Changing smokeless tobacco products new tobacco-delivery systems

Poly-tobacco use and mental health in South Korean adolescents

INTRODUCTION

With the advent of new tobacco products, poly-tobacco use among adolescents is increasing. Smoking among adolescents negatively impacts both their physical and mental health. This study aimed to determine poly-tobacco use among adolescents in South Korea and to identify the mental health problems caused by single-, dual-, and poly-tobacco use.

METHODS

Data from 54948 adolescents in the 2020 Korea Youth Behavior Web-based Survey were included. Mental health variables of our primary outcome were loneliness, anxiety, and depression. Descriptive statistics, Rao-Scott χ2 test and complex sample multivariable logistic regression analysis were conducted to determine the association between the type of tobacco product use and mental health.

RESULTS

Among the subjects, 95.2% were non-tobacco users, followed by single (3.0%), dual (1.1%), and poly users (0.7%). The subjects with poly-tobacco use had significantly higher rates of loneliness (33.2%, p<0.001), anxiety (22.3%, p<0.001), and depression (49.9%, p<0.001) than those who used fewer tobacco products. Subjects who used poly-tobacco products were 2.13 (95% CI: 1.61-2.83) times more likely to report loneliness, 1.52 (95% CI: 1.12-2.07) times more likely to report anxiety, and 2.18 (95% CI: 1.68-2.82) times more likely to report depression than non-tobacco users.

CONCLUSIONS

Among adolescents, poly-tobacco use is associated with symptoms of loneliness, depression, and anxiety, which are internalized mental health problems. Poly-tobacco use warrants early assessment of high-risk groups, education on the need for tobacco-use cessation, and active intervention for the psychological difficulties that these high-risk groups experience.

Society for Research on Nicotine and Tobacco as an Outgrowth of the 1988 Surgeon General's Report on Nicotine Addiction: Reflections of the Early Presidents

INTRODUCTION

The Society for Research on Nicotine and Tobacco began in the United States as a scientific organization "to stimulate the generation and dissemination of new knowledge concerning nicotine and tobacco in all its manifestations." Now in its 30th year, the Society is taking on new challenges in tobacco control, nicotine vaping, product regulation, and public policy.

AIMS AND METHODS

This Review describes the formative years of the Society from the perspective of researchers who were in leadership positions during that time, documenting how biobehavioral and clinical research in the first 10 years was a continuation of the scientific mission of the 1988 United States Surgeon General's Report on Nicotine Addiction and summarizing organizational innovations during each president's term of office.

CONCLUSIONS

The Society's promotion of scientific research served as a catalyst for funding, policy, and regulation, setting the stage for its influence and credibility.

IMPLICATIONS

This Commentary provides context and an overview of the scientific research and the organizational innovations that occurred during the early years of the Society for Research on Nicotine and Tobacco using publications and available documentation. The Society was able to thrive because biobehavioral research on nicotine addiction provided the scientific underpinnings for the tobacco control enterprise as a whole. The objective of this Commentary is to describe formative events in the Society's history based on the accomplishments of its early leaders.

Quantitative measurement of harmful and potentially harmful constituents, pH, and moisture content in 16 commercial smokeless tobacco products

Smokeless tobacco products expose adult and youth tobacco users to various addictive and carcinogenic constituents that can cause long-term nicotine dependence and oral cancers. In this study, nicotine, benzo[a]pyrene (B[a]P), N'-nitrosonornicotine (NNN), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), acetaldehyde, crotonaldehyde, formaldehyde, moisture, and pH levels in 16 smokeless tobacco products were measured on a wet-weight basis (wwb). In addition, change in analytical variability with increasing replicate measurements was assessed. Total nicotine in the products varied from 6.2 to 35.5 mg/g. The percentage of total nicotine in the unprotonated form ranged from 0.1 to 62%; whereas, product moisture varied from 7.4 to 57%. The quantities of harmful and potentially harmful constituents (HPHCs) range from 0.46 to 179.9 ng/g for B [a]P, 270-12206 and 81-20716 ng/g for NNN and NNK, respectively, and 0.33-6.85 and 0.13-5.67 μg/g for acetaldehyde and formaldehyde, respectively. This study shows wide variation in smokeless tobacco product HPHC quantities. The results also show that analytical variability stabilizes after seven replicate measurements.

Does the content and source credibility of health and risk messages related to nicotine vaping products have an impact on harm perception and behavioural intentions? A systematic review

AIMS

To systematically review the literature on (i) whether and how various risk messages about nicotine vaping products (NVPs) alter harm perception and behavioural intentions of smokers and non-smokers and (ii) how trust in sources of NVP risk communication affects message reception and behavioural intentions.

METHODS

Seven electronic databases and reference lists of relevant articles were searched for articles published up to April 2020. Experimental and quasi-experimental studies on message effects and cross-sectional studies on source credibility were included. The Newcastle-Ottawa Scale and the Evidence Project Risk of Bias Tool were used to assess the quality of observational and intervention studies, respectively. For each outcome variable, we indicated whether there was an effect (as a 'yes' or 'no') and used effect direction plots to display information on the direction of effects.

RESULTS

Nicotine addiction messages resulted in greater health and addiction risk perceptions, relative risk messages comparing the health risks of NVPs to cigarette smoking increased the perception that NVPs are less harmful than combustible cigarettes, and a nicotine fact sheet corrected misperceptions of nicotine and NVPs. Smokers' intention to purchase, try or switch to NVPs was higher when exposed to a relative risk message and lower when exposed to nicotine addiction warnings. Trust in NVP risk information from public health agencies was associated with lower odds of; (i) NVP use and (ii) perceiving NVPs as less harmful, whereas those who trusted information from NVP companies were more likely to perceive NVPs as less harmful than combustible cigarettes.

CONCLUSIONS

Relative risk messages may help improve the accuracy of harm perceptions of nicotine vaping products and increase smokers' intentions to quit smoking and/or to switch to vaping, although the literature is nascent.

The Consequence of Aqueous Extract of Tobacco Leaves (Nicotiana tabacum. L) on Feed Intake, Body Mass, and Hematological Indices of Male Wistar Rats fed under Equal Environmental Conditions

OBJECTIVE

While the dangers of consuming tobacco by smoking has been of concern, the hazardous effect of other forms of tobacco consumption (in smokeless form) on health indices are less well explored. In this paper, we explored the effect of different doses of aqueous extract of tobacco leaves on feed intake, body mass, and hematological indices of male Wistar rats under equal environmental conditions.

METHOD

Using an oral route of administration, the rats (n = 24; w = 65-85 g; 2-3 weeks old) were administered at different doses of 100, 200, 400, 0 mg/kg body weight (b.w.) per day to group A, B, C, and D for 42 days, after phytochemical and acute toxicity testing of the tobacco leaves.

RESULTS

Compared to the negative control group (D), packed cell volume, hemoglobin concentration, red blood cells, and lymphocytes reduced dose-dependently in contrast to the white blood cells, neutrophils, mean corpuscular hemoglobin concentration, mean corpuscular hemoglobin, and mean corpuscular volume. As body mass and feed intake in relation to the different doses of aqueous extract of tobacco leaves reduced significantly (p < 0.05), the reverse was observed for body mass and feed intake in relation to room temperature.

CONCLUSIONS

By influencing hematological indices, feed intake, and body mass, the extract of tobacco leaves can be hazardous to health. However, to assess safety and to come up with a conscious conclusion, future studies should explore the effect of the extract on organs histopathology, biochemical parameters, and lipid profile of the body.

The Association between E-Cigarette Price and TV Advertising and the Sales of Smokeless Tobacco Products in the USA

This study aims to examine how e-cigarette prices and advertising, key determinants of e-cigarette demand, are associated with the demand for smokeless tobacco (SLT) products in the US. Market-level sales and price data by year (2010-2017), quarter, and type of retail store were compiled from Nielsen retail store scanner database. E-cigarette TV advertising ratings data were compiled from Kantar Media. Four-way (market, year, quarter, store type) fixed-effect models were used to estimate the associations between e-cigarette price and TV advertising and sales of SLT products (chewing loose leaf, moist snuff, and snus). Our results showed that a 1% rise in own price was associated with a reduction in sales by 1.8% for chewing loose leaf, 1.6% for moist snuff, and 2.2% for snus, respectively. In addition, a 1% rise in disposable e-cigarette price was associated with 0.3% and 0.6% increased sales for moist snuff and snus, respectively. The association between e-cigarette TV advertising and SLT product sales was not significant. Our results suggest that disposable e-cigarettes and certain SLT products (moist snuff and snus) are potential substitutes. Policies aiming to regulate e-cigarette use and sales need to consider their potential link with the demand for SLT products.

