Randomised clinical trial of snus versus medicinal nicotine among smokers interested in product switching

Systematic review and meta-analysis investigating nicotine, cotinine and carbon monoxide exposures in people who both smoke and use nicotine replacement therapy

AIMS

To determine effects of concurrent smoking and nicotine replacement therapy (NRT) use on reported heaviness of smoking, nicotine (cotinine) body fluid and exhaled air carbon monoxide (CO) concentrations.

METHODS

Systematic review and meta-analysis of RCTs, which test interventions permitting concurrent NRT use and smoking and comparing, within participants, outcomes when smoking with those when smoking and using NRT concurrently. Measurements included reported number of cigarettes smoked per day (CPD), body fluid cotinine and expired air CO concentrations.

RESULTS

Twenty-nine studies were included in the review. Meta-analysis of nine showed that, compared with when solely smoking, fewer cigarettes were smoked daily when NRT was used (mean difference during concurrent smoking and NRT use, -2.06 CPD [95% CI = -3.06 to -1.07, P < 0.0001]). Meta-analysis of seven studies revealed a non-significant reduction in exhaled CO during concurrent smoking and NRT use (mean difference, -0.58 ppm [95% CI = -2.18 to 1.03, P = 0.48]), but in the three studies that tested NRT used in the lead-up to quitting (i.e. as preloading), a similar reduction in exhaled CO was statistically significant (mean difference, -2.54 ppm CO [95% CI = -4.14 to -0.95, P = 0.002]). Eleven studies reported cotinine concentrations, but meta-analysis was not possible because of data reporting heterogeneity; of these, seven reported lower cotinine concentrations with concurrent NRT use and smoking, four reported no differences, and none reported higher concentrations.

CONCLUSIONS

People who smoke and also use nicotine replacement therapy report smoking less heavily than people who solely smoke. When nicotine replacement therapy is used in the lead-up to quitting (preloading), this reported smoking reduction has been biochemically confirmed. There is no evidence that concurrent smoking and nicotine replacement therapy use result in greater nicotine exposure than solely smoking.

Efficacy of smokeless tobacco for smoking cessation: a systematic review and meta-analysis

OBJECTIVE

Smoking remains prevalent in many countries despite rigorous tobacco control strategies. The use of Swedish snus, a type of low-nitrosamine smokeless tobacco, has been promoted as a tobacco harm reduction strategy.

DATA SOURCES AND STUDY SELECTION

Three databases were searched for studies that assessed the effectiveness of snus in promoting smoking abstinence. A total of 28 studies were reviewed (5 randomised controlled trials (RCTs), 7 longitudinal and 16 cross-sectional studies).

DATA EXTRACTION

Separate meta-analyses were conducted by study type, pooling effect estimates where outcome measures and design were sufficiently comparable. Study details and quality assessment (Risk of Bias 2 for RCTs, Newcastle-Ottawa Scale for observational studies) are provided for each study.

DATA SYNTHESIS

While the meta-analysis of RCTs did not show a significant association between snus use and smoking cessation (risk ratio (RR)=1.33, 95% CI 0.71 to 2.47 and RR=0.62, 95% CI 0.27 to 1.41), the results of the meta-analysis of longitudinal cohort studies (RR=1.38, 95% CI 1.05 to 1.82, p=0.022) and cross-sectional studies (OR=1.87, 95% CI 1.29 to 2.72, p=0.001) indicated that use of snus was associated with an increased likelihood of quitting or having quit smoking. There was significant heterogeneity in the cross-sectional studies, and leave-one-out analysis indicated that the longitudinal cohort results were driven by one study. Most studies examined were subject to an elevated risk of bias.

CONCLUSION

There is weak evidence for the use of snus for smoking cessation. Better RCTs and longitudinal studies are needed; meanwhile, existing cessation aids may be better placed than snus to promote abstinence.

Effects of a Reduced Risk Claim on Adolescents' Smokeless Tobacco Perceptions and Willingness to Use

PURPOSE

United States Smokeless Tobacco Company LLC submitted a modified risk tobacco product application to the US Food and Drug Administration, proposing a claim that switching to Copenhagen snuff fine cut from cigarettes reduces lung cancer risk. This claim could affect adolescents' smokeless tobacco perceptions and its use.

METHODS

Students (N = 592; mean age: 15.3 years; 46% male; 32% nonHispanic White; 8% smokeless tobacco ever-users) at seven California high schools were randomized within a survey to view a Copenhagen snuff image, either with or without the proposed reduced risk claim. Participants were then asked about the harm of smokeless tobacco and their willingness to try Copenhagen snuff if a friend offered. Postimage harm rating and willingness were compared between image groups overall, stratified by past 30-day tobacco use (87% of tobacco users were e-cigarette users), and adjusted for participant characteristics using multivariable regression.

RESULTS

Participants who viewed the claim were less likely to perceive smokeless tobacco to cause "a lot" of harm (56% vs. 64%; p = .03), including after statistical adjustment (risk ratio [RR]: 0.84; 95% confidence interval [CI]: 0.75, 0.94), and with a numerically stronger effect among tobacco users (RR: 0.65; 95% CI: 0.48, 0.86). The claim did not increase willingness overall (17% vs. 20%; p = .41) but did increase willingness among tobacco users (RR: 1.67; 95% CI: 1.05, 2.67).

