A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy

Does cannabis and electronic nicotine delivery system (ENDS) use interfere with cigarette smoking cessation in young adulthood?

AIMS

Reducing combustible cigarette smoking is a major public health concern. Research identifies both electronic nicotine delivery systems (ENDS) and cannabis use as factors that are related to combustible cigarette cessation. The current study examined whether using substances in similar ways (e.g., inhaling them) triggers the urge to smoke, thereby undermining attempts to quit.

DESIGN

Analyses examined how using ENDS and smoking or vaping cannabis, both separately and together, were associated with reductions in daily combustible cigarette smoking among young adult smokers.

PARTICIPANTS

Three waves of data from the Community Youth Development Study, including 909 participants who reported daily cigarette smoking at age 23, 26, and/or 28, were included in analyses.

SETTING

Participants were dispersed throughout 48 US states.

MEASUREMENTS

Latent growth modeling was used to model daily cigarette smoking over time. Models using past-month ENDS use, past-month smoking/vaping cannabis, and past-month co-use of ENDS and cannabis (using ENDS and smoking/vaping cannabis within the past month) as time-varying covariates were tested.

FINDINGS

Over time, there was a tendency towards cessation of daily combustible cigarette use among this smoking sample. Smoking/vaping cannabis was associated with a decreased rate of daily combustible cigarette cessation among the sample, whereas ENDS use was associated with an increased rate of daily smoking cessation. The predicted additive effect of using ENDS and smoking/vaping cannabis was not significant.

CONCLUSIONS

Among young adult daily cigarette smokers, smoking cannabis, on its own, poses a risk to quitting combustible cigarettes, while using ENDS may promote cigarette cessation, possibly through substitution.

Vaping and Smoking Cessation

BACKGROUND

Electronic cigarettes (e-cigarettes) or vaping address a significant unmet need for traditional smokers who are endeavoring to quit this practice.

OBJECTIVES

We conducted an extensive PubMed search to review the studies involving e-cigarettes as an ostensibly healthier alternative to cigarette smoking and an approach to smoking cessation.

RESULTS

E-cigarettes are potentially carcinogenic, may confer severe cardiopulmonary symptoms and are inconclusively effective at occasioning smoking cessation; hence, consumers should be circumspect when considering this inhalation practice, especially vulnerable populations (e.g., teenagers and young adults) who may exhibit a greater proclivity to adopting this lifestyle choice.

CONCLUSIONS

Since the smoking cessation results are equivocal and the long-term safety and addictive nature of nicotine-containing e-cigarettes remain concerning, the use of e-cigarettes should be inadvisable until proven otherwise.

How can engagement with underserved communities be enhanced? A co-inquiry informed model of stop smoking outreach

AIMS

This co-inquiry project aimed to develop a qualitatively informed model of professionally led stop smoking outreach. It involved 13 staff from a Stop Smoking Service (SSS) which operates across three Local Authorities in England (Central Bedfordshire, Bedford Borough and Milton Keynes). Staff's outreach sought to engage people from the most deprived areas who smoked but were not engaging with the service.

METHODS

The co-inquiry comprised six reflection sessions and ethnographic research which aimed to explicate and examine staff's assumptions about how outreach works, conducted over 12 months. Data included 32 diary entries, eight observations of staff's outreach events, 10 interviews with staff and eight interviews with members of the communities being targeted. Data were reflected on to develop a 'real-world' logic model and summarised using thematic analysis.

RESULTS

Professionally led outreach can raise awareness of service offers, remove access barriers and generate referrals. A non-judgemental, person-centred approach is vital through which staff carefully initiate conversations with community members about smoking, and tailor information to community members' needs and preferences. Such an approach, in combination with an e-cigarette support option, can generate interest in SSS and challenge negative perceptions. However, outreach is time-consuming for busy frontline staff, unpredictable and best implemented via effective community partnerships.

CONCLUSIONS

Our findings suggest that stop smoking advisors' outreach can contribute substantially to national ambition to create a 'smoke free generation' provided that sufficient investment is provided. Professionally led outreach, delivered in partnership with community organisations, can generate referrals among people who are disconnected from health services. Such non-traditional referral routes are likely to become more significant as smoking prevalence further declines in the general population.

Cigarette Smoking Relapse Among People Who Switched to E-cigarettes or Other Tobacco Products

INTRODUCTION

Little is known about how quitting and switching to other tobacco products affects cigarette smoking relapse. Additionally, there is no consensus on the best definition of relapse.

AIMS AND METHODS

Respondents who smoked cigarettes at baseline, had quit by the first follow-up, and completed the second follow-up survey in the Population Assessment of Tobacco and Health Study were included. We employed multivariable logistic regressions to assess the association between non-cigarette tobacco use at follow-up 1 and smoking relapse risk at follow-up 2, considering three definitions of relapse.

RESULTS

54.8% of the 1686 respondents who had recently quit smoking cigarettes relapsed according to Measure I (any smoking in the past 12 months), 40.3% using Measure II (any smoking in the past 30 days), and 30.1% using Measure III (smoked on ≥3 days in the past 30 days). Compared with no tobacco use at follow-up 1, any tobacco use was associated with increased relapse risk using Measure I (adjusted risk difference [aRD] = 7.14, CI [0.64 to 13.64]). The association was nonsignificant using Measures II (aRD = -0.53, CI [-6.62 to 5.56]) or III (aRD = -4.11, CI [-9.28 to 1.06]). Similarly, exclusive e-cigarette use was significantly associated with Measure I, but not with Measures II or III.

CONCLUSIONS

Compared with respondents who had recently quit and were tobacco-free at follow-up 1, those who switched to non-cigarette tobacco products may be more likely to slip but showed no difference in the likelihood of relapse when employing a relapse definition less strict than any smoking in the past 12 months.

IMPLICATIONS

The distinction between a slip and relapse needs to be considered more carefully, with researchers undertaking further studies that help us contemplate how we should define relapse. People who recently quit smoking cigarettes and switched to non-cigarette tobacco products (including e-cigarettes) may be more likely to slip compared to people who recently quit and were tobacco-free, but they are not clearly more likely to relapse.

Next-generation immunotherapeutic strategy and clinical advances of vaccines against nicotine addiction

Smoking causes death of millions of people every year. However, available therapies for nicotine addiction are partially effective and exhibit frequent side effects. Thus vaccines targeted at drug nicotine not brain offer a promising strategy to treat nicotine addiction. They cannot pass blood-brain barrier, avoiding serious side effects relevant with central nervous system. The specific nicotine antibody produced by vaccines would convert to complex after combined with nicotine in serum, decreasing or even blocking the distribution of nicotine in brain. This review summarizes the pre-clinical and clinical advances of nicotine vaccines and then addresses future directions of nicotine vaccine and the practical aspects of deployments.

Patterns of Use of e-Cigarettes and Their Respiratory Effects: A Critical Umbrella Review

E-cigarettes (ECs) are a well-established consumer product. To study their respiratory health effects, there is the issue of heterogenous patterns of use: concurrently with cigarette smoking (dual use), exclusive use after smoking cessation (exclusive use), or use initiated without any prior or current use of cigarettes (naïve use). Our primary goal was to synthesize the evidence on the respiratory effects of ECs use in adults, categorized by their pattern of use. Additionally, we identified the highest quality systematic reviews and critically evaluated the current literature on this topic. The review was developed with published umbrella review guidelines. The database searches were Medline, Scopus, Cochrane, Epistemonikos, LILACS, and grey literature databases. The criterion for inclusion of systematic reviews was analyses of respiratory tests from randomized controlled trials or cohort studies. Quality assessments were performed with AMSTAR2 and a checklist of reporting biases. A narrative analysis was synthesized by test method: spirometry, impulse oscillometry, breath gasses, biomarkers, and clinical serious adverse events. Twelve systematic reviews were included. The findings on respiratory functioning were statistically non-significant across all patterns of use. Reporting bias was frequently observed. Based on the current research, there is no evidence of significant change in the short or medium term in respiratory function with any pattern of ECs use. We attribute the null findings to the weaknesses of acute studies, the participants' smoking history masking testing, and the inclusion of participants with a low frequency of use.

Knowledge and Perceptions of Dentists Regarding E-Cigarettes: Implications for Oral Health and Public Awareness and Education

Background/Objectives: The rising popularity of e-cigarette use is creating new challenges for oral healthcare. Factors such as targeted marketing, appealing flavors, and the perception that e-cigarettes are a safer alternative to traditional smoking have contributed to their widespread adoption. This trend is particularly prevalent among young adults and teenagers, many of whom turn to e-cigarettes despite having no prior history of regular cigarette use. This study aimed to evaluate dentists' knowledge and perceptions regarding e-cigarettes, focusing on their health effects, regulatory status, and potential risks to oral health. Assessing dentists' knowledge of e-cigarette risks is important, as they guide patients on the potential oral health dangers of vaping. E-cigarette use has been linked to several oral health problems. Methods: A cross-sectional survey was conducted among 189 dentists in Kosovo, comprising both general dentists and specialists. The questionnaire assessed participants' awareness of e-cigarettes' FDA approval status, their perceptions of health impacts, and their understanding of e-cigarettes' association with oral conditions such as caries, periodontal disease, and oral cancer. Data were analyzed using SPSS 22, with significance set at p < 0.05. Results: The findings revealed significant knowledge gaps, with 74.1% of respondents being uncertain about the FDA approval status of e-cigarettes and 82.0% recognizing their harmful effects on general and oral health. Nearly half (49.7%) of the participants identified e-cigarettes as a potential risk factor for caries, while 66.1% and 64.6% associated their use with oral cancer and periodontal disease, respectively. Gender and professional specialization did not significantly influence these perceptions. Conclusions: Dentists need better education on the risks of e-cigarette use, including their harmful effects on oral health. Incorporating this knowledge into dental curricula and professional training is essential to give dentists the information needed to advise patients effectively. Raising public awareness through dental health professionals can help mitigate the oral health risks associated with e-cigarettes.

