Showing papers in "Tobacco Control in 2019"
TL;DR: In a rapidly changing media environment, where successful and influential marketing campaigns can be conducted on social media at little cost, marketing expenditures alone may not fully capture the influence, reach and engagement of tobacco marketing.
Abstract: Background While national surveys showed declines in e-cigarette use in the USA between 2015 and 2016, recent reports indicate that JUUL, a sleekly designed e-cigarette that looks like a USB drive, is increasingly being used by youth and young adults. However, the extent of JUUL’s growth and its marketing strategy have not been systematically examined. Methods A variety of data sources were used to examine JUUL retail sales in the USA and its marketing and promotion. Retail store scanner data were used to capture the retail sales of JUUL and other major e-cigarette brands for the period 2011–2017. A list of JUUL-related keywords was used to identify JUUL-related tweets on Twitter; to identify JUUL-related posts, hashtags and accounts on Instagram and to identify JUUL-related videos on YouTube. Results In the short 3-year period 2015–2017, JUUL has transformed from a little-known brand with minimum sales into the largest retail e-cigarette brand in the USA, lifting sales of the entire e-cigarette category. Its US$150 million retail sales in the last quarter of 2017 accounted for about 40% of e-cigarette retail market share. While marketing expenditures for JUUL were moderate, the sales growth of JUUL was accompanied by a variety of innovative, engaging and wide-reaching campaigns on Twitter, Instagram and YouTube, conducted by JUUL and its affiliated marketers. Conclusions The discrepancies between e-cigarette sales data and the prevalence of e-cigarette use from surveys highlight the challenges in tracking and understanding the use of new and emerging tobacco products. In a rapidly changing media environment, where successful and influential marketing campaigns can be conducted on social media at little cost, marketing expenditures alone may not fully capture the influence, reach and engagement of tobacco marketing.
466 citations
TL;DR: Review of peer-reviewed evidence on heat-not-burn tobacco products, their secondhand emissions and use by humans and findings were largely similar for independent and industry-funded studies found HnB exposed users and bystanders to toxicants, although at substantially lower levels than cigarettes.
Abstract: Objective To review peer-reviewed evidence on heat-not-burn tobacco products (HnB), their secondhand emissions and use by humans; to identify differences between independent and industry-funded studies. Data sources Medline, Embase, PsycINFO, ProQuest, Scopus and Web of Science databases were searched up to 6 November 2017 for studies on HnB published after December 2009; reference lists were screened and other researchers contacted, yielding 637 records. Study selection Thirty-one publications on HnB secondhand emissions (n=16) or use by humans (n=15) were selected by two reviewers with excellent agreement (k=0.75). Data extraction Data on authors’ affiliations, HnB products, secondhand emissions and human exposure were extracted by one reviewer. Two reviewers assessed the quality of experimental HnB studies using the Effective Public Health Practice Project tool. Data synthesis Twenty out of 31 studies were affiliated with tobacco industry. Studies on secondhand emissions varied by methodology, products and comparators. Compared with cigarettes, HnB delivered up to 83% of nicotine and reduced levels of harmful and potentially harmful toxicants by at least 62% and particulate matter by at least 75%. Experimental HnB use studies were limited to one product, reductions of human exposure to toxicants varied between 42% and 96%. HnB use suppressed urges to smoke, but participants rated HnB less satisfying than cigarettes. While limited by methodological heterogeneity, findings were largely similar for independent and industry-funded studies. Conclusions Studies on HnB secondhand emissions and human use were heterogeneous and largely affiliated with the manufacturers. HnB exposed users and bystanders to toxicants, although at substantially lower levels than cigarettes.
211 citations
TL;DR: The use of pods among adolescents, surveyed patients 12–21 years seen at three Stony Brook Children’s Hospital outpatient clinics from April 2017 to April 2018, found no data on nicotine exposure among youth who use pod systems.
Abstract: Although e-cigarette use among US youth decreased in 2016 for the first time since 2011,1 2 with the introduction of the new generation of nicotine vapourisers, ‘pods,’ this trend may not continue Pods are compact, lightweight, ultraportable and easy to use inconspicuously Popularity of these devices has increased in the past year, most notably, one brand, Juul Use of Juul and similar products (‘ juuling ’) among youth has parents, teachers and the lay public appropriately concerned However, to date, there are no data on nicotine exposure among youth who use pod systems
### Survey
To characterise the use of pods among adolescents, we surveyed patients 12–21 years seen at three Stony Brook Children’s Hospital outpatient clinics (Long Island, New York) from April 2017 to April 2018 All participants/parents provided written consent Participants completed a 60-item anonymous questionnaire about personal use of e-cigarettes, including specific product types and brands, and provided a spot urine sample
### Product analysis
Using previously described analytical methods,3 we measured total nicotine concentration in pod products, purchased online, that were popular among our participants We also measured total nicotine yields in aerosols generated from these products using a smoking machine and standardised laboratory puffing protocol (70 mL puff volume, 2 s puff duration and puff intervals of 10 s)3 We used gas chromatography-mass …
183 citations
TL;DR: JUUL has triggered a widespread rush among aerosol purveyors to market e-liquid in unprecedentedly high nicotine concentrations, which threatens to addict a generation of youth and force regulators to enact protective measures.
Abstract: Objective Until recently, purveyors of vaping products marketed e-liquids in the 1%–3% range of nicotine concentration with those at 3% described as ‘super high’ intended for two packs/day smokers. The goal of this study is to evaluate the degree to which JUUL, with its 5% nicotine and 75% US market share, has spurred other e-liquid vendors to raise the nicotine levels of their products. Methods Online search to identify brands offering e-liquid in exceptionally high nicotine concentration (≥5%) and to catalogue the appearance of devices which emulate JUUL. Results JUUL compatible pods (14) and JUUL knock off devices (39) were identified which offer equal or higher nicotine than JUUL. More than 70 e-liquid brands sell high-nicotine products (≥5%) in bulk (≥30 mL) equivalent to >40 cigarette packs. All of these products come in multiple youth appealing sweet and fruity flavours. It was noted that nicotine percentage is inconsistently reported (eg, JUUL is 5% by weight vs 5.9% by volume). Conclusions JUUL has triggered a widespread rush among aerosol purveyors to market e-liquid in unprecedentedly high nicotine concentrations. The rapidly rising popularity of high-nicotine e-liquids threatens to addict a generation of youth. When sold in large quantity bottles (eg, 30 mL) they represent a childhood poisoning risk. Labelling of nicotine concentration in e-liquids needs to be standardised to avoid consumer confusion. The addictiveness and toxicity of these products makes it imperative that regulators act swiftly to enact protective measures.
