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Audrain-McGovern J, Wileyto EP, Klapec O, Koita F, Strasser AA. Switching from cigarettes to IQOS: the relative importance of IQOS-associated reward, reinforcement and abstinence relief. Tob Control 2024:tc-2024-058635. [PMID: 38871445 DOI: 10.1136/tc-2024-058635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION This study investigated whether IQOS, a heated tobacco product, can fully substitute for combustible cigarettes and the factors that promote substitution. METHODS Adults who smoked cigarettes daily (N=90; 21-65 years) completed a baseline ad-lib smoking period (days 1-5), two laboratory visits (days 6-7) and a 2-week period where they were instructed to switch from smoking cigarettes to using IQOS 3.0 (days 8-21). Mixed-effect modelling estimated the changes in cigarettes per day (CPD) and the percentage of baseline CPD substituted by HeatSticks during the switch period. Predictors included IQOS-associated subjective reward, relative reinforcing value, craving relief and withdrawal relief. RESULTS Participants reduced their CPD to about 30% of their baseline smoking rate by the end of the 14-day switch period (p<0001). A lower versus higher reinforcing value of smoking relative to IQOS (RRV; break point <5 vs ≥5) predicted greater reductions in CPD (β=-1.31 (95% CI -2.35 to -0.27) p=0.013). Initially, IQOS use was 72% of the baseline smoking rate (β=71.64 (95% CI 42.79 to 100.48) p<0.0001) and climbed by 0.8% per day (β=0.82 (95% CI 0.01 to 1.64) p=0.05), for an average substitution rate of 83%. The subjective reward of IQOS was the only predictor of a higher substitution rate (β=4.26 (95% CI 1.03 to 7.50) p=0.01). CONCLUSIONS IQOS fully substituted for cigarettes in ~20% of people who were not immediately interested in quitting smoking while the remainder significantly reduced their smoking. Positive reinforcing effects of IQOS foster use and the transition away from combustible cigarettes. TRIAL REGISTRATION NUMBER NCT05076708.
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Affiliation(s)
- Janet Audrain-McGovern
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - E Paul Wileyto
- Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Olivia Klapec
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fodie Koita
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew A Strasser
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Berg CJ, Duan Z, Wang Y, Thrasher JF, Bar-Zeev Y, Abroms LC, Romm KF, Khayat A, Levine H. Impact of FDA endorsement and modified risk versus exposure messaging in IQOS ads: a randomised factorial experiment among US and Israeli adults. Tob Control 2024; 33:e69-e77. [PMID: 36428095 DOI: 10.1136/tc-2022-057639] [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: 07/11/2022] [Accepted: 11/15/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND IQOS was the first heated tobacco product to receive Food and Drug Administration (FDA) authorisation for 'reduced exposure' marketing claims, which has been exploited globally. METHODS In November-December 2021, we conducted a survey-based 3×3 factorial experiment among US (n=1128) and Israeli adults (n=1094). We presented: (1) reduced exposure, reduced risk and control messaging and (2) 2 variations of FDA endorsement and control messaging. Each participant was randomly assigned to evaluate 2 ads (displayed on different ad imagery), then completed assessments of perceived relative harm, exposure and disease risk and likelihood of personally trying or suggesting IQOS to smokers. Ordinal logistic regression examined messaging conditions and their interactions, on the 5 outcomes, respectively, adjusting for covariates. RESULTS Control (vs reduced exposure) messaging resulted in higher perceived relative harm (adjusted OR (aOR)=1.29, 95% CI=1.12 to 1.48), exposure (aOR=1.34, 95% CI=1.17 to 1.54) and disease risk (aOR=1.23; 95% CI=1.08 to 1.40), and lower likelihood of suggesting IQOS to smokers (aOR=0.85; 95% CI=0.74 to 0.97). Reduced risk (vs exposure) messaging resulted in lower perceived relative harm (aOR=0.86; 95% CI=0.75 to 0.99). One FDA endorsement message ('IQOS (completed) the US FDA examination of tobacco products. FDA concluded that IQOS is a better choice for adult smokers') was associated with greater likelihood of suggesting IQOS to smokers, relative to control (aOR=1.19; 95% CI=1.04 to 1.37). No interactions between risk/exposure messaging and FDA endorsement messaging were found. Additionally, Israeli participants, cigarette users and men perceived lower relative harm and exposure and greater likelihood of trying or suggesting IQOS to smokers. CONCLUSIONS Regulators must monitor direct and indirect advertising content of modified risk tobacco product-authorised products and prevent potentially harmful misinterpretations.
