Should the health community promote smokeless tobacco (snus) as a harm reduction measure?

Perceived Truthfulness of Reduced Lung Cancer Risk Advertising Claims Influences Consumers' Intention to try and to Purchase Snus

The objective of the current study was to evaluate the impact of a reduced risk claim about lung cancer, presented in various formats, on smokers' and non-smokers' interest in trying Camel Snus and intention to purchase Camel Snus. We varied claim formats by varying advertising messages for Camel Snus in 4 ways (1) text only; (2) bar chart; (3) text/testimonial; and (4) bar chart/testimonial. 3001 participants were recruited from a web-based consumer specialty panel via an email invitation. In 2015, a second study was conducted, using similar methods, where 3001 additional participants were recruited. Overall, controlling for other factors, the presence of an MRTP claim was not significantly related to interest in trying snus [X2 (4) = 8.567, P = .073], or purchase intentions [X2 (4) = 1.148, P = .887]. Relative to a control ad where no explicit health risk claim was made, the Graphic + testimonial [OR = 1.29] or Text only [OR = 1.41] claims did significantly increase interest in trying Camel Snus. However, the adverting format did not impact interest in purchasing Camel Snus. While current smokeless tobacco users (95%) and smokers (59%) expressed interest in trying Camel Snus, non-tobacco users (7%) showed low interest in trying or purchasing Camel Snus (P < .001). Interest in trying Camel Snus was stronger in younger smokers compared to older smokers. Among current smokers, worry about lung cancer (the key focus of the reduced risk claim) was not associated with interest in trying Camel Snus or with purchase intention [OR = .91, 95% CI: .72, 1.14] or intention to purchase snus [OR = 1.07, 95% CI: .86, 1.32]. Future research should evaluate how claim and messaging formats influence perceived truthfulness and whether this effect differs among sub-groups of consumers, such as adolescents, those with tobacco-related disease, and former smokers. It will also be helpful to understand whether perceptions of ad truthfulness result in changes in product use patterns over time. In sum, giving people truthful, credible information about relative product risks, such as through authorized MRTP claims, is important, but such information is likely insufficient to get smokers to switch.

Establishing the Association Between Snus Use and Mental Health Problems: A Study of Norwegian College and University Students

INTRODUCTION

Smoking and mental health problems are public health concerns worldwide. Studies on smoke-free tobacco products, especially snus are scarce. Snus is considered less harmful than smoking and in the United States allowed to be marketed accordingly, but may still add to the burden of disease.

AIMS AND METHODS

Data stem from the Norwegian Students' Health and Wellbeing Study (SHoT study) in 2018 (162 512 invited, 50 054 (30.8%) completed). Smoking, snus use, health service and medication usage and mental health problems, including the Hopkins Symptom Checklist-25 (HSCL-25), were assessed using self-report. The aims were to explore the associations between smoking and snus use and mental health problems and treatments. Furthermore, the association between both daily smoking and daily snus use and mental health problems. Associations were tested with χ2-, t-tests, and logistic regression.

RESULTS

Daily snus users had 38% increased odds (odds ratio [OR]: 1.38, CI: 1.30 to 1.46), and daily smokers had 96% increased odds (OR: 1.96, CI: 1.65 to 2.34) of having a high HSCL-25 score, adjusted for gender, low socioeconomic status (SES), using tobacco, participating in therapy and using antidepressants daily.

CONCLUSIONS

Both daily smoking and daily snus use were associated with an increased level of mental health problems. The adjusted probability for mental health problems was lower for snus use; however, snus use prevalence was tenfold in our sample.

IMPLICATIONS

Despite the lack of causal and directional conclusions, these associations may have implications for future legislation on snus. They also highlight the importance of more research, especially as snus is considered less harmful and seemingly replacing smoking in Norway.

Combined Associations of Changes in Noncombustible Nicotine or Tobacco Product and Combustible Cigarette Use Habits With Subsequent Short-Term Cardiovascular Disease Risk Among South Korean Men: A Nationwide Cohort Study

BACKGROUND

The associations of changes in noncombustible nicotine or tobacco product (NNTP) and combustible cigarette (CC) use habits with subsequent cardiovascular disease (CVD) risk are still unclear.

METHODS

The study population consisted of 5 159 538 adult men who underwent health screening examinations during both the first (2014-2015) and second (2018) health screening periods from the Korean National Health Insurance Service database. All participants were divided into continual CC-only smokers, CC and NNTP users, recent (<5 years) CC quitters without NNTP use, recent CC quitters with NNTP use, long-term (≥5 years) CC quitters without NNTP use, long-term CC quitters with NNTP use, and never smokers. Propensity score matching analysis was conducted to further compare CVD risk among CC quitters according to NNTP use. Starting from the second health screening date, participants were followed up until the date of CVD event, death, or December 31, 2019, whichever came earliest. Multivariable Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% CIs for CVD risk according to changes in NNTP and CC smoking habits.

RESULTS

Compared with continual CC-only smokers, CC and NNTP users (aHR, 0.83 [95% CI, 0.79-0.88]) and initial CC smokers who quit CCs and switched to NNTP use only (recent CC quitters with NNTP use, aHR, 0.81 [95% CI, 0.78-0.84]) had lower risk for CVD. After propensity score matching, recent CC quitters with NNTP use (aHR, 1.31 [95% CI, 1.01-1.70]) had higher risk for CVD than recent CC quitters without NNTP use. Similarly, compared with long-term CC quitters without NNTP use, long-term CC quitters with NNTP use (aHR, 1.70 [95% CI, 1.07-2.72]) had higher CVD risk.

CONCLUSIONS

Switching to NNTP use among initial CC smokers was associated with lower CVD risk than continued CC smoking. On CC cessation, NNTP use was associated with higher CVD risk than CC quitting without NNTPs. Compared with CC smokers who quit without NNTP use, CC quitters who use NNTPs may be at higher future CVD risk.

A Practice Theory Approach to Understanding Poly-Tobacco Use in the United States

This paper uses practice theory to explore a poorly understood phenomenon with important health implications: How and why an increasing number of young Americans regularly use multiple tobacco products. Practice theory is a promising alternative to traditional public health frameworks for understanding everyday activities related to health. It broadens the analytic focus from characteristics of individuals to viewing practices as having lives of their own in competing for, winning, and losing practitioners. We drew from in-depth interviews with 21 young adults (ages 18-29; California) who regularly use cigarettes, electronic nicotine delivery systems (ENDS), and/or smokeless tobacco. Participants described their everyday routines. We examined the characterizing elements of each tobacco product use practice and the roles of each within participants' routines. We found that each product comprises a distinct substance use practice with different roles to play in different situations and contexts. Notably, many participants rotated between or modulated use of different products as a strategy for reducing perceived tobacco-related harms. Cigarettes are uniquely capable of aiding in the space-time organization of everyday activities and coping with crisis, while ENDS and smokeless tobacco open up times and spaces for nicotine consumption. This kind of approach aids our understanding and anticipation of the evolution of tobacco use practices as new products and regulations are introduced.

Characteristics of "American Snus" and Swedish Snus Products for Sale in Massachusetts, USA

Introduction

Snus may present lower health risks than cigarettes, but its harm reduction potential may be undermined if used dually with cigarettes. The likelihood of exclusive snus use compared with dual use may depend in part on the capacity of snus to deliver nicotine in doses that are satisfactory to smokers. We examined characteristics of "American snus" products, including nicotine levels, and compared to snus products that are more typical of Sweden.

Methods

Tobacco industry reports for snus products submitted to the Massachusetts Department of Public Health for the year 2014 were used to assess moisture (%), pH, total nicotine, and unionized (free) nicotine (both mg/g and percent of total). A total of 14 ("American") snus products made by American manufacturers Philip Morris USA (n = 6), R.J. Reynolds Tobacco Company (n = 6), and US Smokeless Tobacco Company (n = 2), were compared with Swedish-style ("Swedish") snus products (n = 10) made by Swedish Match North America.

