Cross-sectional study on the awareness, susceptibility and use of heated tobacco products among adolescents in Guatemala City, Guatemala

A Scoping Review of Behavioural Studies on Heated Tobacco Products

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

Tobacco industry strategies to influence the regulation of new and emerging tobacco and nicotine products in Latin America and the Caribbean

Objective

To document tobacco industry strategies to influence regulation of new and emerging tobacco and nicotine products (NETNPs) in Latin America and the Caribbean.

Methods

We analyzed industry websites, advocacy reports, news media and government documents related to NETNPs, focusing on electronic cigarettes and heated tobacco products. We also conducted a survey of leading health advocates. We applied the policy dystopia model to analyze industry action and argument-based strategies on NETNP regulations.

Results

Industry actors engaged in four instrumental strategies to influence NETNP regulation - coalition management, information management, direct involvement in and access to the policy process, and litigation. Their actions included: lobbying key policy-makers, academics and vaping associations; providing grants to media groups to disseminate favorable NETNP information; participating in public consultations; presenting at public hearings; inserting industry-inspired language into draft NETNP legislation; and filing lawsuits to challenge NETNP bans. The industry disseminated its so-called harm reduction argument through large/influential countries (e.g., Argentina, Brazil, and Mexico). Industry discursive strategies claimed NETNPs were less harmful, provided safer alternatives, and should be regulated as so-called harm reduction products or have fewer restrictions on their sale and use than those currently in place.

Conclusion

Our analysis provides a better understanding of industry strategies to undermine tobacco and nicotine control. To help counter industry efforts, health advocates should proactively strengthen government capacities and alert policy-makers to industry attempts to create new regulatory categories (so-called reduced-risk products), provide misleading information of government authorizations of NETNPs, and co-opt so-called harm-reduction messages that serve the industry's agenda.

Susceptibility to e-cigarette adoption among tobacco-naïve youths: a cross-sectional study in Shenzhen, China

Background

The rise in e-cigarette use among youth is a significant global public health issue. It is important to identify those at increased risk and implement effective strategies to reduce e-cigarette popularity among the youth.

Objective

This study aims to identify predictors of e-cigarette uptake in youths with no prior tobacco use, considering individual, familial and the broader societal environmental factors.

Methods

For this investigation, a group of 2,487 tobacco-free youths was selected from 15 high schools in Shenzhen, China. Susceptibility to e-cigarettes was determined by assessing the possibility of future use and the openness to trying e-cigarettes if presented by friends. Both chi-square tests and logistic regression were applied to identify factors linked to susceptibility to e-cigarette use.

Results

Among the respondents, 5.5% (n = 136) were found to be susceptible to e-cigarette use. The analysis revealed factors tied to this risk: perceptions of e-cigarettes, the impact of vaping peers, paternal parenting styles, the extent of social support, exposure to messages both for and against e-cigarettes use, and secondhand smoke (SHS) exposure. Youths who downplayed the addictive nature of e-cigarettes (aOR = 2.01; 95% CI: 1.14-3.55; p = 0.016), those with friends who engaged in vaping (aOR = 3.43-7.64; 95%CI: 2.36-20.42; p < 0.001), those experiencing over-protective or rejective maternal parenting (aOR = 1.68-3.01; 95%CI: 1.11-5.77; p = 0.001-0.014) or rejective paternal parenting (aOR = 3.63; 95%CI: 1.99-6.59; p < 0.001), those aware of e-cigarette advertisements (aOR = 1.82; 95%CI: 1.28-2.60; p = 0.001), and those exposed to SHS at home (aOR = 1.68; 95%CI: 1.17-2.41; p = 0.005) or at public places (aOR = 1.72-1.79; 95%CI: 1.21-2.57; p = 0.002-0.003) were more prone to e-cigarettes. In contrast, youths who believed using e-cigarettes reduces one's attractiveness (aOR = 0.34; 95%CI: 0.16-0.72; p = 0.005) or perceived that vaping made social interactions less enjoyable (aOR = 0.26; 95%CI: 0.12-0.58; p = 0.001), those who benefited from high social support (aOR = 0.30-0.60; 95%CI: 0.17-0.97; p < 0.001), and those who noticed message about e-cigarettes' adverse consequence (aOR = 0.54; 95%CI: 0.38-0.77; p = 0.001) were less likely to be inclined toward e-cigarette use.

