Flavored and nonflavored smokeless tobacco products: rate, pattern of use, and effects

A Method for Amending Loose Smokeless Tobacco With Menthol for Administration in Clinical Studies

INTRODUCTION

Menthol has long been incorporated as a flavor additive in tobacco products and can impact use behaviors. Despite its inclusion in some of the most popular flavored smokeless tobacco (ST) products (eg, "mint" flavored products), few studies have systematically investigated the impact of menthol on ST use behaviors in prospective empirical studies. Rigorous investigation of ST menthol content on behavioral and physiological outcomes requires ST products with stable and precise levels of menthol; however, commercial product composition variability prevents product comparisons when evaluating the effects of systematic changes in menthol content on clinical outcomes.

AIMS AND METHODS

We developed amended loose moist snuff ST products by treating commercially available, unflavored loose ST with an ethanol-based menthol spiking solution or a nonmentholated ethanol control solution to develop test products with different levels of menthol: 0, 1, 3, and 5 mg menthol/g tobacco. We evaluated the stability of menthol content in these products over 24 months and evaluated menthol exposure associated with the products through pharmacokinetic analysis of plasma menthol-glucuronide in human participants (n = 22).

RESULTS

Menthol content of the amended products was on target, homogenous, and stable for up to 24 months. Menthol exposure (menthol-glucuronide Cmax and AUC) significantly differed between each test product.

CONCLUSIONS

These data suggest that stable products with nonoverlapping menthol content can be developed using a menthol spiking solution and can be subsequently administered for clinical assessments of mentholated loose ST.

IMPLICATIONS

The results from this study suggest that a menthol spiking solution can be used to mentholate unflavored, loose ST to a target menthol content. With this method, the ST menthol content was stable for at least 24 months, and the products exposed users to menthol in a dose-dependent manner. This method yielded loose ST products with precise, stable levels of menthol to allow systematic evaluation of ST menthol content on clinical outcomes. The method may have applications for systematically evaluating changes in other tobacco product ingredients.

Levels of nicotine and tobacco-specific nitrosamines in oral nicotine pouches

BACKGROUND

Nicotine pouches without tobacco are new products that deliver nicotine into the body via the oral mucosa. There is a lack of independent research on the chemical composition and product characteristics of these products, contributing to uncertainties regarding product regulation. This study sought to address knowledge gaps by assessing levels of nicotine and screening for tobacco-specific nitrosamines (TSNAs) in a sample of these products.

METHODS

Nicotine pouches (n=44) and nicotine-free pouches (n=2) from 20 different manufacturers were analysed regarding their contents of nicotine and TSNAs by gas chromatography with flame ionisation and liquid chromatography-tandem mass spectrometry, respectively. Product labelling and pH values of aqueous extracts were determined.

RESULTS

Nicotine contents of products ranged from 1.79 to 47.5 mg/pouch; median product weight, pH, and proportion of free-base nicotine were 0.643 g, 8.8, and 86%, respectively. A clear labelling of the nicotine content was missing on 29 products and nicotine strength descriptions were ambiguous. TSNAs were detected in 26 products, with a maximum of 13 ng N-nitrosonornicotine/pouch.

CONCLUSION

Although nicotine pouches may potentially be a reduced risk alternative for cigarette smokers or users of some other oral tobacco products, nicotine contents of some pouches were alarmingly high. Presence of carcinogenic TSNAs in the nicotine pouches is of serious concern. Better manufacturing processes and quality control standards should be implemented. Labels of nicotine strength on most products are misleading. A strict regulation regarding nicotine contents and its labelling would be advisable.

Physical and chemical characterization of smokeless tobacco products in India

The rapid proliferation of smokeless tobacco (SLT) in India has occurred without adequate information on the possible dangers and toxicity of these products. Tobacco flavors as well as nicotine (both protonated and un-protonated) are responsible for health dangers and addiction. The study aimed to offer information on the physical characteristics of commonly used smokeless tobacco products (including microscopic analysis), along with nicotine content (both total and un-protonated), pH, moisture, and flavors. The Standard Operating Procedures (SOPs) validated by the World Health Organization (WHO) recognized Tobacco Testing Laboratory TobLabNet) were applied for the analysis of various constituents of the SLTs. The microscopic analysis indicated that some of the SLT products like khaini were finely processed and available in filter pouches for users' convenience and prolonged use leading to prolonged retention and addiction potential. Nicotine absorption and availability (both protonated and un-protonated) are affected by moisture and pH. Essences provide a pleasant aroma and flavor, with an increased risk of misuse and other health problems. Few chewing tobacco and Zarda had the lowest levels of un-protonated nicotine (0.10-0.52% and 0.15-0.21%, respectively), whereas Gul, Gudhaku, and Khaini had the highest levels, ranging from 95.33 to 99.12%. Moisture and pH ranged from 4.54 to 50.19% and 5.25-10.07 respectively. Menthol (630.74-9681.42 µg/g) was the most popular flavour, followed by Eucalyptol (118.16-247.77 µg/g) and camphor (148.67 and 219.317 µg/g). SLT's health concerns and addiction dangers are exacerbated by the high proportion of bioavailable nicotine coupled with flavors. The findings of this study have important implications for the regulation and use of SLT in countries where use of SLT is prevalent.

Longitudinal associations between flavored tobacco use and tobacco product cessation in a national sample of adults

Use of flavored tobacco has been associated with lower likelihood of short-term abstinence from tobacco. It is unknown whether longer-term associations exist, particularly for a variety of products and specific flavor categories. This study used adult survey data from the Population Assessment of Tobacco and Health (PATH) Study (2013-2018). We tested associations of past 30-day tobacco product use at wave 2 using both a 2-category any flavor versus unflavored variable and 4-category specific flavor (menthol/mint, sweet, and both menthol/mint and sweet) versus unflavored variable with past 12-month cessation from the same product two years later at wave 4. Separate models were run for each product (combustible cigarettes, cigars, hookah, e-cigarettes, and smokeless), adjusting for wave 1 sociodemographic characteristics. For all five products, past 30-day use of any flavored (versus unflavored) product at wave 2 was associated with reduced likelihood of same-product cessation at wave 4. Most specific flavor categories were associated with reduced odds of same-product cessation across all products. Any flavor use was also associated with reduced likelihood of longer-term cessation (i.e., past 24-months at both waves 3 and 4) and cessation from all five tobacco products in several analyses. Exploratory moderation results indicated that the association between e-cigarette flavor use and lower likelihood of cessation was stronger for young adults (18-24) versus older adults (25+). Current use of flavored tobacco products is associated with lower likelihood of product cessation. Flavored tobacco products warrant consideration in regulatory policy to reduce the adverse public health impact of tobacco use.