Identifying factors that conjointly influence nicotine vaping product relative harm perception among smokers and recent ex-smokers: Findings from the 2016 ITC Four Country Smoking and Vaping Survey

BACKGROUND

Use of nicotine vaping products (NVPs) to replace smoking is often influenced by perceived harmfulness of these products relative to smoking. This study aimed to identify factors that conjointly influenced NVP relative harm perception among smokers and ex-smokers.

METHODS

Data (n = 11,838) from adult smokers and ex-smokers (quit < 2 years) who participated in the 2016 ITC 4 Country Smoking and Vaping Surveys in Australia, Canada, England and the US were analyzed. Decision tree models were used to classify respondents into those who perceived vaping as less harmful than smoking ("correct" perception) versus otherwise ("incorrect" perception) based on their socio-demographic, smoking and vaping related variables.

RESULTS

Decision tree analysis identified nicotine replacement therapy (NRT) harmfulness perceptions relative to smoking, perceived vaping portrayal in the media and other sources as positive, negative or balanced, recency of seeking online vaping information, and age as the key variables that interacted conjointly to classify respondents into those with "correct" versus "incorrect" harm perceptions of vaping relative to smoking (model performance accuracy = 0.70-0.74). In all countries, NRT relative harmfulness perception and vaping portrayal perception were consistently the two most important classifying variables, with other variables showing some country differences.

CONCLUSIONS

In all four countries, perception of NVP relative harmfulness among smokers and recent ex-smokers is strongly influenced by a combination of NRT relative harmfulness perception and vaping portrayal in the media and other sources. These conjoint factors can serve as useful markers for identifying subgroups more vulnerable to misperception about NVP relative harmfulness to benefit from corrective intervention.

COVID-19 in Smokeless Tobacco Habitués: Increased Susceptibility and Transmission

As the coronavirus disease (COVID-19) pandemic continues to sweep across the globe, the world is responding by implementing public awareness campaigns, social distancing measures, and other preventive strategies to arrest the spread of this lethal disease. Infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exacts a heavy toll on patients with existing comorbidities. Smokeless tobacco (SLT) consumption is of particular concern in countries in South Asia with high population densities, as it facilitates exposure to SARS-CoV-2 within or between communities by the act of public spitting. Salivary droplets generated in this act are a potential threat because they can transmit this airborne infection. Moreover, large gatherings at tobacco retail outlets, frequent hand-to-mouth contact, and sharing of apparatus by SLT habitués could also aid in increasing the spread of SARS-CoV-2. SLT-induced higher expression of angiotensin-converting enzyme 2 receptors along with the presence of furin in the oral mucosa and dysfunctional immune responses among SLT habitués increase viral dissemination and an individual's susceptibility to COVID-19. Issuing rigorous regulations to restrict the use of various forms of SLT products and the obnoxious act of spitting in public can assist in arresting the spread of COVID-19. Widespread education campaigns enlightening the community regarding the adverse effects of SLT consumption and its relationship with COVID-19, along with providing effective assistance to quit for those who are addicted, would decrease the spread of COVID-19.

The acceptability of smokeless tobacco products depends on nicotine levels

Understanding the role nicotine plays in initiating and sustaining addiction has been of interest for the scientific community and general population, with the idea that low levels of nicotine will reduce abuse liability associated with smokeless tobacco products. Previously, research has relied on subjective assessments to determine consumer acceptability, but these measures cannot provide a characterization of the physiological responses associated with nicotine use. Consumer acceptability arises from psychological and neurophysiological factors, thus establishing the need to use subjective and objective measurements in conjunction. This study provides a comprehensive characterization of the subjective and objective effects of smokeless tobacco product use with varying levels of nicotine. EEG data were recorded before and after the use of four different smokeless tobacco products and one control product over five separate visits, with participants arriving to each visit after 12 h of tobacco abstinence. These products have distinct consumer acceptability levels and patterns of use characteristics ranging from starter products to those used primarily by established users. Subjective results showed that smokeless tobacco products with higher levels of nicotine were more successful in reducing craving and more reinforcing than those with lower levels. These results were concordant with the activity present in the EEG recordings where products with high nicotine levels produced larger changes in the amplitude of the event-related signal than those with low levels. This study is fundamental in understanding the relationship between subjective and objective smokeless tobacco acceptability measurements, as mediated by the different levels of nicotine in each product.

Toxic Elements in Human Saliva of Smokeless Tobacco Users

The occurrence and mobility of different elements in oral smokeless tobacco products (STPs) were determined because the effects on human health must take into account their availability. In this research, the elemental analysis of 15 oral STPs of different brands purchased in local specialty stores in Europe, and the determination of % extraction of the different elements into an artificial salivary juice during the sucking or chewing operations were performed. In all samples analyzed, cobalt (Co) and chromium (Cr) (total) levels were <0.326 mg/kg. As far as non-essential or toxic elements, U was always <1.0 mg/kg, Th and Ti <0.1 mg/kg, Cd was <0.5. Pb was detectable in 60% of the samples, As in 33.3% and Ce in 20% of the samples; La was <1 mg/kg in 13 samples; Sb was <5 mg/kg in all sample with exception of sample 13; Al, Ni, Sr, Rb, Ba, Sn, Te, Ti and Hg were detectable in all samples. Using artificial saliva, the data of extractable levels show that the toxic elements, although poorly extracted, are not totally retained within the STPs, with a consequent potential health hazard associated with oral use of these products.

Tobacco product transition patterns in rural and urban cohorts: Where do dual users go?

Introduction

Understanding diverse tobacco product consumption represents a crucial area for tobacco regulatory science. With the increase in dual/poly use of tobacco products, transition patterns among exclusive and dual users are of considerable interest. We describe transition patterns of dual users over 18 months.

Methods

A cohort of 145 adults in urban and rural Ohio who reported dual tobacco product use at least some days/week was enrolled during 2014–17. Participants completed follow-up interviews every six months where they were classified into one of five categories: 1) exclusive combustible, 2) exclusive smokeless, 3) exclusive e-cigarette, 4) dual (at least 2 of the previous 3 categories), and 5) less than some days/week. Participants categorized as exclusive and dual (1–4) used their products at least some days per week. Separately within the rural and urban cohorts, 6, 12, and 18 month transition probabilities between the categories were estimated.

Results

The probability of remaining a dual user after 6 months is 43% in the rural and 37% in the urban cohort. The decline continues through 18 months with 24% of rural and 22% of urban dual users remaining in the category. The probability of a dual user consuming combustibles and e-cigarettes transitioning to exclusive combustible use in 6 months is over 50% in both the rural and urban cohorts.

Conclusions

Dual use is an unstable state with users being more likely to transition to exclusive combustible use than to remain in the dual use category. Transitions are similar in the rural and urban cohorts.

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Exclusive tobacco users remain loyal to their product category over time.

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Dual tobacco users often transition to the use of an exclusive category.

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Tobacco product transition patterns are similar between rural and urban cohorts.

Characteristics of the Tobacco User Adult Cohort in Urban and Rural Ohio

Objectives

Identifying characteristics associated with the use of new and emerging tobacco products is a priority. The enumeration and baseline characteristics of a new cohort of adult tobacco users are described.

Methods

Residents, ≥18 years of age, in urban Franklin County, or one of 6 rural Appalachian counties, and who were exclusive users of combustible, smokeless (SLT), or electronic nicotine delivery systems (ENDS) tobacco products, or were dual users, were targeted for recruitment. Participants were interviewed in-person at baseline on sociodemographic characteristics, tobacco product use, and cognitive/affective and purchasing factors.

