Is use of illicit tobacco associated with reduced
motivation to stop smoking and making a quit
attempt?
Belinda Iringe-Koko, Ann McNeill, Robert West and Andy McEwen
UKNSCC
27th-28th JUNE 2013
Dr Lynn McFayden PhD Studentship
in Tobacco Control
Illicit tobacco trade
The existence of illicit tobacco undermines the effect tax rises
(above the rate of inflation) have on encouraging smokers to quit
and preventing the initiation of smoking.
 11.6 % of the global cigarette market is illicit, costing
governments across the world in excess of $40 billion in lost
revenue (Joossens et al., 2009).
 In the UK the Illicit market share for cigarettes is 9% and 38%
for HRT (2010-11).
 Costs the UK government £2 billion in lost revenue.
 Exacerbates health inequalities.
 Encourages smoking in young people.
Illicit tobacco use and smoking cessation
Hyland et al. (2005, 2006)
 Accessibility to a source of low-taxed or untaxed cigarettes reduces the
likelihood that a smoker will make a quit attempt and successfully quit
smoking.
Luk et al. (2009)
 Recent purchase of illicit tobacco has been associated with having no plans
to quit smoking.
Licht et al (2009)
 Smokers who engage in any price/tax avoidance behaviours were 24% less
likely to report quit attempts.
Choi et al (2012)
 Smokers who used at least one price minimising strategy were less likely to
attempt to quit smoking or cut back on cigarette consumption.
Study Aim
The aim of this study was to assess whether reported use of illicit
tobacco was associated with motivation to quit smoking and having
made a quit attempt in the past year.
The current study sought to answer the following research questions:
i.
Are illicit tobacco users less likely to report any motivation to
quit compared with smokers who purchased duty paid tobacco?
ii. Is there an association between illicit tobacco use and having
made a quit attempt in the past year?
Methods
The current study combined data from three surveys collected
through the Smoking Toolkit Study, a monthly population based
cross-sectional survey (www.smokinginengland.info).
 Data were collected in December 2007 and March to May 2008,
December 2010 to May 2011 and May to December 2012.
A total of 7,588 were current adult smokers aged 16+.
Participants socio-demographics and smoking characteristics were
recorded.
Illicit Tobacco Purchase
‘In the last 6 months, have you bought any cigarettes or hand rolled tobacco from any of the
following?:
Newsagent\Off licence\Corner shop
Newsagent\Off licence\Corner shop – Under the Counter
Petrol garage shop
Supermarket
Cash and carry
Internet
Pub (behind the bar)
Pub (vending machine)
Pub (somebody who comes round selling cigarettes cheap)
People who sell cheap cigarettes on the street
People in the local area who are a ready supply of cheap cigarettes
Buy them cheap from friends
Buy them from abroad and bring them back with me
Have not bought any in the last 6 months
Don’t Know
Motivation to Stop Scale (MTSS)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
“I don’t want to stop smoking”
“I think I should stop smoking but don’t really want to”
“I want to stop smoking but haven’t thought about when”
“I REALLY want to stop smoking but I don’t know when I will”
“I want to stop smoking and hope to soon”
“I REALLY want to stop smoking and intend to in the next 3 months”
“I REALLY want to stop smoking and intend to in the next month”
Past Quit Attempts

Participants past quit attempts were assessed by asking: ‘How
many serious attempts to stop smoking have you made in the last
12 months’?
Demographic and Smoking characteristics of study participants
Characteristics
Age, (years) % (n)
16-24
25-34
35-44
45-54
55-64
65+
Gender, % (n)
Male
Female
Social status, % (n)
AB
C1
C2
D
E
Type of Tobacco smoked, % (N)
Cigarettes
Cigarettes & RYO
RYO only
Cigarettes per day (CPD), mean (sd)
Time to first cigarette,% (n)
>61 minutes
31-60 minutes
6-30 minutes
<5 minutes
Made quit attempt, % (n)
Motivation to quit, mean (SD)
Levels of motivation, % (n):
1. ‘I don’t want to stop smoking’
2. ‘I think I should stop smoking but don’t really
want to’
3. ‘I want to stop smoking but haven’t thought
about when’
4. ‘I REALLY want to stop smoking but I don’t
know when I will’
5. ‘I want to stop smoking and hope to soon’
6. ‘I REALLY want to stop smoking and intend
to in the next 3 months’
7. ‘I REALLY want to stop smoking and intend
to in the next month’
Total
(n=6,776)
Tobacco/Cigarette purchase source
Illicit only (n=273)
Duty paid and illicit
(n=611)
Duty paid only
(n=5892)
19.0 (1288)
19.8 (1340)
20.8 (1408)
17.8 (1206)
12.7 (862)
9.9 (673)
14.3 (39)
16.5 (45)
21.6 (59)
21.2 (58)
15.0 (41)
11.4 (31)
27.0 (165)
19.3 (118)
22.7 (139)
18.8 (115)
9.0 (55)
3.3 (20)
18.4 (1084)
20.0 (1177)
20.5 (1210)
17.5 (1033)
