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Differences in Smoking Cessation Behaviors and Vaping Status among Adult Daily Smokers with and Without Depression, Anxiety, and Alcohol Use: Findings from the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys

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This study examined differences in quit attempts, 1-month quit success, and vaping status at follow-up among a cohort of 3709 daily smokers with and without depression, anxiety, and regular alcohol use who participated in both the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys. At baseline, a survey with validated screening tools was used to classify respondents as having no, or one or more of the following: 1) depression, 2) anxiety, and 3) regular alcohol use. Multivariable adjusted regression analyses were used to examine whether baseline (2018) self-report conditions were associated with quit attempts; quit success; and vaping status by follow-up (2020). Results showed that respondents who reported depressive symptoms were more likely than those without to have made a quit attempt (aOR = 1.32, 95% CI:1.03–1.70, p = 0.03), but were less likely to have quit (aOR = 0.55, 95% CI:0.34–0.89, p = 0.01). There were no differences in quit attempts or quit success between those with and without self-reported anxiety diagnoses or regular alcohol use. Among successful quitters, respondents with baseline depressive symptoms and self-reported anxiety diagnoses were more likely than those without to report vaping at follow-up (aOR = 2.58, 95% CI:1.16–5.74, p = 0.02, and aOR = 3.35 95% CI:1.14–9.87, p = 0.03). In summary, it appears that smokers with depression are motivated to quit smoking but were less likely to manage to stay quit, and more likely to be vaping if successfully quit. As smoking rates are higher among people with mental health conditions, it is crucial for healthcare professionals to identify these vulnerable groups and offer tailored smoking cessation support and continued support during their quit attempt.

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Data Availability Statement

In each country participating in the International Tobacco Control Policy Evaluation (ITC) Project, the data are jointly owned by the lead researcher(s) in that country and the ITC Project at the University of Waterloo. Data from the 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. The criteria for data usage approval and the contents of the Data Usage Agreement are described online ( The authors of this paper obtained the data following this application process. They did not have any special access privileges. Others would be able to access these data in the same manner as the authors.


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The authors would like to acknowledge and thank all those that contributed to the International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Survey: all study investigators and collaborators, and the project staff at their respective institutions, and Dr. Sara Hitchman for her valuable and constructive suggestions during the planning and development of this manuscript.


This study was supported by grants from the US National Cancer Institute (P01 CA200512), the Canadian Institutes of Health Research (FDN-148477), and by the National Health and Medical Research Council of Australia (GNT 1106451). Additional support to GTF was provided by a Senior Investigator Award from the Ontario Institute for Cancer Research (IA-004). The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit for publication.

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All authors contributed to the study conception and design. Data analyses were performed by Pongkwan Yimsaard. The first draft of the manuscript was written by Pongkwan Yimsaard, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Pongkwan Yimsaard.

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Ethics Approval

The survey protocols and all materials, including the survey questionnaires, were cleared for ethics by Office of Research Ethics, University of Waterloo, Canada (REB#20803/30570, REB#21609/30878); Research Ethics Office, King’s College London, UK (RESCM-17/18–2240); Human Research Ethics, Cancer Council Victoria, Australia (HREC1603); Human Ethics, Research Management Office, University of Queensland, Australia (2016000330/HREC1603); Institutional Review Board Medical University of South Carolina (waived due to minimal risk). All respondents provided consent to participate.

Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all respondents for being included in the study.

Competing Interests

GTF has served as an expert witness or consultant for governments defending their country’s policies or regulations in litigation. GTF and SG served as paid expert consultants to the Ministry of Health of Singapore in reviewing the evidence on plain/standardized packaging. DH has served as a paid expert witness on behalf of governments and public health authorities in legal challenges against tobacco and vaping companies. KMC has received payment as a paid expert witness in litigation filed against cigarette manufacturers. All other authors have no conflicts of interest to declare.

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Yimsaard, P., Gravely, S., Meng, G. et al. Differences in Smoking Cessation Behaviors and Vaping Status among Adult Daily Smokers with and Without Depression, Anxiety, and Alcohol Use: Findings from the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys. Int J Ment Health Addiction (2023).

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