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Lund KE, Saebo G. Challenges in legitimizing further measures against smoking in jurisdictions with robust infrastructure for tobacco control: how far can the authorities allow themselves to go? Harm Reduct J 2024; 21:33. [PMID: 38321438 PMCID: PMC10848560 DOI: 10.1186/s12954-024-00951-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 01/28/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND According to a recently published study, approximately half of those who currently smoke in Norway have little or no desire to quit despite a hostile regulatory and socio-cultural climate for smoking. On this background, we discuss some challenges that regulators will face in a further tightening of structural measures to curb smoking. MAIN BODY Central to our discussion is the research literature concerned with the concept of state-paternalism in tobacco control-the line between an ethically justified interference with the freedom of those who smoke and an exaggerated infringement disproportionate to the same people's right to live as they choose. In countries with an already advanced infrastructure for tobacco control, this dilemma might become quite intrusive for regulators. We ask that if people, who smoke are aware of and have accepted the risks, are willing to pay the price, smoke exclusively in designated areas, and make decisions uninfluenced by persuasive messages from manufacturers-is a further tightening of anti-smoking measures still legitimate? Strengthening of the infrastructure for tobacco control can be seen as a "help" to people who-due to some sort of "decision failure"-continue to smoke against their own will. However, for those who want to continue smoking for reasons that for them appear rational, such measures may appear unwanted, punitive, and coercive. Is it within the rights of regulators to ignore peoples' self-determination for the sake of their own good? We problematize the "help" argument and discuss the authorities' right to elevate the zero-vision of smoking as universally applicable while at the same time setting up barriers to switching to alternative nicotine products with reduced risk. CONCLUSION We recommend that a further intensification of smoking control in countries that already have a well-developed policy in this area requires that regulators start to exploit the opportunity that lies in the ongoing diversification of the recreational nicotine market.
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Affiliation(s)
- Karl Erik Lund
- Department for Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health (NIPH), Folkehelseinstituttet, Postboks 222, 0213, Skøyen, Oslo, Norway.
| | - Gunnar Saebo
- Department for Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health (NIPH), Folkehelseinstituttet, Postboks 222, 0213, Skøyen, Oslo, Norway
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Li L, Borland R, Le Grande M, Gartner C. Future nicotine use preferences of current cigarette smokers: Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey. Drug Alcohol Rev 2024; 43:359-370. [PMID: 38113310 PMCID: PMC10922120 DOI: 10.1111/dar.13791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/21/2023] [Accepted: 11/12/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION Consumer preferences should be important factors that are considered when developing health policies and interventions. This paper examines the prevalence of, and factors associated with, consumer preferences regarding smoking behaviour 1 to 2 years in the future. METHODS At least weekly cigarette smokers in the 2020 wave of the International Tobacco Control Four Country Smoking and Vaping Survey (USA, Canada, England and Australia) (N = 8642) were asked if they preferred to continue to smoke or to quit with or without an alternative nicotine product (ANP) over the next 1-2 years. RESULTS Country-specific weighted data showed 21.5% preferred to continue smoking and 8.0% were uncertain, leaving 70.6% preferring to quit: 13.7% using an ANP and 56.9% completely quitting nicotine. Apart from interest in quitting, the main predictors of preferring to quit were history of vaping, being aged 55 and over, smoking weekly, worrying about smoking harms, regretting starting and believing vaping is less harmful relative to smoking. Among those preferring to quit, preferring to use ANPs in future was very strongly associated with current vaping (especially daily), being younger, living in England, reporting strong urges to smoke, believing vaping is much less harmful than smoking, and not strongly regretting starting to smoke, and not wanting to quit. DISCUSSION AND CONCLUSIONS A significant minority of smokers preferred not to quit, at least in the next year or two. Both interest in quitting and preference for ANPs over complete cessation were associated with similar covariates, including interest in vaping.
