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Lindson N, Butler AR, McRobbie H, Bullen C, Hajek P, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Livingstone-Banks J, Morris T, Hartmann-Boyce J. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2024; 1:CD010216. [PMID: 38189560 PMCID: PMC10772980 DOI: 10.1002/14651858.cd010216.pub8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review. OBJECTIVES To examine the safety, tolerability and effectiveness of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence, in comparison to non-nicotine EC, other smoking cessation treatments and no treatment. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register to 1 February 2023, and Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2023, and reference-checked and contacted study authors. SELECTION CRITERIA We included trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention as these studies have the potential to provide further information on harms and longer-term use. Studies had to report an eligible outcome. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Critical outcomes were abstinence from smoking after at least six months, adverse events (AEs), and serious adverse events (SAEs). We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in pairwise and network meta-analyses (NMA). MAIN RESULTS We included 88 completed studies (10 new to this update), representing 27,235 participants, of which 47 were randomized controlled trials (RCTs). Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 58 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There is high certainty that nicotine EC increases quit rates compared to nicotine replacement therapy (NRT) (RR 1.59, 95% CI 1.29 to 1.93; I2 = 0%; 7 studies, 2544 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6 more). There is moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs is similar between groups (RR 1.03, 95% CI 0.91 to 1.17; I2 = 0%; 5 studies, 2052 participants). SAEs were rare, and there is insufficient evidence to determine whether rates differ between groups due to very serious imprecision (RR 1.20, 95% CI 0.90 to 1.60; I2 = 32%; 6 studies, 2761 participants; low-certainty evidence). There is moderate-certainty evidence, limited by imprecision, that nicotine EC increases quit rates compared to non-nicotine EC (RR 1.46, 95% CI 1.09 to 1.96; I2 = 4%; 6 studies, 1613 participants). In absolute terms, this might lead to an additional three quitters per 100 (95% CI 1 to 7 more). There is moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 1840 participants). There is insufficient evidence to determine whether rates of SAEs differ between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 9 studies, 1412 participants; low-certainty evidence). Due to issues with risk of bias, there is low-certainty evidence that, compared to behavioural support only/no support, quit rates may be higher for participants randomized to nicotine EC (RR 1.88, 95% CI 1.56 to 2.25; I2 = 0%; 9 studies, 5024 participants). In absolute terms, this represents an additional four quitters per 100 (95% CI 2 to 5 more). There was some evidence that (non-serious) AEs may be more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low-certainty evidence; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 0.89, 95% CI 0.59 to 1.34; I2 = 23%; 10 studies, 3263 participants; very low-certainty evidence). Results from the NMA were consistent with those from pairwise meta-analyses for all critical outcomes, and there was no indication of inconsistency within the networks. Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence, evidence for these is limited, with CIs often encompassing both clinically significant harm and benefit. AUTHORS' CONCLUSIONS There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain due to risk of bias inherent in the study design. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but the longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
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Affiliation(s)
- Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Peter Hajek
- Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rachna Begh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caitlin Notley
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tari Turner
- Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Tom Morris
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Jamie Hartmann-Boyce
- Department of Health Promotion and Policy, University of Massachusetts, Amherst, MA, USA
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Hartmann-Boyce J, Lindson N, Butler AR, McRobbie H, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Fanshawe TR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2022; 11:CD010216. [PMID: 36384212 PMCID: PMC9668543 DOI: 10.1002/14651858.cd010216.pub7] [Citation(s) in RCA: 67] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, although some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review. OBJECTIVES To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2022, and reference-checked and contacted study authors. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and randomized cross-over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants, or both. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta-analyses. MAIN RESULTS We included 78 completed studies, representing 22,052 participants, of which 40 were RCTs. Seventeen of the 78 included studies were new to this review update. Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 50 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There was high certainty that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (RR 1.63, 95% CI 1.30 to 2.04; I2 = 10%; 6 studies, 2378 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6). There was moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs was similar between groups (RR 1.02, 95% CI 0.88 to 1.19; I2 = 0%; 4 studies, 1702 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.12, 95% CI 0.82 to 1.52; I2 = 34%; 5 studies, 2411 participants). There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 1840 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 8 studies, 1272 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.66, 95% CI 1.52 to 4.65; I2 = 0%; 7 studies, 3126 participants). In absolute terms, this represents an additional two quitters per 100 (95% CI 1 to 3). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that (non-serious) AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.03, 95% CI 0.54 to 1.97; I2 = 38%; 9 studies, 1993 participants). Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit. AUTHORS' CONCLUSIONS There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Rachna Begh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caitlin Notley
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tari Turner
- Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Hajek
- Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Phillips-Waller A, Przulj D, Pesola F, Smith KM, Hajek P. Nicotine Delivery and User Ratings of IQOS Heated Tobacco System Compared With Cigarettes, Juul, and Refillable E-Cigarettes. Nicotine Tob Res 2021; 23:1889-1894. [PMID: 33983450 PMCID: PMC8496472 DOI: 10.1093/ntr/ntab094] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/11/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Reduced-risk nicotine products are more likely to replace smoking if they match cigarettes in nicotine delivery and user satisfaction. AIMS AND METHODS We examined the nicotine delivery profile and user ratings of IQOS heated tobacco system and compared it with own brand cigarettes (OBC), Juul, and refillable e-cigarettes (EC).Participants (N = 22) who were daily vapers smoking <1 cigarette per day on average, attended after overnight abstinence from smoking and vaping, to test at separate sessions OBC, IQOS, and Juul. Eight participants also tested two refillable EC using e-liquid with 20 mg/mL nicotine. At each session, a baseline blood sample was taken before participants used the product ad libitum for 5 minutes. Further samples were taken at 2, 4, 6, 8, 10, and 30 minutes. Maximum nicotine concentration (Cmax), time to Cmax (Tmax), and nicotine delivered over 30 minutes (AUC0->30) were calculated. Participants rated their urge to smoke and product characteristics. RESULTS IQOS delivered less nicotine than OBC (AUC0->30: z = -2.73, p = .006), and than Juul (AUC0->30: z = -3.08, p = .002; Cmax: z = -2.65, p = .008), and received less favorable ratings than Juul (effect on urges to smoke: z = -3.23, p = .001; speed of urge relief: z = -2.75, p = .006; recommendation to friends: z = -2.45, p = .014). Compared with refillable EC, IQOS delivered nicotine faster (Tmax: z = -2.37, p = .018), but received less favorable overall ratings (recommended to friends: z = -2.32, p = .021). CONCLUSIONS IQOS' pharmacokinetic profile suggests that it may be less effective than Juul for smoking cessation, but at least as effective as refillable EC; although participants, who were experienced vapers rather than IQOS users, preferred refillable EC. IMPLICATIONS Because IQOS provided less efficient nicotine delivery than cigarettes and Juul in this sample, and also had a weaker effect on urges to smoke than Juul, it could be less helpful than Juul in assisting such dual users, and possibly smokers generally, to switch to an alternative product. IQOS, however, provided nicotine faster than refillable EC products, although participants preferred EC.
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Affiliation(s)
| | - Dunja Przulj
- Health and Lifestyle Research Unit, Queen Mary University of London, London, UK
| | - Francesca Pesola
- Health and Lifestyle Research Unit, Queen Mary University of London, London, UK
| | - Katie Myers Smith
- Health and Lifestyle Research Unit, Queen Mary University of London, London, UK
| | - Peter Hajek
- Health and Lifestyle Research Unit, Queen Mary University of London, London, UK
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Hartmann-Boyce J, McRobbie H, Butler AR, Lindson N, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Fanshawe TR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2021; 9:CD010216. [PMID: 34519354 PMCID: PMC8438601 DOI: 10.1002/14651858.cd010216.pub6] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol formed by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, but some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit and if they are safe to use for this purpose. This is an update conducted as part of a living systematic review. OBJECTIVES To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 May 2021, and reference-checked and contacted study authors. We screened abstracts from the Society for Research on Nicotine and Tobacco (SRNT) 2021 Annual Meeting. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and randomized cross-over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants or both. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta-analyses. MAIN RESULTS We included 61 completed studies, representing 16,759 participants, of which 34 were RCTs. Five of the 61 included studies were new to this review update. Of the included studies, we rated seven (all contributing to our main comparisons) at low risk of bias overall, 42 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.53, 95% confidence interval (CI) 1.21 to 1.93; I2 = 0%; 4 studies, 1924 participants). In absolute terms, this might translate to an additional three quitters per 100 (95% CI 1 to 6). There was low-certainty evidence (limited by very serious imprecision) that the rate of occurrence of AEs was similar (RR 0.98, 95% CI 0.80 to 1.19; I2 = 0%; 2 studies, 485 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.30, 95% CI 0.89 to 1.90: I2 = 0; 4 studies, 1424 participants). There was moderate-certainty evidence, again limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 3 studies, 601 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 1.06, 95% CI 0.47 to 2.38; I2 = 0; 5 studies, 792 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.61, 95% CI 1.44 to 4.74; I2 = 0%; 6 studies, 2886 participants). In absolute terms this represents an additional six quitters per 100 (95% CI 2 to 15). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that non-serious AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants), and again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.51, 95% CI 0.70 to 3.24; I2 = 0%; 7 studies, 1303 participants). Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that ECs with nicotine increase quit rates compared to NRT and compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs. Overall incidence of SAEs was low across all study arms. We did not detect evidence of harm from nicotine EC, but longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is now a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Rachna Begh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caitlin Notley
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tari Turner
- Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Hajek
- Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Hatsukami DK, Xu D, Ferris Wayne G. Regulatory approaches and implementation of minimally addictive combusted products. Nicotine Tob Res 2021; 24:453-462. [PMID: 34192324 DOI: 10.1093/ntr/ntab138] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 06/29/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION A joint meeting was held by the World Health Organization (WHO) and the Convention Secretariat of the WHO Framework Convention on Tobacco Control to examine the potential effects of a regulatory policy to reduce nicotine in cigarettes to minimally addictive levels. This paper reviews the feasibility of and approaches to implementing a nicotine product standard. METHODS Prior WHO reports on this topic were consulted and a systematic review of the scientific literature was conducted. The paper was reviewed by the participants at the aforementioned meeting and their feedback was incorporated. RESULTS The nicotine dose most likely to consistently reduce smoking behavior and dependence is < 0.4 mg nicotine/g tobacco. An immediate rather than a gradual nicotine reduction approach appears to be more beneficial. Smokers are likely to seek nicotine from alternate sources (e.g., nicotine replacement therapies, e-cigarettes) or potentially, the illegal market. As such, the availability of alternative products, as well as strong policies against illegal markets, can potentially mitigate unintended consequences. An effective reduced nicotine regulation must be imbedded in a comprehensive and strong tobacco control program that includes public education and surveillance. Barriers and challenges to implementing a nicotine product standard exist, particularly in low-capacity countries. CONCLUSION Not all countries will have the capacity to implement a regulation to reduce nicotine in cigarettes (and preferably other combusted tobacco products) to minimally addictive levels. However, for the countries that choose to implement it, such a policy could potentially dramatically reduce the burden of tobacco use.
