Patterns of Non-Cigarette Tobacco and Nicotine Use Among Current Cigarette Smokers and Recent Quitters: Findings From the 2020 ITC Four Country Smoking and Vaping Survey

A Scoping Review of Behavioural Studies on Heated Tobacco Products

Heated tobacco products (HTPs) are electronic devices that heat tobacco sticks to temperatures much lower than those which cause pyrolysis and combustion in cigarettes. While this electrical heating causes the formation of an inhalable aerosol which contains nicotine, the aerosol from HTPs contains significantly fewer and lower levels of the harmful and potentially harmful chemicals found in cigarette smoke. As a result, HTP use potentially conveys reduced risks to health compared to cigarette smoking. While this relative reduction in individual health risk is becoming clearer, what is less certain is the impact of HTPs on overall population‑level health, taking into account both the potential positive impact on adult smokers who completely switch to using HTPs and any unintended impacts such as use by tobacco non‑users and particularly by youth. The aim of this scoping review was to collate and evaluate the published scientific evidence to date, with a cut‑off of 1 January 2024, investigating the impact of HTPs on population‑level health. This evaluation suggests that HTP use is almost exclusively observed among those with a history of cigarette smoking, and there is a growing body of evidence for the ability of HTPs to provide support for adult smokers to transition away from cigarette smoking, in the absence of any significant "gateway" into tobacco use initiation. Many studies have reported a significant degree of dual use of cigarettes and HTPs, and efforts to assess the reasons for such patterns of use, whether these provide overall exposure reductions, and whether dual use acts as a bridge towards a complete transition away from cigarette smoking, requires further investigation. In addition, correction of the widespread and increasing misperceptions of HTPs among adult smokers is recommended to promote HTP uptake as a potentially less harmful alternative to smoking in this population.

The Potential Impact of Oral Nicotine Pouches on Public Health: A Scoping Review

INTRODUCTION

Oral nicotine pouches (ONPs) are a new class of nicotine products. This scoping review summarizes evidence on ONPs and explores their potential public health impact.

AIMS AND METHODS

We conducted a structured literature search for empirical studies across three electronic databases through January 10, 2024. Outcomes included ONP product characteristics, use patterns, beliefs and perceptions, toxicity, and marketing and sales.

RESULTS

Sixty-two studies were included, 17 were industry-funded. Most studies were from the United States. While large variations across studies were observed in ONP youth prevalence estimates, nationally representative U.S. studies find current use at 1.5% and lifetime use below 2.5% through 2023. Between 35% and 42% of U.S. adolescents and young adults have heard of ONPs, and 9-21% of tobacco-naïve youth were susceptible to trying them. U.S. adult-use estimates varied widely (0.8%-3% current; 3%-16% lifetime use) and were limited to populations with a history of tobacco use. The chemical composition of ONPs suggests fewer harmful/potentially harmful compounds at lower levels than cigarettes and smokeless tobacco (SLT), except formaldehyde. Industry-funded studies find substantially less cytotoxicity compared to cigarettes and suggest that higher nicotine-strength ONPs can deliver nicotine at levels comparable to or higher than SLT or cigarettes, although with slower nicotine release than cigarettes. Evidence on the cytotoxicity of ONPs relative to SLT is mixed.

CONCLUSIONS

ONPs appear to be less toxic than cigarettes and deliver comparable nicotine, presenting an alternative for combustible product users, although key data are mainly available from industry-funded studies. Data from independent research is critically needed. Industry marketing of ONPs may encourage initiation in youth and situational and dual use in adults.

IMPLICATIONS

The review provides an initial assessment of the potential role of ONPs in harm reduction and aims to determine unintended consequences of their use (youth uptake and dual-use) and identify populations that disproportionately use the product. This information is essential for tobacco regulatory bodies in determining the net public health impact of nicotine pouches.

Evaluating the Role of Nicotine Stereoisomer on Nicotine Pouch Abuse Liability: A Randomized Crossover Trial

INTRODUCTION

Many oral nicotine pouch (ONP) brands use synthetic nicotine, which typically contains a racemic (50:50) mixture of nicotine's two stereoisomers: S-nicotine and R-nicotine. Because tobacco-derived nicotine contains more than 99% S-nicotine, the effects of R-nicotine in humans are not well known. We compared systemic nicotine exposure and product appeal of ONPs containing more than 99% S-nicotine versus racemic nicotine.

