Abstract
Background:
Some countries are exploring policies that might help lower cigarette smoking prevalence to below 5% by 2030. This study assesses support for three policies among adults who smoke–1) ending smoked tobacco sales within 10 years; 2) limiting cigarette nicotine content to make them less addictive; and 3) restricting smoked tobacco sales for life to anyone currently under 18 (Smoke-Free Generation, SFG).
Methods:
Data were from the 2022 International Tobacco Control Four Country Smoking and Vaping Survey, including 2,723 adults who smoked at least monthly in Australia, Canada, England, and the United States (US). We estimated the weighted prevalence of support and used logistic regression to assess whether support (vs. no support) differed by sociodemographic variables (country, gender, age, race/ethnicity, education, income).
Results:
Support was 27.1% for ending smoked tobacco sales within 10 years, 53.5% for limiting the nicotine content of cigarettes, and 51.7% for a SFG law. US adults had consistently lower odds of support compared to those in Canada and England (all policies: p<0.01). Women and white individuals had lower odds of supporting an end to smoked tobacco sales (aOR:0.63, p=0.02; 0.69, p=0.03) and a SFG law (aOR:0.72, p=0.04; 0.66, p=0.01). Women (aOR:1.41, p<0.01) were more supportive of nicotine reduction. Individuals with moderate (aOR vs. high:1.36, p=0.03) and low (aOR:1.43, p=0.03) education, and those with financial difficulties (aOR:1.36, p=0.04) showed higher support for a SFG law. No differences in support were observed by age in the pooled data.
Conclusions:
Support for policies to reduce the use of commercial cigarettes was moderate-to-high among adults who smoke, although it varied significantly by country, gender, and income. Tailored communication strategies could help increase support and promote policy adoption.
Keywords: Support, commercial tobacco endgame policies, social determinants of health
INTRODUCTION
Comprehensive tobacco control policies have successfully contributed to reducing tobacco-related morbidity and mortality[1,2] by decreasing the smoking prevalence[3]. This success has encouraged some countries to pursue a smoke-free future, aiming to reduce smoking to below 5% prevalence[4]. This threshold, often called an ‘endgame’, marks a point at which the smoking-tobacco epidemic[5] would become unsustainable[6]. Several policies have been proposed to achieve this goal, including completely ending smoked tobacco sales[7], making cigarettes minimally or non-addictive by introducing a very low nicotine content (VLNC) standard[8], and a smoke-free generation law that would prohibit smoked tobacco sales to anyone born after a certain year[9].
Several countries have publicly announced plans to reduce smoking prevalence below 5%, including New Zealand and Ireland by 2025, England and Australia by 2030, Canada by 2035, and Scotland by 2034[10], although exact definitions of prevalence may vary. A country’s readiness to implement these strategies can also be influenced by public support[11], which in turn is related to the extent to which smoking has been denormalised[12]. Therefore, assessing public opinion, particularly among people who still smoke, is crucial when considering these measures. Policies that garner widespread public support, especially among those most impacted by the policy, have a greater chance of being successfully implemented and avoiding unintended consequences[13]. A recent systematic review, which includes studies primarily from New Zealand and the United States (US), assessed differences in support across relevant subgroups, such as people who smoke or adolescents/young adults, and found high public support for most tobacco endgame policies, with the majority of the population in favour of them[13]. However, it did not report differences across social strata, primarily due to lack of available data.
In high-income countries, recent studies show that people who continue to smoke cigarettes are overrepresented among lower socioeconomic status (SES) groups[14] who in turn perceive smoking as more normalised[15]. This aligns with evidence that population-based tobacco control policies[16] and cessation programs[17] are less effective among disadvantaged groups. Although SES is one of the most powerful determinants of smoking behaviour, it interacts with a range of other social and structural factors, such as race/ethnicity and gender, often referred to as the social determinants of health[18]. Therefore, understanding the social determinants of support for tobacco endgame policies is crucial for effective advocacy and compliance, as individuals are more likely to adhere to policies they support[19].
Herein, we report the results of an international study conducted in Canada, the US, England, and Australia examining the social determinants of support among adults who currently smoke for three policies to reduce cigarette consumption, including: (1) ending smoked tobacco sales within 10 years, if nicotine remains available in vaping products and nicotine replacement therapies (NRT), (2) introducing a VLNC standard for cigarettes and roll-your-own (RYO) tobacco to make them less addictive, if nicotine remained available in vaping products and NRT; and (3) restricting cigarettes sales for life to anyone currently under the age of 18 (also known as, Smoke-Free Generation (SFG) law).