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Affiliation(s)
- Carla J Berg
- Department of Prevention and Community Health, The George Washington University Milken Institute School of Public Health, Washington, District of Columbia, USA
| | - Zongshuan Duan
- Department of Prevention and Community Health, The George Washington University Milken Institute School of Public Health, Washington, District of Columbia, USA
| | - Yan Wang
- Department of Prevention and Community Health, The George Washington University Milken Institute School of Public Health, Washington, District of Columbia, USA
| | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, USA
| | - Yael Bar-Zeev
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
| | - Lorien C Abroms
- Department of Prevention and Community Health, The George Washington University Milken Institute School of Public Health, Washington, District of Columbia, USA
| | - Katelyn F Romm
- Department of Pediatrics, College of Medicine; TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amal Khayat
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
| | - Hagai Levine
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
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DeAtley T, Stone MD, Strasser AA, Audrain-McGovern J. The role of IQOS risk perceptions on cigarette smoking behaviours: results from a prospective pilot study. Tob Control 2024; 33:263-266. [PMID: 36002165 PMCID: PMC10394684 DOI: 10.1136/tc-2022-057461] [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: 04/11/2022] [Accepted: 08/09/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND IQOS is a heated tobacco product marketed as an alternative to combustible cigarette smoking. Little is known about cigarette smokers' IQOS health risk perceptions and if these risk perceptions impact IQOS use and cigarette smoking behaviour. METHODS Adult, daily, non-treatment-seeking cigarette smokers (n=27), naïve to IQOS, were recruited from Philadelphia, Pennsylvania, USA. Participants were introduced to IQOS and then completed measures of risk perceptions. Participants were given an IQOS 2.4 holder, charger and HeatSticks, and asked to switch completely from cigarettes to IQOS for 14 days. The effects of risk perceptions on changes in IQOS use, cigarettes per day (CPD), the substitution of IQOS for cigarettes and motivation to quit smoking were evaluated. RESULTS Over the 14-day switch period, CPD significantly decreased (B=-0.18, 95% CI=-0.26 to -0.09, p<0.0001), IQOS use significantly increased (B=0.02, 95% CI=0.00 to 0.03, p=0.042), as did the percentage IQOS HeatSticks that replaced CPD (B=0.02, 95% CI=0.01 to 0.03, p=0.005). Participants who perceived IQOS as less risky than cigarettes used fewer IQOS HeatSticks per day. A lower percentage of IQOS HeatStick substitution for cigarettes was observed for participants with higher versus lower risk perceptions (B=-0.14, 95% CI=-0.28 to -0.01, p=0.042). Motivation to quit increased from a mean of 5.53 to 6.79 on the contemplation ladder from baseline to day 14 (B=1.26, 95% CI=0.54 to 1.97, p<0.001). CONCLUSIONS Smokers reduced their smoking rate and increased motivation to quit smoking while using IQOS. IQOS risk perceptions did not directly account for reductions in smoking, although they may contribute indirectly through increased IQOS use.
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Affiliation(s)
- Teresa DeAtley
- Department of Psychiatry and Tobacco Center of Regulatory Science, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew D Stone
- Department of Psychiatry and Tobacco Center of Regulatory Science, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew A Strasser
- Department of Psychiatry and Tobacco Center of Regulatory Science, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Janet Audrain-McGovern
- Department of Psychiatry and Tobacco Center of Regulatory Science, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Sharma A, Fix B, Hyland A, Bansal-Travers M, Quisenberry A, O’Connor R. Exposure to IQOS ads and reduced exposure claims, and association with perceived risk from COVID-19 on IQOS purchase and use intentions: results from a web-based survey. Front Public Health 2024; 11:1307484. [PMID: 38269390 PMCID: PMC10805831 DOI: 10.3389/fpubh.2023.1307484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
Introduction IQOS was authorized to be marketed as a reduced exposure product by the Food and Drug Administration in October 2020 during the global COVID-19 pandemic. Those who smoke may be more sensitive to reduced exposure marketing claims and may have an increased inclination toward IQOS use. We evaluated the likelihood of trying and purchasing IQOS as a function of exposure to ads, product appeal, and COVID-19 risk perceptions using the original IQOS ads with reduced exposure marketing. Method An online cross-sectional survey recruited 604 US adults (18-45 years), both who smoke and do not smoke. Participants saw one of the six randomly assigned IQOS ads with or without reduced exposure claims, and they answered questions about product appeal and likelihood to try and purchase IQOS. Generalized linear models were used to examine associations. Results A per unit increase in product appeal was associated with a greater likelihood of purchasing (B = 0.17, 95% CI: 0.15-0.18) and trying IQOS (B = 0.16, 95% CI = 0.14-0.18). Current smokers and former e-cigarette users reported greater intentions to try IQOS than never-smokers and never e-cigarette users, respectively. Likelihood to purchase IQOS was associated with greater confidence in not contracting COVID-19 (B = 0.11, 95% CI: 0.01-0.21). No significant differences were observed between different ad conditions. Current (B = -0.34, 95% CI = -0.50-(-0.19)) and former (B = -0.92, 95% CI = -0.15-(-0.68)) cigarette smokers who were someday e-cigarette users reported less intentions to purchase IQOS than never e-cigarette users. However, never smokers who were someday (B = 0.58, 95% CI = 0.27-0.89; B = 0.68, 95% CI = 0.39-0.98) and former e-cigarette (B = 0.38, 95% CI = 0.15-0.61) users reported greater intentions to purchase and try IQOS, respectively. Discussion IQOS may have a higher product appeal, especially for those who currently smoke and those who have lower risk perceptions from COVID-19. Among never smokers, those who currently use or have used e-cigarettes in the past may be more receptive to IQOS marketing. The data are informative for potential trends in the use of IQOS in the future and may have implications for marketing regulations of heated tobacco products (HTPs).
