Showing papers in "Tobacco Control in 2021"

Is e-cigarette use in non-smoking young adults associated with later smoking? A systematic review and meta-analysis.

Abstract: Objective The aim of this review was to investigate whether e-cigarette use compared with non-use in young non-smokers is associated with subsequent cigarette smoking. Data sources PubMed, Embase, Web of Science, Wiley Cochrane Library databases, and the 2018 Society for Research on Nicotine and Tobacco and Society for Behavioural Medicine conference abstracts. Study selection All studies of young people (up to age 30 years) with a measure of e-cigarette use prior to smoking and an outcome measure of smoking where an OR could be calculated were included (excluding reviews and animal studies). Data extraction Independent extraction was completed by multiple authors using a preprepared extraction form. Data synthesis Of 9199 results, 17 studies were included in the meta-analysis. There was strong evidence for an association between e-cigarette use among non-smokers and later smoking (OR: 4.59, 95% CI: 3.60 to 5.85) when the results were meta-analysed in a random-effects model. However, there was high heterogeneity (I2=88%). Conclusions Although the association between e-cigarette use among non-smokers and subsequent smoking appears strong, the available evidence is limited by the reliance on self-report measures of smoking history without biochemical verification. None of the studies included negative controls which would provide stronger evidence for whether the association may be causal. Much of the evidence also failed to consider the nicotine content of e-liquids used by non-smokers meaning it is difficult to make conclusions about whether nicotine is the mechanism driving this association.

Exposure to health misinformation about COVID-19 and increased tobacco and alcohol use: a population-based survey in Hong Kong.

Abstract: Introduction Health information about COVID-19 has been circulating in social networking sites, including unproven claims that smoking and alcohol drinking could protect against COVID-19. We examined if exposure to such claims was associated with changes in tobacco and alcohol consumption. Methods We conducted a population-based, landline and mobile phone survey of 1501 randomly sampled adults aged 18 years or older (47.5% male) in Hong Kong in April 2020. Respondents reported if they had ever seen claims that ‘smoking/alcohol drinking can protect against COVID-19’ from popular social networking platforms. Current tobacco and alcohol users reported if they had increased or reduced their consumption since the outbreak. Prevalence data were weighted by sex, age and education of the general adult population. Results 19.0% (95% CI 16.8% to 21.4%) of all respondents reported having seen claims that ‘smoking/alcohol drinking can protect against COVID-19’ from social networking sites. Multinomial logistic regression showed that exposure to the claims was significantly associated with increased tobacco use (OR 2.37, 95% CI 1.08 to 5.20) in current tobacco users (N=280) and increased alcohol use (OR 4.16, 95% CI 2.00 to 8.67) in current drinkers (N=722), adjusting for sex, age, education level, alcohol/tobacco use status, home isolation, anxiety and depressive symptoms, and survey method. Conclusion Our results first showed that exposure to health misinformation that smoking/alcohol drinking can protect against COVID-19 was associated with self-reported increases in tobacco and alcohol consumption in Chinese during the pandemic.

Global review of tobacco product flavour policies.

Abstract: Objective We determined which countries prohibit flavoured tobacco products and the details of those restrictions in order to identify possible gaps and opportunities for these and other countries to address. Methods We reviewed the grey literature, scanned news articles and consulted with key informants and identified 11 countries and the European Union (EU) that ban or restrict tobacco product flavours. We reviewed policy documents for their stated policy rationale, terms and definitions of flavours, tobacco products covered and restrictions on the use of flavour imagery and terms on tobacco product packaging. Results Countries with a tobacco product flavour policy include the USA, Canada, Brazil, Ethiopia, Uganda, Senegal, Niger, Mauritania, EU (28 Member States), Moldova, Turkey and Singapore. Most of the countries’ policies provide a rationale of dissuading youth from taking up tobacco use. Ten of the 12 policies use the terms ‘flavours’ (n=6) or ‘characterising flavours’ (n=4). Six policies cover all products made entirely or partly of tobacco leaf. Countries consistently prohibit flavours associated with fruits, vanilla and spices. The USA and Niger make an exception for menthol, while Mauritania and Uganda do not specify the scope of flavours or ingredients covered by their policies. Eight policies make no specific reference to restricting flavour descriptors on tobacco product packaging. Conclusion Countries looking to implement policies restricting flavours in tobacco products can build on existing comprehensive policies. Future research could examine the implementation and impacts of these policies, to inform other countries interested in acting in this policy domain.

Impact of COVID-19 lockdown on smoking consumption in a large representative sample of Italian adults.

Abstract: OBJECTIVES: Italy is one of the first countries that imposed a nationwide stay-at-home order during the COVID-19 outbreak, inevitably resulting in changes in lifestyles and addictive behaviours. The aim of this work is to investigate the impact of lockdown restrictions on smoking habits using data collected within the Lost in Italy project. METHODS: A web-based cross-sectional study was conducted on a representative sample of 6003 Italian adults aged 18-74 years. Study subjects were recruited from 27 April to 3 May 2020 and were asked to report changes in smoking habits before the lockdown and at the time of interview. RESULTS: During the lockdown, 5.5% of the overall sample quit or reduced smoking, but 9.0% of the sample started, relapsed smoking or increased their smoking intensity. In total, the lockdown increased cigarette consumption by 9.1%. An improvement in smoking habits was associated with younger age, occasional smoking and unemployment, whereas a worsening was mainly associated with mental distress. In particular, an increase in cigarette consumption during lockdown was more frequently reported among those with worsening quality of life (OR: 2.05; 95% CI: 1.49 to 2.80), reduction in sleep quantity (OR: 2.29; 95% CI: 1.71 to 3.07) and increased anxiety (OR: 1.83; 95% CI: 1.38 to 2.43) and depressive symptoms (OR: 2.04; 95% CI: 1.54 to 2.71). CONCLUSIONS: COVID-19 lockdown had a huge impact on smoking consumption of the Italian general population. The main concern is for smokers who increase their cigarette consumption due to an increased mental distress. Providing greater resources for cessation services capable of reducing mental health symptoms in smokers is urgently needed.