Results

Compared with Swedish snus, American snus brands contained significantly lower concentrations of unionized nicotine (median: 0.52 mg/g vs. 6.52 mg/g; p < .001) and proportion of unionized nicotine (median: 3.17% vs. 81.8%; p < .001). American snus brands also had significantly lower pH (median: 6.54 vs. 8.68; p < .001) and moisture (median: 30.3% vs. 53.4%; p < .001).

Conclusions

Swedish-made snus has higher unionized nicotine, measured by concentration and proportion of total nicotine, compared with snus products made by American manufacturers. These findings suggest that American snus products have lower addiction potential than Swedish snus, and may be more likely to be used dually with cigarettes than as a sole source of nicotine.

Implications

American snus products contain significantly lower unionized nicotine, lower pH, and lower moisture, compared with Swedish snus products. Snus addiction potential and patterns of usage, including co-use with cigarettes, may differ between American and Swedish snus products due to differences in snus product characteristics.

Ecological momentary assessment of various tobacco product use among young adults

INTRODUCTION

Young adults are at high risk for using traditional and novel tobacco products. However, little is known about daily/weekly use patterns or psychosocial triggers for using various tobacco products.

METHODS

This ecological momentary assessment (EMA) study examined timing, tobacco cravings, affect, social context, and other substance use (alcohol, marijuana) in relation to use of cigarettes, electronic nicotine delivery systems (ENDS), and any tobacco product (i.e., cigarettes, ENDS, cigars, hookah), respectively. We also examined interactions between these predictors, sex, and race/ethnicity. From a longitudinal study of 3418 18-25 year-olds from seven Georgia colleges/universities, we recruited 72 reporting current tobacco use to participate in the 21-day EMA study; 43 participated, of which 31 completed ≥66% assessments and were analyzed. Cravings, affect, social context, and substance use were assessed daily across four four-hour windows.

RESULTS

Of the 31 participants, average age was 21.10 years (SD = 1.95), 45.2% were female, and 71.0% non-Hispanic White; 71.0% used cigarettes, 58.1% ENDS, 38.7% cigars, and 25.8% hookah (25.6% used one product, 46.5% two, 27.9% ≥ three). Predictors of cigarette use included higher anxiety, greater odds of marijuana and alcohol use, and higher boredom levels among women. Predictors of ENDS use included being non-White and greater odds of marijuana use, as well as higher tobacco cravings among women and higher boredom among men. Predictors of any tobacco product use included being non-White, higher boredom levels, and greater odds of marijuana and alcohol use.

CONCLUSIONS

Distinct interventions may be needed to address use of differing tobacco products among young adults.

Truth Telling about Tobacco and Nicotine

Research suggests that many people in the US are misinformed about the relative harms of various tobacco and nicotine products. Concerns about public misinformation have often been framed as relevant only to the degree that public health institutions agree to prioritize conventional approaches to tobacco harm reduction. We argue that while the information priorities of public health professionals are important, ethical and credible information sharing also requires consideration of broader issues related to public trust. To promote trust, public health institutions must develop truth telling relationships with the communities they serve and be genuinely responsive to what people themselves want to know about tobacco and nicotine products.

Psychological Risk Factors for Alcohol, Cannabis, and Various Tobacco Use among Young Adults: A Longitudinal Analysis

BACKGROUND

Alcohol, cannabis, and tobacco use are prevalent in young adults and may be differentially related to psychological symptoms characterized as externalizing or internalizing.

OBJECTIVES

This study examined the use of alcohol, cannabis, and various tobacco products in relation to externalizing (ADHD) versus internalizing factors (depression, anxiety), hypothesizing alcohol and cannabis use are associated with externalizing factors whereas tobacco use is related to internalizing factors.

METHODS

Data from a 2-year longitudinal study of 2,397 US college students (aged 18-25) launched in 2014 were analyzed. Adult ADHD Self-Report Scale, Patient Health Questionnaire-9 item (assessing depressive symptoms), and the Zung Self-Rating Anxiety Scale scores were examined in relation to subsequent past 30-day use of alcohol, cannabis, and tobacco products (cigarettes, little cigars/cigarillos, smokeless tobacco, e-cigarettes, hookah), as well as nicotine dependence per the Hooked on Nicotine Checklist.

RESULTS

Participants were 20.49 (SD = 1.93) years old, 64.7% female, and 65.5% White. In multivariable analyses, greater ADHD symptoms predicted alcohol and cannabis use (p = .042 and p = .019, respectively). Cigarette and little cigar/cigarillo use were predicted by greater depressive (p = .001 and p = .002, respectively), and anxiety symptoms (p = .020 and p = .027, respectively). Nicotine dependence was correlated with greater anxiety symptoms (p = .026). Counter to hypotheses, smokeless tobacco use was predicted by greater ADHD symptoms (p = .050); neither e-cigarette nor hookah use were predicted by these psychological symptoms. Conclusions/Importance: Research examining risk factors for tobacco use must distinguish among the various tobacco products. Moreover, interventions may need to differentially target use of distinct substances, including among the range of tobacco products.

Cigarette and Smokeless Tobacco Perception Differences of Rural Male Youth

Objectives

Compare cigarette and smokeless tobacco (ST) perceptions within a youth population where ST use is common.

Methods

Male baseball players (N = 594) at 36 rural high schools in California rated separately 20 potential risks or benefits associated with cigarettes or ST, along with global harm ratings. Informed by principal components analysis, 3 composite categories were created: oral/rule-breaking risks (eg, mouth cancer, getting in trouble), systemic risks (eg, heart attack), and benefits (eg, relaxation). Standardized composite scores and harm ratings were compared by product and by tobacco use status.

Results

Cigarettes were perceived as likely to impart oral/rule-breaking risks and systemic risks, unlikely to cause benefits, and as very harmful overall. ST was perceived similarly as cigarettes regarding oral/rule-breaking risks, but less likely to cause systemic risks, and more beneficial. Most participants rated cigarettes as more harmful than ST. Similar patterns existed in all tobacco use groups, including non-users and dual-users.

Conclusions

In this population, cigarettes were perceived as very harmful. ST was perceived similarly to cigarettes only for some risks and as less harmful overall. Communication for rural adolescents should consider multifaceted aspects of ST risk.

Comparative risk assessment and cessation information seeking among smokeless tobacco users

INTRODUCTION

This research examined (1) smokeless tobacco users' comparative optimism in assessing the health and addiction risks of their own product in comparison with cigarettes, and (2) the effects of comparative optimism on cessation information-seeking.

METHODS

A nationally-representative sample from the 2015 Health Information National Trends Survey (HINTS)-FDA was employed.

RESULTS

The analyses revealed the presence of comparative optimism in assessing both health and addiction risks among smokeless tobacco users. Comparative optimism was negatively correlated with most cessation information-seeking variables. Health bias (the health risk rating gap between the subject's own tobacco product and cigarettes) was associated with decreased intent to use cessation support. However, the health bias and addiction bias (the addiction risk rating gap between the subject's own tobacco product and cigarettes) were not consistent predictors of all cessation information-seeking variables, when covariates of socio-demographics and tobacco use status were included. In addition, positive correlations between health bias and past/recent cessation-information searches were observed.

CONCLUSIONS

Optimisic biases may negatively influence cessation behaviors not only directly but also indirectly by influencing an important moderator, cessation information-seeking. Future interventions should prioritize dispelling the comparative optimism in perceiving risks of smokeless tobacco use, as well as provide more reliable cessation information specific to smokeless tobacco users.

Initiation, continuation of use and cessation of alternative tobacco products among young adults: A qualitative study

INTRODUCTION

Diverse non-cigarette alternative tobacco products are increasingly popular in the United States. This study investigates the reasons why young adults initiate and continue the use of these products, as well as potential motivations and approaches for quitting. Products assessed include cigarettes, little cigars/cigarillos (LCCs), smokeless tobacco, e-cigarettes, and hookahs.

METHODS

We conducted 60 telephone interviews, of 30-minute duration, with tobacco users enrolled in colleges in Georgia. Qualitative analysis was used to identify themes emerging from the data.

