Evaluating smoking control policies in the e-cigarette era: a modelling study

Perception of e-cigarette control policies and education in schools on increased legal knowledge, harm perception, susceptibility and e-cigarette use among students in Thailand: A cross-sectional classroom-based survey

INTRODUCTION

In Thailand, school smoke-free policies initially targeted cigarette smoking but now extend to include electronic cigarettes (e-cigarettes). Yet, the impact of this expansion on curbing e-cigarette use in schools is uncertain. This study seeks to explore how e-cigarette control policies and educational initiatives in Thai secondary schools influence students' legal knowledge, perception of harm, current e-cigarette use, and susceptibility to future use.

METHODS

This cross-sectional survey was conducted in four regions of Thailand between May and August 2023, involving 6147 students selected through multistage sampling. Data collection utilized a self-reported online questionnaire in Thai, developed using Google Forms. For continuous outcomes, multiple linear regression models assessed relationships between school e-cigarette policy perceptions, covariates, knowledge of e-cigarette laws, and harm perception. Multiple logistic regression models analyzed the association between policy perceptions, covariates, and categorical outcomes: current e-cigarette use and susceptibility.

RESULTS

Adjusting for covariates, a positive association was found between students' perceptions of e-cigarette policies and teachings and their knowledge of e-cigarette control laws (B=0.083, p<0.001) and harm perceptions (B=0.491, p<0.001). Additionally, these perceptions were protective against current e-cigarette use (AOR=0.970; 95% CI: 0.95-0.99, p=0.002) and susceptibility among non-users (AOR=0.962; 95% CI: 0.95-0.97; p<0.001).

CONCLUSIONS

A heightened perception of e-cigarette policies and teachings in schools is associated with increased legal knowledge, heightened harm perception, and a lower likelihood of current or future e-cigarette use. This underscores the importance of enforcing the e-cigarette-free policy in schools to mitigate vaping susceptibility amid the ongoing youth e-cigarette epidemic.

How do New Zealand youth perceive the smoke-free generation policy? A qualitative analysis

INTRODUCTION

Aotearoa New Zealand (NZ) plans to introduce a smoke-free generation (SFG) policy, alongside denicotinisation and reducing the availability of tobacco products. The SFG has a clear rationale, yet we know little about how young people, those the policy targets, perceive it. To inform policy design, communication and implementation, we explored how NZ youth perceived the SFG.

METHODS

We undertook in-depth interviews with a sample of 20 youth aged 17 or 18 and explored their knowledge of the SFG, and how they perceived its individual and societal implications. We interpreted the data using a reflexive thematic analysis approach.

RESULTS

We identified two overarching themes. The first theme, 'societal good and protection from harm', reflected benefits participants associated with the SFG, which outweighed perceptions of lost freedoms. The second theme, 'privileging personal choice', corresponded to two small groups within the sample. The first preferred measures they considered less restrictive, such as increasing the purchase age, and some came to support the SFG as they rationalised their views. The second subgroup expressed more entrenched opposition and felt the SFG deprived them of a choice.

CONCLUSIONS

Young people's deep reflection on the SFG led most to view it as liberating rather than restrictive. Communications that avoid prompting heuristic-based responses could encourage youth to reflect on the policy and elicit strong support from the group the SFG aims to benefit.

Healthcare costs attributable to e-cigarette use and subsequent uptake of cigarette smoking by Australians who have never smoked

Objective New legislation to curb the rapid increase in e-cigarette use among youth is underway. We estimated the future healthcare costs for chronic diseases from e-cigarette use among never smokers who transition to tobacco smoking. Methods Using population-attributable fractions, we estimated the health expenditure attributable to e-cigarettes based on the prevalence of e-cigarette use, uptake of tobacco smoking, and risk of smoking on developing chronic disease. Data for men and women were derived from published reports on e-cigarette use prevalence, risk of smoking-related disease and addiction, and health expenditure for 25 diseases. Sensitivity analyses were undertaken to address data input variation. Results Future healthcare costs attributed to new e-cigarette-initiated smokers were conservatively estimated to be (in Australian dollars) $179.6 million annually. Collectively, the estimated costs were highest for respiratory diseases ($102.2 million; 57% of total costs), malignant cancers ($49.6 million; 28%), and cardiovascular disease ($27.7 million; 15%). The uptake rate of e-cigarettes was more important in driving healthcare costs than the proportion moving from e-cigarettes to cigarette smoking. Conclusion High avoidable health system costs are predicted for the treatment of chronic conditions created by e-cigarette-initiated smoking. These costs exclude the immediate and direct healthcare harms of e-cigarette-related poisoning, lung injury, and respiratory problems, and costs associated with the unknown health harms of e-cigarette use alone. The proposed regulations to curb recreational e-cigarette use in Australia are set to prevent expensive health care arising sometime in the future from new cigarette smokers.