Factors that influence smokers' and ex-smokers' use of IQOS: a qualitative study of IQOS users and ex-users in the UK.

Abstract: Background One of the most widely available heated tobacco products is IQOS by Philip Morris International. However, there is a lack of independent research exploring IQOS initiation and subsequent use among smokers and ex-smokers. Aims To (1) explore the reasons why smokers and ex-smokers use and continue/discontinue IQOS and (2) consider implications for future research and policy. Participants Adult (18+) current (n=22) and ex-users (n=8) of IQOS who either currently smoked or quit smoking in the last 2 years. Methods Qualitative interview study in London, UK. Results Six main factors influenced initiation and use of IQOS: (1) Health—wanting to reduce/quit smoking and perceptions of reduced harm (while understanding IQOS was not risk-free). Branded packaging, absence of pictorial warnings and physical health improvements conveyed reduced harm. (2) Financial—including high start-up costs, but cheaper ongoing costs than smoking. (3) Physical—mixed views on enjoyment and satisfaction. Sensory experiences influenced use including discreetness, cleanliness, reduced smell and tactile similarities relative to combustible cigarettes. (4) Practical—issues of accessibility, shortcomings with maintenance/operation limited ongoing use, whereas use in smoke-free places increased use. (5) Psychological—similarities in rituals and routines, although new practices developed to charge and clean; some liked trailblazing new technology. (6) Social—improved social interactions from using IQOS instead of smoking, but with more limited shared social experiences for some. Conclusion For some, IQOS facilitated smoking substitution. Factors such as packaging, labelling, risk communication, price and smoke-free policies appear to influence initiation and use.

News coverage of the E-cigarette, or Vaping, product use Associated Lung Injury (EVALI) outbreak and internet searches for vaping cessation.

Abstract: Background In the latter half of 2019, an outbreak of pulmonary disease in the USA resulted in 2807 hospitalisations and 68 deaths, as of 18 February 2020. Given the severity of the outbreak, we assessed whether articles during the outbreak era more frequently warned about the dangers of vaping and whether internet searches for vaping cessation increased. Methods Using Tobacco Watcher, a media monitoring platform that automatically identifies and categorises news articles from sources across the globe, we obtained all articles that (a) discussed the outbreak and (b) primarily warned about the dangers of vaping. We obtained internet search trends originating from the USA that mentioned ‘quit’ or ‘stop’ and ‘e cig(s),’ ‘ecig(s),’ ‘e-cig(s),’ ‘e cigarette(s),’ ‘e-cigarette(s),’ ‘electronic cigarette(s),’ ‘vape(s),’ ‘vaping’ or ‘vaper(s)’ from Google Trends (eg, ‘how do I quit vaping?’). All data were obtained from 1 January 2014 to 18 February 2020 and ARIMA models were used with historical trends to forecast the ratio of observed to expected search volumes during the outbreak era. Results News of the vaping-induced pulmonary disease outbreak was first reported on 25 July 2019 with 195 articles, culminating in 44 512 articles by 18 February 2020. On average, news articles warning about the dangers of vaping were 130% (95% prediction interval (PI): −15 to 417) and searches for vaping cessation were 76% (95% PI: 28 to 182) higher than expected levels for the days during the period when the sources of the outbreak were unknown (25 July to 27 September 2019). News and searches stabilised just after the US Centers for Disease Control and Prevention reported that a primary source of the outbreak was an additive used in marijuana vapes on 27 September 2019. In sum, there were 12 286 articles archived in Tobacco Watcher primarily warning about the dangers of vaping and 1 025 000 cessation searches following the outbreak. Conclusion The vaping-induced pulmonary disease outbreak spawned increased coverage about the dangers of vaping and internet searches for vaping cessation. Resources and strategies that respond to this elevated interest should become a priority among public health leaders.

Rapid increase in heated tobacco product (HTP) use from 2015 to 2019: from the Japan 'Society and New Tobacco' Internet Survey (JASTIS).

Abstract: Heated tobacco products (HTPs) were introduced in Japan in 2014 without sufficient scientific evidence about the associated health risks. Our previous report found substantial HTP use in Japan after 2016.1 This study aims to clarify how the prevalence of HTP use (IQOS, Ploom TECH and glo) has increased over the last 5 years in Japan using ongoing retrospective Japan ‘Society and New Tobacco’ Internet Survey (JASTIS) data. We calculated the prevalence of HTP use from 2015 to 2019 from the JASTIS dataset. At baseline in 2015, 8240 participants aged 15–69 years were randomly selected from a Japanese large internet search agency, Rakuten Research.2 Adjusted estimates using inverse probability weighting (IPW) obtained from a propensity score (calculated by logistic regression models using basic demographic and socioeconomic factors) were calculated to correct for the selectivity of internet-based samples, using a probability sample that is representative of the Japanese …

Menthol e-cigarette sales rise following 2020 FDA guidance.

Abstract: Objective To explore patterns in flavoured e-cigarette sales following Juul Labs’ 2019 removal of mint-flavoured products and the Food and Drug Administration’s (FDA) 2020 e-cigarette flavour guidance which prohibits flavoured cartridge-based sales, but allows for the sale of tobacco-flavoured and menthol-flavoured cartridges, open-system and disposable e-cigarettes. Methods We examined Nielsen Retail Scanner data from September 2013 to March 2020. Inflation-adjusted sales dollars for e-liquid-containing products were classified into five flavour categories (fruit, menthol, mint, tobacco and other). Results Following the Juul Labs 2019 and FDA 2020 actions, total e-cigarette sales declined; however, menthol-flavoured e-cigarette sales dollars increased, while mint-flavoured e-cigarette sales dollars decreased in both instances. Juul Labs’ removal of mint-flavoured products was followed by a 59.4% increase in the market share of menthol-flavoured e-cigarettes over 4 weeks. The FDA’s 2020 guidance was followed by a 54.5% increase in the market share of menthol-flavoured e-cigarettes over 4 weeks and a 82.8% increase over 8 weeks. Conclusions Juul Labs’ self-regulation and the current FDA flavour guidance were followed by a shift towards menthol-flavoured e-cigarettes. Industry self-regulation and current federal guidance appear insufficient in reversing the youth vaping epidemic. E-cigarettes must be fully regulated as a tobacco product including the removal of flavoured e-cigarettes, including menthol, from the market to reduce youth e-cigarette use.

