Potential deaths averted in USA by replacing cigarettes with e-cigarettes

The role of E-liquid vegetable glycerin and exhaled aerosol on cue reactivity to tank-based electronic nicotine delivery systems (ENDS)

RATIONALE

Electronic nicotine delivery systems (ENDS or e-cigarettes) share salient features of combustible smoking, such as inhalation and exhalation behaviors, and evidence indicates that first- and second-generation ENDS generalize as smoking cues. The present study examined whether newer, tank-based third-generation ENDS ("mods") also evoke smoking urges, and whether enhancing the visibility of exhaled aerosol clouds-by increasing the e-liquid vegetable glycerin (VG) content-strengthens the cue salience of ENDS.

OBJECTIVES

The objective was to assess the role of exhaled aerosol clouds on ENDS cue potency using a standardized laboratory paradigm designed to mimic real-world exposures.

METHODS

Using a mixed design, young adult smokers (n = 50; mean age 26.5 years; ≥ 5 cigarettes/day) observed a study confederate drinking bottled water (control cue) and vaping an ENDS mod containing e-liquid with either high (73%) or low (0%) VG. Participants completed the Brief Questionnaire on Smoking Urges (BQSU) and visual analog scales (VAS) assessing cigarette and e-cigarette desire pre- and post-cue exposure.

RESULTS

Increasing the e-liquid content of VG enhanced the size and visibility of the exhaled aerosol clouds and evoked a greater increase in smoking desire and a more sustained increase in e-cigarette desire relative to the low VG cue. Both cues elicited increases in smoking urges. These results remained after controlling for sex, prior ENDS experience, recent smoking behavior, and menthol preference.

CONCLUSIONS

Observation of tank-based ENDS use generalizes as a smoking cue and its cue salience is strengthened by increasing the e-liquid content of VG to enhance the visibility of the exhaled aerosol cloud.

Do population trends in adolescent electronic cigarette use coincide with changes in prevalence of cigarette smoking?

Adolescents who initiate electronic cigarette (EC) use without having ever used tobacco are more likely than those that have not initiated EC use to try cigarette smoking over time. However, whether rates of EC use coincide with cigarette smoking rates at the population level remains unknown. This study aimed to compare trends in ever, current, and daily use of EC and cigarette smoking among adolescents in Iceland from 2015 to 2018. We analyzed four waves of pooled cross-sectional population-based school survey data with students enrolled in the 8th, 9th and 10th grades in the national Icelandic school system (n = 42,440, boys = 50.1%). Response rates ranged between 83.3% and 86.0%. Findings for 8th, 9th, and 10th grade students, and the combined sample, revealed a consistent pattern: prevalence of cigarette smoking either remained unchanged or decreased minimally over the study period. In the combined sample rates of ever smoking remained between 9 and 10% during the entire study period, whereas the prevalence of daily cigarette smoking was around 1%. The use of EC increased 2- to 3-fold in all age groups. Ever use increased from 12% to roughly 30% in the combined group and daily use increased from about 2% to 6% during the same period. We conclude that the prevalence of adolescent cigarette smoking in Iceland remained mostly unchanged between the years 2015 and 2018, whereas EC use increased exponentially during the same period. The prevalence of EC use now far outweighs cigarette smoking in 8th–10th grade youth in Iceland.

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Trends in adolescent e-cigarette use and cigarette smoking, 2015–2018, is reported.

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Cigarette smoking remained mostly unchanged during the study period.

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E-cigarette use increased exponentially in all age groups during the study period.

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E-cigarette use now far outweighs cigarette smoking among youth in Iceland.

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Over 40% of 10th grade students have tried e-cigarettes and 10% are daily users.

Association of electronic cigarette vaping and subsequent smoking relapse among former smokers

BACKGROUND

Former combustible cigarette smokers who vape e-cigarettes after quitting smoking may experience health benefits if post-quit vaping prevents smoking relapse.

METHODS

Former combustible cigarette smokers aged >18 that were recent (quit ≤ 12 months) or long-term (quit > 12 months) quitters at baseline were re-surveyed at 1-year follow-up in the Population Assessment of Tobacco and Health (PATH) U.S. nationally-representative longitudinal study. Associations of baseline e-cigarette vaping status (never use, prior use, current occasional use, and current regular use) and smoking relapse (vs. abstinence) at follow-up were estimated.

RESULTS

Among recent quitters (N = 884), the prevalence of follow-up smoking relapse was 31.6%, 39.0%, 51.6%, and 31.9% among never (N = 233), prior (N = 399), current occasional (N = 56), and current regular (N = 196) baseline e-cigarette users, respectively. Baseline e-cigarette use was not associated with smoking relapse at follow-up after covariate adjustment. In long-term quitters (n = 3210), follow-up smoking relapse was 1.8%, 10.4%, 9.6%, and 15.0% among never (N = 2479), prior (N = 588), current occasional (N = 45), and current regular (N = 98) baseline e-cigarette users, respectively. Both prior use (AOR = 2.00, CI [1.25-3.20]) and current regular use of e-cigarettes (AOR = 3.77, CI [1.48-9.65]) had higher odds of subsequent smoking relapse as compared to never e-cigarette users after covariate adjustment. Among relapsers, baseline e-cigarette vaping was not associated with smoking frequency or intensity at follow-up.

CONCLUSIONS

Vaping more than one year after quitting smoking was associated with smoking relapse at 12-month follow-up in a nationally-representative sample. Further studies are needed to evaluate whether this association is causal.