AIMS AND METHODS

N = 18 adult smokers (Mage = 45 years, 66.7% male, 77.8% White) enrolled in a three-visit single-blind, randomized crossover study. During each visit, participants used one wintergreen-flavored, 3 mg nicotine ONP for 30 min following at least12 h nicotine abstinence. Study ONP #1 contained more than 99% S-nicotine and the other two study ONPs contained racemic nicotine (collapsed for analyses). Plasma nicotine assessments and measures of withdrawal relief occurred at t = 0, 5, 15, 30, 60, and 90 min; measures of product appeal were assessed following ONP use.

RESULTS

Using the ONP with more than 99% S-nicotine resulted in greater plasma nicotine concentration from 15 to 90 min (p < .0001) and greater maximum plasma nicotine concentration than the ONPs with racemic nicotine (M = 9.9 ng/mL [SD = 2.5] vs. M = 5.7 ng/mL [SD = 2.8], respectively; p < .0001). Product liking and withdrawal relief were similar across ONPs, although participants reported more "bad effects" when using the ONP with more than 99% S-nicotine.

CONCLUSIONS

Participants reported few subjective differences in ONPs according to nicotine stereoisomer, but plasma nicotine concentration was greater for ONPs using more than 99% S-nicotine. ONPs with more than 99% S-nicotine (vs. racemic nicotine) might be better substitutes for cigarettes, but research into other ONP characteristics (eg flavors, freebase nicotine) is needed to inform regulation.

IMPLICATIONS

Little is known about the effects of racemic (vs. S-) nicotine in humans. In a sample of adults who smoke cigarettes, we identified that oral nicotine pouches containing racemic nicotine exposed participants to less nicotine than oral nicotine pouches containing only S-nicotine, but both types of oral nicotine pouches held similar, moderate appeal. Additional research evaluating the roles that flavorings, total nicotine concentration, and freebase nicotine play in the abuse liability of oral nicotine pouches would inform comprehensive product regulations to support public health.

Trends in Exclusive Non-Cigarette Tobacco Smoking in England: A Population Survey 2013-2023

INTRODUCTION

The UK Government intends to implement a "smokefree generation" policy prohibiting the sale of all tobacco products to people born after 2008. National surveys provide comprehensive data on cigarette smoking, but little is known about patterns of non-cigarette tobacco smoking across key population groups.

AIMS AND METHODS

Using data from a nationally representative cross-sectional survey of adults in England, collected monthly between September 2013 and September 2023 (n = 196 721), we estimated time trends in exclusive non-cigarette tobacco (eg, cigar/pipe/shisha) smoking prevalence, overall and by age, gender, occupational social grade, region, ethnicity, and vaping status. Interviews were conducted face-to-face until March 2020 and via telephone thereafter.

RESULTS

From September 2013 to September 2023, there was a non-linear increase in exclusive non-cigarette tobacco smoking prevalence (from 0.36% to 1.68%; prevalence ratio = 4.72 [95% CI = 3.43-6.48]). Prevalence was relatively stable up to February 2020 (at an average of 0.46%), then increased sharply at the start of the COVID-19 pandemic (at the same time as survey methods changed), to 0.90% (0.82%-0.99%) in March 2020. This was followed by a steadier rise, peaking at 1.97% in May 2022, before falling slightly to 1.68% by September 2023. In 2022/2023, 1 in 10 smokers (10.8% [9.64%-12.0%]) exclusively used non-cigarette tobacco. The rise in prevalence was observed across all subgroups but was most pronounced among younger adults (eg, reaching 3.21% of 18-year-olds vs. 1.09% of 65-year-olds). Prevalence was consistently higher among men and current vapers.

CONCLUSIONS

Although exclusive use of non-cigarette combustible tobacco remains rare among adults in England, it has increased in recent years, particularly among younger ages. As of September 2023, there were approximately 772 800 adult exclusive non-cigarette tobacco smokers in England; around five times more than a decade earlier.