What Do We Know About the Harms of Electronic Cigarettes?

Electronic cigarettes are commonly misperceived as safe, hence the importance of health care providers understanding the harms of these devices. To date, there is substantial evidence of impaired immune defenses leading to increased risk for severe infections. Electronic cigarette users have increased respiratory symptoms, including bronchitis, cough, and wheeze. There is evidence of emphysema from electronic cigarette use in both laboratory mouse studies and population health surveys. There is evidence of increased cardiovascular disease from electronic cigarettes in both laboratory mouse models and population health surveys. There have been many cases of acute severe lung disease leading to hospitalization and death in electronic cigarette users; although most cases reported were associated with vitamin E acetate in tetrahydrocannabinol-containing products, some cases report exclusive use of nicotine-containing electronic cigarettes. Recently, constrictive bronchiolitis has been found in lung biopsies of electronic cigarette users with dyspnea. There are multiple carcinogenic chemicals in electronic cigarette emissions. Mouse models demonstrate increased rates of lung cancer and carcinogenic chemicals accumulate in the urine of human users. Neurotoxicity has been demonstrated in laboratory mouse models. There is concern about nicotine exposure adversely impacting brain development and serving as a gateway drug for other harmful drug use. Dual use of electronic and combustible cigarettes appears to be more harmful than the use of combustible cigarettes alone. Conclusion: Electronic cigarettes have substantial harms and are not a safe alternative to combustible tobacco use. It is important for health care providers to know these harms and counsel their patients.

Disposable e-cigarette use: Factors, frequency and cigarette smoking among United States high school students

BACKGROUND AND AIMS

Disposable e-cigarette use has increased among United States (US) high school students in recent years. However, there is limited research on the profile of these users, how often they use these products, and whether they displace cigarette smoking. This study aimed to measure how disposable e-cigarette use among US youth varies according to demographic characteristics and whether there is any association between e-cigarette use and reduced use of traditional cigarettes.

DESIGN

We used cross-sectional data from the 2022 National Youth Tobacco Survey and conducted a multinomial logistic regression to examine factors associated with the types of e-cigarette devices used in the prior 30 days, adjusting for sex, sexual identity, grade level and race/ethnicity. We also used a finite mixture model to account for unobserved differences among users and identify e-cigarette use patterns in different subgroups of users.

SETTING

United States.

PARTICIPANTS

High school students in grades 9-12 (n = 14 389).

MEASUREMENTS

Survey participants self-reported the type of e-cigarette device used, the frequency of e-cigarettes used and cigarettes smoked over the past 30 days.

FINDINGS

Disposable e-cigarettes were the most popular e-cigarette type. Sex, sexual orientation, grade level and race/ethnicity were associated with disposable e-cigarette use. The odds of disposable e-cigarette use were lower in male students than in female students (odds ratio [OR] = 0.78, 95% confidence interval [CI] = [0.64-0.96]), and higher in students who identified as gay or lesbian (OR = 1.70, 95% CI = [1.11-2.61]) or bisexual (OR = 1.52, 95% CI = [1.16-1.99]) than in heterosexual students. The odds of disposable use were higher among students in higher grades (10th, 11th and 12th) than in 9th graders (OR = 1.71, 2.24 and 2.52, respectively). Disposable e-cigarette users had a lower frequency of traditional cigarette use than other e-cigarette users, both in the low-frequency class (incidence rate ratio [IRR] = 0.33, 95% CI = [0.12-0.92]) and the high-frequency class (IRR = 0.27, 95% CI = [0.08-0.92]).

CONCLUSIONS

Disposable e-cigarette use appears to be higher among United States high school students who are female, older and/or identify as gay, lesbian or bisexual. Disposable e-cigarettes appear to be associated with reduced traditional cigarette use.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

A Pilot Study to Test the Feasibility of a Randomized Controlled Trial of E-cigarettes as Harm Reduction Tools Among People Who Smoke and Previously Failed to Quit With Pharmacotherapy

INTRODUCTION

We conducted a pilot study to test the feasibility of a future randomized controlled trial comparing e-cigarettes to traditional pharmacotherapy among people who smoke daily, were motivated to quit, and failed to quit within the past 5 years using pharmacotherapy.

AIMS AND METHODS

Eligible participants were assigned to either: (1) an e-cigarette (n = 20) or (2) combination nicotine replacement therapy (NRT; patches and lozenges; n = 10). Participants received 5 weeks of product and selected a quit date 1 week later. Assessments were completed weekly, and electronic diaries were completed each day. As a pilot randomized controlled trial, outcomes focus on effect sizes and not statistical significance.

RESULTS

Participants in the e-cigarette and NRT groups had a mean age of 51 (SD = 13) and 50 (SD = 10) years old, were 55% and 60% female, and were 15% and 0% nonWhite, respectively. At least 90% of participants completed each weekly assessment and 77% of participants completed at least 80% of daily diaries. Mean cigarettes smoked per day reduced from 18 (SD = 6.2) to 2.4 (SD = 4.4) per day in the e-cigarette group and 16.5 (SD = 8.5) to 4.9 (SD = 5.9) per day in the NRT group. Rates of biochemically confirmed 7-day point-prevalence abstinence at the end of treatment were numerically, but not statistically, higher in the e-cigarette group than the NRT group (35% vs. 10%, OR = 4.8, 95% CI = 0.5 to 46.5).

CONCLUSIONS

Among current daily cigarette smokers who have previously tried to quit and failed with standard pharmacotherapies, the provision of an e-cigarette is a feasible intervention. A larger adequately powered trial is warranted.

IMPLICATIONS

This pilot study suggests that e-cigarettes may serve as an acceptable harm reduction intervention for people who smoke but cannot quit smoking with traditional pharmacotherapy, however, adequately powered randomized controlled trials are needed.

Cost-Effectiveness Analysis of E-cigarettes Compared to Nicotine Replacement Therapy for Smoking Cessation Among Medicaid Users in California

INTRODUCTION

Smoking is the leading preventable cause of death and disability in the United States. A 2019 randomized controlled trial found e-cigarettes are more effective than nicotine replacement therapy (NRT) in achieving abstinence when both are combined with behavioral counseling. Few cost-effectiveness studies have been performed regarding e-cigarettes as an adjunct to cessation efforts, and none in a U.S. context. This study evaluated the cost-effectiveness of e-cigarettes compared to NRT, both with counseling, and as cessation aids for Medicaid smokers in California.

AIMS AND METHODS

A cost-effectiveness analysis from a U.S. societal perspective comparing e-cigarettes with NRT was constructed. Using a lifetime horizon, smokers were followed to different health states to their expected lifespan. Costs were expressed in 2020 U.S. dollars and health outcomes in quality-adjusted life years (QALY). All costs and outcomes were discounted at a 3% annual rate and model findings were assessed with a series of sensitivity analyses.

RESULTS

Using U.S. willingness-to-pay thresholds, e-cigarettes were more cost-effective than NRT, with an incremental cost-effectiveness ratio of $11 454 per additional QALY gained over smokers' lifetimes. Results were sensitive to smokers' healthcare costs, model start ages, discount rates, and QALY weights.

CONCLUSIONS

E-cigarettes used as a cessation treatment by smokers are more cost-effective relative to NRT. However, e-cigarettes as a treatment are currently unapproved by the Food and Drug Administration (FDA). Despite the lack of FDA approval, e-cigarettes are a popular choice among smokers trying to quit. Policymakers should consider whether providing financial support for e-cigarettes as a harm reduction strategy is worth pursuing.

IMPLICATIONS

As e-cigarettes grow in popularity and are an increasingly preferred choice of smoking cessation aid among smokers attempting to quit, it is important to examine the inclusion of these products in tobacco policy, research, and practice. Several countries have now adopted or are in the process of adopting e-cigarettes as a medically licensed and regulated smoking cessation aid. Future smoking cessation strategies by U.S. policymakers may consider the adoption of e-cigarettes as a cost-effective harm reduction tool for use by current smokers seeking to quit.

Acute Effects of Nicotine on Non-Drug-Related Reward in Smokers and Non-Smokers

INTRODUCTION

Nicotine increases the reward value of non-drug-related stimuli in animals and dependent smokers; however, research on people who are not dependent on nicotine is limited. This study aimed to explore whether nicotine delivered by oral spray can enhance responding to self-selected sensory rewards in both smokers and non-smokers.

AIMS AND METHODS

Minimally abstinent smokers (n = 30) and non-smokers (n = 31) completed subjective ratings of nicotine withdrawal, and received either 2 mg nicotine or placebo oral spray and visual analogue scales to measure the perceived effects of the spray. An operant conditioning task (Applepicker) that required button clicks to find apples was completed twice, with and without a reward of 30 seconds of pre-prepared music for each reinforcer earned. Measures taken were the number of apples found (reinforcers), number of clicks (responses), and time spent on the task (in seconds).

RESULTS

There were no differences between smokers and non-smokers on ratings of nicotine withdrawal or effects of the spray. All participants spent longer searching for apples, earned more reinforcers, and produced more responses when listening to music. Nicotine administration led to a higher number of reinforcers earned and, when music was playing, an increase in a number of responses. A three-way interaction revealed that non-smokers who had received nicotine spent the longest searching for apples.

CONCLUSIONS

Nicotinic enhancement of sensory rewards was seen in non-smokers only which cannot be accounted for by learned associations with nicotine or reversal of withdrawal effects. Smokers, however, may require higher doses of nicotine to achieve the same effect.

IMPLICATIONS

Nicotinic enhancement of sensory rewards was demonstrated in non-smokers, but not in everyday smokers, suggesting it is unlikely to be related to nicotine dependence or learned associations between nicotine and pleasure. The absence of this effect in smokers suggests that higher levels of nicotine than those obtained from 2 mg oral sprays may be required to achieve enhancement of reward in people who regularly consume nicotine. For nicotine replacement (including e-cigarettes) to become more effective at reducing anhedonia during quit attempts, smokers may require nicotine doses that more closely replicate levels achieved through smoking.