Results

We recruited 1210 participants (urban, N = 595; rural, N = 615). Urban participants were less likely to use tobacco daily, began using tobacco later, used tobacco for less time, and had higher cessation interest. ENDS users were significantly less likely to have made a quit attempt than users of other tobacco products. Duration of tobacco use and nicotine dependence also differed by product type.

Conclusion

This cohort's enumeration allowed us to compare factors associated with tobacco product preferences and the use of novel products. The inclusion of rural Appalachia-a region with high tobacco use and disease burden-may provide additional insights into the implementation of tobacco control interventions.

Beyond the brotherhood: Skoal Bandits' role in the evolution of marketing moist smokeless tobacco pouches

Background

Since 2006, "snus" smokeless tobacco has been sold in the U.S.. However, U.S. Smokeless Tobacco (USST) and Swedish Match developed and marketed pouched moist snuff tobacco (MST) since 1973.

Methods

Analysis of previously secret tobacco documents, advertisements and trade press.

Results

USST partnered with Swedish Match, forming United Scandia International to develop pouch products as part of the "Lotus Project." Pouched MST was not commonly used, either in Sweden or the U.S. prior to the Lotus Project's innovation in 1973. The project aimed to transform smokeless tobacco from being perceived as an "unsightly habit of old men" into a relevant, socially acceptable urban activity, targeting 15-35 year-old men. While USST's initial pouched product "Good Luck," never gained mainstream traction, Skoal Bandits captured significant market share after its 1983 introduction. Internal market research found that smokers generally used Skoal Bandits in smokefree environments, yet continued to smoke cigarettes in other contexts. Over time, pouch products increasingly featured increased flavor, size, nicotine strength and user imagery variation.

Conclusions

Marlboro and Camel Snus advertising mirrors historical advertising for Skoal Bandits, designed to recruit new users and smokers subjected to smokefree places. Despite serious efforts, pouched MST marketing has been unable to dispel its association with traditional smokeless tobacco stereotypes as macho and rural. Public education efforts to discourage new users and dual use of MST and cigarettes should emphasize that "new" pouch products are simply repackaging "old" smokeless tobacco.

Biomarkers of exposure to new and emerging tobacco delivery products

Accurate and reliable measurements of exposure to tobacco products are essential for identifying and confirming patterns of tobacco product use and for assessing their potential biological effects in both human populations and experimental systems. Due to the introduction of new tobacco-derived products and the development of novel ways to modify and use conventional tobacco products, precise and specific assessments of exposure to tobacco are now more important than ever. Biomarkers that were developed and validated to measure exposure to cigarettes are being evaluated to assess their use for measuring exposure to these new products. Here, we review current methods for measuring exposure to new and emerging tobacco products, such as electronic cigarettes, little cigars, water pipes, and cigarillos. Rigorously validated biomarkers specific to these new products have not yet been identified. Here, we discuss the strengths and limitations of current approaches, including whether they provide reliable exposure estimates for new and emerging products. We provide specific guidance for choosing practical and economical biomarkers for different study designs and experimental conditions. Our goal is to help both new and experienced investigators measure exposure to tobacco products accurately and avoid common experimental errors. With the identification of the capacity gaps in biomarker research on new and emerging tobacco products, we hope to provide researchers, policymakers, and funding agencies with a clear action plan for conducting and promoting research on the patterns of use and health effects of these products.

Prevalence and Factors Associated with Smokeless Tobacco Use, 2014-2016

OBJECTIVES

We aimed to determine whether the prevalence of current use of smokeless tobacco products (STPs) changed during 2014-2016 and examine factors associated with use among adults in the United States (US).

METHODS

Data were obtained from Tobacco Products and Risk Perceptions Surveys of probability samples representative of US adults in 2014, 2015, and 2016. Change over time in current (past 30 day) STP use was examined using pairwise comparisons of proportions and multivariable logistic regression. Associated factors were examined using Rao-Scott χ2 and multivariable logistic regression.

RESULTS

The prevalence of current STP use was higher in 2015 (3.6%) than in 2014 (2.3%, p < .001) and 2016 (2.7%, p = .018) among US adults. In 2016, current STP use was associated with being male, under age 60, currently using hookah or e-cigarettes, and having less than a college degree. Rates of use did not vary by cigarette smoking status, race/ethnicity, income, or metropolitan statistical area (MSA).

CONCLUSIONS

The prevalence of current STP use peaked in 2015. In 2016, current STP use was more prevalent among males and adults with lower education. Continuous monitoring of STP use is needed, particularly non-cigarette tobacco product users.

Smokeless tobacco products harbor diverse bacterial microbiota that differ across products and brands

Smokeless tobacco products contain numerous chemical compounds, including known human carcinogens. Other smokeless tobacco constituents, including bacteria, may also contribute to adverse health effects among smokeless tobacco users. However, there is a lack of data regarding the microbial constituents of smokeless tobacco. Our goal was to characterize the bacterial microbiota of different smokeless tobacco products and evaluate differences across product types and brands. DNA was extracted from 15 brands of smokeless tobacco products (including dry snuff, moist snuff, snus, and Swedish snus) and 6 handmade products (e.g., toombak) using an enzymatic and mechanical lysis approach. Bacterial community profiling was performed using PCR amplification of the V1-V2 hypervariable region of the 16S rRNA gene, followed by 454 pyrosequencing of the resulting amplicons and sequence analysis using the QIIME package. Total viable counts were also determined to estimate the number of viable bacteria present in each product. Average total viable counts ranged from 0 to 9.35 × 10⁷ CFU g^-1. Analysis of the 16S rRNA gene sequences revealed high bacterial diversity across the majority of products tested: dry snuff products where characterized by the highest diversity indices compared to other products. The most dominant bacterial phyla across all products were Firmicutes, Proteobacteria, Actinobacteria, and Bacteroidetes. Significant differences in both bacterial community composition and in silico predicted gene content were observed between smokeless tobacco product types and between brands of specific smokeless tobacco products. These data are useful in order to comprehensively address potential health risks associated with the use of smokeless tobacco products.

Differences in the Bacteriome of Smokeless Tobacco Products with Different Oral Carcinogenicity: Compositional and Predicted Functional Analysis

Smokeless tobacco (ST) products vary significantly in their oral carcinogenicity. Much is known about the differences in the chemical, but not the bacterial, constituents of these products. In this study, we explored the composition and function of the bacteriome in ST products from four countries using quantitative polymerase chain reaction (qPCR) and 16S rRNA-based next generation sequencing. The bacterial load (16S rRNA copies/gram) was lowest in Swedish snus (3.4 × 10⁶) and highest in Yemeni shammah (6.6 × 10¹¹). A total of 491 species-level taxa, many of which are potentially novel, belonging to 178 genera and 11 phyla were identified. Species richness and diversity were highest for Swedish snus and lowest for Yemeni shammah. Bacillus, Paenibacillus, and Oceanobacillus spp. were the most abundant in American snuff; species of Pseudomonas, Massilia, Propionibacterium, Puniceispirillum, and Gloeothece predominated in Swedish snus. In Sudanese toombak, Facklamia, Desemzia, Atopostipes, and Lysinibacillus spp. accounted for the majority of the bacteriome. Yemeni shammah exclusively contained Bacillus spp. Functional prediction by phylogenetic investigation of communities by reconstruction of unobserved states (PICRUSt) showed that genes encoding cadmium/zinc and nickel transport systems were enriched in the presumptively “high carcinogenicity” products. The bacteriome of ST products thus differed qualitatively, quantitatively, and functionally. The relevance of these differences, particularly with respect to nickel and cadmium, to oral carcinogenesis warrants further investigation.

210Po in Human Saliva of Smokeless Tobacco Users

The occurrence and mobility of Po in oral smokeless tobacco products (STPs) were determined because its effects on human health must be taken into account. This research was subdivided into two parts: determination by alpha spectrometry of the Po activity concentration in 16 oral smokeless tobacco products of different brands purchased in local specialty stores in Europe and evaluation of its percent extraction into an artificial salivary gland during sucking or chewing operations. Polonium-210 was detected in all samples, and its concentrations ranged from 3.46 to 14.8 Bq kg (mean value of 7.45 ± 3.82 Bq kg). The highest concentration was found in chewing tobacco. The samples showed no significant difference in the content of Po level. The data obtained in this study show that the polonium, although poorly extracted (12.8 ± 8.96%) by artificial saliva, is not totally retained within the smokeless tobacco products, with a consequent potential health hazard associated with oral use of these products.

