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Foxon F, Selya A, Gitchell J, Shiffman S. Increased e-cigarette use prevalence is associated with decreased smoking prevalence among US adults. Harm Reduct J 2024; 21:136. [PMID: 39026245 PMCID: PMC11256395 DOI: 10.1186/s12954-024-01056-0] [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: 01/05/2024] [Accepted: 07/09/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND If US adults who smoke cigarettes are switching to e-cigarettes, the effect may be observable at the population level: smoking prevalence should decline as e-cigarette prevalence increases, especially in sub-populations with highest e-cigarette use. This study aimed to assess such effects in recent nationally-representative data. METHODS We updated a prior analysis with the latest available National Health Interview Survey data through 2022. Data were cross-sectional estimates of the yearly prevalence of smoking and e-cigarette use, respectively, among US adults and among specific age, race/ethnicity, and sex subpopulations. Non-linear models were fitted to observed smoking prevalence in the pre-e-cigarette era, with a range of 'cut-off' years explored (i.e., between when e-cigarettes were first introduced to when they became widely available). These trends were projected forward to predict what smoking prevalence would have been if pre-e-cigarette era trends had continued uninterrupted. The difference between actual and predicted smoking prevalence ('discrepancy') was compared to e-cigarette use prevalence in each year in the e-cigarette era to investigate whether the observed decline in smoking was statistically associated with e-cigarette use. RESULTS Observed smoking prevalence in the e-cigarette era was significantly lower than expected based on pre-e-cigarette era trends; these discrepancies in smoking prevalence grew as e-cigarette use prevalence increased, and were larger in subpopulations with higher e-cigarette use, especially younger adults aged 18-34. Results were robust to sensitivity tests varying the analysis design. CONCLUSIONS Population-level data continue to suggest that smoking prevalence has declined at an accelerated rate in the last decade in ways correlated with increased uptake of e-cigarette use.
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Affiliation(s)
- Floe Foxon
- Pinney Associates, Inc, 201 North Craig Street, Suite 320, Pittsburgh, PA, 15213, USA.
| | - Arielle Selya
- Pinney Associates, Inc, 201 North Craig Street, Suite 320, Pittsburgh, PA, 15213, USA
| | - Joe Gitchell
- Pinney Associates, Inc, 201 North Craig Street, Suite 320, Pittsburgh, PA, 15213, USA
| | - Saul Shiffman
- Pinney Associates, Inc, 201 North Craig Street, Suite 320, Pittsburgh, PA, 15213, USA
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2
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Selya A, Ruggieri M, Polosa R. Measures of youth e-cigarette use: strengths, weaknesses and recommendations. Front Public Health 2024; 12:1412406. [PMID: 39015391 PMCID: PMC11250581 DOI: 10.3389/fpubh.2024.1412406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/31/2024] [Indexed: 07/18/2024] Open
Abstract
This perspective discusses how to best define "e-cigarette use" among youth in a way that is relevant to individual and human health. Commonly-used definitions of youth e-cigarette use have been adapted from measures validated for tobacco cigarette smoking among adults, but may not carry the same meaning for a different product (with a much lower risk profile and very different patterns of use) and a different population (whose use is more often transient and experimental, rather than frequent and persistent). We discuss strengths and weaknesses of different definitions, and recommend improvements in defining youth e-cigarette use. We find that current literature employs a range of definitions of e-cigarette use, from lifetime use ("even a puff") to daily use. More lenient measures capture more potentially at-risk youth, but much of this is transient experimentation that has negligible risks in and itself, if not persistent. More stringent measures such as daily use are more relevant to individual and public health. Future research should examine possible improvements to definitions which include intensity of use (e.g., number of puffs per day) and persistence/duration of use, either via self-report or technology-assisted data capture.
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Affiliation(s)
- Arielle Selya
- PinneyAssociates, Inc., Pittsburgh, PA, United States
| | - Martino Ruggieri
- Center of Excellence for the Acceleration of Harm Reduction (CoEHAR), University of Catania, Catania, Italy
- Unit of Pediatric Clinic, AOU “Policlinico”, PO “G. Rodolico”, Department of Clinical & Experimental Medicine, University of Catania, Catania, Italy
| | - Riccardo Polosa
- Unit of Pediatric Clinic, AOU “Policlinico”, PO “G. Rodolico”, Department of Clinical & Experimental Medicine, University of Catania, Catania, Italy
- Department of Clinical & Experimental Medicine, University of Catania, Catania, Italy
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3
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Levy DT, Issabakhsh M, Warner KE, Liber A, Meza R, Cummings M. Evaluating trends in cigarette and HTP use in Japan and measurement issues in the National Health and Nutrition Survey. Tob Control 2024:tc-2023-058526. [PMID: 38906697 DOI: 10.1136/tc-2023-058526] [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: 11/26/2023] [Accepted: 06/11/2024] [Indexed: 06/23/2024]
Abstract
INTRODUTION Studies have reported that the rapid rise in heated tobacco product (HTP) sales in Japan accompanied an accelerated decline in cigarette sales. However, these studies do not distinguish whether those who previously smoked cigarettes became dual users with HTPs (smoking fewer cigarettes) or instead switched completely to HTPs. If HTPs present lower health risks than cigarettes, replacing cigarettes with HTPs is more likely to improve public health than cigarette users continuing as dual users. METHODS To evaluate the role of HTP introduction relative to smoking prevalence, we examine trends in cigarette prevalence as related to trends in HTP use using Japan's National Health and Nutrition Survey (NHNS) from 2011 to 2019. We develop measures of relative changes in smoking prevalence use by age and gender in the pre-HTP and post-HTP periods. We then analyse prevalence data by year using joinpoint regression to statistically distinguish changes in trend. RESULTS Compared with the pre-HTP 2011-2014 period, cigarette prevalence decreased more rapidly during the post-HTP 2014-2017 period, particularly among younger age groups. However, the changing format of NHNS questions limits our ability to determine the impact on smoking prevalence, particularly after 2017. CONCLUSIONS While suggesting that HTPs helped some people who smoke to quit smoking, this study also shows the difficulties in eliciting accurate survey responses about product use and distinguishing the impact of a potentially harm-reducing product in an environment subject to rapidly evolving patterns of use.
