute on Minority Health and Health Disparities, The National Institutes of Health. Dr SCH is a member of the UK Centre for Tobacco & Alcohol Studies, a UK Clinical Research Collaboration under Public Health Research Centre of Excellence whose work is supported by funding from the Medical Research Council, British Heart Foundation, Cancer Research UK, Economic and Social Research Council, and the National Institute for Health Research under the auspices of the UK Clinical Research Collaboration (MR/K023195/1).

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The ITC US Surveys were cleared for ethics by Research Ethics Boards or International Review Boards at the University of Waterloo (Canada), Roswell Park Cancer Institute (USA) and Medical University of South Carolina (USA).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data from the International Tobacco Control Policy Evaluation (ITC) Project are available to approved researchers 2 years after the date of issuance of cleaned data sets by the ITC Data Management Centre. Researchers interested in using ITC data are required to apply for approval by submitting an International Tobacco Control Data Repository (ITCDR) request application and subsequently to sign an ITCDR Data Usage Agreement. To avoid any real, potential or perceived conflict of interest between researchers using ITC data and tobacco-related entities, no ITCDR data will be provided directly or indirectly to any researcher, institution or consultant that is in current receipt of any grant monies or in-kind contribution from any tobacco manufacturer, distributor or other tobacco-related entity. The criteria for data usage approval and the contents of the Data Usage Agreement are described online (