DISCUSSION

Brief exposure to a reduced-risk claim decreased adolescents' smokeless tobacco harm perceptions and increased willingness to try among tobacco users. The Food and Drug Administration order permitting this claim could increase some adolescents' susceptibility to smokeless tobacco, particularly those already using other tobacco products like e-cigarettes.

Characterization of Ad Libitum Use Behavior of On! Nicotine Pouches

Objectives: Actual use of nicotine pouch products is not well studied. The objectives of this study were to characterize on ® nicotine pouch (Test Products (TP)) use behavior, including association with cigarette and smokeless tobacco (ST) product use. Methods: Adults who smoke cigarettes (AS) and/or adults who use ST (ASTU) (N=1147) that were not planning to quit and had expressed interest in trying and using TP after a 5-day trial were offered ad libitum use of TPs (7 flavors at 5 nicotine levels) for 6 weeks. Results: Participants used a median of ~5-6 pouches/day of a variety of flavors and nicotine levels. In the final week of the study, 27% of AS and 71% of ASTU reported no use of cigarettes or ST respectively, while reporting continued use of TPs. Additionally, 39% of AS and 14% of ASTU reduced consumption of cigarettes or ST products respectively by 50%-99%, compared to reported use at screening. We found a statistically significant inverse relationship between TP flavor varieties and number of cigarettes/ST. Conclusions: These data suggest that TPs can be potential substitutes for cigarettes/ST products, and complete switching may offer harm reduction potential for AS and ASTU not interested in quitting.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Designing Studies to Inform Tobacco Harm Reduction: Learnings From an Oral Nicotine Pouch Actual Use Pilot Study

Background

Introduction of new tobacco products in the United States, including those that may be lower on the risk continuum than traditional combustible cigarettes, requires premarket authorization by the US Food and Drug Administration and information on the potential impact of the products on consumer behaviors. Efficient recruitment and data capture processes are needed to collect relevant information in a near-to-real-world environment.

Objective

The aim of this pilot study was to develop and test a protocol for an actual use study of a new tobacco product. The product included in this study was a commercially available oral nicotine pouch. Through the process of study design and execution, learnings were garnered to inform the design, execution, analysis, and report writing of future full-scale actual use studies with tobacco products.

Methods

A small sample (n=100) of healthy adult daily smokers of 7 or more cigarettes per day were recruited to participate in an 8-week prospective observational study conducted at 4 geographically dispersed sites in the United States. A smartphone-based customized electronic diary (eDiary) was employed to capture daily tobacco product use, including 1 week of baseline smoking and 6 weeks during which participants were provided with oral nicotine pouches for use as desired.

Results

Online screening procedures with follow-up telephone interviews and on-site enrollment were successfully implemented. Of 100 participants, 97 completed the study, with more than half (59/99, 60%) identifying as dual- or poly-users of cigarettes and other types of tobacco products at baseline. There was more than 90% (91-93/99, 92%-94%) compliance with daily eDiary reporting, and the majority (92/99, 93%) of participants expressed satisfaction with the study processes. Product use data from the eDiary indicated that after an initial period of trial use, pouches per day increased among those continuing to use the products, while per day average cigarette consumption decreased for 82% (79/97) of all study participants. At the end of the week 6, 16% (15/97) of participants had reduced their cigarette consumption by more than half.

Conclusions

The design of this study, including recruiting, enrollment, eDiary use, and oversight, was successfully implemented through the application of a detailed protocol, a user-friendly eDiary, electronically administered questionnaires, and remote monitoring procedures. High-resolution information was obtained on prospective changes in tobacco product use patterns in the context of availability of a new tobacco product. Future, larger actual use studies will provide important evidence supporting the role that alternatives to combustible cigarettes may play in smoking reduction and/or cessation and lowering the population health burden of tobacco and nicotine-containing products.

Intention to purchase alternative tobacco products as a function of smoking status and responses to advertising, packaging, and sensory experiences

INTRODUCTION

Tobacco manufacturers design and marketed products with appealing sensory characteristics to drive product uptake and continued use. We assessed smokers' and non-smokers' cognitive, affective, and sensory responses to Camel Snus (CS) and Nicotine gum (NG) to gauge future intentions to use.

METHOD

In a single laboratory session, 348 participants (including current smokers and nonsmokers in Buffalo, NY and Boston, MA) were exposed to CS and NG products in counterbalanced order. Exposure involved a cumulative set of 3 steps in which participants i) viewed an advertisement; ii) viewed the packaging, and iii) touched and smelled the product, without actual use. Current daily and non-daily smokers were invited to undertake a fourth exposure step by sampling the product. Following product exposure, participants completed perception measures and reported future intentions to use either product at the end of the survey. After each exposure, participants' reported feelings of valence and arousal.

RESULTS

Smokers reported greater preference to try NG (63.8%) compared with CS (17.4%) or neither (18.8%), whereas majority of nonsmokers preferred neither product (64.3%) (p < 0.01). Of those offered to sample the products, 78.3% daily smokers and 68.4% non-daily smokers opted to sample. When asked about intentions to try, a greater proportion of smokers stated a preference to try NG over CS, as did the small number of nonsmokers who expressed a preference.

CONCLUSION

Intentions to try CS were low despite different levels of exposure to product, and this low product appeal and interest in use may translate to limited potential of CS to serve as a reduced harm product for smokers.