The effect of emerging tobacco related products and their toxic constituents on thrombosis

Although conventional cigarette smoking is declining, emerging tobacco related products (ETRPs) are currently gaining ground, especially among the youth. These products include electronic cigarettes, waterpipes/hookah, cigars/cigarillo, smokeless tobacco, and heat-not-burn cigarettes. The observed increase in the use of ETRPs is multifactorial and complex but appears to be mainly driven by efforts from the major tobacco companies to reinvent themselves, and present more appealing and allegedly safe(r) tobacco products. However, it is becoming apparent that these products produce substantial amounts of toxic chemicals, many of which have been shown to exert negative health effects, including in the context of the cardiovascular system. Thus, there has been research efforts, albeit limited in general, to characterize the health impact of these products on occlusive/thrombotic cardiovascular diseases (CVD). In this review, we will discuss the potential impact of ETRPs on thrombosis-based CVD. Specifically, we will review how these products and the major chemicals they produce and/or emit can trigger key players in the process of thrombosis, namely inflammation, oxidative stress, platelets, coagulation, and the vascular endothelium, and the relationship between these effects.

The efficacy of health warnings and package branding on perceptions of cannabis products among youth and young adults

INTRODUCTION

Little empirical evidence exists about the efficacy of labelling and marketing restrictions in a regulated cannabis market. This study examined perceptions of cannabis product packaging designs, health warning labels (HWL) and perceptions of packs displaying brand imagery and leading descriptors on measures of appeal, and perceived consumer attributes.

METHODS

An online experimental survey of Canadian cannabis users and non-users (n = 870) aged 16-30 years containing eight between-group experiments was conducted in October 2017. Primary outcomes were appeal and perceived consumer attributes of cannabis product packaging, including the likelihood of being younger, female, fashionable, health conscious and likely to go out and party.

RESULTS

When cannabis product branding was present, respondents were more likely (P = 0.027) to report greater appeal than when branding was absent. When an HWL was present, respondents were less likely (P = 0.010) to report greater appeal than when absent. The presence of a celebrity sponsor (P < 0.001), music references (P < 0.001) or party references (P < 0.001) increased the likelihood that respondents perceived the product as targeted at someone younger, and a party lifestyle. Differences by cannabis use status were observed across experiments; those who had used were more likely to find branding elements appealing.

DISCUSSION AND CONCLUSIONS

The findings demonstrate that brand imagery on cannabis packaging can promote lifestyle associations and increase the appeal of cannabis products among young people. Plain/standardised packs displaying HWLs were perceived as less appealing than packs with branding or without HWLs. Lifestyle associations can be communicated through brand imagery on cannabis packaging.

The greater use of flavoured snus among ever-smokers versus never-smokers in Norway

Background

Similar to the debate around e-cigarettes, an increase in snus use among Norwegian adolescents has prompted debate on whether flavour options in snus should be limited. To this end, we compared use of flavoured snus among snus users with different smoking status.

Methods

Questions about flavoured snus use were included in an online omnibus study conducted from 2015 to 2019 (N = 65,445) that included 16,295 ever snus users (aged 15+). Current snus users (N = 9783) were asked “Do you usually use snus that has a flavouring (liquorice, mint, wintergreen, etc.)? Adjusted predicted probabilities and 95% confidence intervals (CI) were calculated from a logistic regression model.

Results

Less than 25% of the snus users reported never having smoked. The overall probability of using flavoured snus was .45 (95% CI .44–.46), highest among daily (.51, 95% CI .47–.54) and former daily smokers (.50, 95% CI .48–.52), and lowest among never (.41, 95% CI .39–.43) and occasional smokers without any prior history of daily smoking (.41, 95% CI .38–.44). Use of flavoured products was higher among female snus users (p = .67, 95% CI .65–.69) compared to males (p = .35, 95% CI .34–.36), highest among the youngest age group, 15–24 years (p = .58, 95% CI .56–.60) and decreased with increasing age.

Conclusion

Regulation that would ban or limit flavoured snus use may affect smokers—an at risk population—more than never smokers. The health authorities should be mindful of the real-world complexity governing potential harms and benefits of flavour restrictions on snus. A further assessment of flavour limitations should acknowledge that flavoured snus products also function as alternatives to cigarettes.

Correlates of youth vaping flavor preferences

Among youth who use electronic nicotine delivery systems (ENDS), e-cigarettes are often the first tobacco product tried. Flavor is a common reason for experimentation with e-cigarettes. This study assessed flavor preferences and the choice of ENDS as an initial product among youth by selected demographic characteristics. The analysis sample included 1549 participants who had ever tried ENDS, drawn from a national online survey of youth aged 13-18 in 2017. Fruit was the most common favorite flavor among ENDS users, followed by menthol/mint/wintergreen. Preference for flavor varied by age, sex and racial/ethnic background. ENDS were the tobacco products most likely to be tried first, particularly among participants under age 17. Those who preferred fruit flavor were twice as likely to have tried ENDS first, compared to those with other flavor preferences, while those who preferred menthol/mint/wintergreen flavor were half as likely to have tried ENDS first. Our findings support an association between flavor and ENDS use. Our research supports previous findings indicating that: 1) flavor is one of the primary reasons for experimentation with ENDS among youth; 2) fruit flavor is strongly associated with use of ENDS as the first tobacco product; and 3) preference of fruit flavor varies by age, sex and racial/ethnic background. These findings have relevance for developing targeted messages for specific youth audiences and implications for tobacco regulatory policies. In addition to January 2020 federal regulations, the authors recommend tighter restrictions, specifically that the marketing and sale of all e-cigarette flavors other than tobacco be eliminated.

Longitudinal pathways of exclusive and polytobacco smokeless use among youth, young adults and adults in the USA: findings from the PATH Study Waves 1-3 (2013-2016)

OBJECTIVE

Use of smokeless tobacco (SLT) with other tobacco products is growing, yet gaps in understanding transitions among SLT and other product use remain. The aim of this study is to examine cross-sectional prevalence and longitudinal pathways of SLT use among US youth (12-17 years), young adults (18-24 years) and adults 25+ (25 years and older).

DESIGN

Data were drawn from the first three waves (2013-2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth and adults. Respondents with data at all three waves (youth, n=11 046; young adults, n=6478; adults 25+, n=17 188) were included in longitudinal analyses.