Synthetic nicotine has arrived.

Abstract: The introduction of a new product line of the popular disposable electronic cigarette brand Puffbar, advertised as containing synthetic nicotine, has drawn attention to the increasing use of synthetic nicotine in marketed products and its uncertain regulatory status. A search of the Truth Tobacco Industry Documents revealed that the industry considered using synthetic nicotine already in the 1960s, efforts that were abandoned due to high costs and insufficient purity. Recent patents revealed renewed efforts to develop more efficient strategies for the synthesis of nicotine. Nicotine exists as two stereoisomers, S-nicotine and R-nicotine. While S-nicotine is the prevalent (>99%) form of nicotine in tobacco, a market-leading form of synthetic nicotine contains both stereoisomers at equal amounts, raising concerns about inaccurate labelling and the poorly understood health effects of R-nicotine. Other manufacturers, including a leading vendor of pharmaceutical grade nicotine, developed stereospecific strategies to synthesise pure S-nicotine, now added to electronic cigarette products marketed in the USA and UK. While S-nicotine and R-nicotine can be differentiated by enantioselective High Performance Liquid Chromatography (HPLC), differentiation of synthetic (fossil-derived) from tobacco-derived S-nicotine will require development of methods to measure carbon isotope (14C or 13C) content. Vendors claim that the FDA has no authority to regulate synthetic nicotine as a tobacco product, allowing them to circumvent the premarket tobacco product application process. However, legal analysis suggests that FDA may have the authority to regulate synthetic nicotine as a drug. Alternatively, Congress needs to include nicotine from any source within the legal definition of tobacco products.

Evaluating the impact of menthol cigarette bans on cessation and smoking behaviours in Canada: longitudinal findings from the Canadian arm of the 2016-2018 ITC Four Country Smoking and Vaping Surveys.

Abstract: Objective To evaluate the impact of menthol cigarette bans in seven Canadian provinces between 2016 and 2018 Methods Longitudinal data from the Canadian arm of the 2016 and 2018 ITC Four Country Smoking and Vaping Survey 1098 non-menthol and 138 menthol smokers were surveyed pre-menthol and post-menthol cigarette bans Multivariate logistic regression models examined associations between pre-post ban changes in smoking behaviour, including differences between menthol and non-menthol smokers in quit attempts and quitting Results At follow-up, 591% of pre-ban menthol smokers switched to non-menthol cigarettes; 215% quit smoking and 195% still smoked menthols, primarily purchased from First Nations reserves Menthol smokers were more likely than non-menthol smokers to make a quit attempt (adjusted OR (aOR)=161, 95% CI 103 to 251), and to remain quit (aOR=230, 95% CI 106 to 501) Menthol smokers did not differ significantly from non-menthol smokers in quit success (aOR=172, 95% CI 098 to 301); however, daily menthol smokers were more likely than daily non-menthol smokers to quit (aOR=221, 95% CI 115 to 424), and daily menthol smokers who quit before the ban were more likely than daily non-menthol smokers to remain quit (aOR=281, 95% CI 115 to 685) Conclusions Although menthol smokers were most likely to switch to non-menthol cigarettes, the menthol ban was also significantly associated with higher rates of quit attempts and quit success among menthol smokers compared with non-menthol smokers, and may have helped to prevent relapse among menthol smokers who had quit smoking before the ban Results confirm and extend evaluation of Ontario’s menthol ban across provinces covering 83% of the Canadian population

Comprehensive overview of common e-liquid ingredients and how they can be used to predict an e-liquid's flavour category

Abstract: Objectives Flavours increase e-cigarette attractiveness and use and thereby exposure to potentially toxic ingredients. An overview of e-liquid ingredients is needed to select target ingredients for chemical analytical and toxicological research and for regulatory approaches aimed at reducing e-cigarette attractiveness. Using information from e-cigarette manufacturers, we aim to identify the flavouring ingredients most frequently added to e-liquids on the Dutch market. Additionally, we used flavouring compositions to automatically classify e-liquids into flavour categories, thereby generating an overview that can facilitate market surveillance. Methods We used a dataset containing 16 839 e-liquids that were manually classified into 16 flavour categories in our previous study. For the overall set and each flavour category, we identified flavourings present in more than 10% of the products and their median quantities. Next, quantitative and qualitative ingredient information was used to predict e-liquid flavour categories using a random forest algorithm. Results We identified 219 unique ingredients that were added to more than 100 e-liquids, of which 213 were flavourings. The mean number of flavourings per e-liquid was 10±15. The most frequently used flavourings were vanillin (present in 35% of all liquids), ethyl maltol (32%) and ethyl butyrate (28%). In addition, we identified 29 category-specific flavourings. Moreover, e-liquids’ flavour categories were predicted with an overall accuracy of 70%. Conclusions Information from manufacturers can be used to identify frequently used and category-specific flavourings. Qualitative and quantitative ingredient information can be used to successfully predict an e-liquid’s flavour category, serving as an example for regulators that have similar datasets available.

Association of initial e-cigarette and other tobacco product use with subsequent cigarette smoking in adolescents: a cross-sectional, matched control study.