143 citations
TL;DR: The inverse relationship between vaping and smoking was robust across different data sets for both youth and young adults and for current and more established smoking.
Abstract: Background The 2018 National Academies of Sciences, Engineering, and Medicine Report found substantial evidence that electronic cigarette use (vaping) by youth is strongly associated with an increased risk of ever using cigarettes (smoking) and moderately associated with progressing to more established smoking. However, the Report also noted that recent increases in vaping have been associated with declining rates of youth smoking. This paper examines the temporal relationship between vaping and youth smoking using multiple data sets to explore the question of whether vaping promotes smoking initiation in the USA. Methods Using publicly available, nationally representative data on smoking and vaping among youth and young adults, we conducted a trend line analysis of deviations from long-term trends in smoking starting from when vaping became more prevalent. Results There was a substantial increase in youth vaping prevalence beginning in about 2014. Time trend analyses showed that the decline in past 30-day smoking prevalence accelerated by two to four times after 2014. Indicators of more established smoking rates, including the proportion of daily smokers among past 30-day smokers, also decreased more rapidly as vaping became more prevalent. Conclusions The inverse relationship between vaping and smoking was robust across different data sets for both youth and young adults and for current and more established smoking. While trying electronic cigarettes may causally increase smoking among some youth, the aggregate effect at the population level appears to be negligible given the reduction in smoking initiation during the period of vaping’s ascendance.
141 citations
TL;DR: The FCTC has increased the implementation of measures across several policy domains, and these implementations have resulted in measurable impacts on tobacco consumption, prevalence and other outcomes, however, F CTC implementation must be accelerated and Parties need to meet all their Treaty obligations and consider measures that exceed minimum requirements.
Abstract: Objective To present findings of a narrative review on the implementation and effectiveness of 17 Articles of the WHO Framework Convention on Tobacco Control (FCTC) during the Treaty’s first decade. Data sources Published reports on global FCTC implementation; searches of four databases through June 2016; hand-search of publications/online resources; tobacco control experts. Study selection WHO Convention Secretariat global progress reports (2010, 2012, 2014); 2015 WHO report on the global tobacco epidemic; studies of social, behavioural, health, economic and/or environmental impacts of FCTC policies. Data extraction Progress in the implementation of 17 FCTC Articles was categorised (higher/intermediate/lower) by consensus. 128 studies were independently selected by multiple authors in consultation with experts. Data synthesis Implementation was highest for smoke-free laws, health warnings and education campaigns, youth access laws, and reporting/information exchange, and lowest for measures to counter industry interference, regulate tobacco product contents, promote alternative livelihoods and protect health/environment. Price/tax increases, comprehensive smoking and marketing bans, health warnings, and cessation treatment are associated with decreased tobacco consumption/health risks and increased quitting. Mass media campaigns and youth access laws prevent smoking initiation, decrease prevalence and promote cessation. There were few studies on the effectiveness of policies in several domains, including measures to prevent industry interference and regulate tobacco product contents. Conclusions The FCTC has increased the implementation of measures across several policy domains, and these implementations have resulted in measurable impacts on tobacco consumption, prevalence and other outcomes. However, FCTC implementation must be accelerated, and Parties need to meet all their Treaty obligations and consider measures that exceed minimum requirements.
135 citations
TL;DR: JUUL emits a high-nicotine concentration aerosol predominantly in the protonated form, and its nicotine-normalised formaldehyde and total aldehyde yields are lower than other previously studied ECIGs and combustible cigarettes.
Abstract: Introduction JUUL is an electronic cigarette (ECIG) with a compact form factor. It is prefilled with a liquid that is advertised to contain a high concentration of nicotine salt. JUUL commands 50% of the US ECIG market share, and its wide popularity with underage users has triggered unprecedented actions by the US FDA. Apart from its nicotine salt-containing liquid and compact form, a salient advertised design feature is a control circuit that limits the heating coil temperature, presumably reducing unwanted toxicants. In this study, several tobacco-flavoured JUUL devices were reverse engineered, and their aerosol emissions were studied. Methods Total nicotine and its partitioning (freebase and protonated), propylene glycol/vegetable glycerin (PG/VG) ratio, and carbonyls were quantified by gas chromatography (GC) and high performance liquid chromatography (HPLC). The temperature control functionality of JUUL was investigated using a temperature-controlled bath in which the coil was submerged. Results The liquid nicotine concentration was found to be 69 mg/mL, and the liquid and aerosol PG/VG ratio was found to be 30/70. In 15 puffs, JUUL emitted 2.05 (0.08) mg of nicotine, overwhelmingly in the protonated form. Carbonyl yields were significantly lower than those reported for combustible cigarettes, but similar to other closed-system ECIG devices. The heating coil resistance was 1.6 (0.66) Ohm, while the maximum power delivered by the JUUL device was 8.1 W. The control circuit limited the peak operating temperature to approximately 215C. Conclusions JUUL emits a high-nicotine concentration aerosol predominantly in the protonated form. JUUL’s nicotine-normalised formaldehyde and total aldehyde yields are lower than other previously studied ECIGs and combustible cigarettes.
127 citations
TL;DR: JUUL use was significantly higher among young people, with those under 21 having significantly higher odds of ever and current use and strong regulatory actions are needed to prevent youth and young adult uptake.