The experimental tobacco marketplace: Narrative influence on electronic cigarette substitution

Despite promising decreases in overall smoking rates, a significant proportion of the population continues to engage in this costly behavior. Substituting e-cigarettes for conventional cigarettes is an increasingly popular harm-reduction strategy. Narratives may be one method of increasing the substitutability of e-cigarettes. Participants (N = 160) were assigned to 1 of 4 narratives that described a close friend becoming ill. In the positive narrative, participants read about a friend that became ill but learned it was only the flu. In the negative narrative, the friend became ill from smoking cigarettes; in the negativeregret narrative, the friend became ill from smoking cigarettes and explicitly expressed regret for having started smoking; and in the negativechange narrative, the friend became ill from smoking, switched to e-cigarettes, and made a full recovery. Participants then completed an experimental tobacco marketplace (ETM) in which they could purchase conventional cigarettes and alternative nicotine products, including e-cigarettes. Across ETM trials, the price of conventional cigarettes increased while the price of the alternative products remained constant. Initial purchasing of conventional cigarettes decreased and initial purchasing of e-cigarettes increased in the negative-change group compared with the other three groups. This finding was moderated by conventional cigarette dependence and perception of e-cigarette risk but not previous e-cigarette exposure. Narratives can change conventional cigarette and e-cigarette purchasing in an ETM that mimics real-world marketplaces. Narratives can be a valuable harm-reduction tool because they are cost-effective, can be widely disseminated, and can be personalized to individuals. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Impact of messages about scientific uncertainty on risk perceptions and intentions to use electronic vaping products

BACKGROUND

The science surrounding e-cigarettes and other electronic vaping products (EVPs) is rapidly evolving, and the health effects of vaping are unclear. Little research has explored how individuals respond to information acknowledging scientific uncertainty. The aim of the present study was to understand the impact of messages about scientific uncertainty regarding the health effects of vaping on risk perceptions and behavioral intentions.

METHODS

Adults in an online experiment (n = 2508) were randomly exposed to view either a control message (a short factual statement about EVPs) or an uncertainty message (the control message plus additional information describing why EVP-related research is limited or inconclusive). Participants rated the risks of vaping and their intentions to try or stop vaping.

RESULTS

Individuals who viewed the uncertainty message rated vaping as less risky than those who viewed the control message. Message exposure did not impact intentions to try vaping soon or intentions to stop vaping in the next 6 months.

CONCLUSIONS

Acknowledging scientific uncertainty made EVP use seem less risky. Future research should explore possible drivers of this response, such as deeper message processing or emotional reactions. Researchers and practitioners designing public health campaigns about vaping might consider a cautious approach to presenting information about scientific uncertainty.

E-cigarette palatability in smokers as a function of flavorings, nicotine content and propylthiouracil (PROP) taster phenotype

BACKGROUND

The popularity of E-cigarettes is due in part to their flavorings. The purpose of this study was to determine the effect on smokers' sensory perceptions and liking of various e-cigarette flavorings, and the degree to which those perceptions are influenced by nicotine level, sex, and PROP bitter taster phenotype.

METHODS

We recruited 132 non-treatment-seeking, daily cigarette smokers. In repeated trials in one laboratory session participants vaped the Joyetech eGo-C e-cigarette with each of the following flavorings (in random order): unflavored, tobacco, cherry, chocolate, and menthol. Participants vaped the e-juice first without nicotine and then with high nicotine (18 mg/ml), and provided sensory (bitterness/sourness, irritation, sweetness) and liking ratings. Perceived intensity of 6-n-propylthiouracil (PROP) was used to classify the participants as non-tasters (n = 28), medium-tasters (n = 74), or supertasters (n = 28). Mixed-effects linear models and generalized estimating equations were used to evaluate ratings as a function of flavor interacting with nicotine content, sex and taster phenotype, adjusting for age, race/ethnicity, menthol use, and nicotine dependence.

RESULTS

Regardless of nicotine level, cherry (β = 1.76, p < .001) and chocolate (β = 0.69, p < .001) were rated as sweeter, but were not better liked, than unflavored e-juice. Menthol elicited the highest liking rating, especially for women (β = 12.23, p < .05) and supertasters (β = 20.52, p < .05). Regardless of flavor, high nicotine was rated as more irritating (OR = 1.43, 95% CI = 1.02-2.01) than the no-nicotine e-juice. Irritation (β = -13.65, p < .001), bitterness/sourness (β = -11.38, p < .001), and sweetness (β = 4.79, p < .001) were associated with liking.

CONCLUSION

Menthol may enhance e-cigarette palatability for some smokers, which may increase e-cigarette utility in smoking cessation.

Health risk perceptions and reasons for use of tobacco products among clients in addictions treatment

INTRODUCTION

We examined rates of use, health risk perceptions and reasons for use of combustible and non-combustible tobacco products among clients enrolled in addictions treatment across the United States.

METHODS

Participants (N = 1153) completed tobacco use surveys and rated health risk perception of all products. Users of non-cigarette products reported their main reason for use of each product. Logistic regression analyses examined associations between health risk perceptions and product use, including combustible cigarette use, and between reasons for use and non-cigarette product use.

RESULTS

Cigarette smoking was reported by 77.5%, followed by use of e-cigarettes (26.6%), little filtered cigars (LFCs)/cigarillos (15.4%), smokeless tobacco (11.4%), and cigars (8.4%). Lower perceived health risk of cigarettes was associated with smoking cigarettes (OR = 0.985, 95% CI: 0.975-0.995, p = 0.005). Lower perceived health risk of e-cigarettes was associated with e-cigarette use (OR = 0.991, 95% CI: 0.984-0.998, p = 0.023). Users of cigars and users of LFC/cigarillos (versus other product use) were more likely to report their main reason for use as "enjoying flavor/ taste", and smokeless tobacco users were more likely to report "at times when can't smoke" as their main reason for use compared with other reasons. E-cigarette users were more likely to report to "reduce/quit cigarettes" as their main reason for use as compared to all other reasons except "reduce health risk".

CONCLUSION

Treating smoking in addictions treatment should assess all tobacco product use, accuracy of health risk perceptions, and use of e-cigarettes to reduce/quit smoking, in order to promote cessation of combustible tobacco.