Conclusion

The propensity of the youth to e-cigarette usage is shaped by a multiple element. An all-encompassing strategy that addresses the individual, familial, and the broader societal aspects is imperative for the effective prevention of e-cigarette initiation among youth.

Factors Associated With the Changes in Smoking and Electronic cigarette use in Adolescents During the COVID-19 Pandemic: A Longitudinal Analysis

PURPOSE

Explore the factors associated with the changes in smoking and electronic cigarette (e-cigarette) use and susceptibility among adolescents during the COVID-19 pandemic.

METHODS

We surveyed a cohort of students (7th-12th grade) from private schools in Guatemala. Baseline (May-September 2019) was conducted in-person and follow-up (June-November 2020) online during the lockdown. Separate Generalized Estimating Equations logistic models regressed current smoking (n = 3,729), current e-cigarette use (n = 3,729), smoking susceptibility among never-smokers (n = 2,596), and susceptibility to e-cigarette use among never-users (n = 1,597) on online ad exposure, visiting stores, social network smoking/e-cigarette use, substance use (alcohol, marihuana, and cigarette or e-cigarette), perceived harm of using cigarettes/e-cigarettes, sociodemographic characteristics, and survey wave. Interactions were assessed between time and ad exposures, friends smoking and e-cigarette use.

RESULTS

Frequency of store visits, exposure to online ads, and the use of cigarette and e-cigarette lowered at follow-up. Online e-cigarette ads, having family and friends who smoke, and current e-cigarette use increased the likelihood of being a current smoker. Frequent exposure to online e-cigarette ads, having family who use e-cigarettes, and being a current smoker were associated with higher likelihood of current e-cigarette use. Exposure to either online ads or having friends that smoke or use e-cigarettes, increased susceptibility to using either product. Interaction results showed that high exposure to online e-cigarette ads overtime increased the susceptibility to use e-cigarettes.

DISCUSSION

Exposure to online ads and friends and family cigarette and e-cigarette use increased adolescent consumption and susceptibility during the pandemic.

Changes in substance use among adolescents before and during the COVID-19 pandemic in Guatemala

Objectives

Due to the COVID-19 pandemic, on March 16th, schools had to be closed in Guatemala and went to online teaching. We sought to analyze the change in substance use among high school students in Guatemala associated with the lockdown.

Methods

Data from two surveys (2019, n=2096, and 2020, n=1606) of a student cohort in private high schools in Guatemala City was used. Logistic models for past 30-day cigarette, e-cigarette, marijuana, and alcohol (including binge drinking) were used, regressing these on survey wave, while adjusting for sex, scholastic performance, high school year of student, parental education, substance use, and household member tobacco use.

Results

Prevalence declined for smoking (10% to 3%, p<0.001), e-cigarette (31% to 14%, p<0.001), marijuana (4.3% to 1.9%, p<0.001), and alcohol use (47% to 38.5%, p<0.001), and binge drinking (24% to 13%, p<0.001). Adjusted models showed wave 2 associated with lower odds of using cigarettes (AOR=0.44, 95%CI=0.32-0.62), e-cigarettes (AOR=0.41, 95% CI=0.35-0.49, p<0.001), and binge drinking (AOR=0.73, 95%CI=0.59-0.89; p=0.002).

Conclusion

Among Guatemalan adolescents, COVID-19 restrictions were associated with a significant decrease in smoking, e-cigarette use, and binge drinking.