IMPLICATIONS

The proportion of adults in England who do not use cigarettes at all but smoke other combustible tobacco products has increased substantially in recent years, with a particularly pronounced rise among young people. The inclusion of non-cigarette combustible tobacco products under the proposed "smokefree generation" policy is therefore likely to be important for achieving the greatest reduction in youth uptake of tobacco smoking, as it would ensure young people who are unable to legally buy cigarettes do not buy other combustible tobacco products that are similarly harmful to health.

Evaluating the effects of nicotine concentration on the appeal and nicotine delivery of oral nicotine pouches among rural and Appalachian adults who smoke cigarettes: A randomized cross-over study

BACKGROUND AND AIMS

Oral nicotine pouches (ONPs) probably offer reduced harm compared with cigarettes, but independent data concerning their misuse liability are lacking. We compared nicotine delivery and craving relief from ONPs with different nicotine concentrations to cigarettes.

DESIGN

This was a single-blind, three-visit (≥ 48-hour washout), randomized-cross-over study. Participants were encouraged to complete all study visits in less than 1 month.

SETTING

The study took place in Rural/Appalachian Ohio.

PARTICIPANTS

Participants comprised 30 adults who smoke cigarettes. Participants (meanage  = 34.5) were 60% men and 90% White.

INTERVENTION

Participants who were ≥ 12-hour tobacco-abstinent used: (1) a 3-mg nicotine concentration ONP, (2) a 6-mg nicotine concentration ONP and (3) usual brand cigarette in separate visits. ONPs (wintergreen Zyn) were used for 30 minutes; cigarettes were puffed every 30 sec for 5 minutes.

MEASUREMENTS

Plasma nicotine and self-reported craving were assessed at t = 0, 5, 15, 30, 60 and 90 minutes. The primary outcome was plasma nicotine concentration at t = 30 minutes. A secondary outcome was craving relief at t = 5 minutes.

FINDINGS

At t = 30, mean [95% confidence interval (CI)] plasma nicotine was 9.5 ng/ml (95% CI = 7.1, 11.9 ng/ml) for the 3 mg nicotine ONP, 17.5 ng/ml (95% CI = 13.7, 21.3) for the 6 mg nicotine ONP and 11.4 ng/ml (95% CI = 9.2, 13.6 ng/ml) for the cigarette. Mean plasma nicotine at t = 30 minutes differed between the 3- and 6-mg nicotine ONPs (P = 0.001) and between the 6-mg nicotine ONP and cigarette (P = 0.002). Mean (95% CI) craving at t = 5 minutes was lower for the cigarette (mean = 1.00, 95% CI = 0.61, 1.39) than either the 3 mg (mean = 2.25, 95% CI = 1.68, 2.82; P < 0.0001) or 6 mg nicotine (mean = 2.19, 95% CI = 1.60, 2.79; P < 0.0001) ONP.

CONCLUSIONS

Among adult smokers, using 6-mg nicotine concentration oral nicotine pouches (ONPs) was associated with greater plasma nicotine delivery at 30 minutes than 3-mg ONPs or cigarettes, but neither ONP relieved craving symptoms at 5 minutes as strongly as a cigarette. Accelerating the speed of nicotine delivery in ONPs might increase their misuse liability relative to cigarettes.

Future nicotine use preferences of current cigarette smokers: Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey

INTRODUCTION

Consumer preferences should be important factors that are considered when developing health policies and interventions. This paper examines the prevalence of, and factors associated with, consumer preferences regarding smoking behaviour 1 to 2 years in the future.

METHODS

At least weekly cigarette smokers in the 2020 wave of the International Tobacco Control Four Country Smoking and Vaping Survey (USA, Canada, England and Australia) (N = 8642) were asked if they preferred to continue to smoke or to quit with or without an alternative nicotine product (ANP) over the next 1-2 years.

RESULTS

Country-specific weighted data showed 21.5% preferred to continue smoking and 8.0% were uncertain, leaving 70.6% preferring to quit: 13.7% using an ANP and 56.9% completely quitting nicotine. Apart from interest in quitting, the main predictors of preferring to quit were history of vaping, being aged 55 and over, smoking weekly, worrying about smoking harms, regretting starting and believing vaping is less harmful relative to smoking. Among those preferring to quit, preferring to use ANPs in future was very strongly associated with current vaping (especially daily), being younger, living in England, reporting strong urges to smoke, believing vaping is much less harmful than smoking, and not strongly regretting starting to smoke, and not wanting to quit.