A Deliberate Choice? Exploring the Decision to Switch from Cigarettes to E-Cigarettes

E-cigarettes are increasingly popular among both cigarette smokers and non-users. Although smoking cessation yields the most individual and population health benefits, switching to exclusive e-cigarette use offers some individual health benefits for cigarette smokers. However, e-cigarette use is not harmless, and its use among non-cigarette smokers should be prevented. Our study aims to explore the decision-making process about e-cigarettes among an e-cigarette users, cigarette smokers, and non-users. We conducted 12 semi-structured focus group interviews with e-cigarette users, cigarette smokers, and non-users. We performed a thematic analysis of the interview transcripts. First, knowledge reported by e-cigarette users was mainly based on other users’ experiences. Second, cigarette smokers and non-users were more negative towards e-cigarettes than e-cigarette users. Third, e-cigarette users considered switching from cigarette smoking to e-cigarette use by deliberating relevant information, and weighing up the benefits and disadvantages of e-cigarette use versus smoking. Additionally, important factors in the decision-making process were a perception of risks and benefits of e-cigarettes compared to cigarettes, a supportive social environment about e-cigarette use, and trust in information offered about the risks and benefits of e-cigarettes. Our findings provide insight into what we can learn from the conscious decision-making process of e-cigarette users who switched from cigarettes to e-cigarettes. This information can be considered to develop targeted communications strategies to stimulate a conscious decision-making process, these may highlight benefits of switching to e-cigarettes for cigarette smokers, discussing the risks of smoking, and correcting misperceptions about the perceived risks and benefits of e-cigarette use.

Tobacco smoking and nicotine delivery alternatives: patterns of product use and perceptions in 13 countries

Background: Smoking tobacco products remains a significant public health problem. The Foundation for a Smoke-Free World commissioned a 13-country survey to gain a clearer understanding of the current landscape of smoking behavior and preferences across the world. Methods: Over 17,000 participants in 13 countries, representing different regions and income groups, answered questions on their smoking patterns and product use, their social context, their motivation to smoke, quit, or switch, and their perception of risks of products and substances. Rim weighting was done for each country to align responses with population demographics, and an additional 200 smokers for each country were surveyed to achieve sufficient sample size for sub-analyses of smoker data. Results: The observed prevalence of smoking ranged from an age-adjusted high of 57.5% in Lebanon to 8.4% in New Zealand among men, with lower rates for women. The majority of smokers were between 25-54 years old, had daily routines and social patterns associated with smoking, used boxed cigarettes, and rated their health more poorly compared to never smokers. Among a range of products and substances, smokers tended to give both cigarettes and nicotine the highest harm ratings. Smokers in high income countries were largely familiar with electronic nicotine delivery systems; the most commonly given reasons for using them were to cut down or quit smoking. A majority of smokers had tried to quit at least once, and while many tried without assistance, motivations, intentions, and methods for smoking cessation, including professional help, nicotine replacement therapies or medications, or electronic cigarettes, varied among countries. Conclusions: Smoking is deeply integrated in smokers' lives worldwide. Although a majority of smokers have tried to quit, and are concerned for their health, they do not seek help. Smokers lack understanding of the harmful components of smoking tobacco products and the risk profile of alternatives.

Tobacco smoking and nicotine delivery alternatives: patterns of product use and perceptions in 13 countries

Background: Smoking tobacco products remains a significant public health problem. The Foundation for a Smoke-Free World commissioned a 13-country survey to gain a clearer understanding of the current landscape of smoking behavior and preferences across the world. Methods: Over 17,000 participants in 13 countries, representing different regions and income groups, answered questions on their smoking patterns and product use, their social context, their motivation to smoke, quit, or switch, and their perception of risks of products and substances. Rim weighting was done for each country to align responses with population demographics, and an additional 200 smokers for each country were surveyed to achieve sufficient sample size for sub-analyses of smoker data. Results: The observed prevalence of smoking ranged from an age-adjusted high of 57.5% in Lebanon to 8.4% in New Zealand among men, with lower rates for women. The majority of smokers were between 25-54 years old, had daily routines and social patterns associated with smoking, used boxed cigarettes, and rated their health more poorly compared to never smokers. Among a range of products and substances, smokers tended to give both cigarettes and nicotine the highest harm ratings. Smokers in high income countries were largely familiar with electronic nicotine delivery systems; the most commonly given reasons for using them were to cut down or quit smoking. A majority of smokers had tried to quit at least once, and while many tried without assistance, motivations, intentions, and methods for smoking cessation, including professional help, nicotine replacement therapies or medications, or electronic cigarettes, varied among countries. Conclusions: Smoking is deeply integrated in smokers' lives worldwide. Although a majority of smokers have tried to quit, and are concerned for their health, they do not seek help. Smokers lack understanding of the harmful components of smoking tobacco products and the risk profile of alternatives.

Considerations related to vaping as a possible gateway into cigarette smoking: an analytical review

Background: Toxicant levels are much lower in e-cigarettes than cigarettes. Therefore, introducing e-cigarettes into the market seems likely to reduce smoking-related diseases (SRD). However, vaping might provide a gateway into cigarette smoking for those who otherwise would never have smoked, a concern fuelled by cohort studies showing vaping predicts subsequent smoking initiation in young people. Methods: In this discussion paper, we consider various aspects of the gateway issue in youths. We provide a descriptive critical review of results from prospective studies relating to the gateway effect and the extent to which the studies considered other potential confounding variables associated with smoking initiation. We then estimate the effects of omitting a confounding variable, or misclassifying it, on the association between vaping and subsequent smoking initiation, and determine how the prevalence of smoking might be affected by any true gateway effects of vaping. Finally, we examine trends in e-cigarette and smoking prevalence in youths based on national surveys. Results: First, we demonstrate that although studies report that vaping significantly predicts smoking initiation following adjustment for various other predictors, the sets of predictors considered are quite incomplete. Furthermore, no study considered residual confounding arising from inaccurate measurement of predictors. More precise adjustment may substantially reduce the association. Second, we show any true gateway effect would likely affect smoking prevalence only modestly. Third, we show smoking prevalence in U.S. and U.K. youths in 2014-2016 declined somewhat faster than predicted by the preceding trend; a substantial gateway effect suggests the opposite. Finally, we argue that even if some gateway effect exists, introducing e-cigarettes still likely reduces SRDs. Conclusions: Given that the existence of any true gateway effect in youth is not yet clearly demonstrated the population health impact of introducing e-cigarettes is still likely to be beneficial.