RESULTS

Reasons for initiation, continued use, and (potential) cessation showed similarities and differences across products. Most commonly cited reasons for initiation included: peer influence (all products), flavors/tastes (all products except cigarettes), and easy environmental access and/or low costs (LCCs, smokeless tobacco, and e-cigarettes). Participants discussed several influences on continued use, such as peer influence (cigarettes, LCCs, and hookahs), stress management (all products except hookahs), and use with other substances (cigarettes, LCCs, and hookahs). Primary motivations for cessation mentioned by participants were family responsibilities (cigarettes, e-cigarettes, and hookahs) and health concerns (all products except e-cigarettes). Frequently used cessation strategies included avoidance of other tobacco users (cigarettes, LCCs, and hookahs) and a reduction of nicotine intake (cigarettes and e-cigarettes).

CONCLUSIONS

Our findings suggest that researchers should consider the differences in reasons for use and discontinued use of tobacco products in order to develop targeted messaging strategies, particularly noting the differential impact of interpersonal influences and health concerns. We also point to a need for regulatory action that limits diversification and accessibility of different products.

Assessing the effect of public health information by incentivised risk estimation: An example on Swedish snus

BACKGROUND

The provision of accurate information on health damaging behaviours and products is a widely accepted and widespread governmental task. It is easily mismanaged. This study demonstrates a simple method which can help to evaluate whether such information corrects recipient risk beliefs.

METHODS

Participants assess risks numerically, before and after being exposed to a relevant risk communication. Accuracy is incentivised by awarding financial prizes to answers closest to a pursued risk belief. To illustrate this method, 228 students from the University of Oslo, Norway, were asked to estimate the mortality risk of Swedish snus and cigarettes twice, before and after being exposed to one of three risk communications with information on the health dangers of snus.

RESULTS

The data allow us to measure how participants updated their risk beliefs after being exposed to different risk communications. Risk information from the government strongly distorted risk perceptions for snus. A newspaper article discussing the relative risks of cigarettes and snus reduced belief errors regarding snus risks, but increased belief errors regarding smoking. The perceived quality of the risk communication was not associated with decreased belief errors.

CONCLUSION

Public health information can potentially make the public less informed on risks about harmful products or behaviours. This risk can be reduced by targeting identified, measurable belief errors and empirically assessing how alternative communications affect these. The proposed method of incentivised risk estimation might be helpful in future assessments of risk communications.

Monitoring harm perceptions of smokeless tobacco products among U.S. adults: Health Information National Trends Survey 2012, 2014, 2015

INTRODUCTION

Changes to the U.S. smokeless tobacco landscape in recent years include a change to health warnings on packages, the implementation of bans in some stadiums, and the launch of a federal youth prevention campaign. It is unclear whether such changes have impacted consumer beliefs about smokeless tobacco. This study examines relative harm perceptions of smokeless tobacco compared to cigarettes among adults and assesses changes in smokeless tobacco harm perceptions over time.

METHODS

We analyzed data from three cycles (2012, 2014, 2015) of the Health Information National Trends Survey (HINTS). Using 2015 data, we assessed bivariate associations between smokeless tobacco harm perceptions and tobacco use, beliefs, information seeking, and demographics. Using 2012, 2014, and 2015 data, we assessed whether smokeless tobacco harm perceptions changed over time within demographic groups using chi-square tests. We then used a weighted multinomial logistic regression to assess the association between smokeless tobacco perceptions and survey year, adjusting for covariates.

RESULTS

When asked whether smokeless tobacco products are less harmful than cigarettes, the majority of respondents across cycles said "no." The percent of respondents who selected this response option decreased over time. Findings showed significant differences in relative harm perceptions of smokeless tobacco versus cigarettes for specific demographic subgroups. Among subgroups, these shifts did not occur with a discernible pattern.

CONCLUSIONS

Understanding factors associated with perceptions of smokeless tobacco can inform tobacco control efforts. Additional monitoring of these trends may provide researchers with a deeper understanding of how and why smokeless tobacco harm perceptions change.

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

INTRODUCTION

Tobacco use has shifted increasingly from cigarettes to other products. While the focus has been mostly on cigarette-oriented policies, it is important to gauge the effects of policies targeting other products. We review and critique the literature on how policies affect smokeless tobacco (ST).

METHODS

We conducted a search of the literature on tobacco control policies as they relate to ST use, focusing on tobacco taxes, smoke-free air laws, media campaigns, advertising restrictions, health warnings, cessation treatment policies, and youth access policies. Findings from 78 total studies are summarized.

RESULTS

ST taxes, media campaigns, health warnings, and cessation treatment policies were found to be effective tools in reducing ST use. Evidence on the effects of current youth access policies is less strong. Studies have not yet been conducted on marketing or product content restrictions, but the literature indicates that product marketing, through advertising, packaging, flavorings, and extension of cigarette brands, plays an important role in ST use.

CONCLUSIONS

Although the evidence base is less established for ST policies than for cigarette policies, the existing literature indicates ST use responds to tobacco control policies. Policies should be structured in a way that aims to reduce all tobacco use while at the same time increasing the likelihood that continuing tobacco users use the least risky products.

IMPLICATIONS

Studies find that policies targeting smoking and policies targeting smokeless products affect smokeless use, but studies are needed to examine the effect of policies on the transitions between cigarette and smokeless use.

Taking Stock of Tobacco Control Program and Policy Science and Impact in the United States

The 60% decline in the prevalence of cigarette smoking among U.S. adults over the past 50 years represents a significant public health achievement. This decline was steered in part by national, state, and local tobacco control programs and policies, such as public education campaigns; widespread smoke-free air laws; higher cigarette prices that have been driven by large increases in federal, state, and local cigarette excise taxes; and other tobacco control policy and systems-level changes that discourage smoking. Using the MPOWER framework informed by the Centers for Disease Control and Prevention (CDC) Office on Smoking and Health and the World Health Organization (WHO), this paper reviews these accomplishments and identifies gaps in tobacco control policy implementation and additional research needed to extend these historic successes.

The Advertising Strategies of Early E-cigarette Brand Leaders in the United States

Objectives

We examined differential advertising strategies used by 4 major United States e-cigarette companies with differential affiliations with the traditional tobacco industry (ie, Njoy - independent, Blu - acquired, Vuse and MarkTen - launched by cigarette companies) over time.

Methods

We conducted a mixed-methods study regarding e-cigarette adspend, adspend per media channel (eg, TV, print), and advertising messaging strategies among these 4 top e-cigarette brands from January 2013 through December 2015.

Results

E-cigarette adspend increased from $59 million in 2013 to $91 million in 2014, followed by a sharp decline to $37 million in 2015. These companies showed distinct spending trajectories overall and across media channels, with Njoy and Vuse spending a higher proportion of their dollars on TV and Blu and MarkTen spending more on print. Marketing messages were also different by company. Key themes included switching from cigarettes (particularly by Njoy and Blu), circumventing smoke-free policies (particularly by Blu), and technological advancement (particularly by Vuse and MarkTen).

Conclusions

These e-cigarette brands have shifted their adspend, use of media channels, and advertising messaging strategies over time. Some differing strategies may reflect the different affiliations of each brand to the traditional cigarette industry.

The credibility of risk information about licit substances: An exploratory study of attitudes among Swedish adults

Aims

Providing risk information on licit substances is a central health promotion strategy. There is, however, very little knowledge about public attitudes on this information. In this exploratory study we analyse the extent to which Swedish adults: 1) trust risk information regarding alcohol, cigarettes and wet snuff (“snus”) provided by public authorities, 2) perceive risk information regarding alcohol, cigarettes and snus as consistent, and 3) have received an adequate amount of risk information from public authorities regarding these substances. The aim is also to investigate if certain characteristics among participants are related to their perceptions of such risk information.

Methods

A questionnaire was mailed to a random sample of individuals aged 18 to 70 (n=1623, 54% response rate). Descriptive statistics and logistic regression techniques were used to process data.