These three endgame measures are gaining international prominence following the report of the WHO Framework Convention on Tobacco Control (FCTC) Expert Group on Article 2.1, established at the 10th session of the Conference of the Parties (COP, February 2024) to “identify and describe forward-looking tobacco control measures and measures that expand or intensify current approaches”[20]. The measures examined in this study are among the 16 forward-looking actions outlined in the Expert Group’s report, presented to the COP at its 11th session (November 2025)[21].
METHODS
Study design, procedure and sample
Data for this study are from the 2022 wave (Wave 4) of the International Tobacco Control Smoking and Vaping Four Country (ITC 4CV) Survey, a longitudinal cohort study conducted every two years among adults in Canada, the US, England, and Australia. Adults (≥18 years) were recruited from commercial panels using probability and non-probability-based sampling methods. All data were collected online, and respondents were remunerated for completing the survey[22]. In each country, the sample was designed and weighted to be as representative as possible of people who smoke and/or vape by age, sex, and region. Full details about the ITC 4CV methods can be found in the Wave 4 (2022) technical report[23].
Cross-sectional data for this study were from the Wave 4 ITC 4CV Survey (conducted August to December 2022). Eligible respondents in the analytical sample included adults who smoked cigarettes at least monthly (daily, weekly or monthly) at the time of the survey and had complete data for at least one of the questions about endgame policy support (Figure S1). A total of 2,723 adults who smoked at least monthly were included, nearly 50% of whom were replenishment participants. Supplemental Table S1 summarises the sociodemographic characteristics and consumption patterns of the study sample overall and by country.
Outcomes
The primary outcome variables measured support for 1) ending smoked tobacco sales within 10 years if nicotine remained available in vaping products and NRT; 2) introducing a VLNC standard in cigarettes and RYO tobacco to make them less addictive if nicotine was available in vaping products and NRT; and 3) preventing smoked tobacco sales to anyone currently under 18 in their lifetime (SFG law). Exact wording is available online[24].
For all three questions, response options were ‘strongly support’, ‘support’, ‘oppose’, ‘strongly oppose’ or ‘don’t know’. Responses were grouped into ‘support’, ‘oppose’ and ‘neutral’ (don’t know) to estimate the level of support for each measure. Respondents who refused to answer were excluded from the analyses (<0.3% of cases). For the multivariable analysis, we dichotomised responses for each variable as ‘support’ vs ‘no support’ (‘oppose’/’neutral’) because our primary interest was identifying positive opinions toward policy adoption.
Independent variables
Sociodemographic variables
Measures of social determinants of health included contextual and/or structural factors that may influence public opinion, such as respondents’ country of residence (Canada, US, England, Australia), age (18–29, 30–44, 45–59, ≥60 years), gender (man/woman), race/ethnicity (white [or non-indigenous English speaker at home in Australia]/other ethnicities), education level (low, moderate, high), and household income (low, moderate, high). Age groups were defined to balance sample distribution, with the youngest category extended to 18–29 years (instead of 18–24) to ensure adequate sample size and reliable comparisons. Gender data were collected by asking each respondent, ‘What is your gender?’ (Man, Woman or Other). For respondents who selected ‘Other’, gender was derived based on their recorded sex at birth, as this group represented only 0.4% of the total sample.
Additional measures of socioeconomic status included perceived financial stress, assessed with the question ‘In the last 30 days, because of a shortage of money, were you unable to pay any important bills on time, such as electricity, telephone or rent bills?’ (yes/no); and receiving social benefits from the government (yes/no).
Covariates
Covariates included other sociodemographic variables, such as respondents’ marital status (married, widowed/separated/divorced, single) and whether they had underaged children living at home (yes/no); smoking frequency, measured with the question ‘How often do you currently smoke ordinary cigarettes (either factory-made/pack or roll-your-own)?’, classified as ‘daily’ or ‘non-daily’ (weekly/monthly); and vaping status, derived from responses to the question: ‘How often do you currently vape?’. Response were categorised as ‘current users’ if respondents reported currently vaping daily, weekly, monthly or less-than-monthly; ‘former users’ if they had vaped daily or occasional in the past, and ‘never users’ if they had vaped only once or had never tried or heard of vaping.
Data analysis
Unweighted descriptive statistics were used to describe the study sample. All other analyses were conducted on weighted data. The weight calibration used benchmarks from national surveys from each of the respective countries[23]. All analyses were conducted in STATA Version 18.5.