Trends in use of cigarettes and e-cigarettes among young adults who had smoked in adolescence: 2017-2022

BACKGROUND

This study considers recent trends in combustible and e-cigarette use among US young adults who smoked cigarettes in adolescence, who are the originating source of most adults who smoke.

METHODS

Data come from the Monitoring the Future study, which includes young adults aged 19-30 who were first surveyed in 12th grade as part of a nationally-representative sample. The analysis centres on 3623 observations from 2377 young adults surveyed from 2017 to 2022 who reported they had ever smoked a combustible cigarette in the initial, 12th grade survey.

RESULTS

Among young adults who had smoked in adolescence, the percentage who used a combustible cigarette currently (in the past 30 days) significantly declined from 45% in 2017-2018 to 35% in 2021-2022. The percentage who currently used nicotine hovered around 50%, as measured by current use of an e-cigarette or combustible cigarette and this percentage did not significantly trend over the study period. The percentage who currently used e-cigarettes exclusively and not combustible cigarettes tripled from 6% in 2017-2018 to 21% in 2021-2022. About half of this exclusive e-cigarette group deliberately used e-cigarettes to quit combustible cigarettes, in all years. Dual use of both e-cigarettes and combustible cigarettes significantly increased from 11% in 2017-2018 to 17% in 2021-2022. Trends were robust in multivariable regression analyses that controlled demographics.

CONCLUSION

Among young adults who had smoked in adolescence, a 10-point decline in cigarette prevalence from 2017 to 2022 coincided with a 7-point increase in the percentage who deliberately used e-cigarettes to quit combustible cigarettes.

Electronic cigarettes for smoking cessation

BACKGROUND

Electronic cigarettes (ECs) are handheld electronic vaping devices that produce an aerosol by heating an e-liquid. People who smoke, healthcare providers, and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review.

OBJECTIVES

To examine the safety, tolerability, and effectiveness of using EC to help people who smoke tobacco achieve long-term smoking abstinence, in comparison to non-nicotine EC, other smoking cessation treatments, and no treatment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 February 2024 and the Cochrane Tobacco Addiction Group's Specialized Register to 1 February 2023, reference-checked, and contacted study authors.

SELECTION CRITERIA

We included trials randomizing people who smoke to an EC or control condition. We included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report an eligible outcome.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. We used the risk of bias tool (RoB 1) and GRADE to assess the certainty of evidence. Critical outcomes were abstinence from smoking after at least six months, adverse events (AEs), and serious adverse events (SAEs). Important outcomes were biomarkers, toxicants/carcinogens, and longer-term EC use. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in pairwise and network meta-analyses (NMA).

MAIN RESULTS

We included 90 completed studies (two new to this update), representing 29,044 participants, of which 49 were randomized controlled trials (RCTs). Of the included studies, we rated 10 (all but one contributing to our main comparisons) at low risk of bias overall, 61 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. Nicotine EC results in increased quit rates compared to nicotine replacement therapy (NRT) (high-certainty evidence) (RR 1.59, 95% CI 1.30 to 1.93; I2 = 0%; 7 studies, 2544 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6 more). The rate of occurrence of AEs is probably similar between groups (moderate-certainty evidence (limited by imprecision)) (RR 1.03, 95% CI 0.91 to 1.17; I2 = 0%; 5 studies, 2052 participants). SAEs were rare, and there is insufficient evidence to determine whether rates differ between groups due to very serious imprecision (RR 1.20, 95% CI 0.90 to 1.60; I2 = 32%; 6 studies, 2761 participants; low-certainty evidence). Nicotine EC probably results in increased quit rates compared to non-nicotine EC (moderate-certainty evidence, limited by imprecision) (RR 1.46, 95% CI 1.09 to 1.96; I2 = 4%; 6 studies, 1613 participants). In absolute terms, this might lead to an additional three quitters per 100 (95% CI 1 to 7 more). There is probably little to no difference in the rate of AEs between these groups (moderate-certainty evidence) (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 840 participants). There is insufficient evidence to determine whether rates of SAEs differ between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 9 studies, 1412 participants; low-certainty evidence). Compared to behavioural support only/no support, quit rates may be higher for participants randomized to nicotine EC (low-certainty evidence due to issues with risk of bias) (RR 1.96, 95% CI 1.66 to 2.32; I2 = 0%; 11 studies, 6819 participants). In absolute terms, this represents an additional four quitters per 100 (95% CI 3 to 5 more). There was some evidence that (non-serious) AEs may be more common in people randomized to nicotine EC (RR 1.18, 95% CI 1.10 to 1.27; I2 = 6%; low-certainty evidence; 6 studies, 2351 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 0.93, 95% CI 0.68 to 1.28; I2 = 0%; 12 studies, 4561 participants; very low-certainty evidence). Results from the NMA were consistent with those from pairwise meta-analyses for all critical outcomes. There was inconsistency in the AE network, which was explained by a single outlying study contributing the only direct evidence for one of the nodes. Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons; hence, evidence for these is limited, with CIs often encompassing both clinically significant harm and benefit.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care or no treatment also suggests benefit, but is less certain due to risk of bias inherent in the study design. Confidence intervals were, for the most part, wide for data on AEs, SAEs, and other safety markers, with no evidence for a difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT, but low-certainty evidence for increased AEs compared with behavioural support/no support. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but longer, larger studies are needed to fully evaluate EC safety. Our included studies tested regulated nicotine-containing EC; illicit products and/or products containing other active substances (e.g. tetrahydrocannabinol (THC)) may have different harm profiles. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

Literacy among tobacco users and healthcare professionals about tobacco harm reduction strategies: a scoping review protocol

Objective

The proposed review identifies and describes the extent of Tobacco Harm Reduction (THR) strategies in Pakistan. It also examines the awareness and understanding of these strategies among healthcare professionals and tobacco users in Pakistan.

Introduction

Tobacco consumption poses a significant threat to human health and is a leading cause of non-communicable diseases. Over the last two decades, the prevalence of tobacco use has increased in low-and middle-income countries (LMICs), which has considerably contributed to the increasing prevalence of Non-Communicable Diseases (NCDs). Tobacco is consumed in various forms, including manufactured cigarettes, hookah/shisha, chewing tobacco, and dipping tobacco. Tobacco use can be reduced and prevented through various strategies adopted by many countries worldwide. One prominent strategy is THR. THR involves the use of safer nicotine products in recommended doses to cope with the symptoms of withdrawal and increase tobacco users' chances of quitting smoking. In Pakistan, the concept of tobacco harm reduction (THR) is not widely recognized by healthcare professionals and tobacco users.

Inclusion and exclusion criteria

Literature available on Pakistani adults and adolescents (aged 13 years and above) will be included. Literature available as free full text will be included regardless of the publication date. Furthermore, literature available in English or Urdu will be considered eligible. Also, literature available in any form of publication, such as research studies, reviews, organizational websites or blogs, will be considered eligible. Literature that includes Pakistani data mixed with data from any other country will be excluded.

Methods

The literature search will use PubMed, CINAHL, ProQuest Theses & Dissertations, EBSCO Dentistry and Oral Sciences, and PsycInfo databases for online and gray literature. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram will record the included and excluded literature. Two independent reviewers will screen all the retrieved literature. After confirming the eligibility criteria, data from included records will be extracted on an Excel sheet that will record the important characteristics of the literature source and the main findings. Meta-synthesis of collated data will be performed, and the results will be presented as narrative summaries and frequency tables.

Systematic review registration

https://osf.io/dashboard.

Differences in the effectiveness of individual-level smoking cessation interventions by socioeconomic status

BACKGROUND

People from lower socioeconomic groups are more likely to smoke and less likely to succeed in achieving abstinence, making tobacco smoking a leading driver of health inequalities. Contextual factors affecting subpopulations may moderate the efficacy of individual-level smoking cessation interventions. It is not known whether any intervention performs differently across socioeconomically-diverse populations and contexts.

OBJECTIVES

To assess whether the effects of individual-level smoking cessation interventions on combustible tobacco cigarette use differ by socioeconomic groups, and their potential impact on health equalities.

SEARCH METHODS

We searched the Cochrane Database of Systematic Reviews from inception to 1 May 2023 for Cochrane reviews investigating individual-level smoking cessation interventions. We selected studies included in these reviews that met our criteria. We contacted study authors to identify further eligible studies.

SELECTION CRITERIA

We included parallel, cluster or factorial randomised controlled trials (RCTs) investigating any individual-level smoking cessation intervention which encouraged complete cessation of combustible tobacco cigarette use compared to no intervention, placebo, or another intervention in adults. Studies must have assessed or reported smoking quit rates, split by any measure of socioeconomic status (SES) at longest follow-up (≥ six months), and been published in 2000 or later.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening, data extraction, and risk of bias assessment. We assessed the availability of smoking abstinence data by SES in lieu of selective reporting. The primary outcome was smoking cessation quit rates, split by lower and higher SES, at the longest follow-up (≥ six months). Where possible, we calculated ratios of odds ratios (ROR) with 95% confidence intervals (CIs) for each study, comparing lower to higher SES. We pooled RORs by intervention type in random-effects meta-analyses, using the generic inverse-variance method. We subgrouped by type of SES indicator and economic classification of the study country. We summarised all evidence in effect direction plots and categorised the intervention impact on health equality as: positive (evidence that the relative effect of the intervention on quit rates was greater in lower rather than higher SES groups), possibly positive, neutral, possibly neutral, possibly negative, negative, no reported statistically significant difference, or unclear. We evaluated certainty using GRADE.