Modeling the future of tobacco control: Using SimSmoke to explore the feasibility of the tobacco endgame in Korea

INTRODUCTION

We used a simulation model to assess the feasibility of reaching the tobacco endgame target (reducing the smoking prevalence to below 5% by 2050) and explored potential implementation strategies.

METHODS

The impact of strengthened tobacco-control policies on smoking prevalence was analyzed using Korea SimSmoke, a discrete-time Markov process. We considered the effects of various scenarios from 2023 and predictions were conducted until 2050. To confirm the stability of the results, deterministic and probabilistic sensitivity analyses were carried out by increasing and decreasing parameter estimates.

RESULTS

The implementation of tobacco-control policies in accordance with the WHO MPOWER (Μonitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco smoking; Warn of the dangers of tobacco; Enforce bans on tobacco advertising, promotion, and sponsorship; Raise taxes on tobacco) measures were insufficient to achieve the tobacco endgame objective of 5% by 2050. The overall predicted smoking prevalence in 2050 is 4.7% if all policies are fully implemented in accordance with the FCTC guidelines together with a complete ban on the sale of cigarettes to people born after 2003 and annual 10% increases in price. Sensitivity analyses using the varying policy effect assumptions demonstrated the robustness of the simulation results.

CONCLUSIONS

For a substantive reduction in smoking prevalence, it is essential to strongly implement the MPOWER strategy. Beyond this foundational step, the eradication of smoking requires a paradigm shift in the perception of conventional tobacco-control policies, including a tobacco-free generation strategy and radical increases in the price of tobacco products.

Predicting the long-term effects of electronic cigarette use on population health: a systematic review of modelling studies

OBJECTIVE

To systematically review and synthesise the findings of modelling studies on the population impacts of e-cigarette use and to identify potential gaps requiring future investigation.

DATA SOURCE AND STUDY SELECTION

Four databases were searched for modelling studies of e-cigarette use on population health published between 2010 and 2023. A total of 32 studies were included.

DATA EXTRACTION

Data on study characteristics, model attributes and estimates of population impacts including health outcomes and smoking prevalence were extracted from each article. The findings were synthesised narratively.

DATA SYNTHESIS

The introduction of e-cigarettes was predicted to lead to decreased smoking-related mortality, increased quality-adjusted life-years and reduced health system costs in 29 studies. Seventeen studies predicted a lower prevalence of cigarette smoking. Models that predicted negative population impacts assumed very high e-cigarette initiation rates among non-smokers and that e-cigarette use would discourage smoking cessation by a large margin. The majority of the studies were based on US population data and few studies included factors other than smoking status, such as jurisdictional tobacco control policies or social influence.

CONCLUSIONS

A population increase in e-cigarette use may result in lower smoking prevalence and reduced burden of disease in the long run, especially if their use can be restricted to assisting smoking cessation. Given the assumption-dependent nature of modelling outcomes, future modelling studies should consider incorporating different policy options in their projection exercises, using shorter time horizons and expanding their modelling to low-income and middle-income countries where smoking rates remain relatively high.