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Affiliation(s)
- Akshika Sharma
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Brian Fix
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Andrew Hyland
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Maansi Bansal-Travers
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Amanda Quisenberry
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Richard O’Connor
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
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DeAtley T, Johnson AC, Stone MD, Audrain-McGovern J, Mercincavage M, Strasser AA. Effects of Modified Tobacco Risk Products with Claims and Nicotine Features on Perceptions among Racial and Ethnic Groups. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6454. [PMID: 37568996 PMCID: PMC10418819 DOI: 10.3390/ijerph20156454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023]
Abstract
Research suggests consumers may misunderstand modified risk tobacco product (MRTP) claims. We examined the effects of nicotine content across four tobacco products with and without MRTP claims among a racially and ethnically diverse sample of adults who do and do not smoke. Adults (n = 1484) aged 21-65 completed an online experiment using a 2 × 2 × 4 mixed factorial design to examine the effects of tobacco product (Classic White Snus, IQOS, JUUL e-cigarette, and VLN cigarette) and nicotine content (high vs. low) stratified by MRTP claim (present vs. absent) across four outcomes: (1) likely to try (2) serious disease if used regularly, (3) least addictive, and (4) ease of quitting smoking. Not including an MRTP claim resulted in an increased likelihood of trying a product, decreased concern of serious disease, lower perceived addictiveness, and increased ease of quitting smoking. Participants selected low nicotine IQOS without a claim as the least likely to cause serious disease. Low nicotine JUUL, without a claim, was selected as least addictive and most likely to facilitate quitting. Intentions to try were highest for low nicotine JUUL. Participants selected low-nicotine products as less addictive than high nicotine products. Regulatory efforts should consider how MRTP claims interact with different product characteristics. Subtle differences exist across outcomes between racial and ethnic groups, which indicates that further research is warranted.
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Affiliation(s)
- Teresa DeAtley
- Department of Psychiatry and Tobacco Center of Regulatory Science, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (A.C.J.); (J.A.-M.); (M.M.); (A.A.S.)
| | - Andrea C. Johnson
- Department of Psychiatry and Tobacco Center of Regulatory Science, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (A.C.J.); (J.A.-M.); (M.M.); (A.A.S.)
| | - Matthew D. Stone
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, CA 92093, USA;
| | - Janet Audrain-McGovern
- Department of Psychiatry and Tobacco Center of Regulatory Science, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (A.C.J.); (J.A.-M.); (M.M.); (A.A.S.)
| | - Melissa Mercincavage
- Department of Psychiatry and Tobacco Center of Regulatory Science, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (A.C.J.); (J.A.-M.); (M.M.); (A.A.S.)
| | - Andrew A. Strasser
- Department of Psychiatry and Tobacco Center of Regulatory Science, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (A.C.J.); (J.A.-M.); (M.M.); (A.A.S.)
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Mays D, Johnson AC, Glasser A, Mercincavage M, Strasser AA. Effects of IQOS health warnings and modified risk claims among young adult cigarette smokers and non-smokers. Tob Control 2023; 32:505-508. [PMID: 34716283 PMCID: PMC9050959 DOI: 10.1136/tobaccocontrol-2021-056810] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/18/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Heated tobacco products, including Marlboro IQOS, are available globally. In the USA, IQOS was authorised to be advertised with claims about reduced toxicant exposure relative to cigarettes. The effects of such modified risk claims and health warnings have not been studied among young adult cigarette smokers and non-smokers. METHODS In 2020, US young adult (18-30 years, n=1328) cigarette smokers and non-smokers viewed an IQOS ad in a 4 (modified risk claim variations or none) by 3 (warning variations or none) between-subjects experiment. Outcome measures assessed perceived credibility and effectiveness of the health or risk message for discouraging IQOS use, perceived harms, efficacy beliefs, and IQOS use intentions. RESULTS Smokers reported significantly higher (p<0.05) perceived credibility, lower perceived effectiveness, higher efficacy beliefs about switching to IQOS and higher intentions to use IQOS than non-smokers. Among smokers, health warnings increased perceived credibility (p<0.001) and effectiveness (p<0.05), but claims did not affect outcomes examined. Among non-smokers, warnings and claims increased perceived credibility, and warnings increased perceived effectiveness (p<0.003). The reduced exposure claim increased non-smokers' intentions to use IQOS (b=0.40, 95% CI 0.07 to 0.73). CONCLUSIONS Among young adult smokers, health warnings increased perceived effectiveness at discouraging IQOS use and perceived credibility. Among non-smokers, warnings and claims increased perceived credibility and warnings increased perceived effectiveness, but the Food and Drug Administration-authorised reduced exposure claim increased intentions to use IQOS. Research is warranted to understand how the content of modified risk claims and health warnings for IQOS affects IQOS use in this population.