DISCUSSION AND CONCLUSIONS

A significant minority of smokers preferred not to quit, at least in the next year or two. Both interest in quitting and preference for ANPs over complete cessation were associated with similar covariates, including interest in vaping.

Tobacco-Free Nicotine Pouches and Their Potential Contribution to Tobacco Harm Reduction: A Scoping Review

Tobacco harm reduction (THR) refers to strategies designed to reduce the health risks associated with tobacco smoking but may involve continued use of nicotine and/or tobacco. Next-generation products (NGPs) are a THR alternative as they do not burn tobacco or produce smoke and deliver nicotine and have fewer and substantially lower levels of harmful chemicals compared to cigarettes. Tobacco‑free nicotine pouches (TFNPs) are an emerging category of nicotine‑containing oral products that do not combust or contain tobacco leaf. Similar to Swedish snus, TFNPs are placed between a user's lip and gum, and nicotine is absorbed through the oral mucosa rather than being inhaled. The aim of this scoping review was to systematically collate and evaluate published scientific evidence (cut‑off of 31 May 2023) identified from bibliometric databases investigating the potential of TFNPs to contribute to THR. Overall, studies examining chemical constituents indicated that the use of TFNPs may result in lower exposure to toxicants than other tobacco or nicotine-containing products, both combustible and non‑combustible. This reduction in toxicant exposure has been demonstrated by multiple human biomarker studies and in vitro toxicological assessments to translate to harm reduction potential in smokers switching to TFNPs. However, further study is warranted. At present, there is some evidence from human behavioral research that TFNPs can support either transitioning away from smoking or reducing cigarette consumption. Furthermore, TFNP use appears very much limited to current users of traditional tobacco products, and youth uptake has been limited. In conclusion, the findings of this review indicate that TFNPs have the potential to support THR efforts and may help inform evidence‑based regulation.

Nicotine pouch product awareness, interest and ever use among US adults who smoke, 2021

BACKGROUND

Tobacco-free nicotine pouches are one of the fastest growing tobacco product categories in the US market. However, data on awareness, appeal or ever use of these products in the USA are limited.

METHODS

We surveyed a population-based sample of US adults who smoked (n=1018) between January and February 2021 about awareness, ever use of or interest in nicotine pouches. Multivariable logistic regression models explored the relationship between nicotine pouch variables and demographic and tobacco use characteristics.

RESULTS

In early 2021, 29.2% of adults who smoked had ever seen or heard of nicotine pouches, 5.6% had ever tried pouches and 16.8% reported interest in using pouches in the next 6 months. Adults who smoked aged 18-44 years and those who had ever used smokeless tobacco (SLT) were more likely to be aware of nicotine pouches. Interest in using nicotine pouches was more prevalent among adult smokers who planned to quit within 6 months, attempted to quit before using counselling or another tobacco product and had ever used pouches. Among adults who smoked, those with more education had lower odds of ever using nicotine pouches while those who had attempted to quit before using traditional methods or ever used SLT had higher odds of ever use.

CONCLUSION

Levels of awareness, appeal and trial of nicotine pouches among US adults who smoke were modest, with variation by age, education, quit plans and quit attempt methods. Continued surveillance is warranted, including among naïve users and users of other tobacco and nicotine products.

Nicotine Pouch Awareness and Use Among Youth, National Youth Tobacco Survey, 2021

INTRODUCTION

This manuscript examines prevalence of awareness and use of nicotine pouches among U.S. middle and high school students by sociodemographic characteristics and other tobacco product use and characterizes nicotine pouch and other tobacco product use behaviors among current nicotine pouch users.

AIMS AND METHODS

Data are from the 2021 National Tobacco Youth Survey, a cross-sectional, school-based survey of middle and high school students (N = 20 413; overall response rate: 44.6%), which included questions on nicotine pouches in 2021 for the first time. Prevalence estimates, 95% confidence intervals, and estimated population counts were assessed for nicotine pouch awareness, ever use, and current (past 30 days) use, and for use behaviors related to nicotine pouches (frequency of use, flavor(s) used) and other tobacco products (ever, current, frequency of use) among current nicotine pouch users.