Naturalistic assessment of demand for cigarettes, snus, and nicotine gum

RATIONALE

Behavioral economic measures of demand provide estimates of tobacco product abuse liability and may predict effects of policy-related price regulation on consumption of existing and emerging tobacco products.

OBJECTIVE

In the present study, we examined demand for snus, a smokeless tobacco product, in comparison to both cigarettes and medicinal nicotine. We used both a naturalistic method in which participants purchased these products for use outside the laboratory, as well as laboratory-based self-administration procedures.

METHODS

Cigarette smokers (N = 42) used an experimental income to purchase their usual brand of cigarettes and either snus or gum (only one product available per session) across a range of prices, while receiving all products they purchased from one randomly selected price. In a separate portion of the study, participants self-administered these products during laboratory-based, progressive ratio sessions.

RESULT

Demand elasticity (sensitivity of purchasing to price) was significantly greater for snus than cigarettes. Elasticity for gum was intermediate between snus and cigarettes but was not significantly different than either. Demand intensity (purchasing unconstrained by price) was significantly lower for gum compared to cigarettes, with no significant difference observed between snus and cigarettes. Results of the laboratory-based, progressive ratio sessions were generally discordant with measures of demand elasticity, with significantly higher "breakpoints" for cigarettes compared to gum and no significant differences between other study products. Moreover, breakpoints and product purchasing were generally uncorrelated across tasks.

CONCLUSIONS

Under naturalistic conditions, snus appears more sensitive to price manipulation than either cigarettes or nicotine gum in existing smokers.

A longitudinal, naturalistic study of U.S. smokers' trial and adoption of snus

To refine public health policy amidst a changing landscape of tobacco products in the United States, it is first necessary to describe fully the nature of smokers' alternative product use. Little research addresses smokers' snus use, and most studies are limited by small samples, cross-sectional designs, and crude outcome measurement. This study sample includes 626 adult US smokers who denied intention to quit in the next month and were randomized to receive free snus during a 6-week sampling period, after which no snus was provided. Participants were then followed for one year. Outcome data were collected via phone. Participants (mean age: 48.7years) were predominately female, White non-Hispanic. Eighty-four percent reported trial of snus. Eleven percent reported purchase (i.e., adoption). Current use declined from 47.1% at the end of the sampling period to 6.5% at the end of follow-up. Frequency and quantity of snus use among current users was low. Among snus users, 79.3% said it functioned as an alternative to smoking and 58.4% said it provided a means of coping with smoking restrictions; options not mutually exclusive. In logistic regressions, men were more likely to report trial (odds ratio [OR]=2.33, p<0.01) and adoption (OR=1.84, p<0.05) than women. Baseline expectations about the nature of snus use also predicted snus outcomes (OR=1.28-1.78, p<0.05). Smokers showed willingness to try snus, but product interest waned over time. Snus as currently marketed is unlikely to play a prominent role in US tobacco control efforts.

Trends and Factors Related to Smokeless Tobacco Use in the United States

BACKGROUND

While declines in smoking prevalence in the United States have been well documented, trends in smokeless tobacco (SLT) use are less clear. This study updates previous analyses of US SLT use prevalence to better understand trends and factors related to SLT use.

METHODS

We used the Tobacco Use Supplement of the Current Population Survey (TUS-CPS) to examine trends and factors related to SLT use using joinpoint and logistic regression models. SLT consumption from 1985 to 2011 was obtained from the 2011 Federal Trade Commission Smokeless Tobacco Report. Sensitivity analyses were conducted for assessing the impact of varying frequency definitions of SLT use.

RESULTS

Decreasing trends in smoking and SLT prevalence overall were observed from 1992 to 2003 independently of use definition. SLT prevalence in the total adult population significantly decreased at an annual percent change (APC) of 4.5% per year from 1992 to 2003, but has been approximately constant ever since. Similar patterns were also found in adult males (APC = -4.4%) and young males (APC = -9.5%). SLT per capita consumption decreased significantly from 1991 to 1999 (APC = -2.2%), but has since decreased at only 0.35% per year (1999-2011). SLT use was found to be associated with former smoker status, younger age, white race, living in rural areas, residence in the South, lower education and unemployment, adjusting for other factors.

CONCLUSIONS

Declines in SLT use were found in the United States, suggesting tobacco control has had positive impacts, but these have slowed since 2003. Targeting tobacco control policies to at-risk demographic groups is needed to further reduce SLT use in the United States.

IMPLICATIONS

This study confirms that the declines in SLT use prevalence stopped in 2003 across different demographic groups, consistent with trends in SLT consumption. In addition, the longer period of analysis in comparison with earlier studies allows for quantitative characterization of SLT use trends using joinpoint regression. The study also shows the impact of different SLT use definitions in determining tobacco product use prevalence and trends.

Advertising Receptivity and Youth Initiation of Smokeless Tobacco

BACKGROUND

Cross-sectional data suggests that adolescents' receptivity to the advertising of smokeless tobacco is correlated with use of chewing tobacco or snuff. Lack of longitudinal data has precluded determination of whether advertising receptivity precedes or follows initiation of smokeless tobacco.

OBJECTIVES

The objective of this study was to test for the association between advertising receptivity and subsequent initiation of smokeless tobacco among adolescent males.

METHODS

Adolescent males from the 1993-1999 Teen Longitudinal California Tobacco Survey were selected at the baseline survey for never having used smokeless tobacco. Separate longitudinal analyses corresponded to two dependent variables, ever use of smokeless tobacco (1993-1996; N = 1,388) and use on 20 or more occasions (1993-1999; N = 1,014). Models were adjusted for demographic variables, risk factors for smokeless tobacco use, and exposure to users of smokeless tobacco.

RESULTS

Advertising receptivity at baseline was predictive of ever use by late adolescence (RR(95% CI) = 2.0 (1.5, 2.8)) and regular use by young adulthood (RR(95% CI) = 3.7 (2.1, 6.7)) in models that were adjusted for covariates. Conclusions/ Importance: The findings challenge the tobacco industry's assertion that tobacco marketing does not impact youth initiation. This is particularly relevant to tobacco control in the United States because the 2009 Tobacco Control Act places fewer restrictions on smokeless tobacco products compared to cigarettes.

The changing tobacco landscape: What dental professionals need to know

BACKGROUND

Tobacco products in the United States and the patterns of tobacco use are changing. Although cigarette smoking prevalence has declined, dental professionals are likely to encounter substantial numbers of patients who have tried and are continuing to use new and alternative tobacco products, including cigars, water pipes (hookahs), and electronic cigarettes, as well as conventional and new smokeless tobacco products.

METHODS

The authors reviewed conventional and new tobacco products in the United States, their adverse oral and systemic health effects, and their prevalence of use.

RESULTS

Tobacco products other than cigarettes account for a substantial portion of tobacco use. For this reason, tobacco-use prevention and cessation counseling provided by dental health care professionals must address all tobacco products, including cigarettes, cigars, water pipes, and electronic cigarettes, as well as conventional and new smokeless tobacco products. Cigarette smoking and smokeless tobacco use are associated with immediate and long-term adverse health effects, including nicotine addiction, oral and systemic disease, and death. Novel products may attract new tobacco users, potentially leading to addiction that results in enduring tobacco product use and associated adverse health effects.

CONCLUSIONS

This critical review of conventional, new, and emerging tobacco products presents information that dental professionals can use in providing tobacco-related counseling to patients who use or who are at risk for using tobacco products.

PRACTICAL IMPLICATIONS

It is essential that dental professionals are knowledgeable about tobacco products and are able to answer patients' questions and provide them with evidence-based tobacco-related counseling. This information may prevent patients from initiating use or help reduce or cease use to avoid immediate and long-term adverse health effects, including nicotine addiction, oral and systemic disease, and death.