Understanding e-cigarette content and promotion on YouTube through machine learning

INTRODUCTION

YouTube is a popular social media used by youth and has electronic cigarette (e-cigarette) content. We used machine learning to identify the content of e-cigarette videos, featured e-cigarette products, video uploaders, and marketing and sales of e-cigarette products.

METHODS

We identified e-cigarette content using 18 search terms (eg, e-cig) using fictitious youth viewer profiles and predicted four models using the metadata as the input to supervised machine learning: (1) video themes, (2) featured e-cigarette products, (3) channel type (ie, video uploaders) and (4) discount/sales. We assessed the association between engagement data and the four models.

RESULTS

3830 English videos were included in the supervised machine learning. The most common video theme was 'product review' (48.9%), followed by 'instruction' (eg, 'how to' use/modify e-cigarettes; 17.3%); diverse e-cigarette products were featured; 'vape enthusiasts' most frequently posted e-cigarette videos (54.0%), followed by retailers (20.3%); 43.2% of videos had discount/sales of e-cigarettes; and the most common sales strategy was external links for purchasing (34.1%). 'Vape trick' was the least common theme but had the highest engagement (eg, >2 million views). 'Cannabis' (53.9%) and 'instruction' (49.9%) themes were more likely to have external links for purchasing (p<0.001). The four models achieved an F1 score (a measure of model accuracy) of up to 0.87.

DISCUSSION

Our findings indicate that on YouTube videos accessible to youth, a variety of e-cigarette products are featured through diverse videos themes, with discount/sales. The findings highlight the need to regulate the promotion of e-cigarettes on social media platforms.

New tobacco and nicotine products in Latin America and the Caribbean: assessing the market and regulatory environment

OBJECTIVE

To document the regulatory environment of new tobacco and nicotine products (NTNPs), including electronic nicotine delivery systems (ENDS) and heated tobacco products (HTPs), in Latin America and the Caribbean (LAC).

METHODS

Review of market research reports and databases, regulatory websites, Campaign for Tobacco-Free Kids, relevant published literature and the 2021 WHO Report on the Global Tobacco Epidemic.

RESULTS

ENDS entered the LAC market in the 2010s and are now available in most LAC countries. A majority of LAC countries (n=18) have either banned the commercialisation of ENDS (n=7) or regulated ENDS as tobacco products (n=7), medicinal products (n=1) or consumer products (n=3). The remaining LAC countries (n=15) do not regulate ENDS. HTPs were first introduced in 2017 and have been officially launched in five countries (Colombia, Guatemala, Dominican Republic, Mexico and Costa Rica). Few countries have banned HTP commercialisation (n=3) or regulated commercialisation and use (n=7), while the majority of countries have existing legislation that applies to HTPs (n=19). A few countries (n=4) have no tobacco control legislation and therefore do not regulate HTPs.

CONCLUSION

NTNPs are emerging products in the LAC region. Governments should follow WHO guidance and the decisions of the Conference of Parties to the WHO Framework Convention on Tobacco Control and ban or regulate NTNPs as tobacco products; otherwise NTNPs could create a new generation of tobacco and nicotine users.

First tobacco product tried and current use of cigarettes and electronic cigarettes among adolescents from Guatemala City

OBJECTIVE

To assess how first experimenting with ciga-rettes or e-cigarettes is associated with current use in Gua-temala, a middle-income country with weak tobacco control and no e-cigarette regulations.

MATERIALS AND METHODS

We surveyed students from private schools in Guatemala City, limiting analyses to ever users (n=1 026). Multinomial logistic models regressed current product use on first product used, adjusting for sociodemographics and friends and family use.

RESULTS

The most common first product used was e-cigarettes (56%), followed by flavored cigarettes (24%) and regular cigarettes (20%). At the time of the survey, 4% were exclusive smokers, 37% were exclusive e-cigarette users, 18% dual users, and 40% had ever tried either but were not current users. Compared to those who first tried cigarettes, students who first tried e-cigarettes were less likely to be current smokers (RR=0.19 [CI: 0.11,0.31]) or dual users (RR=0.26 [CI: 0.14,0.49]) and students who first tried flavored cigarettes were more likely to be current smokers (RR=1.66 [CI=1.13,2.42]).