RESULTS

Young adults had the highest current SLT use compared with other age groups. Among Wave 1 (W1) past 30-day youth and young adult SLT users, most were SLT and cigarette polytobacco users compared with adults 25+, who more often used SLT exclusively. Among W1 exclusive SLT users, persistent exclusive use across all three waves was more common among adults 25+, while transitioning from exclusive SLT use to SLT polytobacco use at Wave 2 or Wave 3 was more common among youth and young adults. Among W1 SLT and cigarette polytobacco users, a common pathway was discontinuing SLT use but continuing other tobacco use.

CONCLUSIONS

Our results showed distinct longitudinal transitions among exclusive and SLT polytobacco users. Deeper understanding of these critical product transitions will allow for further assessment of population health impact of these products.

Oral Health Effects of Combusted and Smokeless Tobacco Products

The oral cavity is usually the first part of a consumer's body exposed to the constituents of tobacco products or their emissions. Consequently, the oral cavity is a frequent site for carcinogenic, microbial, immunologic, and clinical effects of tobacco use. This article summarizes 5 presentations on various aspects of oral health affected by combusted or noncombusted tobacco products from a recent conference, "Oral Health Effects of Tobacco Products: Science and Regulatory Policy," sponsored by the American Association for Dental Research and the Food and Drug Administration.

Dissociating the effect of flavor and nicotine in smokeless tobacco products using electroencephalography: The case of wintergreen flavors

The increased consumption of tobacco products in recent years has been linked, among other factors, to the presence of added flavors. Although flavors are important in explaining consumption, their effects in the brain have until now been unexplored. In the present study, we investigated how electrophysiology can serve to dissociate the effects of nicotine and flavor. Participants attended 4 sessions (2-by-2 factorial design, with flavor and nicotine as within-subject factors), in each session an oddball task was performed before and after smokeless tobacco consumption. We explored the dissociation of neural responses to flavor and nicotine. While event-related potentials did not show modulation due to flavors, time-frequency showed a flavor-nicotine dissociation. Low-frequency activity (delta, theta and alpha) showed only effects of nicotine, and high-frequency activity (beta1, beta2 and gamma) showed effects only susceptible to flavor. Flavors in smokeless tobacco not only made the product more desirable but also triggered the allocation of cognitive resources. This long-lasting effect of flavor may enhance the addictive potential of the tobacco product. Further research is being developed to determine the precise role of flavors in contributing to addiction. This is the first study investigating the neural effects of flavor (specifically wintergreen) in smokeless tobacco products. By understanding the effects of flavors in the brain we can explain the precipitants of tobacco consumption behaviors, and the addictive potential of flavors. Regulators will be able to determine if and in which amount flavors should be allowed in tobacco products.

The US Cigarette Industry: An Economic and Marketing Perspective

Objectives

Tobacco company conduct has been a central concern in tobacco control. Nevertheless, the public health community has not taken full advantage of the large economics and marketing literature on market competition in the cigarette industry.

Methods

We conducted an unstructured narrative review of the economics and marketing literature using an antitrust framework that considers: 1) market; definition, 2) market concentration; 3) entry barriers; and 4) firm conduct.

Results

Since the 1960s, U.S. cigarette market concentration has increased primarily due to mergers and growth in the Marlboro brand. Entry barriers have included brand proliferation, slotting allowance contracts with retailers and government regulation. While cigarette sales have declined, established firms have used coordinated price increases, predatory pricing and price discrimination to sustain their market power and profits.

Conclusions

Although the major cigarette firms have exercised market power to increase prices and profits, the market could be radically changing, with consumers more likely to use several different types of tobacco products rather than just smoking a single cigarette brand. Better understanding of the interaction between market structure and government regulation can help develop effective policies in this changing tobacco product market.

Triangulating abuse liability assessment for flavoured cigar products using physiological, behavioural economic and subjective assessments: a within-subjects clinical laboratory protocol

INTRODUCTION

In the USA, Food and Drug Administration regulations prohibit the sale of flavoured cigarettes, with menthol being the exception. However, the manufacture, advertisement and sale of flavoured cigar products are permitted. Such flavourings influence positive perceptions of tobacco products and are linked to increased use. Flavourings may mask the taste of tobacco and enhance smoke inhalation, influencing toxicant exposure and abuse liability among novice tobacco users. Using clinical laboratory methods, this study investigates how flavour availability affects measures of abuse liability in young adult cigarette smokers. The specific aims are to evaluate the effect of cigar flavours on nicotine exposure, and behavioural and subjective measures of abuse liability.

METHODS AND ANALYSES

Participants (projected n=25) are healthy smokers of five or more cigarettes per day over the past 3 months, 18-25 years old, naive to cigar use (lifetime use of 50 or fewer cigar products and no more than 10 cigars smoked in the past 30 days) and without a desire to quit cigarette smoking in the next 30 days. Participants complete five laboratory sessions in a Latin square design with either their own brand cigarette or a session-specific Black & Mild cigar differing in flavour (apple, cream, original and wine). Participants are single-blinded to cigar flavours. Each session consists of two 10-puff smoking bouts (30 s interpuff interval) separated by 1 hour. Primary outcomes include saliva nicotine concentration, behavioural economic task performance and response to various questionnaire items assessing subjective effects predictive of abuse liability. Differences in outcomes across own brand cigarette and flavoured cigar conditions will be tested using linear mixed models.

ETHICS AND DISSEMINATION

The Virginia Commonwealth University Institutional Review Board approved the study (VCU IRB: HM20007848). Dissemination channels for study findings include scientific journals, scientific meetings, and policy briefs.

TRIAL REGISTRATION NUMBER

NCT02937051.

The US SimSmoke tobacco control policy model of smokeless tobacco and cigarette use

Background

Smokeless tobacco (SLT) prevalence had been declining in the US prior to 2002 but has since increased. Knowledge about the impact of tobacco control policies on SLT and cigarette use is limited. This study examines the interrelationship between policies, cigarette use, and SLT use by applying the SimSmoke tobacco control policy simulation model.

Methods

Using data from large-scale Tobacco Use Supplement and information on policies implemented, US SimSmoke was updated and extended to incorporate SLT use. The model distinguishes between exclusive SLT and dual use of SLT and cigarettes, and considers the effect of implementing individual and combined tobacco control policies on smoking and SLT use, and on deaths attributable to their use. After validating against Tobacco Use Supplement (TUS) survey data through 2015, the model was used to estimate the impact of policies implemented between 1993 and 2017.