Abstract: Objective To estimate the prevalence of JUUL use and identify demographic and psychosocial correlates of use among youth and young adults in the USA. Methods A national, probability-based sample was recruited via address-based sampling, with subsamples recruited from an existing probability-based online panel. Participants (N=14 379) ages 15–34 were surveyed about JUUL use, tobacco use, electronic nicotine delivery system (ENDS) harm perceptions, sensation seeking and demographic characteristics. Data were collected February–May 2018. Χ2 analyses assessed differences in JUUL use by demographic and psychosocial characteristics. Logistic regressions identified significant correlates of ever and current JUUL use. Results Overall, 6.0% reported ever JUUL use, and 3.3% reported past 30-day (ie, current) use. Rates were higher among participants aged 15–17 and 18–21 years, with 9.5% and 11.2% reporting ever use, and 6.1% and 7.7% reporting current use, respectively. Among current users aged 15–17 years, 55.8% reported use on 3 or more days in the past month, and over a quarter reported use on 10–30 days. Significant correlates of use included younger age, white race, greater financial comfort, perceptions of ENDS as less harmful than cigarettes, household ENDS use, high sensation seeking and current combustible tobacco use. Conclusion JUUL use was significantly higher among young people, with those under 21 having significantly higher odds of ever and current use. Frequency of use patterns suggest youth may not be experimenting with the device but using it regularly. Given the high nicotine content of JUUL, there is concern over the potential for addiction and other serious health consequences among young people. Findings suggest strong regulatory actions are needed to prevent youth and young adult uptake.
120 citations
TL;DR: The vaping industry has demonstrated much ingenuity in devising discreet vaporisers and de-emphasising exhaled vapour plumes and their aroma, with JUUL accounting for 70.5% of sales (July 2018).
Abstract: Background Some consumers wish to use vapour devices discreetly so that family members, teachers and coworkers do not recognise their use of nicotine ortetrahydrocannabinol (THC) laden vapour Methods Stealthy vapour devices, as well as low-odour and low-vapour e-juices, were identified via a comprehensive online search between March and June 2018 Results As evidence of their popularity, a search for ‘stealth vaping’ on YouTube found 18 200 videos A variety of cleverly designed vapour devices disguised as USB sticks, pens, remote controls, car fobs, smart phones, sweatshirt drawstrings and even asthma inhalers are on the market JUUL, which resembles a USB stick, is the archetype of these devices and is especially popular among youth A search of ‘JUUL’ on YouTube yielded 148 000 videos with 57 videos having >100 000 views Searches on ‘JUUL at school’ (15 500), ‘JUUL in class’ (6840), ‘hiding JUUL in school’ (2030) and ‘JUUL in school bathroom’ (1040) illustrate the product’s popularity among students Some e-juices promote themselves as having low visibility plumes while others profess to be of subtle odour to avoid detection Numerous techniques have been described to hide the exhaled vapour plume such as by swallowing it or blowing it into one’s clothing or into a backpack Conclusions The vaping industry has demonstrated much ingenuity in devising discreet vaporisers and de-emphasising exhaled vapour plumes and their aroma The US market for vaping devices with stealthy characteristics is anything but inconspicuous, with JUUL alone accounting for 705% of sales (July 2018)
110 citations
TL;DR: Current vapers had lower risk in wheezing and related respiratory symptoms than current smokers or dual users but higher than non-users, while both dual use and smoking significantly increased the risk of wheazing andrelated respiratory symptoms.
Abstract: Background Wheezing is a symptom of potential respiratory disease and known to be associated with smoking. Electronic cigarette use (‘vaping’) has increased exponentially in recent years. This study examined the cross-sectional association of vaping with wheezing and related respiratory symptoms and compare this association with smokers and dual users. Methods The Population Assessment of Tobacco and Health study wave 2 data collected from October 2014 to October 2015 with 28 171 adults were used. The cross-sectional association of vaping with self-reported wheezing and related respiratory symptoms relative to smokers and dual users of tobacco and electronic cigarettes were studied using multivariable logistic and cumulative logistic regression models with consideration of complex sampling design. Results Among the 28 171 adult participants, 641 (1.2%) were current vapers who used e-cigarettes exclusively, 8525 (16.6%) were current exclusive smokers, 1106 (2.0%) were dual users and 17 899 (80.2%) were non-users. Compared with non-users, risks of wheezing and related respiratory symptoms were significantly increased in current vapers (adjusted OR (aOR)=1.67, 95% CI: 1.23 to 2.15). Current vapers had significantly lower risk in wheezing and related respiratory symptoms compared with current smokers (aOR=0.68, 95% CI: 0.53 to 0.87). No significant differences were found between dual users and current smokers in risk of wheezing and related respiratory symptoms (aOR=1.06, 95% CI: 0.91 to 1.24). Conclusions Vaping was associated with increased risk of wheezing and related respiratory symptoms. Current vapers had lower risk in wheezing and related respiratory symptoms than current smokers or dual users but higher than non-users. Both dual use and smoking significantly increased the risk of wheezing and related respiratory symptoms.
91 citations
TL;DR: This study found that the tobacco plug does char and that charring increases when the device is not cleaned between heatsticks, and if the polymer-film filter is potentially harmful.
Abstract: Objective To evaluate performance of the I quit original smoking (iQOS) heat-not-burn system as a function of cleaning and puffing topography, investigate the validity of manufacturer’s claims that this device does not burn tobacco and determine if the polymer-film filter is potentially harmful. Methods iQOS performance was evaluated using five running conditions incorporating two different cleaning protocols. Heatsticks were visually and stereomicroscopically inspected preuse and postuse to determine the extent of tobacco plug charring (from pyrolysis) and polymer-film filter melting, and to elucidate the effects of cleaning on charring. Gas chromatography–mass spectrometry headspace analysis was conducted on unused polymer-film filters to determine if potentially toxic chemicals are emitted from the filter during heating. Results For all testing protocols, pressure drop decreased as puff number increased. Changes in testing protocols did not affect aerosol density. Charring due to pyrolysis (a form of organic matter thermochemical decomposition) was observed in the tobacco plug after use. When the manufacturer’s cleaning instructions were followed, both charring of the tobacco plug and melting of the polymer-film filter increased. Headspace analysis of the polymer-film filter revealed the release of formaldehyde cyanohydrin at 90°C, which is well below the maximum temperature reached during normal usage. Discussion Device usage limitations may contribute to decreases in interpuff intervals, potentially increasing user’s intake of nicotine and other harmful chemicals. This study found that the tobacco plug does char and that charring increases when the device is not cleaned between heatsticks. Release of formaldehyde cyanohydrin is a concern as it is highly toxic at very low concentrations.