Results

Participants trusted risk information concerning cigarettes, snus and alcohol provided by public authorities, and reported that they had received an adequate amount of it. Information about cigarettes was seen as more trustworthy and consistent than information about alcohol and snus. The study suggests that attitudes on risk information are substance-specific and associated in complex ways with gender, age, education and experience of own substance use.

Conclusion

While only a first attempt to map an under-investigated area, our study highlights complexities in how people perceive risk information about licit substances. It also indicates that the general population in Sweden receives what is seen as an adequate amount of knowledge from public authorities, and finds it consistent and trustworthy.

The Impact of Health Warning Labels for Swedish Snus Advertisements on Young Adults' Snus Perceptions and Behavioral Intentions

INTRODUCTION

This study examined the impact of warning labels conveying the potential harms and addictiveness of Swedish snus and the potential-reduced harms of Swedish snus among young adult nonsmokers and smokers.

METHODS

A convenience sample of young adults aged 18-30 residing in the United States (n = 517, 56% male, 33% smokers) participated in an online experiment. Participants completed baseline measures and were randomized to 1 of 5 experimental conditions where they viewed a Swedish snus ad with warning labels that varied by condition: (1) Control-no warning; (2) Addiction-warning conveying the addictiveness of snus; (3) Harm-warning communicating the potential harms of snus; (4) Harm Reduction-warning conveying the potential-reduced harms of snus compared with cigarettes; (5) Harm Reduction Switch-warning communicating the potential-reduced harms of snus when switching completely from cigarettes to snus. Outcomes measured included perceived harms and addictiveness of snus, thoughts about not using snus, and intentions to use snus.

RESULTS

Participants in the Harm Reduction and Harm Reduction Switch conditions perceived snus to be less harmful than cigarettes compared with the Control, Addiction, and Harm conditions. Nonsmokers in the Harm Reduction condition reported fewer thoughts about not using snus than nonsmokers in the Harm condition.

CONCLUSIONS

Warnings conveying the potential-reduced harms of Swedish snus compared with cigarettes generate perceptions that snus is less harmful than cigarettes and produce fewer thoughts about not using snus among nonsmokers. Such perceptions have been associated with snus use in prior studies.

Adolescents' Perceptions of Health Risks, Social Risks, and Benefits Differ Across Tobacco Products

OBJECTIVE

This study assesses perceptions of overall harm, short-term health and social risks, long-term health risks, and benefits associated with various tobacco products including conventional cigarettes, e-cigarettes, cigars, chew, and hookah. This study also assesses whether and how perceptions differ by age, gender, race/ethnicity, and previous experience with tobacco.

METHODS

A total of 722 high school students completed an online survey, answering questions about their use and perceptions of a variety of tobacco products. Differences in perceptions across products were assessed using a generalized estimation equation with an exchangeable correlation structure.

RESULTS

Adolescents rated the various tobacco products as conferring significantly different levels of risks and benefits. Generally, adolescents rated cigarettes as most risky, followed by cigars and chew, with hookah and e-cigarettes rated as least risky. Adolescents rated hookah followed by cigarettes and e-cigarettes as most likely to make them look cool or fit in and cigars and chew as least likely to confer these benefits. There were interaction effects by age and use, with older adolescents and those with tobacco experience holding lower perceptions of risk. There were no significant interaction effects by race/ethnicity or gender.

CONCLUSION

Given the significant differences in adolescents' perceptions of risks and benefits of using different tobacco products and research showing the predictive relationship between perceptions and behavior, there is a need for comprehensive messaging that discusses risks of all tobacco products, particularly hookah and e-cigarettes. There is also a need to address perceived benefits of tobacco products, especially hookah and e-cigarettes.

The Case to Include Brand of Moist Snuff in Health Surveys

INTRODUCTION

Brand of smokeless tobacco was added to the most recent Tobacco Use Supplement to the Current Population Survey (TUS-CPS), but deleted from the Centers for Disease Control's National Adult Tobacco Survey. The objective of this study was to assess the utility of brand in distinguishing users of moist snuff.

METHODS

The sample consisted of participants from the 2010-2011 TUS-CPS who reported having used one of 14 brands of moist snuff in the past month (n = 2334). The brands were categorized into one of three types: snus, discount snuff, premium snuff. Multinomial logistic regression was employed for testing for associations between brand type and a series of demographic and tobacco use measures.

RESULTS

Females, metropolitan residents, current smokers, and moderate users of snuff had significantly greater odds of using snus relative to premium snuff in the adjusted model (P < .001). Frequent users of snuff (eg, daily users), current smokers, young adults, participants with low household income, and those exhibiting dependence on nicotine had greater odds of using discount versus premium snuff. Separate analyses among current smokers (n = 470) and former smokers (n = 70) revealed positive associations between smoking cessation attempts and smokers' switch to discount snuff.

CONCLUSIONS

Differences among the three categories of snuff users are likely attributed to variations in marketing campaigns. The differences are sufficient to warrant inclusion of snuff brand in health surveys because brand type could serve as a proxy measure for snuff use and dependence.

IMPLICATIONS

Inclusion of brand of moist snuff in health surveys will enable researchers to categorize snuff users by brand type. Findings from this study indicate that brand type, defined according to cost (ie, discount vs. premium brands) and type of preferred snuff (ie, snus vs. other moist snuff), can distinguish snuff users by various demographic and tobacco use measures. Consequently, categorization by brand type could be used as a proxy measure for studies whose surveys do not include detailed information on snuff use and behavior.

Preferred flavors and reasons for e-cigarette use and discontinued use among never, current, and former smokers

OBJECTIVES

To compare e-cigarette flavors preferred and reasons for use and discontinued use across never, current, and former e-cigarette users and cigarette smokers.

METHODS

We recruited 1567 participants aged 18-34 years through Facebook ads targeting tobacco users and nonusers in August 2014 to complete an online survey. We assessed tobacco use, preferred flavors, and reasons for e-cigarette use and discontinued use.

RESULTS

Our sample was 49 % male, 87 % White; 56 % current cigarette smokers; and 53 % e-cigarette users. Current e-cigarette users used an average of 20.9 days in the past 30 (SD = 11.7) and 55.2 puffs/day (SD = 37.3). Compared to never and current smokers, former smokers used e-cigarettes more frequently (p's <0.001). Among users and nonusers, the most preferred was fruit flavors, and the most commonly reported reason for e-cigarette use was "they might be less harmful than cigarettes". The most endorsed reason for discontinued e-cigarette use was "using other tobacco products instead". Never, current, and former smokers had distinct reasons for e-cigarette use and discontinued use and differed in flavor preferences.

CONCLUSIONS

Regulating marketing and flavors may impact e-cigarette uptake by young adults.

Using Electrophysiological Measures to Assess the Consumer Acceptability of Smokeless Tobacco Products

INTRODUCTION

Adequate evaluation of novel tobacco products must include investigation of consumers' psychological response to such products. Traditionally, subjective scales of product liking have been used to assess consumer acceptability of tobacco products. However, subjective scales may miss cognitive changes that can only be captured by direct neurophysiological assessment. The present investigation explored the viability of using electroencephalography (EEG), in combination with traditional subjective measures, to assess consumer acceptability of five smokeless tobacco products. Given previous work linking product liking to arousal/attentional (executive function) enhancement, we focused on EEG measures of attention/arousal to objectively characterize cognitive changes associated with tobacco product use.

METHODS

During five separate laboratory visits, smokeless tobacco users used Verve discs, Ariva dissolvables, Skoal snuff, Camel snus, or Nicorette lozenges. The N2 and P3b event-related potential components elicited by an oddball task were used to index attentional changes before/after product usage. Additionally, resting state alpha band EEG activity was analyzed before/after product usage to index cortical arousal.

RESULTS

Although analyses of the subjective results provided limited inference, analyses of the electrophysiological measures, particularly the alpha suppression measure, revealed robust differences between products. Skoal elicited significantly enhanced alpha suppression compared to all four other products tested. Additionally, alpha suppression was found to correlate positively with subjective measures of satisfaction and psychological reward, but was unrelated to perceived aversion.