RESULTS

Over one-third of students (35.5%) had ever heard of nicotine pouches. An estimated 1.9% (490 000) reported ever using them, while 0.8% (200 000) reported current use. Among current nicotine pouch users, 61.6% reported flavored nicotine pouch use, 64.2% reported current e-cigarette use, and 52.6% used multiple (≥2) tobacco products. Current use of nicotine pouches was common among current smokeless tobacco users (41.3%).

CONCLUSIONS

Overall, in 2021, while relatively few students had ever tried nicotine pouches or currently used them, more than one-third had heard of them. Current nicotine pouch users tended to use other tobacco products, particularly e-cigarettes and smokeless tobacco. Given previous rapid increases in youth uptake of e-cigarettes, it is important to continue monitoring nicotine pouch use among young people.

IMPLICATIONS

This study's findings provide an important baseline for future monitoring of nicotine pouch awareness and use among middle and high school students. Emerging tobacco products, particularly those that are flavored, widely available, discreet, and inexpensive have the potential to attract youth. Given the potential of these products to appeal to young people, ongoing monitoring of nicotine pouch use behaviors is important to inform public health and regulatory efforts.

Multiple Pharmacotherapy Adaptations for Smoking Cessation Based on Treatment Response in Black Adults Who Smoke: A Randomized Clinical Trial

Importance

Adapting to different smoking cessation medications when an individual has not stopped smoking has shown promise, but efficacy has not been tested in racial and ethnic minority individuals who smoke and tend to have less success in quitting and bear a disproportionate share of tobacco-related morbidity and mortality.

Objective

To evaluate efficacy of multiple smoking cessation pharmacotherapy adaptations based on treatment response in Black adults who smoke daily.

Design, Setting, and Participants

This randomized clinical trial of adapted therapy (ADT) or enhanced usual care (UC) included non-Hispanic Black adults who smoke and was conducted from May 2019 to January 2022 at a federally qualified health center in Kansas City, Missouri. Data analysis took place from March 2022 to January 2023.

Interventions

Both groups received 18 weeks of pharmacotherapy with long-term follow-up through week 26. The ADT group consisted of 196 individuals who received a nicotine patch (NP) and up to 2 pharmacotherapy adaptations, with a first switch to varenicline at week 2 and, if needed, a second switch to bupropion plus NP (bupropion + NP) based on carbon monoxide (CO)-verified smoking status (CO ≥6 ppm) at week 6. The UC group consisted of 196 individuals who received NP throughout the duration of treatment.

Main Outcomes and Measures

Anabasine-verified and anatabine-verified point-prevalence abstinence at week 12 (primary end point) and weeks 18 and 26 (secondary end points). The χ2 test was used to compare verified abstinence at week 12 (primary end point) and weeks 18 and 26 (secondary end points) between ADT and UC. A post hoc sensitivity analysis of smoking abstinence at week 12 was performed with multiple imputation using a monotone logistic regression with treatment and gender as covariates to impute the missing data.

Results

Among 392 participants who were enrolled (mean [SD] age, 53 [11.6] years; 224 [57%] female; 186 [47%] ≤ 100% federal poverty level; mean [SD] 13 [12.4] cigarettes per day), 324 (83%) completed the trial. Overall, 196 individuals were randomized to each study group. Using intent-to-treat and imputing missing data as participants who smoke, verified 7-day abstinence was not significantly different by treatment group at 12 weeks (ADT: 34 of 196 [17.4%]; UC: 23 of 196 [11.7%]; odds ratio [OR], 1.58; 95% CI, 0.89-2.80; P = .12), 18 weeks (ADT: 32 of 196 [16.3%]; UC: 31 of 196 [15.8%]; OR, 1.04; 95% CI, 0.61-1.78; P = .89), and 26 weeks (ADT: 24 of 196 [12.2%]; UC: 26 of 196 [13.3%]; OR, 0.91; 95% CI, 0.50-1.65; P = .76). Of the ADT participants who received pharmacotherapy adaptations (135/188 [71.8%]), 11 of 135 (8.1%) were abstinent at week 12. Controlling for treatment, individuals who responded to treatment and had CO-verified abstinence at week 2 had 4.6 times greater odds of being abstinent at week 12 (37 of 129 [28.7%] abstinence) than those who did not respond to treatment (19 of 245 [7.8%] abstinence; OR; 4.6; 95% CI, 2.5-8.6; P < .001).

