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

Use of Machine Learning Tools in Evidence Synthesis of Tobacco Use Among Sexual and Gender Diverse Populations: Algorithm Development and Validation

BACKGROUND

From 2016 to 2021, the volume of peer-reviewed publications related to tobacco has experienced a significant increase. This presents a considerable challenge in efficiently summarizing, synthesizing, and disseminating research findings, especially when it comes to addressing specific target populations, such as the LGBTQ+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, Two Spirit, and other persons who identify as part of this community) populations.

OBJECTIVE

In order to expedite evidence synthesis and research gap discoveries, this pilot study has the following three aims: (1) to compile a specialized semantic database for tobacco policy research to extract information from journal article abstracts, (2) to develop natural language processing (NLP) algorithms that comprehend the literature on nicotine and tobacco product use among sexual and gender diverse populations, and (3) to compare the discoveries of the NLP algorithms with an ongoing systematic review of tobacco policy research among LGBTQ+ populations.

METHODS

We built a tobacco research domain-specific semantic database using data from 2993 paper abstracts from 4 leading tobacco-specific journals, with enrichment from other publicly available sources. We then trained an NLP model to extract named entities after learning patterns and relationships between words and their context in text, which further enriched the semantic database. Using this iterative process, we extracted and assessed studies relevant to LGBTQ+ tobacco control issues, further comparing our findings with an ongoing systematic review that also focuses on evidence synthesis for this demographic group.

RESULTS

In total, 33 studies were identified as relevant to sexual and gender diverse individuals' nicotine and tobacco product use. Consistent with the ongoing systematic review, the NLP results showed that there is a scarcity of studies assessing policy impact on this demographic using causal inference methods. In addition, the literature is dominated by US data. We found that the product drawing the most attention in the body of existing research is cigarettes or cigarette smoking and that the number of studies of various age groups is almost evenly distributed between youth or young adults and adults, consistent with the research needs identified by the US health agencies.

CONCLUSIONS

Our pilot study serves as a compelling demonstration of the capabilities of NLP tools in expediting the processes of evidence synthesis and the identification of research gaps. While future research is needed to statistically test the NLP tool's performance, there is potential for NLP tools to fundamentally transform the approach to evidence synthesis.

Environment and social support for smoking cessation among community smokers in Beijing, China

INTRODUCTION

This study investigated the relationship between environment support, social support and smoking cessation, to provide suggestions for the construction of environment and social support for tobacco control.

METHODS

This was a secondary analysis based on two cross-sectional surveys of adult smokers who participated in the six-month community smoking cessation intervention projects in Beijing. The study subjects were divided into a successful group (n=159) and an unsuccessful group (n=253). The status of the environment support, community tobacco exposure, and social support were compared between groups. A structural equation model (SEM) was established for Confirmatory Factor Analysis.

RESULTS

The univariate analysis showed that there were differences in smoking cessation outcomes among smokers with different home tobacco regulations, workplace tobacco regulations and number of smokers in the family. Differences in 6-month smoking reduction were also found with different promotion levels of anti-tobacco messaging and the frequency of smoking events at home. The logistic regression analysis indicated that home tobacco regulations (OR=1.30; 95% CI: 1.00-1.69), workplace tobacco regulations (OR=1.27; 95% CI: 1.05- 1.54), and frequency of smoking events at home (OR=1.15; 95% CI: 1.02-1.29), were associated with smoking cessation. The results of the SEM showed that environment support (β=0.39; 95% CI: 0.05-0.73, p=0.026) and social support (β=0.37; 95% CI: 0.05-0.68, p=0.022) had influence on smoking cessation.

CONCLUSIONS

Environment support and social support are related to smoking cessation. Attention should be paid to the smoking regulations at home and workplace, anti-tobacco messaging, and social support by the family.

TRIAL REGISTRATION

The study was registered on the official website of the China Clinical Trial Registration Center. Identifier: ChiCTR1900024991.