Abstract: Introduction This study assessed whether initiating e-cigarette use increases the uptake of cigarette smoking in US adolescents compared with behavioural and synthetic controls. Methods Data come from 78 265 adolescents in the National Youth Tobacco Survey (2014–2017) of whom 38 630 provided information about the first tobacco product they had used in 2014/15. Ever, past 30 day and established (30 day use and 100+ lifetime cigarettes) cigarette smoking was compared in adolescents who first used an e-cigarette (exposure group), a non-cigarette combustible (CT) or other non-combustible tobacco (NT) product (behavioural controls), and propensity score matched adolescents without initial e-cigarette use (synthetic controls). Results Relative to behavioural controls, adolescents who tried e-cigarettes first were less likely to have ever smoked cigarettes (26% vs CT (42.4%; OR 0.48, 95% CI 0.40 to 0.57), or NT initiators (52.7%; OR 0.32, 95% CI 0.26 to 0.39)), to be past 30 day (6% vs CT (11.9%; OR 0.48, 95% CI 0.36 to 0.62), or NT initiators (20.0%; OR 0.26, 95% CI 0.19 to 0.35)) or be established cigarette smokers (0.7% vs CT (3.9%; OR 0.17, 95% CI 0.10 to 0.30), or NT initiators (8.4%; OR 0.08, 95% CI 0.04 to 0.13)). E-cigarette initiators were also less likely than synthetic controls (without initial e-cigarette use) to have ever smoked cigarettes (OR 0.76, 95% CI 0.62 to 0.93), be past 30 day (OR 0.71, 95% CI 0.55 to 0.91) or be established cigarette smokers (OR 0.26, 95% CI 0.13 to 0.51). Conclusion Less than 1% of US adolescents who use e-cigarettes first were established cigarette smokers. They were less likely to be smokers than adolescents who tried other combustible or non-combustible tobacco products first and propensity score matched adolescents without initial e-cigarette use.

Nicotine delivery and cigarette equivalents from vaping a JUULpod.

Abstract: With patented nicotine salt technology, JUUL dominates the e-cigarette market. We reviewed studies of JUUL’s nicotine pharmacokinetic profile and studies quantifying nicotine in a JUULpod, emitted in the aerosol and absorbed by users. Examined in eight studies, JUUL’s peak nicotine levels were half to three-quarters that of a combustible cigarette in industry-conducted studies with JUUL-naive users, while comparable to or greater than combustible cigarettes in independent studies of experienced e-cigarette users. JUUL Labs reports each 5% (nicotine-by-weight) cartridge contains approximately 40 mg nicotine per pod and is ‘approximately equivalent to about 1 pack of cigarettes.’ In five independent studies, nicotine in the liquid in a JUULpod ranged from 39.3 to 48.3 mg. Seven studies measured nicotine delivery via vaping-machine generated aerosols, varying in puffing regimes and equipment. One study estimated 68% transfer efficiency to the aerosol, measuring 28.8 mg nicotine per JUULpod. The other studies reported nicotine values ranging from 72 to 164 µg/puff. At 200 puffs, this is 14.4–32.8 mg of nicotine per pod with equivalence to 13–30 cigarettes. A study measuring nicotine levels in JUUL users during a 5-day controlled switch found equivalence to 18 cigarettes. One JUULpod appears capable of delivering the nicotine equivalent to smoking about a pack of cigarettes, with variability. In JUUL-naive smokers, JUUL’s nicotine boost was lower than that of combustible cigarettes; while in experienced users, JUUL was comparable. Minimising harshness and adaptive to user experience, JUUL’s design facilitates initiation to a high nicotine, and ultimately, highly addictive vaping product.

Nearly 20 000 e-liquids and 250 unique flavour descriptions: an overview of the Dutch market based on information from manufacturers

Abstract: Objectives Flavours increase attractiveness of electronic cigarettes and stimulate use among vulnerable groups such as non-smoking adolescents. It is important for regulators to monitor the market to gain insight in, and regulate the range of e-liquid flavours that is available to consumers. E-liquid manufacturers are required to report key product information to authorities in the European Member States in which they plan to market their products. This information was used to provide an overview of e-liquid flavour descriptions marketed in the Netherlands in 2017. Methods Two researchers classified 19 266 e-liquids into the 16 main categories of the e-liquid flavour wheel, based on information from four variables in the European Common Entry Gate system. Flavour descriptions were further specified in subcategories. Results For 16 300 e-liquids (85%), sufficient information was available for classification. The categories containing the highest number of e-liquids were fruit (34%), tobacco (16%) and dessert (10%). For all e-liquids, excluding unflavoured ones, 245 subcategories were defined within the main categories. In addition to previously reported subcategories, various miscellaneous flavours such as sandwich, buttermilk and lavender were identified. Conclusions In 2017, ~20 000 e-liquids were reported to be marketed in the Netherlands, in 245 unique flavour descriptions. The variety of marketed flavour descriptions reflects flavour preference of e-cigarette users as described in literature. Our systematic classification of e-liquids by flavour description provides a tool for organising the huge variety in market supply, serves as an example for other countries to generate similar overviews and can support regulators in developing flavour regulations.

Co-optation of harm reduction by Big Tobacco.

Abstract: Harm reduction is a respected public health strategy for managing addictive behaviours that pose severe health risks. Such an approach recognises that for people unable to abstain from a certain risky behaviour, public health interventions can be used to mitigate the potential dangers and health risks. For drugs such as heroin, harm reduction applications include needle exchange and supervised injection sites where the provision of sterile injection equipment can minimise the risk of HIV and other infections, naloxone can be administered to manage overdoses and medical staff can arrange treatment referrals. In such instances, harm reduction applications can serve as a gateway to accessing vulnerable and marginalised groups.1 Harm reduction, which is typically overseen by clinicians, nurse practitioners and outreach workers, represents a movement that tends to be community-based, activism-driven and concerned with human rights. An important question pertains to the multitude of stakeholders involved and who is overseeing the harm reduction intervention. For tobacco harm reduction, the curious involvement and role of the industry prove to be contentious.2 3 Multinational tobacco companies, such as British American Tobacco (BAT) and Philip Morris International (PMI), have adopted harm reduction in their public relations initiatives and marketing communication, which provides them an opportunity to showcase their engagement in new product development of self-styled ‘next-generation products’.4 BAT, for example, publishes an annual report on sustainability that includes a section on harm reduction where their e-cigarette brand, Vype, is offered as a harm reduction product.5 During a 2017 annual shareholder meeting, Altria—the parent owner of Philip Morris USA—identified ‘tobacco harm reduction’ as a responsibility priority for the company with their branded ‘innovative products’ and heated tobacco products presented as examples.6 Also in 2017, PMI established a Foundation for a Smoke-Free World with committed funding of roughly US$1 billion and …

Acute effects of JUUL and IQOS in cigarette smokers.