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Affiliation(s)
- Darren Mays
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Andrea C Johnson
- Department of Psychiatry and Tobacco Center of Regulatory Science, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Allison Glasser
- College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Melissa Mercincavage
- Department of Psychiatry and Tobacco Center of Regulatory Science, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Andrew A Strasser
- Department of Psychiatry and Tobacco Center of Regulatory Science, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Martín-Álvarez JM, Almeida A, Golpe AA, Asensio E. Electronic device or regulated tobacco product? Learning from the diffusion of heated tobacco products in Spain. Public Health 2023; 219:61-66. [PMID: 37119795 DOI: 10.1016/j.puhe.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 03/17/2023] [Accepted: 03/19/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVES Tobacco companies have introduced heated tobacco product (HTP) in many countries and marketed it on the grounds that it is a less harmful alternative to health. However, tobacco companies have been widely criticized for taking advantage of a loophole that allows electronic devices to circumvent regulations limiting tobacco advertising. This work aims to determine whether HTPs respected the rules that regulate tobacco advertising when it was introduced in Spain. STUDY DESIGN This is an observational epidemiological study. METHODS Using monthly time series data from September 2016 to June 2020, we analyzed whether the adoption of HTPs has followed the same behavior patterns as other brands that were introduced under the same conditions of use. The Bass model is used to analyze the diffusion of HTPs, and 30 other traditional cigarette brands introduced under the same conditions as this HTPs. RESULTS The adoption of HTPs in Spain has been like that of brands of slim cigarettes that are mistakenly considered to be healthier than traditional cigarettes. The results indicate that the use of HTPs has spread in the same way as additive-free and ultra-slim cigarette brands. CONCLUSIONS Policymakers should keep in mind that laws should restrict any marketing of tobacco products that promotes positive connotations between tobacco use and being healthy. If manufacturers are allowed to classify a category and/or brand of tobacco products as less harmful to health, the imitation effect is very high, leading to the proliferation of smoking.
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Affiliation(s)
- J M Martín-Álvarez
- Department of Quantitative Analysis International University of La Rioja Spain
| | - A Almeida
- Department of Quantitative Analysis International University of La Rioja Spain
| | - A A Golpe
- Department of Economics and Centro de Estudios Avanzados en Física, Matemáticas y Computación, University of Huelva, Spain.
| | - E Asensio
- Department of Quantitative Analysis International University of La Rioja Spain
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Mays D, Long L, Alalwan MA, Wagener TL, Shang C, Roberts ME, Patterson JG, Keller-Hamilton B. The Effects of Oral Nicotine Pouch Packaging Features on Adult Tobacco Users' and Non-Users' Product Perceptions. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3383. [PMID: 36834078 PMCID: PMC9965054 DOI: 10.3390/ijerph20043383] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/08/2023] [Accepted: 02/14/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Oral nicotine pouches (ONPs) are novel products that are marketed as "tobacco-free" alternatives to cigarettes and smokeless tobacco (ST). This study examined the effects of ONP packaging features on adult tobacco users' and non-users' product perceptions. MATERIALS AND METHODS Adult tobacco users (cigarettes, ST, and dual cigarette/ST) and non-users (total N = 301) viewed ONP pack images in a 4 × 3 × 2 between-subject experiment testing the effects of the displayed flavor (cool mint, coffee, dark frost, and smooth), nicotine concentration (none displayed on the package, 3 mg, and 6 mg), and addiction warning label (yes or no). The outcomes were perceived substitutability of ONPs for cigarettes and ST and perceived risks. We modeled the effects of tobacco user status and the experimental factors on these outcomes. RESULTS All tobacco user groups perceived ONPs to be significantly less harmful and less addictive than non-users. There were significant effects of nicotine concentration on perceived risks. Compared to packages that did not display nicotine concentration, packages displaying 6 mg nicotine concentration produced significantly lower perceived harm (β = -0.23, 95% CI -0.44, -0.02), perceived addictiveness (β = -0.28, 95% CI -0.51, -0.05), risk appraisals of harm (β = -0.50, 95% CI -0.88, -0.12) and risk appraisals of addictiveness (β = -0.53, 95% CI -0.95, -0.11). CONCLUSIONS The study findings demonstrate that the nicotine concentration displayed on ONP packaging can affect adults' perceptions of ONPs. Further research on the effects of ONP packaging features emphasizing nicotine (e.g., "tobacco free" nicotine claims) on tobacco users and non-users is needed to assess their potential public health impact.