Conclusions and Relevance

In this randomized clinical trial of adapted vs standard of care pharmacotherapy, adaptation to varenicline and/or bupropion + NP after failure of NP monotherapy did not significantly improve abstinence rates for Black adults who smoke relative to those who continued treatment with NP. Those who achieved abstinence in the first 2 weeks of the study were significantly more likely to achieve later abstinence, highlighting early treatment response as an important area for preemptive intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT03897439.

"I Crave a Blunt, I Don't Crave a Cigarillo": A Focus Group Study on Perceptions of Nicotine and Addiction among US Adults Who Currently Smoke Little Cigars or Cigarillos

While the US Food and Drug Administration (FDA)'s proposal to reduce the nicotine content in cigarettes is gaining traction, it is still undetermined whether the policy will also include other combustible tobacco products, such as little cigars and cigarillos (LCCs), and how such a policy should be communicated given the patterns of use and perceptions around LCCs. This study examined perceptions of nicotine and addiction related to LCC use and involved data collection from eight semi-structured virtual focus groups conducted in Summer 2021 in the US. Participants were adults who reported past-30-day use of LCCs, consisting of African American males (n = 9), African American females (n = 9), white males (n = 14), and white females (n = 11). Participants discussed their perceptions of nicotine and addiction in general and in relation to LCC use. Inductive thematic analysis of transcripts was conducted. Differences across race and sex groups were examined. Participants did not consider nicotine to be a characterizing feature of LCCs; rather, they generally associated nicotine with cigarettes. Participants' views of nicotine and addiction related to LCCs were discussed along four dimensions: context of use, frequency of use, the presence of cravings, and whether a product is modified (e.g., by adding marijuana). Social and infrequent use, a lack of cravings, and the use of LCCs for marijuana were considered indicative of a lack of addiction and reasons not to be concerned about nicotine in LCCs. Because perceptions of nicotine and addiction related to LCCs differ from those of cigarettes, communications about a reduced nicotine policy that includes LCCs should consider these differences to ensure the policy is understood by people who currently use LCCs and to prevent people who use cigarettes from switching to LCCs.

Willingness to Use Commercial Nicotine Gums, Lozenges, and Gummies Among Nontobacco Using Adolescents in Southern California

PURPOSE

New oral nicotine products (ONPs), often advertised as "tobacco-free" (i.e., pouches, gum, lozenges, gummies), come in nontobacco flavors appealing to adolescents. It is unknown how adolescent willingness to use ONPs differs by product type and flavor, and whether sociodemographic disparities exist.

METHODS

Adolescent never tobacco product users (n = 1, 289) in ninth or 10th grade from 11 high schools in Southern California were surveyed in fall 2021 about ever and past 6-month use of ONPs and sociodemographic characteristics. Adolescents were randomized to view five different ONPs in either fruit or mint flavor, and asked to rate their willingness to use each product. Multivariable logistic random effect-repeated measures regression examined associations of product type, flavor, and sociodemographic characteristics with any willingness to use ONPs.

RESULTS

Compared to traditional smokeless tobacco (willingness = 17.8%), adolescents reported greater willingness to use ONPs (gum, 28.2%; pouches, 21.1%; lozenge, 22.4%; gummies, 24.1%); adjusted odd ratios [aORs] 1.25-1.84; p-values<.001). Mint flavor (23.3%) compared to fruit flavor (21.4%), significantly increased odds of willingness to use across all ONPs (aOR [95%CI] = 1.15 [1.05, 1.26], p = .004). Younger adolescents (ninth, 24.2% vs. 10th grade, 21.4%) and LGBTQ+ (34.2%) versus heterosexual (19.7%) and cisgender (18.8%) adolescents were more willing to use these products.

DISCUSSION

Adolescents reported greater willingness to use new ONPs compared to traditional smokeless tobacco. Adolescents who were younger (vs. older adolescents) or identified as LGBTQ+ (vs. heterosexual and cisgender) were more willing to use new ONPs. Efforts to monitor adolescents' willingness to use and actual use of these products are warranted.