Abstract: Background JUUL is an electronic cigarette that aerosolises a nicotine-containing liquid, while IQOS heats tobacco to produce an aerosol. Both are marketed to smokers, but their effects have seldom been examined in this population. Methods Eighteen cigarette smokers (13 men) with no JUUL or IQOS experience completed a within-subject, laboratory study assessing nicotine delivery and subjective effects after controlled (10 puffs, ~30 s interpuff interval) and ad libitum (90 min) use of JUUL, IQOS or own-brand (OB) cigarettes. Results JUUL increased mean plasma nicotine concentration significantly from 2.2 (SD=0.7) ng/mL to 9.8 (4.9) ng/mL after 10 puffs and to 11.5 (9.3) ng/mL after ad libitum use. IQOS increased mean plasma nicotine significantly from 2.1 (0.2) ng/mL to 12.7 (6.2) ng/mL after 10 puffs and to 11.3 (8.0) ng/mL after ad libitum use. OB increased mean plasma nicotine significantly from 2.1 (0.2) ng/mL to 20.4 (11.4) ng/mL after 10 puffs and to 21.0 (10.2) ng/mL after ad libitum use. Mean OB plasma nicotine concentration was significantly higher than JUUL and IQOS. OB increased expired carbon monoxide concentration, but IQOS and JUUL did not. ‘Craving a cigarette/nicotine’ and ‘Urges to smoke’ were reduced significantly for all products following the directed bout. Conclusions Among smokers, JUUL and IQOS delivered less nicotine than cigarettes. Also, in this sample, IQOS and OB reduced abstinence symptoms more effectively than JUUL. Additional work with experienced JUUL and IQOS users is needed, as their nicotine delivery profiles and subjective experiences may differ.

Prevalence and predictors of heated tobacco product use and its relationship with attempts to quit cigarette smoking among Korean adolescents.

Abstract: Introduction Heated tobacco products (HTPs) have been available in the Korean market since June 2017. In this study, we examined the prevalence and predictors of HTP use among Korean adolescents and the association between HTP and electronic cigarette (EC) use and attempts to quit conventional cigarette (CC) smoking. Methods We analysed the data of a representative sample (n=60 040) of 13–18-year-old middle-school and high-school students in Korea who had participated in the 14th Korea Youth Risk Behavior Web-based Survey in 2018. Results The prevalence of ever HTP use among Korean adolescents was 2.9% (men: 4.4%, women: 1.2%), a year after the introduction of HTPs in the Korean market. Furthermore, 81.3% of the 1568 ever HTP users were triple users of HTPs, ECs and CCs. Multivariate analysis revealed that ever HTP use was greater among men, higher-grade students, current CC and/or EC users and risky alcohol drinkers. Among current CC smokers, ever users of ECs (28%–30%) and ever HTP users and current EC users (48%) were more likely to have attempted to quit CC smoking than those who had never used HTPs and ECs. However, there were fewer HTP and/or EC ever users among ever CC smokers who successfully quit smoking. Conclusions Many adolescents, especially CC and EC users, had already used HTPs shortly after the introduction of HTPs in Korea. The use of newer types of tobacco products is associated with lower odds of abstinence from CCs; therefore, it is important to protect adolescents from them.

Differences in flavourant levels and synthetic coolant use between USA, EU and Canadian Juul products.

Abstract: Background ‘Juul’ is the dominant US e-cigarette brand and was recently introduced to Canada, UK, France, Germany and Italy, with several flavours available across countries. US/Canadian products are sold with 5%, 3% and 1.5% (Canada only) nicotine content, whereas European Union (EU) regulation limits nicotine content to 1.7%. The differential nicotine content raises the question if flavour profiles and Juul device power output differ between countries. Methods ‘Mint’, ‘Vanilla’ and ‘Mango’ e-liquids from all six countries were purchased in 2019 and analysed by GC/MS for their principal flavourant and nicotine content. In addition, device power specifications were compared for devices purchased from the respective countries. Results Compositions of Juul e-liquids from the USA and Canada were identical and differed from the EU-marketed liquids, in which principal flavourant concentrations were significantly lower. EU Juul ‘Mint’ e-liquids contained a synthetic coolant, N-ethyl-p-menthane-3-carboxamide (WS-3), absent in US/Canadian products. US/Canadian ‘Mango’ e-liquid contained triethyl-citrate, an emulsifier. Nicotine contents matched label information, and devices had identical power specifications. Conclusions Tested US/Canadian Juul e-liquids contained higher flavour concentrations than EU products, likely reflecting adaptation to user preferences. In EU, ‘Mint’ e-liquid, menthol is partially substituted with the synthetic coolant WS-3 that elicits a cooling effect like menthol but lacks its distinct ‘minty’ odour. The inhalational safety of WS-3 is unknown. The use of an emulsifier in US/Canadian ‘Mango’ Juul e-liquid may be necessary to keep the product homogeneous. Similar power specifications of devices between countries suggest that nicotine aerosol delivery is likely proportional to the e-liquid nicotine content.

Analysis of FDA's IQOS marketing authorisation and its policy impacts.

Abstract: Background Philip Morris Products SA (PMPSA) submitted a premarket tobacco application (PMTA) to US Food and Drug Administration (FDA) seeking an order permitting it to market IQOS in the USA US law requires FDA to deny marketing authorisation if applicants fail to demonstrate that their product is ‘appropriate for the protection of the public health’ FDA issued a marketing order for IQOS in April 2019, which Philip Morris is using to promote IQOS outside the USA Methods We analysed FDA’s Technical Project Lead Review and marketing order for IQOS, relevant law and guidance on PMTAs and independent research on the health impacts of IQOS Results FDA found that the evidence PMPSA submitted did not demonstrate reduction in long-term disease risks and that IQOS aerosol emits toxins with carcinogenic and genotoxic potential, some at higher levels than conventional cigarettes PMPSA did not appropriately consider the health impacts of dual use, the product’s attractiveness to youth or data showing that consumers do not accurately perceive the addiction risks of IQOS Despite FDA’s own scientists’ recommendations and independent research showing that IQOS presents serious risks to users including cytotoxic, genotoxic, hepatotoxic, cardiovascular and pulmonary risks, FDA concluded that IQOS is ‘appropriate for the protection of the public health’ Conclusion FDA’s decision allowing IQOS to be marketed in the USA disregarded valid scientific evidence and misapplied the public health standard mandated by law This decision may have important health impacts, influence marketing IQOS outside the USA and erode public confidence in FDA’s future PMTA decisions

Prevalence of heated tobacco product use in Japan: the 2020 JASTIS study.