TL;DR: A proliferation of JUUL-related content on Instagram focused on product promotion and nicotine and addiction that included youth culture and lifestyle appeals should be restricted, particularly on social media platforms where young people are a primary audience.
Abstract: Background JUUL, a high-tech, popular vaping device, was the first major electronic cigarette (e-cigarette) brand to incorporate social media into its marketing strategy. There is growing concern around the increasing use of JUUL and other electronic nicotine delivery devices among youth, and their potential to addict a new generation to nicotine. The current study analysed the amount and characteristics of JUUL-related posts on Instagram, a social media platform used frequently among youth and young adults. Methods Hashtag-based keyword queries (n=50) were used to collect JUUL-related posts from the Instagram application programming interface, March 2018–May 2018. Using a combination of machine learning methods, keyword algorithms and human coding, posts were characterised as featuring content related to product promotion, nicotine and addiction, youth culture and lifestyle. Results Keyword queries captured 14 838 JUUL-relevant posts by 5201 unique users. Over one-third of posts were promotional (eg, linked to commercial website) and 11% contained nicotine and addiction-related information. Approximately half of posts featured content related to youth (55%) or lifestyle (57%). Youth-related content or lifestyle appeals were also notably present within promotional posts and nicotine and addiction-related posts, respectively. Nicotine and addiction-related posts featured memes, hashtags (eg, #nichead, #juulbuzz) and tag lines (eg, ‘more flavor, more buzz’). Conclusions Findings reveal a proliferation of JUUL-related content on Instagram, which focused on product promotion and nicotine and addiction that included youth culture and lifestyle appeals. Regulatory actions should focus on restricting promotional efforts for e-cigarette products, particularly on social media platforms where young people are a primary audience.
TL;DR: The PATH Study questions were developed using a careful protocol and the results indicate the answers provide reliable and valid information about tobacco use.
Abstract: Introduction This paper reports a study done to estimate the reliability and validity of answers to the Youth and Adult questionnaires of the Population Assessment of Tobacco and Health (PATH) Study. Methods 407 adults and 117 youth respondents completed the wave 4 (2016–2017) PATH Study interview twice, 6–24 days apart. The reinterview data were used to estimate the reliability of answers to the questionnaire. Kappa statistics, gross discrepancy rates and correlations between answers to the initial interview and the reinterview were used to measure reliability. We examined every item in the questionnaire for which there were at least 100 observations. After the reinterview, most respondents provided a saliva sample that allowed us to assess the accuracy of their answers to the tobacco use questions. Results There was generally a very high level of agreement between answers in the interview and reinterview. On the key current tobacco use items, the average kappa (the agreement rate adjusted for chance agreement) was 0.79 for adult respondents (age 18 or older). Youth respondents exhibited equally high levels of agreement across interviews. The items on current tobacco use also exhibited high levels of agreement with saliva test results (kappa=0.72). Rating scale items showed lower levels of exact agreement across interviews but the answers were generally within one scale point or category. Conclusions The PATH Study questions were developed using a careful protocol and the results indicate the answers provide reliable and valid information about tobacco use.
TL;DR: A new product category is emerging with several large tobacco companies now selling ‘tobacco-free’ nicotine pouches, sold as preportioned pouche similar to snus, but instead of containing tobacco leaf, they are filled with white nicotine-containing powder.
Abstract: A new product category is emerging with several large tobacco companies now selling ‘tobacco-free’ nicotine pouches. These products are sold as preportioned pouches similar to snus, but instead of containing tobacco leaf, they are filled with white nicotine-containing powder (figure 1). The pouches are placed between the lip and gum, and require no spitting or refrigeration.1 2 At least five large tobacco manufacturers currently sell nicotine pouch products. British American Tobacco sells Lyft in the UK and Sweden,2 3 and Velo (through RJ Reynolds Vapor Company) in the USA.4 Swedish Match sells Zyn in Europe and the USA,5 Kretek International sells Dryft in the USA1 and Japan Tobacco International sells Nordic Spirit in Sweden.6 Moreover, Altria recently agreed to acquire 80% of …
TL;DR: E-cigarette health warnings may motivate users to quit vaping and discourage smoking, and the most promising warnings include health hazards (other than nicotine addiction) and imagery.
Abstract: Background A prevailing hypothesis is that health warnings for electronic cigarettes (e-cigarettes) could drive people away from vaping and towards smoking cigarettes. We consider an alternative hypothesis that e-cigarette warnings discourage both vaping and smoking. Methods Participants were a national convenience sample of 2218 US adults who used e-cigarettes, cigarettes or both. In August 2018, we randomised participants to one of three warning types (control text about littering, text-only e-cigarette warning or pictorial e-cigarette warning). We further randomised participants viewing e-cigarette warnings to one of three topics (nicotine addiction, health hazards of use, or both health hazards and harms of use). The preregistered primary outcome was intentions to quit vaping among e-cigarette users. Secondary outcomes included interest in smoking and Tobacco Warnings Model constructs: attention, negative affect, anticipated social interactions and cognitive elaboration. Results Text warnings elicited higher intentions to quit vaping than control among e-cigarette users (d=0.44, p Discussion E-cigarette health warnings may motivate users to quit vaping and discourage smoking. The most promising warnings include health hazards (other than nicotine addiction) and imagery. We found no support for the hypothesis that e-cigarette warnings could encourage smoking cigarettes.
TL;DR: A ban on flavoured e-cigarettes alone would likely increase the choice of cigarettes in smokers, arguably the more harmful way of obtaining nicotine, whereas a ban on menthol cigarettes alone would most likely be more effective in reducing the choices of cigarettes.