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Affiliation(s)
- Lin Li
- Melbourne Centre for Behaviour Change, School of Psychological Sciences, University of Melbourne, Melbourne, Australia
| | - Ron Borland
- Melbourne Centre for Behaviour Change, School of Psychological Sciences, University of Melbourne, Melbourne, Australia
| | - Michael Le Grande
- Melbourne Centre for Behaviour Change, School of Psychological Sciences, University of Melbourne, Melbourne, Australia
| | - Coral Gartner
- School of Public Heath, The University of Queensland, Brisbane, Australia
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Vedøy TF, Lund KE. How do Smokers in a Snus-Prevalent Society Consider E-cigarettes, Snus, and Nicotine Replacement Therapy Products as Relevant Replacements for Cigarettes in the Event They Should Stop Smoking? Nicotine Tob Res 2023; 25:1753-1761. [PMID: 37410922 PMCID: PMC10475606 DOI: 10.1093/ntr/ntad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/24/2023] [Accepted: 07/03/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Around 50 percent of the tobacco in Norway is consumed in the form of snus, a smokeless oral tobacco. We examined Norwegian smokers' openness, and thereby the potential reach, to use e-cigarettes, nicotine replacement therapy products (NRT), and snus in the event of quitting smoking, in a society where snus use is common. METHODS Using data from an online survey of 4073 smokers from 2019 to 2021, we calculated predicted probabilities of smokers' being open, undecided, and not open to use e-cigarettes, snus, and NRT in the event they should quit smoking. RESULTS Among daily smokers, the probability of being open to use e-cigarettes in the event of quitting smoking was .32. The corresponding probabilities for using snus and NRT were .22 and .19. Snus was the product with the highest probability of not being open (.60). NRT had the highest probability of being undecided (.39). Among smokers who had never used e-cigarettes or snus, the probabilities of being open were .13 for e-cigarettes, .02 for snus and .11 for NRT. CONCLUSIONS In a snus-friendly norm climate where smokers have traditionally used snus as an alternative to cigarettes, the probability of using e-cigarettes in the event of smoking cessation was higher compared to both snus and NRT. However, among smokers who had never used e-cigarettes or snus, the likelihood of being open to use of NRT was similar to e-cigarettes, and higher than snus, which suggests that NRT may still play a role in smoking cessation. IMPLICATIONS In a snus-prevalent country in the endgame phase of the cigarette epidemic, where robust infrastructure for tobacco control in combination with the availability of snus has reduced smoking to a minimum, the remaining smokers seem to prefer e-cigarettes to snus if they should quit smoking. This indicates that availability of several nicotine alternatives might increase the likelihood of a future product replacement within the small group of remaining smokers.
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Affiliation(s)
- Tord Finne Vedøy
- Department Alcohol, Tobacco, and Drugs, Norwegian Institute of Public Health, Oslo, Norway
| | - Karl Erik Lund
- Department Alcohol, Tobacco, and Drugs, Norwegian Institute of Public Health, Oslo, Norway
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Mallock-Ohnesorg N, Rinaldi S, Malke S, Dreiack N, Pieper E, Laux P, Schulz T, Zimmermann R, Luch A. Oral nicotine pouches with an aftertaste? Part 1: screening and initial toxicological assessment of flavorings and other ingredients. Arch Toxicol 2023; 97:2357-2369. [PMID: 37389646 PMCID: PMC10404176 DOI: 10.1007/s00204-023-03538-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023]
Abstract
Nicotine pouches are oral products that deliver nicotine without containing tobacco. Previous studies mainly focused on the determination of known tobacco toxicants, while yet no untargeted analysis has been published on unknown constituents, possibly contributing to toxicity. Furthermore, additives might enhance product attractiveness. We therefore performed an aroma screening with 48 different nicotine-containing and two nicotine-free pouches using gas chromatography coupled to mass spectrometry, following acidic and basic liquid-liquid extraction. For toxicological assessment of identified substances, European and international classifications for chemical and food safety were consulted. Further, ingredients listed on product packages were counted and grouped by function. Most abundant ingredients comprised sweeteners, aroma substances, humectants, fillers, and acidity regulators. 186 substances were identified. For some substances, acceptable daily intake limits set by European Food Safety Agency (EFSA) and Joint FAO/WHO Expert Committee on Food Additives are likely exceeded by moderate pouch consumption. Eight hazardous substances are classified according to the European CLP regulation. Thirteen substances were not authorized as food flavorings by EFSA, among them impurities such as myosmine and ledol. Three substances were classified by International Agency for Research on Cancer as possibly carcinogenic to humans. The two nicotine-free pouches contain pharmacologically active ingredients such as ashwagandha extract and caffeine. The presence of potentially harmful substances may point to the need for regulation of additives in nicotine-containing and nicotine-free pouches that could be based on provisions for food additives. For sure, additives may not pretend positive health effects in case the product is used.