Reappraising Choice in Addiction: Novel Conceptualizations and Treatments for Tobacco Use Disorder

The introduction of alternative nicotine and tobacco products (such as e-cigarettes, heat-not-burn devices, nicotine pouches) warrants an updated framework from which to conceptualize tobacco use disorder (TUD). The following review provides considerations for TUD within the context of novel products. Historically, the tobacco industry falsely claimed that cigarettes were not addictive or harmful and that those who smoked simply chose to do so. This generated an inaccurate lay perception that smoking is a free or informed choice. Research on nicotine pharmacology demonstrates the powerful addictive potential of nicotine, which is shaped by dose, speed of delivery, and other constituents generated. In addition, non-pharmacologic reinforcers motivate and maintain tobacco use behaviors for both traditional cigarettes and novel products. The negative consequences of combustible tobacco use are well known; however, these outcomes may differ for alternative products. Strategies used for combustible product cessation may be adapted for novel products, and treatment recommendations for TUD should be made within the context of a harm reduction framework wherein alternative product use may be the desired outcome. Providers must therefore be willing to modify their perceptions of products and treatment recommendations accordingly. Better public health outcomes are accomplished through promotion of abstinence from combustible smoking. For those who cannot wean from nicotine entirely, switching to less risky modes of delivery might be a secondary goal, with an eventual aim of stopping use of the alternative product. Implications: Given the advent of novel, alternative tobacco products, tobacco use disorder (TUD) must be conceptualized within a contemporary framework that includes harm reduction and alternative outcomes. The unique contributions of nicotine pharmacology, non-pharmacologic reinforcers, and consequences of use can be used to inform treatments for TUD with the ultimate goal of improving the health of individuals who use tobacco.

A Randomized Clinical Trial of Snus Examining the Effect of Complete Versus Partial Cigarette Substitution on Smoking-Related Behaviors, and Biomarkers of Exposure

INTRODUCTION

This 8-week multisite, randomized controlled trial of snus examined the differential effects of instructions on (1) snus use, (2) smoking and smoking-related measures, and (3) exposure to tobacco-related constituents.

METHOD

US adult daily cigarette smokers (n = 150; 43.3% female; Medianage = 43.5) were recruited from Minneapolis, Minnesota; Columbus and Coshocton, Ohio; and Buffalo, New York. Following a 1-week sampling phase of snus, participants who used at least 7 pouches were randomized to either (1) partial substitution (PS; "use snus as you like with your cigarettes"), (2) complete substitution (CS; "avoid cigarettes"), or (3) usual brand cigarettes (UB). Analyses included between-group analyses (eg, PS vs. CS) using Wilcoxon rank sum test of cigarettes per day and snus pouches per day, and a linear mixed model (biomarkers).

RESULTS

Compared to the PS and UB groups, smokers assigned to CS reported greater reductions in cigarettes per day (ps < .001), using more snus pouches per day (p = .02), and more smoke-free days (CS median = 14.5, PS and UB medians = 0, p < .001). In addition, results demonstrated reductions in carbon monoxide (p < .001), total nicotine equivalents (p = .02), and four out of five measured volatile organic compounds (ps < .01) over time among the CS group. Exposure to N'-nitrosonornicotine increased by trial end only among the PS group (p < .04). Phenanthrene tetraol increased among all groups by trial end (p = .02) with no difference between groups.

CONCLUSIONS

Instructions to completely switch from cigarettes to snus resulted in the greatest reduction in cigarettes and exposure to harmful constituents.

IMPLICATIONS

Directly instructing smokers to switch completely to snus, rather than using ad libitum (with no instructions to avoid cigarettes), is necessary for reductions in smoking and subsequent exposure to harmful constituents.

Cigarette smokers' concurrent use of smokeless tobacco: dual use patterns and nicotine exposure

BACKGROUND

The concurrent use of cigarettes with other tobacco products, such as smokeless tobacco (SLT), is increasingly common. Extant work with cigarette smokers who also use SLT is based heavily on retrospective reports and between-group comparisons. The purpose of this study was to assess prospectively the patterns of dual users' product use and nicotine exposure on days when cigarettes were smoked exclusively (single use) versus concurrently with SLT (dual use).

DESIGN

Forty-six dual cigarette-SLT users recorded their product use in real time via ecological momentary assessment for a 2-week longitudinal design. They responded to questions about situational factors (eg, location, mood) using this same diary, and collected saliva samples each night for later cotinine measurement. At the end of this 2-week period, users reported on their reasons for and beliefs about SLT use.

RESULTS

Cotinine levels were significantly higher on dual versus single use days (mean±SEM=374.48±41.08 ng/mL vs 300.17±28.13 ng/mL, respectively; p<0.01), and the number of cigarettes logged was higher on dual versus single use days (11.13±0.98 vs 9.13±1.11, respectively; p<0.01). Product use was distinguished by situational factors, with the strongest predictor being location of use. Moreover, the most common reason for initiating (56.52%) and continuing (67.39%) SLT use was to circumvent indoor smoking restrictions.

CONCLUSIONS

Results support the idea of product supplementation rather than replacement among this convenience sample of dual users. For smokers whose primary motivation for SLT use involves situations where they would otherwise be tobacco free, the potential benefits of clean indoor air laws may be diminished.