CONCLUSIONS

In our sample, Guatemalan adolescents from private schools more frequently experiment and continue to use e-cigarettes than cigarettes. There is urgent need to implement e-cigarette restrictions in addition to tobacco control policy implementation.

Analysis of mainstream emissions, secondhand emissions and the environmental impact of IQOS waste: a systematic review on IQOS that accounts for data source

OBJECTIVE

To highlight the general features of IQOS literature focusing on the chemical analysis of IQOS emissions.

DATA SOURCES

PubMed, Web of Science and Scopus databases were searched on 8 November 2021 using the terms 'heated tobacco product', 'heat-not-burn', 'IQOS' and 'tobacco heating system' with time restriction (2010-2021). The search yielded 5480 records.

STUDY SELECTION

Relevant publications on topics related to IQOS assessment were retrieved (n=341). Two reviewers worked separately and reached agreement by consensus.

DATA EXTRACTION

Data on author affiliation and funding, article type and date of publication were extracted. Publications were categorised depending on their focus and outcomes. Data on IQOS emissions from the chemical analysis category were extracted.

DATA SYNTHESIS

Of the included publications, 25% were published by Philip Morris International (PMI) affiliates or PMI-funded studies. PMI-sponsored publications on emissions, toxicology assessments and health effects were comparable in number to those reported by independent research, in contrast to publications on IQOS use, market trends and regulation. Data on nicotine yield, carbonyl emissions, other mainstream emissions, secondhand emissions and IQOS waste were compared between data sources to highlight agreement or disagreement between PMI-sponsored and independent research.

CONCLUSIONS

Our analysis showed agreement between the data sources on nicotine yield from IQOS under the same puffing conditions. Also, both sources agreed that IQOS emits significantly reduced levels of some emissions compared with combustible cigarettes. However, independent studies and examination of PMI's data showed significant increases in other emissions from and beyond the Food and Drug Administration's harmful and potentially harmful constituents list.

Heated tobacco product use, its correlates, and reasons for use among Mexican smokers

BACKGROUND

Little is known about the use of novel heated tobacco products (HTPs) in low- and middle-income countries. We examined among smokers in Mexico the prevalence and correlates of HTP use, as well as reasons for using HTPs.

METHODS

We analyzed data from five surveys (November 2019-March 2021) of an open cohort of adult smokers (n = 6500), including an oversample of those who also use e-cigarettes. Mixed-effects multinomial logistic models were used to estimate associations between study variables and current HTP use or prior HTP trial relative to never trying HTPs.

RESULTS

The weighted prevalence of current HTP use was 1.1%. Independent correlates of current HTP use included smoking frequency, intention to quit, e-cigarette use, having partners/family-members who use e-cigarettes, friends who use HTPs, and exposure to HTP information inside/outside tobacco shops. Having partners/family members who smoke and not knowing about the harm of HTPs relative to cigarettes were associated with lower likelihood of current HTP use. Having tried HTPs was more likely among light daily smokers, those with family who use HTPs and exposure to HTP information outside shops and on newspapers/magazines. Among current users, the top reasons for using HTPs were greater social acceptability (50.6%) and lower perceived harm (34.9%) relative to cigarettes.

CONCLUSIONS

Uptake of HTPs appears relatively low among Mexican smokers, and correlates of use are similar to those for e-cigarette use. Further research is needed to determine if HTPs use promotes or impedes smoking cessation, given current HTP users are also likely to use various nicotine products.