Follow the money: a closer look at US tobacco industry marketing expenditures

INTRODUCTION

While much of the concern with tobacco industry marketing has focused on direct media advertising, a less explored form of marketing strategy is to discount prices. Price discounting is important because it keeps the purchase price low and can undermine the impact of tax increases.

METHODS

We examine annual US marketing expenditures from 1975 to 2019 by the largest cigarette and smokeless tobacco companies as reported to the Federal Trade Commission. We consider three categories: direct advertising, promotional allowances and price discounting. In addition to considering trends in these expenditures, we examine how price discounting expenditures relate to changes in product prices and excise taxes.

RESULTS

US direct advertising expenditures for cigarettes fell from 80% of total industry marketing expenditures in 1975 to less than 3% in 2019, while falling from 39% in 1985 to 6% in 2019 for smokeless tobacco. Price discounting expenditures for cigarettes became prominent after the Master Settlement Agreement and related tax increases in 2002. By 2019, 87% of cigarette marketing expenditures were for price discounts and 7% for promotional allowances. Smokeless marketing expenditures were similar: 72% for price promotions and 13% for promotional allowances. Price discounting increased with prices and taxes until reaching their currently high levels.

CONCLUSIONS

Between 1975 and 2019, direct advertising dramatically fell while price discounting and promotional expenditures increased. Local, state and federal policies are needed that apply non-tax mechanisms to increase tobacco prices and restrict industry contracts to offset industry marketing strategies. Further study is needed to better understand industry decisions about marketing expenditures.

Exploring factors associated with smokeless tobacco use among young people: A systematic scoping review

PURPOSE

While smoking is declining among young people, smokeless tobacco use is increasing. Identifying who is using smokeless tobacco and why is essential in preventing smokeless tobacco use. This study aimed to comprehensively explore the factors of young people's use of smokeless tobacco in western countries and identify research gaps.

METHODS

We conducted a systematic scoping review of studies that examined factors associated with smokeless tobacco use among young people (ages 13-29) from western countries published between January 2011 and September 2021. Searches were conducted in CINAHL, Medline, and Scopus. Studies on adults, total tobacco use (i.e., did not differentiate between tobacco product types), dual and multiple uses of tobacco, and studies on smokeless tobacco cessation programs were excluded.

RESULTS

A total of 160 studies were included in this scoping review. The studies were primarily undertaken in the US and the Scandinavian countries, and the majority explored smokeless tobacco use without distinguishing between the specific types. Smokeless tobacco users were more likely to be male, non-Hispanic white, engaging in physical activity, and using other substances, including cigarettes and alcohol. The role of friends and family were identified as critical factors that were related to the use of smokeless tobacco.

CONCLUSIONS

This scoping review suggests that preventative measures against smokeless tobacco use should focus on peer and family members' roles and that these measures may benefit from targeting males. Additional research, including systematic reviews on this area to validate the identified associated factors, would improve the understanding of smokeless tobacco use.

The Kentucky SimSmoke Tobacco Control Policy Model of Smokeless Tobacco and Cigarette Use

BACKGROUND

Smokeless tobacco (SLT) prevalence was decreasing in Kentucky before 2007, but has since increased. This study examines the impact of policies on cigarette and SLT use by applying the SimSmoke tobacco control policy simulation model.

METHODS

Using data from the large-scale Tobacco Use Supplement of the Current Population Survey (TUS-CPS) and information on state-specific tobacco policies, Kentucky SimSmoke is updated and extended to incorporate exclusive SLT and dual cigarette and SLT use. The model is validated using survey data through 2017. The model was used to estimate the impact on smoking and SLT prevalence and attributable deaths of policies implemented between 1993 and 2018 and the impact of stronger future policies implemented in 2018 and maintained through 2060.

RESULTS

SimSmoke generally reflects trends in exclusive cigarette use from the TUS-CPS and the Behavioral Risk Factor Surveillance System (BRFSS), but underestimated the increase in SLT prevalence in recent years. SimSmoke projects that policies implemented between 1993 and 2018 reduced male and female cigarette use by 23.7% and 23.0%, and male and female SLT use by 4.9% by 2018, averting 9018 tobacco-attributable deaths by 2018, increasing to 89 547 by 2060. The largest reductions in cigarette and SLT use were attributed to cigarette price increases. Strengthening tobacco control policies could reduce smoking prevalence by 41% and 40%, and reduce SLT prevalence by 33% and 25% for males and females by 2060.