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Affiliation(s)
- Darren Mays
- Department of Internal Medicine, The Ohio State University College of Medicine, Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43214, USA
| | - Lauren Long
- Department of Internal Medicine, The Ohio State University College of Medicine, Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43214, USA
| | - Mahmood A. Alalwan
- Department of Internal Medicine, The Ohio State University College of Medicine, Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43214, USA
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH 43210, USA
| | - Theodore L. Wagener
- Department of Internal Medicine, The Ohio State University College of Medicine, Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43214, USA
| | - Ce Shang
- Department of Internal Medicine, The Ohio State University College of Medicine, Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43214, USA
| | - Megan E. Roberts
- Division of Health Behavior and Health Promotion, College of Public Health, The Ohio State University, Columbus, OH 43210, USA
| | - Joanne G. Patterson
- Division of Health Behavior and Health Promotion, College of Public Health, The Ohio State University, Columbus, OH 43210, USA
| | - Brittney Keller-Hamilton
- Department of Internal Medicine, The Ohio State University College of Medicine, Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43214, USA
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Levine H, Duan Z, Bar-Zeev Y, Abroms LC, Khayat A, Tosakoon S, Romm KF, Wang Y, Berg CJ. IQOS Use and Interest by Sociodemographic and Tobacco Behavior Characteristics among Adults in the US and Israel. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3141. [PMID: 36833831 PMCID: PMC9961058 DOI: 10.3390/ijerph20043141] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 06/18/2023]
Abstract
Heated tobacco products (HTPs) have expanded globally. IQOS, a global HTP leader, was launched in Israel in 2016 and the US in 2019. To inform tobacco control efforts, it is critical to understand who is likely to use HTPs in different countries with distinct regulatory and marketing contexts. Thus, we conducted a cross-sectional survey among adult (ages 18-45) online panelists in the US (n = 1128) and Israel (n = 1094), oversampling tobacco users, in the fall of 2021, and used multivariable regression to identify correlates of (1) ever using IQOS; (2) past-month vs. former among ever users; and (3) interest in trying IQOS among never users. Among US adults, correlates of ever use included being Asian (aOR = 3.30) or Hispanic (aOR = 2.83) vs. White, and past-month use of cigarettes (aOR = 3.32), e-cigarettes (aOR = 2.67), and other tobacco (aOR = 3.34); in Israel, correlates included being younger (aOR = 0.97), male (aOR = 1.64), and cigarette (aOR = 4.01), e-cigarette (aOR = 1.92) and other tobacco use (aOR = 1.63). Among never users, correlates of greater interest included cigarette and e-cigarette use in the US (β = 0.57, β = 0.90) and Israel (β = 0.88, β = 0.92). IQOS use prevalence was low (US: 3.0%; Israel: 16.2%) but represented in vulnerable subpopulations (younger adults, racial/ethnic minorities).
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Affiliation(s)
- Hagai Levine
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem 9112002, Israel
| | - Zongshuan Duan
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
| | - Yael Bar-Zeev
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem 9112002, Israel
| | - Lorien C. Abroms
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
| | - Amal Khayat
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem 9112002, Israel
| | - Sararat Tosakoon
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
| | - Katelyn F. Romm
- TSET Health Promotion Research Center, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Yan Wang
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
| | - Carla J. Berg
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
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Chen-Sankey JC, Kechter A, Barrington-Trimis J, McConnell R, Krueger EA, Cruz TB, Unger JB, Chaffee BW, Leventhal A. Effect of a hypothetical modified risk tobacco product claim on heated tobacco product use intention and perceptions in young adults. Tob Control 2023; 32:42-50. [PMID: 34059552 PMCID: PMC8630081 DOI: 10.1136/tobaccocontrol-2021-056479] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Modified risk tobacco product (MRTP) claims for heated tobacco products (HTPs) that convey reduced exposure compared with conventional cigarettes may promote product initiation and transition among young people. We assessed the effects of a hypothetical MRTP claim for HTPs on young adults' intention and perceptions of using HTPs and whether these effects differed by their current cigarette and e-cigarette use. METHODS We embedded a randomised between-subjects experiment into a web-based survey administered among a cohort of 2354 Southern California young adults (aged 20-23) in 2020. Participants viewed depictions of HTPs with an MRTP claim (n=1190) or no claim (n=1164). HTP use intention and HTP-related harm and use perceptions relative to cigarettes and e-cigarettes were assessed. RESULTS Overall, participants who viewed versus did not view the claim did not differ in HTP use intention (28.5% vs 28.7%) but were more likely to perceive HTPs as less harmful than cigarettes (11.4% vs 7.0%; p<0.001). The experimental effect on HTP use intention did not differ among past 30-day cigarette smokers versus non-smokers (interaction adjusted OR (AOR)=0.78, 95% CI 0.36 to 1.76) but differed among past 30-day e-cigarette users versus non-users (interaction AOR=1.67, 95% CI 1.02 to 2.68). DISCUSSION The hypothetical MRTP claim may lower young adults' HTP harm perceptions compared with cigarettes but may not change HTP use intention overall or differentially for cigarette smokers. The larger effect on HTP use intention among e-cigarette users than non-users raises the question of whether MRTP claims may promote HTP use or HTP and e-cigarette dual use among young e-cigarette users.