Considerations related to vaping as a possible gateway into cigarette smoking: an analytical review

Background: Toxicant levels are much lower in e-cigarettes than cigarettes. Therefore, introducing e-cigarettes into the market seems likely to reduce smoking-related diseases (SRD). However, vaping might provide a gateway into cigarette smoking for those who otherwise would never have smoked, a concern fueled by cohort studies showing vaping predicts subsequent smoking initiation in young people. Methods: In this discussion paper, we consider various aspects of the gateway issue in youths. We provide a descriptive critical review of results from prospective studies relating to the gateway effect and the extent to which the studies considered other potential confounding variables associated with smoking initiation.  We then estimate the effects of omitting a confounding variable, or misclassifying it, on the association between vaping and subsequent smoking initiation, and determine how the prevalence of smoking might be affected by any true gateway-in effects of vaping. Finally, we examine trends in e-cigarette and smoking prevalence in youths based on national surveys. Results:  First, we demonstrate that although studies report that vaping significantly predicts smoking initiation following adjustment for various other predictors, the sets of predictors considered are quite incomplete. Furthermore, no study considered residual confounding arising from inaccurate measurement of predictors. More precise adjustment may substantially reduce the association. Second, we show any true gateway effect would likely affect smoking prevalence only modestly. Third, we show smoking prevalence in U.S. and U.K. youths in 2014-2016 declined somewhat faster than predicted by the preceding trend; a substantial gateway effect suggests the opposite. Finally, we argue that even if some gateway effect exists, introducing e-cigarettes still likely reduces SRDs. Conclusions: We have shown that the existence of any true gateway-in effect in youth is not yet clearly demonstrated and that the population health impact of introducing e-cigarettes is still likely to be beneficial.

Considerations related to vaping as a possible gateway into cigarette smoking: an analytical review

Background: Compared to cigarette smoking, e-cigarette use is likely to present a reduced risk of smoking-related disease (SRD). However, several studies have shown that vaping predicts smoking initiation and might provide a gateway into smoking for those who otherwise would never have smoked. This paper considers various aspects of the gateway issue in youths. Methods: Here, we reviewed studies (N=15) of the gateway effect examining how extensively they accounted for confounders associated with smoking initiation in youths. We estimated how omitting a confounder, or misclassifying it, might bias the association between vaping and smoking initiation. We assessed how smoking prevalence might be affected by any true gateway effect, and examined trends in youth smoking and e-cigarette use from national surveys. Results: The list of smoking predictors adjusted for in studies reporting a significant gateway effect is not comprehensive, rarely considering internalising/externalising disorders, outcome expectancies, school performance, anxiety, parental smoking and peer attitudes. Furthermore, no study adjusted for residual confounding from inaccurately measured predictors. Better adjustment may substantially reduce the estimated gateway effect. Calculations showed that as any true gateway effects increase, there are much smaller increases in smoking prevalence, and that gateway effects increase only if initiating vaping is more frequent than initiating smoking. These effects on prevalence also depend on the relative odds of quitting vs. initiation. Data from five surveys in US/UK youths all show that, regardless of sex and age, smoking prevalence in 2014-2016 declined faster than predicted by the preceding trend, suggesting the absence of a substantial gateway effect. We also present arguments suggesting that even with some true gateway effect, introducing e-cigarettes likely reduces SRD risk. Conclusions: A true gateway effect in youths has not yet been demonstrated. Even if it were, e-cigarette introduction may well have had a beneficial population health impact.

Neurobiological Considerations for Tobacco Use Disorder

PURPOSE OF REVIEW

Neurobiological studies of tobacco/nicotine use examining genetic, molecular, functional, and behavioral correlates have improved our understanding of nicotine/tobacco dependence and have informed treatment. Recent work extending previously established findings and reporting novel methodologies and discoveries in preclinical and human studies are reviewed.

RECENT FINDINGS

Recent work in preclinical models has focused on the differential roles of nicotinic receptor subtypes and nicotine's effects on neural systems beyond cortico-striatal dopaminergic pathways, and utilizing advanced methodologies such as pharmacogenetics, optogenetics and rodent fMRI to identify targets for treatment. Likewise, human neuroimaging studies have identified molecular and functional dynamic shifts associated with tobacco/nicotine use that further inform treatment.

SUMMARY

Nicotine/tobacco use is associated with widespread neural adaptations that are persistent and function to maintain addiction. The continued identification of genetic, molecular, neural, and behavioral endophenotypes related to nicotine/tobacco use, dependence, and addiction will facilitate the development and delivery of personalized treatment.

Managing nicotine without smoke to save lives now: Evidence for harm minimization

Tobacco control has made strides in prevention and cessation, but deaths will not decline rapidly without massive behavior change. Currently, inhaled smoke from combusting tobacco is chiefly responsible for prematurely killing 7.2 million people worldwide and 530,000 in the United States annually. An array of noncombustible nicotine products (NNPs) has emerged and has disrupted the marketplace. Saving lives more speedily will require societal acceptance of locating a "sweet spot" within a three-dimensional framework where NNPs are simultaneously: 1. Less toxic, 2. Appealing (can reach smokers at scale), and 3. Satisfying (adequate nicotine delivery) to displace smoking. For this harm minimization framework to eliminate smoking, a laser focus on "smoking control" (not general tobacco control) is needed. By adopting these economically viable NNPs as part of the solution, NNPs can be smoking control's valued ally. Synthesis of the science indicates that policy and regulation can sufficiently protect youth while speeding the switch away from smoking. Despite some risks of nicotine dependence that can be mitigated but not eliminated, no credible evidence counters the assertion that NNPs will save lives if they displace smoking. But scientific evidence and advocacy has selectively exaggerated NNP harms over benefits. Accurate communication is crucial to dispel the misperception of NNPs harms and reassure smokers they can successfully replace smoking cigarettes with NNPs. Saving more lives now is an attainable and pragmatic way to call for alignment of all stakeholders and factions within traditional tobacco control rather than perpetuate the unrealized and unrealizable perfection of nicotine prohibition.