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Affiliation(s)
- David T Levy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
| | - Mona Issabakhsh
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
| | - Kenneth E Warner
- School of Public Health, University of Michigan-Ann Arbor, Ann Arbor, Michigan, USA
| | - Alex Liber
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
- Research Triangle Institute, Research Triangle Park, North Carolina, USA
| | - Rafael Meza
- Department of Integrative Oncology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Michael Cummings
- Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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4
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Jit M, Cook AR. Informing Public Health Policies with Models for Disease Burden, Impact Evaluation, and Economic Evaluation. Annu Rev Public Health 2024; 45:133-150. [PMID: 37871140 DOI: 10.1146/annurev-publhealth-060222-025149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Conducting real-world public health experiments is often costly, time-consuming, and ethically challenging, so mathematical models have a long-standing history of being used to inform policy. Applications include estimating disease burden, performing economic evaluation of interventions, and responding to health emergencies such as pandemics. Models played a pivotal role during the COVID-19 pandemic, providing early detection of SARS-CoV-2's pandemic potential and informing subsequent public health measures. While models offer valuable policy insights, they often carry limitations, especially when they depend on assumptions and incomplete data. Striking a balance between accuracy and timely decision-making in rapidly evolving situations such as disease outbreaks is challenging. Modelers need to explore the extent to which their models deviate from representing the real world. The uncertainties inherent in models must be effectively communicated to policy makers and the public. As the field becomes increasingly influential, it needs to develop reporting standards that enable rigorous external scrutiny.
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Affiliation(s)
- Mark Jit
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom;
| | - Alex R Cook
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- National University Health System, Singapore
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5
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Valadez-Cuen K, Bhatt T, Mendez IE, Solanki D, Abdi N, Shelar V, Akplor JJ, Reddy Bhumanapalli SA, Vinyak S, Patel D, Tirupathi R, Shah V, Patel UK, Rana RK. E-cigarette Use and Severe Coronavirus Disease 2019 (COVID-19) Outcomes: A Meta-Analysis. Cureus 2024; 16:e59591. [PMID: 38832202 PMCID: PMC11144579 DOI: 10.7759/cureus.59591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/03/2024] [Indexed: 06/05/2024] Open
Abstract
E-cigarettes have been known to cause varied poor health outcomes prior to coronavirus disease 2019 (COVID-19), but after the impact of COVID-19, evidence came out that was, in some instances, not as expected regarding the severity of COVID-19 among e-cigarette users (vapers). A meta-analysis was performed on the available evidence to comprehensively find the effect of COVID-19 on existing or past e-cigarette users (vapers). The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were used to perform this meta-analysis. PubMed was searched for observational studies that described outcomes after COVID-19 positivity from December 1, 2019, to December 2023. Medical Subject Headings (MeSH) keywords were used for searching the relevant studies highlighting the relationship between COVID-19 and e-cigarette users. Calculations for pooled prevalence, 95% confidence interval (95% CI), weights for current e-cigarette users and vapers, and outcomes (events) were made. To analyze the data, Review Manager V.5.4 was used. The I² statistic was used to assess statistical heterogeneity. The I² statistic of >50% was considered significant heterogeneity. The "leave-one-out" method was used for sensitivity analysis. Out of 3231 studies, four studies reported data on vaping and non-vaping status and composite outcomes, resulting in a sample size of 653 COVID-19-positive cases. The pooled prevalence of being COVID-19 positive, having symptoms, or visiting an emergency room was 7.78% (653/8392). COVID-19 patients with current vaping status had decreased odds of poor outcomes compared to non-smokers, with a pooled odds ratio (OR) of 0.09 (95% CI 0.00-2.42; p>0.05) with heterogeneity between studies (I²=99%, p=0.15). Because of difficulties related to data collection and other factors, this meta-analysis was unable to conclusively establish the correlation between e-cigarette usage and severe COVID-19 outcomes such as hospitalization, admission to the intensive care unit, and fatality. Additional research using more detailed data is necessary to fully understand this correlation.