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Affiliation(s)
- Dorothy K Hatsukami
- Masonic Cancer Center and Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota
| | - Dongqun Xu
- National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
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Denlinger-Apte RL, Pacek LR, Ross JC, Bansal-Travers M, Donny EC, Hatsukami DK, Carroll DM. Risk Perceptions of Low Nicotine Cigarettes and Alternative Nicotine Products across Priority Smoking Populations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:5311. [PMID: 34067652 PMCID: PMC8156883 DOI: 10.3390/ijerph18105311] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/07/2021] [Accepted: 05/11/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND As the U.S. Food and Drug Administration considers a low nicotine product standard for cigarettes, it is important to examine how people who smoke, especially individuals from priority populations disproportionately affected by smoking, perceive low nicotine content (LNC) cigarettes and their relative risk perceptions of alternative nicotine delivery system (ANDS) products, including e-cigarettes and snus, and medicinal nicotine. METHODS Data are from Wave 4 (2016-2017) of the adult Population Assessment of Tobacco Use and Health (PATH) Study. We examined respondents' absolute risk perceptions about nicotine, LNC cigarettes, ANDS products and medicinal nicotine; their relative risk perceptions of LNC cigarettes and ANDS products compared to conventional cigarettes; and their relative risk perceptions of medicinal nicotine compared to ANDS products. RESULTS The majority of respondents across priority smoking populations indicated snus, e-cigarettes, and LNC cigarettes were 'about the same' level of harmfulness or addictiveness as conventional cigarettes. The majority of respondents indicated e-cigarettes to be 'about the same' harmfulness as medicinal nicotine. CONCLUSIONS Our study indicates that adults who smoke cigarettes generally have misperceptions about the harms of nicotine and the relative risks of ANDS products and such misperceptions exist regardless of their racial/ethnic identity, sexual orientation, and gender identity.
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Affiliation(s)
- Rachel L. Denlinger-Apte
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; (R.L.D.-A.); (J.C.R.)
| | - Lauren R. Pacek
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27705, USA;
| | - Jennifer Cornacchione Ross
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; (R.L.D.-A.); (J.C.R.)
| | - Maansi Bansal-Travers
- Roswell Park Comprehensive Cancer Center, Department of Health Behavior, Buffalo, NY 14263, USA;
| | - Eric C. Donny
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA;
| | - Dorothy K. Hatsukami
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN 55414, USA;
| | - Dana Mowls Carroll
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, MN 55414, USA
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7
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Hartmann-Boyce J, McRobbie H, Lindson N, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Butler AR, Fanshawe TR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2021; 4:CD010216. [PMID: 33913154 PMCID: PMC8092424 DOI: 10.1002/14651858.cd010216.pub5] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol formed by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, but some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit and if they are safe to use for this purpose. This is an update of a review first published in 2014. OBJECTIVES To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke achieve long-term smoking abstinence. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 February 2021, together with reference-checking and contact with study authors. SELECTION CRITERIA We included randomized controlled trials (RCTs) and randomized cross-over trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. To be included, studies had to report abstinence from cigarettes at six months or longer and/or data on adverse events (AEs) or other markers of safety at one week or longer. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included changes in carbon monoxide, blood pressure, heart rate, blood oxygen saturation, lung function, and levels of known carcinogens/toxicants. We used a fixed-effect Mantel-Haenszel model to calculate the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data from these studies in meta-analyses. MAIN RESULTS We included 56 completed studies, representing 12,804 participants, of which 29 were RCTs. Six of the 56 included studies were new to this review update. Of the included studies, we rated five (all contributing to our main comparisons) at low risk of bias overall, 41 at high risk overall (including the 25 non-randomized studies), and the remainder at unclear risk. There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.69, 95% confidence interval (CI) 1.25 to 2.27; I2 = 0%; 3 studies, 1498 participants). In absolute terms, this might translate to an additional four successful quitters per 100 (95% CI 2 to 8). There was low-certainty evidence (limited by very serious imprecision) that the rate of occurrence of AEs was similar) (RR 0.98, 95% CI 0.80 to 1.19; I2 = 0%; 2 studies, 485 participants). SAEs occurred rarely, with no evidence that their frequency differed between nicotine EC and NRT, but very serious imprecision led to low certainty in this finding (RR 1.37, 95% CI 0.77 to 2.41: I2 = n/a; 2 studies, 727 participants). There was moderate-certainty evidence, again limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.70, 95% CI 1.03 to 2.81; I2 = 0%; 4 studies, 1057 participants). In absolute terms, this might again lead to an additional four successful quitters per 100 (95% CI 0 to 11). These trials mainly used older EC with relatively low nicotine delivery. There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 3 studies, 601 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 0.60, 95% CI 0.15 to 2.44; I2 = n/a; 4 studies, 494 participants). Compared to behavioral support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.70, 95% CI 1.39 to 5.26; I2 = 0%; 5 studies, 2561 participants). In absolute terms this represents an increase of seven per 100 (95% CI 2 to 17). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was no evidence that the rate of SAEs differed, but some evidence that non-serious AEs were more common in people randomized to nicotine EC (AEs: RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants; SAEs: RR 1.17, 95% CI 0.33 to 4.09; I2 = 5%; 6 studies, 1011 participants, very low certainty). Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued use. Very few studies reported data on other outcomes or comparisons and hence evidence for these is limited, with confidence intervals often encompassing clinically significant harm and benefit. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that ECs with nicotine increase quit rates compared to ECs without nicotine and compared to NRT. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the size of effect, particularly when using modern EC products. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, though evidence indicated no difference in AEs between nicotine and non-nicotine ECs. Overall incidence of SAEs was low across all study arms. We did not detect any clear evidence of harm from nicotine EC, but longest follow-up was two years and the overall number of studies was small. The evidence is limited mainly by imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information, this review is now a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Rachna Begh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caitlin Notley