Are we guilty of errors of omission on the potential role of electronic nicotine delivery systems as less harmful substitutes for combusted tobacco use?

Two of the more controversial tobacco control and regulatory strategies in recent years are the nicotine reduction and tobacco harm reduction (THR) strategies. They have become inextricably intertwined as a successful nicotine reduction policy might only be possible in an environment in which alternative, noncombusted forms of nicotine like electronic nicotine delivery systems (ENDS) are available to address the needs of those who were unable or unwilling to completely give up nicotine. Unfortunately, ENDS have emerged as particularly controversial, in part, because they are the first product to carry reduced risk potential while being broadly appealing to cigarette smokers across demographic groups and subpopulations, and to a much smaller extent nonsmokers including, and most controversial, adolescents. In an effort to better understand some of the reasons that make this a controversial topic, we review some of the relevant history and discuss a broader dilemma that faces practitioners and policy developers of medical and public health interventions, namely, weighing the potential consequences of errors of commission versus omission. Commission errors involve a salient, direct link between an action and associated adverse or unintended consequences while omission errors are typically less salient with a more indirect link between inaction and associated adverse consequences. Decision-making research demonstrates that humans have a bias towards avoidance of commission errors and insensitivity to omission errors. This bias may be contributing to some of the aforementioned difficulties in finding common ground regarding the potential contribution of ENDS to reducing the harm of combusted tobacco use.

The Use of Electronic Cigarettes in Pregnancy: A Review of the Literature

Importance

Electronic cigarette (e-cigarette) use in pregnancy has been steadily increasing and has been hyped as being a safe alternative to cigarette smoking during pregnancy. This review discloses what is currently known about e-cigarette use in pregnancy and the effects of its use on pregnancy outcomes.

Objective

To determine what is currently known about the prevalence of e-cigarette use in pregnancy and the effects of e-cigarette use on pregnancy and perinatal/neonatal outcomes.

Evidence Acquisition

A PubMed, CINAHL, and EMBASE search was undertaken using the search terms "pregnancy" OR "pregnancy complications" OR "pregnancy outcome" OR "newborn" OR "neonate" OR "birth" AND "electronic cigarettes" OR "e-cigarettes" OR "ecigarettes" OR "vaping" OR "vape." The search was limited to the English language and between 2007 and October 12, 2017.

Results

The search identified 91 articles, 40 of which are the basis for this review. The prevalence of e-cigarette use is 0.6% to 15%. The amount of nicotine consumed by e-cigarette users is comparable to that consumed by cigarette smokers. Most of the animal model studies suggest a potential danger to the developing fetus primarily because of the nicotine consumed and that consumption has multiple effects on the immune system, neural development, lung function, and cardiac function. There is a widespread flawed perception that e-cigarettes are safe to use during pregnancy.

Conclusions

The marketing of e-cigarette use as a safer alternative to cigarette smoking has led to an increasing use even in pregnancy. The nicotine consumed by e-cigarettes is similar to that consumed by cigarette smoking. Animal studies confirm the dangers of nicotine to the developing fetus. More research needs to be done specifically assessing e-cigarette use, pregnancy, and pregnancy outcomes.

Relevance

The amount of nicotine consumed in cigarette smoking is similar to the amount of nicotine consumed with e-cigarettes. The effects of nicotine exposure during fetal development are well known and include effects on multiple organ systems.

Modelling the impact of a new tobacco product: review of Philip Morris International's Population Health Impact Model as applied to the IQOS heated tobacco product

OBJECTIVES

We review the Population Health Impact Model (PHIM) developed by Philip Morris International and used in its application to the US Food and Drug Administration (FDA) to market its heated tobacco product (HTP), IQOS, as a modified-risk tobacco product (MRTP). We assess the model against FDA guidelines for MRTP applications and consider more general criteria for evaluating reduced-risk tobacco products.

METHODS

In assessing the PHIM against FDA guidelines, we consider two key components of the model: the assumptions implicit in the model (outcomes included, relative harm of the new product vs cigarettes, tobacco-related diseases considered, whether dual or polyuse of the new product is modelled, and what other tobacco products are included) and data used to estimate and validate model parameters (transition rates between non-smoking, cigarette-only smoking, dual use of cigarettes and MRTP, and MRTP-only use; and starting tobacco use prevalence).

RESULTS

The PHIM is a dynamic state transition model which models the impact of cigarette and MRTP use on mortality from four tobacco-attributable diseases. The PHIM excludes morbidity, underestimates mortality, excludes tobacco products other than cigarettes, does not include FDA-recommended impacts on non-users and underestimates the impact on other population groups.

CONCLUSION

The PHIM underestimates the health impact of HTP products and cannot be used to justify an MRTP claim. An assessment of the impact of a potential MRTP on population health should include a comprehensive measure of health impacts, consideration of all groups impacted, and documented and justifiable assumptions regarding model parameters.

Perceived barriers to smoking cessation and perceptions of electronic cigarettes among persons living with HIV

Smoking is more prevalent in persons living with HIV than the general population and is linked to increased morbidity and mortality. Some have suggested that based on current knowledge of harms and benefits, it may be feasible to advise smokers who are unable or unwilling to quit to switch to electronic cigarettes (ECs) as a less harmful alternative. We conducted 25 qualitative interviews with HIV-positive current or former smokers to explore perceived barriers to smoking cessation and perceptions of ECs. A high level of nicotine dependence, smoking as a form of stress management, motivational factors (including lack of readiness, low self-efficacy, ambivalence toward quitting), and having a social network of smokers were identified as cessation barriers. Low knowledge of ECs and uncertainty about EC safety and efficacy were barriers to EC uptake. However, current smokers indicated a willingness to try ECs. This study provides evidence that HIV-positive smokers face significant individual and environmental barriers to cessation. ECs may have potential as a harm reduction strategy in this population; however, there is a significant need for education regarding use and relative safety.