CONCLUSIONS

The present results provide evidence that electrophysiological measures can yield important insights into consumer acceptability of novel tobacco products and are a valuable complement to subjective measures.

IMPLICATIONS

This study is the first to employ a combination of electrophysiological measures and traditional subjective assays in order to assess the consumer acceptability of smokeless tobacco products. The results highlight the importance of adopting a multidimensional/multi-method approach to studying the consumer acceptability of tobacco products.

Awareness and Use of Dissolvable Tobacco Products in the United States

INTRODUCTION

Little is known about dissolvable tobacco products (DTPs) compared with other alternative tobacco products (ATPs) like e-cigarettes and snus. We sought to understand US adults' awareness and use of DTPs.

METHODS

A nationally representative sample of US adults (age ≥ 18 years, N = 17 522) completed an online survey in March 2013 assessing their awareness and use of DTPs.

RESULTS

Approximately 16% of all respondents were aware of DTPs. Few reported ever using DTPs (1.6%). DTP awareness among all respondents was greatest among males, younger adults, current and former smokers, never married respondents, blacks and Latinos, and those who used other ATPs. Among current smokers, DTP awareness was greatest for males, younger adults, blacks and Latinos, those who used other ATPs, and Southerners. DTP use among all respondents was greatest among males, younger adults, Lesbian, Gay, Bisexual, and Transgender (LGBT) respondents, former and current smokers, and those who used other ATPs. Among current smokers, DTP use was greatest among males, younger adults, LGBT respondents, those who used other ATPs, those who intended to quit, and those who received medical advice to quit.

CONCLUSIONS

DTP awareness and use have increased since 2009. DTPs are being used as smoking cessation aids thereby increasing risk of polytobacco use. Medical professionals should emphasize use of empirically-supported smoking cessation aids when advising patients to quit. Regulations are needed to prevent tobacco company promotion of DTPs as smoking cessation aids and to inform consumers of the risks associated with DTPs and polytobacco use. Increased national surveillance of DTP use is recommended.

Understanding the emergence of the tobacco industry's use of the term tobacco harm reduction in order to inform public health policy

OBJECTIVES

To explore the history of transnational tobacco companies' use of the term, approach to and perceived benefits of 'harm reduction'.

METHODS

Analysis of internal tobacco industry documents, contemporary tobacco industry literature and 6 semistructured interviews.

RESULTS

The 2001 Institute of Medicine report on tobacco harm reduction appears to have been pivotal in shaping industry discourse. Documents suggest British American Tobacco and Philip Morris International adopted the term 'harm reduction' from Institute of Medicine, then proceeded to heavily emphasise the term in their corporate messaging. Documents and interviews suggest harm reduction offered the tobacco industry two main benefits: an opportunity to (re-) establish dialogue with and access to policy makers, scientists and public health groups and to secure reputational benefits via an emerging corporate social responsibility agenda.

CONCLUSIONS

Transnational tobacco companies' harm reduction discourse should be seen as opportunistic tactical adaptation to policy change rather than a genuine commitment to harm reduction. Care should be taken that this does not undermine gains hitherto secured in efforts to reduce the ability of the tobacco industry to inappropriately influence policy.

Cigarette users' interest in using or switching to electronic nicotine delivery systems for smokeless tobacco for harm reduction, cessation, or novelty: a cross-sectional survey of US adults

INTRODUCTION

We examined: (a) current (past 30-day) smokers' interest in using or switching to electronic nicotine delivery systems (ENDS) or smokeless tobacco for various reasons; (b) correlates of interest in these products; and (c) subgroups of current smokers in relation to interest in these products.

METHODS

We conducted a cross-sectional survey assessing sociodemographics, tobacco use, interest in ENDS and smokeless tobacco among smokers, and knowledge about ENDS among 2,501 US adults recruited through an online consumer panel. We oversampled tobacco users (36.7% current cigarette smokers), ethnic minorities, and southeastern US state residents.

RESULTS

On average, participants were more interested in ENDS than smokeless tobacco across all reasons provided. Additionally, they were less interested in either product because of their potential use in places prohibiting smoking or due to curiosity and more interested in reducing health risk or cigarette consumption or to aid in cessation. We documented high rates (27.9%) of misbeliefs about Food and Drug Administration approval of ENDS for cessation, particularly among current smokers (38.5%). Also, 27.2% of current smokers had talked with a health care provider about ENDS, with 18.0% reporting that their provider endorsed ENDS use for cessation. Furthermore, cluster analyses revealed 3 groups distinct in their interest in the products, sociodemographics, and smoking-related characteristics.

CONCLUSIONS

This study highlights higher interest in ENDS versus smokeless tobacco and greater interest in both for harm reduction and cessation than due to novelty or smoking restrictions. Developing educational campaigns and informing practitioners about caveats around ENDS as cessation or harm reduction aids are critical.

Perceived harm of tobacco products and individual schemas of a smoker in relation to change in tobacco product use over one year among young adults

INTRODUCTION

Given increases in nondaily smoking and alternative tobacco use among young adults, we examined the nature of change of various tobacco product use among college students over a year and predictors of use at one-year follow-up.

METHODS

An online survey was administered to students at six Southeast colleges and universities (N = 4,840; response rate = 20.1%) in Fall 2010, with attempts to follow up in Fall 2011 with a random subsample of 2,000 participants (N = 718; response rate = 35.9%). Data were analyzed from 698 participants with complete data regarding tobacco, marijuana, and alcohol use over a one-year period, perceived harm of tobacco use, and schemas of a "smoker" (as per the Classifying a Smoker Scale).

RESULTS

Baseline predictors of current smoking at follow-up included being White (p = .001), frequency of smoking (p < .001), alternative tobacco use (p < .001), and perceived harm of smoking (p = .02); marginally significant predictors included marijuana use (p = .06) and lower scores on the Classifying a Smoker Scale (p = .07). Baseline predictors of current smoking at follow-up among baseline nondaily smokers included more frequent smoking (p = .008); lower Classifying a Smoker Scale score was a marginally significant predictor (p = .06). Baseline predictors of alternative tobacco use at follow-up included being male (p = .007), frequency of smoking (p = .04), alternative tobacco use (p < .001), and frequency of alcohol use (p = .003); marginally significant predictors included marijuana use (p = .07) and lower perceived harm of smokeless tobacco (p = .06) and cigar products (p = .08).

CONCLUSIONS

Tobacco control campaigns and interventions might target schemas of a smoker and perceived risks of using various tobacco products, even at low levels.

Perceived harm, addictiveness, and social acceptability of tobacco products and marijuana among young adults: marijuana, hookah, and electronic cigarettes win

BACKGROUND

There has been an increase in non-daily smoking, alternative tobacco product and marijuana use among young adults in recent years.

OBJECTIVES

This study examined perceptions of health risks, addictiveness, and social acceptability of cigarettes, cigar products, smokeless tobacco, hookah, electronic cigarettes, and marijuana among young adults and correlates of such perceptions.

METHODS

In Spring 2013, 10,000 students at two universities in the Southeastern United States were recruited to complete an online survey (2,002 respondents), assessing personal, parental, and peer use of each product; and perceptions of health risks, addictiveness, and social acceptability of each of these products.

RESULTS

Marijuana was the most commonly used product in the past month (19.2%), with hookah being the second most commonly used (16.4%). The least commonly used were smokeless tobacco products (2.6%) and electronic cigarettes (4.5%). There were high rates of concurrent product use, particularly among electronic cigarette users. The most positively perceived was marijuana, with hookah and electronic cigarettes being second. While tobacco use and related social factors, related positively, influenced perceptions of marijuana, marijuana use and related social factors were not associated with perceptions of any tobacco product. Conclusions/Importance: Marketing efforts to promote electronic cigarettes and hookah to be safe and socially acceptable seem to be effective, while policy changes seem to be altering perceptions of marijuana and related social norms. Research is needed to document the health risks and addictive nature of emerging tobacco products and marijuana and evaluate efforts to communicate such risks to youth.