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Affiliation(s)
- Nadja Mallock-Ohnesorg
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany.
| | - Selina Rinaldi
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
- Chair of Analytical Chemistry, Joint Mass Spectrometry Centre, University of Rostock, 18059, Rostock, Germany
| | - Sebastian Malke
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Nadine Dreiack
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Elke Pieper
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Peter Laux
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Thomas Schulz
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Ralf Zimmermann
- Chair of Analytical Chemistry, Joint Mass Spectrometry Centre, University of Rostock, 18059, Rostock, Germany
| | - Andreas Luch
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
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Levy DT, Cadham CJ, Li Y, Yuan Z, Liber AC, Oh H, Travis N, Issabakhsh M, Sweanor DT, Sánchez-Romero LM, Meza R, Cummings KM. A Decision-Theoretic Public Health Framework for Heated Tobacco and Nicotine Vaping Products. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13431. [PMID: 36294011 PMCID: PMC9602493 DOI: 10.3390/ijerph192013431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/22/2022] [Accepted: 09/30/2022] [Indexed: 06/16/2023]
Abstract
Markets for nicotine vaping products (NVPs) and heated tobacco products (HTPs) have grown as these products became positioned as harm-reduction alternatives to combusted tobacco products. Herein, we present a public health decision-theoretic framework incorporating different patterns of HTP, NVP, and cigarette use to examine their impacts on population health. Our framework demonstrates that, for individuals who would have otherwise smoked, HTP use may provide public health benefits by enabling cessation or by discouraging smoking initiation and relapse. However, the benefits are reduced if more harmful HTP use replaces less harmful NVP use. HTP use may also negatively impact public health by encouraging smoking by otherwise non-smokers or by encouraging initiation or relapse into smoking. These patterns are directly influenced by industry behavior as well as public policy towards HTPs, NVPs, and cigarettes. While substantial research has been devoted to NVPs, much less is known about HTPs. Better information is needed to more precisely define the health risks of HTPs compared to cigarettes and NVPs, the relative appeal of HTPs to consumers, and the likelihood of later transitioning to smoking or quitting all products. While our analysis provides a framework for gaining that information, it also illustrates the complexities in distinguishing key factors.