Weighted descriptive statistics were used to estimate the prevalence of support for each policy. Pairwise analyses of categorical variables were conducted using Pearson’s Chi-square tests to examine differences in proportions between groups.
Three separate adjusted logistic regression models were fitted to identify correlates of support for each policy. Akaike and Bayesian Information Criteria were used to determine the optimal model specification, and collinearity among independent variables was assessed by the Variance Inflation Factor. All logistic regression models were adjusted for social determinants of health, marital status, having underage children living at home, smoking frequency and vaping status. Interaction effects were examined by including age-by-gender interaction terms in the logistic regression models. The interaction term ‘Gender x Age’ was included in the three models. For the models on ending smoked tobacco sales and the SFG law, the interaction term was retained despite not being statistically significant, as the predictive margins indicated different patterns of support across age groups by gender, suggesting a potential variation in effect. However, for the VLNC standard model, the interaction term was not retained, as there was no indication of effect modification.
Finally, given a considerable percentage of respondents were classified as ‘neutral’ for each of the three policies (ending sales: n=333, 12.3%; VLNC: n=498, 18.3%; and SFG: n=313, 11.5%), we conducted a multinomial regression analysis, as a sensitivity analysis, assessing ‘support’ and ‘neutral’ vs ‘oppose’ adjusted for social determinants of health, marital status, having underage children living at home, smoking frequency and vaping status.
RESULTS
Prevalence of support among adults who smoke at least monthly towards policies aiming to end use of commercial cigarettes
Table 1 shows overall support was 27.1% for ending smoked tobacco sales within 10 years, 53.5% for introducing a VLNC standard, both if access to alternative sources of nicotine were available, and 51.7% for adopting a SFG law.
Table 1.
Association of participants’ characteristics with attitudes towards support for commercial tobacco endgame policies (cross-sectional population-weighted data), 2022 International Tobacco Control Smoking and Vaping Four Country Survey.
| Ending of smoked tobacco sales within 10 years if nicotine remained available in vaping products and NRT | Limit nicotine in cigarettes and roll-your own tobacco if nicotine remained available in vaping products and NRT |
Restrict sales to anyone under 18 to never buy cigarettes/ tobacco | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
||||||||||||||
| N | Sup. | Neut. | Opp. | P | Sup. | Neut. | Opp. | P | Sup. | Neut. | Opp. | P | ||
|
|
||||||||||||||
| Total | 2723 | 27.1% | 14.2% | 58.6% | 53.5% | 20.4% | 1.2% | 51.7% | 12.3% | 36.1% | ||||
|
| ||||||||||||||
| Country | Canada | 722 | 31.5% | 14.2% | 54.3% | 0.036 | 57.2% | 18.4% | 24.4% | <0.001 | 53.5% | 11.8% | 34.8% | 0.088 |
| United States | 647 | 20.6% | 16.9% | 62.5% | 45.1% | 28.5% | 26.4% | 44.4% | 14.7% | 40.9% | ||||
| England | 852 | 30.5% | 13.1% | 56.4% | 58.9% | 20.8% | 20.4% | 53.5% | 13.1% | 33.4% | ||||
| Australia | 502 | 25.0% | 12.9% | 62.1% | 51.6% | 14.1% | 34.3% | 55.0% | 9.4% | 35.7% | ||||
|
| ||||||||||||||
| Gender | Men | 1371 | 29.5% | 11.0% | 59.5% | 0.001 | 50.1% | 18.9% | 31.0% | <0.001 | 51.2% | 11.2% | 37.6% | 0.255 |
| Women | 1352 | 24.4% | 18.1% | 57.6% | 57.5% | 22.2% | 20.3% | 52.3% | 13.5% | 34.2% | ||||
|
| ||||||||||||||
| Age | 18–29 | 296 | 27.5% | 10.5% | 62.0% | 0.501 | 65.7% | 7.1% | 27.2% | <0.001 | 58.2% | 6.0% | 35.8% | 0.235 |
| 30–44 | 700 | 29.3% | 14.9% | 55.9% | 54.0% | 17.8% | 28.2% | 52.4% | 12.3% | 35.3% | ||||