Perceived parental reactions to substance use among adolescent vapers compared with tobacco smokers and non-users in Iceland

OBJECTIVES

The objective is to assess perceived parental reactions to cigarette smoking, vaping, drunkenness, and marijuana use among cigarette smokers, vapers, and those who neither smoke nor vape (non-users).

STUDY DESIGN

It is a population-based, cross-sectional, school survey with all accessible 13- to 16-year-old students in Iceland (response rate: 84.1%).

METHODS

Data were analyzed in Mplus using multinomial logistic regression for categorical data with maximum likelihood and robust standard errors, adjusting for potential school clustering.

RESULTS

Across all four outcome categories and controlling for background factors, non-users were more likely than vapers and smokers to perceive their parental reactions to substance use as negative (P < 0.01). Vapers were significantly more likely than smokers to perceive their parental reactions as negative toward all types of substance use (P < 0.01).

CONCLUSIONS

Adolescent smokers, vapers, and non-users appear to form a sequential risk gradient toward perceived parental reactions to substance use, with smokers being least likely to perceive their parental reactions as negative and vapers thereafter; non-users are most likely to perceive their parental reactions toward substance use as negative.

Projections in Breast and Lung Cancer Mortality among Women: A Bayesian Analysis of 52 Countries Worldwide

Among women, lung cancer mortality rates have surpassed those for breast cancer in several countries. This reflects the breast cancer mortality declines due to access to screening and effective treatment alongside the entrance of certain countries in stages of the tobacco epidemic in which smoking becomes more prevalent in women. In this study, we project lung and breast cancer mortality until 2030 in 52 countries. Cancer mortality data were obtained from the WHO Mortality Database. Age-standardized mortality rates (ASMR), per 100,000, were calculated (direct method) for 2008 to 2014 and projected for the years 2015, 2020, 2025, and 2030 using a Bayesian log-linear Poisson model. In 52 countries studied around the world, between 2015 and 2030, the median ASMR are projected to increase for lung cancer, from 11.2 to 16.0, whereas declines are expected for breast cancer, from 16.1 to 14.7. In the same period, the ASMR will decrease in 36 countries for breast cancer and in 15 countries for lung cancer. In half of the countries analyzed, and in nearly three quarters of those classified as high-income countries, the ASMR for lung cancer has already surpassed or will surpass the breast cancer ASMR before 2030. The mortality for lung and breast cancer is higher in high-income countries than in middle-income countries; lung cancer mortality is lower in the latter because the tobacco epidemic is not yet widespread. Due to these observed characteristics of lung cancer, primary prevention should still be a key factor to decrease lung cancer mortality.Significance: The mortality for lung and breast cancer is projected to be higher in high-income countries than in middle-income countries, where lung cancer mortality is expected to surpass breast cancer mortality before 2030. Cancer Res; 78(15); 4436-42. ©2018 AACR.

FDA's regulatory shift on tobacco control

In July 2017, the Food and Drug Administration (FDA) announced that it wants to reduce the nicotine in cigarettes to make them less addictive. Also, it is delaying for several years a key regulation affecting cigars and e-cigarettes, including flavored vaping products that tend to appeal to younger consumers. Specifically, it postponed the requirement that such products be approved by the agency. Both actions are part of a comprehensive plan to eventually wean smokers off conventional cigarettes and steer them toward less harmful alternative forms of nicotine. With its new approach to the fight against smoking, the FDA has unquestionably made great strides toward more effectively addressing the prevalence of related deaths and diseases in the U.S. However, much important work must be undertaken before this ultimate goal can be accomplished. For instance, further research into long-term effects of e-cigarettes must be conducted before these products can truly be seen as safer alternatives to combustible cigarettes. Additionally, public education is necessary to inform smokers about the range of tobacco products available and the actual harms associated with their use. Finally, the agency might have to work alongside the powerful tobacco industry to minimize potential legal challenges and to convince businesses that a shift to low-nicotine products and e-cigarettes is best for their future success and for the health of the American citizenry.

How close are we to definitively identifying the respiratory health effects of e-cigarettes?

INTRODUCTION

Use of electronic cigarettes (e-cigarettes) is frequently promoted as a less harmful alternative to cigarette smoking. The impact of repeated inhalation of e-cigarette aerosols on respiratory health is not well understood. Areas covered: Using results from laboratory, observational, and clinical studies, we synthesize evidence relevant to potential respiratory health effects that may result from inhalation of e-cigarette aerosols. Expert commentary: Chemical analyses reveal that e-cigarette aerosols contain numerous respiratory irritants and toxicants. There are documented cytotoxic effects of e-cigarette constituents on lung tissue. Studies among ex-smokers who switched to e-cigarettes note reduced exposure to numerous respiratory toxicants, reduced asthma exacerbations, and chronic obstructive pulmonary disease symptoms. Regular exposure to e-cigarette aerosols is associated with impaired respiratory functioning. Potential respiratory health risks resulting from secondhand e-cigarette aerosol exposure have not been sufficiently evaluated. Current evidence indicates that although e-cigarettes are not without risk, these products seemingly pose fewer respiratory health harms issues compared to tobacco cigarettes. Data from prospective studies and randomized controlled trials examining the impact of e-cigarette use on lung health are needed to better understand respiratory health risks tied to use of these products.

Association of E-Cigarette Use With Smoking Cessation Among Smokers Who Plan to Quit After a Hospitalization: A Prospective Study

BACKGROUND

Many smokers report using e-cigarettes to help them quit smoking, but whether e-cigarettes aid cessation efforts is uncertain.

OBJECTIVE

To determine whether e-cigarette use after hospital discharge is associated with subsequent tobacco abstinence among smokers who plan to quit and are advised to use evidence-based treatment.