MAIN RESULTS

We included 77 studies (73 from high-income countries), representing 127,791 participants. We deemed 12 studies at low overall risk of bias, 13 at unclear risk, and the remaining 52 at high risk. Included studies investigated a range of pharmacological interventions, behavioural support, or combinations of these. Pharmacological interventions We found very low-certainty evidence for all the main pharmacological interventions compared to control. Evidence on cytisine (ROR 1.13, 95% CI 0.73 to 1.74; 1 study, 2472 participants) and nicotine electronic cigarettes (ROR 4.57, 95% CI 0.88 to 23.72; 1 study, 989 participants) compared to control indicated a greater relative effect of these interventions on quit rates in lower compared to higher SES groups, suggesting a possibly positive impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring higher SES groups. There was a lower relative effect of bupropion versus placebo on quit rates in lower compared to higher SES groups, indicating a possibly negative impact on health equality (ROR 0.05, 95% CI 0.00 to 1.00; from 1 of 2 studies, 354 participants; 1 study reported no difference); however, the CI included the possibility of no clinically important difference. We could not determine the intervention impact of combination or single-form nicotine replacement therapy on relative quit rates by SES. No studies on varenicline versus control were included. Behavioural interventions We found low-certainty evidence of lower quit rates in lower compared to higher SES groups for print-based self-help (ROR 0.85, 95% CI 0.52 to 1.38; 3 studies, 4440 participants) and text-messaging (ROR 0.76, 95% CI 0.47 to 1.23; from 3 of 4 studies, 5339 participants; 1 study reported no difference) versus control, indicating a possibly negative impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring lower SES groups. There was very low-certainty evidence of quit rates favouring higher SES groups for financial incentives compared to balanced intervention components. However, the CI included the possibility of no clinically important difference and of favouring lower SES groups (ROR 0.91, 95% CI 0.45 to 1.85; from 5 of 6 studies, 3018 participants; 1 study reported no difference). This indicates a possibly negative impact on health equality. There was very low-certainty evidence of no difference in quit rates by SES for face-to-face counselling compared to less intensive counselling, balanced components, or usual care. However, the CI included the possibility of favouring lower and higher SES groups (ROR 1.26, 95% CI 0.18 to 8.93; from 1 of 6 studies, 294 participants; 5 studies reported no difference), indicating a possibly neutral impact. We found very low-certainty evidence of a greater relative effect of telephone counselling (ROR 4.31, 95% CI 1.28 to 14.51; from 1 of 7 studies, 903 participants; 5 studies reported no difference, 1 unclear) and internet interventions (ROR 1.49, 95% CI 0.99 to 2.25; from 1 of 5 studies, 4613 participants; 4 studies reported no difference) versus control on quit rates in lower versus higher SES groups, suggesting a possibly positive impact on health equality. The CI for the internet intervention estimate included the possibility of no difference. Although the CI for the telephone counselling estimate only favoured lower SES groups, most studies narratively reported no clear evidence of interaction effects.

AUTHORS' CONCLUSIONS

Currently, there is no clear evidence to support the use of differential individual-level smoking cessation interventions for people from lower or higher SES groups, or that any one intervention would have an effect on health inequalities. This conclusion may change as further data become available. Many studies did not report sufficient data to be included in a meta-analysis, despite having tested the association of interest. Further RCTs should collect, analyse, and report quit rates by measures of SES, to inform intervention development and ensure recommended interventions do not exacerbate but help reduce health inequalities caused by smoking.

E-Cigarette Use and Depression Among American Indian Adults Who Smoke

OBJECTIVE

This study examined the association of e-cigarette use status and history of depression among American Indian (AI) adults who smoke.

METHOD

We conducted a secondary data analysis using survey data from 375 AI adult smokers collected in 2016 at a tribally operated healthcare facility in northeast Oklahoma. Multivariable logistic regression was used to estimate the association between e-cigarette use and self-reported history of depression while adjusting for potential confounders.

RESULTS

In the adjusted analyses, compared to never users, current and former e-cigarette users had higher estimated odds of depression history (adj. OR 2.66; 95% CI 1.25-5.72 and adj. OR 2.38; 95% CI 1.36-4.26, respectively). Additional factors independently associated with a history of depression included having strong cravings to smoke (adj. OR 2.28; 95% CI 1.13-4.88) and having a history of chronic disease (adj. OR 2.09; 95% CI 1.20-3.70) after controlling for confounding variables.

CONCLUSIONS

E-cigarette use among AI adult smokers was independently associated with a history of depression. Whether e-cigarette use among people who smoke results from depression or whether depression results from the combined use of e-cigarettes and cigarettes requires future research using a prospective cohort design.

E-liquid flavors and nicotine concentration choices over 6 months after a smoking cessation attempt with ENDS: Secondary analyses of a randomized controlled trial

INTRODUCTION

Many tobacco smokers try to quit with electronic nicotine delivery systems (ENDS or e-cigarettes). We aimed to describe e-liquid flavors and nicotine concentration use over 6 months in a prospective cohort of smokers willing to quit with ENDS.

METHODS

We included 622 participants from the intervention group of the Efficacy, Safety and Toxicology of ENDS randomized controlled trial. Participants were adult smokers smoking at least five cigarettes a day. They received free ENDS and a choice of 6 e-liquid flavors in 4 nicotine concentrations and smoking cessation counseling. We tracked flavor choice and nicotine concentration at 1, 2, 4, and 8 weeks, and at 6 months, after the target quit date, comparing participants who reported only vaping (exclusive e-cigarette users) to those who vaped and smoked (dual users) over the last 7 days. We applied multivariable regression models to compute adjusted risk ratios (ARR).

RESULTS

At Week 1, 66% (n=409) were exclusive e-cigarette users, and 21% (n=129) were dual users. At Month 6, 43% (n=266) were exclusive e-cigarette users, and 16% (n=102) were dual users. While flavor choices were similar at Week 1, at 6 months, exclusive e-cigarette users reported using more fruity flavors than dual users (31% vs 22%, ARR=2.10; 95% CI: 1.21-3.66). The nicotine concentration used initially was similar in both groups and diminished over time. At 6 months, exclusive e-cigarette users used a lower mean nicotine concentration than dual users (6.3 vs 8.2 mg/mL, difference= -1.55; 95% CI: -2.84 - -0.25 mg/mL).

CONCLUSIONS

After 6 months, exclusive e-cigarette users used more fruity-flavored e-liquids and chose a lower mean nicotine concentration than dual users.

Differences in Pain Severity and Interference between Latinx Combustible Cigarette Smokers and Dual Users with Current Pain

Latinx individuals who smoke represent a tobacco health disparities group. Yet, limited research has focused on examining dual combustible and electronic cigarette use among Latinx populations. Importantly, Latinx persons who smoke also evince elevated rates of pain problems and symptoms and prior research has consistently linked pain problems and severity to smoking prevalence, maintenance, and behavior. Accordingly, the current study sought to build from the limited work that exists among dual combustible cigarette and electronic cigarette Latinx users comparing levels of pain severity and interference. The current sample consists of 196 adult Latinx daily cigarette smokers (35.48 years old; 39.4% female), of which 72 reported current daily dual use of an e-cigarette. Results indicated that Latinx dual users reported greater levels of pain severity (ηp2 = .12) and pain interference (ηp2 = .10) than exclusive combustible cigarette users. The study adds uniquely to the limited literature on the clinical importance of dual cigarette use in relation to pain severity and interference in that pain may serve as an important risk factor for the initiation and maintenance of dual use for increased analgesic nicotine effects.

Understanding stakeholder responses to the electronic cigarette flavor ban in China: A news media analysis

OBJECTIVES

Electronic cigarettes (e-cigarettes) have been attracting users around the world due in part to appealing flavors. Many countries and regions have now taken action to limit the sales of flavored e-cigarettes. In 2022, China implemented a flavor ban on e-cigarettes, prohibiting all but tobacco-flavor. It is important for international tobacco control efforts to understand responses to the ban by analyzing news media content.

STUDY DESIGN

Articles identified through keyword searches in the HuiKe newspaper database were qualitatively examined by thematic analysis, focusing on stakeholder reactions and regulatory impacts.

METHODS

Using HuiKe news database and searching between May 1, 2022, and March 1, 2023, 125 news articles were identified and coded using thematic analysis to explore the main stakeholders mentioned in relation to the e-cigarette flavor ban, actions undertaken, and perceptions expressed.

RESULTS

Four stakeholders were identified: administrative departments, businesses, users and the public. Eight themes were developed through analysis: the purpose of the prohibition, supervision and penalties for illegal products, approaches adopted for legal sales, approaches adopted for illegal sales, shifting use habits, speculation about the impact of the prohibition, health concerns, and suggestions for reducing illegal sales.

CONCLUSION

The study revealed that enforcement of the policy is portrayed as a significant concern and that controlling the spread of illegal online sales remains a significant challenge. A comprehensive regulatory strategy to address youth e-cigarette use more effectively is urgently needed. Adaptive e-cigarettes control policy should co-evolve with ever-changing industries and markets.

Prevalence and correlates of negative side effects from vaping nicotine: Findings from the 2020 ITC four country smoking and vaping survey

INTRODUCTION

This study examined prevalence and correlates of self-reported negative side effects from nicotine vaping product (NVP) use among people who currently or recently vape.

METHODS

This cross-sectional study analysed data from 3906 adults (aged 18+ years) from the 2020 ITC Four Country Smoking and Vaping Survey (Canada, US, England and Australia) who reported they had ever smoked cigarettes and were either currently vaping daily/weekly or had vaped in the last month. Participants were asked about experiencing and seeking medical advice for any negative side effects from vaping in the past month. Logistic regressions were used to estimate prevalence and identify correlates.