Strategies to tackle non-communicable diseases in Afghanistan: A scoping review

Non-communicable diseases (NCDs) and their risk factors are the leading cause of death worldwide and contribute to 74.3% of deaths globally in 2019. The burden of NCDs is escalating in Afghanistan. Currently, every seconds, people in Afghanistan are dying of NCDs. Addressing this challenge in Afghanistan needs effective and practical interventions. This study aimed to identify the strategies developed and implemented in countries with low non-communicable premature death. To conduct a scoping review, we followed the six-step Arksey and O'Malley protocol and searched for eligible articles on eight international databases and the gray literature. The study followed the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. The inclusion criteria were English documents and evidence produced up to 30 November 2021 for the control of NCDs. We excluded incomplete texts, duplicates, and dissertations due to lack of access. We used EndNote X9 and MaxQDA software for data management and analysis. We conducted content analysis for this study. A total of 122 documents developed between 1984 and 2021 met the inclusion criteria. We identified 35 strategies from which the most used strategies were related to unhealthy diets and smoking cessation programs. Canada (26.4%), Korea (19.8%), and the United Kingdom (19%) have the most publications on the control and prevention of NCDs among the countries included in the study. Most strategies were implemented over 2 years (41%). This study recommends specific interventions to control and prevent NCDs for the main risk factors of tobacco use, unhealthy diet, physical inactivity, and the main non-communicable diseases such as heart diseases, cancers, diabetes, and chronic obstructive pulmonary diseases. Afghanistan Ministry of Public Health, the WHO country office, and other involved stakeholders can use the findings of this review to design and implement strategies for controlling and preventing NCDs in Afghanistan. International organizations such as the World Health Organization, United Nations Agencies, the World Bank, and other involving communities should invest in strengthening good health governance in Afghanistan. The Afghan Government should focus on promoting and funding health literacy among the public and self-care to control and prevent NCDs.

Tobacco endgame intervention impacts on health gains and Māori:non-Māori health inequity: a simulation study of the Aotearoa/New Zealand Tobacco Action Plan

BACKGROUND

The Aotearoa/New Zealand Government is aiming to end the tobacco epidemic and markedly reduce Māori:non-Māori health inequalities by legislating: (1) denicotinisation of retail tobacco, (2) 95% reduction in retail outlets and (c) a tobacco free-generation whereby people born after 2005 are unable to legally purchase tobacco. This paper estimates future smoking prevalence, mortality inequality and health-adjusted life year (HALY) impacts of these strategies.

METHODS

We used a Markov model to estimate future yearly smoking and vaping prevalence, linked to a proportional multistate life table model to estimate future mortality and HALYs.

RESULTS

The combined package of strategies (plus media promotion) reduced adult smoking prevalence from 31.8% in 2022 to 7.3% in 2025 for Māori, and 11.8% to 2.7% for non-Māori. The 5% smoking prevalence target was forecast to be achieved in 2026 and 2027 for Māori males and females, respectively.The HALY gains for the combined package over the population's remaining lifespan were estimated to be 594 000 (95% uncertainty interval (UI): 443 000 to 738 000; 3% discount rate). Denicotinisation alone achieved 97% of these HALYs, the retail strategy 19% and tobacco-free generation 12%.By 2040, the combined package was forcat to reduce the gap in Māori:non-Māori all-cause mortality rates for people 45+ years old by 22.9% (95% UI: 19.9% to 26.2%) for females and 9.6% (8.4% to 11.0%) for males.

CONCLUSION

A tobacco endgame strategy, especially denicotinisation, could deliver large health benefits and dramatically reduce health inequities between Māori and non-Māori in Aotearoa/New Zealand.

Closing the gaps in tobacco endgame evidence: a scoping review

OBJECTIVE

Tobacco endgame policies aim to rapidly and permanently reduce smoking to minimal levels. We reviewed evidence syntheses for: (1) endgame policies, (2) evidence gaps, and (3) future research priorities.

DATA SOURCES

Guided by JBI scoping review methodology, we searched five databases (PubMed, CINAHL, Scopus, Embase and Web of Science) for evidence syntheses published in English since 1990 on 12 policies, and Google for publications from key national and international organisations. Reference lists of included publications were hand searched.

STUDY SELECTION

Two reviewers independently screened titles and abstracts. Inclusion criteria were broad to capture policy impacts (including unintended), feasibility, public and stakeholder acceptability and other aspects of policy implementation.

DATA EXTRACTION

We report the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

DATA SYNTHESIS

Eight policies have progressed to evidence synthesis stage (49 publications): mandatory very low nicotine content (VLNC) standard (n=26); product standards to substantially reduce consumer appeal or remove the most toxic products from the market (n=1); moving consumers to reduced risk products (n=8); tobacco-free generation (n=4); ending sales (n=2); sinking lid (n=2); tax increases (n=7); and restrictions on tobacco retailers (n=10). Based on published evidence syntheses, the evidence base was most developed for a VLNC standard, with a wide range of evidence synthesised.