DESIGN

Secondary data analysis of a randomized controlled trial. (ClinicalTrials.gov: NCT01714323 [parent trial]).

SETTING

3 hospitals.

PARTICIPANTS

1357 hospitalized adult cigarette smokers who planned to stop smoking, received tobacco cessation counseling in the hospital, and were randomly assigned at discharge to a tobacco treatment recommendation (control) or free tobacco treatment (intervention).

MEASUREMENTS

Self-reported e-cigarette use (exposure) was assessed 1 and 3 months after discharge; biochemically validated tobacco abstinence (outcome) was assessed 6 months after discharge.

RESULTS

Twenty-eight percent of participants used an e-cigarette within 3 months after discharge. In an analysis of 237 propensity score-matched pairs, e-cigarette users were less likely than nonusers to abstain from tobacco use at 6 months (10.1% vs. 26.6%; risk difference, -16.5% [95% CI, -23.3% to -9.6%]). The association between e-cigarette use and quitting varied between intervention patients, who were given easy access to conventional treatment (7.7% vs. 29.8%; risk difference, -22.1% [CI, -32.3% to -11.9%]), and control patients, who received only treatment recommendations (12.0% vs. 24.1%; risk difference, -12.0% [CI, -21.2% to 2.9%]) (P for interaction = 0.143).

LIMITATIONS

Patients self-selected e-cigarette use. Unmeasured confounding is possible in an observational study.

CONCLUSION

During 3 months after hospital discharge, more than a quarter of smokers attempting to quit used e-cigarettes, mostly to aid cessation, but few used them regularly. This pattern of use was associated with less tobacco abstinence at 6 months than among smokers who did not use e-cigarettes. Additional study is needed to determine whether regular use of e-cigarettes aids or hinders smoking cessation.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

Private Paternalism, the Commitment Puzzle, and Model-Free Equilibrium

Paternalism is a policy that advances an individual's interests by restricting his or her freedom. In a setting with present-biased agents, I characterize the scope of private paternalism—paternalism implemented by private institutions. Private paternalism arises from two channels: (i) agents who seek commitment because they hold sophisticated beliefs about their present bias, and (ii) agents (naive or sophisticated) who use model-free forecasts to choose organizations that have a history of generating high experienced utility flows for their members (O'Donoghue and Rabin 1999b). When naive consumers are common, private paternalism will be shrouded, explaining why commitment mechanisms are typically shrouded in the labor market (the commitment puzzle). Private paternalism has greater traction when production occurs in the formal sector instead of the informal (household) sector, where monitors are not always present, able, or willing to implement socially efficient forcing mechanisms.

Harm Minimization and Tobacco Control: Reframing Societal Views of Nicotine Use to Rapidly Save Lives

Inhalation of the toxic smoke produced by combusting tobacco products, primarily cigarettes, is the overwhelming cause of tobacco-related disease and death in the United States and globally. A diverse class of alternative nicotine delivery systems (ANDS) has recently been developed that do not combust tobacco and are substantially less harmful than cigarettes. ANDS have the potential to disrupt the 120-year dominance of the cigarette and challenge the field on how the tobacco pandemic could be reversed if nicotine is decoupled from lethal inhaled smoke. ANDS may provide a means to compete with, and even replace, combusted cigarette use, saving more lives more rapidly than previously possible. On the basis of the scientific evidence on ANDS, we explore benefits and harms to public health to guide practice, policy, and regulation. A reframing of societal nicotine use through the lens of harm minimization is an extraordinary opportunity to enhance the impact of tobacco control efforts.

Quantifying population-level health benefits and harms of e-cigarette use in the United States

BACKGROUND

Electronic cigarettes (e-cigarettes) may help cigarette smokers quit smoking, yet they may also facilitate cigarette smoking for never-smokers. We quantify the balance of health benefits and harms associated with e-cigarette use at the population level.

METHODS AND FINDINGS

Monte Carlo stochastic simulation model. Model parameters were drawn from census counts, national health and tobacco use surveys, and published literature. We calculate the expected years of life gained or lost from the impact of e-cigarette use on smoking cessation among current smokers and transition to long-term cigarette smoking among never smokers for the 2014 US population cohort.

RESULTS

The model estimated that 2,070 additional current cigarette smoking adults aged 25-69 (95% CI: -42,900 to 46,200) would quit smoking in 2015 and remain continually abstinent from smoking for ≥7 years through the use of e-cigarettes in 2014. The model also estimated 168,000 additional never-cigarette smoking adolescents aged 12-17 and young adults aged 18-29 (95% CI: 114,000 to 229,000), would initiate cigarette smoking in 2015 and eventually become daily cigarette smokers at age 35-39 through the use of e-cigarettes in 2014. Overall, the model estimated that e-cigarette use in 2014 would lead to 1,510,000 years of life lost (95% CI: 920,000 to 2,160,000), assuming an optimistic 95% relative harm reduction of e-cigarette use compared to cigarette smoking. As the relative harm reduction decreased, the model estimated a greater number of years of life lost. For example, the model estimated-1,550,000 years of life lost (95% CI: -2,200,000 to -980,000) assuming an approximately 75% relative harm reduction and -1,600,000 years of life lost (95% CI: -2,290,000 to -1,030,000) assuming an approximately 50% relative harm reduction.

CONCLUSIONS

Based on the existing scientific evidence related to e-cigarettes and optimistic assumptions about the relative harm of e-cigarette use compared to cigarette smoking, e-cigarette use currently represents more population-level harm than benefit. Effective national, state, and local efforts are needed to reduce e-cigarette use among youth and young adults if e-cigarettes are to confer a net population-level benefit in the future.