RESULTS

Overall, 87.1 % reported no negative side effects from vaping. The most common side effects were throat irritation (5.8 %), cough (5.5 %), and mouth irritation (4.1 %). The top two that led to seeking medical advice were: mouth irritation (46.8 %) and loss of taste (45.2 %). Those more likely to self-report side effects were younger, male, currently smoking (vs quit), vaping for <6 months (vs >1 year), using disposables or cartridges/pods (vs tanks), using vapes with nicotine (vs without nicotine), using menthol/mint flavour (vs sweet flavour), currently smoking (vs quit), believing vaping causes various diseases (e.g., heart disease), and believing that vaping is equally/more harmful than smoking.

CONCLUSION

Negative side effects associated with NVP use were rare and mainly minor in all four countries. Shorter duration of vaping, concurrent smoking while vaping and perceptions of greater vaping harms relative to smoking were associated with more reported negative side effects attributed to vaping.

Effect of nicotine mouth spray on urges to vape: A randomized, placebo-controlled, pharmacodynamic clinical trial in exclusive e-cigarette users

AIMS

To determine whether nicotine mouth spray provides rapid and prolonged relief of urges to vape and measure the steady-state plasma nicotine levels during vaping and ad libitum mouth spray usage in e-cigarette users.

DESIGN

Randomized, parallel group, double-blind trial.

SETTING

Single site at Hammersmith Medicines Research Ltd (HMR), London, UK.

PARTICIPANTS

216 (25.9% females, average age 27.6 ± 7.63 [standard deviation, SD]) exclusive vapers who used their e-cigarette within 30 minutes of waking up and had vaped about 2 years on average.

INTERVENTIONS

Two sprays of 1 mg nicotine mouth spray (Nicorette QuickMist Freshmint, n = 109), or placebo (identical in appearance and presentation, n = 107).

MEASUREMENTS

Urge to vape was rated on a 100 mm visual analogue scale before and repeatedly for 2 hours after administration. The primary outcome measured average change from baseline in urges to vape ratings during the first hour.

FINDINGS

Nicotine mouth spray achieved statistically significantly greater reductions in urges to vape than placebo from the first assessment point at 30 seconds to 1 hour, when the estimated mean treatment difference was 11.90 mm (95% confidence interval [CI] = 6.86-16.95, P < 0.001). The integrated urge to vape over 11 hours ad libitum usage showed a statistically significant benefit compared with placebo (2.00 [0.88 SD] vs 2.51 [0.84 SD], P < 0.001). Mean steady-state plasma nicotine concentrations were lower after nicotine mouth spray usage compared with vaping (6.22 [4.70 SD] ng/ml vs 9.91 [7.59 SD] ng/ml, respectively). Adverse events were more commonly reported in the nicotine mouth spray group and were mostly mild.

CONCLUSIONS

Among regular e-cigarette users, nicotine mouth spray provided statistically significant and fast relief of urges to vape one hour after dosing. Nicotine mouth spray showed statistically significant reductions in urges to vape as soon as 30 seconds and up to 2 hours after dosing compared with placebo, and nicotine mouth spray was well-tolerated and safe.

Examining e-cigarettes as a smoking cessation treatment: A critical umbrella review analysis

INTRODUCTION

This umbrella review identified the current high-quality systematic reviews on e-cigarettes as a smoking cessation aid. What is the comparative effectiveness of e-cigarettes compared to other cessation treatments or approaches? We also investigated the systematic reviews for reporting biases.

METHODS

This umbrella review was based on the Methods for Overviews of Reviews (MOoR) framework and the Preferred Reporting Items for Overviews of Reviews (PRIOR). The search was conducted in six databases and grey literature searches in four sources, plus four secondary searches. A Vote Counting Direction of Effect was selected for the analysis method because of high heterogeneity among the primary studies and the potential overweighting of data from two primary studies.

RESULTS

Sixteen systematic reviews were retrieved. Eight with an AMSTAR2 rating of moderate or high confidence were included, encompassing 24 randomized controlled trials. The analysis found that in 8 of 11 comparisons, e-cigarettes were more effective, and 3 of 11 comparisons reported no statistically significant difference. No reviews concluded that e-cigarettes were significantly less effective than any treatment or no treatment.

CONCLUSIONS

Our analysis indicated that e-cigarettes are more effective than other treatments for smoking cessation. For ENDS compared solely to NRT, the evidence was mixed and still favored the effectiveness of ENDS. In any case, the success rates for cessation with ENDS was 10 % - 12 % at 6 months to one year, and the effect of relapse has not been sufficiently studied. New treatments and approaches are urgently needed.

REGISTRATION

PROSPERO CRD42023406165; International Registered Report Identifier (IRRID): PRR1-10.2196/47711.

Functionally important respiratory symptoms and continued cigarette use versus e-cigarette switching: population assessment of tobacco and health study waves 2-6

Background

Substitution of noncombustible tobacco products for cigarettes could improve respiratory symptoms. We hypothesized that complete cigarette-to-e-cigarette switching would improve respiratory symptoms compared to continued smoking.

Methods

Longitudinal analysis of data from waves 2-6 (W2-W6; 2014-2021) of the Population Assessment of Tobacco and Health (PATH) Study, an observational cohort study that surveyed 5653 US adults ≥18 years without COPD/chronic bronchitis/emphysema. We compiled 14,947 two-wave (1-2 year) observations with persons who smoked cigarettes at baseline and compared the relation between functionally important respiratory symptoms and switching to exclusive e-cigarette use or quitting tobacco versus continued cigarette use (reference). A 9-point wheezing/nighttime cough index was dichotomized based on index scores of ≥2 or ≥3, previously associated with poorer functional health. Multivariable models assessed how changes in cigarette use predicted worsening/improvement of symptoms.

Findings

Among those with an index score <2, 3.5% switched to e-cigarettes, and 11.1% quit all tobacco. Functionally important respiratory symptoms worsened (≥2 at follow-up) in 15.4%, 10.0% and 10.1% of those who continued cigarettes, switched to e-cigarettes, and quit, respectively. Adjusted relative risk (RR) for respiratory symptom worsening was 0.69 (95% confidence interval (CI), 0.52, 0.91) for e-cigarette switching and 0.73 (95% CI, 0.54, 0.97) for quitting. Of persons with index score ≥2, 2.8% switched to e-cigarettes, and 6.7% quit. Respiratory symptoms improved (<2 at follow-up) in 27.7%, 45.8% and 42.1% of those who continued cigarettes, switched to e-cigarettes, and quit, respectively. The RR for improving was 1.31 (95% CI, 1.05, 1.64) for e-cigarette switching and 1.36 (95% CI, 1.15, 1.62) for quitting. The RRs for exclusive e-cigarette use with a cutoff of ≥3 for respiratory symptom worsening and improvement were not significant (0.74 [0.53, 1.05] and 1.20 [0.95, 1.51] respectively) but were significant in an unweighted analysis that included partial data for individuals lost to follow-up (0.74 [0.57, 0.95] and 1.21 [1.06, 1.39] respectively).

Interpretation

Switching completely from past 30-day use of cigarettes to e-cigarettes had short-term beneficial associations with functionally important respiratory symptoms similar to quitting tobacco completely.

Funding

This manuscript is supported with Federal funds from the National Institute on Drug Abuse (NIDA) at the National Institutes of Health (NIH), and the Center for Tobacco Products (CTP) at the Food and Drug Administration (FDA), Department of Health and Human Services, under contract to Westat (contract nos. HHSN271201100027C and HHSN271201600001C), and through an interagency agreement between NIH NIDA and FDA CTP. Heather L. Kimmel was substantially involved in the scientific management of and providing scientific expertise for contract nos. HHSN271201100027C and HHSN271201600001C.

Perceptions and intentions regarding IQOS among current US adults who use cigarettes and/or electronic nicotine delivery systems

INTRODUCTION

IQOS was sold in the US in 2019-2021 and will likely return in 2024. It is important to anticipate IQOS' market penetration; thus, this study examined US adults' prior awareness and perceptions, intentions to try and reactions to an IQOS reduced-risk exposure statement.

METHODS

61 adults from three US cities were recruited to represent four tobacco use subgroups: current cigarette and never electronic nicotine delivery systems (ENDS) use; current cigarette and discontinued ENDS use; current cigarette and ENDS use; and former cigarette use and switched to ENDS. Participants were shown IQOS marketing material and probed about IQOS awareness, knowledge, perceptions, use intentions and reactions to a reduced exposure statement. Analysis used a hybrid inductive/deductive qualitative approach.

RESULTS

Participants reported low awareness and knowledge of IQOS and uncertainty about its functionality and health effects. Other impressions varied by subgroup. People who currently smoked but never tried ENDS reacted mostly negatively to IQOS; people who had switched to ENDS were disinterested in returning to 'real tobacco' use; people who currently used cigarettes and ENDS were curious but had mixed feelings; and people who had rejected ENDS exhibited the greatest interest but were concerned about perceived cost. Reactions to the reduced exposure statement were mixed; some groups viewed it as a meaningful endorsement of harm reduction benefits while others were sceptical.

CONCLUSIONS

Across tobacco use groups, there was varied interest and inclination to try IQOS and thus varied potential use as a complete substitute for cigarettes.

Examining Differences in Real-World Effectiveness of e-Cigarettes for Smoking Cessation by Source of Purchase in England: An Observational Study of Different Contexts Before and After the COVID-19 Pandemic

INTRODUCTION

The effectiveness of e-cigarettes for smoking cessation may differ by source of purchase. The changing influence of self-selection on purchase location caused by COVID-19 pandemic-related vape shop closures means we can examine the association between smoking abstinence e-cigarette use by purchase source and test for the moderation of this association by the timing of the pandemic.

AIMS AND METHODS

Repeat-cross-sectional nationally representative surveys, conducted between January 2017 and August 2023. Participants (N = 1284; ≥18 years, 46.9% women) who made a past-year quit attempt, used an e-cigarette in their most recent attempt, currently vaping and provided data on the purchase source were included. The association between e-cigarette purchase source and continuous abstinence following the most recent quit attempt was assessed with adjusted regression, including an interaction between the timing of pandemic restrictions (March 2020 through January 2022).