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Affiliation(s)
- Julia C Chen-Sankey
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA
| | - Afton Kechter
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jessica Barrington-Trimis
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- Institute for Addiction Science, University of Southern California, Los Angeles, California, USA
| | - Rob McConnell
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Evan A Krueger
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Tess Boley Cruz
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jennifer B Unger
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Benjamin W Chaffee
- Preventive and Restorative Dental Sciences, University of California San Francisco, San Francisco, California, USA
| | - Adam Leventhal
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- Institute for Addiction Science, University of Southern California, Los Angeles, California, USA
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Wang Y, LoParco CR, Cui Y, Duan Z, Bar-Zeev Y, Levine H, Abroms LC, Khayat A, Berg CJ. Profiles of tobacco product use and related consumer characteristics in the US and Israel: A multiple-group latent class analysis. Glob Public Health 2023; 18:2267652. [PMID: 37885277 PMCID: PMC10683865 DOI: 10.1080/17441692.2023.2267652] [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: 06/26/2023] [Accepted: 09/29/2023] [Indexed: 10/28/2023]
Abstract
Despite tobacco marketing diversification, limited research has examined use profiles across countries, particularly in relation to consumer values (e.g. appeal of innovation, conscientiousness). Using 2021 data, latent class analysis assessed past-month use of seven tobacco products (cigarettes, electronic cigarettes [e-cigarettes], heated tobacco products, cigars, hookah, pipe, smokeless) among adults reporting past-month use in the United States (US n = 382) and Israel (n = 561). Multivariable multinomial regression examined consumer values and sociodemographics in relation to country-specific class membership. US classes included: primarily cigarette 58.1%; e-cigarette-no cigarette 17.5%; primarily cigar 14.9%; and poly-product 9.9%. Higher innovation correlated with e-cigarette-no cigarette and poly-product (vs. primarily cigarette) use. Other correlates included being: younger with e-cigarette-no cigarette; male, Black, and more educated with primarily cigar; and Black and Asian (vs. White) with poly-product. Israel classes included: primarily cigarette 39.0%; moderate poly-product 40.3%; high poly-product 13.4%; and hookah 7.3%. Lower conscientiousness correlated with moderate poly-product (vs. primarily cigarette) use; higher innovation correlated with high poly-product; lower innovation correlated with hookah. Other correlates included being: younger, male, and more educated with moderate poly-product; male and sexual minority with high poly-product; and Arab with hookah. Tobacco consumer segments within and across countries likely reflect different consumer values and industry marketing targets.
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Affiliation(s)
- Yan Wang
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
- George Washington Cancer Center, George Washington University, Washington, DC, USA
| | - Cassidy R. LoParco
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Yuxian Cui
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Zongshuan Duan
- Department of Population Health Sciences, School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Yael Bar-Zeev
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
| | - Hagai Levine
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
| | - Lorien C. Abroms
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
- George Washington Cancer Center, George Washington University, Washington, DC, USA
| | - Amal Khayat
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
| | - Carla J. Berg
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
- George Washington Cancer Center, George Washington University, Washington, DC, USA
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12
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Duan Z, Wysota CN, Romm KF, Levine H, Bar-Zeev Y, Choi K, Berg CJ. Correlates of Perceptions, Use, and Intention to Use Heated Tobacco Products Among US Young Adults in 2020. Nicotine Tob Res 2022; 24:1968-1977. [PMID: 35901840 PMCID: PMC9653079 DOI: 10.1093/ntr/ntac185] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 06/09/2022] [Accepted: 07/25/2022] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Despite the increased heated tobacco product (HTP) marketing in the United States, little is known about HTP perceptions and correlates of HTP use and use intentions among young adults. AIMS AND METHODS Using 2020 cross-sectional data from 2,470 young adults (ages 18-34) from 6 US metropolitan areas, we conducted exploratory factor analysis to identify factors regarding perceived utility/appeal of HTPs, specifically IQOS, and examined these factors in relation to lifetime HTP use and use