CONCLUSION

Our results suggest that cigarette-oriented policies were effective in reducing SLT use but have been less successful in recent years. Future use rates can be further reduced through more restrictive statewide policies, which also target non-combustible nicotine products.

Online Tobacco Advertising and Current Chew, Dip, Snuff and Snus Use among Youth and Young Adults, 2018-2019

OBJECTIVE

To understand the relationship between exposure to online tobacco advertising and current smokeless tobacco use in the context of tobacco control policies.

METHODS

Three waves of a national probability-based sample of (n = 15,985) youth and young adults were used. Analysis consisted of GEE logistic models controlling for social media use, demographics, tobacco use, average price of smokeless tobacco inclusive of taxes, smoke-free indoor air laws (SFIA) and state tobacco control expenditures.

RESULTS

Frequent exposure to tobacco advertising on social media is associated with greater odds of current smokeless use (aOR: 2.05, 95% CI: 1.62, 2.60). Higher prices and SFIA coverage were associated with reduced current smokeless use when examined separately from other tobacco policy variables (aOR: 0.79, CI: 0.73, 0.85; aOR: 0.44, CI: 0.28, 0.70).

CONCLUSIONS

Greater exposure to tobacco advertising online is associated with greater odds of smokeless use among surveyed youth and young adults. This effect of social media marketing exposure on smokeless use outweighs the mitigating impact of existing tobacco control policies. The findings underscore the need for strong advertising regulation of evolving tobacco products, including smokeless products, on social media and surveillance of digital marketing tactics to young people.

Smokeless Tobacco Use and Prevalence of Cardiovascular Disease Among Males in the Population Assessment of Tobacco and Health (PATH) Study, Waves 1–4

•

Oral smokeless tobacco (SLT) products are non-combusted forms of tobacco that can be dependence producing.

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SLT use may pose health risks to users such as cardiovascular disease (CVD) through various pathways including influencing hemodynamics, endothelial dysfunction, inflammation, insulin resistance, hyperlipidemia, and arrhythmogenesis.

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Past studies have suggested a small, elevated risk of CVD among SLT users compared to never tobacco users.

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This study advances the literature by exploring how the duration of regular SLT use relates to CVD prevalence.

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In this study of ≥ 40-year-old men only, we did not find a consistent dose–response trend for years of SLT use and prevalence of CVD.

The purpose of this period prevalence study is to compare the prevalence of cardiovascular disease (CVD) in current/former established smokeless tobacco (SLT) users (ever SLT users who have used the product fairly regularly) to those who were: 1) never established cigarette smokers and SLT users, and 2) current/former established exclusive cigarette smokers (have smoked at least a 100 or more cigarettes in lifetime) only, adjusting for known risk factors for CVD. Analyses included 4,703 men ≥ 40 years of age who participated in the Population Assessment of Tobacco and Health (PATH) Study, Waves: 1–4, conducted between 2013 and 2017. Current users were those using SLT products daily or on some days, whereas former users had not used SLT and/or cigarettes in the past 12 months. CVD prevalence was defined as a self-reported diagnosis of congestive heart failure, stroke, or myocardial infarction. Among current/former established SLT users, years of use defined exposure history, while pack-years defined exposure history for smokers. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were reported with trend tests to examine dose–response associations. Current/former established exclusive SLT users were not significantly more likely to have had any CVD compared to never established cigarette and SLT users (OR = 1.7 [0.8–3.7]), or current/former established exclusive cigarette smokers (OR = 0.9 [0.5–1.8]). Current/former established exclusive cigarette smokers were more likely to have had any CVD compared to those who were never established cigarette and SLT users (OR = 1.6 [1.1–2.3]).