Evolution of tobacco products: recent history and future directions

Declines in cigarette smoking prevalence in many countries and the consolidation of the tobacco industry have prompted the introduction of other forms of nicotine delivery. These include electronic nicotine delivery systems (ENDS), heated tobacco products (HTPs) and oral nicotine products (ONPs). Evolving over time, some of these products now deliver nicotine at levels comparable to cigarettes and may serve as effective substitutes for smokers. However, certain products, especially ENDS like JUUL, have also appealed to youth and non-smokers, prompting concerns about expanding nicotine use (and potentially nicotine addiction). The tobacco industry could shift away from primarily promoting cigarettes to promoting ENDS, HTPs and/or ONPs, though at this time it continues to heavily promote cigarettes in low and middle-income countries. Differing regulatory regimes may place upward and downward pressures on both cigarettes and these newer products in terms of population use, and may ultimately drive the extent to which cigarettes are or are not displaced by ENDS, HTPs and/or ONPs in the coming decade.

Awareness, use and perceptions of cigarillos, heated tobacco products and nicotine pouches: A survey among Dutch adolescents and adults

OBJECTIVES

Many tobacco and related products (TRPs) are less strictly regulated and marketed as less harmful than cigarettes. Little is known about their awareness, use, user profile, use behavior, reasons for use and risk perception, especially for the newest products. In an exploratory survey study among Dutch adolescents and adults, we have investigated three examples of non-cigarette TRPs available on the worldwide market.

METHODS

In a two-step web-based design, data on cigarillos, heated tobacco products (HTPs) and nicotine pouches were collected. In the first step (N = 5805), a representative sample (≥13 years) was studied to quantify their awareness, ever and current use in the Dutch population. In the second step (N = 526), in-depth data regarding use behavior, reasons for use and risk perception were collected among users and non-users.

RESULTS

Awareness (<50%) and use (<15% ever use and <2% current use) is relatively low for all three products, but overall higher among men, (e-)cigarette users and respondents with higher education and social economic status. Most participants became aware of the products through people they knew. Reasons for use were mainly curiosity, pleasant taste, flavour variety, and lower harmfulness. All products were perceived as (slightly) less harmful and addictive than cigarettes.

CONCLUSIONS

This study is one of the first to investigate awareness and use of cigarillos, HTPs and nicotine pouches. To prevent increased use, we recommend regulators to extend flavour and smoking bans to these products. In addition, public information may discourage use by increasing awareness of health risks.

Heated tobacco product use and hypertensive disorders of pregnancy and low birth weight: analysis of a cross-sectional, web-based survey in Japan

OBJECTIVES

Knowledge on the impact of heated tobacco product (HTP) use in pregnant women with associated maternal and neonatal risks for hypertensive disorders of pregnancy (HDP) and low birth weight (LBW) is limited. We aimed to assess the status of HTP use among pregnant women in Japan and explore the association of HTP use with HDP and LBW.

DESIGN

Cross-sectional study.

SETTING

Data from the Japan 'COVID-19 and Society' Internet Survey study, a web-based nationwide survey.

PARTICIPANTS

We investigated 558 postdelivery and 365 currently pregnant women in October 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

Information on HDP and LBW was collected from the postdelivery women's Maternal and Child Health Handbooks (maternal and newborn records). We estimated the age-adjusted ORs and 95% CIs of ever HTP smokers for HDP and LBW and compared them with those of never HTP smokers in a logistic regression analysis.

RESULTS

The prevalence of ever and current HTP use were 11.7% and 2.7% in postdelivery women and 12.6% and 1.1% in currently pregnant women, respectively. Among currently pregnant women who were former combustible cigarette smokers, 4.4% (4/91) were current HTP smokers. Among postdelivery women, ever HTP smokers had a higher HDP incidence (13.8% vs 6.5%, p=0.03; age-adjusted OR=2.48, 95% CI 1.11 to 5.53) and higher LBW incidence (18.5% vs 8.9%, p=0.02; age-adjusted OR=2.36, 95% CI 1.16 to 4.87).

CONCLUSIONS

In Japan, the incidence of ever HTP use exceeded 10% among pregnant women, and HTP smoking may be associated with maternal and neonatal risks.