Non-cigarette combustible tobacco use and its associations with subsequent cessation of smoking among daily cigarette smokers: findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2016-20)

AIMS

To examine whether polyuse of cigarettes and other smoked products (polysmoking) is predictive of quit attempts and quit success.

DESIGN

A prospective multi-country cohort design.

SETTING

Australia, Canada, England and the United States.

PARTICIPANTS

A total of 3983 adult daily cigarette smokers were surveyed in 2016 (wave 1 of data collection) and were re-contacted in 2018 (wave 2) (i.e. waves 1-2 cohort) in the International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) surveys; and 3736 smokers were surveyed in 2018 and re-contacted in 2020 (wave 3) (i.e. waves 2-3 cohort).

MEASUREMENTS

Participants were asked about their cigarette smoking and use of cigars, cigarillos, pipes and waterpipes. Outcomes were quit attempts between two survey waves and success, defined as having quit smoking all the combustible tobacco at the subsequent survey for 1 month or more.

FINDINGS

Levels of polysmoking were 12.7% in the waves 1-2 cohort and 10.5% for the waves 2-3 cohort. Compared with cigarette-only smokers, polysmokers were more likely to attempt to quit between waves 1 and 2 [54.9 versus 42.7%, adjusted odds ratio (aOR) = 1.37, 95% confidence interval (CI) = 1.08-1.74, P < 0.01], but not between waves 2 and 3 (43.8 versus 40.1%, aOR = 0.94, 95% CI = 0.72-1.22). Polysmoking predicted reduced likelihood of success in both cohorts among attempters and the overall samples. Between waves 2 and 3 there were significantly more transitions to non-daily smoking among the polysmokers (12.4 versus 5.3%, χ2  = 40.4, P < 0.001).

CONCLUSIONS

There is a consistent association between polysmoking (use of cigarettes together with other smoked products) and reduced quit success for combustible tobacco, but it is probably due to increased likelihood of transitioning to non-daily use rather than complete cessation.

Oral Nicotine Product Awareness and Use Among People Who Smoke and Vape in the U.S

INTRODUCTION

Tobacco-free oral nicotine products are an emerging class of noncombustible nicotine products. Oral nicotine product sales have increased since 2016, although little research has investigated consumer awareness, use, or correlates of oral nicotine product use. The purpose of this analysis was to assess the prevalence and correlates of oral nicotine product awareness and use.

METHODS

This paper is a cross-sectional analysis of 2,507 U.S. participants from Wave 3 (February-June 2020) of the International Tobacco Control Four Country Smoking and Vaping Survey, a population-based survey of current and former cigarette smokers and nicotine vaping product users in the U.S. Oral nicotine product awareness and use prevalence were compared with those of heated tobacco products. Analyses conducted in late 2021 assessed the correlates of oral nicotine product awareness and use such as demographic characteristics, tobacco use (cigarettes, nicotine vaping products, smokeless tobacco), and tobacco quit attempts.

RESULTS

Almost 1 in 5 respondents claimed to have heard of oral nicotine products, 3.0% reported ever use, and 0.9% were current users, all of which were lower than for heated tobacco products. Ever use of oral nicotine products was more common among younger adults (e.g., aged 18-24 years), males, and current users of smokeless tobacco. Oral nicotine product prevalence was higher among those who reported having made attempts to stop smoking or vaping.

CONCLUSIONS

Oral nicotine product use was low among current and former smokers and nicotine vaping product users. Oral nicotine product users were demographically similar to use among individuals who smoke/vape and also use smokeless tobacco. Future studies are needed to understand emerging oral nicotine products, particularly whether they are being used as product supplements (dual use), replacements (switching), or cessation aids (quitting).