Perceived Health Risks of Snus and Medicinal Nicotine Products

INTRODUCTION

Perceived health risk (PHR) of a tobacco product may influence both uptake and continued use. In this study, we examined PHRs of snus and medicinal nicotine using the PHR scale and the relationship of PHR responses to use of these products in smokers seeking an alternative to smoking.

METHODS

Smokers were randomly assigned to snus or to medicinal nicotine for a period of 12 weeks and asked to only use the assigned product. The PHR scale involves rating the extent of perceived risk of a product for different diseases and was given at baseline and weeks 4 and 12 during treatment. Relationships between PHR scale scores and study attrition, compliance with only using the product, and continued use of the product after treatment were determined.

RESULTS

Response to the PHR scale showed no significant differences between the snus and medicinal nicotine for perceived risks for lung cancer, emphysema, and bronchitis. However, significant differences were observed for other cancers, heart disease, stroke and risk for addiction, particularly after product use, with higher scores among those assigned to snus. Scores on the PHR scale were not related to any of the trial outcome variables.

CONCLUSIONS

Among smokers seeking an alternative to smoking in a clinic setting, PHR of a product changes after product use but may not be related to product use patterns.

IMPLICATIONS

PHRs of snus or medicinal nicotine in smokers assigned to these products become more accurate after product use. PHR does not appear to be associated with patterns of product use; rather satisfaction with a product is a better indicator as to whether a smoker is compliant with only using the product or continues to use the product.

Chemical and toxicological characteristics of conventional and low-TSNA moist snuff tobacco products

Use of smokeless tobacco products (STPs) is associated with oral cavity cancer and other health risks. Comprehensive analysis for chemical composition and toxicity is needed to compare conventional and newer STPs with lower tobacco-specific nitrosamines (TSNAs) yields. Seven conventional and 12 low-TSNA moist snuff products purchased in the U.S., Sweden, and South Africa were analyzed for 18 chemical constituents (International Agency for Research on Cancer classified carcinogens), pH, nicotine, and free nicotine. Chemicals were compared in each product using Wilcoxon rank-sum test and principle component analysis (PCA). Conventional compared to low-TSNA moist snuff products had higher ammonia, benzo[a]pyrene, cadmium, nickel, nicotine, nitrate, and TSNAs and had lower arsenic in dry weight content and per mg nicotine. Lead and chromium were significantly higher in low-TSNA moist snuff products. PCA showed a clear difference for constituents between conventional and low-TSNA moist snuff products. Differences among products were reduced when considered on a per mg nicotine basis. As one way to contextualize differences in constituent levels, probabilistic lifetime cancer risk was estimated for chemicals included in The University of California's carcinogenic potency database (CPDB). Estimated probabilistic cancer risks were 3.77-fold or 3-fold higher in conventional compared to low-TSNA moist snuff products under dry weight or under per mg nicotine content, respectively. In vitro testing for the STPs indicated low level toxicity and no substantial differences. The comprehensive chemical characterization of both conventional and low-TSNA moist snuff products from this study provides a broader assessment of understanding differences in carcinogenic potential of the products. In addition, the high levels and probabilistic cancer risk estimates for certain chemical constituents of smokeless tobacco products will further inform regulatory decision makers and aid them in their efforts to reduce carcinogen exposure in smokeless tobacco products.

Will chronic e-cigarette use cause lung disease?

Chronic tobacco smoking is a major cause of preventable morbidity and mortality worldwide. In the lung, tobacco smoking increases the risk of lung cancer, and also causes chronic obstructive pulmonary disease (COPD), which encompasses both emphysema and chronic bronchitis. E-cigarettes (E-Cigs), or electronic nicotine delivery systems, were developed over a decade ago and are designed to deliver nicotine without combusting tobacco. Although tobacco smoking has declined since the 1950s, E-Cig usage has increased, attracting both former tobacco smokers and never smokers. E-Cig liquids (e-liquids) contain nicotine in a glycerol/propylene glycol vehicle with flavorings, which are vaporized and inhaled. To date, neither E-Cig devices, nor e-liquids, are regulated by the Food and Drug Administration (FDA). The FDA has proposed a deeming rule, which aims to initiate legislation to regulate E-Cigs, but the timeline to take effect is uncertain. Proponents of E-Cigs say that they are safe and should not be regulated. Opposition is varied, with some opponents proposing that E-Cig usage will introduce a new generation to nicotine addiction, reversing the decline seen with tobacco smoking, or that E-Cigs generally may not be safe and will trigger diseases like tobacco. In this review, we shall discuss what is known about the effects of E-Cigs on the mammalian lung and isolated lung cells in vitro. We hope that collating this data will help illustrate gaps in the knowledge of this burgeoning field, directing researchers toward answering whether or not E-Cigs are capable of causing disease.

High levels of tobacco-specific N-nitrosamines and nicotine in Chaini Khaini, a product marketed as snus

INTRODUCTION

Recently, a tobacco product, Chaini Khaini, identified as snus appeared in India. The product marketing emphasises its discreet nature and explicitly claims safety by referring to the existing evidence on Swedish snus. We analysed tobacco-specific nitrosamines and nicotine in 12 samples of Chaini Khaini purchased in 2013 at open markets in India.

METHODS

Samples were purchased twice: in March 2013 from Mumbai and in November 2013 from Mumbai and Ahmedabad. Chemical constituents were measured by our routine validated methods.

RESULTS

Levels of carcinogenic nitrosamines NNN, NNK and NNAL averaged 22.9 (±4.9), 2.6 (±1.0) and 3.1 (±1.5) µg/g tobacco (wet weight), respectively. The levels of NAB, which is normally present in trace levels in tobacco products, ranged from 3.9 to 12.9 µg/g tobacco. Total nicotine levels in all samples averaged 10.0 mg/g tobacco and unprotonated nicotine accounted for an average 95.4% of the total nicotine content.

CONCLUSIONS

Chaini Khaini, which is labelled as snus and is marketed as a safe alternative to other tobacco products contains very high levels of carcinogenic nitrosamines and biologically available nicotine. Interventions are urgently needed to educate current and potential consumers of this product.

Determination of Aflatoxin B1 in Smokeless Tobacco Products by Use of UHPLC-MS/MS

This work developed a UHPLC-MS/MS method for the detection and quantitation of aflatoxins in smokeless tobacco products, which was then used to determine aflatoxin B1 concentrations in 32 smokeless tobacco products commercially available in the United States. Smokeless tobacco products were dried, milled, and amended with (13)C17-labeled internal standards, extracted in water/methanol solution in the presence of a surfactant, isolated through use of immunoaffinity column chromatography, and reconstituted in mobile phase prior to UHPLC-MS/MS analysis. The method was capable of baseline separation of aflatoxins B1, B2, G1, and G2 in a 2.5 min run by use of a fused core C18 column and a water/methanol gradient. MS/MS transition (m/z) 313.3 → 241.2 was used for aflatoxin B1 quantitation, with 313.3 → 285.1 used for confirmation. The limit of detection (LOD) for aflatoxin B1 was 0.007 parts per billion (ppb). Method imprecision for aflatoxin B1 (expressed as coefficient of variation) ranged from 5.5 to 9.4%. Spike recoveries were 105-111%. Aflatoxin B1 concentrations in the smokeless tobacco products analyzed ranged from <LOD to 0.271 ppb (dry mass). Aflatoxin B1 was most frequently detected in dry snuffs and chews, whereas all moist snuff products tested were below LOD. The amounts of aflatoxin B1 detected were low relative to the 20 ppb regulatory limit established by the U.S. Food and Drug Administration for foods and feeds.

Validation of a Measure of Normative Beliefs About Smokeless Tobacco Use

INTRODUCTION

Validated methods to evaluate consumer responses to modified risk tobacco products (MRTPs) are needed. Guided by existing literature that demonstrates a relationship between normative beliefs and future intentions to use tobacco the current research sought to (1) develop a measure of normative beliefs about smokeless tobacco (ST) and establish the underlying factor structure, (2) evaluate the structure with confirmatory factor analysis utilizing an independent sample of youth, and (3) establish the measure's concurrent validity.