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Affiliation(s)
- Karen Valadez-Cuen
- Department of Internal Medicine, Las Palmas Del Sol Healthcare, El Paso, USA
| | - Tulsi Bhatt
- Department of Internal Medicine, Pramukhswami Medical College, Karamsad, IND
| | - Ileana E Mendez
- Department of Medical Sciences, Universidad Autónoma de Centro América (UACA), San José, CRI
| | - Dhanshree Solanki
- Department of Hospital Administration, Rutgers University, New Brunswick, USA
| | - Nawal Abdi
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Vrushali Shelar
- Department of Internal Medicine, Saratov State Medical University, Saratov, RUS
| | - Jerry J Akplor
- Faculty of Medicine, Hebei North University, Zhangjiakou, CHN
| | - Sai Akhila Reddy Bhumanapalli
- Department of Internal Medicine, State University of New York (SUNY) Downstate Health Sciences University, School of Public Health (SPH), New York, USA
| | - Suprada Vinyak
- Department of Internal Medicine, Wellmont/Norton Community Hospital (NCH), Norton, USA
| | - Digantkumar Patel
- Department of Medicine, Springfield Memorial Hospital, Springfield, USA
| | | | - Viray Shah
- Department of Hospital Medicine, MedStar Good Samaritan Hospital, Baltimore, USA
| | - Urvish K Patel
- Department of Public Health and Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Rishabh K Rana
- Department of Preventive and Social Medicine/Community Medicine, Shaheed Nirmal Mahto Medical College and Hospital (Erstwhile Patliputra Medical College), Dhanbad, IND
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Rubenstein D, Carroll DM, Denlinger-Apte RL, Cornacchione Ross J, McClernon FJ. Differences in Normative Beliefs and Tobacco Product Use by Age Among Adults Who Smoke: Cross-Sectional Analysis of a Nationally Representative Sample. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:54-64. [PMID: 38258860 DOI: 10.1177/29767342231210554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND The prevalence of combusted cigarette (CC) smoking among older adults is stagnant, with 0 declines attributable to e-cigarette (EC) use. Given that normative beliefs are associated with quitting and switching to ECs, we assessed cross-sectional associations between age, CC, and EC descriptive and injunctive norms and potential interactions with tobacco use behavior. METHODS Data are from people with current, established (≥100 lifetime CCs) CC use (n = 8072) at Wave 5 (2018-2019) of the adult Population Assessment of Tobacco and Health Study. We used adjusted multivariable logistic regressions to model social norms as a function of age (18-24, 25-34, 35-44, 45-54, 55-64, ≥65 years). We also dichotomized age (≥55 vs 18-54) to investigate interactions between age and social norms on past 12-month CC quit attempts and past-month EC use. RESULTS Older age was positively associated with pro- and anti-CC norms and anti-EC norms. Significant interactive effects revealed that being advised to quit smoking by a healthcare provider was more strongly associated with CC quit attempts among adults ≥55 years (adjusted odds ratio [aOR] [95% CI]: 2.12 [1.66, 2.71]) than adults <55 years (aOR: 1.63 [1.34, 2.00]). Reporting people close to you use ECs was also more strongly associated with EC use among adults ≥55 years (aOR: 4.37 [3.35, 5.69]) than among adults <55 years (aOR: 3.43 [2.89, 4.08]). CONCLUSIONS This study identified modifiable risk factors for tobacco use that may be particularly beneficial for older adults. Behavioral and communication interventions that target normative beliefs may maximize smoking cessation, or harm reduction when cessation is not possible.
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Affiliation(s)
- Dana Rubenstein
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- Clinical and Translational Science Institute, Duke University School of Medicine, Durham, NC, USA
| | - Dana M Carroll
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Rachel L Denlinger-Apte
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jennifer Cornacchione Ross
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - F Joseph McClernon
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- Clinical and Translational Science Institute, Duke University School of Medicine, Durham, NC, USA
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7
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Levy DT, Cadham CJ, Yuan Z, Li Y, Gravely S, Cummings KM. Comparison of smoking prevalence in Canada before and after nicotine vaping product access using the SimSmoke model. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2023; 114:992-1005. [PMID: 37540451 PMCID: PMC10661672 DOI: 10.17269/s41997-023-00792-3] [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: 01/05/2023] [Accepted: 05/29/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES The public health impact of nicotine vaping products (NVPs) is subject to complex transitions between NVP and cigarette use. To circumvent the data limitations and parameter instability challenges in modeling transitions, we indirectly estimate NVPs' impact on smoking prevalence and resulting smoking-attributable deaths using the SimSmoke simulation model. METHODS Canada SimSmoke uses age- and sex-specific data on Canadian population, smoking prevalence and tobacco control policies. The model incorporates the impact of cigarette-oriented policies on smoking prevalence but not the explicit contribution of NVPs. The model was calibrated from 1999 to 2012, thereby projecting smoking prevalence before NVPs were widely used in Canada. The NVP impact on smoking prevalence is inferred by comparing projected 2012-2020 smoking trends absent NVPs to corresponding trends from two Canadian national surveys. We further distinguish impacts before and after NVPs became regulated in 2018 and more available. RESULTS Comparing 2012-2020 survey data of post-NVP to SimSmoke projected smoking prevalence trends, one survey indicated an NVP-related relative reduction of 15% (15%) for males (females) age 15+, but 32% (52%) for those ages 15-24. The other survey indicated a 14% (19%) NVP-related smoking reduction for ages 18+, but 42% (53%) for persons ages 18-24. Much of the gain occurred since Canada relaxed NVP restrictions. NVP-related 2012-2020 smoking reductions yielded 100,000 smoking-attributable deaths averted from 2012 to 2060. CONCLUSION Smoking prevalence in Canada, especially among younger adults, declined more rapidly once NVPs became readily available. The emergence of NVPs into the Canadian marketplace has not slowed the decline in smoking.