Challenges in Predicting the Change in the Cumulative Exposure of New Tobacco and Related Products Based on Emissions and Toxicity Dose-Response Data

Many novel tobacco products have been developed in recent years. Although many may emit lower levels of several toxicants, their risk in the long term remains unclear. We previously published a method for the exposure assessment of mixtures that can be used to compare the changes in cumulative exposure to carcinogens among tobacco products. While further developing this method by including more carcinogens or to explore its application to non-cancer endpoints, we encountered a lack of data that are required for better-substantiated conclusions regarding differences in exposure between products. In this special communication, we argue the case for more data on adverse health effects, as well as more data on the composition of the emissions from tobacco products. Such information can be used to identify significant changes in relevance to health using the cumulative exposure method with different products and to substantiate regulatory decisions.

Experienced Effects on Well-Being following Smoking Cessation: Findings from the 2020 ITC Four Country Smoking and Vaping Survey

BACKGROUND AND AIMS

There has been limited research addressing changes in subjective well-being as a result of quitting smoking. This paper examines recent ex-smokers' well-being related experiences overall and as a function of (1) duration of cessation and (2) continued nicotine use from vaping.

METHODS

A sample of 1379 ever-daily smoking ex-smokers (quit for up to 5 years) from the 2020 ITC Four Country Smoking and Vaping Survey (Australia, Canada, the UK, and the US), of which 27.1% currently vaped daily. Well-being measures were perceived changes post-quitting in emotion coping (stress and negative emotions), enjoyment of life, and day-to-day functioning. We also assessed the level of persisting worry about past smoking leading to future health problems.

RESULTS

Overall, among those answering all four well-being measures, 51.8% of the ex-smokers reported positive effects and no negatives, but 27.3% reported at least one negative effect, with the remainder reporting no change in any measure. Positive effects were greater among those who had quit more than 1 year prior. The largest improvement (56.3%) was for daily functioning, which showed improvement over time since having quit. Current daily vapers reported similar well-being as those not vaping; however, fewer daily vapers reported worsening ability to cope with stress (10.2% vs. 20.7%). Overall, 84% reported being worried about future negative health effects of smoking, with no clear differences by quitting duration or vaping status.

CONCLUSIONS

Most ex-smokers reported changes in their well-being since quitting, with more reporting improvements than declines. Well-being improved with duration of time since quitting, but did not appear to be influenced by daily vaping use, but stress coping may be better among vapers. Persisting worries about possible future health effects from smoking may be reducing the experienced benefits of quitting smoking for some.

Tobacco-free nicotine pouch use in Great Britain: a representative population survey 2020-2021

INTRODUCTION

Tobacco-free nicotine pouches are products that are placed between the lip and gum, where they deliver nicotine to users. Little is known about nicotine pouch use in Great Britain since they entered the market in 2019.

METHODS

Data came from a monthly representative survey of the adult (≥18y) population in Great Britain (England, Scotland, and Wales) between November 2020 and October 2021 (n=25,698). We estimated the weighted prevalence of pouch use, overall and stratified by demographics, smoking status, and other nicotine use.

RESULTS

Nicotine pouch use was rare among adults, with a weighted prevalence of just 0.26% (95% compatibility interval [CI]=0.19-0.35). Prevalence doubled from November 2020 to October 2021 (0.14% to 0.32%; Prevalence ratio [PR]=2.22, 95%CI=1.33-3.70). Pouch use was four times more common among men than women (0.42% versus 0.09%; PR=4.55, 95%CI=2.27-9.09) but less common in older age groups (p<.001). Pouch use was more prevalent among current smokers (0.87%; PR=13.60, 95%CI=5.46-33.89), recent former smokers (0.97%; PR=15.21, 95%CI=4.03-57.42), and long-term (>1y) former smokers (0.24%; PR=3.71, 95%CI=1.36-10.15), compared with never smokers (0.06%). Prevalence was also elevated among e-cigarette (1.64% versus 0.15%; PR=10.59, 95%CI=5.74-19.52) and nicotine replacement therapy users (2.02% versus 0.21%; PR=9.75, 95%CI=4.64-20.49).

CONCLUSIONS

One in 400 adults in Great Britain use nicotine pouches, but prevalence increased from 2020 to 2021.

IMPLICATIONS

Tobacco-free nicotine pouches were introduced to the market in Great Britain in 2019. We found that, while pouch use is currently rare in Great Britain, these products have become more popular over time. Pouch use is largely concentrated among younger and middle-aged men who use other nicotine products and have a history of smoking. Continued monitoring of nicotine pouch use is needed.