Current advances in research in treatment and recovery: Nicotine addiction

The health harms of combusted tobacco use are undeniable. With market and regulatory pressures to reduce the harms of nicotine delivery by combustion, the tobacco product landscape has diversified to include smokeless, heated, and electronic nicotine vaping products. Products of tobacco combustion are the main cause of smoking-induced disease, and nicotine addiction sustains tobacco use. An understanding of the biology and clinical features of nicotine addiction and the conditioning of behavior that occurs via stimuli paired with frequent nicotine dosing, as with a smoked cigarette, is important for informing pharmacologic and behavioral treatment targets. We review current advances in research on nicotine addiction treatment and recovery, with a focus on conventional combustible cigarette use. Our review covers evidence-based methods to treat smoking in adults and policy approaches to prevent nicotine product initiation in youth. In closing, we discuss emerging areas of evidence and consider new directions for advancing the field.

Snus and Snuff Use in Switzerland Among Young Men: Are There Beneficial Effects on Smoking?

Introduction

There are few recent longitudinal studies on smokeless tobacco (SLT) products and smoking outside the United States or European Nordic countries. The present longitudinal study tests whether Swedish-type snus and nasal snuff use decreases smoking incidence and prevalence in a central European country.

Methods

The sample consisted of 5198 Swiss men (around 20 years of age). Retention rate was 91.5% over 15 months. Regression models, adjusting for a variety of psychosocial, smoking-related, and other risk factors, assessed whether no, low (less than weekly), and high (weekly or more) use baseline groups showed changes or maintenance in snus and snuff use related to smoking initiation, cessation, and reduction.

Results

Among baseline nonsmokers, snus initiators (OR = 1.90, p = .003) and low baseline maintainers (OR = 4.51, p < .001) were more likely to start smoking (reference: persistent nonusers of snus). Among baseline smokers, initiators (OR = 2.79, p < .001) and low baseline maintainers (OR = 2.71, p = .005) more often continued smoking, whereas snus quitters less frequently continued smoking (OR = 0.57, p = .009). High baseline maintainers were non-significantly less likely to continue smoking (OR = 0.71, p = .315). Among continuing smokers, only snus quitters significantly reduced the number of cigarettes smoked per day (b = -1.61, p = .002) compared with persistent nonusers of snus. Results were similar for snuff.

Conclusions

SLT use did not have any significant beneficial effects on young men in Switzerland but significantly increased the likelihood of smoking initiation and continuation, independent of whether the substance is legally sold (snuff) or not (snus). This does not exclude that there may be beneficial effects at older ages.

Implications

Our research provides evidence that SLT use has no benefits for cigarette smoking initiation, cessation, or reduction among young men in a central European country, where SLT is not highly promoted or receives tax incentives. This is true for both legally sold nasal snuff and Swedish-type snus that cannot be legally sold. Results indicate that without incentives for using it, among young people shifts from smoking to SLT use are questionable and confirms the need for country-specific studies before the global public health community engages in promoting SLT.

Assessing likelihood of product use for snus with modified-risk information among adult current cigarette smokers, former tobacco users, and never tobacco users

Introduction

Switching from cigarettes to snus by smokers unlikely to quit would be expected to benefit overall population health, with any potential benefit needing to be weighed against potential harms from snus use by tobacco non-users and smokers likely to quit. This study evaluates likelihood of snus use among tobacco users and non-users provided modified-risk information.

Methods

An online sample of 11,302 U.S. adults was randomized to view advertisements for snus that either provided modified-risk information or only described snus. Intent to purchase ratings were converted to projected purchase (use) rates using an empirically derived algorithm.

Results

Projected product use for snus was significantly higher among current smokers than former or never tobacco users (p < 0.0001) for both the modified-risk and control information. A significant interaction effect between information and tobacco user group (p < 0.0001) indicated the modified-risk information differentially increased projected use among smokers (8.2% vs. 6.9%), with much lower projections for both the test and control information among former (1.2%) and never tobacco users (0.4%). Among never users, projected use was highest among those susceptible to smoking. These findings were generally similar for young adults, ages 18–24. Smokers expecting to quit who viewed modified-risk information had lower projected use (4.2%) than those not expecting to quit (8.7%).

Conclusions

Results suggest that providing modified-risk information for snus is unlikely to increase use among those not using tobacco. Interest in snus was greatest among current smokers who would benefit by switching to snus as communicated in the modified-risk advertisement.

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We tested the effect of communicating the reduced risk of snus compared to smoking.

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Such communication increased likely use of snus among smokers.

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Likely use of snus did not increase in never and former tobacco users.

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Projected use of snus was highest among smokers not likely to quit.

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Providing risk information is unlikely to cause harm and may confer benefits.