E-Cigarettes: Implications for Health Promotion in the Asian Pacific Region

Since their introduction to the United States in 2007, electronic cigarettes (e-cigarettes) use has grown exponentially. This rapid growth in e-cigarette use has been heralded by some as a potential important public health measure that could ultimately replace tobacco cigarettes, while others recommend a cautionary approach until there is clear evidence they will not become “new tobacco” bringing a possible myriad of other problems. E-cigarettes may have real benefits, however they do expose users and those nearby to organic compounds, solvents and particulate matter, with there being limited data relating to their health impact. It is unclear as to whether this relatively new device has the potential to exacerbate nicotine addictions, or play a part in reducing harm and smoking cessation. The fundamental requirement of public health practice is to do no harm and from the inconclusive evidence we have to date on e-cigarettes, it appears a cautious approach is warranted. This commentary reviews evidence that supports a cautious approach to e-cigarette availability in Australia and the Asian Pacific region.

An Online Survey of New Zealand Vapers

Using electronic cigarettes (vaping) is controversial, but is increasingly widespread. This paper reports the results of an electronic survey of vapers in New Zealand, a country where the sale and supply of e-liquids containing nicotine is illegal, although vapers can legally access e-liquids from overseas. An on-line survey was conducted, using vaper and smoking cessation networks for recruitment, with follow up surveys conducted 1 and 2 months after the initial survey. 218 participants were recruited. Almost all had been smokers, but three quarters no longer smoked, with the remainder having significantly reduced their tobacco use. Three participants were non-smokers before starting to vape, but none had gone on to become smokers. The overriding motivation to begin and continue vaping was to stop or to reduce smoking. The results were consistent with a progression from initially both vaping and smoking using less effective electronic cigarette types, then moving to more powerful devices, experimentation with flavors and nicotine strengths—all resulting in reducing or stopping tobacco use. Lack of access to nicotine and lack of support for their chosen cessation method were the main problems reported. Vaping had resulted in effective smoking cessation for the majority of participants.

Favourable Perceptions of Electronic Cigarettes Relative to Cigarettes and the Associations with Susceptibility to Electronic Cigarette Use in Hong Kong Chinese Adolescents

We investigated favourable perceptions of electronic cigarettes (ECs) relative to cigarettes and their associations with EC use susceptibility in adolescents. Hong Kong Chinese Secondary 1-6 (U.S. grade 7-12) students (n = 40,202) were surveyed in 2014/2015 on EC use, cigarette smoking, favourable perceptions of ECs relative to cigarettes, EC use susceptibility, family smoking, and socio-demographic characteristics. Cox regression yielded adjusted prevalence ratios (APRs) of EC use susceptibility in never users, excluding those unaware of ECs. In all students, 8.9% were ever EC users, 47.2% reported favourable perceptions of ECs relative to cigarettes, such as less likely to cause accidents (25.2%) and less harmful to users (24.5%), and 28.9% did not know ECs. Among never EC users who were aware of ECs (n = 24,663), EC use susceptibility was associated with each of the favourable perceptions, especially greater attractiveness (APR 2.84, 95% CI 2.53-3.19), and better parental (2.75, 2.41-3.15) and school acceptability (2.56, 2.15-3.05). An increased number of favourable perceptions of ECs relative to cigarettes was associated more strongly with the susceptibility (p for trend < 0.001). Our findings inform strategies to reduce unwarranted favourable perceptions and prevent adolescent EC use.

The Effects of Electronic Cigarette (ECIG)-Generated Aerosol and Conventional Cigarette Smoke on the Mucociliary Transport Velocity (MTV) Using the Bullfrog (R. catesbiana) Palate Paradigm

Background: While ECIGs are under scrutiny concerning safety, particularly in reference to the physiological impact that aerosolized ECIG liquid (E-liquid) may have on respiratory tissues, others believe that ECIGs are a “Harm Reduction” alternative to conventional cigarettes. Previous studies investigating ciliated respiratory epithelium indicate that smoking shortens cilia length, reduces cilia beat frequency and disrupts respiratory epithelium, which most likely contributes to the inhibition of mucocilliary clearance. Monitoring mucous clearance of respiratory tissues exposed to ECIG-generated aerosol or conventional cigarette smoke, as indexed by mucous transport velocity (MTV), is one way to gauge the impact aerosol and smoke have on the respiratory tract. Therefore, we designed an experiment to test the effect of ECIG-generated aerosol and smoke on MTV using the frog palate paradigm.

Methods: Peristaltic pumps transport ECIG-generated aerosol and conventional cigarette smoke into custom-made chambers containing excised bullfrog palates. MTVs were determined before exposure, immediately after exposure and approximately 1 day following exposure. MTVs were also determined (at the same time points) for palates exposed to air (control). Surface and cross sectional SEM images of palates from all three groups were obtained to support MTV data.

Results: The results indicate that ECIG-generated aerosol has a modest inhibitory effect (p < 0.05) on MTV 1 day post-exposure (0.09 ± 0.01) compared to control MTV (0.16 ± 0.03 mm/s). In contrast, smoke completely inhibits MTV from 0.14 ± 0.03 mm/s immediately before exposure to 0.00 mm/sec immediately after exposure and the MTV is unable to recover 1 day later. SEM images of control palates and palates exposed to ECIG-generated aerosol both show cilia throughout their epithelial surface, while some areas of palates exposed to smoke are completely devoid of cilia. Additionally, the epithelial thickness of aerosol-exposed palates appears thicker than control palates while smoke-exposed palates appear to be thinner due to epithelial disruption.

Conclusions: These results indicate that ECIG-generated aerosol has only a modest effect on mucocilary clearance of bullfrog palates and aerosol sedimentation accounts for epithelial thickening. In accordance with the primary literature, conventional cigarette smoke dramatically inhibits mucociliary clearance and is, in part, due to decreased number of cilia and disruption of the smoke-exposed epithelium.

The changing nicotine products landscape: time to outlaw sales of combustible tobacco products?

Combustible tobacco products are unique both for the extraordinary harm they cause, and the fact that more than 50 years after these harms became known, they continue to be widely and legally available globally. However, the rapid evolution of the nicotine product marketplace in recent years warrants a re-assessment of the viability of phasing out commercial sales of combustible tobacco, and presents an opportunity to end the exceptionalism of combustible tobacco being permitted for sale.