Abstract: Objectives To provide the policy-relevant estimates of impacts of alternative flavour bans on preferences and demand for cigarettes and e-cigarettes in adult smokers and recent quitters. Methods A best–best discrete choice experiment (DCE) is used to elicit smokers’ and recent quitters’ preferences for flavours, price, health impact and nicotine level in cigarettes and e-cigarettes. Choice of tobacco products and an opt-out option were examined. An efficient design yielded 36 choice sets. Exploded logit choice models were estimated. Flavour bans are modelled by restricting flavour coefficients in the estimated model. Setting and participants A sample of 2031 adult smokers and recent quitters was recruited to complete an online survey and DCE. Results Current smokers and recent quitters, on average, prefer cigarettes and menthol cigarettes over flavoured e-cigarettes. However, there is substantial preference heterogeneity by younger adults (ages 18–25), race/ethnicity and respondents with higher education. Our predictions suggest that a ban on menthol cigarettes would produce the greatest reduction in the choice of cigarettes (−5.2%), but with an accompanying increase in e-cigarettes use (3.8%). In contrast, banning flavours in e-cigarettes, while allowing menthol in cigarettes would result in the greatest increase in the selection of cigarettes (8.3%), and a decline in the use of e-cigarettes (−11.1%). A ban on all flavours, but tobacco in both products would increase ‘opting-out’ the most (5.2%) but would also increase choice of cigarettes (2.7%) and decrease choice of e-cigarettes (−7.9%). Conclusions A ban on flavoured e-cigarettes alone would likely increase the choice of cigarettes in smokers, arguably the more harmful way of obtaining nicotine, whereas a ban on menthol cigarettes alone would likely be more effective in reducing the choice of cigarettes. A ban on all flavours in both products would likely reduce the smoking/vaping rates, but the use of cigarettes would be higher than in the status quo. Policy-makers should use these results to guide the choice of flavour bans in light of their stance on the potential health impacts both products.
TL;DR: The study found higher rates of quitting among daily and occasional menthol smokers in Ontario 1 year after the implementation of a menthol ban compared with non-menthol smokers, and suggests that restrictions on menthol may lead to substantial improvements in public health.
Abstract: Objectives The province of Ontario, Canada, banned the use of menthol-flavoured tobacco products as of 1 January 2017. The long-term impact of a menthol ban on smoking behaviour has not been previously evaluated. Methods Population cohort study with baseline survey conducted September–December 2016 and follow-up January–August 2018 among residents of Ontario, Canada, 16 years old and over who reported current smoking (past 30 days) at baseline survey and completed follow-up (n=913) including 187 reporting smoking menthol cigarettes daily, 420 reported smoking menthol cigarettes occasionally, and 306 were non-menthol cigarette smokers. Relative rates of making a quit attempt and being a non-smoker at follow-up were estimated with Poisson regression controlling for smoking and demographic characteristics at baseline. Results At follow-up, 63% of daily menthol smokers reported making a quit attempt since the ban compared with 62% of occasional menthol smokers and 43% of non-menthol smokers (adjusted relative rate (ARR) for daily menthol smokers compared with non-menthol smokers: 1.25; 95% CI 1.03 to 1.50). At follow-up, 24% of daily menthol smokers reported making a quit since the ban compared with 20% of occasional menthol smokers and 14% of non-menthol smokers (ARR for daily menthol smokers compared with non-menthol smokers: 1.62; 95% CI 1.08 to 2.42). Conclusions The study found higher rates of quitting among daily and occasional menthol smokers in Ontario 1 year after the implementation of a menthol ban compared with non-menthol smokers. Our findings suggest that restrictions on menthol may lead to substantial improvements in public health.
TL;DR: Significantly higher tobacco taxes will be needed to achieve Healthy China 2030 target for reduced smoking even after the implementation of other tobacco control measures.
Abstract: Background The Healthy China 2030 strategy sets ambitious targets for China’s policy-makers, including a decrease in the smoking rate from 27.7% in 2015 to 20% by 2030. China has made progress on tobacco control in recent years, but many key measures remain underused. This study explores the potential for full implementation of these measures to achieve the targeted reduction in smoking by 2030. Methods First, a ‘business as usual’ scenario for China’s cigarette market was developed based only on underlying economic parameters. Second, non-price tobacco control measures were then added assuming they are fully implemented by 2030. Third, excise per pack was raised to a level that would increase the real price of cigarettes by 50% in 2030. Findings Under the business as usual scenario, the rate of smoking falls to around 26.6% in 2030. When non-price measures are included, the rate of smoking falls to 22.0% (20.9%~23.1%). Thus, non-price measures alone are unlikely to achieve the Healthy China target. Under the third scenario, excise per pack was roughly doubled in 2030 in order to increase real cigarette prices by 50%. The rate of smoking then falls to 19.7% (18.2%~21.3%), reflecting 78 million (59~97 million) fewer smokers compared with 2016. In addition, real excise revenue from cigarettes increases by 21% (−3%~47%) compared with 2016. Conclusion Significantly higher tobacco taxes will be needed to achieve Healthy China 2030 target for reduced smoking even after the implementation of other tobacco control measures.
TL;DR: If industry data on ITT cannot meet the standards of accuracy and transparency set by high-quality research publications, a solution may be to tax tobacco companies and administer the resulting funds to experts, independent of the tobacco industry, who use previously developed reliable models for measuring ITT.