Results

SimSmoke reflected trends in exclusive cigarette use from the TUS, but over-estimated the reductions, especially among 18–24 year olds, until 2002 and under-estimated the reductions from 2011 to 2015. By 2015, SimSmoke projections of exclusive SLT and dual use were close to TUS estimates, but under-estimated reductions in both from 1993 to 2002 and failed to estimate the growth in male exclusive SLT use, especially among 18–24 year olds, from 2011 to 2015. SimSmoke projects that policies implemented between 1993 and 2017 reduced exclusive cigarette use by about 35%, dual use by 32.5% and SLT use by 16.5%, yielding a reduction of 7.5 million tobacco-attributable deaths by 2067. The largest reductions were attributed to tax increases.

Conclusions

Our results indicate that cigarette-oriented policies may be effective in also reducing the use of other tobacco products. However, further information is needed on the effect of tobacco control policies on exclusive and dual SLT use and the role of industry.

Strong preference for mint snus flavor among research participants

Introduction

The Family Smoking Prevention and Tobacco Control Act of 2009 allows the US FDA to regulate tobacco products, including the banning of characterizing flavors, such as fruit and candy, cigarettes. The availability of mint flavored snus may facilitate the use of the product if consumers find it more palatable with respect to taste, odor, pleasantness, and intensity.

Methods

This study assessed product evaluation (PES), odor identification, odor intensity, and odor hedonics among 151 smokers enrolled in a clinical trial of snus substitution for cigarettes.

Results

Far more participants selected Winterchill (N = 110) than Robust (N = 41), regardless of their menthol cigarette smoking status. Nicotine dependence was higher among those who selected Winterchill (4 vs 3 on Fagerstrom scale, p = 0.017). Those who found Winterchill to be more satisfying, less aversive, and having a more intense, more pleasant odor than Robust were substantially more likely to select Winterchill for their one week trial.

Conclusions

Findings indicate that subjective effect measures such as the PES and DEQ are capable of differentiating products in terms of flavor preference, and that smokers express a strong preference for mint flavored snus.

•

Subjective effect measures such as the PES and DEQ are capable of differentiating products in terms of flavor preference

•

Odor intensity and pleasantness were positively associated with product selection

•

Smokers express a strong preference for mint flavored snus

The Effect of Tobacco Control Policies on US Smokeless Tobacco Use: A Structured Review

INTRODUCTION

Tobacco use has shifted increasingly from cigarettes to other products. While the focus has been mostly on cigarette-oriented policies, it is important to gauge the effects of policies targeting other products. We review and critique the literature on how policies affect smokeless tobacco (ST).

METHODS

We conducted a search of the literature on tobacco control policies as they relate to ST use, focusing on tobacco taxes, smoke-free air laws, media campaigns, advertising restrictions, health warnings, cessation treatment policies, and youth access policies. Findings from 78 total studies are summarized.

RESULTS

ST taxes, media campaigns, health warnings, and cessation treatment policies were found to be effective tools in reducing ST use. Evidence on the effects of current youth access policies is less strong. Studies have not yet been conducted on marketing or product content restrictions, but the literature indicates that product marketing, through advertising, packaging, flavorings, and extension of cigarette brands, plays an important role in ST use.

CONCLUSIONS

Although the evidence base is less established for ST policies than for cigarette policies, the existing literature indicates ST use responds to tobacco control policies. Policies should be structured in a way that aims to reduce all tobacco use while at the same time increasing the likelihood that continuing tobacco users use the least risky products.

IMPLICATIONS

Studies find that policies targeting smoking and policies targeting smokeless products affect smokeless use, but studies are needed to examine the effect of policies on the transitions between cigarette and smokeless use.

ST product characteristics and relationships with perceptions and behaviors among rural adolescent males: a qualitative study

Although smoking declines in the United States, the prevalence of male adolescent smokeless tobacco (ST; moist snuff and chewing tobacco) use remains unchanged. ST product characteristics, such as flavoring, packaging, and branding, could influence adolescents' ST initiation and continued use. This qualitative study examines the potential role of product characteristics in shaping ST-related perceptions and behaviors among rural adolescent males. Semi-structured individual interviews were conducted at three California rural high schools. ST users were asked about their experiences and perceptions related to product characteristics. Interviews were transcribed, coded, and analyzed using a general inductive approach. Participants associated flavored ST with appealing non-tobacco products, such as chewing gum and alcohol. Availability of different varieties and flavors stimulated interest and curiosity in sampling or switching between ST products. Time-limited promotional flavors and packaging also enhanced product appeal. Adolescent ST users preferred certain brands based on perceived brand features and perceived nicotine content, associating higher-strength brands as better suited for experienced ST users. Brand preferences frequently reflected perceived ST brand popularity within peer groups. Based on these observations, potential ST regulation and health education campaigns to address misconceptions about ST characteristics could influence adolescents' ST-related perceptions and reduce ST use among this vulnerable population.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pilot Experiment: The Effect of Added Flavorants on the Taste and Pleasantness of Mixtures of Glycerol and Propylene Glycol

Introduction

The US Food and Drug Administration banned most "sweet" flavorants for use in cigarettes due to the concern that sweet flavors appeal to young, beginning smokers. However, many of the same flavors, including fruity and confection-associated aromas (e.g. vanilla) are still used in e-cigarettes. Sweet flavors may have a number of effects, including enhancement of the taste of other ingredients. The current work focused on the impact of model flavorants on the taste of a mixture of propylene glycol and vegetable glycerine, solvents used in most e-cigarettes and related products.

Methods

A device delivered mixtures of propylene glycol and vegetable glycerine into the mouth in parallel with puffs of clean air (control) or odorized air. Aromas included two "fruity" esters ("pineapple" and "banana"), two confection-associated aromas ("vanilla" and "caramel/malty"), menthol (not a "sweet" aroma, but commonly used in e-cigarettes), and a "burnt" aroma not expected enhance flavor. Twenty young adults, aged 18-25, rated the sweetness, bitterness, and pleasantness of all stimuli (within-subjects design).

Results

Both fruity aromas significantly enhanced sweetness, both confection-associated aromas significantly enhanced pleasantness, and the caramel/malty aroma significantly reduced bitterness. Menthol and the "burnt" aroma had no measurable effects on the taste of solvent mixtures.

Conclusion

Some flavorants modulated the taste of solvents commonly used in e-cigarettes in ways consistent with an enhanced sensory profile.

Implications

If similar effects occur in actual products, improved flavor profiles could facilitate continued use, particularly in non-smokers experimenting with e-cigarettes and related products.