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Affiliation(s)
- David T Levy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA.
| | - Christopher J Cadham
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Zhe Yuan
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Yameng Li
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Shannon Gravely
- Department of Psychology, University of Waterloo, Waterloo, ON, Canada
| | - K Michael Cummings
- Department of Psychiatry & Behavioral Science, Medical University of South Carolina, Charleston, SC, USA
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Levy DT, Thirlway F, Sweanor D, Liber A, Maria Sanchez-Romero L, Meza R, Douglas CE, Michael Cummings K. Do Tobacco Companies Have an Incentive to Promote "Harm Reduction" Products?: The Role of Competition. Nicotine Tob Res 2023; 25:1810-1821. [PMID: 36692328 PMCID: PMC10664083 DOI: 10.1093/ntr/ntad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 12/19/2022] [Accepted: 01/23/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Some cigarette companies have started to talk about replacing cigarettes with less harmful alternatives, which might include nicotine vaping products (NVPs), heated tobacco products (HTPs), and oral nicotine delivery products. We consider market competition as a primary driver of whether cigarette companies follow through on their stated intentions. AIMS AND METHODS We focus on the behavior of cigarette companies in the United States. We compare competition in the pre- and post-2012 time periods, analyze the impact of the growth in NVPs on smoking prevalence and cigarette company profits, and examine the potential future role of competition. RESULTS Since 2006, consumers have broadened their use of non-combustible nicotine delivery products (NCNDPs) to include, inter alia, NVPs, HTPs, and oral nicotine pouches. U.S. cigarette companies have acquired major stakes in each of these product categories which corresponds to a period of rapidly declining adult smoking prevalence, especially among younger adults (ages 18-24 years). The shifting dynamics of the nicotine product marketplace are also reflected in cigarette company stock prices. While cigarette companies are likely to promote HTPs and nicotine delivery products over NVPs, their incentives will be directly related to competition from independent firms, which in turn will depend on government regulation. CONCLUSIONS Although cigarette companies will back alternatives to combusted tobacco when threatened by competition, the prospects for their lasting conversion to NCNDPs will depend on the extent of such competition, which will be influenced by government regulation of tobacco products. IMPLICATIONS Regulations that limit competition from independent firms while also protecting cigarette company profits risk slowing or even reversing recent declines in smoking, especially among youth and young adults. Regulations that reduce the appeal and addictiveness of combusted tobacco products, such as higher cigarette taxes or a reduced nicotine standard, will encourage smokers to quit and/or switch to less harmful non-combusted forms of tobacco. The regulation of non-combustible nicotine delivery products and cigarettes should be proportionate to their relative risks, so that smokers have incentives to switch from combustibles to safer alternatives, and cigarette companies have incentives to promote safer products.
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Affiliation(s)
- David T Levy
- Oncology Department, Lombardi Comprehensive Center, Georgetown University, Washington, DC, USA
| | | | - David Sweanor
- Centre for Health Law, Policy and Ethics, University of Ottawa, Ottawa, Ontario, Canada
| | - Alex Liber
- Oncology Department, Lombardi Comprehensive Center, Georgetown University, Washington, DC, USA
| | | | - Rafael Meza
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Clifford E Douglas
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - K Michael Cummings
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charlestown, SC, USA
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Levy DT, Warner KE, Liber AC, Travis N, Sweanor DT, Meza R, Cummings KM. Potential Implications for Tobacco Industry Transformation of the Acquisition of Swedish Match by Philip Morris International. Nicotine Tob Res 2023; 25:1899-1903. [PMID: 37535864 PMCID: PMC10664079 DOI: 10.1093/ntr/ntad138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 06/25/2023] [Accepted: 08/02/2023] [Indexed: 08/05/2023]
Abstract
Philip Morris International's recent purchase of Swedish Match may prove to be a vital tobacco industry development. We focus on PMIs potential progress in moving from primarily selling cigarettes toward primarily selling noncombustible nicotine delivery products (NCNDPs). We also consider the potential contribution of the acquisition to industry transformation whereby other cigarette firms may potentially move toward primarily selling NCNDPs. We examine the potential impact on noncombustible nicotine delivery product use, including nicotine pouches (a major Swedish Match product), e-cigarettes, heated tobacco products, and, most importantly, on sales of the industry's staple, combustible cigarettes. We focus on the United States as a special case, where PMI is limited from entering the cigarette market. Implications: Philip Morris International's purchase of Swedish Match and policies regarding nicotine pouches (NPs) have been overlooked in the tobacco control literature. The acquisition indicates the importance of the NP market to the largest nonstate-owned tobacco company. The acquisition has the potential through pricing and marketing tactics to either encourage or discourage the use of NPs, e-cigarettes, heated tobacco products, and most importantly cigarettes. Due to its inability to sell cigarettes in the United States, PMI will have incentives to use its alternative nicotine delivery products, including its newly acquired NPs, to reduce the sale of cigarettes by other companies. However, the potential effects in other countries, where PMI does sell cigarettes, are less clear. Monitoring and analyzing tobacco company acquisitions is essential to studying future transitions in using different kinds of tobacco products, especially from cigarettes to lower-risk alternative nicotine delivery products.
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Affiliation(s)
- David T Levy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Kenneth E Warner
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Alex C Liber
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Nargiz Travis
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - David T Sweanor
- Centre for Health Law, Policy & Ethics, University of Ottawa, Ottawa, Canada
| | - Rafael Meza
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, Canada
| | - K Michael Cummings
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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Kim H, Park S, Kang H, Kang N, Levy DT, Cho SI. Modeling the future of tobacco control: Using SimSmoke to explore the feasibility of the tobacco endgame in Korea. Tob Induc Dis 2023; 21:147. [PMID: 37954490 PMCID: PMC10632939 DOI: 10.18332/tid/174127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/11/2023] [Accepted: 10/14/2023] [Indexed: 11/14/2023] Open
Abstract
INTRODUCTION We used a simulation model to assess the feasibility of reaching the tobacco endgame target (reducing the smoking prevalence to below 5% by 2050) and explored potential implementation strategies. METHODS The impact of strengthened tobacco-control policies on smoking prevalence was analyzed using Korea SimSmoke, a discrete-time Markov process. We considered the effects of various scenarios from 2023 and predictions were conducted until 2050. To confirm the stability of the results, deterministic and probabilistic sensitivity analyses were carried out by increasing and decreasing parameter estimates. RESULTS The implementation of tobacco-control policies in accordance with the WHO MPOWER (Μonitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco smoking; Warn of the dangers of tobacco; Enforce bans on tobacco advertising, promotion, and sponsorship; Raise taxes on tobacco) measures were insufficient to achieve the tobacco endgame objective of 5% by 2050. The overall predicted smoking prevalence in 2050 is 4.7% if all policies are fully implemented in accordance with the FCTC guidelines together with a complete ban on the sale of cigarettes to people born after 2003 and annual 10% increases in price. Sensitivity analyses using the varying policy effect assumptions demonstrated the robustness of the simulation results. CONCLUSIONS For a substantive reduction in smoking prevalence, it is essential to strongly implement the MPOWER strategy. Beyond this foundational step, the eradication of smoking requires a paradigm shift in the perception of conventional tobacco-control policies, including a tobacco-free generation strategy and radical increases in the price of tobacco products.