Trends and Patterns of Tobacco and Nicotine Product Use Among Youth in Canada, England, and the United States From 2017 to 2019

PURPOSE

The tobacco and nicotine market is diversifying. Implications for public health will depend on trends in use, including overall use, and who is using these products. This study examined differences over time (2017-2019), across countries (Canada, England, the United States (US)), and by smoking and vaping, in use of other tobacco/nicotine products and overall use.

METHODS

The study includes online repeat cross-sectional surveys of youth aged 16-19 years in Canada (N = 11,714), England (N = 11,170), US (N = 11,838) in 2017, 2018, and 2019. Past 30-day use of tobacco/nicotine products (any, cigarette, e-cigarette, other combusted [cigars/cigarillos/waterpipe], other non-combusted [smokeless tobacco/nicotine replacement therapies) were examined by country, year, and, for other combusted and non-combusted products, past 30-day cigarette smoking and vaping. Use of emerging products (IQOS, nicotine pouches) was explored in 2018-2019.

RESULTS

From 2017 to 2019, use of any product increased in Canada (17.1%-23.2%, AOR = 1.07 [95% CI = 1.04-1.09]) and the US (18.0%-24.0%, AOR = 1.06 [1.04-1.09]) but not England (20.8%-21.7%, AOR = 1.01 [.99-1.03]). Use of other combusted products (cigars/cigarillos/waterpipe) showed little change (Canada: 8.1%-7.8%; England: 6.3%-7.3%; US: 8.6%-8.5%; p ≥ .151). Use of other non-combusted products (smokeless/nicotine replacement therapies) increased in all countries (Canada: 1.5%-3.2%, AOR = 1.02 [1.01-1.02]; England: 1.4%-2.6%, AOR = 1.02 [1.01-1.03]; US: 3.3%-4.9%, AOR = 1.02 [1.01-1.02]). Vaping increased in all countries (Canada: 8.4%-17.8%; England: 8.7%-12.6%; United States: 11.1%-18.5%; all p < .001). Smokers and vapers reported greater use of other combusted and non-combusted products than those who neither smoked/vaped (p < .001). Emerging product use was rare (≤1.5%).

CONCLUSIONS

Youth past 30-day tobacco and nicotine product use increased from 2017 to 2019 in Canada and the United States, largely due to increases in vaping and other non-combusted products. "Other" tobacco/nicotine products were used predominantly by youth who smoked cigarettes and/or vaped.

Global impact of tobacco control policies on smokeless tobacco use: a systematic review protocol

INTRODUCTION

Smokeless tobacco (ST) was consumed by 356 million people globally in 2017. Recent evidence shows that ST consumption is responsible for an estimated 652 494 all-cause deaths across the globe annually. The WHO Framework Convention on Tobacco Control (FCTC) was negotiated in 2003 and ratified in 2005 to implement effective tobacco control measures. While the policy measures enacted through various tobacco control laws have been effective in reducing the incidence and prevalence of smoking, the impact of ST-related policies (within WHO FCTC and beyond) on ST use is under-researched and not collated.

METHODS AND ANALYSIS

A systematic review will be conducted to collate all available ST-related policies implemented across various countries and assess their impact on ST use. The following databases will be searched: Medline, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Scopus, EconLit, ISI Web of Science, Cochrane Library (CENTRAL), African Index Medicus, LILACS, Scientific Electronic Library Online, Index Medicus for the Eastern Mediterranean Region, Index Medicus for South-East Asia Region, Western Pacific Region Index Medicus and WHO Library Database, as well as Google search engine and country-specific government websites. All ST-related policy documents (FCTC and non-FCTC) will be included. Results will be limited to literature published since 2005 in English and regional languages (Bengali, Hindi and Urdu). Two reviewers will independently employ two-stage screening to determine inclusion. The Effective Public Health Practice Project's 'Quality Assessment Tool for Quantitative Studies' will be used to record ratings of quality and risk of bias among studies selected for inclusion. Data will be extracted using a standardised form. Meta-analysis and narrative synthesis will be used.