Abstract: Background Japan is the leading market for heated tobacco products (HTPs). We assessed the latest prevalence of HTP use including novel products (Ploom S, glo sens, and Pulze). Methods Data were obtained from an internet-based, self-reported survey conducted during February-March 2020 with individuals aged 15–74 years in Japan(n=9044). Prevalence of current (past 30-day) HTP use and cigarette smoking was computed. Poison regression analysis was conducted to examine predictors of HTP use among current cigarette smokers (n=1478). All analyses were weighted to account for selection bias in the internet survey using a nationally representative sample of Japanese population. Results In 2020, prevalence of current HTP use and cigarette smoking was 10.9% and 25.9% in Japan, respectively. The most commonly used HTP brand was IQOS (5.7%) followed by Ploom TECH/Ploom TECH+ (5.4%) and glo (2.6%). Use of Ploom S, glo sens and Pulze was 1.6%, 0.8% and 0.6%, respectively. Among current cigarette smokers, 34.9% of those who were interested in quitting smoking and 30.5% of those who were not interested in quitting reported concurrent use of HTP, respectively (difference not significant). Cigarette smokers who reported having multiple chronic conditions (aPR=2.31), alcohol consumption (aPR=2.07), and e-cigarette use (aPR=1.88) were more likely to use an HTP compared to those who did not report such characteristics. Conclusions HTP use remained prevalent in Japan. One in three current cigarette smokers used HTPs regardless of whether they were interested inquitting smoking. Continuedsurveillance is important to inform national and global tobaccocontrol strategies.

Flavour chemicals, synthetic coolants and pulegone in popular mint-flavoured and menthol-flavoured e-cigarettes.

Abstract: Author(s): Omaiye, Esther E; Luo, Wentai; McWhirter, Kevin J; Pankow, James F; Talbot, Prue | Abstract: BackgroundThe Food and Drug Administration (FDA) has recently banned flavours from pod-style electronic cigarettes (e-cigarettes), except for menthol and tobacco. JUUL customers have quickly discovered that flavoured disposable e-cigarettes from other manufacturers, such as Puff, are readily available. Our goal was to compare flavour chemicals, synthetic coolants and pulegone in mint-flavoured/menthol-flavoured e-cigarettes from JUUL and Puff, evaluate the cytotoxicity of the coolants and perform a cancer risk assessment for pulegone, which is present in both JUUL pods and disposable Puff products.MethodsIdentification and quantification of chemicals were performed using gas chromatography/mass spectrometry. Cytotoxicity of the coolants was evaluated with BEAS-2B cells using the MTT 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. The cancer risk of pulegone was calculated using the margin of exposure (MOE).ResultsMenthol was the dominant flavour chemical (g1 mg/mL) in all products from both manufacturers. Minor flavour chemicals (l1 mg/mL) differed in the JUUL and Puff fluids and may produce flavour accents. The concentrations of WS-3 and WS-23 were higher in Puff than in JUUL. WS-23 was cytotoxic in the MTT assay at concentrations 90 times lower than concentrations in Puff fluids. The risk of cancer (MOEl10 000) was greater for mint than for menthol products and greater for Puff than for JUUL.ConclusionsSwitching from flavoured JUUL to Puff e-cigarettes may expose users to increased harm due to the higher levels of WS-23 and pulegone in Puff products. Cancer risk may be reduced in e-cigarettes by using pure menthol rather than mint oils to produce minty-flavoured e-cigarette products.

Compliance with San Francisco's flavoured tobacco sales prohibition

Abstract: Background In June 2018, San Francisco voters upheld the first comprehensive prohibition on sales of flavoured tobacco products (all products including menthol, everywhere in the city with no exceptions). Methods This paper used data collected by the San Francisco Department of Public Health as part of its implementation and enforcement of San Francisco’s city-wide ban on the sale of flavoured tobacco products. Every licensed tobacco retailer was visited and inspected. The San Francisco Department of Public Health and volunteers conducted an educational campaign from September 2018 to December 2018, including emailing all licensed tobacco retailers about the law, mailing a fact sheet poster, conducting four listening sessions and visiting permitted tobacco retailers to educate them about the law and solicit questions. Results Compliance inspections started in December 2018, which found that compliance was 17%. Compliance increased in January 2019 and averaged 80% between January 2019 and December 2019. After the phase-in period, all retailers were visited as part of routine inspections. This effort resulted in 80% compliance. Conclusion Including retailer education prior to enforcement can result in compliance with a comprehensive ban on the sale of menthol and other flavoured tobacco products.

Vape shop and consumer activity during COVID-19 non-essential business closures in the USA.