A Twin Study of Cigarette and Snus Initiation and Quantity of Use in Norwegian Adult Twins

While snus has been the focus of increasing public health interest, twin studies have examined neither sources of individual variation for its use nor the sources of resemblance between snus and cigarette use. Twins from the Norwegian Institute of Public Health Panel were assessed by self-report questionnaire for the initiation of regular use and maximal quantity used for snus and cigarettes. Twin modeling was performed using OpenMx on data from 2767 twins including 856 complete pairs. Fitting univariate twin models produced similar results for cigarette initiation and quantity with estimates of additive genetic, shared environmental and unique environmental effects of approximately 77%, 0% and 23%, respectively. Estimates of snus initiation and quantity were, respectively, approximately 53%, 26% and 21%. Joint analyses suggested that the genetic, shared environmental and unique environmental correlations between cigarette and snus initiation and quantity were +.82, 0 and +.42, respectively. However, these results could not be statistically distinguished from a model which postulated that resemblance between cigarette initiation and quantity resulted from genetic and unique environmental correlations of +.47 and +.43. Compared with cigarette initiation and quantity of use in Norwegian twins, the role of genes was less prominent and shared environment more prominent for initiation and quantity of use of snus. Joint analyses of both tobacco phenotypes suggested, but did not confirm definitively, that genetic risk factors for cigarette and snus use were similar but not identical, while shared environmental factors existed that were specific to snus use.

Consortium on Methods Evaluating Tobacco: Research Tools to Inform US Food and Drug Administration Regulation of Snus

Introduction

The US Food and Drug Administration (FDA) has purview over tobacco products. To set policy, the FDA must rely on sound science, yet most existing tobacco research methods have not been designed to specifically inform regulation. The NCI and FDA-funded Consortium on Methods Evaluating Tobacco (COMET) was established to develop and assess valid and reliable methods for tobacco product evaluation. The goal of this article is to describe these assessment methods using a US manufactured "snus" as the test product.

Methods

In designing studies that could inform FDA regulation, COMET has taken a multidisciplinary approach that includes experimental animal models and a range of human studies that examine tobacco product appeal, addictiveness, and toxicity. This article integrates COMET's findings over the last 4 years.

Results

Consistency in results was observed across the various studies, lending validity to our methods. Studies showed low abuse liability for snus and low levels of consumer demand. Toxicity was less than cigarettes on some biomarkers but higher than medicinal nicotine.

Conclusions

Using our study methods and the convergence of results, the snus that we tested as a potential modified risk tobacco product is likely to neither result in substantial public health harm nor benefit.

Implications

This review describes methods that were used to assess the appeal, abuse liability, and toxicity of snus. These methods included animal, behavioral economics, consumer perception studies, and clinical trials. Across these varied methods, study results showed low abuse-liability and appeal of the snus product we tested. In several studies, demand for snus was lower than for less toxic nicotine gum. The consistency and convergence of results across a range of multi-disciplinary studies lends validity to our methods and suggests that promotion of snus as a modified risk tobacco products is unlikely to produce substantial public health benefit or harm.

Perceptions of Snus Among US Adult Smokers Given Free Product

Introduction

Snus uptake is nominal among US smokers. This longitudinal study examines (1) perceptions of snus among US smokers given free snus for 6 weeks and (2) a method for assessment of an alternative tobacco product at the population level.

Methods

Adult smokers (n = 543; 69.2% female; Mage = 49.3 years), uninterested in quitting, received free snus for ad libitum use. Based on their snus use during a 6-week sampling period, participants included: (1) never users (18.4%, n = 100); (2) experimenters; that is, used ≥ once, but not during the last week of sampling (33.1%; n = 180); and (3) persistent users; that is, used ≥ once during the final week, and ≥ once during any other week of the sampling period. (48.4%; n = 263).

Results

Following the sampling period, those who became persistent users were more likely than experimenters to report that switching to alternative tobacco products would lower their risk for health problems (66.5% vs. 50.0%; p = .006). Persistent users also reported greater negative affect relief and craving reduction (ps < .001) than experimenters. Finally, persistent users were more likely than experimenters to describe snus in favorable terms with respect to ease of use, satisfaction, and liking (ps < .05).

Conclusions

Subjective experiences with snus, rather than nicotine dependence, explained experimentation versus persistent use. Even among smokers who became persistent snus users, snus was perceived as a poor substitute for cigarettes. This study design (randomized, yet naturalistic) could be extended to other novel tobacco products, including e-cigarettes, to help understand the role new products may have in the tobacco landscape.

Implications

This is the first large scale, US-based naturalistic assessment of smokers' reactions to snus during an extended sampling period. This study is directly in line with FDA goals to better understand predictors of initiation, uptake, and use of other tobacco products such as snus, and serves as model for assessment methods of alternative tobacco products at the population level. Most smokers tried the provided sample of snus (approximately 82%). Subjective experiences with snus, rather than nicotine dependence, explained experimentation versus persistent use. Even among smokers who became persistent snus users, snus was perceived as a poor substitute for cigarettes.

Self-perceived Mental Health and Population-level Tobacco Use Disparities

Objectives

Poor mental health is associated with increased cigarette smoking, yet whether this extends to alternative tobacco product use remains unknown.

Methods

Wave 1 data from the Population Assessment of Tobacco and Health study assessed relationships between self-perceived mental health (SPMH) and prevalence of and motives for tobacco use among US adults (N = 32,320).

