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Cross-country comparison of smokers' reasons for thinking about quitting over time: findings from the International Tobacco Control Four Country Survey (ITC-4C), 2002–2015
  1. Karin A Kasza1,
  2. Andrew J Hyland1,
  3. Ron Borland2,
  4. Ann McNeill3,
  5. Geoffrey T Fong4,5,6,
  6. Matthew J Carpenter7,
  7. Timea Partos3,
  8. K Michael Cummings7
  1. 1Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, New York, USA
  2. 2Cancer Council Victoria, Melbourne, Victoria, Australia
  3. 3National Addiction Centre and Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
  4. 4School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
  5. 5Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
  6. 6Ontario Institute for Cancer Research, Toronto, Ontario, Canada
  7. 7Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
  1. Correspondence to Karin A Kasza, Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY 14263, USA; karin.kasza{at}


Objective To explore between-country differences and within-country trends over time in smokers' reasons for thinking about quitting and the relationship between reasons and making a quit attempt.

Methods Participants were nationally representative samples of adult smokers from the UK (N=4717), Canada (N=4884), the USA (N=6703) and Australia (N=4482), surveyed as part of the International Tobacco Control Four Country Survey between 2002 and 2015. Generalised estimating equations were used to evaluate differences among countries in smokers' reasons for thinking about quitting and their association with making a quit attempt at follow-up wave.

Results Smokers' concern for personal health was consistently the most frequently endorsed reason for thinking about quitting in each country and across waves, and was most strongly associated with making a quit attempt. UK smokers were less likely than their counterparts to endorse health concerns, but were more likely to endorse medication and quitline availability reasons. Canadian smokers endorsed the most reasons, and smokers in the USA and Australia increased in number of reasons endorsed over the course of the study period. Endorsement of health warnings, and perhaps price, appears to peak in the year or so after the change is introduced, whereas other responses were not immediately linked to policy changes.

Conclusions Differences in reasons for thinking about quitting exist among smokers in countries with different histories of tobacco control policies. Health concern is consistently the most common reason for quitting and the strongest predictor of future attempts.

  • Public policy
  • Packaging and Labelling
  • Price
  • Media

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  • Contributors KAK conducted the statistical analysis and drafted the initial manuscript; all authors contributed to study conceptualisation, data interpretation and manuscript revision.

  • Funding The ITC Four Country Survey has been funded by the US National Cancer Institute (P50 CA111326, P01 CA138389, R01 CA100362, R01 CA090955), Canadian Institutes of Health Research (57897, 79551 and 115016), Commonwealth Department of Health and Aging, National Health and Medical Research Council of Australia (265903, 450110, 1005922 and 1106451), Cancer Research UK (C312/A3726, C312/A6465 and C312/A11039, C312/A11943), Robert Wood Johnson Foundation (045734) and Canadian Tobacco Control Research Initiative (014578). 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.

  • Disclaimer None of the sponsors played any direct role in the design or conduct of the study, the collection, management, analysis or interpretation of the data, the preparation of the manuscript, or the decision to submit the manuscript for publication.

  • Competing interests KMC has received grant funding from Pfizer to study the impact of a hospital-based tobacco cessation intervention and also has served as an expert witness in litigation filed against the tobacco industry.

  • Ethics approval The ITC-4C study protocol was approved by the institutional review boards/research ethics boards of the University of Waterloo (Canada), Roswell Park Cancer Institute (USA), University of Strathclyde (UK), University of Stirling (UK), The Open University (UK), and The Cancer Council Victoria (Australia).

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