Perceived Flavored Smokeless Tobacco Ease-of-use and Youth Susceptibility

OBJECTIVES

Beliefs that flavored smokeless tobacco (ST) is more pleasant, less potent, or otherwise easier to use could contribute to youth initiation. We evaluated associations between perceived ease-of-use of flavored ST (moist snuff and chewing tobacco) and ST initiation susceptibility in a representative sample of US youth.

METHODS

Among 7,718 tobacco never-users in the Population Assessment of Tobacco and Health study (age: 12-17; collected: 2013-2014), we compared 4 ST susceptibility items (curiosity, expectation, willingness to try, and a composite) according to whether participants reported flavored ST to be "easier to use" than unflavored ST. We calculated marginal prevalences of ST susceptibility and odds ratios adjusted for socio-demographic characteristics, tobacco advertisement receptivity, warning label exposure, and sensation seeking.

RESULTS

ST susceptibility was greatest among tobacco never-users who perceived flavored ST as easier to use. Adjusted odds of potential ST susceptibility (≥1 item) were 1.5-fold higher (95% confidence interval: 1.2, 1.8) among adolescents who perceived flavored ST as easier to use than unflavored ST.

CONCLUSIONS

ST flavors could contribute to perceptions that facilitate youth initiation. Alternatively, youth susceptible to ST use may perceive flavored varieties differently. Prospective studies are warranted to strengthen causal evidence and measure ST initiation according to perceived ease-of-use.

Influence of the Flavored Cigarette Ban on Adolescent Tobacco Use

INTRODUCTION

This paper estimated the association between the U.S. Food and Drug Administration's 2009 ban on flavored cigarettes (which did not apply to menthol cigarettes or tobacco products besides cigarettes) and adolescents' tobacco use.

METHODS

Regression modeling was used to evaluate tobacco use before and after the ban. The analyses controlled for a quadratic time trend, demographic variables, prices of cigarettes and other tobacco products, and teenage unemployment rate. Data from the 1999-2013 National Youth Tobacco Surveys were collected and analyzed in 2016. The sample included 197,834 middle and high schoolers. Outcomes were past 30-day cigarette use; cigarettes smoked in the past 30 days among smokers; rate of menthol cigarette use among smokers; and past 30-day use of cigars, smokeless tobacco, pipes, any tobacco products besides cigarettes, and any tobacco products including cigarettes.

RESULTS

Banning flavored cigarettes was associated with reductions in the probability of being a cigarette smoker (17%, p<0.001) and cigarettes smoked by smokers (58%, p=0.005). However, the ban was positively associated with the use by smokers of menthol cigarettes (45%, p<0.001), cigars (34%, p<0.001), and pipes (55%, p<0.001), implying substitution toward the remaining legal flavored tobacco products. Despite increases in some forms of tobacco, overall there was a 6% (p<0.001) reduction in the probability of using any tobacco.

CONCLUSIONS

The results suggest the 2009 flavored cigarette ban did achieve its objective of reducing adolescent tobacco use, but effects were likely diminished by the continued availability of menthol cigarettes and other flavored tobacco products.

Determinants associated with E-cigarette adoption and use intention among college students

OBJECTIVE

This study investigated characteristics of potential and current e-cigarette users based on four different levels of use acceptability along with the determinants that promote e-cigarette use acceptability among college students.

METHODS

College students (N=1198) aged 18-25years at a Midwestern university were surveyed in September-October 2015. Participants were categorized into four groups based on e-cigarette use acceptability adapted from the Diffusion of Innovation Theory (i.e., laggards, late majority, early majority, and adopters). Multinomial logistic regressions and Heckman two-step selection procedures were performed to examine the determinants that promote e-cigarette use acceptability.

RESULTS

Approximately 40% of the participants reported ever using e-cigarettes. E-cigarette adopters agreed that e-cigarettes are more socially acceptable than traditional tobacco cigarettes (relative risk ratio [RRR]=1.43, p<0.01). Unique features such as flavor appeared to encourage college students' experimentation with e-cigarettes (ps<0.05). Participants mentioned positive sensory experiences as a reason for e-cigarette use (ps<0.01) and reported caring about their appearance more than their health (ps<0.05) when asked about possible outcomes of e-cigarette use.

CONCLUSIONS

Study findings indicate a possible explosive increase in e-cigarette experimentation or use among college students. Unique features of e-cigarettes such as flavor and USB rechargeability appear to be strong factors making e-cigarettes more acceptable and appealing to young adults regardless of their smoking status. Concerted efforts should be initiated to effectively counter or eliminate attractive features that lure young adults to experiment with e-cigarettes.

Acute effects of snus in never-tobacco users: a pilot study

BACKGROUND

Snus tobacco characteristics may attract non-tobacco users, including relatively low, but pharmacologically active, doses of nicotine. Lower nicotine doses may limit adverse drug effects while also producing a physiologically active response.

OBJECTIVES

This pilot study is the first to profile the acute effects of snus on physiological and subjective assessments in a sample of never-tobacco users.

METHODS

Eleven never-tobacco users (five women; <100 uses/lifetime) were recruited from the community via university-approved advertisements. Using a within-subject design, participants consumed six pouches in ascending dose order (0, 1.6, 3.2, 4.8, 6.4, and 8.0 mg nicotine) within one session. The start of each snus bout was separated by 45 minutes, and pre- and post-pouch assessments included ratings of drug effects and physiological response.

RESULTS

The average heart rate and systolic blood pressure increased significantly from pre- to post-pouch use as a function of dose, though these increases were reliable for 8.0 mg nicotine only (p < .05). Collapsed across time, diastolic blood pressure was significantly higher for 8.0 mg nicotine than for all other doses (p < .05). Subjective ratings for "excessive salivation" and "satisfying" increased significantly from pre- to post-pouch use (p < .05), independent of dose.

CONCLUSION

Significant increases in physiological response at some doses suggest that users were exposed to pharmacologically active doses of nicotine. The lack of reliable subjective effects may be the product of the dosing regimen or the relatively small sample size. Findings highlight the need for identification of doses of snus that may promote abuse among naïve users.

Impact of non-menthol flavours in tobacco products on perceptions and use among youth, young adults and adults: a systematic review

Objective

This systematic review examines the impact of non-menthol flavours in tobacco products on tobacco use perceptions and behaviours among youth, young adults and adults.

Data sources

English-language peer-reviewed publications indexed in 4 databases were searched through April 2016.