Results

Fair/poor SPMH, as compared to good/excellent SPMH, was associated with increased current cigarette (AOR = 2.91, 95% CI = 2.64, 3.20), e-cigarette (AOR = 1.35, 95% CI = 1.20, 1.53), cigarillo (AOR = 1.38, 95% CI = 1.22, 1.56), filtered cigar (AOR = 1.43, 95% CI = 1.21, 1.70), and smokeless tobacco (AOR = 1.17, 95% CI = 1.01, 1.36), but not traditional cigar use (AOR = 1.04, 95% CI = 0.90, 1.20). Whereas most motives for tobacco use were similar across SPMH rating, those with fair/poor SPMH, as compared to good/excellent SPMH, were more likely to report using traditional cigars due to affordability (AOR = 1.56, 95% CI = 1.23, 1.98) and e-cigarettes (AOR = 1.43, 95% CI = 1.15, 1.79) and smokeless tobacco (AOR = 1.84, 95% CI = 1.19, 2.83) due to appealing advertising.

Conclusions

Although individuals with poor SPMH are more likely to use alternative tobacco products than those with better SPMH, most motives for use are strikingly similar. These findings highlight the importance of continual monitoring of tobacco use trends among vulnerable populations.

Evaluating the utility of subjective effects measures for predicting product sampling, enrollment, and retention in a clinical trial of a smokeless tobacco product

INTRODUCTION

Subjective effects of drugs, representing pharmacological and non-pharmacological effects, have been shown to be associated with future use and abuse. This also is the case for tobacco products and so measuring subjective effects, such as liking, satisfaction, and aversion, is crucial to gaining an understanding of consumer perception leading to increased use. This study examined the predictive validity of subjective drug and product effects with respect to product adoption.

METHODS

Smokers (N=151) were enrolled in Minneapolis, Columbus, and Buffalo. Participants were shown two snus products (Camel Snus Winterchill and Robust), asked to try each of the products for 5min and to rate them using the Product Evaluation Scale (PES) and Drug Effects Questionnaire (DEQ). This was followed by a one-week use period of their preferred product and those who used at least 1 unit of Camel Snus per day (or at least 7 pouches total) were eligible to enroll in the Clinical Trial Phase assessing the impact of complete switching or dual use with smoking. Key outcomes for this study were product evaluation, extent of product use, and Clinical Trial enrollment.

RESULTS

We noted no relationships between participant characteristics such as gender, age, prior smokeless use, baseline cigarettes per day (CPD), or PES and DEQ scores with any of these outcome variables. Subjective effects were weak predictors of product use, which totaled approximately 3units of snus per day.

CONCLUSIONS

Regardless of product, it appears that PES and DEQ ratings were uniformly poor predictors of trial enrollment and retention, though they do predict the amount of snus used during the sampling phase. Findings indicate that while subjective effects predict product preference in the short-term, they did not consistently predict extent of use or enrollment in the trial, suggesting that these initial measures have limited implications for long-term behavior.

A Naturalistic, Randomized Pilot Trial of E-Cigarettes: Uptake, Exposure, and Behavioral Effects

Background: Most studies of electronic nicotine delivery systems (ENDS) compare self-selected users versus nonusers. The few randomized studies to date generally support a positive impact on reducing smoking behavior, but these studies are focused on guided ENDS use. This study presents a randomized, naturalistic trial of ENDS with prospective outcomes of uptake and behavioral changes in smoking.Methods: Adult smokers with minimal ENDS history were randomized in a 2:1 ratio to receive product for 3 weeks (n = 46), or not (n = 22). Changes in nicotine delivery (16 vs. 24 mg), midway through the study allowed a compelling opportunity to examine two ENDS products compared with the control group. Primary outcomes, assessed via daily diaries during sampling period and in-person laboratory visits over 4 months, included uptake and usage of ENDS, cessation-related outcomes, and exposure to smoke constituents.Results: All ENDS participants tried product at least once, with 48% of 24 mg and 30% of 16 mg using their assigned product for the entire sampling period. Within the 24 mg ENDs group, 57% made an independent purchase of ENDS, versus 28% of 16 mg, and 14% of control participants (P = 0.01). Smokers in both ENDS groups significantly reduced their smoking, whereas control participants did not (P = 0.03). Cessation behaviors (quit attempts, biologically verified abstinence) numerically but not statistically favored ENDS participants.Conclusions: Results suggest that cigarette smokers are willing to use ENDS with trends toward reduced cigarette smoking and positive changes in cessation-related behaviors.Impact: Randomized, naturalistic trials such as presented herein are needed to understand the population impact of e-cigarettes. Cancer Epidemiol Biomarkers Prev; 26(12); 1795-803. ©2017 AACR.

Snus undermines quit attempts but not abstinence: a randomised clinical trial among US smokers

BACKGROUND

Observational studies and a few clinical trials suggest that use of low nitrosamine smokeless tobacco (snus) can facilitate smoking cessation. To better understand the real-world impact of snus on smoking behaviour, a large-scale, long-term clinical trial of naturalistic snus use among smokers is needed.

STUDY DESIGN

A nationwide clinical trial compared abstinence outcomes among smokers who were randomised to receive free samples of snus versus not. Participants (N=1236) were recruited throughout the US and assessed for 1 year following a 6-week naturalistic sampling period, with high retention throughout. Primary outcomes included self-reported quit attempts, floating abstinence (any 7-day period of non-smoking) and 7-day point-prevalence abstinence at 6 months and 12 months. Secondary outcomes were changes in smoking, motivation and confidence to quit and adverse events. No tobacco industry support was provided.