intentions, using multivariable logistic and linear regression, respectively. RESULTS 19.1% had heard of HTPs and 4.1% ever used HTPs; 14.7% had heard of IQOS specifically and 2.8% were ever-users. Use intentions were low (M = 1.27, scale: 1 = not at all to 7 = extremely). Factor analysis identified five perceived utility/appeal factors: innovation (M = 3.17, scale: 1 = not at all to 7 = extremely), cigarette substitute (M = 2.99), and youth appeal (M = 2.82), e-cigarette/nicotine substitute (M = 2.36), and fashionable (M = 2.04). Controlling for sociodemographics and other tobacco use, perceiving IQOS as more fashionable and e-cigarette substitutes positively correlated with lifetime HTP use (aOR = 1.60, 95%CI = 1.17, 2.17; aOR = 1.48, 95%CI = 1.11, 1.97, respectively) and use intentions (β = 0.26, 95%CI = 0.21, 0.30; β = 0.14, 95%CI = 0.09, 0.18); perceiving IQOS as cigarette substitutes negatively correlated with ever use (aOR = 0.74, 95%CI = 0.56, 0.97) and use intentions (β = -0.06, 95%CI = -0.10, -0.03). Correlation patterns were similar among past-month cigarette, e-cigarette, and any-tobacco users. CONCLUSIONS Although HTP awareness and use were low, monitoring HTP perceptions and reasons for use as HTPs become more prominent is critical in anticipating their potential impact, particularly as more products seek FDA authorization to use reduced risk or exposure marketing claims. IMPLICATIONS Awareness, ever use, and intentions to use heated tobacco products (HTPs) were low among US young adults in 2020. Perceiving IQOS as fashionable and an e-cigarette substitute were positively correlated with ever use and intention to use HTPs. In addition, perceiving IQOS as a cigarette substitute was negatively correlated with ever use of HTPs and HTP use intentions. Continued surveillance on perceptions and use behaviors is needed to better understand use patterns, intentions to use, and reasons for using HTPs.
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Affiliation(s)
- Zongshuan Duan
- Corresponding Author: Zongshuan Duan, PhD, Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Science & Engineering Hall, 800 22nd St NW, #7000, Washington, DC 20052, USA. Telephone: 706-572-9100; E-mail:
| | - Christina N Wysota
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Katelyn F Romm
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Hagai Levine
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah Medical Organization, Jerusalem, Israel
| | - Yael Bar-Zeev
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah Medical Organization, Jerusalem, Israel
| | - Kelvin Choi
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, MD, USA
| | - Carla J Berg
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA,George Washington Cancer Center, George Washington University, Washington, DC, USA
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13
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Golpe AA, Martín-Álvarez JM, Galiano A, Asensio E. Effect of IQOS introduction on Philip Morris International cigarette sales in Spain: a Logarithmic Mean Divisa Index decomposition approach. GACETA SANITARIA 2022; 36:293-300. [PMID: 35219532 DOI: 10.1016/j.gaceta.2021.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/22/2021] [Accepted: 12/29/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Philip Morris International, has already introduced its heated tobacco product, IQOS, in many countries and marketed it on the grounds that it is a less harmful alternative to health. The company claims that its intention is for its brand's traditional cigarette smokers to replace these with IQOS has rarely been independently tested. METHOD Using time series data from September 2016 to June 2020, we analyze whether Heets sales have been accompanied by an improvement in the position of Philip Morris International in the market or if they have merely replaced lost sales of the rest of the brands sold by that tobacco company. RESULTS Sales of traditional cigarettes of all the brands marketed by PMI have been replaced by IQOS since the introduction of this heated tobacco product in Spain. Almost all of the variations observed in IQOS sales are due to the positioning of this product as a substitute for the range of traditional cigarettes marketed by Philip Morris International. CONCLUSIONS As there is still no consensus that HTPs are explicitly less harmful to health, health authorities must control messages suggesting improved health outcomes thanks to HTP usage when compared to traditional cigarettes. Such messages could generate a false sense of security and lead to an increase in the consumption of tobacco. In Spain Heets in a category that has a lower tax burden than the category of traditional cigarettes. Tax authorities must consider this migration and the impact this may have on tax collection.
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Affiliation(s)
- Antonio A Golpe
- Department of Economics, University of Huelva, Huelva, Spain
| | - Juan M Martín-Álvarez
- Quantitative Methods for Economics and Business, Universidad Internacional de La Rioja, Logroño, Spain.