| 45–59 | 855 | 26.6% | 15.6% | 57.8% | 51.3% | 25.3% | 23.4% | 50.4% | 13.4% | 36.2% | ||||
| ≥ 60 | 872 | 24.5% | 13.4% | 62.1% | 49.8% | 24.1% | 26.1% | 49.1% | 13.7% | 37.2% | ||||
|
| ||||||||||||||
| Race/Ethnicity | White/English (AU)* | 2270 | 26.3% | 14.3% | 59.4% | 0.273 | 53.8% | 19.9% | 26.3% | 0.521 | 50.7% | 12.5% | 36.8% | 0.314 |
| Other ethnicity | 453 | 31.7% | 14.0% | 54.4% | 51.7% | 23.3% | 25.1% | 56.6% | 10.9% | 32.6% | ||||
|
| ||||||||||||||
| Educational level | Low | 683 | 24.5% | 17.2% | 58.3% | 0.102 | 48.5% | 24.5% | 26.9% | 0.018 | 51.5% | 14.0% | 34.5% | 0.197 |
| Moderate | 1217 | 28.3% | 12.7% | 59.0% | 56.9% | 17.5% | 25.5% | 53.8% | 10.8% | 35.4% | ||||
| High | 823 | 29.9% | 11.7% | 58.4% | 55.9% | 18.5% | 25.7% | 46.9% | 12.1% | 41.0% | ||||
|
| ||||||||||||||
| Household income | Low | 706 | 22.4% | 17.4% | 60.3% | 0.019 | 46.9% | 25.6% | 27.5% | 0.019 | 47.0% | 14.6% | 38.4% | 0.103 |
| Moderate | 765 | 27.3% | 15.9% | 56.8% | 55.3% | 19.6% | 25.2% | 53.9% | 13.0% | 33.1% | ||||
| High | 1252 | 30.0% | 11.2% | 58.8% | 56.4% | 17.8% | 25.9% | 53.1% | 10.3% | 36.6% | ||||
|
| ||||||||||||||
| Financial stress | Yes | 556 | 28.6% | 12.5% | 59.0% | 0.620 | 53.9% | 18.1% | 28.0% | 0.488 | 59.4% | 10.1% | 30.5% | 0.012 |
| No | 2167 | 26.7% | 14.7% | 58.5% | 53.4% | 21.1% | 25.6% | 49.5% | 12.9% | 37.7% | ||||
|
| ||||||||||||||
| Receiving social benefits | Yes | 898 | 25.5% | 16.0% | 58.5% | 0.344 | 52.8% | 20.1% | 27.1% | 0.835 | 54.9% | 10.7% | 34.4% | 0.193 |
| No | 1825 | 28.0% | 13.3% | 58.7% | 53.9% | 20.6% | 25.6% | 50.0% | 13.0% | 36.9% | ||||
Values are set in bold for p<0.05.
Non-indigenous English-speaker at home (in Australia). NRT: Nicotine Replacement Treatment.
Support varied significantly by country and by several sociodemographic factors. For ending sales of smoked tobacco products within 10 years, if alternative nicotine products are available, respondents in Canada (31.5%, p=0.002) and England (30.5%, p=0.004) showed higher support compared to those in the US (20.6%). No other differences in support were observed between countries. Males (29.5%) and individuals with high income (30.0%) were more supportive than women (24.4%, p=0.001) and those with low income (22.4%, p=0.004), respectively. No significant differences were observed by age, race/ethnicity, education, financial stress, or receipt of social benefits.
Regarding mandating a VLNC standard, if alternative nicotine products are available, significant differences were found by country (p<0.001), gender (p<0.001), age (p< 0.001), education (p=0.018) and income (p=0.019), with the highest levels of support found among women, younger adults, and those with higher education and income.
Support for a SFG law was significantly higher only among individuals experiencing financial stress (59.4% vs. 49.5%, p=0.012), as differences by other sociodemographic variables were not significant.
Associations between participant characteristics and support stratified by country are shown in Supplemental Table S2.
Correlates of support for tobacco control policies to end the use of commercial cigarettes (adjusted models)
Ending sales of smoked tobacco products within 10 years
Statistically significant differences in support (vs. no support) were observed across countries (Figure 1). Adults in the US had lower odds of supporting ending sales compared to those in Canada (adjusted odds ratio (aOR): 0.51, 95% Confidence Intervals (CI): 0.37–0.71), England (aOR: 0.59, 95% CI: 0.42–0.83), and Australia (aOR: 0.68, 95% CI: 0.46–1.00), although the wide confidence intervals included the possibility of no difference for Australia.
Figure 1. Predicted probabilities of support towards commercial tobacco endgame across four countries (adjusted model), 2022 ITC 4CV Survey.