Prevalence, harm perceptions, and reasons for using noncombustible tobacco products among current and former smokers

OBJECTIVES

We provided estimates of noncombustible tobacco product (electronic nicotine delivery systems [ENDS]; snus; chewing tobacco, dip, or snuff; and dissolvables) use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.

METHODS

We assessed awareness of, prevalence of, purchase of, harm perceptions of, and reasons for using noncombustible tobacco products among 1487 current and former smokers from 8 US designated market areas. We used adjusted logistic regression to identify correlates of noncombustible tobacco product use.

RESULTS

Of the sample, 96% were aware of at least 1 noncombustible tobacco product, but only 33% had used and 21% had purchased one. Noncombustible tobacco product use was associated with being male, non-Hispanic White, younger, and more nicotine dependent. Respondents used noncombustible tobacco products to cut down or quit cigarettes, but only snus was associated with a higher likelihood of making a quit attempt. Users of noncombustible tobacco products, particularly ENDS, were most likely to endorse the product as less harmful than cigarettes.

CONCLUSIONS

Smokers may use noncombustible tobacco products to cut down or quit smoking. However, noncombustible tobacco product use was not associated with a reduction in cigarettes per day or cessation.

Intention to switch to smokeless tobacco use among South African smokers: results from the 2007 South African Social Attitudes Survey

Background

Some smokeless tobacco products (SLT) have been shown to be associated with only a fraction of the risks of cigarettes. This study assessed South African smokers’ interest in switching to a hypothetical reduced harm SLT product.

Methods

The 2007 South African Social Attitudes Survey was analysed for 678 exclusive cigarette smokers. Respondents were asked about their perceptions about relative harm of snuff compared to cigarettes, and their interest in switching to snuff if informed it was 99% less harmful than cigarettes.

Results

About 49.7% of exclusive cigarette smokers believed that snuff was equally as harmful as cigarettes; 12.9% thought snuff was more harmful; 5.7% thought snuff was less harmful; while 31.8% did not know if there was a difference in harm between snuff and cigarettes. Approximately 24.2% of exclusive cigarette smokers indicated interest in switching to snuff, with significantly greater interest observed among those exposed to 100% smoke-free work environment. Interest in switching was highest (34.7%) among smokers who believed a priori that using snuff was more harmful than cigarettes, and lowest (14.5%) among those who did not know if there was a difference in harm. In a multi-variable adjusted logistic regression model, this latter group remained less likely to be interested in harm reduction switching (adjusted odds ratio = 0.42; 95% CI: 0.19–0.91).

Conclusion

About a quarter of smokers indicated interest in harm reduction switching to snuff. SLT products have a potential role in reducing the harm from smoking in South Africa, but only if they are not used to circumvent smoke-free laws that have been associated with reduced smoking.

Snus use and rejection in the USA

OBJECTIVE

To determine whether snus might become a strategy for reducing the harm associated with cigarette smoking in the USA as appears to be the case in Sweden, we examined receptivity to snus use in two cities with the greatest exposure to the major brands.

METHODS

A dual frame, telephone survey and a brief mail survey were conducted in 2011 and 2012 in Indianapolis, Indiana and Dallas/Fort Worth Texas. Over 5000 adults completed surveys. Trial, ever use, current use and reasons for using or quitting snus after trial were measured.

RESULTS

Among male smokers, 29.9% had ever tried snus (CI 22.7 to 38.1) and 4.2% were current users (CI 1.6 to 10.7). Among female smokers, 8.5% ever tried snus (CI 4.4 to 15.7) and current use was unknown. Current use was virtually absent among former smokers and never smokers. A major predictor of any level of snus use was current use of conventional smokeless tobacco. Those who tried and gave up snus cited curiosity (41.3%) and the fact that it was available at low or no cost (30%) as reasons for trial; reasons for not continuing included preferring another form of tobacco (75.1%) and disliking the mouth feel (34.6%). Almost all current snus users indicated that they were trying to cut down on cigarettes, but few (3.9%) were using it to quit smoking entirely.

CONCLUSIONS

The low rate of adoption of snus suggests that neither the hopes nor the fears surrounding this new product are likely to be realised in the USA with the current marketing patterns.

Sociodemographic correlates of exclusive and concurrent use of smokeless and smoked tobacco products among Nigerian men

INTRODUCTION

This study sought to determine the sociodemographic correlates of exclusive and concurrent use of smokeless tobacco (SLT) and smoking (i.e., dual use) and to explore the association between SLT use and the amount of cigarettes smoked per day.

METHODS

Data were obtained from a nationally representative sample of Nigerian men aged 15-59 years (N = 15,453) who participated in the 2008 Nigerian Demographic and Health Survey (NDHS). The NDHS used an interviewer-administered questionnaire to collect data on participants' sociodemographic characteristics and tobacco use status. Taking account of the multistage sampling used in the NDHS, data analyses included descriptive statistics, chi-square analysis, and multivariable adjusted multinomial logistic regression analysis.

RESULTS

Of the respondents, 12.2% (n = 1,842) were tobacco users, out of which 24.5% (n = 477) were exclusive SLT users, 69% (n = 1,236) were exclusive smokers, and 6.5% (n = 129) were dual users. Both SLT use and smoking were most prevalent among the Igbo ethnic group and among the least educated men. SLT use was most prevalent among those in the southeast (9.75%) and north-central (7.71%) regions, where smoking was also common. The number of cigarettes smoked per day was not significantly different among dual users when compared with exclusive smokers (7.3 vs. 5.6; p = .088). Dual users were also more likely to self-identify as traditionalists (RRR = 6.03; 95% CI = 2.96-12.28) compared with self-identifying as practicing Islam or Christianity.

CONCLUSIONS

There are distinctive ethnic and regional differences in tobacco use patterns among Nigerian men, and SLT use was not associated with reduced smoking intensity among dual users.

Sweden SimSmoke: the effect of tobacco control policies on smoking and snus prevalence and attributable deaths

BACKGROUND

This study examines the effect of past tobacco control policies and projects the effect of future policies on smoking and snus use prevalence and associated premature mortality in Sweden.

METHODS

The established SimSmoke model was adapted with population, smoking rates and tobacco control policy data from Sweden. SimSmoke evaluates the effect of taxes, smoke-free air, mass media, marketing bans, warning labels, cessation treatment and youth access policies on smoking and snus prevalence and the number of deaths attributable to smoking and snus use by gender from 2010 to 2040.

RESULTS

Sweden SimSmoke estimates that significant inroads to reducing smoking and snus prevalence and premature mortality can be achieved through tax increases, especially when combined with other policies. Smoking prevalence can be decreased by as much as 26% in the first few years, reaching a 37% reduction within 30 years. Without effective tobacco control policies, almost 54 500 lives will be lost in Sweden due to tobacco use by the year 2040.

CONCLUSION

Besides presenting the benefits of a comprehensive tobacco control strategy, the model identifies gaps in surveillance and evaluation that can help better focus tobacco control policy in Sweden.

The use and perception of electronic cigarettes and snus among the U.S. population

BACKGROUND

E-cigarettes have generated controversy in the tobacco control field similar to that of Swedish snus, which came to the U.S. market six years earlier. Some argue that e-cigarettes have great potential to help smokers quit regular cigarettes while others contend they should be banned for lack of safety and efficacy data. This study examined population data from the U.S.

METHODS

A U.S. population survey with a national probability sample (N=10,041) was conducted (February 24 to March 8, 2012, before any major paid advertisement of e-cigarettes appeared on television). Survey respondents were asked if they had heard about e-cigarettes, where they had heard about them, whether they had used e-cigarettes or snus, how often they used them, and why they used them. Responses were weighted to represent the entire U.S. population.