METHODS

Respondents (smokers and nonsmokers aged 15-65; N = 2991) completed a web-based survey that included demographic characteristics, tobacco use history and dependence, and a measure of attitudes about ST adapted from the Normative Beliefs about Smoking scale. A second sample of youth (aged 14-17; N = 305) completed a similar questionnaire.

RESULTS

Exploratory factor analysis produced the anticipated three-factor solution and accounted for nearly three-quarters of the variance in the data reflecting (1) perceived prevalence of ST use, (2) popularity of ST among successful/elite, and (3) approval of ST use by parents/peers. Confirmatory factor analysis with data from the youth sample demonstrated good model fit. Logistic regression demonstrated that the scales effectively discriminate between ST users and nonusers and are associated with interest in trying snus.

CONCLUSIONS

Assessment of MRTPs for regulatory purposes, which allows messages of reduced risk, should include measurement of social norms. Furthermore, surveillance efforts that track use of new MRTPs should include measures of social norms to determine how norms change with prevalence of use.

Immunochromatographic Assessment of Salivary Cotinine and Its Correlation With Nicotine Dependence in Tobacco Chewers

Background:

This study assessed the correlation between nicotine dependence and salivary cotinine levels in tobacco chewers and checked the reliability of Fagerstorm test in tobacco cessation programmes.

Methods:

The study sample included 75 tobacco chewers aged between 20 to 50 years. Self-reported nicotine dependence was evaluated using Fagerstorm Test for Nicotine dependence-smokeless tobacco questionnaire. Patients were categorized into low, moderate and high dependent chewers based on their answers to the questionnaire. The unstimulated salivary cotinine levels were measured by immunochromatographic assay using the NicAlert saliva test. Data was analysed using the chi-square test for testing intra-group variation, analysis of variance for testing between-groups variation, and the Spearman coefficient for assessing the association between variables.

Results:

No statistically significant association was seen between salivary cotinine levels and nicotine dependence. A weak positive correlation was noted between the above variables (r = 0.230). In the group studied, it was evident that the patients were under-reporting the nicotine dependence.

Conclusions:

The measurement of salivary cotinine by immunochromatographic assay using NicAlert saliva test is a useful and convenient method for studying the nicotine dependence in tobacco chewers. Immunochromatography-based cotinine test strips are an easy method of detecting salivary cotinine in a dental setup. From this study we are of the opinion that a simple questionnaire like Fagerstorm test can give a less adequate analysis of patient’s dependence especially in countries like India, where patients tend to under-report their dependency. Immediate feedback from a chairside test can help both the dentists and patients during a tobacco cessation programme.

Risk perceptions of smokeless tobacco among adolescent and adult users and nonusers

The recent growth in smokeless tobacco (ST) consumption has raised questions about consumer risk perceptions of ST products, especially in high-risk vulnerable populations. This qualitative study examined risk perceptions of ST among adolescent and adult users and nonusers in Ohio Appalachia. Focus groups and interviews were held with adolescents (n = 53; M age = 17 years) and adults (n = 63; M age = 34 years) from four Ohio Appalachian counties. Participants were asked about their perceptions of ST-related health risks, ST safety, and the relative safety of ST compared with cigarettes. Transcriptions were coded independently by two individuals. Overall, participants were knowledgeable about health problems from ST use (e.g., oral cancers, periodontal disease). Nearly all participants stated that ST use is not safe; however, there was disagreement about its relative safety. Some perceived all tobacco products as equally harmful; others believed that ST is safer than cigarettes for either the user or those around the user. Disagreements about ST relative safety may reflect mixed public health messages concerning the safety of ST. Comprehensive consumer messages about the relative safety of ST compared with cigarettes are needed. Messages should address the effect of ST on the health of the user as well as those exposed to the user.

Analysis of hydrazine in smokeless tobacco products by gas chromatography-mass spectrometry

Background

Due to the lower health risks associated with the use of certain categories of smokeless tobacco products (STPs) such as Swedish snus, there is interest in the comparative levels of toxic chemical constituents in different types of STPs. A method has been developed and validated for the analysis of hydrazine in STPs. Seventy four commercial STPs from the US and Sweden, representing 80-90% of the 2010 market share for all the major STP categories in these two countries, as well as three reference STPs, were analysed for hydrazine.

Results

Aqueous extracts of the STPs were treated with excess pentafluorobenzaldehyde (PFB), which reacted with hydrazine in solution to form decafluorobenzaldehyde azine (DFBA). DFBA was partitioned into hexane and then quantified by gas chromatography–mass spectrometry (GC–MS). The method was validated using five different types of STP, was linear in the range 8–170 ng/mL, and had limits of quantification (LOQ) from 26–53 ng of hydrazine per g of STP (as sold). The method was applied to the analysis of 74 contemporary STPs commercially available in the United States and Sweden, none of which were found to contain hydrazine above the LOQ or LOD. Trace levels of compounds showing chromatographic and mass spectral features consistent with hydrazine were identified at very low levels (sub-limit of detection, <10 ng/g) in the chromatograms of less than half of the 74 STPs examined; in contrast, for 40 of the STPs no evidence for the presence of hydrazine was observed. Where present, the levels of compounds consistent with hydrazine were estimated to be at least an order of magnitude lower than the only previous study to have quantified hydrazine in tobacco.

Conclusions

Our results show that hydrazine is not a prevalent constituent of STPs, and when present is not quantifiable using currently available analytical methodology.

Youth tobacco product use in the United States

BACKGROUND

Noncigarette tobacco products are increasingly popular among youth, especially cigarette smokers. Understanding multiple tobacco product use is necessary to assess the effects of tobacco products on population health. This study examines multiple tobacco product use and associated risk factors among US youth.

METHODS

Estimates of current use were calculated for cigarettes, cigars, smokeless tobacco, hookah, e-cigarettes, pipes, bidis, kreteks, snus, and dissolvable tobacco by using data from the 2012 National Youth Tobacco Survey (n = 24 658), a nationally representative sample of US middle and high school students. Associations between use patterns and demographic characteristics were examined by using multinomial logistic regression.

RESULTS

Among youth, 14.7% currently use 1 or more tobacco products. Of these, 2.8% use cigarettes exclusively, and 4% use 1 noncigarette product exclusively; 2.7% use cigarettes with another product (dual use), and 4.3% use 3 or more products (polytobacco use). Twice as many youth use e-cigarettes alone than dual use with cigarettes. Among smokers, polytobacco use was significantly associated with male gender (adjusted relative risk ratio [aRRR] = 3.71), by using flavored products (aRRR = 6.09), nicotine dependence (aRRR = 1.91), tobacco marketing receptivity (aRRR = 2.52), and perceived prevalence of peer use of tobacco products (aRRR = 3.61, 5.73).

CONCLUSIONS

More than twice as many youth in the United States currently use 2 or more tobacco products than cigarettes alone. Continued monitoring of tobacco use patterns is warranted, especially for e-cigarettes. Youth rates of multiple product use involving combustible products underscore needs for research assessing potential harms associated with these patterns.

Animal models to assess the abuse liability of tobacco products: effects of smokeless tobacco extracts on intracranial self-stimulation

BACKGROUND

Preclinical models are needed to inform regulation of tobacco products by the Food and Drug Administration (FDA). Typically, animal models of tobacco addiction involve exposure to nicotine alone or nicotine combined with isolated tobacco constituents (e.g. minor alkaloids). The goal of this study was to develop a model using extracts derived from tobacco products that contain a range of tobacco constituents to more closely model product exposure in humans.

METHODS

This study compared the addiction-related effects of nicotine alone and nicotine dose-equivalent concentrations of aqueous smokeless tobacco extracts on intracranial self-stimulation (ICSS) in rats. Extracts were prepared from Kodiak Wintergreen, a conventional product, or Camel Snus, a potential "modified risk tobacco product". Binding affinities of nicotine alone and extracts at various nicotinic acetylcholine receptor (nAChR) subtypes were also compared.