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tari Turner
- Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Hajek
- Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Hartmann-Boyce J, McRobbie H, Lindson N, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Butler AR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2020; 10:CD010216. [PMID: 33052602 PMCID: PMC8094228 DOI: 10.1002/14651858.cd010216.pub4] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol formed by heating an e-liquid. People who smoke report using ECs to stop or reduce smoking, but some organisations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit and if they are safe to use for this purpose. This review is an update of a review first published in 2014. OBJECTIVES To evaluate the effect and safety of using electronic cigarettes (ECs) to help people who smoke achieve long-term smoking abstinence. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO for relevant records to January 2020, together with reference-checking and contact with study authors. SELECTION CRITERIA We included randomized controlled trials (RCTs) and randomized cross-over trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. To be included, studies had to report abstinence from cigarettes at six months or longer and/or data on adverse events (AEs) or other markers of safety at one week or longer. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, AEs, and serious adverse events (SAEs). Secondary outcomes included changes in carbon monoxide, blood pressure, heart rate, blood oxygen saturation, lung function, and levels of known carcinogens/toxicants. We used a fixed-effect Mantel-Haenszel model to calculate the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data from these studies in meta-analyses. MAIN RESULTS We include 50 completed studies, representing 12,430 participants, of which 26 are RCTs. Thirty-five of the 50 included studies are new to this review update. Of the included studies, we rated four (all which contribute to our main comparisons) at low risk of bias overall, 37 at high risk overall (including the 24 non-randomized studies), and the remainder at unclear risk. There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.69, 95% confidence interval (CI) 1.25 to 2.27; I2 = 0%; 3 studies, 1498 participants). In absolute terms, this might translate to an additional four successful quitters per 100 (95% CI 2 to 8). There was low-certainty evidence (limited by very serious imprecision) of no difference in the rate of adverse events (AEs) (RR 0.98, 95% CI 0.80 to 1.19; I2 = 0%; 2 studies, 485 participants). SAEs occurred rarely, with no evidence that their frequency differed between nicotine EC and NRT, but very serious imprecision led to low certainty in this finding (RR 1.37, 95% CI 0.77 to 2.41: I2 = n/a; 2 studies, 727 participants). There was moderate-certainty evidence, again limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.71, 95% CI 1.00 to 2.92; I2 = 0%; 3 studies, 802 participants). In absolute terms, this might again lead to an additional four successful quitters per 100 (95% CI 0 to 12). These trials used EC with relatively low nicotine delivery. There was low-certainty evidence, limited by very serious imprecision, that there was no difference in the rate of AEs between these groups (RR 1.00, 95% CI 0.73 to 1.36; I2 = 0%; 2 studies, 346 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 0.25, 95% CI 0.03 to 2.19; I2 = n/a; 4 studies, 494 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.50, 95% CI 1.24 to 5.04; I2 = 0%; 4 studies, 2312 participants). In absolute terms this represents an increase of six per 100 (95% CI 1 to 14). However, this finding was very low-certainty, due to issues with imprecision and risk of bias. There was no evidence that the rate of SAEs varied, but some evidence that non-serious AEs were more common in people randomized to nicotine EC (AEs: RR 1.17, 95% CI 1.04 to 1.31; I2 = 28%; 3 studies, 516 participants; SAEs: RR 1.33, 95% CI 0.25 to 6.96; I2 = 17%; 5 studies, 842 participants). Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate over time with continued use. Very few studies reported data on other outcomes or comparisons and hence evidence for these is limited, with confidence intervals often encompassing clinically significant harm and benefit. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that ECs with nicotine increase quit rates compared to ECs without nicotine and compared to NRT. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the degree of effect, particularly when using modern EC products. Confidence intervals were wide for data on AEs, SAEs and other safety markers. Overall incidence of SAEs was low across all study arms. We did not detect any clear evidence of harm from nicotine EC, but longest follow-up was two years and the overall number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information for decision-makers, this review is now a living systematic review. We will run searches monthly from December 2020, with the review updated as relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Rachna Begh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caitlin Notley
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tari Turner
- Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Hajek
- Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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9
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Berman ML, Glasser AM. Nicotine Reduction in Cigarettes: Literature Review and Gap Analysis. Nicotine Tob Res 2020; 21:S133-S144. [PMID: 31867659 PMCID: PMC6939782 DOI: 10.1093/ntr/ntz162] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/28/2019] [Indexed: 11/13/2022]
Abstract
BACKGROUND The US Food and Drug Administration (FDA) is considering reducing nicotine levels in cigarettes to "minimally or non-addictive levels." However, important research gaps remain, and the FDA must determine when the available research is sufficient to support moving forward. METHODS The authors conducted a systematic review of research articles in PubMed relating to nicotine reduction. Building on a review of risk assessment best practices, the authors also developed a risk assessment framework for tobacco regulation and used it to guide a gap analysis of nicotine reduction research. RESULTS The final sample consisted of 78 articles. The majority examined either nicotine dependence on very low nicotine cigarettes (VLNCs) or markers of potential health effects of using VLNCs. One-third of the identified articles reported results from four large randomized controlled trials (RCTs). While these studies report promising results and suggest that a nicotine reduction rule would be a powerful tool to reduce cigarette smoking, our gap analysis suggests that there is a need for studies that better reflect the use and availability of a wide range of tobacco/nicotine products and the potential for dual- or multi-product use. CONCLUSION The current body of research on nicotine reduction is weighted towards RCTs, which is appropriate for a policy that has not yet been implemented anywhere in the world. The FDA must consider a wide range of factors that may impact a product standard's public health impact, including those difficult to assess in RCTs, such as a nicotine reduction rule's impact on smoking initiation and relapse. IMPLICATIONS This systematic review presents a gap analysis based on a risk assessment framework to help identify remaining research priorities to inform FDA's potential product standard to reduce nicotine levels in cigarettes. Quickly addressing those gaps would support the FDA's effort to develop a nicotine reduction product standard that will be effective and withstand legal challenges.