ETHICS AND DISSEMINATION

Permission for ethics exemption of the review was obtained from the Centre for Chronic Disease Control's Institutional Ethics Committee, India (CCDC_IEC_06_2020; dated 16 April 2020). The results will be disseminated through publications in a peer-reviewed journal and will be presented in national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42020191946.

Exposure to the advertisement of toombak at the point-of-sale among adolescents in Khartoum State, Sudan: A cross-sectional study

INTRODUCTION

This study aimed to assess the association between toombak (smokeless tobacco) advertisement at point-of-sale (PoS) and its use among adolescents in Sudan.

METHODS

A cross-sectional school-based and self-administered questionnaire study was conducted. Schools were randomly selected using a one-stage stratified sampling procedure, during 2013–2014, as part of a larger research project focusing on the use of toombak among secondary school students in Khartoum State, Sudan. The sample size was 1526 students. Data were collected on exposure to toombak advertisement, social acceptability, perceived accessibility to toombak, susceptibility, and toombak use.

RESULTS

A total of 41.8% of the adolescents were exposed to an advertisement at PoS, while 12.5% perceived direct access to toombak, 5.3% reported that they were susceptible to use toombak, and 10.9% were ever toombak users. Exposure to the advertisement of toombak at PoS was found to be associated with the older age group (44.3%) (p≤0.05). Males were more than females (45.2% vs 38.8%; p≤0.05). Those exposed to toombak advertisements at PoS reported more social acceptability towards toombak (48.9% vs 37.6%; p≤0.001) and direct accessibility to toombak (68.8% vs 47.2%; p≤0.05). Ever toombak users reported higher exposure to advertisements than non-users (54.5% vs 40.3%; p≤0.001).

CONCLUSIONS

Exposure to toombak advertisements at PoS was found to be high and associated with increased toombak use in Khartoum State, Sudan, in addition to increasing social acceptability to its use and perceived easy accessibility. The current law, which bans toombak advertisement and promotion at PoS, needs to be enforced.

Health warning labels describing snus as less harmful than smoking: effects on perceptions of risk

Background

Using snus (Swedish moist snuff) is less harmful than smoking, but health warning labels (HWLs) on snus products do not reflect this relation. There are few studies on the effects of comparative risk information in snus warning labels. The purpose of this experiment is to examine whether risk perceptions differ after exposure to non-comparative vs. comparative risk information in snus warning labels.

Methods

A total of 254 Norwegians aged 19–69 were exposed to pictures of snus packages in one of four HWL conditions: non-comparative EU-based (“Snus is damaging to your health”), control (the text “Snus” only), general comparative risk (“Snus is less damaging to your health than smoking”), or percentage comparative risk (“Snus is 90% less damaging to your health than smoking”). Perceptions of risk from snus use and smoking were measured before (pre) and during (post) exposure to the HWL. Changes from pre to post in (1) perceptions of risk from snus use and (2) perceptions of risk differences from snus use versus smoking were tested in repeated measures ANOVAs with current snus and cigarette use as covariates.

Results

Both the perceived risks from snus use and its perceived risk difference to smoking decreased more in the control and the percentage HWL conditions than in the EU-based HWL condition. When comparing the general comparative risk and the EU-based HWL, a similar difference was found for the perceived risk difference, but not for the separate measure of snus risk. Both the snus risk and risk difference perception decreased more for the percentage than for the general relative risk HWL.

Conclusions

The non-comparative EU-based HWL claiming that “Snus is health damaging” maintains a high level of perceived risk from snus use, while no HWL and the suggested comparative HWLs adjust perceptions of risk in the direction of lower harm from snus use. An HWL describing snus as 90% less harmful than smoking was more effective than a general claim.

Association of Educational Attainment and Race/Ethnicity With Exposure to Tobacco Advertisement Among US Young Adults

Importance

Associations of educational attainment with improved health outcomes have been found to be weaker among racial/ethnic minority groups compared with those among the racial/ethnic majority group. Recent research has also documented higher than expected prevalence of smoking in highly educated African American and Hispanic adults.