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Affiliation(s)
- Hana Kim
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Susan Park
- Institute of Health and Environment, Seoul National University, Seoul, Republic of Korea
| | - Heewon Kang
- Institute of Health and Environment, Seoul National University, Seoul, Republic of Korea
| | - Naeun Kang
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - David T. Levy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, United States
| | - Sung-il Cho
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
- Institute of Health and Environment, Seoul National University, Seoul, Republic of Korea
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11
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Pesola F, Phillips-Waller A, Beard E, Shahab L, Sweanor D, Jarvis M, Hajek P. Effects of reduced-risk nicotine-delivery products on smoking prevalence and cigarette sales: an observational study. PUBLIC HEALTH RESEARCH 2023; 11:1-39. [PMID: 37795840 DOI: 10.3310/rpdn7327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
Background It is not currently clear what impact alternative nicotine-delivery products (electronic cigarettes, heated tobacco products and snus) have on smoking rates and cigarette sales. Objective To assess whether access to these products promotes smoking in the population. Design and data sources We examined associations of alternative nicotine product use and sales with smoking rates and cigarette sales overall, and in different age and socioeconomic groups, and compared smoking prevalence over time in countries with contrasting regulations of these products. For electronic cigarettes, we examined data from countries with historically similar smoking trajectories but differing current electronic cigarette regulations (United Kingdom and United States of America vs. Australia, where sales of nicotine-containing electronic cigarettes are banned); for heated tobacco, we used data from countries with state tobacco monopolies, where cigarette and heated tobacco sales data are available (Japan, South Korea), and for snus we used data from Sweden. Analysis methods We pre-specified dynamic time series analyses to explore associations between use and sales of alternative nicotine-delivery products and smoking prevalence and cigarette sales, and time series analyses to compare trends of smoking prevalence in countries with different nicotine product policies. Results Because of data and analysis limitations (see below), results are only tentative and need to be interpreted with caution. Only a few findings reached statistical significance and for most results the Bayes factor indicated inconclusive evidence. We did not find an association between rates of smoking and rates of the use of alternative nicotine products. The increase in heated tobacco product sales in Japan was accompanied by a decrease in cigarette sales. The decline in smoking prevalence seems to have been slower in Australia than in the United Kingdom overall, and slower than in both the United Kingdom and the United States of America among young people and also in lower socioeconomic groups. The decline in cigarette sales has also accelerated faster in the United Kingdom than in Australia. Limitations Most of the available data had insufficient data points for robust time series analyses. The assumption of our statistical approach that causal interactions are more likely to be detected when longer-term changes are screened out may not apply for short time series and in product interaction scenarios, where short-term fluctuations can be caused by, for example, fluctuations in prosperity or product supplies. In addition, due to dual use, prevalence figures for smoking and alternative product use overlap. The ecological study design limits the causal inferences that can be made. Longer time periods are needed for any effects of exclusive use of the new products on smoking prevalence to emerge. Conclusions We detected some indications that alternative nicotine products are competing with cigarettes rather than promoting smoking and that regulations that allow their sales are associated with a reduction rather than an increase of smoking, but the findings are inconclusive because of insufficient data points and issues with the assumptions of the pre-specified statistical analyses. Future work As further prevalence and sales data emerge the analyses will become more informative. Accessing sales figures in particular is the current research priority. Study registration The project is registered on Open Science Framework https://osf.io/bd3ah. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR129968) and will be published in full in Public Health Research; Vol. 11, No. 7. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Francesca Pesola
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Anna Phillips-Waller
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Emma Beard
- University College London, Tobacco and Alcohol Research Group, Department of Behavioural Science and Health, London, UK
| | - Lion Shahab
- University College London, Tobacco and Alcohol Research Group, Department of Behavioural Science and Health, London, UK
| | - David Sweanor
- Faculty of Law and Centre for Health Law, Policy and Ethics, University of Ottawa, Ottawa, Canada
| | - Martin Jarvis
- University College London, Tobacco and Alcohol Research Group, Department of Behavioural Science and Health, London, UK
| | - Peter Hajek
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Levy DT, Liber AC, Cadham C, Sanchez-Romero LM, Hyland A, Cummings M, Douglas C, Meza R, Henriksen L. Follow the money: a closer look at US tobacco industry marketing expenditures. Tob Control 2023; 32:575-582. [PMID: 35074930 PMCID: PMC9346571 DOI: 10.1136/tobaccocontrol-2021-056971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 12/12/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION While much of the concern with tobacco industry marketing has focused on direct media advertising, a less explored form of marketing strategy is to discount prices. Price discounting is important because it keeps the purchase price low and can undermine the impact of tax increases. METHODS We examine annual US marketing expenditures from 1975 to 2019 by the largest cigarette and smokeless tobacco companies as reported to the Federal Trade Commission. We consider three categories: direct advertising, promotional allowances and price discounting. In addition to considering trends in these expenditures, we examine how price discounting expenditures relate to changes in product prices and excise taxes. RESULTS US direct advertising expenditures for cigarettes fell from 80% of total industry marketing expenditures in 1975 to less than 3% in 2019, while falling from 39% in 1985 to 6% in 2019 for smokeless tobacco. Price discounting expenditures for cigarettes became prominent after the Master Settlement Agreement and related tax increases in 2002. By 2019, 87% of cigarette marketing expenditures were for price discounts and 7% for promotional allowances. Smokeless marketing expenditures were similar: 72% for price promotions and 13% for promotional allowances. Price discounting increased with prices and taxes until reaching their currently high levels. CONCLUSIONS Between 1975 and 2019, direct advertising dramatically fell while price discounting and promotional expenditures increased. Local, state and federal policies are needed that apply non-tax mechanisms to increase tobacco prices and restrict industry contracts to offset industry marketing strategies. Further study is needed to better understand industry decisions about marketing expenditures.