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Affiliation(s)
- Micah L Berman
- College of Public Health, Ohio State University, Columbus, OH.,Moritz College of Law, Ohio State University, Columbus, OH
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10
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Piper ME, Drobes DJ, Walker N. Behavioral and Subjective Effects of Reducing Nicotine in Cigarettes: A Cessation Commentary. Nicotine Tob Res 2020; 21:S19-S21. [PMID: 31867644 PMCID: PMC6939774 DOI: 10.1093/ntr/ntz100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/14/2019] [Indexed: 12/27/2022]
Abstract
This commentary addresses critical questions regarding the impact of the reduction of nicotine on changes in smoking behavior. There appears to be moderate evidence that use of reduced nicotine cigarettes (RNC) increases the likelihood of making a quit attempt among smokers unmotivated to quit and among smokers motivated to quit who also used nicotine replacement therapy (NRT). There was limited evidence that RNC combined with NRT increased smoking abstinence, regardless of motivation to quit. Several plausible mechanisms via which RNC may influence smoking behavior, including reducing dependence, are reviewed. The moderate evidence that abrupt reduction in nicotine reduces self-reported dependence as well as smoking behavior and likelihood of relapse is also reviewed. The data reviewed here suggest that abrupt switching to, and extended use of, RNC can reduce cigarette dependence and several related constructs, including the ability to quit smoking. The data reviewed in this commentary suggest that abrupt reduction in the level of nicotine in combustible cigarettes could reduce smoking behavior, nicotine dependence, and other related constructs and increase quit attempts and eventual smoking cessation.
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Affiliation(s)
- Megan E Piper
- Department of Medicine, School of Medicine and Public Health, Center for Tobacco Research and Intervention, University of Wisconsin, Madison, WI
| | - David J Drobes
- Tobacco Research and Intervention Program, Moffitt Cancer Center, Tampa, FL.,Departments of Oncologic Sciences & Psychology, University of South Florida, Tampa
| | - Natalie Walker
- National Institute for Health Innovation, School of Population Health, University of Auckland, New Zealand
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11
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Denlinger-Apte RL, Cassidy RN, Colby SM, Sokolovsky AW, Tidey JW. Effects of Cigarette Nicotine Content and Menthol Preference on Perceived Health Risks, Subjective Ratings, and Carbon Monoxide Exposure Among Adolescent Smokers. Nicotine Tob Res 2019; 21:S56-S62. [PMID: 31867646 PMCID: PMC6939772 DOI: 10.1093/ntr/ntz127] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/06/2019] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Minimal research exists on adolescent smokers' perceptions of very low-nicotine-content (VLNC) cigarettes. As approximately half of adolescent smokers prefer menthol cigarettes, it is important to consider the influence of menthol preference on VLNC cigarette perceptions and to what extent menthol preference may affect VLNC smoking behavior. This study examined the effects of cigarette nicotine content and menthol preference or menthol smoking on health risk perceptions, subjective ratings, and carbon monoxide (CO) boost in adolescent smokers. METHODS Across two counterbalanced sessions, adolescent smokers sampled VLNC and normal nicotine content (NNC) research cigarettes following overnight abstinence. Cigarettes were mentholated or non-mentholated consistent with participants' usual brand. In each session, participants smoked the research cigarette and then completed the Perceived Health Risk Scale and Cigarette Evaluation Scale. Breath CO readings were obtained pre- and post-smoking. Mixed-factor ANOVA tests compared outcomes with cigarette type (VLNC vs. NNC) as the within-subjects factor and menthol preference as the between-subjects factor. RESULTS Participants (N = 50) were M = 17.7 years old, smoked M = 8.2 cigarettes/day, and 56% typically smoked menthol cigarettes. Participants reported lower risk of developing lung cancer, other cancers, emphysema, bronchitis, and heart disease (ps ≤ .05) when smoking VLNC cigarettes relative to NNC cigarettes. Perceived risk of addiction and stroke did not differ by nicotine content. Menthol preference or menthol smoking did not moderate risk perceptions, subjective ratings, or CO boost. CONCLUSIONS Adolescents may incorrectly perceive that VLNC cigarettes are less harmful products. Health communication campaigns could help to correct VLNC misperceptions and potentially minimize unintended consequences of a nicotine reduction policy.