Objective

To compare the association of educational attainment with exposure to tobacco advertisements among racial/ethnic groups of US young adults.

Design, Setting, and Participants

This cross-sectional study included data from 6700 young adults who participated in wave 1 of the Population Assessment of Tobacco and Health Study, a nationally representative survey of US adults in 2013. Educational attainment was classified as less than high school diploma, high school graduate, or college graduate. Analysis was conducted between September 20 and October 4, 2019.

Main Outcomes and Measures

The independent variable was educational attainment (less than high school diploma, high school graduate, and college graduate). The dependent variable was any exposure to tobacco advertisements in the past 12 months. Race/ethnicity, age, sex, poverty status, unemployment, and region were the covariates. Binary logistic and Poisson regression were used to analyze the data.

Results

The study included 6700 participants (3366 [50.2%] men) between ages 18 and 24 years. Most participants were non-Hispanic (5257 participants [78.9%]) and white (5394 participants [80.5%]), while 1443 participants (21.5%) were Hispanic. Educational levels included 1167 participants (17.4%) with less than a high school diploma, 4812 participants (71.8%) who were high school graduates, and 4812 participants (10.8%) who were college graduates. A total of 4728 participants (70.6%) reported exposure to tobacco advertisements in the past 12 months. Exposure to tobacco advertising was reported by 383 participants (53.1%) who were college graduates, 3453 participants (71.8%) who were high school graduates, and 892 participants (76.4%) with less than high school educational attainment. In regression analysis, high school graduation (odds ratio, 0.79; 95% CI, 0.68-0.92) and college graduation (odds ratio, 0.46; 95% CI, 0.39-0.54) were associated with lower odds of exposure to tobacco advertisements compared with young adults with lower educational attainment. Compared with non-Hispanic participants, high school education had a weaker protective association for tobacco advertisement exposure among Hispanic participants (odds ratio, 1.44; 95% CI, 1.03-2.01; P = .03), suggesting that the association of high school graduation with lower exposure to tobacco advertisement is weaker among Hispanic young adults than non-Hispanic young adults.

Conclusions and Relevance

This study found that high school graduation had a weaker inverse association with tobacco advertisement exposure among Hispanic than non-Hispanic young adults. Future research should explore the role of targeted marketing strategies of the tobacco industry that largely advertise tobacco in areas with high concentrations of racial/ethnic minority groups. Future research should also evaluate the efficacy of more restrictive marketing policies on racial/ethnic disparities in tobacco use.

Pathway Analysis of Global Metabolomic Profiles Identified Enrichment of Caffeine, Energy, and Arginine Metabolism in Smokers but Not Moist Snuff Consumers

Existing US epidemiological data demonstrate that consumption of smokeless tobacco, particularly moist snuff, is less harmful than cigarette smoking. However, the molecular and biochemical changes due to moist snuff consumption relative to smoking remain incompletely understood. We previously reported that smokers (SMK) exhibit elevated oxidative stress and inflammation relative to moist snuff consumers (MSC) and non-tobacco consumers (NTC), based on metabolomic profiling data of saliva, plasma, and urine from MSC, SMK, and NTC. In this study, we investigated the effects of tobacco consumption on additional metabolic pathways using pathway-based analysis tools. To this end, metabolic pathway enrichment analysis and topology analysis were performed through pair-wise comparisons of global metabolomic profiles of SMK, MSC, and NTC. The analyses identified >8 significantly perturbed metabolic pathways in SMK compared with NTC and MSC in all 3 matrices. Among these differentially enriched pathways, perturbations of caffeine metabolism, energy metabolism, and arginine metabolism were mostly observed. In comparison, fewer enriched metabolic pathways were identified in MSC compared with NTC (5 in plasma, none in urine and saliva). This is consistent with our transcriptomics profiling results that show no significant differences in peripheral blood mononuclear cell gene expression between MSC and NTC. These findings, taken together with our previous biochemical, metabolomic, and transcriptomic analysis results, provide a better understanding of the relative changes in healthy tobacco consumers, and demonstrate that chronic cigarette smoking, relative to the use of smokeless tobacco, results in more pronounced biological changes, which could culminate in smoking-related diseases.