Study selection

A search strategy was developed related to tobacco products and flavours. Of 1688 articles identified, we excluded articles that were not English-language, were not peer-reviewed, were qualitative, assessed menthol-flavoured tobacco products only and did not contain original data on outcomes that assessed the impact of flavours in tobacco products on perceptions and use behaviour.

Data extraction

Outcome measures were identified and tabulated. 2 researchers extracted the data independently and used a validated quality assessment tool to assess study quality.

Data synthesis

40 studies met the inclusion criteria. Data showed that tobacco product packaging with flavour descriptors tended to be rated as more appealing and as less harmful by tobacco users and non-users. Many tobacco product users, especially adolescents, reported experimenting, initiating and continuing to use flavoured products because of the taste and variety of the flavours. Users of many flavoured tobacco products also showed decreased likelihood of intentions to quit compared with non-flavoured tobacco product users.

Conclusions

Flavours in most tobacco products appear to play a key role in how users and non-users, especially youth, perceive, initiate, progress and continue using tobacco products. Banning non-menthol flavours from tobacco products may ultimately protect public health by reducing tobacco use, particularly among youth.

Tobacco industry use of flavourings to promote smokeless tobacco products

BACKGROUND

While fruit, candy and alcohol characterising flavours are not allowed in cigarettes in the USA, other flavoured tobacco products such as smokeless tobacco (ST) continue to be sold. We investigated tobacco manufacturers' use of flavoured additives in ST products, the target audience(s) for flavoured products, and marketing strategies promoting products by emphasising their flavour.

METHODS

Qualitative analysis of internal tobacco industry documents triangulated with data from national newspaper articles, trade press and internet.

RESULTS

Internally, flavoured products have been consistently associated with young and inexperienced tobacco users. Internal studies confirmed that candy-like sweeter milder flavours (eg, mint, fruit) could increase appeal to starters by evoking a perception of mildness, blinding the strong tobacco taste and unpleasant mouth feel; or by modifying nicotine delivery by affecting product pH.

DISCUSSION

Similar to cigarettes, flavoured ST is likely to encourage novices to start using tobacco, and regulations limiting or eliminating flavours in cigarettes should be extended to include flavoured ST products.

Association between use of flavoured tobacco products and quit behaviours: findings from a cross-sectional survey of US adult tobacco users

BACKGROUND

Non-menthol characterising flavours (eg, fruit, candy) are banned in cigarettes, yet are still permitted in non-cigarette tobacco (NCT) products. This study examined associations between first use and current use of flavoured tobacco products, and current flavoured tobacco use and quit behaviours.

METHODS

A nationally representative, telephone-based survey completed in 2012 by 1443 US adult tobacco users asked about use of 9 tobacco products: cigarettes, e-cigarettes, cigars, cigarillos, little filtered cigars, pipes, hookah, smokeless tobacco and snus. Ever users reported first use of flavoured products, while current users also reported current flavoured product use. Current users reported quit attempts made in the past year. Data were weighted to reflect the US adult tobacco user population. Logistic regression models were used to examine associations between first/current flavour use and quit behaviours.

RESULTS

Over 70% of respondents reported first use of a flavoured tobacco product, while 54% reported current use of at least one flavoured product. Odds of current flavoured product use were greater among those who reported first use of a flavoured product (OR 14.82, 95% CI 9.96 to 22.06). First use of a flavoured product was associated with being a current tobacco user (OR 1.55, 95% CI 1.08 to 2.22). Compared to single product users, polytobacco users exhibited greater odds of reporting current use of flavoured products (OR 2.09, 95% CI 1.47 to 2.97). Forty-four percent of current tobacco users reported a past-year quit attempt. Adjusted analyses among current NCT users of at least one flavoured tobacco product showed reduced odds of reporting a quit attempt.

CONCLUSIONS

First use of a flavoured tobacco product was associated with current flavoured tobacco use and polytobacco use. Users of only flavoured NCT products exhibited reduced odds of reporting a quit attempt. Findings from this study reinforce the importance of flavoured product availability in the USA, which may have significant implications for efforts to reduce tobacco initiation and use at a population level. The relationship between characterising flavours and quit behaviours merits further exploration in longitudinal, population-based samples.

Correlates of current menthol cigarette and flavored other tobacco product use among U.S. young adults

BACKGROUND

Flavored and menthol tobacco products are particularly appealing to young adults. However, little is known about factors associated with their use in this population.

PURPOSE

To examine characteristics associated with using menthol cigarettes, flavored other tobacco products (OTP), and flavored e-cigarettes among young adults.

METHODS

Using a nationally representative online sample of young adults (n=4239) from the Truth Initiative Young Adult Cohort Study, mutually exclusive groups were created from the subset of current tobacco users (N=1037) for users of menthol cigarettes (N=311; 30%), non-menthol cigarettes (N=426; 41%), flavored OTP only users (N=114; 11%), and non-flavored OTP only users (N=186; 18%) to examine factors of being in any one group. Data were collected in July 2012.

RESULTS

In the full multivariable model, significant correlates of current menthol cigarette use were female gender (AOR=2.08), Black race (AOR=5.31), other race (AOR=2.72), Hispanic ethnicity (AOR=2.46) and self-identifying as a smoker, social smoker, or occasional smoker (AOR=10.42). Significant correlates of current flavored OTP use were younger age (18-24; AOR=3.50), self-identifying as a smoker, social smoker, or occasional smoker (AOR=30) and generalized anxiety (AOR=0.30).

CONCLUSIONS

This study highlights female gender, Blacks/other race/Hispanics, smokers, social smokers and sexual minorities as correlates of menthol cigarette use and younger age as a predictor of flavored OTP use. Restricting access to flavored tobacco products may be one intervention to help slow the tobacco epidemic, particularly among many of the most vulnerable groups-young women and racial and/or ethnic minorities.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

[Measurement of Nicotine, Tobacco-Specific Nitrosamines, and Additives in the Filler and Gas from Japanese Brand Snuff]

OBJECTIVE

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) reported that understanding the use and impact of smokeless tobacco (SLT) products is complicated by product diversity. Many different SLT products with different characteristics are used worldwide. ZERO STYLE STIX(TM) (sold by Japan Tobacco Inc.) is a brand of snuff, a type of smokeless tobacco. Our objective was to determine the constituents of the gas from SLT and analyze the ingredients in tobacco fillers.