Abstract: Introduction Vaping and vape shops pose risk for COVID-19 and its transmission. Objectives We examined vape shop non-compliance with state-ordered business closures during COVID-19, changes in their marketing and experiences among consumers. Methods As part of a longitudinal study of vape retail in six metropolitan statistical areas (MSAs; Atlanta, Boston, Minneapolis, Oklahoma City, San Diego and Seattle), we conducted: (1) legal research to determine whether statewide COVID-19 orders required vape shops to close; (2) phone-based and web-based surveillance to assess vape shop activity in March–June 2020 during shelter-in-place periods; and (3) a concurrent online survey of e-cigarette users about their experiences with vape retail. Results Non-essential business closure varied in timing/duration across states and applied to vape shops in California, Massachusetts, Minnesota, Oklahoma (for a brief period) and Washington (Georgia’s orders were ambiguous). Surveillance analysis focused on the five MSAs in these states. Of 156 vape shops, 53.2% were open as usual, 11.5% permanently closed and 3.8% temporarily closed; 31.4% offered pick-up/delivery services. Among survey respondents (n=354, Mage=23.9±4.6; 46.9% male, 71.8% white, 13.0% Hispanic), 27.4% worried their vape shop would close/go out of business during COVID-19; 7.3% said their vape shop did so. Few noticed increases in vape product delivery options (7.3%), discounts/price promotions (9.9%) and/or prices (9.3%). While 20.3% stockpiled vape products, 20.3% tried to reduce use and 15.8% tried to quit. Conclusions Many vape shops were non-compliant with state COVID-19 orders. E-cigarette users were as likely to stockpile vape products as to attempt to reduce or quit using e-cigarettes.

Vaping on TikTok: a systematic thematic analysis.

Abstract: Introduction The rising popularity of TikTok among adolescents may influence their awareness and perceptions of e-cigarette use via user-generated content. This study aimed to examine how e-cigarette/vaping-related videos are portrayed on TikTok. Methods The nine most viewed hashtag based keywords were used to identify popular e-cigarette/vaping-related videos on TikTok (n=1000) from its inception (earliest upload date: January 2019) to November 2020. Five researchers independently coded the number of views, likes, user category and theme. Results A final sample of 808 e-cigarette/vaping-related videos that met study criteria were included. Collectively, these videos were viewed over 1.5 billion times, with a median view count of 1 000 000 (range 112 900–78 600 000) and a median ‘likes’ count of 143 000 (range 10 000–1 000 000). A majority of the videos portrayed e-cigarette use positively (63%; collectively viewed over 1.1 billion times). Neutral depictions of e-cigarette use were viewed a total of 290 million times (24%) and negative depictions of e-cigarettes were viewed a total of 193 million times (13%). The video themes included (not mutually exclusively): ‘comedy and joke’ (52%; total of 618 million views), ‘lifestyle and acceptability’ (35%; 459 million), ‘marketing’ (29%; 392 million), ‘vaping tricks’ (20%; 487 million), ‘nicotine and addiction’ (20%; 194 million), ‘creativity’ (16%; 322 million) and ‘warning’ (11%; 131 million). Conclusion Our findings illustrated that positively framed e-cigarette and vaping-related postings available without age restrictions on TikTok—a rising video-sharing platform that is popular among adolescents—have been viewed many times. Effective age restrictions are needed to reduce adolescents’ potential exposure to videos that portray vaping positively.

An estimation of the harm of menthol cigarettes in the United States from 1980 to 2018.

Abstract: Background Menthol cigarettes are thought to encourage smoking initiation among youths and young adults and make it more difficult for smokers to quit, thus increasing cigarette harm. However, no study to date has quantified the damage that menthol cigarettes have caused the US population. Objective To estimate the excess smoking prevalence, smoking initiation, and mortality in the US from 1980 through 2018 that can be attributed to menthol cigarettes. Methods Using a well-established simulation model of smoking prevalence and health effects and data from the National Health Interview Survey (NHIS), we first reproduced the overall US adult smoking prevalence between 1980 and 2018 (pseudo-R2=0.98) and associated mortality. Then we re-ran the model, assuming that menthol cigarettes were not present in the market over the same period. Finally, we compared both scenarios to quantify the public health harm attributable to menthol over the 1980–2018 period. Results From 1980 to 2018, we found that menthol cigarettes were responsible for slowing down the decline in smoking prevalence by 2.6 percentage points (13.7% vs 11.1% in 2018). Our results also show that menthol cigarettes were responsible for 10.1 million extra smokers, 3 million life years lost and 378 000 premature deaths during that period. Conclusions With millions of excess smoking initiators and thousands of smoking-related deaths due to mentholated cigarettes from 1980 through 2018, our results indicate that these products have had a significant detrimental impact on the public’s health and could continue to pose a substantial health risk. Our findings can assist the Food and Drug Administration in evaluating potential regulatory actions for mentholated tobacco products.

Oral nicotine marketing claims in direct-mail advertising.

Abstract: Background Little is known regarding how oral nicotine products (eg, nicotine pouches, lozenges) are marketed to consumers, including whether potential implicit reduced harm claims are used. In the current study, we explored the marketing claims present in a sample of direct-mail oral nicotine advertisements sent to US consumers (March 2018–August 2020). Methods Direct-mail ads (n=50) were acquired from Mintel and dual-coded for the following claims: alternative to other tobacco products, ability to use anywhere, spit-free, smoke-free and product does not contain tobacco leaf. We merged the coded data with Mintel’s volume estimate (number of mail pieces sent to consumers) and calculated the proportion of oral nicotine advertisements containing claims by category. Results Of the 38 million pieces of oral nicotine direct-mail sent to US consumers, most featured claims that the product could be used anywhere (84%, 31.8 million pieces); was an alternative to other tobacco products (69%, 26.1 million pieces); and did not contain tobacco leaf (eg, ‘tobacco leaf-free’, ‘simple’ approach of extracting nicotine from tobacco; 55%, 20.7 million pieces). A slightly smaller proportion contained claims that oral nicotine was ‘spit-free’ (52%, 19.8 million pieces) or ‘smoke-free’ (31%, 11.7 million pieces). Conclusion Our results provide an early indication of marketing claims used to promote oral nicotine. The strategies documented, particularly the use of language to highlight oral nicotine is tobacco-free, may covey these products as lower-risk to consumers despite the lack of evidence or proper federal authorisation that oral nicotine products are a modified-risk tobacco product. Future research is needed to examine consumer perceptions of such claims.

E-cigarette and cigarette purchasing among young adults before and after implementation of California's tobacco 21 policy.