RESULTS

Within snus group, 82% used at least once, and 16% were using regularly at end of sampling period. Compared to control participants, smokers in the snus group were less likely to make any quit attempt (RR=0.83; 95% CI 0.70 to 1.00), and any 24 h quit attempt (RR=0.77; 95% CI 0.63 to 0.95). There were no group differences on any measure of abstinence.

CONCLUSIONS

Provision of snus in a naturalistic context resulted in minimal uptake, and as a whole, undermined quit attempts and did not increase smoking abstinence. Results do not support the unguided, free provision of snus among smokers not motivated to quit as a means to facilitate quit attempts.

TRIAL REGISTRATION NUMBER

NCT01509586, Results.

Naturalistic assessment of demand for cigarettes, snus, and nicotine gum

RATIONALE

Behavioral economic measures of demand provide estimates of tobacco product abuse liability and may predict effects of policy-related price regulation on consumption of existing and emerging tobacco products.

OBJECTIVE

In the present study, we examined demand for snus, a smokeless tobacco product, in comparison to both cigarettes and medicinal nicotine. We used both a naturalistic method in which participants purchased these products for use outside the laboratory, as well as laboratory-based self-administration procedures.

METHODS

Cigarette smokers (N = 42) used an experimental income to purchase their usual brand of cigarettes and either snus or gum (only one product available per session) across a range of prices, while receiving all products they purchased from one randomly selected price. In a separate portion of the study, participants self-administered these products during laboratory-based, progressive ratio sessions.

RESULT

Demand elasticity (sensitivity of purchasing to price) was significantly greater for snus than cigarettes. Elasticity for gum was intermediate between snus and cigarettes but was not significantly different than either. Demand intensity (purchasing unconstrained by price) was significantly lower for gum compared to cigarettes, with no significant difference observed between snus and cigarettes. Results of the laboratory-based, progressive ratio sessions were generally discordant with measures of demand elasticity, with significantly higher "breakpoints" for cigarettes compared to gum and no significant differences between other study products. Moreover, breakpoints and product purchasing were generally uncorrelated across tasks.

CONCLUSIONS

Under naturalistic conditions, snus appears more sensitive to price manipulation than either cigarettes or nicotine gum in existing smokers.

A longitudinal, naturalistic study of U.S. smokers' trial and adoption of snus

To refine public health policy amidst a changing landscape of tobacco products in the United States, it is first necessary to describe fully the nature of smokers' alternative product use. Little research addresses smokers' snus use, and most studies are limited by small samples, cross-sectional designs, and crude outcome measurement. This study sample includes 626 adult US smokers who denied intention to quit in the next month and were randomized to receive free snus during a 6-week sampling period, after which no snus was provided. Participants were then followed for one year. Outcome data were collected via phone. Participants (mean age: 48.7years) were predominately female, White non-Hispanic. Eighty-four percent reported trial of snus. Eleven percent reported purchase (i.e., adoption). Current use declined from 47.1% at the end of the sampling period to 6.5% at the end of follow-up. Frequency and quantity of snus use among current users was low. Among snus users, 79.3% said it functioned as an alternative to smoking and 58.4% said it provided a means of coping with smoking restrictions; options not mutually exclusive. In logistic regressions, men were more likely to report trial (odds ratio [OR]=2.33, p<0.01) and adoption (OR=1.84, p<0.05) than women. Baseline expectations about the nature of snus use also predicted snus outcomes (OR=1.28-1.78, p<0.05). Smokers showed willingness to try snus, but product interest waned over time. Snus as currently marketed is unlikely to play a prominent role in US tobacco control efforts.

Gender differences in snus versus nicotine gum for cigarette avoidance among a sample of US smokers

INTRODUCTION

Women are more susceptible to the harmful effects of cigarette smoking. Thus, identifying effective harm reduction approaches for women is necessary. The goal of this project was to examine gender differences in response to snus versus nicotine gum for cigarette avoidance, as a means of harm reduction.

METHODS

Participants were randomly assigned to use snus or nicotine gum as a method to avoid cigarette smoking. Participants attended clinic visits to receive study product, as well as provide biological samples to assess smoking avoidance and biomarkers and report on use of study product and cigarettes. A secondary analysis comparing men and women by randomization to study product was conducted.

RESULTS

Participants (n=391; 47% women) were randomized into the snus group (n=196; 45% women) and the gum group (n=195; 49% women). Men used more snus whereas women used more gum (p=0.02). During treatment, men in the snus group had higher total nicotine equivalent values whereas women did not vary by group (p=0.03). Overall, fewer men in the snus group completely avoided cigarettes compared to men in the gum group (e.g., continuous abstinence at Week 12: odds ratio=0.43, 95% confidence interval=0.20-0.93). Among women, there were no differences by randomization in cigarette avoidance.

CONCLUSIONS

Despite a number of gender differences in response to snus versus nicotine gum, these data suggest that snus may not be an optimal harm reduction approach for either gender.

Interventions to reduce harm from continued tobacco use

BACKGROUND

Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced-exposure tobacco products (PREPs), as an alternative to cigarettes.

OBJECTIVES

To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long-term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco?

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free-text and MeSH terms for harm reduction, smoking reduction and cigarette reduction.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention.

DATA COLLECTION AND ANALYSIS

We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long-term smoking abstinence), using fixed-effect models. Where it was not possible to meta-analyse data, we summarized findings narratively.