| | - Aida Galiano
- Quantitative Methods for Economics and Business, Universidad Internacional de La Rioja, Logroño, Spain
| | - Eva Asensio
- Quantitative Methods for Economics and Business, Universidad Internacional de La Rioja, Logroño, Spain
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14
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Berg CJ, Romm KF, Patterson B, Wysota CN. Heated tobacco product awareness, use, and perceptions in a sample of young adults in the U.S. Nicotine Tob Res 2021; 23:1967-1971. [PMID: 33822111 DOI: 10.1093/ntr/ntab058] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/31/2021] [Indexed: 11/12/2022]
Abstract
SIGNIFICANCE The emergence of heated tobacco products (HTPs) in the US marks a critical time for identifying those most likely to use, particularly among young adults. METHODS We analyzed Fall 2019 data from a longitudinal study of young adults (ages 18-34; n=2,375, Mage=24.66±4.68) in 6 US cities, 24.1% of whom used cigarettes and 32.7% e-cigarettes. We assessed HTP awareness, use, and sources, as well as perceived risk, social acceptability, and likelihood of future use. RESULTS In this sample, 9.7% (n=230) heard of HTPs, 3.5% (n=84) ever used them, and 2.4% (n=56) reported past-year purchases (tobacco shops, 66.1%; traditional retailers, 60.7%; online, 39.3%; IQOS specialty stores, 35.7%). In multivariable analyses, having heard of HTPs correlated with being older, male, and current cigarette and e-cigarette users; among those ever hearing of them, using HTPs correlated with being non-Hispanic and current cigarette and e-cigarette users. Greater likelihood of future use correlated with being older, male, sexual minority, non-Hispanic, and current cigarette and e-cigarette users. Among past-month users (n=78), the average number of days used was 5.48 (SD=5.54). Past-month cigarette and e-cigarette users, respectively, who tried HTPs were more likely to report consistent or more frequent use of their respective product than a year ago (p's<.001). HTPs were perceived as less addictive than cigarettes, smokeless tobacco, and e-cigarettes, and less harmful and more socially acceptable than other tobacco products except e-cigarettes and hookah. CONCLUSIONS The relatively positive perceptions of HTPs and access via various channels underscores potential penetration of HTPs among US young adults.
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Affiliation(s)
- Carla J Berg
- Department of Prevention and Community Health, Milken Institute School of Public Health, Washington, DC, USA
- George Washington Cancer Center, George Washington University, Washington, DC, USA
| | - Katelyn F Romm
- Department of Prevention and Community Health, Milken Institute School of Public Health, Washington, DC, USA
| | - Brooke Patterson
- Department of Global Health, Milken Institute School of Public Health, Washington, DC, USA
| | - Christina N Wysota
- Department of Prevention and Community Health, Milken Institute School of Public Health, Washington, DC, USA
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15
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Kim M, Watkins SL, Koester KA, Mock J, Kim HC, Olson S, Harvanko AM, Ling PM. Unboxed: US Young Adult Tobacco Users' Responses to a New Heated Tobacco Product. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8108. [PMID: 33153143 PMCID: PMC7662359 DOI: 10.3390/ijerph17218108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 12/28/2022]
Abstract
The heated tobacco product (HTP) IQOS was authorized for sale in the US in 2019. We investigated how young adults with experience using multiple tobacco products reacted to, perceived, and developed interest in IQOS, informing policies that might prevent HTPs from becoming ubiquitous. We used a novel qualitative method in which 33 young adult tobacco users in California (fall 2019) "unboxed" an IQOS device, tobacco sticks, and marketing materials and narrated their impressions and opinions. We conducted content and thematic analyses of participants' reactions, sensory experiences, and interest. Multiple attributes influenced appeal for participants, including sleek electronic design, novel technology, perceived harmfulness, complexity, and high cost. The "no smoke" claim and heating technology suggested that smoking IQOS was safer than smoking cigarettes. Public health programs should closely monitor HTP marketing and uptake, particularly as "reduced exposure" claims were authorized in July 2020. Evidence-based regulations (e.g., requiring plain packaging for tobacco sticks), actions addressing IQOS' unique attributes (e.g., regulating device packaging to reduce high-tech appeal), and public education might help to counter the appeal generated by potentially misleading IQOS marketing tactics.
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Affiliation(s)
- Minji Kim
- Center for Tobacco Control Research and Education, University of California, San Francisco, CA 94143, USA; (M.K.); (A.M.H.); (P.M.L.)
| | - Shannon Lea Watkins
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA 52242, USA
| | - Kimberly A. Koester
- Department of Medicine, University of California, San Francisco, CA 94143, USA; (K.A.K.); (H.C.K.); (S.O.)
| | - Jeremiah Mock
- Department of Social and Behavioral Sciences, Institute for Health & Aging, University of California, San Francisco, CA 94143, USA;
| | - Hyunjin Cindy Kim
- Department of Medicine, University of California, San Francisco, CA 94143, USA; (K.A.K.); (H.C.K.); (S.O.)
| | - Sarah Olson
- Department of Medicine, University of California, San Francisco, CA 94143, USA; (K.A.K.); (H.C.K.); (S.O.)
| | - Arit Michael Harvanko
- Center for Tobacco Control Research and Education, University of California, San Francisco, CA 94143, USA; (M.K.); (A.M.H.); (P.M.L.)
| | - Pamela M. Ling
- Center for Tobacco Control Research and Education, University of California, San Francisco, CA 94143, USA; (M.K.); (A.M.H.); (P.M.L.)
- Department of Medicine, University of California, San Francisco, CA 94143, USA; (K.A.K.); (H.C.K.); (S.O.)
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