Abstract: Background Tobacco 21 (T21) laws, which raise the minimum legal age of sale of tobacco products to 21, have been proposed and implemented in states and cities across the USA. However, limited data are available on the effect of T21 laws on youth tobacco purchasing behaviours and access to tobacco products. Methods Participants in a population-based prospective cohort in southern California completed questionnaires before (n=1609, age=18–19 y) and after (n=1502, age=19–20 y) T21 was implemented in California (June 2016). We examined the prevalence of past 30-day cigarette and e-cigarette use, and among past 30-day users, purchase location of tobacco products before (pre-) versus after (post-) T21. We also examined whether, post-T21, participants were refused purchase of tobacco products due to their age, and the perceived relative ease of purchasing cigarettes and e-cigarettes (vs pre-T21). Results Negligible changes in cigarette and e-cigarette use were observed pre-T21 versus post-T21. At both time points, the majority of past 30-day users purchased cigarettes from gas stations and e-cigarettes from vape shops. Post-T21, the proportion of participants who reported purchasing cigarettes at gas stations decreased. Post-T21, most past 30-day cigarette or e-cigarette users were not refused purchase of cigarettes (65.4%) or e-cigarettes (82.0%) in the past 30 days, despite being under 21; half of the participants felt it was harder to purchase cigarettes (54.3%) and e-cigarettes (43.6%) post-T21. Conclusion Post-T21, few participants were refused purchase of any tobacco product, despite the illegality of such sales. Better enforcement of T21 is needed to improve the efficacy of T21 legislation.

Youth and young adult risk perceptions and behaviours in response to an outbreak of e-cigarette/vaping-associated lung injury (EVALI) in the USA.

Abstract: Objective To determine whether awareness of emerging vaping-attributable health conditions influences vaping-related risk perceptions and behaviours among young people. Design Respondents aged 15–24 years (n=3536) were drawn from a repeated cross-sectional online panel survey (222 participants/week) during an e-cigarette/vaping-associated lung injury (EVALI) outbreak in the USA (September 2019–January 2020). Logistic regression models tested for associations between EVALI awareness and perceived lung injury risk and product harm, stratified by e-cigarette/vape use and controlling for awareness of other e-cigarette/vaping news stories, demographic characteristics and outbreak week. Other models measured the association between perceived risk of lung injury and intentions to use (non-users) or intentions to quit (current users) e-cigarettes/vape products. Changes in national retail e-cigarette sales data were examined during national EVALI outbreak reporting. Results EVALI awareness was associated with: perceived risk of lung injury (current users OR 1.59, p=0.004; non-users OR 2.11, p Conclusions News of vaping-attributable health conditions may prevent e-cigarette/vape use and encourage cessation among young people. Tobacco control campaigns should address uncertain health effects of e-cigarettes or vape products and align with risk communication by public health agencies during outbreaks.

Google shopping queries for vaping products, JUUL and IQOS during the E-cigarette, or Vaping, product use Associated Lung Injury (EVALI) outbreak.

Abstract: Objectives To assess whether the late 2019 US outbreak of pulmonary disease linked to vaping (‘E-cigarette, or Vaping, product use Associated Lung Injury’ (EVALI)) impacted online shopping queries for vaping products and the Philip Morris ‘IQO’ brand of heated tobacco. Methods We tracked online shopping queries for vape(s), JUUL and IQOS by analysing rates of Google queries indicative of shopping (eg, buy IQOS) after news of the outbreak was first reported (the week of 29 July 2019) until hospitalisations ceased (the week of 16 February 2020). We compared observed rates of shopping during the outbreak to counterfactual expected rates that were predicted using an autoregressive iterative moving average model fit to queries from 1 January 2014 to the week of 21 July 2019. Results During the outbreak, vape shopping queries were 34% (95% CI 30% to 38%) lower than expected and JUUL shopping queries were 39% (95% CI 34% to 45%) lower than expected, translating into about 7.2 and 1.0 million fewer searches. IQOS shopping queries were 58% (95% prediction interval (PI): 34–87) higher than expected, translating into 35 000 more searches. Moreover, IQOS shopping queries reached a historic high the week they were discussed as a potentially safe alternative to vaping (the week of 29 September 2019), when they were 382% (95% PI: 219–881) above expected rates for the week. Conclusions These results suggest that unplanned events, such as the EVALI outbreak, can provoke changes in the epidemiology of product usage. Tobacco companies should be prohibited from using events such as disease outbreaks to position their products as less harmful without prior approval.

Trends in e-cigarette brands, devices and the nicotine profile of products used by youth in England, Canada and the USA: 2017–2019

Abstract: Background The e-cigarette market has rapidly evolved, with a shift towards higher nicotine concentration and salt-based products, such as JUUL; however, the implications for youth vaping remain unclear. Methods Repeat cross-sectional online surveys were conducted in 2017, 2018 and 2019, with national samples of youth aged 16–19 years recruited from commercial panels in Canada (n=12 018), England (n=11 362) and the USA (n=12 110). Regression models examined differences between countries and over time in the types of e-cigarette products used (design and nicotine content), reasons for using brands and differences in patterns of use, sociodemographics and dependence symptoms by brand/nicotine content. Results In 2019, the use of pod- or cartridge-style e-cigarettes was greater in Canada and the USA than England, with Smok and JUUL the leading brands in all countries. In 2019, youth vapers in England were less likely to report using e-cigarettes with ≥2% nicotine (12.8%) compared with Canada (40.5%; adjusted OR (AOR)=4.96; 95% CI 3.51 to 7.01) and the USA (37.0%; AOR=3.99, 95% CI 2.79 to 5.71) and less likely to report using nicotine salt-based products (12.3%) compared with Canada (27.1%; AOR=2.77, 95% CI 1.93 to 3.99) and the USA (21.9%; AOR=2.00, 95% CI 1.36 to 2.95). In 2019, self-reported use of products with higher nicotine concentration was associated with significantly greater frequency of vaping, urges to vape and perceived vaping addiction (p Conclusions The use of high-nicotine salt-based products is associated with greater symptoms of dependence, including JUUL and other higher-nicotine brands. Greater use of high-nicotine salt-based products may account for recent increases in the frequency of vaping among youth in Canada and the USA.