13.0 (766)
10.6 (622)
53.3 (3614)
46.7 (3162)
63.4 (173)
36.6 (100)
63.3 (387)
36.7 (224)
51.8 (3054)
48.2 (2838)
15.2 (1033)
25.1 (1700)
25.1 (1703)
20.8 (1412)
13.7 (929)
9.2 (25)
15.4 (42)
27.5 (75)
27.1 (74)
20.9 (57)
10.9 (67)
23.9 (146)
29.1 (178)
22.5 (138)
13.6 (83)
16.0 (941)
25.7 (1512)
24.6 (1450)
20.4 (1200)
13.4 (789)
59.6(3457)
7.1(414)
33.2(1928)
12.5 (8.38)
31.5(74)
5.1(12)
63.4(149)
13.8 (9.10)
46.2(258)
15.6(87)
38.2(213)
14.5 (8.55)
62.4(3125)
6.3(315)
31.3(1566)
12.2 (8.29)
27.1 (1835)
22.0 (1494)
31.5 (2136)
18.9 (1281)
31.7 (2150)
3.6(2.07)
27.0 (74)
13.1 (36)
35.4 (97)
24.1 (66)
26.6 (73)
3.0(1.90)
21.6 (132)
19.1 (117)
34.5 (211)
24.2 (148)
35.9 (219)
3.5(1.94)
27.7 (1629)
22.8 (1341)
31.0 (1828)
18.1 (1067)
31.6 (1858)
3.6 (2.08)
25.5(1345)
12.6(662)
37.3 (81)
11.5 (25)
22.3 (84)
15.2 (57)
25.2(1180)
12.4 (580)
8.9(471)
9.2 (20)
9.8 (37)
8.8 (414)
17.1(899)
15.2 (33)
15.7 (59)
17.2 (807)
14.9 (786)
9.5 (500)
16.6 (36)
6.0 (13)
21.3 (80)
7.4 (28)
14.3 (670)
9.8 (459)
11.6 (609)
4.1 (9)
8.2 (31)
12.2 (569)
p Value
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p = 0.016
p<0.001
p<0.001
Results [1]
Table 1: Association between any use of illicit tobacco and motivation
to quit and having made a quit attempt in the previous year
Unadjusted
OR (95% CI)
Motivation to quit
Smoking
Duty paid only
Duty paid and illicit
Illicit only
Past quit attempt
Duty paid only
Duty paid and illicit
Illicit only
p value
Adjusted
ORa (95% CI)
p value
Reference
Reference
0.95 (0.90 – 1.00) 0.058
0.94 (0.89 – 0.99) 0.033
0.86 (0.81 – 0.93) p<0.001 0.87 (0.81 – 0.94) p<0.001
Reference
0.84 (0.66 – 1.06) 0.147
1.01 (0.74 – 1.38) 0.957
Reference
0.88 (0.69 – 1.12) 0.296
1.02 (0.74 – 1.41) 0.892
Results [2]
Table 2: Adjusted odds ratio (aOR) of illicit tobacco, duty paid and illicit
tobacco purchase for the various levels of motivation
Levels of motivation
1. ‘I don’t want to stop
smoking’
2. ‘I think I should stop
smoking but don’t really
want to’
3. ‘I want to stop smoking
but haven’t thought about
when’
4. ‘I REALLY want to
stop smoking but I don’t
know when I will’
5. ‘I want to stop smoking
and hope to soon’
6. ‘I REALLY want to
stop smoking and intend
to in the next 3 months’
7. ‘I REALLY want to
stop smoking and intend
to in the next month’
Illicit only
aOR (95% CI)
p value
Duty paid and illicit
aOR (95% CI)
p value
3.47 (1.80 – 6.70)
p<0.001
1.50 (0.97 – 2.31)
p=0.067
2.08 (1.00 – 4.33)
p=0.050
2.19 (1.40 – 3.42)
p=0.001
2.78 (1.33 – 5.82)
p=0.007
1.62 (0.99 – 2.66)
p=0.055
2.22 (1.12 – 4.40)
p=0.022
1.15 (0.73 – 1.80)
p=0.552
2.80 (1.42 – 5.52)
p=0.003
1.82 (1.18 – 2.80)
p=0.007
1.48 (0.67 – 3.30)
p=0.335
1.21 (0.73 – 2.00)
p=0.464
Reference
Reference
Discussion
 Illicit tobacco users being less motivated to stop smoking is possibly as a
result of their ability to access cheap tobacco which reduces the financial
motivation to quit.
 Smokers who used both duty paid and illicit sources (most likely opportunistic
buyers of illicit tobacco) showed lower odds of reduced motivation to quit
compared with exclusive illicit tobacco users.
 Use of illicit tobacco did not appear to discourage the making of quit attempts
despite a negative association with motivation to stop. A possible explanation
for this is that smokers’ in the current study may have been engaging in illicit
tobacco purchase for some time, during which they could have made some
attempts to quit smoking albeit unsuccessfully.
Policy implications
 An effective approach to tackling illicit tobacco trade cannot focus
solely on tackling supply through increased enforcement (although
this is warranted) but also demand by targeting illicit tobacco users
with specialised smoking cessation strategies to increase quit rates
and reduce smoking prevalence.
 There is scope for targeted smoking cessation efforts that maybe
more effective in achieving successful quit attempts in this group.
Conclusion
 Illicit tobacco use appeared to be associated with reduced
motivation to quit smoking. Further research is warranted to
determine whether illicit tobacco users being less motivated to
quit smoking is down to the availability of illicit tobacco, being
able to obtain it at a cheap price or smokers’ social scene.
 Reports of any illicit tobacco use were not related to making a
past quit attempt, but may impact on the success of quit
attempts. In order to promote successful smoking cessation in
smokers reporting illicit tobacco use, limiting the accessibility
to illicit tobacco as well as more targeted smoking cessation
interventions is recommended.
Acknowledgements
Dr Andy McEwen
Professor Robert West
Professor Ann McNeill
 UCL Tobacco Research Group
belinda.iringe-koko.09@ucl.ac.uk
www.smokinginengland.info
Dr Lynn McFayden PhD Studentship
in Tobacco Control