All logistic regression models were adjusted for marital status, having underage children at home, smoking frequency (daily, non-daily), and vaping status (current, former, never). Financial stress and receipt of social benefits were excluded from the models for ‘ending sales of smoked tobacco products within 10 years’ and ‘limiting nicotine in cigarettes and RYO’ because, according to AIC/BIC, they did not improve model fit.
As shown in Table 2, women (aOR vs. men: 0.63, 0.44–0.91) and individuals identifying as white (aOR vs. other ethnicities: 0.69, 0.49–0.97) showed lower odds of support.
Table 2.
Adjusted logistic regression analysis of correlates of overall support (vs oppose or neutral) towards support for commercial tobacco endgame policies, 2022 International Tobacco Control Smoking and Vaping Four Country Survey
| Ending of smoked tobacco sales within 10 years if nicotine remained available in vaping products and NRT | Limit nicotine in cigarettes and roll-your own tobacco if nicotine remained available in vaping products and NRT | Restrict sales to anyone under 18 to never buy cigarettes/ tobacco | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
|
||||||||||
| Total | Total | Total | ||||||||
| N=2,703 | N=2,706 | N=2,705 | ||||||||
|
|
||||||||||
| OR | 95% CI | OR | 95% CI | OR | 95% CI | |||||
|
| ||||||||||
| Country | Canada | 1.00 | 1.00 | 1.00 | ||||||
| United States | 0.51 | 0.36 | 0.71 | 0.63 | 0.47 | 0.84 | 0.59 | 0.44 | 0.79 | |
| England | 0.87 | 0.63 | 1.19 | 0.89 | 0.66 | 1.19 | 0.93 | 0.69 | 1.26 | |
| Australia | 0.75 | 0.52 | 1.10 | 0.77 | 0.54 | 1.09 | 1.04 | 0.74 | 1.47 | |
|
| ||||||||||
| Gender | Men | 1.00 | 1.00 | 1.00 | ||||||
| Women | 0.63 | 0.44 | 0.91 | 1.41 | 1.13 | 1.75 | 0.72 | 0.53 | 0.99 | |
|
| ||||||||||
| Age | ≥ 60 | 1.00 | 1.00 | 1.00 | ||||||
| 45–59 | 0.88 | 0.60 | 1.30 | 0.91 | 0.71 | 1.17 | 0.81 | 0.58 | 1.14 | |
| 30–44 | 1.02 | 0.64 | 1.61 | 0.85 | 0.61 | 1.18 | 0.68 | 0.44 | 1.05 | |
| 18–29 | 0.61 | 0.30 | 1.24 | 1.33 | 0.81 | 2.20 | 0.94 | 0.46 | 1.89 | |
|
| ||||||||||
| Gender x Age | Women # ≥ 60 | 1.00 | 1.00 | |||||||
| Women # 45–59 | 1.33 | 0.78 | 2.25 | 1.25 | 0.80 | 1.98 | ||||
| Women # 30–44 | 0.99 | 0.53 | 1.83 | 1.63 | 0.94 | 2.84 | ||||
| Women # 18–29 | 2.22 | 0.91 | 5.39 | 1.30 | 0.55 | 3.06 | ||||
|
| ||||||||||
| Race/Ethnicity | White/English (AU)* | 1.00 | 1.00 | 1.00 | ||||||
| Other ethnicity | 1.48 | 1.05 | 2.09 | 0.92 | 0.67 | 1.26 | 1.52 | 1.11 | 2.09 | |
|
| ||||||||||
| Educational level | High | 1.00 | 1.00 | 1.00 | ||||||
| Moderate | 0.99 | 0.73 | 1.35 | 1.06 | 0.80 | 1.40 | 1.34 | 1.01 | 1.77 | |
| Low | 0.94 | 0.67 | 1.34 | 0.83 | 0.60 | 1.15 | 1.41 | 1.02 | 1.95 | |
|
| ||||||||||
| Household income | High | 1.00 | 1.00 | 1.00 | ||||||
| Moderate | 1.03 | 0.76 | 1.39 | 1.02 | 0.77 | 1.34 | 1.01 | 0.77 | 1.33 | |
| Low | 0.92 | 0.66 | 1.27 | 0.86 | 0.64 | 1.15 | 0.74 | 0.54 | 1.03 | |
|
| ||||||||||
| Financial stress | No | 1.00 | ||||||||
| Yes | 1.36 | 1.02 | 1.82 | |||||||
|
| ||||||||||
| Receiving social benefits | No | 1.00 | ||||||||
| Yes | 1.32 | 0.99 | 1.75 | |||||||
All logistic regression models were adjusted for marital status, having underage children at home, smoking frequency (daily, non-daily) and vaping status (current, former, never). Financial stress and receipt of social benefits were excluded from the models for ‘ending sales of smoked tobacco products within 10 years’ and ‘limiting nicotine in cigarettes and roll-your-own’ because, according to Akaike and Bayesian Information Criteria, they did not improve model fit. Values are set in bold for p<0.05.