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Affiliation(s)
- David T Levy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Alex C Liber
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Christopher Cadham
- Department of Health Management and Policy, University of Michigan School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Andrew Hyland
- Health Behavior, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Michael Cummings
- Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Cliff Douglas
- Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Rafael Meza
- Epidemiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa Henriksen
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA
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He Y, Ma S, Yang Q, Shang C. How cigarette excise tax pass-through to prices responds to the uptake and evolution of e-cigarettes (ECs). Tob Control 2023:tc-2023-058078. [PMID: 37640531 PMCID: PMC10915895 DOI: 10.1136/tc-2023-058078] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/13/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND How excise taxes are passed through to prices determines whether tax policies will be effective in changing smoking behaviours. Though previous literature has documented that cigarette taxes are overly shifted to prices, there is limited evidence on how cigarette tax pass-through to prices is affected by the uptake and evolution of e-cigarettes (ECs) in the US market. OBJECTIVE This study investigates how cigarette excise tax pass-through rate varied by price levels (the 25th, 50th, and 75th percentile prices) and the uptake and evolution of ECs. METHODS Tax pass-through rates were assessed using ordinary least squares regressions while controlling for state, year and month fixed effects. Different trends were then tested for the pre-EC uptake era (2006-2011), EC uptake era (2012-2016) and the evolution of nicotine salt-based ECs era (2017 and later). FINDINGS Cigarette excise taxes were fully shifted to the 25th and 50th percentile prices and overly shifted to the 75th percentile prices at a 1:1.1 rate. While cigarette excise taxes had a continuous impact on raising prices, the tax pass-through rates were lower for lower priced cigarettes, and states imposed lower taxes. CONCLUSIONS Continuing to raise cigarette taxes may be needed to create financial incentives to encourage people who smoke to switch to ECs. In addition, continuing to raise cigarette taxes and additional pricing policies such as price promotion restrictions are needed to increase retail prices and reduce price minimisation opportunities.
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Affiliation(s)
- Yanyun He
- Center for Tobacco Research, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Shaoying Ma
- Center for Tobacco Research, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Qian Yang
- Center for Tobacco Research, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ce Shang
- Center for Tobacco Research, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Internal Medicine, Medical Oncology Division, The Ohio State University, Columbus, Ohio, USA
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14
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Vu GT, Stjepanović D, Sun T, Leung J, Chung J, Connor J, Thai PK, Gartner CE, Tran BX, Hall WD, Chan G. Predicting the long-term effects of electronic cigarette use on population health: a systematic review of modelling studies. Tob Control 2023:tc-2022-057748. [PMID: 37295941 DOI: 10.1136/tc-2022-057748] [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: 09/12/2022] [Accepted: 05/29/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To systematically review and synthesise the findings of modelling studies on the population impacts of e-cigarette use and to identify potential gaps requiring future investigation. DATA SOURCE AND STUDY SELECTION Four databases were searched for modelling studies of e-cigarette use on population health published between 2010 and 2023. A total of 32 studies were included. DATA EXTRACTION Data on study characteristics, model attributes and estimates of population impacts including health outcomes and smoking prevalence were extracted from each article. The findings were synthesised narratively. DATA SYNTHESIS The introduction of e-cigarettes was predicted to lead to decreased smoking-related mortality, increased quality-adjusted life-years and reduced health system costs in 29 studies. Seventeen studies predicted a lower prevalence of cigarette smoking. Models that predicted negative population impacts assumed very high e-cigarette initiation rates among non-smokers and that e-cigarette use would discourage smoking cessation by a large margin. The majority of the studies were based on US population data and few studies included factors other than smoking status, such as jurisdictional tobacco control policies or social influence. CONCLUSIONS A population increase in e-cigarette use may result in lower smoking prevalence and reduced burden of disease in the long run, especially if their use can be restricted to assisting smoking cessation. Given the assumption-dependent nature of modelling outcomes, future modelling studies should consider incorporating different policy options in their projection exercises, using shorter time horizons and expanding their modelling to low-income and middle-income countries where smoking rates remain relatively high.