MAIN RESULTS

Twenty-four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically-heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as 'low' or 'very low', due to imprecision and indirectness. 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.

AUTHORS' CONCLUSIONS

People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking. This could simply be due to the lack of high-quality studies (our confidence in cessation outcomes for these aids is rated 'low' or 'very low' due to imprecision by GRADE standards), meaning that we may have missed a worthwhile effect, or due to a lack of effect on reduction or quit rates. It is therefore important that more high-quality RCTs are conducted, and that these also measure the long-term health effects of treatments.

Self-Administration of Smokeless Tobacco Products in Rats

OBJECTIVE

Preclinical abuse liability assessment is an essential component of tobacco regulatory science. The goal of this project was to evaluate the relative abuse liability of smokeless tobacco products in rats using aqueous extracts of those products. These extracts provide exposure to an extensive range of nicotine and non-nicotine tobacco constituents as occurs in humans.

METHODS

Rats were trained to self-administer either nicotine alone or extracts of Camel Snus or Kodiak smokeless tobacco at an equivalent nicotine unit dose. In Experiment 1, the relative reinforcing efficacy of these formulations was assessed in adults and adolescents using a progressive ratio schedule under limited-access conditions. In Experiment 2, relative reinforcing efficacy was assessed in adolescents under unlimited-access conditions using behavioral economic demand curve analysis.

RESULTS

The reinforcing efficacy of nicotine formulations was higher in adolescents than adults, but no difference was observed between formulations in either age group. Similarly, there was no difference in elasticity of demand between formulations in adolescents.

CONCLUSIONS

The present findings suggest that the abuse liability of these smokeless tobacco products is similar to nicotine alone, and that nicotine dose is the primary determinant of the reinforcing efficacy of systemic exposure to these products.

Application of the Smokeless Tobacco Expectancies Questionnaire to Snus

OBJECTIVE

Measures of consumer perceptions of emerging tobacco products are needed for understanding the potential for product adoption and use. The purpose of this research was to evaluate the applicability of the Smokeless Tobacco Expectancies Questionnaire to snus, and examine its association with interest in using snus.

METHODS

We recruited 116 adolescents (14-17 years of age), 463 young adults (18-34 years of age), and 596 older adults (35-65 years of age) from a Web-based opt-in panel. Participants completed a 10-item Snus Expectancies Questionnaire and questions about their interest in trying snus in the next month.

RESULTS

Confirmatory factor analysis supported a latent factor structure representing Positive Reinforcement (PR) and Negative Health Consequences (NHC) within each age group. The scales differentiate smokers and smokeless tobacco users and nonusers. Each scale was associated with interest in purchasing snus for younger (PR: OR 1.90; NHC: OR 0.66) and older (PR: OR 1.36; NHC: OR 0.69) adults controlling for tobacco use status.

CONCLUSIONS

The modified Smokeless Tobacco Expectancies Questionnaire is a valid measure of snus-related outcome expectancies, which are in turn, associated with self-reported tobacco use, and may help to identify groups who are susceptible to snus initiation and use.

Perceived Health Risks of Snus and Medicinal Nicotine Products

INTRODUCTION

Perceived health risk (PHR) of a tobacco product may influence both uptake and continued use. In this study, we examined PHRs of snus and medicinal nicotine using the PHR scale and the relationship of PHR responses to use of these products in smokers seeking an alternative to smoking.

METHODS

Smokers were randomly assigned to snus or to medicinal nicotine for a period of 12 weeks and asked to only use the assigned product. The PHR scale involves rating the extent of perceived risk of a product for different diseases and was given at baseline and weeks 4 and 12 during treatment. Relationships between PHR scale scores and study attrition, compliance with only using the product, and continued use of the product after treatment were determined.

RESULTS

Response to the PHR scale showed no significant differences between the snus and medicinal nicotine for perceived risks for lung cancer, emphysema, and bronchitis. However, significant differences were observed for other cancers, heart disease, stroke and risk for addiction, particularly after product use, with higher scores among those assigned to snus. Scores on the PHR scale were not related to any of the trial outcome variables.

CONCLUSIONS

Among smokers seeking an alternative to smoking in a clinic setting, PHR of a product changes after product use but may not be related to product use patterns.

IMPLICATIONS

PHRs of snus or medicinal nicotine in smokers assigned to these products become more accurate after product use. PHR does not appear to be associated with patterns of product use; rather satisfaction with a product is a better indicator as to whether a smoker is compliant with only using the product or continues to use the product.

Exploring Smoking Stigma, Alternative Tobacco Product Use, & Quit Attempts

OBJECTIVES

Investigate smoking stigma among different tobacco user types.

METHODS

US adults (N=1,812) responded to an online survey, including non-smokers, smokeless tobacco users, exclusive smokers, and smokeless and cigarette "dual users".

RESULTS

Dual users perceived the highest smoking stigma. Stigma was higher for smokers open to quitting by switching to smokeless. E-cigarette users (smokers) reported higher stigma than non-users. Making a past-year quit attempt was predicted by smoking stigma, and smokeless and/or e-cigarette use.

CONCLUSIONS

Smoking stigma and dual use of smokeless tobacco and/or e-cigarettes with cigarettes predict quit attempts. However, smoking stigma might prevent smokers from consulting doctors and induce use of alternative tobacco products as cessation aids.