RESULTS

Kodiak and Camel Snus extracts contained levels of minor alkaloids within the range of those shown to enhance nicotine's behavioral effects when studied in isolation. Nonetheless, acute injection of both extracts produced reinforcement-enhancing (ICSS threshold-decreasing) effects similar to those of nicotine alone at low to moderate nicotine doses, as well as similar reinforcement-attenuating/aversive (ICSS threshold-increasing) effects at high nicotine doses. Extracts and nicotine alone also had similar binding affinity at all nAChRs studied.

CONCLUSIONS

Relative nicotine content is the primary pharmacological determinant of the abuse liability of Kodiak and Camel Snus as measured using ICSS. These models may be useful to compare the relative abuse liability of other tobacco products and to model FDA-mandated changes in product performance standards.

Comparing college smokers' and dual users' expectancies towards cigarette smoking

BACKGROUND

As no agreed upon definition exists for dual use (i.e., individuals who concurrently use more than one form of tobacco), this population remains largely unstudied in the substance use literature, despite increases in smokeless tobacco use among young adults. Individuals 18-25years of age report the highest rates of smokeless tobacco use, dual use, and cigarette use. The current study compared the smoking outcome expectancies of college student dual users to those who reported only smoking cigarettes.

METHODS

The Short Form of the Smoking Consequences Questionnaire was used to examine potential differences in positive or negative expectations regarding cigarette use.

RESULTS

Data from this study suggest that smokers believe that smoking will lead to greater positive consequences ("cigarettes taste good"), negative reinforcement ("cigarettes help me deal with anger"), and weight/appetite reduction ("smoking controls my appetite") when compared to dual users. Conversely, dual users believed that smoking would lead to greater negative consequences (e.g., "smoking is taking years off of my life").

DISCUSSION

These results may help to explain why some smokers choose not to use smokeless tobacco products for harm reduction or smoking cessation purposes, as well as why increases are being observed in smokeless tobacco rates among young adults.

Epidemiology and public health policy of tobacco use and cardiovascular disorders in low- and middle-income countries

All forms of tobacco lead to an increased risk of cardiovascular disorders. During the past few decades, the number of people who consume tobacco has increased worldwide because of an overall increase in the global population. It is estimated that close to 80% of the >1.3 billion people who smoke tobacco in the world are in low- and middle-income countries. Smokeless forms of tobacco are also widely consumed in low- and middle-income countries, including chewable and snuffed forms. Lack of targeted and effective strategies to control tobacco consumption contributes to a large burden of cardiovascular disorders in low- and middle-income countries, where cardiovascular disorders have become the leading cause of morbidity and mortality. In this review, we evaluate the epidemiology of tobacco use in low- and middle-income countries and assess the public health policies needed to control tobacco use in such regions for the prevention of cardiovascular disorders and other tobacco-related morbidities and mortality.

Cigarette smokers' use of unconventional tobacco products and associations with quitting activity: findings from the ITC-4 U.S. cohort

INTRODUCTION

The purpose of this study was to evaluate the prevalence and correlates of use of nicotine-containing tobacco products such as cigars, pipe tobacco, and cigarettes that promise less exposure to toxins; e-cigarettes; and smokeless tobacco products among a cohort of conventional cigarette smokers followed over the past decade. We also evaluated associations between use of such products and cigarette quitting.

METHODS

Participants were 6,110 adult smokers in the United States, who were interviewed as part of the International Tobacco Control Four Country Survey between 2002 and 2011. Respondents reported their concurrent use of other smoked tobacco products (including cigars, pipe tobacco, and cigarillos), smokeless tobacco products (including chewing tobacco, snus, and snuff), unconventional cigarettes (including Omni, Accord, and Eclipse), and electronic cigarettes. Prevalence and correlates of use and associations between use and cigarette quitting were assessed using regression analyses via generalized estimating equations.

RESULTS

Most cigarette smokers did not use unconventional tobacco products, although use of any of these products started to rise at the end of the study period (2011). For each type of tobacco product evaluated, use was most prevalent among those aged 18-24 years. Smokers who did use unconventional tobacco products did not experience a clear cessation advantage.

CONCLUSIONS

During the past decade, relatively few cigarette smokers reported also using other tobacco products. Those that did use such products were no more likely to stop using conventional cigarettes compared with those who did not use such products.

The debate over weight- versus price-based taxation of snuff in the United States' state legislatures

Discount snuff, known for its cheap price, high nicotine content, and popularity among youth, has increased substantially in market share in the United States. As a likely result, the leading manufacturer of premium snuff has supported legislation changing the basis for taxing snuff from price to weight. To determine which public health issues arose in legislative debates, we transcribed 17 of 52 bills from US state legislatures and coded for arguments broadly categorized into public health, fair taxation, tax revenue, tax efficiency, and anti-competitiveness. State legislators expressed frustration that equitable taxation, revenue generation, and prevention of youth tobacco use were frequently conflated in the debates. Public health advocates expressed concerns over youths' incentives to purchase low-weight snuff, but seldom discussed youths' growing preference for discount snuff. The evolving market of moist snuff is a critical consideration for US state legislators as well as policy makers from other countries who may evaluate taxation methods for alternate tobacco products.

First-year college students' interest in trying dissolvable tobacco products

BACKGROUND

Dissolvable tobacco products (DTPs) have been introduced into test markets in the U.S. We sought to gauge the level of interest in trying these products and correlates of interest among potential consumers.

METHODS

A web-based survey of freshman at 11 universities in North Carolina and Virginia was conducted in fall 2010. Multivariable logistic regression analyses were used to identify correlates of students' likelihood to try DTPs if offered a free sample.

RESULTS

Weighted prevalence of likelihood to try DTPs was 3.7%. Significant correlates of likelihood to try included male gender, current cigarette smoking, current snus use, sensation seeking, lifetime illicit drug use, and perceived health risk of using DTPs. Among current smokers, current snus use, current use of chewing tobacco, and considering quitting smoking were associated with likelihood to try DTPs.

CONCLUSIONS

While overall interest in trying these products was low, current users of cigarettes and snus were much more likely than others in trying a free sample. Some current smokers may consider DTPs to be an aid to smoking cessation, although the population-level impact of introducing these products is unknown.

Brief, instructional smokeless tobacco use among cigarette smokers who do not intend to quit: a pilot randomized clinical trial

INTRODUCTION

Low-nitrosamine smokeless tobacco (SLT) may have efficacy for smoking reduction and cessation, but its public health impact depends on how smokers use it.

METHODS

This pilot study explored brief, instructional low-nitrosamine SLT use among smokers unmotivated to quit. Participants (N = 57) were randomized to either a free 2-week supply of Camel Snus group or a no-supply group. Of those randomized to use Camel Snus, half were told to use it to cope with smoking restrictions (Snus to Cope), and the remaining half were advised to use it to reduce smoking (Snus to Reduce). Participants were assessed before, during, and immediately after the intervention.

RESULTS

Many Snus to Cope and Snus to Reduce participants reported daily use of Camel Snus, although the amount of use was low. Snus to Cope (18.4%) and Snus to Reduce (37.6%) participants reported a decline in number of cigarettes used per day, which was not reported by the control participants (p < .001). Intention to quit smoking and intention to quit all tobacco use (ps < .001) increased to a greater extent among Snus to Cope and Snus to Reduce participants than among control participants.

CONCLUSIONS

This study replicates previous work that shows that low-nitrosamine SLT use can lead to reduced smoking and increased intention to quit, and it adds direct evidence to suggest that the function of low-nitrosamine SLT use-either to cope with smoking restrictions or to reduce smoking-can have a differential impact on smoking behavior. Overall, the results highlight the importance of messaging and, more specifically, marketing of low-nitrosamine SLT to smokers.

A content analysis of smokeless tobacco coverage in U.S. newspapers and news wires

INTRODUCTION

Research attention on smokeless tobacco (SLT) has focused on SLT use, health risks, harm-reduction potential, and risk perceptions, but few studies have examined mediated communications about SLT. This study aims to contribute to the literature by providing the first description of SLT coverage in the news, an important communication channel given its ability to educate and shape public opinion about tobacco issues.