Non-indigenous English-speaker at home (in Australia). NRT: nicotine replacement therapy.
In the country-stratified results (Table S3), statistically significant associations were observed in England, where women (aOR vs. men: 0.43, 0.21–0.85) and individuals with a low education (aOR vs. high education: 0.41, 0.21–0.82) had lower odds of support for ending sales in 10 years’ time. In Australia, individuals aged 18–29 (aOR vs. those aged ≥60: 0.04, 0.00–0.42) and 45–59 (aOR: 0.34, 0.14–0.83) were less likely to be supportive. No other statistically significant associations were identified for participant sociodemographic characteristics.
Limit nicotine in cigarettes and RYO tobacco to make them less addictive
Support for mandating a VLNC standard, if alternative nicotine products were available, also differed significantly by country (Figure 1). Adults in the US had lower odds of support than those in Canada (aOR: 0.63, 0.47–0.84) and England (aOR: 0.71, 0.53–0.95). No significant difference was observed between the US and Australia (aOR: 0.82, 0.59–1.15).
In the data pooled across countries, women had higher odds of supporting this policy compared with men (aOR: 1.41, 1.13–1.75) (Table 2). In the country-stratified results (Table S3), in Canada, individuals aged 30 to 44 (aOR: 0.43, 0.44–0.86) and those with moderate income (aOR: 0.57, 0.34–0.97) had lower odds of support compared to those aged ≥60 and with high income, respectively. In the US, only differences by gender were observed, with women showing higher odds of support compared to men (aOR: 1.77, 1.21–2.58). Similar findings were observed in England (aOR: 1.79, 1.20–2.65). In England, additional associations were found for age and education: younger adults had higher odds of support than those ≥60 (aOR: 1.91, 1.01–3.64), while individuals with low education were less likely to support a VLNC policy compared to those with high education (aOR: 0.32, 0.15–0.68). In Australia, individuals with moderate income were more likely to support the policy than those with high income (aOR: 2.23, 1.10–4.52).
Restrict sales to anyone under 18 to never buy smoked tobacco (SFG law)
Statistically significant country differences were also observed for support for a SFG law (Figure 1). Adults in the US had lower odds of support compared to those in Canada (aOR: 0.59, 0.45–0.79), England (aOR: 0.64, 0.47–0.86) and Australia (aOR: 0.57, 0.41–0.80).
In the data pooled across countries, support for a SFG law varied significantly by gender, race/ethnicity, education, and financial stress (Table 2). While women were less likely to support this policy (aOR vs. men: 0.72, 95% CI: 0.53–0.99), individuals identifying as ethnicities other than white, those with moderate or low education, and those experiencing financial stress had higher odds of support compared to their counterparts—white (aOR: 1.52, 1.11–2.09), high education (aOR [moderate]: 1.34, 1.01–1.77; [low]: 1.41, 1.02–1.95), and those not experiencing financial stress (aOR: 1.36, 1.02–1.82), respectively.
Country-specific findings (Table S3) showed that in Canada, women and individuals aged 30–44 had lower odds of support compared to men (aOR: 0.49, 0.24–0.97) and those aged ≥60 (aOR: 0.25, 0.10–0.65). In the US, support was higher among individuals with moderate or low education (aOR [moderate]: 1.81, 1.07–3.06; [low]: 2.21, 1.29–3.79), and those experiencing financial stress (aOR: 1.97, 1.19–3.26) compared to their respective counterparts. In Australia, women and individuals aged 30–44 were also less likely to support this policy (aOR vs. men:0.38; 0.17–0.83; aOR vs. ≥60: 0.37 (95% CI: 0.14–0.99).
Individual sensitivity analyses using multinomial logistic regression (oppose vs. support/ neutral) for each policy were consistent with the main sociodemographic correlates of support (Table S4).
DISCUSSION
Among adults who smoke at least monthly, support for ending smoked tobacco sales in 10 years had the lowest level of support overall in all four countries. The VLNC standard for cigarettes combined with access to lower risk nicotine products and a SFG law had similar levels of support with the majority of participants endorsing these policy options. Support varied significantly by country, gender, and income, with US respondents, women, and those with lower income generally showing lower odds of support. Country-stratified results revealed varying patterns of support across sociodemographic variables by country.