Abstract: Objective To examine the quality of tobacco industry-funded data on the illicit tobacco trade (ITT) through a systematic review of existing assessments of industry-funded data on ITT. Data sources Papers and reports assessing tobacco industry-funded data on ITT were obtained via searches of 8 academic databases, Google searches and correspondence with ITT experts. Study selection Inclusion criteria identified 35 English-language papers containing an original assessment of tobacco industry-funded data. Data extraction Using a coding framework, information was extracted from the assessments regarding the quality of tobacco industry data. Documents were second-coded, achieving 94% intercoder reliability with all disagreements resolved. Data synthesis Of the 35 assessments reviewed, 31 argued that tobacco industry estimates were higher than independent estimates. Criticisms identified problems with data collection (29), analytical methods (22) and presentation of results (21), which resulted in inflated ITT estimates or data on ITT that were presented in a misleading manner. Lack of transparency from data collection right through to presentation of findings was a key issue with insufficient information to allow replication of the findings frequently cited. Conclusions Tobacco industry data on ITT are not reliable. At present, the tobacco industry continues to fund and disseminate ITT research through initiatives such as PMI IMPACT. If industry data on ITT cannot meet the standards of accuracy and transparency set by high-quality research publications, a solution may be to tax tobacco companies and administer the resulting funds to experts, independent of the tobacco industry, who use previously developed reliable models for measuring ITT.
TL;DR: Stealth vaping is a common behaviour for many experienced e-cigarette users and its potential health and safety implications could help researchers and regulators to design interventions to minimise the public health impact of stealth vaping.
Abstract: Introduction ‘Stealth vaping’ is the practice of vaping discreetly in places where electronic cigarette (e-cigarette) use is prohibited. While anecdotal evidence suggests that stealth vaping is common, there have been no formal studies of the behaviour. The purpose of this study is to examine stealth vaping behaviour among experienced e-cigarette users. Methods Data were collected from the follow-up survey of a large longitudinal cohort study of adult experienced e-cigarette users conducted in January 2017. To measure stealth vaping behaviour, participants were asked ‘Have you ever ‘stealth vaped’, that is to say, used an e-cig in a public place where it was not approved and attempted to conceal your e-cig use? (yes/no)’. Participants indicating yes completed additional questions about the frequency of stealth vaping and were asked to select all the locations where they commonly stealth vape. Frequencies were used to examine the overall prevalence, frequency and common locations for stealth vaping. A logistic regression model was run to predict stealth vaping. Results Approximately two-thirds (64.3%, n=297/462) of the sample reported ever stealth vaping, of which 52.5% (n=156/297) reported stealth vaping in the past week. Among stealth vapers (n=297), 31% reported owning a smaller device solely for stealth vaping. The most common places to stealth vape included at work (46.8%), followed by bars/nightclubs (42.1%), restaurants (37.7%), at the movies (35.4%) and in airports/on airplanes (11.7%). Predictors of stealth vaping were greater dependence and owning a smaller device solely for stealth vaping. Conclusions Stealth vaping is a common behaviour for many experienced e-cigarette users. More research is needed to understand the reasons for stealth vaping and its potential health and safety implications. This information could help researchers and regulators to design interventions to minimise the public health impact of stealth vaping.
TL;DR: Governments should assume the TI seeks to control T&T systems in order to avoid scrutiny and minimise excise tax payments and that any T &T system based on Codentify, on intellectual property currently or previously owned by the TI, or being promoted or implemented by companies with TI links, is incompatible with the ITP and would not serve to reduce illicit trade.
Abstract: Background The Illicit Trade Protocol (ITP) requires a global track and trace (T&T) system to reduce tobacco smuggling. Given the tobacco industry’s (TI) historical involvement in tobacco smuggling, it stipulates that T&T ‘shall not be performed by or delegated to the tobacco industry’. This paper explores the rationale for & nature of the TI’s effors to influence the ITP & its T&T system. Methods Analysis of leaked TI documents and publicly available data; ,investigation of front groups, trademark and patent ownership. Findings Growing & diverse sources of evidence indicate that the TI remains involved in tobacco smuggling and that TI cigarettes account for around two-thirds of the illicit cigarette market. The TI therefore has a vested interest in controlling the global T&T system aimed to curtail this behaviour. To this end, Philip Morris International (PMI) adapted its pack marker system, Codentify, to meet T&T requirements, licensed it for free to its three major competitors who then collectively promoted it to governments using front groups and third parties including companies claiming to be independent despite clear TI links. PMI also sought to suggest Codentify was independent by selling some parts of its intellectual property on Codentify while retaining others, leaving a complex web of shared interests. In Africa, British American Tobacco used payments to obtain data suggesting its smaller competitor companies were evading taxes and secure influence with tax authorities. Regulatory capture has been enhanced by a public relations effort involving TI funding for conferences, training, research, and international police and anti-corruption organisations. Collectively this has created public messaging and a powerful network of organisations supportive of the TI’s misleading postion on illicit. Conclusions Governments should assume the TI seeks to control T&T systems in order to avoid scrutiny and minimise excise tax payments and that any T&T system based on Codentify, on intellectual property currently or previously owned by the TI, or being promoted or implemented by companies with TI links, is incompatible with the ITP and would not serve to reduce illicit trade.
TL;DR: There are more e-cigarette explosion and burn injuries in the USA than estimated in the past reports, and the National Electronic Injury Surveillance System (NEISS) could be a valuable resource for e-cigarettes injury surveillance.
Abstract: Background Electronic cigarette (e-cigarette) battery failure can result in explosions and burn injuries. Previous attempts to quantify these events has been limited to compilations of case studies, federal agency reports and media reports. Although e-cigarette explosions and burn injuries are thought to be rare, current surveillance methods likely underestimate actual occurrences. Methods Analyses were conducted on cross-sectional data from the US Consumer Product Safety Commission’s (CPSC) National Electronic Injury Surveillance System (NEISS). A keyword search of case narrative text was used to identify e-cigarette-related explosion and burn injuries presenting to US emergency departments from 2015 to 2017. Sampling weights were applied to make conservative national incidence estimates. Results From 2015 to 2017, there were an estimated 2035 e-cigarette explosion and burn injuries presenting to US hospital emergency departments (95% CI 1107 to 2964). Conclusions There are more e-cigarette explosion and burn injuries in the USA than estimated in the past reports. Improved surveillance of e-cigarette injuries and regulation of e-cigarette devices is urgently needed. NEISS could be a valuable resource for e-cigarette injury surveillance.
TL;DR: As vaping became more widespread and normative and users moved into larger tank and mod style e-cigarettes, there was less need to persuade people to try e-cigarette with a disposable product.