METHODS

ZERO STYLE STIX smokeless tobacco was released in the Japanese market in 2010. Nicotine, menthol, and tobacco-specific nitrosamines in the smokeless tobacco fillers were determined by gas chromatography-mass spectrometry (GC/MS) and liquid chromatography-tandem mass spectrometry (LC/MS/MS). The gaseous compounds were collected by a smoking machine using two smoking protocols, i.e., the ISO and Health Canada Intense methods. Nicotine and menthol in the gas were determined by GC/MS.

RESULTS

Nicotine, menthol, and the total tobacco-specific nitrosamines were detected in the tobacco fillers. The level of menthol in the snuff was more than ten times that of nicotine. The determined levels of the two components of the gas from the snuff were higher when using the Health Canada Intense protocol than when using the ISO protocol. In addition, flavors other than menthol were emitted from the smokeless tobacco.

CONCLUSION

The new type of snuff introduced in the Japanese market in 2010 contained added flavors, and was attractive smokeless tobacco. Flavors in tobacco products need to regulate on the basis of FCTC 9 and 10 in JAPAN.

Cigarette smoking susceptibility among youth alternate tobacco product users: implications of flavoured tobacco from a national cross-sectional Canadian sample (YSS 2012/2013)

OBJECTIVES

Declines in cigarette smoking have been accompanied by increases in alternative tobacco product (ATP) use, particularly among youth. This study examines smoking susceptibility and ATP use in a national sample of Canadian youth.

METHODS

Data from grades 9-12 students who participated in the 2012/2013 Youth Smoking Survey, a nationally generalisable sample of Canadian students (n=27,404) were used to examine cigarette smoking susceptibility among never smokers (n=17,396). Logistic regression models were used to examine differences in smoking susceptibility by use of flavoured and all ATPs and by sociodemographic and lifestyle characteristics.

RESULTS

Overall, 30% of Canadian grades 9-12 never smokers were susceptible to cigarette smoking. Compared to never users, those who had ever tried ATPs (OR=1.96, 95% CI 1.59 to 2.42) and those who had ever tried flavoured ATPs (OR=2.20, 95% CI 1.63 to 2.96) had significantly higher odds of being susceptible to cigarette smoking.

CONCLUSIONS

ATP use is associated with smoking susceptibility among youth never smokers. Findings from this study, along with existing evidence, can be used by policymakers to improve regulation around youth access to ATPs (particularly flavoured varieties).

First tobacco product tried: associations with smoking status and demographics among college students

INTRODUCTION

As the tobacco market expands, so too have the opportunities for youth to be introduced to nicotine. The goal of this study was to identify product choice for initial tobacco trial, correlates associated with product choice, and the relationship between first product and current cigarette smoking among college students.

METHODS

A cross-sectional web survey of 3146 first-year students at 11 universities in North Carolina and Virginia was conducted in fall 2010.

RESULTS

Weighted prevalence of ever use of tobacco was 48.6%. Cigarettes were the most common first product (37.9%), followed by cigars (29.3%), hookahs (24.6%), smokeless tobacco (6.1%), and bidis/kreteks (2.2%). Two thirds (65%) of current smokers initiated with cigarettes, but 16.4% started with cigars, 11.1% with hookahs, 5.7% with smokeless, and 1.7% with bidis/kreteks. Females were more likely to report their first product was cigarettes and hookahs, while males were more likely to start with cigars and smokeless tobacco. Compared to those whose first product trial occurred after the age of 18, younger age of initiation (17years or younger) was associated with cigarettes and smokeless as first products, while older age of initiation (18 or older) was associated with starting with hookahs and cigars. Dual or poly tobacco use was more common among those who initiated with hookahs and smokeless tobacco.

CONCLUSIONS

While over a third of students used cigarettes first, two thirds started with a non-cigarette product. Just about a third of current cigarette smokers initiated with a non-cigarette product, suggesting that those non-cigarette products may have facilitated escalation to cigarettes.

Characteristics and Patterns of Black & Mild Use Among African American Smokers

INTRODUCTION

Increased consumption of little cigars and cigarillos (LCCs) among late adolescent and young adult African American smokers is an emerging public health concern. Despite a growing body of epidemiological evidence, there is scant research on systematic variations in LCC use among young adult African Americans. This study aimed to disaggregate African American Black & Mild (B&M) smokers and to identify subgroups of cigarillo smokers' behaviors and associated characteristics.

METHODS

Using telephone screening data for a NIH-funded clinical laboratory study of toxicant exposure associated with B&M use, latent class analysis (LCA) was used to classify 331 African American B&M smokers' based on daily use, average daily consumption, preference for flavors, preference for product design tips, and product modification behaviors.

RESULTS

Results showed five classes, three of which (Daily-Hypers, Daily-Flavored, and Heavy-Daily-Hypers) reflected daily use and average daily consumption rate ranging between 2.7 and 8.9 B&M cigarillos per day. Non-Daily-Hypers and Non-Daily-Flavored classes represented non-daily use patterns and averaged less than 1.0 B&M cigarillo per day. Both sets of classes defined by daily users and non-daily users included smokers who preferred flavored tobacco and who practiced product modification techniques involving hyping and blunting.

CONCLUSIONS

Latent class analysis is a useful method to detect subtle differences in B&M product preferences and smoking behaviors among African Americans. Study findings highlight the importance of developing tailored interventions that consider within group differences in order to reduce the prevalence of cigarillo smoking among those with the greatest burden.

IMPLICATIONS

The current study is the first to identify unique subgroups of African American B&M smokers based on cigarillo use behaviors and associated characteristics. Latent class analyses may prove useful for understanding other subgroups of tobacco users. Current findings concerning patterns of LCC use illustrate how future tobacco cessation and prevention interventions may be tailored for African American smokers.

Flavored Tobacco Products in the United States: A Systematic Review Assessing Use and Attitudes

OBJECTIVES

We systematically reviewed research examining use of and attitudes toward nonmenthol-flavored tobacco products to provide information relevant to a decision to regulate these products in the future.

METHODS

To identify eligible studies, we searched PubMed, CINHAL, Embase, LILACS, and PsycINFO on September 19, 2013, without date restrictions. We obtained additional studies via gray literature searches, expert contacts, and hand-searching citations of included articles. We included participants of all ages. We conducted a qualitative synthesis for included studies.

RESULTS

The 32 studies included in this review exhibited substantial heterogeneity and were of varied methodological quality. Findings from observational, experimental, and quasiexperimental studies suggest that flavored tobacco use is associated with young age and that consumers may perceive flavored products more favorably than nonflavored products. Evidence from qualitative studies indicates that flavoring in tobacco is viewed favorably by users and nonusers of these products.