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Affiliation(s)
- David T. Levy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Christopher J. Cadham
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Yameng Li
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Zhe Yuan
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Alex C. Liber
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Hayoung Oh
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Nargiz Travis
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Mona Issabakhsh
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - David T. Sweanor
- Centre for Health Law, Policy & Ethics, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Faculty of Law, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | | | - Rafael Meza
- Department of Integrative Oncology, BC Cancer Institute, Vancouver, BC V5Z1L3, Canada
| | - K. Michael Cummings
- Department of Psychiatry and Behavioral Sciences, Medical University of Charleston, Charleston, SC 29425, USA
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Vedøy TF, Lund KE. Nicotine Content in Swedish-Type Snus Sold in Norway From 2005 to 2020. Nicotine Tob Res 2022; 24:1130-1133. [PMID: 35022786 PMCID: PMC9199937 DOI: 10.1093/ntr/ntac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 12/27/2021] [Accepted: 01/07/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Use of snus (moist smokeless tobacco) is widespread in Scandinavia and increasingly popular in the U.S. Snus products vary in terms of product design, portion size, and nicotine content. The aim of this study was to examine variations in the nicotine content in snus sold on the Norwegian market from 2005 to 2020. METHODS We calculated the nicotine content in dry snus in milligram per gram (mg/g) and milligram per serving (mg/s), weighted by the products' market share from data on nicotine content, water content, and portion size (both for portion and loose snus) for the ten most sold snus products from each of the three largest manufacturers in 2005, 2010, 2015, and 2020. RESULTS In all snus products combined, the nicotine content per gram snus (mg/g) increased from 16.3 to 24.1, while nicotine per serving (mg/s) was stable around 13.0. In portion snus, the nicotine content increased for both mg/g and mg/s, most notably from 2005 to 2010. In loose snus, mg/g decreased marginally, while mg/s was stable throughout the period. CONCLUSIONS In a period with increasing snus use, the nicotine content in snus increased per gram snus, but not per serving. The stability in nicotine per serving is likely due to a decreasing market share of loose snus which accounted for 54% of the snus products in 2005 and 5% in 2020, and which traditionally has a high content of nicotine per serving. IMPLICATIONS Use of snus is popular in Scandinavia, most notably in Sweden and Norway, but also increasingly common in Finland, especially among young adults. There are no prior market-based studies of variations in the nicotine content in Swedish snus over time. We found that the average amount of nicotine per gram snus sold on the Norwegian market increased in the period 2005 to 2020, most notably from 2005 to 2010, while the amount of nicotine per serving was stable in the same period, primarily due to a decreasing share of loose snus.
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Affiliation(s)
- Tord Finne Vedøy
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, PO Box 222-Skøyen, 0213 Oslo, Norway
| | - Karl Erik Lund
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, PO Box 222-Skøyen, 0213 Oslo, Norway
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Lund M, Lund I. Smoking cessation aids and strategies: a population-based survey of former and current smokers in Norway. BMC Public Health 2022; 22:631. [PMID: 35361172 PMCID: PMC8973793 DOI: 10.1186/s12889-022-13032-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Norway, tobacco consumption is equally divided between combustible (cigarettes) and non-combustible (snus) tobacco. In the process of quitting, people who smoke can choose between several smoking cessation aids and strategies based on what is available on the market or what are recommended as cessation aids. A quit attempt may be planned or unplanned and consist of a gradual decline in consumption or an abrupt quitting. This study explores smoking cessation aids and strategies used at the latest quit attempt among people who have ever smoked. How prevalent is the use of various cessation aids and strategies, and do they correlate with each other? Are there any differences in successful quits depending on the use of a specific cessation aid or strategy? METHOD We used repeated cross-sectional representative surveys in Norway for 2017, 2018, 2019 and 2020. The analytic sample consists of people aged 20 years or older who have ever smoked daily, more precisely current daily smokers with at least one quit attempt (n = 476), and former daily smokers who quit in 2012 or later (n = 397). Participants answered questions on cessation aids and strategies used at their last quit attempt. Logistic regression analysis was used to estimate the associations between cessation aids and strategies and sociodemographic and smoking-related variables and successful quit attempts. RESULTS Fifty-six percent of people who ever smoked daily reported any use of cessation aids, and nicotine replacement therapy (NRT), snus and e-cigarettes were the most commonly used cessation aids. Snus and web/mobile use was associated with successful quits, while NRT was associated with unsuccessful quit attempts. When exclusive use was separated from the combined use of several aids, only snus was associated with successful quits. CONCLUSION Snus use was found to be a "stand-alone" cessation aid, and only weakly associated with the use of other cessation aids. Further investigation of cessation aid preferences is needed, especially among smokers with little or no contact with health services and/or for whom traditional cessation aids have no appeal.
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Affiliation(s)
- Marianne Lund
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway.
| | - Ingeborg Lund
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway
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Hellman M. Messages from research: Tobacco, drug use, gambling. NORDIC STUDIES ON ALCOHOL AND DRUGS 2021; 38:537-539. [PMID: 35309852 PMCID: PMC8900175 DOI: 10.1177/14550725211059054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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