CONCLUSIONS

VLNC cigarettes have attracted the most attention, in terms of synthesised evidence. Additional focus on policies that reduce the availability of tobacco is warranted given these measures are being implemented in some jurisdictions.

Improving on estimates of the potential relative harm to health from using modern ENDS (vaping) compared to tobacco smoking

BACKGROUND

Although the harm to health from electronic nicotine delivery systems (ENDS) compared to smoked tobacco remains highly uncertain, society and governments still need to know the likely range of the relative harm to inform regulatory policies for ENDS and smoking.

METHODS

We identified biomarkers with specificity of association with different disease groupings e.g., volatile organic compound (VOCs) for chronic obstructive pulmonary disease; and tobacco-specific N´-nitrosamines (TSNAs) and polycyclic aromatic hydrocarbons (PAHs) for all cancers. We conducted a review of recent studies (post January 2017) that compared these biomarkers between people exclusively using ENDS and those exclusively smoking tobacco. The percentage differences in these biomarkers, weighted by study size and adjusted for acrolein from other sources, were used as a proxy for the assumed percentage difference in disease harm between ENDS and smoking. These relative differences were applied to previously modelled estimates of smoking-related health loss (in health-adjusted life-years; HALYs).

RESULTS

The respective relative biomarker levels (ENDS vs smoking) were: 28% for respiratory diseases (five results, three studies); 42% for cancers (five results, four studies); and 35% for cardiovascular (seven results, four studies). When integrated with the HALY impacts by disease, the overall harm to health from ENDS was estimated to be 33% that of smoking.

CONCLUSIONS

This analysis, suggests that the use of modern ENDS devices (vaping) could be a third as harmful to health as smoking in a high-income country setting. But this estimate is based on a limited number of biomarker studies and is best be considered a likely upper level of ENDS risk given potential biases in our method (i.e., the biomarkers used being correlated with more unaccounted for toxicants in smoking compared to with using ENDS).

A Longitudinal Examination of Behavioral Transitions among Young Adult Menthol and Non-Menthol Cigarette Smokers Using a Three-State Markov Model

INTRODUCTION

Young adult cigarette smoking behaviors are complex and dynamic. Emerging research suggests a growing rate of switching from non-menthol to menthol cigarettes. Transitions across cigarette smoking states are not well understood. This research longitudinally explores transitions in cigarette smoking behaviors among 18-29 year olds.

METHODS

We applied a Markov model to data collected biannually for 1542 initially 18-29 year old young adults (mean age: 20.9 years; SD = 2.6) in Texas, who provided 7021 total observations from Fall 2014 to Spring 2017. All participants were past 30 day menthol or non-menthol cigarette smokers at first observation. We examined transitions across three states of cigarette smoking (menthol, non-menthol, and nonsmoking) and compared predictors of each transition, during young adulthood.

RESULTS

Descriptively, 22.2% of menthol and 14.3% of non-menthol smokers switched products while 25.6% of menthol and 26.0% of non-menthol smokers quit smoking. Among quitters, 20.0% relapsed via menthol and 28.2% relapsed via non-menthol cigarettes. Results from Markov model indicated that Hispanic/Latinos (Hazard Ratio [HR]: 3.69) and Asians (HR: 2.85) were significantly more likely to switch from non-menthol to menthol cigarettes, relative to non-Hispanic whites. Among recent quitters, the use of non-cigarette products was associated with increased risk of relapse via menthol (HR: 1.54) and non-menthol (HR: 1.85) cigarettes.

CONCLUSION

A substantial proportion of young adult cigarette smokers transitioned across cigarette smoking states over the course of 2.5 years. Other tobacco use and nicotine dependence were impediments to becoming and remaining a non-smoker. Hispanic/Latinos and Asians, relative to non-Hispanic whites, had greater odds of transitioning from non-menthol smoking to both non-smoking and to menthol smoking. Findings suggest racial/ethnic differences in cigarette smoking transitions during young adulthood.

IMPLICATIONS

This paper examined multidirectional transitions across cigarette smoking, including switching between menthol and non-menthol cigarettes, among young adults. Results indicate that Hispanic/Latino and Asian young adults are at increased risk of transition to menthol cigarette smoking compared with non-Hispanic white young adults. Findings highlight need for further study of Hispanic/Latino and Asian young adult smoking behaviors.