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Affiliation(s)
- Giang T Vu
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| | - Daniel Stjepanović
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Tianze Sun
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| | - Janni Leung
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| | - Jack Chung
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| | - Jason Connor
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Discipline of Psychiatry, The University of Queensland, Brisbane, Queensland, Australia
| | - Phong K Thai
- Queensland Alliance for Environmental Health Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Coral E Gartner
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Bach Xuan Tran
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Viet Nam
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Wayne D Hall
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
- Queensland Alliance for Environmental Health Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Gary Chan
- National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Queensland, Australia
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Rubenstein D, Denlinger-Apte RL, Cornacchione Ross J, McClernon FJ. Adoption of E-Cigarettes Among Older Adults Who Smoke to Reduce Harm and Narrow Age-Related Disparities: An Application of the Health Belief Model. Nicotine Tob Res 2023; 25:1212-1214. [PMID: 36702774 PMCID: PMC10202631 DOI: 10.1093/ntr/ntad016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/19/2022] [Accepted: 01/24/2023] [Indexed: 01/28/2023]
Affiliation(s)
- Dana Rubenstein
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27705, USA
| | - Rachel L Denlinger-Apte
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Jennifer Cornacchione Ross
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - F Joseph McClernon
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27705, USA
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16
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Rubenstein D, Denlinger-Apte RL, Cornacchione Ross J, Carroll DM, McClernon FJ. Older age is associated with greater misperception of the relative health risk of e-cigarettes and cigarettes among US adults who smoke. Tob Control 2023:tc-2023-057943. [PMID: 37137702 PMCID: PMC10622327 DOI: 10.1136/tc-2023-057943] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/25/2023] [Indexed: 05/05/2023]
Abstract
INTRODUCTION The prevalence of cigarette smoking among adults aged ≥55 has remained stagnant over the past decade. National data modelling suggests no reduction in cigarette smoking prevalence attributable to e-cigarette use in the USA among people aged ≥45. Misperceptions about the absolute risks (ie, cigarettes are not harmful) and relative risks (ie, e-cigarettes are more harmful than cigarettes) of tobacco products may contribute to sustained smoking prevalence and hesitancy to switch from cigarettes to e-cigarettes among older adults. METHODS Participants reported cigarette use (n=8072) at Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health Study. Weighted multivariable logistic regressions included six age categories (independent variable) and cigarette and e-cigarette risk perceptions (outcomes). Additional models assessed the associations between dichotomous age (≥55 vs 18-54), risk perceptions and an interaction term (independent variables) with past 12-month quit attempts and past-month e-cigarette use (outcomes). RESULTS Adults aged ≥65 were less likely than adults aged 18-24 to rate cigarettes as very/extremely harmful (p<0.05). Odds of rating e-cigarettes as more harmful than cigarettes among adults aged 55-64 and ≥65 were 1.71 (p<0.001) and 1.43 (p=0.024) greater than for adults aged 18-24. This misperception was negatively associated with past-month e-cigarette use and was stronger among adults aged ≥55 (p<0.001) than adults aged <55 (p<0.001). DISCUSSION Adults aged ≥55 are more likely to have misperceptions about the absolute and relative risks of tobacco products, which may contribute to continued smoking. Health communications targeting this age group could modify beliefs about the perceived harms of tobacco products.
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Affiliation(s)
- Dana Rubenstein
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Clinical and Translational Science Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel L Denlinger-Apte
- Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jennifer Cornacchione Ross
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Dana Mowls Carroll
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - F Joseph McClernon
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Clinical and Translational Science Institute, Duke University School of Medicine, Durham, North Carolina, USA
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17
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Foxon F, Selya A, Gitchell J, Shiffman S. Population-level counterfactual trend modelling to examine the relationship between smoking prevalence and e-cigarette use among US adults. BMC Public Health 2022; 22:1940. [PMID: 36261808 PMCID: PMC9580416 DOI: 10.1186/s12889-022-14341-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/21/2022] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Studies have suggested that some US adult smokers are switching away from smoking to e-cigarette use. Nationally representative data may reflect such changes in smoking by assessing trends in cigarette and e-cigarette prevalence. The objective of this study is to assess whether and how much smoking prevalence differs from expectations since the introduction of e-cigarettes. METHODS Annual estimates of smoking and e-cigarette use in US adults varying in age, race/ethnicity, and sex were derived from the National Health Interview Survey. Regression models were fitted to smoking prevalence trends before e-cigarettes became widely available (1999-2009) and trends were extrapolated to 2019 (counterfactual model). Smoking prevalence discrepancies, defined as the difference between projected and actual smoking prevalence from 2010 to 2019, were calculated, to evaluate whether actual smoking prevalence differed from those expected from counterfactual projections. The correlation between smoking discrepancies and e-cigarette use prevalence was investigated. RESULTS Actual overall smoking prevalence from 2010 to 2019 was significantly lower than counterfactual predictions. The discrepancy was significantly larger as e-cigarette use prevalence increased. In subgroup analyses, discrepancies in smoking prevalence were more pronounced for cohorts with greater e-cigarette use prevalence, namely adults ages 18-34, adult males, and non-Hispanic White adults. CONCLUSION Population-level data suggest that smoking prevalence has dropped faster than expected, in ways correlated with increased e-cigarette use. This population movement has potential public health implications.