Abstract: For the first few years of the vaping epidemic, to draw in smokers, the tobacco industry provided disposable ‘try it and throw it out’ cigalike electronic cigarettes (e-cigarettes), potentially driven by desire to convince people to try a new product that looked similar to cigarettes with a low initial cost—about the same as (or less than) a pack of cigarettes1; much less than a typical reusable e-cigarette starter kit. As vaping became more widespread and normative and users moved into larger tank and mod style e-cigarettes,2 there was less need to persuade people to try e-cigarettes with a disposable product. Moreover, their availability from online vendors became more scarce and expensive, with the proportion of online vendors selling disposable e-cigarettes dropping from 55.2% in …
TL;DR: Cigarettes with flavour-changing capsules in the filter, a continuing success story for tobacco companies, have grown exponentially since being introduced in 2007 and now have market share greater than 10% in four European countries and have increased 12% in the Middle East and Africa.
Abstract: Cigarettes with flavour-changing capsules in the filter, a continuing success story for tobacco companies, have grown exponentially since being introduced in 2007. The global capsule market is estimated to be 150 billion sticks in 2017.1 We provide an update on the capsule market since 2014.2 From this time, capsule cigarettes have been introduced in new markets in Europe (Croatia, Spain), Africa (Tunisia), Latin America (Bolivia, Ecuador, Uruguay) and Asia (China, India, Philippines, Thailand, Vietnam).3 They are the fastest growing segment of the combustible market,4 with market share increasing between 2014 and 2017 in 52 of the 67 countries where they are sold and monitored by tobacco analyst Euromonitor.3 These products now have market share greater than 10% in four European countries (UK, Hungary, Ireland, Poland), and have increased 12% in the Middle East and Africa.1 The five most popular capsule markets remain in Latin America (see figure 1), with market share increasing by at least 40% …
TL;DR: The introduction of IQOS likely reduced cigarette sales in Japan and the net population health impact cannot be assessed without resolving several key uncertainties related to the direct harms ofIQOS and the precise patterns of both smoking and IQOS use.
Abstract: Background Philip Morris International, one of the largest transnational cigarette manufacturers, has heavily invested in its new heated tobacco product, IQOS, marketing it aggressively as a less harmful alternative to cigarette smoking. The company’s assertions that the product replaces cigarettes in a market have never been independently tested. The objective of this study is to determine whether introduction of IQOS affected cigarette sales in a large economy. Data and Methods Using 2014 to 2018 monthly retailer panel data from Japan, we analyse whether different dates of IQOS introduction across Japan’s regions are reflected in the patterns of cigarette sales in those regions. A series of placebo models are estimated to test if events other than IQOS introduction could have better explained the observed trends in cigarette sales. Results Cigarette sales begin to substantially decline at the time of the introduction of IQOS in each of 11 Japanese regions (Chow tests p Conclusions The introduction of IQOS likely reduced cigarette sales in Japan. The net population health impact, however, cannot be assessed without resolving several key uncertainties related to the direct harms of IQOS and the precise patterns of both smoking and IQOS use.
TL;DR: Adolescents’ reports of frequency of e-cigarette use and degree of addiction correlated significantly with cotinine as a biomarker of nicotine exposure, and the EASI and days per month are recommended as brief general measures.
Abstract: Background and objectives With high rates of use and uncertain consequences, valid electronic cigarette (e-cigarette) use frequency and addiction measures for adolescents are needed. This cross-sectional study examined correlations for multiple measures of adolescent e-cigarette use with nicotine exposure quantified with salivary cotinine levels. Methods Adolescents (N=173, age 13–18) who reported past-month e-cigarette use were recruited from the San Francisco Bay Area. Participants self-reported: (1) days of e-cigarette use in a typical month, (2) number of e-cigarette sessions in a typical day (sessions per day; SPD) and the (3) E-Cigarette Addiction Severity Index (EASI). Participants also completed the 10-item Penn State Electronic Cigarette Dependence Index (ECDI), which we examined in full and as a 2-item Heaviness of Vaping Index (HVI; the sum of the ECDI items on use frequency and time to first vaping on wakening). Sessions per month (SPM) were calculated using days per month and SPD. Cotinine levels, SPD and SPM were log-transformed. Results Among frequency measures, SPM correlated most strongly with cotinine (r=0.59), followed closely by days per month (r=0.58) and SPD (r=0.57), p Conclusions Adolescents’ reports of frequency of e-cigarette use and degree of addiction correlated significantly with cotinine as a biomarker of nicotine exposure. We recommend the EASI and days per month as brief general measures. SPM and the ECDI are more extensive measures that may yield a more nuanced understanding of use.
TL;DR: There was a marginal slowing in the decline in regular smoking during the period following 2010, when e-cigarettes were emerging but relatively unregulated, however, these patterns were not unique to tobacco use and the drop in the acceptability of smoking behaviour among youth accelerated during this time.
Abstract: Background Small yet significant impacts of e-cigarettes on population smoking cessations rates indicate promise for harm reduction. However, non-smoking young people are increasingly experimenting with e-cigarettes, and while regular use remains rare, arguments for regulation have been driven by fears that e-cigarettes re-normalize smoking. Others counter that e-cigarettes may displace youth smoking and further de-normalize it. This study tests whether the secular decline in youth smoking prevalence, as well as perceived smoking norms, slowed or accelerated during the period from 2011–2015 (when e-cigarettes were emerging but prior to recent moves to regulate their use).
Methods Data were taken from the Smoking Drinking and Drug Use survey in England, Health Behaviour in School Aged Children/School Health Research Network surveys in Wales, and the Scottish Adolescents Lifestyle and Substance Use Surveys between 1998 and 2015, including 247,515 13 and 15 year-old respondents. Segmented regression analyses examined trends for smoking prevalence (ever smoking and weekly smoking) and perceived smoking norms, testing for change in trend from 2011–15. Falsifiability checks examined change in trends for alcohol use and cannabis use for the same period.