FINDINGS

A high proportion, 75.4%, reported having heard about e-cigarettes. Television ranked as the number one source of information, followed by "in-person conversation" and "Internet." About 8.1% had tried e-cigarettes, and 1.4% were current users. These rates were twice those of snus (4.3% and 0.8%, respectively). Among current smokers, 32.2% had tried e-cigarettes, and 6.3% were current users. Over 80% of current e-cigarette users were non-daily users. Women were significantly more likely to have tried e-cigarettes than men. Those who had tried e-cigarettes were more likely than those who tried snus to report their products being safer than regular cigarettes (49.9% vs. 10.8%). Almost half (49.5%) of current smokers were susceptible to using e-cigarettes in the future.

CONCLUSIONS

That e-cigarettes have surpassed snus in adoption rate, even before any promotion by major tobacco companies, suggests that the former have tapped into smokers' intuitive preference for potentially harm-reducing products, probably due to the product design. E-cigarette use is likely to increase in the next few years.

Demand for smokeless tobacco: role of advertising

While the prevalence of smokeless tobacco (ST) is low relative to smoking, the distribution of ST use is highly skewed with consumption concentrated among certain segments of the population (rural residents, males, whites, low-educated individuals). Furthermore, there is suggestive evidence that use has trended upwards recently for groups that have traditionally been at low risk of using ST, and thus started to diffuse across demographics. This study provides the first estimates, at the national level, of the effects of magazine advertising on ST use. The focus on magazine advertising is significant given that ST manufacturers have been banned from using other conventional media since the 1986 Comprehensive ST Act and the 1998 ST Master Settlement Agreement. This study is based on the 2003-2009 waves of the National Consumer Survey (NCS), a unique data source that contains extensive information on the reading habits of individuals, matched with magazine-specific advertising information over the sample period. This allows detailed and salient measures of advertising exposure at the individual level and addresses potential bias due to endogeneity and selective targeting. We find consistent and robust evidence that exposure to ST ads in magazines raises ST use, especially among males, with an estimated elasticity of 0.06. There is suggestive evidence that both ST taxes and cigarette taxes reduce ST use, indicating contemporaneous complementarity between these tobacco products. Sub-analyses point to some differences in the advertising and tax response across segments of the population. The effects from this study inform the debate on the cost and benefits of ST use and its potential to be a tool in overall tobacco harm reduction.

Harm reduction and the medicalisation of tobacco use

In tobacco control the focus has, for some time, been on abstinence from all types of tobacco use as the only solution to the problem of smoking, and harm reduction approaches are controversial. The most recent English tobacco strategy has incorporated harm reduction approaches in the form of new 'routes' to quitting smoking that encourage those who cannot quit to use safer sources of nicotine. This move away from a focus on abstinence can be seen as the result of gradual shifts over the past 50 years in the way that that the problem of smoking is understood and the solutions that are offered. These shifts have involved increasingly seeing tobacco use as a medical problem. This article uses conceptual tools from science and technology studies to examine developments over the last decade in England, primarily the increasing importance of harm reduction approaches. Drawing on 20 semi-structured qualitative interviews with key stakeholders and documentary analysis, I suggest that the shape harm reduction has taken in English tobacco control policy has been another shift towards the medicalisation of tobacco use, but that this process has occurred in ways that provide a contrast to commonly outlined 'drivers' of medicalisation.

Initial reactions to tobacco use and risk of future regular use

INTRODUCTION

Studies suggest that initial smoking pleasure influences future smoking behavior. We investigated how initial reactions to cigarettes or Swedish smokeless tobacco (snus) were associated with future use among 10,708 adults from the Swedish Twin Registry.

METHODS

The Early Smoking Experience questionnaire captured physiologic reactions to initial tobacco use. Binary recursive partitioning (BRP) identified combinations of initial reactions predictive of regular tobacco use. Analyses, stratified by sex, were conducted separately among those who experimented with only cigarettes (EC), only snus (ES), and both products (EC+S).

RESULTS

Among EC, 39.8% of men and 43.7% of women became smokers, while among ES, 78.6% of men and 53.7% of women became snus users. Among EC+S, 31.3% of men and 20.0% of women became dual users. BRP identified different reactions as predictive of future smoking for men (buzz) and women (dizziness, difficulty inhaling). No initial reaction predicted future snus use among men, but pleasant sensations, later age at first use, and relaxation predicted future snus use for women. Among EC+S, future exclusive use of either product was associated with a favorable initial reaction to that product. Dual users experienced higher prevalence of pleasant reactions and lower prevalence of unpleasant reactions in response to both products.

CONCLUSIONS

Our findings support that those who progress to regular tobacco use may be sensitive to the rewarding effects of nicotine but suggest that initial reactions differ by tobacco type. A high proportion of men became regular snus users regardless of initial reactions.

Awareness, perceptions and use of snus among young adults from the upper Midwest region of the USA

BACKGROUND

Since its introduction in 2006, snus has been aggressively marketed by tobacco companies. However, little is known about the awareness, perceptions and use of snus among young adults after Camel and Marlboro snus were sold nationwide in 2010.

METHODS

Data were collected from 2607 young adults (ages 20-28) who participated in the Minnesota Adolescent Community Cohort Study in 2010-2011. Data include awareness of snus, ever and past 30-day use, perceived potential of snus as a quit aid, and perceived harmfulness and addictiveness of snus relative to cigarettes. The authors assessed the associations between these outcome variables and socio-demographic characteristics.

RESULTS

Overall, 64.8% of participants were aware of snus, 14.5% ever used snus and 3.2% used snus in the past 30 days. Men and participants who smoked >100 cigarettes in their lifetime were associated with these three outcomes (p<0.05). Among those who were aware of snus, 16.3% agreed snus can help people quit smoking, 17.3% agreed snus is less harmful than cigarettes and 11.3% agreed snus is less addictive than cigarettes. These perceptions were associated with ever use and the past 30-day use of snus (p<0.05).

CONCLUSIONS

In this regional sample of US young adults, the majority of young adults were aware of snus, and over one in 10 had used snus. More young adults in the sample than the overall US adult population believed that snus is less harmful than cigarettes. Perceptions of snus are associated with snus use. Strategic health communication interventions targeting young adults to confront the positive perceptions associated with snus may be needed to curb the interest in snus.

Young adults' favorable perceptions of snus, dissolvable tobacco products, and electronic cigarettes: findings from a focus group study

OBJECTIVES

We explored young adults' perceptions of snus (spitless moist snuff packed in porous bags), dissolvable tobacco products, and electronic cigarettes and intention to try these products.

METHODS

We conducted 11 focus group discussions involving a total of 66 young adults (18-26 years old) on these new tobacco products (e.g., harmfulness, potential as quit aids, intention to try) held between July and December 2010. We analyzed discussions using a thematic approach.

RESULTS

Participants generally reported positive perceptions of the new products, particularly because they came in flavors. Few negative perceptions were reported. Although some participants believed these products were less harmful than cigarettes and helpful in quitting smoking, others thought the opposite, particularly regarding electronic cigarettes. Participants also commented that these products could be gateways to cigarette smoking. Half of the participants, including a mix of smokers and nonsmokers, admitted they would try these products if offered by a friend.

CONCLUSIONS

Young adults perceive the new tobacco products positively and are willing to experiment with them. Eliminating flavors in these products may reduce young adults' intentions to try these products.

Use of emerging tobacco products in the United States

This paper provides the first nationally representative estimates for use of four emerging products. Addressing the issue of land-line substitution with cell phones, we used a mixed-mode survey to obtain two representative samples of US adults. Of 3,240 eligible respondents contacted, 74% completed surveys. In the weighted analysis, 13.6% have tried at least one emerging tobacco product; 5.1% snus; 8.8% waterpipe; 0.6% dissolvable tobacco products; 1.8% electronic nicotine delivery systems (ENDS) products. Daily smokers (25.1%) and nondaily smokers (34.9%) were the most likely to have tried at least one of these products, compared to former smokers (17.2%) and never smokers (7.7%), P<.001. 18.2% of young adults 18-24 and 12.8% of those >24 have tried one of these products, P<.01. In multivariable analysis, current daily (5.5, 4.3-7.6), nondaily (6.1, 4.0-9.3), and former smoking status (2.7, 2.1-3.6) remained significant, as did young adults (2.2, 1.6-3.0); males (3.5, 2.8-4.5); higher educational attainment; some college (2.7, 1.7-4.2); college degree (2.0, 1.3-3.3). Use of these products raises concerns about nonsmokers being at risk for nicotine dependence and current smokers maintaining their dependence. Greater awareness of emerging tobacco product prevalence and the high risk demographic user groups might inform efforts to determine appropriate public health policy and regulatory action.