RESULTS

Overall, 48.1% usually purchase their e-cigarettes from vape shops, declining from 53.6% prepandemic to 40.6% during the pandemic. There was inconclusive evidence that those purchasing from vape shops had greater odds of quitting smoking (ORadj = 1.25, 95% CI = .92 to 1.76). The association between purchase source and successful quitting did not depend upon whether purchasing occurred before or during the pandemic (F = 0.08, pinteraction = .774; prepandemic: ORadj = 1.23, 0.79-1.91; and pandemic: ORadj = 1.29, 0.81-2.06).

CONCLUSIONS

More data are needed to conclusively determine whether purchasing from a specialist vape shop increases smoking cessation. Given the changing influence of self-selection on purchase location caused by the pandemic, the similar associations between purchase source and quit success across both periods suggest it is unlikely an artifact of unmeasured confounding.

IMPLICATIONS

If purchasing e-cigarettes from a specialist vape shop can increase their effectiveness for smoking cessation is an empirical question. While we found a positive association between purchasing from a specialist vape shop and abstinence rates, the results were inconclusive. Further studies are required to establish whether purchasing from specialist vape shops improves smoking cessation outcomes compared with other purchase sources.

Parent perspectives on the design, implementation, and use of the parent E-cigarette and vaping educational resource (P-EVER)

Background

Adolescent use of e-cigarettes has been recognized as a significant public health concern as rates of adolescent vaping increase. As evidence of respiratory damage and other health concerns continue to emerge, educational resources for parents are critical in combating the vaping epidemic. A vaping educational tool can serve as a resource that parents of adolescents can reference to learn about e-cigarette use and how to address this topic with their families.

Objective

The purpose of this study was to examine parents' perspectives on the design and use of an educational infographic (Parent E-Cigarette and Vaping Educational Resource; P-EVER) to inform parents of adolescents and their families about e-cigarette use, risks, and quitting resources.

Methods

Parents who had an adolescent aged 12 to 18 years were recruited through community pharmacies in Wisconsin through recruitment fliers, emails, and word of mouth between February and June 2023. Participants reviewed the vaping educational handout in a semi-structured interview that was recorded and transcribed verbatim. Two members of the research team independently coded each transcript using NVivo software to conduct inductive thematic analysis. Bi-weekly meetings were held to refine codes, develop the master codebook, and identify prevalent themes (intercoder reliability - 0.83).

Results

Thirty-five parents were interviewed between February and June 2023. Four themes were identified: vaping awareness, P-EVER content and implementation, pharmacist's role, and barriers to pharmacist intervention on vaping. Participants believed the vaping educational handout was an effective resource for disseminating information to parents of adolescents. Responses highlighted the importance of providing educational resources to initiate conversations surrounding health risks to adolescents.

Conclusion

Pharmacists played a crucial role in successfully disseminating the P-EVER education tool to parents of adolescents. Future work is required to determine effective interventions for pharmacists and adolescents to discuss the topic of vaping awareness and safety.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Perceptions of nicotine vaping products among Australians living with HIV

People living with HIV (PLHIV) are two to three times more likely to smoke tobacco compared to the general community. Evidence from the general population suggests that nicotine vaping products (NVPs) can be acceptable and effective smoking cessation aids, but there is limited evidence on the extent to which this is the case among PLHIV. This manuscript reports findings from the Tobacco Harm Reduction with Vaporised Nicotine (THRiVe) trial, a mixed-methods study investigating the feasibility of NVPs as smoking cessation aids among 29 PLHIV who smoked tobacco. Surveys and semi-structured interviews explored participants' experiences and perceptions of NVPs, their features and functions, and support for various NVP regulatory policy options. Participants described seven reasons why NVPs were acceptable cessation aids: they satisfied nicotine cravings; differences between NVPs and cigarettes facilitated habit breaking; fewer adverse effects compared to traditional cessation aids; NVPs allowed for a "weaning process" rather than requiring abrupt abstinence; tobacco became increasingly unpleasant to smoke; NVPs provided an increased sense of control; and participants experienced a deeper understanding of personal smoking behaviours. This study provides valuable insight into the preferred features of NVPs among PLHIV and reasons why NVPs may be effective for promoting smoking cessation among PLHIV.

Prevalence and uptake of vaping among people who have quit smoking: a population study in England, 2013-2024

BACKGROUND

Vaping prevalence has increased rapidly in England since 2021. This study estimated trends between 2013 and 2024 in vaping among ex-smokers, overall and among those who did not use e-cigarettes to support their quit attempt.

METHODS

Data were collected via nationally-representative, monthly cross-sectional surveys in England, October 2013 to May 2024. We analysed data from 54,251 adults (≥ 18y) who reported having tried to stop smoking in the past year or having stopped smoking more than a year ago. Logistic regression estimated associations between time and e-cigarette use.

RESULTS

Across the period, there were increases in the use of e-cigarettes to support attempts to stop smoking (from 26.9% [24.0-30.0%] in October 2013 to 41.4% [37.7-45.2%] in May 2024), in current vaping among ≥ 1y ex-smokers (1.9% [1.5-2.5%] to 20.4% [18.7-22.2%]), and in late uptake of vaping after smoking cessation (i.e., current vaping among people who quit smoking before e-cigarettes started to become popular in 2011; 0.4% [0.2-0.8%] to 3.7% [2.8-4.9%]). These increases were non-linear, with much of the difference occurring since mid-2021, and were greatest at younger ages (e.g., current vaping among ≥ 1y ex-smokers reached 58.9% among 18-year-olds vs. 10.7% among 65-year-olds).

CONCLUSIONS

Vaping prevalence increased substantially among adult ex-smokers in England over the past decade, particularly at younger ages. While this is likely to have been largely driven by increased use of e-cigarettes in quit attempts and continued use thereafter, there was also evidence of increased uptake of vaping among those who had been abstinent from smoking for many years.

A comprehensive non-targeted approach for the analysis of biomarkers in exhaled breath across different nicotine product categories

In the context of the evolving landscape of nicotine consumption, the assessment of biomarkers plays a crucial role in understanding the health impact of different product categories. Exhaled breath (EB) emerges as a promising, non-invasive matrix for biomarker analysis, complementary to conventional urine and plasma data. This study explores distinctive EB biomarker profiles among users of combustible cigarettes (CC), heated tobacco products (HTP), electronic cigarettes (EC), smokeless/oral tobacco (OT), and oral/dermal nicotine products (NRT). We have successfully developed and validated a non-targeted GC-TOF-MS method for the analysis of EB samples across the aforementioned product categories. A total of 66 compounds were identified, with significantly elevated levels in at least one study group. The study found that CC users had higher levels of established VOCs associated with smoking, which supports the proof-of-concept of the method. Breathomic analysis identified increased levels of p-cymene and α-pinene in EC users, while HTP users showed potential biomarker candidates like γ-butyrolactone. This study underscores the utility of EB biomarkers for a comprehensive evaluation of diverse nicotine products. The unique advantages offered by EB analysis position it as a valuable tool for understanding the relationship between exposure and health outcomes.

E-cigarettes, synthetic nicotine, heated-tobacco and smokeless nicotine delivery products: the nicotine landscape beyond combustible cigarettes

Cigarette smoking remains an enormous public health problem causing millions of preventable deaths annually worldwide. Although safe and efficient smoking cessation pharmacotherapies such as nicotine replacement products and the medications varenicline and bupropion are available, long-term abstinence rates remain low and new approaches to help smokers successfully quit smoking are needed. In recent years, electronic nicotine delivery systems such as e-cigarettes and heated-tobacco products, and novel smokeless nicotine delivery products like nicotine pouches have gained widespread popularity. These products can deliver nicotine without combustion of tobacco and might thus present an alternative to the currently available smoking cessation methods if they prove able to help smokers quit smoking conventional cigarettes while decreasing their exposure to toxicants. In this narrative review, we provide a summary of the characteristics of these novel nicotine delivery products and the available data regarding their efficacy as smoking cessation tools and safety profile with a focus on the current situation in Switzerland.

[The role of vaping in smoking cessation]

The electronic cigarette, or vape, has emerged over the last ten years as an alternative way of helping people give up smoking. Tobacco-free, they produce vapor and deliver only minute levels of toxic substances and carcinogens. Several studies confirm the effectiveness of nicotine vaping products in helping people to stop smoking. This article examines the effectiveness of vaping in smoking cessation. It analyzes its advantages and disadvantages, and outlines the best conditions for its use.

Transitions between smoking and vaping: Evidence (or lack thereof) on potential differences by gender and sex

OBJECTIVE

To synthesize existing evidence on possible differential effects by sex and gender from two Cochrane reviews evaluating vaping and smoking transitions.

METHODS

We screened included studies from two Cochrane reviews for studies reporting smoking outcomes based on gender or sex. The first review examines the effects of using e-cigarettes to help people quit smoking and includes randomized controlled trials and uncontrolled intervention studies published to July 2023. The second review aims to assess the evidence on the relationship between the use and availability of e-cigarettes and subsequent smoking in young people (aged 29 and younger) and includes quasi-experimental and cohort studies published to April 2023. Due to the paucity and heterogeneity of data, we report results narratively.

RESULTS

10 of 161 studies included in the two relevant reviews met our criteria. Only five reported analyzing whether observed effects or associations varied based on sex and/or gender. A further three provided relevant descriptive information, and two did not report overall outcomes regarding vaping and smoking transitions but did investigate whether these differed by sex/gender. Synthesized data were largely inconclusive, but there was some suggestion that vaping was more strongly associated with subsequent smoking in young males than females. No studies reported data on nonbinary participants.

CONCLUSIONS

Despite plausible reasons why sex and gender may be moderators of vaping and smoking transitions, there is little evidence investigating this. Future studies of vaping and smoking transitions should conduct and report analyses investigating potential differences based on sex and gender.