CONCLUSIONS

The Food and Drug Administration has expressed interest in regulating flavored tobacco products. This systematic review strengthens the evidence base relating to this issue by synthesizing the literature from the United States on the use of and attitudes toward flavored tobacco. To address gaps in the literature, more research is needed to understand how flavoring impacts tobacco use over time. The evidence base would further be strengthened with the collection of brand-, flavor-, and product-specific data.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Flavored tobacco use among Canadian students in grades 9 through 12: prevalence and patterns from the 2010-2011 youth smoking survey

Introduction

This study examined patterns of use of flavored tobacco products in a nationally generalizable sample of Canadian students in grades 9 through 12 after the implementation of a national ban on certain flavored tobacco products.

Methods

Data from the 2010–2011 Youth Smoking Survey, a nationally generalizable sample of Canadian students in grades 9 through 12 (n = 31,396), were used to examine tobacco product use. Logistic regression models were used to examine differences in use of flavored tobacco products (cigarettes, pipes, little cigars or cigarillos, cigars, roll-your-own cigarettes, bidis, smokeless tobacco, water pipes, and blunt wraps) by sociodemographic and regional characteristics.

Results

Approximately 52% of young tobacco users used flavored products in the previous 30 days. Flavored tobacco use varied by product type and ranged from 32% of cigarette smokers reporting menthol smoking to 70% of smokeless tobacco users reporting using flavored product in the previous 30 days. The percentage of last-30-day users who used flavored tobacco was significantly higher in Quebec than in Ontario and significantly higher among youths who received weekly spending money than among those who received no money.

Conclusion

More than half of tobacco users in grades 9 through 12 in Canada use flavored tobacco, despite a national ban on certain flavored tobacco products.

Smokeless tobacco use among working adults - United States, 2005 and 2010

Smokeless tobacco causes cancers of the oral cavity, esophagus, and pancreas. CDC analyzed National Health Interview Survey (NHIS) data to estimate the proportion of U.S. working adults who used smokeless tobacco in 2005 and 2010, by industry and occupation. This report describes the results of that analysis, which showed no statistically significant change in the prevalence of smokeless tobacco use among workers from 2005 (2.7%) to 2010 (3.0%). In 2010, smokeless tobacco use was highest among adults aged 25-44 years (3.9%), males (5.6%), non-Hispanic whites (4.0%), those with no more than a high school education (3.9%), and those living in the South (3.9%). By industry, the prevalence of smokeless tobacco use ranged from 1.5% in education services to 18.8% in mining industries, and by occupation from 1.3% in office and administrative support to 10.8% in construction and extraction. These findings highlight opportunities for reducing the health and economic burdens of tobacco use among U.S. workers, especially those in certain industries (e.g., mining) and occupations (e.g., construction and extraction) where use of smokeless tobacco is especially common. CDC recommends best practices for comprehensive tobacco control programs, including effective employer interventions, such as providing employee health insurance coverage for proven cessation treatments, offering easily accessible help for those who want to quit, and establishing and enforcing tobacco-free workplace policies.

Impact of smokeless tobacco packaging on perceptions and beliefs among youth, young adults, and adults in the U.S: findings from an internet-based cross-sectional survey

Background

Research demonstrates that tobacco packaging elements (including health warning labels, descriptive characteristics, and corporate branding) are associated with knowledge of health risks and product appeal with cigarettes. Yet, little research has assessed this with smokeless tobacco (SLT) packaging. This study evaluates the association between three SLT packaging elements with knowledge of health risks and perceptions of novelty and appeal. Additionally, we assess how effects of these messages may differ across age groups, including youth (14-17 years), young adults (18-25 years), and older adults (26-65 years).

Methods

1000 participants were administered a web-based survey in 2010 and shown three sets of SLT packs in random order, varied by descriptor (flavor descriptor vs. none), warning label format (graphic vs. text), and corporate branding (branded vs. plain packaging). Participants rated the packs compared with “no difference” on appeal, novelty, and risk perceptions associated with product use. Chi-square tests were used to test for significant differences in pack selections. Multinomial regression was employed to evaluate the association between effects of packaging elements and participant age.

Results

More respondents selected the pack with the graphic warning label as the pack to make them consider the health risks associated with SLT use, attract their attention, and be least attractive to a smoker. The product with the text warning label was the product someone their age would want to be seen using and would appeal to peers. The SLT pack with the flavor descriptor was not associated with health risks associated with product use. The pack with corporate branding was selected as more appealing, to attract attention, and one they would want to be seen using; the plain pack was less attractive to smokers. Youth and young adults were more likely to indicate that pack elements affected their perceptions of appeal and risk associated with SLT products.

Conclusion

These results suggest that SLT pack characteristics have a measurable effect on perceptions of health risk and product appeal. Future research should assess these findings in the context of harm reduction. Specifically, research is needed to determine whether pack elements on SLT products can effectively convey risk and harm.

Not so Cool? Menthol's discovered actions on the nicotinic receptor and its implications for nicotine addiction

Nicotine cigarette smoke is a large public health burden worldwide, contributing to various types of disease. Anti-tobacco media campaigns and control programs have significantly reduced smoking in the United States, yet trends for menthol cigarette smoking have not been as promising. Menthol cigarette smoking is particularly prevalent among young adults and African Americans, with implications for long-term impacts on health care. Continuing high rates of menthol cigarette addiction call into question the role of menthol in nicotine addiction. To date, a biological basis for the high rate of addiction and relapse among menthol cigarette smokers has not been defined. Studies have demonstrated a role for menthol in the metabolism of nicotine in the body. More recent findings now reveal an interaction between menthol and the nicotinic acetylcholine (nACh) receptor in cells. This receptor is central to the actions of nicotine in the brain, and plays an important role in nicotine addiction. The newly discovered effect of menthol on nACh receptors may begin to explain the unique addictive properties of menthol cigarettes.

Ending tobacco-caused mortality and morbidity: the case for performance standards for tobacco products

The US Family Smoking Prevention and Tobacco Control Act and WHO Framework Convention on Tobacco Control provide us with powerful tools to reduce the death and disease caused by the use of tobacco products. One tool that can contribute substantially toward this goal is the authority to establish performance standards for tobacco products. Conjointly with reducing levels of nicotine in cigarettes, performance and quality control standards need to be established for non-combusted tobacco products. Performance standards and incentives should be provided so that tobacco companies are compelled to manufacture and market products with very low or almost non-existent toxicity (eg, nicotine-only products).