Association between willingness to use snus to quit smoking and perception of relative risk between snus and cigarettes

INTRODUCTION

Smokers are often incorrect in their assessment of the relative risk of snus and cigarettes. We have studied how perception of risks of snus compared with cigarettes was associated with the willingness of trying snus as a quit-smoking method.

METHODS

Fourteen thousand seven hundred and forty-four Norwegian men aged 20-50 years were selected at random from a national representative web panel and sent a questionnaire by e-mail. Of the 7,170 (48.6%) who responded, there were 1,155 former daily smokers who reported method for quitting smoking and 1,213 current daily smokers who stated their willingness to try different methods for quitting smoking. They were also asked to assess the relative risk between daily use of snus and cigarettes.

RESULTS

Adjusted odds ratio (AOR) for reporting willingness to try snus in future quit attempts was significantly higher (AOR = 4.82, p < .001) for the 22.9% of the current smokers who, consistent with scientific evidence, believed that the health risks were "far lower" for snus than for cigarettes compared with the 39.8% who incorrectly perceived the health risks to be "equal or higher" for snus (reference AOR = 1). About 37.2% of the daily smokers believed that the risk was "somewhat lower" for snus than for cigarettes and had a significantly higher AOR of reporting willingness to try snus (AOR = 2.31, p < .001) compared with the reference group.

CONCLUSION

Devising a way to inform smokers about the risk continuum of tobacco products could be an important research priority in countries where snus is allowed to compete with cigarettes for market share.

Smokers' perceptions of smokeless tobacco and harm reduction

Existing survey data indicate that most smokers are not receptive to harm reduction incentives of switching to smokeless tobacco (SLT). Little is known about the underlying reasons for these views. To explore smokers' perceptions of SLT, we conducted a focus group (eight in total) study of daily smokers between 2009 and 2010 at the University of California, Irvine. We transcribed each 2-hour focus group verbatim and analyzed it using domain analysis. The discussions revealed several reasons why smokers are not receptive to SLT. First, smokers associated new spit-less SLT (that is, Snus) with historic images of chewing tobacco. Second, smokers viewed smoking as an incentive to take a break from their daily routine. Third, smokers expressed lack of control over nicotine delivery when using SLT, relative to cigarettes. These findings challenge tobacco manufacturers' strategies to market a smokeless alternative as a growing number of smoke-free policies are introduced.

Non-cigarette tobacco products: what have we learnt and where are we headed?

A wide variety of non-cigarette forms of tobacco and nicotine exist, and their use varies regionally and globally. Smoked forms of tobacco such as cigars, bidis, kreteks and waterpipes have high popularity and are often perceived erroneously as less hazardous than cigarettes, when in fact their health burden is similar. Smokeless tobacco products vary widely around the world in form and the health hazards they present, with some clearly toxic forms (eg, in South Asia) and some forms with far fewer hazards (eg, in Sweden). Nicotine delivery systems not directly reliant on tobacco are also emerging (eg, electronic nicotine delivery systems). The presence of such products presents challenges and opportunities for public health. Future regulatory actions such as expansion of smoke-free environments, product health warnings and taxation may serve to increase or decrease the use of non-cigarette forms of tobacco. These regulations may also bring about changes in non-cigarette tobacco products themselves that could impact public health by affecting attractiveness and/or toxicity.

Young adults' perceptions about established and emerging tobacco products: results from eight focus groups

INTRODUCTION

In order to sustain their market, tobacco producers target young adults through novel product design and marketing strategies. Public health professionals need to understand young adults' risks perceptions about and use of new tobacco products to best inform tobacco control interventions.

METHODS

In 2009, researchers conducted 8 focus groups with 67 young adults stratified by self-reported tobacco use and nonuse, residence in rural and urban areas, and living in a state with or without a statewide smoking restriction policy. Participants provided feedback about their knowledge and risk perceptions about and use of tobacco products and marketing.

RESULTS

Participants reported a high level of familiarity with a wide range of novel tobacco products. A great deal of confusion and disagreement appeared with regard to absolute and relative risk of different tobacco products. Participants readily discussed using smokeless tobacco products as alternatives to smoking when smoking is prohibited. Fewer differences in tobacco-related knowledge risk perceptions and use were found between urban and rural participants and those in smoke-free policy and nonpolicy states than between user and nonuser groups. Both users and nonusers were familiar with and skeptical about tobacco marketing and prevention efforts.

CONCLUSIONS

Young adults are familiar with many tobacco products, but they convey little understanding of relative risks of new or trendy tobacco products, such as snus or hookah. Mindful of industry innovation, tobacco control advocates must continuously update prevention efforts, seeking new strategies to limit promotion, marketing, and use of new and conventional products.

The scientific foundation for tobacco harm reduction, 2006-2011

Over the past five years there has been exponential expansion of interest in tobacco harm reduction (THR), with a concomitant increase in the number of published studies. The purpose of this manuscript is to review and analyze influential contributions to the scientific and medical literature relating to THR, and to discuss issues that continue to stimulate debate. Numerous epidemiologic studies and subsequent meta-analyses confirm that smokeless tobacco (ST) use is associated with minimal risks for cancer and for myocardial infarction; a small increased risk for stroke cannot be excluded. Studies from Sweden document that ST use is not associated with benign gastrointestinal disorders and chronic inflammatory diseases. Although any form of nicotine should be avoided during pregnancy, the highest risks for the developing baby are associated with smoking. It is documented that ST use has been a key factor in the declining rates of smoking and of smoking-related diseases in Sweden and Norway. For other countries, the potential population health benefits of ST are far greater than the potential risks. In follow-up studies, dual users of cigarettes and ST are less likely than exclusive smokers to achieve complete tobacco abstinence, but they are also less likely to be smoking. The health risks from dual use are probably lower than those from exclusive smoking. E-cigarette users are not exposed to the many toxicants, carcinogens and abundant free radicals formed when tobacco is burned. Although laboratory studies have detected trace concentrations of some contaminants, it is a small problem amenable to improvements in quality control and manufacturing that are likely with FDA regulation as tobacco products. There is limited evidence from clinical trials that e-cigarettes deliver only small doses of nicotine compared with conventional cigarettes. However, e-cigarette use emulates successfully the cigarette handling rituals and cues of cigarette smoking, which produces suppression of craving and withdrawal that is not entirely attributable to nicotine delivery. THR has been described as having "the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century."

Smokeless tobacco use in Australia

INTRODUCTION AND AIMS

There has been little research published on the use of smokeless tobacco (SLT) in Australia. This study aimed to determine the prevalence of SLT use and the potential for harm reduction in current SLT users and smokers.

DESIGN AND METHODS

We undertook secondary analysis of data from a national household survey of drug use and surveyed 108 Australian SLT users about their patterns of SLT use and tobacco smoking.

RESULTS

The low prevalence of SLT use in the past year in Australia (0.57%; 95% confidence interval 0.48–0.66) might reflect the difficulty in importing these products. Prevalence of recent use was highest among males aged 18–29 who were current weekly smokers. US style oral snuffs were the most popular SLT products in Australia. Most of those surveyed were introduced to SLT by a personal contact and about half had used SLT to quit smoking. Australians who import SLT pay per can AU$21.30 on average and face substantial delays before receiving the product.

DISCUSSION AND CONCLUSIONS

Cost and poor access present a substantial barrier to SLT use as a tobacco harm reduction measure for Australian smokers. Permitting low nitrosamine varieties of SLT to be sold in Australia might reduce harm in current SLT users and provide a viable alternative to cigarettes for some current smokers.