Tobacco use disorder in patients with other mental disorders: a dual disorder perspective from clinical neuroscience

Tobacco smoking is the leading cause of disability and preventable deaths worldwide, but it should be differentiated from tobacco use disorder, which is, according to the Diagnostic and Statistical Manual of Mental Disorders, a bona fide mental disorder. The rapid delivery of nicotine to the brain activates acetylcholine receptors and stimulates the release of dopamine, both systems implicated in other mental disorders. Rates of tobacco use disorder are much higher among people suffering from other mental disorders and these patients find it more difficult to quit. Dual disorders, from a transdiagnostic perspective, identify patients with substance use disorder, in this case tobacco use disorder, and other mental disorders. A dual disorder is a complex clinical condition that is often underdiagnosed, undertreated, and difficult to manage. Appropriate and integrated tobacco use disorder treatment programs for people also suffering from other mental disorders could improve outcomes. Bio-psycho-social approaches to tobacco use disorder include specific biological treatments (e.g., bupropion, varenicline, cytisine, nicotine replacement therapy or deep trans-magnetic stimulation). However, these treatments don't have the same outcomes in patients with dual disorders. Therefore, as in other dual disorders, harm reduction measures, such as vaping nicotine through electronic cigarettes or tobacco replacement therapies should be considered as alternative tools for dual tobacco use disorder management. These clinical considerations emerge from a narrative literature review and expert consensus and will specifically address considerations for changes in clinical practice to improve the treatment of tobacco use disorder and other mental disorders.

Interactions between ENDS and cigarette use: evidence from a 2022 national telephone survey in South Africa

INTRODUCTION

Electronic nicotine delivery systems (ENDS) may serve as a cessation tool for people who smoke cigarettes. However, for people who do not smoke, ENDS may be a gateway to nicotine addiction and cigarette use. This paper aims to quantify these behaviours in South Africa.

METHODS

We analysed a nationally representative telephone survey of 21 263 South Africans living in urban areas. For those respondents who had used both products (N=771), we developed a typology that describes the sequence in which cigarette and ENDS initiation occurred. 'On-rampers' describe people who used ENDS first and later initiated cigarette smoking. 'Off-rampers' describe people who used cigarettes first, took up ENDS and later quit cigarettes while still using ENDS. 'Failed off-rampers' describe people who started using ENDS while smoking cigarettes but later quit using ENDS. 'Continuing dual consumers' describe people still using both products at the time of the interview.

RESULTS

Of the overall sample (N=21 263), 1.7% used or had used ENDS but had no history of using cigarettes. Of dual consumers (N=771), 8.8% were classified as 'on-rampers', 13.9% as 'off-rampers', 20.9% as 'failed off-rampers' and 56.4% as 'continuing dual consumers'. Roughly half of those classified as off-rampers, failed off-rampers or continuing dual consumers stated that they started using ENDS to help them quit cigarettes.

CONCLUSIONS

The typology reveals a multifaceted relationship between ENDS and cigarette use in South Africa. Policy interventions should aim to minimise on-ramping and maximise off-ramping. Given the high prevalence of continued dual use and failed off-ramping, targeted cessation support should be provided for people who use ENDS and are trying to quit cigarettes.

Impact of electronic cigarettes (e-cigs) and heat-not-burn/heated tobacco products (HnB/HTP) on asthma and chronic obstructive pulmonary disease: a viewpoint of the Italian Society of Internal Medicine

The association of cigarette smoking with several severe and very severe diseases (oncological, cardiovascular, respiratory) which have dramatic epidemiological, medical, and financial impact, is a well-known public threat. Asthma and chronic obstructive pulmonary disease (COPD) are highly prevalent diseases in Italy, posing significant public health challenges. Tobacco smoking, a primary risk factor for COPD and a common asthma trigger, remains a critical preventable public health issue. While universally acknowledged that quitting smoking drastically reduces the risk of smoking-related health issues, a significant portion of smokers and patients find quitting challenging or undesirable, hence a need for new ways to deal with it. A worth considering alternative might be the switch to electronic cigarettes (e-cig), and heat-not-burn/heated tobacco products (HnB/HTP). Emerging evidence suggests potential benefits in asthma and COPD management when transitioning from traditional smoking to e-cigs or HnB devices. However, the effectiveness of these products in facilitating smoking cessation is still debated, alongside concerns about their role in promoting smoking initiation among non-smokers. Internists are among the physicians who most frequently assist patients with smoking-related diseases, and in this perspective they cannot avoid paying attention to the progressive diffusion of smoking products alternative to the traditional cigarette, and to the controversies with respect to their use. In this context, the Italian Society of Internal Medicine, also recognizing a growing need for clarity for healthcare providers, has undertaken a comprehensive analysis of existing literature to offer an informed perspective on the health impact of e-cigs and HnB/HTP on asthma and COPD.

Predictors of attrition in a randomized controlled trial of an electronic nicotine delivery system among people interested in cigarette smoking reduction

BACKGROUND

Mitigating attrition is a key component to reduce selection bias in longitudinal randomized controlled trials (RCTs). Few studies of electronic nicotine delivery systems (ENDS) allow for the examination of long-term retention. This analysis explores the relationship between attrition, baseline measures, and condition assigned for a RCT involving ENDS differing in nicotine delivery over a 24-week intervention period.

METHODS

Participants (N = 520) who smoked ≥10 cigarettes per day [CPD] for ≥1 year and reported interest in reducing but not quitting were randomized to 1 of 4 conditions: an ENDS containing 0, 8, or 36 mg/ml liquid nicotine (administered double-blind) or a cigarette-shaped plastic tube. Cox proportional hazards regression models were fit to examine attrition over time and predictors of attrition including baseline characteristics and condition. A stepwise approach was used to determine the final model; alpha was set at 0.05.

RESULTS

Attrition did not differ significantly by condition (223/520), and most (69%) were lost-to-follow-up. Only age, education level, and household income were significantly predictive of attrition. For every additional year of age, attrition risk fell by 3%. Holding a bachelor's degree or higher was associated with reduced attrition risk. Those with the lowest income (<$10 K) were more likely to be withdrawn compared to those earning $10 K-39 K, and those with the highest income ($100 K+) were more likely to be withdrawn compared with the latter bracket and those earning $70-99 K.

CONCLUSION

ENDS nicotine content did not drive differential attrition in this trial, and targeted retention efforts are needed for specific subgroups. Trial Registration #: NCT02342795.

Stopping use of E-cigarettes and smoking combustible cigarettes: findings from a large longitudinal digital smoking cessation intervention study in the United States

OBJECTIVE

Digital interventions have been widely implemented to promote tobacco cessation. However, implementations of these interventions have not yet considered how participants' e-cigarette use may influence their quitting outcomes. We explored the association of e-cigarette use and quitting smoking within the context of a study testing a digital tobacco cessation intervention among individuals in the United States who were 18 years and older, smoked combustible cigarettes, and enrolled in the intervention between August 2017 and March 2019.

RESULTS

We identified four e-cigarette user groups (n = 990) based on the participants' baseline and six-month e-cigarette use (non-users, n = 621; recently started users, n = 60; sustained users, n = 187; recently stopped users, n = 122). A multiple logistic regression was used to estimate the adjusted odds ratios (AOR) of six-month quit outcome and the e-cigarette user groups. Compared to e-cigarette non-users, the odds of quitting smoking were significantly higher among recently stopped users (AOR = 1.68, 95% CI [1.06, 2.67], p = 0.03). Participants who were most successful at quitting combustible cigarettes also stopped using e-cigarettes at follow-up, although many sustained using both products. Findings suggest that digital tobacco cessation interventions may carefully consider how to promote e-cigarette use cessation among participants who successfully quit smoking.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03224520 (July 21, 2017).

Pharmacokinetics and Pharmacodynamics of Inhaled Nicotine Salt and Free-Base Using an E-cigarette: A Randomized Crossover Study

INTRODUCTION

Popular "pod-style" e-cigarettes commonly use nicotine salt-based e-liquids that cause less irritation when inhaled and can deliver higher nicotine concentrations than free-base nicotine. This study investigated the pharmacokinetic and pharmacodynamic effects of different nicotine formulations (salt vs. free-base) and concentrations that might influence systemic nicotine absorption and appeal of e-cigarettes.

AIMS AND METHODS

In this randomized, double-blind, within-subject crossover study, 20 non-nicotine-naïve participants were switched among three e-liquids (free-base nicotine 20 mg/mL, nicotine salt 20 mg/mL, nicotine salt 40 mg/mL) using a refillable pod system and a standardized vaping protocol (one puff every 30 seconds, 10 puffs total). Serum nicotine concentrations and vital signs were assessed over 180 minutes; direct effects, craving, satisfaction, withdrawal, and respiratory symptoms were measured using questionnaires. CYP2A6 genotypes and the nicotine metabolite ratio were also assessed.

RESULTS

Eleven (55%) participants were male and the median age was 23.5 years (range 18-67). All three formulations differed significantly in peak serum nicotine concentration (baseline adjusted Cmax, median (range): 12.0 ng/mL (1.6-27.3), 5.4 ng/mL (1.9-18.7), and 3.0 ng/mL (1.3-8.8) for nicotine salt 40 mg/mL, nicotine salt 20 mg/mL and free-base 20 mg/mL, respectively). All groups reached Cmax 2.0-2.5 minutes (median) after their last puff. Differences in subjective effects were not statistically significant. No serious adverse events were observed.

CONCLUSIONS

Free-base 20 mg/mL formulations achieved lower blood nicotine concentrations than nicotine salt 20 mg/mL, while 40 mg/mL nicotine salt yielded concentrations similar to cigarette smoking. The findings can inform regulatory policy regarding e-liquids and their potential use in smoking cessation.