Interpretation of the results
Although people who smoke are known to show significantly lower support for tobacco control policies than the general population[25], our findings indicate moderate to high support for commercial tobacco endgame measures among this group, particularly for a VLNC standard and a SFG law, consistent with a previous meta-analysis[13]. Many adults who smoke report wanting to quit but often find it challenging to do so successfully[26]. As a result, nicotine reduction policies may garner greater public support than an outright ban due to their perceived effectiveness in reducing addiction and supporting gradual smoking cessation[27,28]. However, reported support for such policies may have been lower if the question had not explicitly mention that alternative sources of nicotine would remain available, as previous studies suggested that the level of support for this policy significantly depends on the range of alternatives offered to those who continue to smoke [19,29]. Moreover, in the US, the Food and Drug Administration, through a statement by Commissioner Gottlieb in March 2018, announced its intent to pursue a policy limiting nicotine in cigarettes; however, no formal proposal was issued until January 2025[30], which may have influenced public support levels.
Although support for ending smoked tobacco sales in the next 10 years was low, there was strong support for a future SFG law. This support may be influenced by several reasons, particularly the fact that survey respondents would not be directly affected by the policy. Other factors may include recognition of smoking’s addictiveness and health risks, along with a sense of social responsibility to protect younger generations by preventing youth from starting to smoke [31,32]. The low support for ending sales, aligns with previous research[19], and may be explained by concerns about addiction and resistance to compromising personal freedom[33].
Despite the four countries leading the global tobacco endgame movement and being at similar stages of the smoking epidemic[5], significant country differences were found in support, consistent with previous ITC findings [19,34]. These differences could be attributed to several factors, including a country’s tobacco control policy environment, smoking prevalence, and cultural attitudes towards smoking[11]. Countries with more stringent tobacco control measures often exhibit higher public support for endgame policies[35].
Social norms around tobacco use and public perceptions of smoking-related harms also play a significant role in shaping support for tobacco control policies[36,37]. Studies indicate that societal disapproval of smoking is higher in Canada and England than in the US, suggesting stronger anti-smoking norms in those countries[38], which may foster greater support for restrictive policies[39]. Notably, under the 2024–25 Tobacco and Vapes Bill, the UK plans to implement a SFG law, reflecting its commitment towards reducing tobacco smoking and established anti-tobacco norms.
Reducing inequities and achieving endgame goals for all population groups should be prioritised, alongside minimising overall smoking prevalence. Identifying social determinants of support and the priorities of populations with high smoking prevalence in each country should, therefore, be an integral part of any endgame action plan from the outset[40]. Similar to earlier studies[19,34,41], support estimates were consistently lower among particular sociodemographic groups, such as women and individuals with a low education and/or income. These patterns may be attributable to a combination of socio-structural factors, including differences in smoking behaviour, perceived risk of dependence, limited policy responsiveness to community needs and higher mistrust of policymakers and healthcare systems[42,43]. As shown previously[19,44], race/ethnicity was also identified as a social determinant of support. In our study, this variable was dichotomised (white vs. other), which limits the ability to examine more detailed racial/ethnic differences and may obscure important variation in how different communities perceive public health interventions. Further research using more granular ethnic categories is needed, as prior ITC data from the US suggest that support may be higher among specific groups such as Hispanic or Black populations [45].
After adjusting for consumption-related variables, some effects were diluted. This suggests that variations in support may be partially driven by smoking behaviour rather than sociodemographic factors alone. Research indicates that people who smoke more frequently and are highly dependent tend to be less supportive due to perceived restrictions and cognitive dissonance[46]. They may also feel unable to quit and are concerned about being forced to go through smoking withdrawal or having to seek out tobacco products from illicit markets. Since smoking is more prevalent and intense among lower-SES individuals, adjusting for smoking behaviour reduces or eliminates socioeconomic disparities in policy support[47], although our findings show that not all effects are completely eliminated.
Implications for commercial tobacco endgame policies
Public support is a key factor in influencing governments[48], as it can drive policy change and increase the likelihood of implementation as well as adherence once implemented. The tobacco industry often opposes such policies by claiming they are unpopular[47]. A receptive social climate may encourage politicians to commit more strongly to implement these policies and reduce the resources needed for enforcement once adopted[49]. Therefore, examining public support for commercial tobacco endgame policies across and within social groups is essential to identifying where advocacy efforts should focus, as increasing support is likely key to the broader adoption of endgame policies[50]. Specifically, policies such as VLNC and SFG law may achieve greater success in the short term due to higher initial public support, while support for ending smoked tobacco sales could be cultivated over time through targeted public campaigns and the ongoing denormalisation of smoking. Moreover, some of these policies are inherently less radical than others; VLNC and SFG laws would leave cigarettes on the market, potentially facing lower resistance from the tobacco industry than a complete ban.