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Affiliation(s)
- Rachel L Denlinger-Apte
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI
| | - Rachel N Cassidy
- Center for Alcohol and Addiction Studies, School of Public Health, Brown University, Providence, RI
| | - Suzanne M Colby
- Center for Alcohol and Addiction Studies, School of Public Health, Brown University, Providence, RI
| | - Alexander W Sokolovsky
- Center for Alcohol and Addiction Studies, School of Public Health, Brown University, Providence, RI
| | - Jennifer W Tidey
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI
- Center for Alcohol and Addiction Studies, School of Public Health, Brown University, Providence, RI
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12
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Apelberg BJ, Feirman SP, Salazar E, Corey CG, Ambrose BK, Paredes A, Richman E, Verzi SJ, Vugrin ED, Brodsky NS, Rostron BL. Potential Public Health Effects of Reducing Nicotine Levels in Cigarettes in the United States. N Engl J Med 2018. [PMID: 29543114 DOI: 10.1056/nejmsr1714617] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Benjamin J Apelberg
- From the Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD (B.J.A., S.P.F., E.S., C.G.C., B.K.A., A.P., E.R., B.L.R.); and Sandia National Laboratories, Albuquerque, NM (S.J.V., E.D.V., N.S.B.)
| | - Shari P Feirman
- From the Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD (B.J.A., S.P.F., E.S., C.G.C., B.K.A., A.P., E.R., B.L.R.); and Sandia National Laboratories, Albuquerque, NM (S.J.V., E.D.V., N.S.B.)
| | - Esther Salazar
- From the Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD (B.J.A., S.P.F., E.S., C.G.C., B.K.A., A.P., E.R., B.L.R.); and Sandia National Laboratories, Albuquerque, NM (S.J.V., E.D.V., N.S.B.)
| | - Catherine G Corey
- From the Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD (B.J.A., S.P.F., E.S., C.G.C., B.K.A., A.P., E.R., B.L.R.); and Sandia National Laboratories, Albuquerque, NM (S.J.V., E.D.V., N.S.B.)
| | - Bridget K Ambrose
- From the Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD (B.J.A., S.P.F., E.S., C.G.C., B.K.A., A.P., E.R., B.L.R.); and Sandia National Laboratories, Albuquerque, NM (S.J.V., E.D.V., N.S.B.)
| | - Antonio Paredes
- From the Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD (B.J.A., S.P.F., E.S., C.G.C., B.K.A., A.P., E.R., B.L.R.); and Sandia National Laboratories, Albuquerque, NM (S.J.V., E.D.V., N.S.B.)
| | - Elise Richman
- From the Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD (B.J.A., S.P.F., E.S., C.G.C., B.K.A., A.P., E.R., B.L.R.); and Sandia National Laboratories, Albuquerque, NM (S.J.V., E.D.V., N.S.B.)
| | - Stephen J Verzi
- From the Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD (B.J.A., S.P.F., E.S., C.G.C., B.K.A., A.P., E.R., B.L.R.); and Sandia National Laboratories, Albuquerque, NM (S.J.V., E.D.V., N.S.B.)
| | - Eric D Vugrin
- From the Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD (B.J.A., S.P.F., E.S., C.G.C., B.K.A., A.P., E.R., B.L.R.); and Sandia National Laboratories, Albuquerque, NM (S.J.V., E.D.V., N.S.B.)
| | - Nancy S Brodsky
- From the Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD (B.J.A., S.P.F., E.S., C.G.C., B.K.A., A.P., E.R., B.L.R.); and Sandia National Laboratories, Albuquerque, NM (S.J.V., E.D.V., N.S.B.)
| | - Brian L Rostron
- From the Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD (B.J.A., S.P.F., E.S., C.G.C., B.K.A., A.P., E.R., B.L.R.); and Sandia National Laboratories, Albuquerque, NM (S.J.V., E.D.V., N.S.B.)
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13
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Hendricks PS, Thorne CB, Lappan SN, Sweat NW, Cheong J, Ramachandran R, Kohler CL, Bailey WC, Harrington KF. The Relationships of Expectancies With E-cigarette Use Among Hospitalized Smokers: A Prospective Longitudinal Study. Nicotine Tob Res 2018; 20:224-230. [PMID: 28199715 PMCID: PMC5896545 DOI: 10.1093/ntr/ntx043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/07/2017] [Indexed: 01/01/2023]
Abstract
Background Expectancies demonstrate cross-sectional associations with e-cigarette use, but the prospective relationships between expectancies and e-cigarette use are unknown. This study examined the longitudinal associations of expectancies with e-cigarette use among hospitalized tobacco cigarette smokers. Methods E-cigarette expectancies (e-cigarette-specific Brief Smoking Consequences Questionnaire-Adult [BSCQ-A]), tobacco cigarette expectancies (tobacco-specific BSCQ-A), and number of days used e-cigarettes in the past 30 days were assessed at baseline hospitalization, 6-months post-hospitalization, and 12-months post-hospitalization among 978 hospitalized tobacco cigarette smokers. Expectancy difference scores (e-cigarette-specific expectancies minus tobacco-specific expectancies) were computed for each of the 10 BSCQ-A scales. Cross-lagged panel models tested the relationships between expectancy difference scores and number of days used e-cigarettes in the past 30 days for each of the 10 BSCQ-A scales. Results Though some models revealed partial associations between expectancies and e-cigarette use, only one yielded results consistent with hypotheses. Greater e-cigarette use at baseline predicted greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at 6 months, which then predicted greater e-cigarette use at 12 months. To a lesser degree greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at baseline predicted greater e-cigarette use at 6 months, which then predicted greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at 12 months. Conclusions Expectancies that e-cigarettes provide similar or more pleasant taste sensations as compared to tobacco cigarettes may be both a cause and consequence of e-cigarette use. Focusing on the taste experience may prove most effective in modifying e-cigarette use behavior. Implications The current study offers the first longitudinal examination of expectancies and e-cigarette use. Results suggest expectancies that e-cigarettes provide similar or more pleasant taste sensations relative to tobacco cigarettes are both a cause and consequence of e-cigarette use. Efforts that focus on the e-cigarette taste experience may prove most effective in modifying e-cigarette use behavior.