IMPLICATIONS

Nicotine salt formulations inhaled by an e-cigarette led to higher nicotine delivery compared to nicotine-free-base formulations with the same nicotine concentration. These findings should be considered in future regulatory discussions. The 40 mg/mL nicotine salt formulation showed similar nicotine delivery as combustible cigarettes, albeit at concentrations over the maximum limit for e-liquids allowed in the European Union. Nicotine delivery resembling combustible cigarettes might be beneficial for smokers willing to quit to adequately alleviate withdrawal symptoms. However, increased nicotine delivery can also pose a public health risk, raising concerns about abuse liability, especially among youth and nonsmokers.

E-Cigarette Use in Adults

This JAMA Insights explores the adverse effects and health outcomes of e-cigarettes vs combusted cigarettes and the effectiveness of using e-cigarettes as a smoking cessation aid among US adults.

Assessment of Respiratory Health Implications of Vaping: A Systematic Review of Toxicity Mechanisms and Adverse Effects of Electronic Nicotine Delivery Systems

E-cigarettes are thought to aid in tobacco smoking cessation, but there are concerns about their overall effectiveness and safety for the general population, particularly adults. This review aims to investigate the mechanisms of toxicity and adverse effects of e-cigarettes on the respiratory system, comparing these effects with those of conventional smoking. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed on PubMed, Embase, and the Cochrane Library using keywords, controlled vocabulary, and text words, with the following criteria: studies published in English from 2014 to 2024, open access, peer-reviewed, and full-text availability. Study selection, quality assessment, and data extraction were carried out by two independent reviewers. The Cochrane Risk of Bias 2.0 tool was used to evaluate the risk of bias in included randomized controlled trials, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was employed to assess the strength of evidence and determine its generalizability. Electronic nicotine delivery systems (ENDS) have diverse mechanisms of toxicity, including inflammation, hypoxia, cardiovascular stress, and metabolic changes. Reported adverse effects include cough, throat irritation, nausea, and hemodynamic changes. However, ENDS are associated with fewer risks compared to conventional cigarette smoking. ENDS users experience fewer respiratory and cardiovascular issues and have lower levels of biomarkers such as NNAL and CO compared to traditional smokers. Additionally, ENDS are more effective than nicotine replacement therapy (nicotine patches) for smoking cessation, particularly in pregnant women. The side effects of ENDS and nicotine-free vaping are similar to those of conventional smoking in pregnant women, with the exception of a lower birth weight among newborns exposed to ENDS (p < 0.05). ENDS present a complex balance of benefits and risks regarding respiratory health. While there are adverse effects, ENDS are considered less detrimental than conventional smoking and a viable option for smoking cessation. Longitudinal studies are needed to evaluate their safety with long-term use (>16 weeks). Policymakers and health practitioners should use these findings to develop balanced public health policies that weigh the benefits of ENDS against potential health risks, enabling informed decision-making for users.

Urgent action needed: addressing the regulatory gap in e-cigarette trade and usage

Tobacco use is associated with serious health problems. Global efforts, such as the World Health Organization's Framework for Tobacco Control, have reduced tobacco use, but challenges remain. Initially perceived as aids for smoking cessation, e-cigarettes have gained popularity among young people and non-smokers. Government approaches to regulating e-cigarettes range from treating them like tobacco, requiring a prescription for their use to outright bans. Although touted as a valuable alternative, evidence suggests that increased e-cigarette use carries potential direct and indirect health risks, necessitating urgent regulatory measures on a global scale. Lack of defined and uniform regulations poses substantial public health risks, compounded by marketing targeting vulnerable groups. Immediate interventions, public awareness, and research are essential to effectively control the current e-cigarette epidemic.

Using Pod Based e-Cigarettes and Nicotine Pouches to Reduce Harm for Adults With Low Socioeconomic Status Who Smoke: A Pilot Randomized Controlled Trial

INTRODUCTION

Alternative Nicotine Delivery Systems (ANDS) such as e-cigarettes (EC) and oral nicotine pouches (ONP) may facilitate the substitution of smoking for those unwilling to quit. This pilot study assesses the harm-reduction potential of EC and ONP among smokers with low socioeconomic status (SES).

AIMS AND METHODS

Adults who smoked daily in the past 6 months, had a household income < 250% federal poverty level and had no intention of quitting smoking in the next 30 days were randomized 2:2:1 to 8 weeks of 5% nicotine EC; 4 mg ONP or assessment-only control (CC). The primary outcome was a within-group change in cigarettes per day (CPD) from Baseline to week 8.

RESULTS

Forty-five individuals were randomized (EC: N = 18; ONP: N = 18; CC: N = 9). Analyses included 33 participants who completed the week 8 visit. The mean age was 50.1 years (SD: 10.7) and the average CPD at baseline was 13.9 (SD: 10.1). For those randomized to EC, the average CPD decreased from 14.7 (95% CI: 10.3 to 19.1) at the Baseline to 2.9 (95% CI: .1 to 5.8) at week 8 (p-value < .001). For those randomized to ONP, average CPD decreased from 15.0 (95% CI: 5.0 to 24.9) to 8.3 (95% CI: 1.3 to 15.2) by week 8 (p-value = .01). In the EC and ONP groups, respectively, 4 (28.6%) and 1 (8.3%) participant fully switched from smoking to the ANDS product by week 8.

CONCLUSIONS

Individuals with low SES who smoke had lower CPD after switching to EC or ONP. These findings show the potential of ANDS in helping smokers switch to less harmful devices.

IMPLICATIONS

This study provides novel evidence that e-cigarettes and nicotine pouches can be a harm-reduction tool for individuals with lower SES who smoke and are not willing to quit smoking, contributing to reducing tobacco-related disparities in this population.Clinical Trials Identifier: NCT05327439.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of adults in the PATH Study in 2017-2019 vs 2019-2021

INTRODUCTION

The use of cigarettes and electronic nicotine delivery system (ENDS) has likely changed since 2019 with the rise of pods and disposables, the lung injuries outbreak, flavour bans, Tobacco 21 and the COVID-19 pandemic.

METHODS

Using the Population Assessment of Tobacco and Health Study, we applied a multistate transition model to 28 061 adults in waves 4-5 (2017-2019) and 24 584 adults in waves 5-6 (2019-2021), estimating transition rates for initiation, cessation and switching products for each period overall and by age group.

RESULTS

Cigarette initiation among adults who never used either product decreased from 2017-2019 to 2019-2021, but ENDS initiation did not significantly change. The persistence of ENDS-only use remained high (75%-80% after 1 year). Cigarette-only use transitions remained similar (88% remaining, 7% to non-current use and 5% to dual or ENDS-only use). In contrast, dual use to ENDS-only transitions increased from 9.5% (95% CI 7.3% to 11.7%) to 20.0% (95% CI 17.4% to 22.6%) per year, decreasing the persistence of dual use. The dual to cigarette-only use transition remained at about 25%. These changes were qualitatively similar across adult age groups, though adults ages 18-24 years exhibited the highest probability of switching from cigarette-only use to dual use and from dual use to ENDS-only use.

CONCLUSIONS

The persistence of ENDS use among adults remained high in 2019-2021, but a larger fraction of dual users transitioned to ENDS-only use compared with 2017-2019. Because the fraction of cigarette-only users switching to dual use remained low, especially among older adults, the public health implications of this change are minimal.

Combustible cigarette smokers versus dual combustible and electronic users: Evaluation of differences in anxiety, depression, and transdiagnostic constructs among Latinx adults

Research on dual combustible and electronic nicotine use among Latinx persons is needed to better understand patterns of use because this group is an established tobacco disparities population. Negative emotional symptoms and related processes (e.g., reactive transdiagnostic vulnerabilities) have been among the most prominent factors linked to the onset, maintenance, and relapse of smoking. As such, the current study sought to compare levels of mental health symptoms among combustible users compared to dual combustible and electronic users among Latinx persons who smoke. The current sample consisted of 297 adult Latinx daily cigarette smokers (Mage = 35.90 years; SD = 8.87; age range 18-61; 36.4% female), of which 92 reported current dual use of an e-cigarette (Mage = 33.34 years; SD = 7.75; age range 19-60; 28.3% female). Differences in anxiety, depression, anxiety sensitivity, emotion dysregulation, and distress tolerance were examined, and we hypothesized that dual users would showcase higher mental health problems. Results indicated that adult Latinx dual users evidenced greater levels of anxiety, depression, emotional dysregulation, anxiety sensitivity, and lower levels of distress tolerance compared to combustible users. The current study sheds light on the clinical importance of affective differences among dual versus combustible Latinx smokers.

A randomized trial of behavioral interventions yielding sustained reductions in distracted driving

Distracted driving is responsible for nearly 1 million crashes each year in the United States alone, and a major source of driver distraction is handheld phone use. We conducted a randomized, controlled trial to compare the effectiveness of interventions designed to create sustained reductions in handheld use while driving (NCT04587609). Participants were 1,653 consenting Progressive® Snapshot® usage-based auto insurance customers ages 18 to 77 who averaged at least 2 min/h of handheld use while driving in the month prior to study invitation. They were randomly assigned to one of five arms for a 10-wk intervention period. Arm 1 (control) got education about the risks of handheld phone use, as did the other arms. Arm 2 got a free phone mount to facilitate hands-free use. Arm 3 got the mount plus a commitment exercise and tips for hands-free use. Arm 4 got the mount, commitment, and tips plus weekly goal gamification and social competition. Arm 5 was the same as Arm 4, plus offered behaviorally designed financial incentives. Postintervention, participants were monitored until the end of their insurance rating period, 25 to 65 d more. Outcome differences were measured using fractional logistic regression. Arm 4 participants, who received gamification and competition, reduced their handheld use by 20.5% relative to control (P < 0.001); Arm 5 participants, who additionally received financial incentives, reduced their use by 27.6% (P < 0.001). Both groups sustained these reductions through the end of their insurance rating period.