Limitations and strengths
As a cross-sectional study, our research cannot establish causal relationships between social predictors of support but can identify associations. Other limitations of this study include the lack of data on additional relevant sociodemographic factors, such as employment status or occupation, which limited further subgroup analyses. Additionally, survey questions were asked within the context of a lengthy questionnaire, which may have influenced the quality of responses, as participants might not have had sufficient time to form well-considered opinions. Finally, the questions were based on initial policy proposals that may not reflect finalized or official plans; therefore, our results may not directly correspond to the policy measures ultimately considered by governments. In addition, changes in administration and governmental priorities can affect these policies, potentially influencing public opinion. Despite these limitations, our study also has several strengths. To our knowledge, it is the first to assess public support for commercial tobacco endgame policies with a special focus on the social determinants of health, offering a more nuanced understanding of equity implications. The use of consistent questionnaires across countries enhances the comparability of findings, and the inclusion of nationally representative samples of people who smoke strengthens the generalizability of the results within each context.
CONCLUSION
People who smoke in Canada, the US, England, and Australia demonstrated moderate to high levels of public support for a VLNC policy alongside the availability of alternative nicotine products and a SFG policy, regardless of their social characteristics. However, support varied significantly by country, gender, education, and income.. These findings provide an evidence base to inform education campaigns and advocacy initiatives, supporting the development of communication strategies tailored to specific target audiences and adaptable across national contexts –a consideration of heightened importance following the recent report of the WHO FCTC Article 2.1 Expert Group[21]. Further research exploring strategies to increase the acceptance of tobacco endgame policies, particularly among priority populations who smoke, would also be valuable in advancing these measures.
Supplementary Material
What is already known
Public support for policies to eliminate the use of commercial cigarettes is lower among people who smoke compared to those who do not smoke.
What this study adds
Among a group of adults who smoke cigarettes, support was 27.1% for completely ending smoked tobacco sales in the next 10 years, 53.5% for limiting the nicotine content of cigarettes, and 51.7% for a smoke-free generation policy.
Support varied significantly by country of residence, gender, and socioeconomic status.
How this study might affect policy
Assessing public support among people who smoke for policies that could accelerate a rapid decline in smoking is important in terms of gauging likelihood of adoption by governments and compliance with the policy by the public.
Findings from this study can inform education campaigns and future advocacy efforts, helping to tailor communication strategies to advance policies that have the potential to markedly reduce cigarette consumption.
Funding
The ITC Four Country Smoking and Vaping Survey was supported by grants from the US National Cancer Institute (P01 CA200512), the Canadian Institutes of Health Research (FDN-148477), and the National Health and Medical Research Council of Australia (GTN1198301). This project has received funding from the European Union’s Horizon 2020 Research and Innovation program under the Marie Sklodowska-Curie Grant Agreement No 101008139 (EUREST-RISE)”. This research and AF have also been supported by an Imperial College Research Fellowship. KE also acknowledges support from Cancer Research UK (PICCTR-2024/100001).
The funder didn’t influence the results/outcomes of the study despite author affiliations with the funder.
Footnotes
Competing interest
GTF has served as an expert witness or consultant for governments defending their country’s policies or regulations in litigation. KMC has in the past and continues to serve as a paid witness in litigation filed against cigarette manufacturers. All other authors have no conflicts of interest to declare.
Ethics approval
The ITC Four Country Smoking and Vaping (Australia, Canada, England, and United States) survey protocols and all materials, including the survey questionnaires, were cleared for ethics by Research Ethics Board, University of Waterloo, Canada (REB#20803/30570, REB#20803/30878), Human Research Ethics at Cancer Council Victoria, Australia (IRB HREC 1603), Human Research Ethics Committee, The University of Queensland, Australia (IRB #00002419), Research Ethics Office, King’s College London, UK (IRB RESCM-17/18–2240, IRB MOD-19/20–2240, IRB LRM-21/22–2240), and ethics clearance at the Medical University of South Carolina, US was waived due to minimal risk.
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 (http://www.itcproject.org).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
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 (http://www.itcproject.org).