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Affiliation(s)
- Peter S Hendricks
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Christopher B Thorne
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Sara N Lappan
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Noah W Sweat
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - JeeWon Cheong
- Department of Health Education and Behavior, College of Health and Human Performance, University of Florida, Gainesville, FL
| | - Rekha Ramachandran
- Division of Preventive Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Connie L Kohler
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - William C Bailey
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Kathleen F Harrington
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
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14
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Initial ratings of different types of e-cigarettes and relationships between product appeal and nicotine delivery. Psychopharmacology (Berl) 2018; 235:1083-1092. [PMID: 29306962 PMCID: PMC5869900 DOI: 10.1007/s00213-017-4826-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/27/2017] [Indexed: 11/13/2022]
Abstract
AIMS Little is known about features of e-cigarettes (EC) that facilitate or hinder the switch from smoking to vaping. We tested eight brands of EC to determine how nicotine delivery and other product characteristics influence user's initial reactions. METHODS Fifteen vapers tested each product after overnight abstinence from both smoking and vaping. At each session, participant's vaped ad lib for 5 min. Blood samples were taken at baseline and at 2, 4, 6, 8, 10 and 30 min after starting vaping. Participants rated the products on a range of characteristics. The products tested included six 'cig-a-like' and two refillable products, one with variable voltage. We also tested participants' own EC. RESULTS All products significantly reduced urges to smoke. Refillable products delivered more nicotine and received generally superior ratings in terms of craving relief, subjective nicotine delivery, throat hit and vapour production but in overall ratings, they were joined by a cig-a-like, Blu. Participants puffed more on low nicotine delivery products. Participants' estimates of nicotine delivery from different EC were closely linked to 'throat hit'. Nicotine delivery was less important in the initial product ratings than draw resistance, mouthpiece comfort and effects on reducing urge to smoke. CONCLUSIONS All EC products reduced urges to smoke. Refillable products received generally more favourable ratings than 'cig-a-likes' with similar nicotine content. Perception of nicotine delivery was guided by throat sensations. Lower nicotine delivery was associated with more frequent puffing. The first impressions of EC products are guided less by nicotine delivery than by sensory signals.
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15
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Chin J, Lustik MB, Pflipsen M. Prevalence of Use and Perceptions of Electronic Smoking Devices in a US Army Infantry Division. Mil Med 2017; 183:e127-e133. [DOI: 10.1093/milmed/usx024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 10/26/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joseph Chin
- Department of Family Medicine, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu HI 96815
| | - Michael B Lustik
- Department of Clinical Investigations, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu HI 96815
| | - Matthew Pflipsen
- Department of Family Medicine, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu HI 96815
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16
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Hartmann‐Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2016; 9:CD010216. [PMID: 27622384 PMCID: PMC6457845 DOI: 10.1002/14651858.cd010216.pub3] [Citation(s) in RCA: 287] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Electronic cigarettes (ECs) are electronic devices that heat a liquid into an aerosol for inhalation. The liquid usually comprises propylene glycol and glycerol, with or without nicotine and flavours, and stored in disposable or refillable cartridges or a reservoir. Since ECs appeared on the market in 2006 there has been a steady growth in sales. Smokers report using ECs to reduce risks of smoking, but some healthcare organizations, tobacco control advocacy groups and policy makers have been reluctant to encourage smokers to switch to ECs, citing lack of evidence of efficacy and safety. Smokers, healthcare providers and regulators are interested to know if these devices can help smokers quit and if they are safe to use for this purpose. This review is an update of a review first published in 2014. OBJECTIVES To evaluate the safety and effect of using ECs to help people who smoke achieve long-term smoking abstinence. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO for relevant records from 2004 to January 2016, together with reference checking and contact with study authors. SELECTION CRITERIA We included randomized controlled trials (RCTs) in which current smokers (motivated or unmotivated to quit) were randomized to EC or a control condition, and which measured abstinence rates at six months or longer. As the field of EC research is new, we also included cohort follow-up studies with at least six months follow-up. We included randomized cross-over trials, RCTs and cohort follow-up studies that included at least one week of EC use for assessment of adverse events (AEs). DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Our main outcome measure was abstinence from smoking after at least six months follow-up, and we used the most rigorous definition available (continuous, biochemically validated, longest follow-up). We used a fixed-effect Mantel-Haenszel model to calculate the risk ratio (RR) with a 95% confidence interval (CI) for each study, and where appropriate we pooled data from these studies in meta-analyses. MAIN RESULTS Our searches identified over 1700 records, from which we include 24 completed studies (three RCTs, two of which were eligible for our cessation meta-analysis, and 21 cohort studies). Eleven of these studies are new for this version of the review. We identified 27 ongoing studies. Two RCTs compared EC