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Affiliation(s)
- Floe Foxon
- PinneyAssociates Inc, 201 North Craig Street, Suite 320, 15213, Pittsburgh, PA, USA.
| | - Arielle Selya
- PinneyAssociates Inc, 201 North Craig Street, Suite 320, 15213, Pittsburgh, PA, USA
| | - Joe Gitchell
- PinneyAssociates Inc, 201 North Craig Street, Suite 320, 15213, Pittsburgh, PA, USA
| | - Saul Shiffman
- PinneyAssociates Inc, 201 North Craig Street, Suite 320, 15213, Pittsburgh, PA, USA
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18
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Levy DT, Cadham CJ, Li Y, Yuan Z, Liber AC, Oh H, Travis N, Issabakhsh M, Sweanor DT, Sánchez-Romero LM, Meza R, Cummings KM. A Decision-Theoretic Public Health Framework for Heated Tobacco and Nicotine Vaping Products. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13431. [PMID: 36294011 PMCID: PMC9602493 DOI: 10.3390/ijerph192013431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/22/2022] [Accepted: 09/30/2022] [Indexed: 06/16/2023]
Abstract
Markets for nicotine vaping products (NVPs) and heated tobacco products (HTPs) have grown as these products became positioned as harm-reduction alternatives to combusted tobacco products. Herein, we present a public health decision-theoretic framework incorporating different patterns of HTP, NVP, and cigarette use to examine their impacts on population health. Our framework demonstrates that, for individuals who would have otherwise smoked, HTP use may provide public health benefits by enabling cessation or by discouraging smoking initiation and relapse. However, the benefits are reduced if more harmful HTP use replaces less harmful NVP use. HTP use may also negatively impact public health by encouraging smoking by otherwise non-smokers or by encouraging initiation or relapse into smoking. These patterns are directly influenced by industry behavior as well as public policy towards HTPs, NVPs, and cigarettes. While substantial research has been devoted to NVPs, much less is known about HTPs. Better information is needed to more precisely define the health risks of HTPs compared to cigarettes and NVPs, the relative appeal of HTPs to consumers, and the likelihood of later transitioning to smoking or quitting all products. While our analysis provides a framework for gaining that information, it also illustrates the complexities in distinguishing key factors.
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Affiliation(s)
- David T. Levy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Christopher J. Cadham
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Yameng Li
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Zhe Yuan
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Alex C. Liber
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Hayoung Oh
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Nargiz Travis
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - Mona Issabakhsh
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20057, USA
| | - David T. Sweanor
- Centre for Health Law, Policy & Ethics, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Faculty of Law, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | | | - Rafael Meza
- Department of Integrative Oncology, BC Cancer Institute, Vancouver, BC V5Z1L3, Canada
| | - K. Michael Cummings
- Department of Psychiatry and Behavioral Sciences, Medical University of Charleston, Charleston, SC 29425, USA
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Levy DT, Gartner C, Liber AC, Sánchez-Romero LM, Yuan Z, Li Y, Cummings KM, Borland R. The Australia Smoking and Vaping Model: The Potential Impact of Increasing Access to Nicotine Vaping Products. Nicotine Tob Res 2022; 25:486-497. [PMID: 36073731 PMCID: PMC9910149 DOI: 10.1093/ntr/ntac210] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 08/08/2022] [Accepted: 09/06/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND We model the potential impact of relaxing current nicotine vaping product (NVP) restrictions on public health in Australia. AIMS AND METHODS A Restricted NVP Scenario was first developed to project current smoking and vaping rates, where a U.S. smoking model was calibrated to recent Australian trends. To model less restrictive NVP policies, a Permissive NVP Scenario applied rates of switching from smoking to vaping, initiation into NVP and cigarette use, and cessation from smoking and vaping based on U.S. trends. The model measures vaping risk relative to the excess mortality rate of smoking. The public health impacts are measured as the difference between smoking- and vaping-attributable deaths (SVADs) and life years lost (LYLs) in the Restricted and Permissive NVP Scenarios. Sensitivity analysis is conducted regarding the NVP excess risk and other factors. RESULTS Assuming an NVP excess risk of 5% that of smoking, 104.2 thousand SVADs (7.7% reduction) and 2.05 million LYLs (17.3% reduction) are averted during 2017-2080 in the Permissive NVP Scenario compared to the Restricted NVP Scenario. Assuming 40% NVP excess risk, 70 thousand SVADs and 1.2 million LYLs are averted. The impact is sensitive to the rate at which smokers switch to NVPs and quit smoking, and relatively insensitive to the smoking initiation and NVP initiation and cessation rates. CONCLUSIONS The model suggests the potential for public health gains to be achieved by relaxing NVP access regulations. However, the model would benefit from better information regarding the impact of NVPs on smoking under a relaxation of current restrictions. IMPLICATIONS Australia has implemented a strong array of cigarette-oriented policies, but has restricted access to NVPs. The Smoking and Vaping Model offers a framework for modeling hypothetical policy scenarios. The Australian model shows the potential for public health gains by maintaining cigarette-oriented policies while relaxing the current restrictive NVP policy. Modeling results under a permissive NVP policy are particularly sensitive to the estimated rates of smoking cessation and switching to vaping, which are not well established and will likely depend on past and future cigarette-oriented policies and the specific NVP policies implemented in Australia.
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Affiliation(s)
- David T Levy
- Corresponding Author: David T. Levy PhD, Georgetown University, 3300 Whitehaven St., NW, Suite 4100, Washington, DC, 20007, USA. Telephone: 301-275-2396; fax: 202-687-0305; E-mail:
| | - Coral Gartner
- School of Public Health, Faculty of Medicine, University of Queensland, Queensland, Australia
| | - Alex C Liber
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington DC, USA
| | | | - Zhe Yuan
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington DC, USA
| | - Yameng Li
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington DC, USA
| | - K Michael Cummings
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, USA
| | - Ron Borland
- Melbourne Centre for Behaviour Change, School of Psychological Sciences, University of Melbourne, Melbourne, Australia
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Levy DT, McNeill A, Jarvis MJ, Brown J, Li Y. Response to Braillon (2021): No, not the exception. Addiction 2021; 116:2924-2926. [PMID: 34159670 DOI: 10.1111/add.15618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 12/01/2022]
Affiliation(s)
| | | | | | | | - Yameng Li
- Georgetown University, Washington, DC, USA
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