Occupational difference in use of heated tobacco products: a cross-sectional analysis of retail workers in Japan

OBJECTIVE

Although heated tobacco products (HTPs) have become popular worldwide, research on occupational differences in smoking HTPs remains scarce. We aimed to examine the prevalence of smoking HTPs among a working population in Japan.

SETTING, DESIGN AND PARTICIPANTS

In 2018, we conducted a cross-sectional study comprised of 7714 retail business workers in the service industry in Japan.

PRIMARY AND SECONDARY OUTCOME MEASURES

For the definition of smoking HTPs, we identified current HTP smokers who only smoked HTPs, using five mutual categories of current smoking status (never, former, HTPs only, combustible cigarettes only and dual smokers who smoked both combustible cigarettes and HTPs). Occupational classes were classified into office workers (eg, upper non-manual workers) and other workers. ORs and 95% CIs of office workers were estimated for HTP usage, adjusted for age, sex, employment type and cigarette smoking-related health knowledge.

RESULTS

The overall prevalence of smoking HTPs was 3.0% (male 5.0%, female 2.2%). The prevalence of HTP smokers differed across occupational classes (5.6% in office workers vs 2.5% in others; p<0.05). Compared with other workers, the adjusted odds of office workers for smoking HTPs remained elevated (OR: 1.97, 95% CI: 1.40 to 2.77). Sensitivity analyses with workers of all smoking status showed the same pattern. When stratified by sex, the occupational difference only remained significant in male workers.

CONCLUSIONS

We found a positive occupational difference in smoking HTPs, particularly among male workers in the retail sector in Japan. National tobacco control should explicitly address this occupational gap and further encourage individuals to quit smoking.

Assessment of IQOS Marketing Strategies at Points-of-Sale in Israel at a Time of Regulatory Transition

INTRODUCTION

IQOS, a tobacco heating system, and accompanying tobacco sticks (HEETS) entered the Israeli market in 2016, prior to rapid regulatory change. This study assessed IQOS marketing strategies and regulatory compliance at IQOS/HEETS point-of-sale (POS) in Israel in December 17, 2019-January 7, 2020, after the ban on advertisement went into effect in March 8, 2019.

METHODS

Research staff audited 80 randomly-selected IQOS/HEETS POS in 4 cities using a structured form to assess store types, product placement, price, promotional strategies, and regulatory compliance. POS data was linked to neighbourhood characteristics, including socioeconomic status (SES), ethnicity, and proximity (under 300 meters) to schools.

RESULTS

Almost half of the stores (48.7%) were convenience stores. HEETS were visible to the customers in 46.1% of POS, 35% carried at least four HEETS colours, 20.0% had IQOS/HEETS special displays, and 13.8% displayed HEETS near youth-oriented merchandise. Mean HEETS pack price was 8.7 USD (range: 7.5-11.3 USD), 27% more than the least expensive cigarette pack, and 39% less than the most expensive cigarette. HEETS promotions were uncommon. Compliance with the newly-introduced advertisement ban was fairly high for HEETS (94.8%). Only one POS was located in a low-SES area; 68.7% were in close proximity to a school.

CONCLUSION

The relatively limited IQOS/HEETS marketing at POS suggests that, with regulatory changes, online or other forms of marketing might be prioritized. IQOS may be promoted to higher SES populations, as indicated by pricing and POS neighbourhood characteristics. Access near schools and placement near youth-oriented merchandise are potential concerns necessitating further research.

IMPLICATIONS

Globally, the point-of-sale is considered the least regulated channel for advertising and marketing of tobacco products. Assessing IQOS marketing strategies at the point-of-sale provides valuable findings that can inform regulatory efforts in Israel and other countries as well. Limited IQOS/HEETS marketing at point-of-sale suggests that primary marketing strategies may shift to online or other forms/channels as regulatory contexts become more progressive/restrictive. Ongoing surveillance of IQOS via online marketing and point-of-sales, specifically with regard to product placement and proximity to schools, is needed.