with placebo (non-nicotine) EC, with a combined sample size of 662 participants. One trial included minimal telephone support and one recruited smokers not intending to quit, and both used early EC models with low nicotine content and poor battery life. We judged the RCTs to be at low risk of bias, but under the GRADE system we rated the overall quality of the evidence for our outcomes as 'low' or 'very low', because of imprecision due to the small number of trials. A 'low' grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A 'very low' grade means we are very uncertain about the estimate. Participants using an EC were more likely to have abstained from smoking for at least six months compared with participants using placebo EC (RR 2.29, 95% CI 1.05 to 4.96; placebo 4% versus EC 9%; 2 studies; 662 participants. GRADE: low). The one study that compared EC to nicotine patch found no significant difference in six-month abstinence rates, but the confidence intervals do not rule out a clinically important difference (RR 1.26, 95% CI 0.68 to 2.34; 584 participants. GRADE: very low).Of the included studies, none reported serious adverse events considered related to EC use. The most frequently reported AEs were mouth and throat irritation, most commonly dissipating over time. One RCT provided data on the proportion of participants experiencing any adverse events. The proportion of participants in the study arms experiencing adverse events was similar (ECs vs placebo EC: RR 0.97, 95% CI 0.71 to 1.34 (298 participants); ECs vs patch: RR 0.99, 95% CI 0.81 to 1.22 (456 participants)). The second RCT reported no statistically significant difference in the frequency of AEs at three- or 12-month follow-up between the EC and placebo EC groups, and showed that in all groups the frequency of AEs (with the exception of throat irritation) decreased significantly over time. AUTHORS' CONCLUSIONS There is evidence from two trials that ECs help smokers to stop smoking in the long term compared with placebo ECs. However, the small number of trials, low event rates and wide confidence intervals around the estimates mean that our confidence in the result is rated 'low' by GRADE standards. The lack of difference between the effect of ECs compared with nicotine patches found in one trial is uncertain for similar reasons. None of the included studies (short- to mid-term, up to two years) detected serious adverse events considered possibly related to EC use. The most commonly reported adverse effects were irritation of the mouth and throat. The long-term safety of ECs is unknown. In this update, we found a further 15 ongoing RCTs which appear eligible for this review.
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Affiliation(s)
- Jamie Hartmann‐Boyce
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
| | - Hayden McRobbie
- Barts & The London School of Medicine and Dentistry, Queen Mary University of LondonWolfson Institute of Preventive Medicine55 Philpot StreetWhitechapelLondonUKE1 2HJ
| | - Chris Bullen
- University of AucklandNational Institute for Health InnovationPrivate Bag 92019Auckland Mail CentreAucklandNew Zealand1142
| | - Rachna Begh
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
| | - Lindsay F Stead
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
| | - Peter Hajek
- Barts & The London School of Medicine and Dentistry, Queen Mary University of LondonWolfson Institute of Preventive Medicine55 Philpot StreetWhitechapelLondonUKE1 2HJ
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Salloum RG, Maziak W, Hammond D, Nakkash R, Islam F, Cheng X, Thrasher JF. Eliciting preferences for waterpipe tobacco smoking using a discrete choice experiment: implications for product regulation. BMJ Open 2015; 5:e009497. [PMID: 26353876 PMCID: PMC4567671 DOI: 10.1136/bmjopen-2015-009497] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Waterpipe smoking is highly prevalent among university students, and has been increasing in popularity despite mounting evidence showing it is harmful to health. The aim of this study was to measure preferences for waterpipe smoking and determine which product characteristics are most important to smokers. SETTING A large university in the Southeastern USA. PARTICIPANTS Adult waterpipe smokers attending the university (N=367). DESIGN Participants completed an Internet-based discrete choice experiment to reveal their preferences for, and trade-offs between, the attributes of hypothetical waterpipe smoking sessions. Participants were presented with waterpipe lounge menus, each with three fruit-flavoured options and one tobacco flavoured option, in addition to an opt out option. Nicotine content and price were provided for each choice. Participants were randomised to either receive menus with a text-only health-warning message or no message. OUTCOME MEASURES Multinomial and nested logit models were used to estimate the impact on consumer choice of attributes and between-subject assignment of health warnings respectively. RESULTS On average, participants preferred fruit-flavoured varieties to tobacco flavour. They were averse to options labelled with higher nicotine content. Females and non-smokers of cigarettes were more likely than their counterparts to prefer flavoured and nicotine-free varieties. Participants exposed to a health warning were more likely to opt out. CONCLUSIONS Fruit-flavoured tobacco and lower nicotine content labels, two strategies widely used by the industry, increase the demand for waterpipe smoking among young adults. Waterpipe-specific regulation should limit the availability of flavoured waterpipe tobacco and require accurate labelling of constituents. Waterpipe-specific tobacco control regulation, along with research to inform policy, is required to curb this emerging public health threat.
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Affiliation(s)
- Ramzi G Salloum
- Department of Health Outcomes and Policy, Institute for Child Health Policy, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Wasim Maziak
- Department of Epidemiology, Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Farahnaz Islam
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Xi Cheng
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - James F Thrasher
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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