The Minnesota SimSmoke Tobacco Control Policy Model of Smokeless Tobacco and Cigarette Use

INTRODUCTION

A previous Minnesota SimSmoke tobacco control policy model is extended to more recent years and to include smokeless tobacco use.

METHODS

Using data from the 1993 Tobacco Use Supplement and information on state policies, the Minnesota SimSmoke model was updated and extended to incorporate smokeless tobacco (both exclusive and dual use) and smokeless tobacco-attributable deaths. The model was then validated against the 2002, 2006/2007, and 2014/2015 Tobacco Use Supplement and the 1999, 2007, 2014, and 2018 Minnesota Adult Tobacco Survey and used to estimate the impact of policies implemented between 1993 and 2018. Analysis was conducted in April 2019.

RESULTS

The model validated well for cigarette and earlier smokeless tobacco use, but it predicted smokeless tobacco use less well in recent years. The model projected that male (female) smoking prevalence was 35% (36%) lower in relative terms by 2018 and 43% (44%) lower by 2040 owing to policies, with lesser reductions projected for male smokeless tobacco use. Tobacco-attributable deaths were reduced by 7,800 by 2018 and 46,900 by 2040. Price increases, primarily through taxes, were projected to have had the greatest impact on cigarette use followed by smoke-free air laws, cessation treatment policies, tobacco control campaign expenditures, and youth access enforcement. Similar effects were projected for smokeless tobacco use, except that smoke-free air laws had smaller effects.

CONCLUSIONS

As cigarettes remain the dominant form of nicotine delivery product, cigarette-oriented policies may be an effective means of reducing the use of all nicotine delivery products. However, noncigarette-oriented policies may also play an important role.

Health Care Utilization and Expenditures Attributable to Smokeless Tobacco Use Among US Adults

Introduction

This study estimated the health care utilization and expenditures attributable to the use of smokeless tobacco (ST) which includes chewing tobacco, snuff, dip, snus, and dissolvable tobacco among US adults aged 18 and older.

Methods

We used data from the 2012-2015 National Health Interview Surveys (n = 139451 adults) to estimate a zero-inflated Poisson (ZIP) regression model on four health care utilization measures among US adults (hospital nights, emergency room [ER] visits, doctor visits, and home care visits) specified as a function of tobacco use status, and other covariates. Tobacco use status was classified into four categories: current ST users, former ST users, non-ST tobacco users, and never tobacco users. ST-attributable utilization was calculated based on the estimated ZIP model using an "excess utilization" approach. It was then multiplied by the unit cost estimated from the 2014 Medical Expenditures Panel Survey data to derive ST-attributable health care expenditures.

Results

During 2012-2015, 2.1% of adults were current ST users and 7.7% were former ST users. ST-attributable health care utilization amounted to 681000 hospital nights, 624000 ER visits, and 4.6 million doctor visits per year (home care visits results were not significant). This resulted in annual excess expenditures of $1.8 billion for hospitalizations, $0.7 billion for ER visits, and $0.9 billion for doctor visits, totaling over $3.4 billion (in 2014 dollars).

Conclusion

Comprehensive tobacco control policies and interventions are needed to reduce ST use and the associated health care burden.

Implications

This is the first study to assess the impact of ST use on health care burden in the United States. Findings indicate that excess annual health care expenditures attributable to ST use for US adults were $3.4 billion in 2014 dollars.

Tobacco Evidence-Based Practice Implementation and Employee Tobacco-Related Outcomes at Small Low-Wage Worksites

OBJECTIVE

The aim of this study was to assess whether tobacco policy, program, and communication evidence-based practice implementation is associated with employee tobacco outcomes [current smoking; quit attempt; smokeless tobacco (SLT) use; and perceived worksite support for cessation] at small low-wage worksites.