Results In final models for the whole sample, there was no change in rate of decline for ever smoking (OR=1.01; CI 0.99 to 1.03), with a marginally significant slowing in the rate of decline for weekly smoking (OR=1.04; CI 1.00 to 1.08). This slowing decline in weekly smoking was however limited to groups for whom rates were declining prior to 2010 at a rate which could not be sustained (i.e. girls and 13 year olds), and occurred in a greater magnitude for other substances, including cannabis use (OR=1.21, CI 1.18 to 1.25) and alcohol use (OR=1.17; CI 1.14 to 1.19). There was consistent evidence across all subgroups of an increased rate of decline in the percentage of young people saying that smoking is ok (OR=0.83; CI 0.81 to 0.86).
Conclusion We found no evidence that the growing prevalence of e-cigarette use has led to increased experimentation with smoking, and some evidence that young people’s perceptions against smoking as a normative behavior have hardened rather than softened. Although the decline in weekly smoking rates is slowing, this appears to reflect a floor effect and is of smaller magnitude than change in trend for other substances. While the idea that e-cigarettes renormalize smoking has been central to much policy debate surrounding regulation, these findings indicate no reason to believe that this renormalization is occurring.
TL;DR: It is demonstrated that SHS exposure during pregnancy is far more common than active smoking in LMICs, accounting for more stillbirths than active Smoking patterns and closely mirrors WHO Global Adult Tobacco Survey male active smoking patterns.
Abstract: Background Secondhand smoke (SHS) exposure during pregnancy increases the risk of infant stillbirth, congenital malformations, low birth weight and respiratory illnesses. However, little is known about the extent of SHS exposure during pregnancy. We assessed the prevalence of SHS exposure in pregnant women in low-income and middle-income countries (LMICs). Methods We used Demographic and Health Survey data collected between 2008 and 2013 from 30 LMICs. We estimated weighted country-specific prevalence of SHS exposure among 37 427 pregnant women. We accounted for sampling weights, clustering and stratification in the sampling methods. We also explored associations between sociodemographic variables and SHS exposure in pregnant women using pairwise multinomial regression model. Findings The prevalence of daily SHS exposure during pregnancy ranged from 6% (95% CI 5% to 7%) (Nigeria) to 73% (95% CI 62% to 81%) (Armenia) and was greater than active tobacco use in pregnancy across all countries studied. Being wealthier, maternal employment, higher education and urban households were associated with lower SHS exposure in full regression models. SHS exposure in pregnant women closely mirrors WHO Global Adult Tobacco Survey male active smoking patterns. Daily SHS exposure accounted for a greater population attributable fraction of stillbirths than active smoking, ranging from 1% of stillbirths (Nigeria) to 14% (Indonesia). Interpretation We have demonstrated that SHS exposure during pregnancy is far more common than active smoking in LMICs, accounting for more stillbirths than active smoking. Protecting pregnant women from SHS exposure should be a key strategy to improve maternal and child health.
TL;DR: The results showing high polytobacco use and the lack of an association between HTP use and cigarette quit attempts call for a ban on HTP advertisements with modified harm claims.
Abstract: Background Heated tobacco products (HTPs) may compromise decades-long efforts to marginalise the tobacco industry. Their appeal to adolescents imposes a risk of a new tobacco epidemic. Empirical evidence on the behavioural patterns of HTP use among adolescents is required. We investigated the prevalence of HTP use and the association between use of HTPs and e-cigarettes and attempts to quit smoking cigarettes. Methods Nationally representative cross-sectional survey data of South Korean adolescents aged 12–18 years (mean age: 15 years) were used. The survey was conducted 1 year after the introduction of HTPs in Korea. A total of 59 532 adolescents were identified. Descriptive statistics and multiple logistic regression results are presented. Results In all, 2.8% of South Korean adolescents were ever HTP users. Among these, 75.5% were current cigarette users, 45.6% were current e-cigarette users and 40.3% were concurrent users of cigarettes and e-cigarettes. Unlike ever use of e-cigarettes, which was associated with a higher likelihood of cigarette quit attempts (adjusted OR (aOR)=1.35, 95% CI: 1.16 to 1.58), no difference in cigarette quit attempts was found for ever use of HTPs (aOR=1.07, 95% CI: 0.91 to 1.26). Conclusion Considering the recent introduction of HTPs to the Korean market and less than 1% prevalence of e-cigarette when first introduced, the prevalence of ever HTP use among Korean adolescents is an important concern. The results showing high polytobacco use and the lack of an association between HTP use and cigarette quit attempts call for a ban on HTP advertisements with modified harm claims.
TL;DR: The key legislative differences between these five countries are reviewed to identify best practice measures and potential lacuna, and how governments planning to introduce plain packaging could strengthen their legislation is discussed.
Abstract: By July 2018, five countries (Australia, France, the UK, New Zealand and Norway) had fully implemented plain (standardised) packaging. Using government documents, we reviewed the key legislative differences between these five countries to identify best practice measures and potential lacuna. We then discuss how governments planning to introduce plain packaging could strengthen their legislation. Differences between countries include the terminology used (either ‘plain’, ‘standardised’ or ‘plain and standardised’), products covered and transition times (ranging from 2 to 12 months). Myriad differences exist with respect to the packaging, including the dimensions (explicitly stated for height, width and depth vs minimum dimensions for the health warnings only), structure (straight-edged flip-top packs vs straight, rounded and bevelled-edged flip-top packs and shoulder boxes) and size (minimum number of cigarettes and weight of tobacco vs fixed amounts) and warning content (eg, inclusion of a stop-smoking web address and/or quitline displayed on warnings on one or both principal display areas). Future options that merit further analysis include banning colour descriptors in brand and variant names, allowing pack inserts promoting cessation and permitting cigarettes that are designed to be dissuasive. Plain packaging legislation and regulations are divergent. Countries moving towards plain packaging should consider incorporating the strengths of existing policies and review opportunities for extending these. While plain packaging represents a milestone in tobacco-control policy, future legislation need not simply reflect the past but could set new benchmarks to maximise the potential benefits of this policy.