METHODS

A content analysis was conducted on SLT-related news and opinion articles between 2006 and 2010 from top circulating national and state newspapers and select news wires. Articles were coded for the main SLT topic, SLT risk references, and slant of opinion articles.

RESULTS

SLT was discussed in news/feature articles (n = 677) in terms of business (28%), new products, product regulation and harm reduction (19%), prevention/cessation (11.4%), taxation (10.2%), profiles/trends in use (9%), bans (8.1%), and tobacco industry promotional activities (4.9%). Health risk references (i.e., addictiveness, carcinogenicity, and specific health effects including oral cancer) were found in 40% of articles, though frequency differed by article topic. Although the majority of opinion articles (n = 176) conveyed an anti-SLT slant (64%), 25.6% were pro-SLT.

CONCLUSIONS

SLT topics of both national and local importance are covered in the news. Public health professionals can participate in SLT coverage by sending in press releases about new study findings, events, or resources and by submitting opinion pieces to share views or respond to previous coverage. Research on SLT news should continue given its potential to shape the public's SLT knowledge and opinions.

Levels of (S)-N'-nitrosonornicotine in U.S. tobacco products

INTRODUCTION

N'-nitrosonornicotine (NNN), an esophageal and oral carcinogen present in tobacco products, has a chiral center in its structure. Of its two enantiomers, (S)-NNN exhibits higher tumorigenic potency than (R)-NNN. There is no information available on the levels of (S)-NNN in various tobacco products currently marketed in the United States.

METHODS

We used chiral gas chromatography analysis to determine (S)-NNN levels in a convenience sample of 37 tobacco products currently marketed in the United States: conventional smokeless tobacco, novel smokeless tobacco products, and cigarette tobacco filler.

RESULTS

Among all products analyzed here, (S)-NNN averaged 62.9 ± 6.3% (SD) of NNN. The absolute amount of (S)-NNN in conventional moist snuff averaged 1.26 ± 0.5 µg/g tobacco; in novel smokeless products 0.70 ± 0.2 µg/g tobacco; and in cigarette filler 1.36 ± 0.6 µg/g tobacco (all values are per wet weight). For each cigarette brand, the enantiomeric composition of NNN in cigarette smoke was similar to that of the corresponding tobacco filler.

CONCLUSIONS

Our results demonstrate that (S)-NNN is the predominant NNN enantiomer in moist snuff, novel smokeless tobacco products, and cigarettes currently marketed in the United States. Efforts toward the reduction of NNN in U.S. tobacco products should take into account its enantiomeric composition, with particular focus on (S)-NNN as a causative agent for esophageal and oral cancers associated with tobacco use.

Alternative tobacco product use and smoking cessation: a national study

OBJECTIVES

We investigated the frequency of alternative tobacco product use (loose leaf, moist snuff, snus, dissolvables, electronic cigarettes [e-cigarettes]) among smokers and the association with quit attempts and intentions.

METHODS

A nationally representative probability-based cross-sectional survey of 1836 current or recently former adult smokers was completed in November 2011. Multivariate logistic regressions evaluated associations between alternative tobacco product use and smoking cessation behaviors.

RESULTS

Of the smokers, 38% had tried an alternative tobacco product, most frequently e-cigarettes. Alternative tobacco product use was associated with having made a quit attempt, and those intending to quit were significantly more likely to have tried and to currently use the products than were smokers with no intentions to quit. Use was not associated with successful quit attempts. Interest in future use of alternative tobacco products was low, except for e-cigarettes.

CONCLUSIONS

Alternative tobacco products are attractive to smokers who want to quit smoking, but these data did not indicate that alternative tobacco products promote cessation. Unsubstantiated overt and implied claims that alternative tobacco products aid smoking cessation should be prohibited.

The chemical composition of smokeless tobacco: a survey of products sold in the United States in 2006 and 2007

Selected toxicant concentrations and other chemical measures have been determined for 43 U.S. smokeless tobacco products sold in 2006 and 2007. Products evaluated included moist snuff, dry snuff, loose leaf, plug, dissolvable and snus tobacco brands. Reference products available for scientific research purposes and eleven Swedish products were also evaluated and compared to the commercial products studied. Chemical endpoints determined included benzo[a]pyrene (B[a]P), N'-nitrosonornicotine (NNN), N'-nitrosoanatabine (NAT), N'-nitrosoanabasine (NAB), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), N-Nitrosodimethylamine (NDMA), nitrite, cadmium, lead, arsenic, nickel, chromium, chloride, water, pH and nicotine. Different toxicant profiles were observed for the products studied, with snus tobacco brands generally containing relatively low concentrations of B[a]P and tobacco specific nitrosamines (TSNAs) compared to other moist snuffs. Smokeless tobacco reference product toxicant profiles were similar to corresponding commercial products, with the exception of the TSNA content of the dry snuff reference material. TSNA concentrations observed for all commercial products were lower than historically reported values, likely reflecting changes in product shelf life, tobacco curing practices and, possibly, product blend formulations during the last 20-30 years. The survey results summarized provide a temporal point of comparison with future data anticipated from FDA "harmful and potentially harmful constituents in tobacco products" reporting.

Trends in the use and advertising of discount versus premium snuff

INTRODUCTION

The Conwood Company, a major producer of discount moist snuff, was awarded a $1 billion antitrust settlement in the year 2000 against its leading competitor, the U.S. Smokeless Tobacco Company. The objective of this study was to examine the trends in use and advertising of discount versus premium snuff since the Conwood settlement, a topic seldom addressed in the tobacco control literature.

METHODS

2 sources of data were analyzed in 2011: (a) male snuff users from the 2002-2009 National Surveys on Drug Use and Health (N = 13,172) and (b) total advertisements of moist snuff identified from over 350 consumer magazines dated 2005-2009 (N = 861). For the survey data, demographic and tobacco-related measures were assessed as predictors of use of discount versus premium snuff in logistic regression models. For the advertising data, associations were examined between the snuff category and nicotine content, magazine youth readership, and year of magazine publication.

RESULTS

The prevalence of discount and premium snuff use among males increased and decreased, respectively, from 2002 to 2009. Significant predictors of using discount versus premium snuff were being an adolescent, being an African-American, being a current or former smoker, living in a less populated region of the country, and using snuff frequently. Discount snuff advertising was associated with publication in magazines with a high youth readership.

CONCLUSIONS

Discount snuff has grown in popularity among male adolescents who have been a target of advertising. The tobacco's cheap price and high nicotine content pose a public health problem because of the potential for long-term tobacco use and dependence.

Delivery of nicotine in an extract of a smokeless tobacco product reduces its reinforcement-attenuating and discriminative stimulus effects in rats

RATIONALE

Animal models of tobacco addiction rely on administration of nicotine alone or nicotine combined with isolated constituents. Models using tobacco extracts derived from tobacco products and containing a range of tobacco constituents might more accurately simulate tobacco exposure in humans.

OBJECTIVE

To compare the effects of nicotine alone and an aqueous smokeless tobacco extract in several addiction-related animal behavioral models.

METHODS

Nicotine alone and nicotine dose-equivalent concentrations of extract were compared in terms of their acute effects on intracranial self-stimulation (ICSS) thresholds, discriminative stimulus effects, and effects on locomotor activity.

RESULTS

Similar levels of nicotine and minor alkaloids were achieved using either artificial saliva or saline for extraction, supporting the clinical relevance of the saline extracts used in these studies. Extract produced reinforcement-enhancing (ICSS threshold-decreasing) effects similar to those of nicotine alone at low to moderate nicotine doses, but reduced reinforcement-attenuating (ICSS threshold-increasing) effects at a high nicotine dose. In rats trained to discriminate nicotine alone from saline, intermediate extract doses did not substitute for the training dose as well as nicotine alone. Locomotor stimulant effects and nicotine distribution to brain were similar following administration of extract or nicotine alone.

CONCLUSIONS

The reinforcement-attenuating and discriminative stimulus effects of nicotine delivered in an extract of a commercial smokeless tobacco product differed from those of nicotine alone. Extracts of tobacco products may be useful for evaluating the abuse liability of those products and understanding the role of non-nicotine constituents in tobacco addiction.