METHODS

We analyzed data from a randomized controlled trial testing an intervention to increase implementation of evidence-based health promotion practices. We used generalized estimating equations to examine relationships between practice implementation and tobacco outcomes.

RESULTS

Communication practice implementation was associated with better perceived worksite support for cessation (P = 0.027). Policy and program implementation were associated with increased odds of being a current SLT user; these findings should be interpreted with caution given small sample sizes.

CONCLUSION

Tobacco communication evidence-based practice implementation was associated with favorable perceptions of worksite support for cessation; more may be needed to change tobacco use behavior.

Smokeless tobacco taxation: Lessons from Southeast Asia

Southeast Asia accounts for nearly 86 per cent of the smokeless tobacco (SLT) consumers in the world. The heterogeneous nature of SLT is a major impediment to using taxation as a tool to regulate SLT. This study was aimed to review issues around fiscal policies on SLT with the objective of providing clarity on the use of taxation as an effective policy instrument to regulate SLT use. Descriptive statistics and graphical representations were used to analyze published data from different sources. An analysis of prices and tax between smoke and SLT products was done to understand the impact of tax policies on SLT consumption. India, Bangladesh and Myanmar together account for 71 per cent of the world SLT users. The retail prices (PPP$) and tax were lower for SLT in low- and lower-middle-income countries and higher in high-income countries, on an average, suggesting a direct relationship between the two. Evidence from India and Bangladesh suggested that taxation had significantly reduced SLT use among adults. The compounded levy scheme used in India to tax SLT was found effective after incorporating speed of packing machines into the assessment of deemed production and tax on SLT products. The current analysis shows that taxation can be an effective instrument to regulate SLT consumption if tax rates are harmonized across SLT products and in a manner not to encourage substitution with other tobacco products. It is also imperative to set a minimum floor price on all tobacco products including SLT.

Smokeless tobacco use: pattern of use, knowledge and perceptions among rural Bangladeshi adolescents

Background

The aim of the study was to investigate the practice and pattern of smokeless tobacco (SLT) use as well as the knowledge and perception about its ill effects among rural Bangladeshi adolescents.

Methods

A cross-sectional survey was conducted among students aged 13-18 years in two rural secondary schools in Bangladesh in August 2015. Data were collected through a self-administered questionnaire which consists of topics derived from the Social Cognitive Theory and Health Belief Model (personal characteristics, environmental factors, self-efficacy, outcome expectancies, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action). Data analysis was performed using SPSS version 24. A descriptive analysis was conducted to determine the current pattern of SLT use and knowledge about its ill effects. A chi-square test and Fisher exact test were conducted to explore associations between variables. Lastly, a logistic regression model was used to locate the predictors for current SLT use.

Results

A total of 790 students participated in the study. Among them, 9.5% (75) had used SLT at least once and 3.7% (29) were current SLT users. Males had a higher incidence of SLT use compared with females. The majority of students (77.3%) initiated SLT use between 10-13 years of age. 'Zarda' was the most common type of SLT used and most of the current users (86%) were able to buy SLT without age restrictions. Most of the current users (90%) wanted to quit SLT immediately; however, professional help was not available in schools. Overall, students had a good knowledge about the harmful effects of SLT with 54.8% (428) of respondents scoring in the good knowledge category. However, the majority of never SLT users (55.4%; 396) had a good knowledge compared to ever SLT users (42.7%; 32). Significant predictors of current SLT use included being a student aged 14 years and above (OR = 6.58, 95% CI [2.23-28.31]) as well as the variables of self-efficacy (OR = 5.78, 95% CI [1.46-19.65]), perceived barriers (OR = 0.30, 95% CI [0.10-0.74]), perceived benefit (OR = 0.21, 95% CI [0.05-1.03]) and perceived severity (OR = 0.36, 95% CI [0.16-0.91]).

Discussion

This study demonstrates the need for comprehensive prevention and control programme in rural schools targeting young adolescents. Effective measure should be taken to reshape the attitude of rural adolescents towards self-confidence and competence, as to prevent SLT use.

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.