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Wu YS, Cheung YTD, Ho SY, Tong HSC, Lai VWY, Lam TH, Wang MP. Perception of heated tobacco products and support for regulations: a cross-sectional study in Hong Kong. Tob Control 2024; 33:e132-e135. [PMID: 36344255 DOI: 10.1136/tc-2022-057401] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hong Kong has proposed banning the sale of heated tobacco products (HTPs). Perceptions of reduced harms and effectiveness for quitting combustible cigarettes (CCs) of HTPs due to their promotions may erode public support for regulations. We assessed the associations between perceptions of HTPs and support for regulations in Hong Kong. METHODS In two population-based landline surveys conducted in 2018-2019, 1985 respondents (51.4% male; 22.7% aged 60+ years) reported perceived relative harm of HTPs to CCs and effectiveness for quitting CCs, and support for five HTP regulations (ban on promotion and advertisements, use in smoke-free areas, sales to minors, registration before sale, sale licence) and a total ban on sale. Current and former smokers were oversampled due to low prevalence. Descriptive statistics were weighted to the general population. Associations were analysed, adjusting for sociodemographic characteristics, smoking status and ever HTP use. RESULTS 27.4% (N=515) of respondents perceived HTPs as less harmful, and 18.8% (N=1299) perceived them as effective for quitting CCs. Support was generally high (at least one regulation, 99.1%, N=1959; all five regulations, 66.8%, N=1114; total ban, 63.5%, N=946). Perceptions of reduced harm were associated with lower support for all five regulations (adjusted risk ratio 0.85, 0.75 to 0.96) and a total ban on sale (0.58, 0.51 to 0.66). Results were similar for perceptions of effectiveness for quitting. CONCLUSIONS Lower support for HTP regulations and a total ban on sale were associated with perceptions of reduced harm and effectiveness for quitting CCs of HTPs in Hong Kong.
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Affiliation(s)
| | | | - Sai Yin Ho
- School of Public Health, The University of Hong Kong, Hong Kong, Hong Kong
| | | | | | - Tai Hing Lam
- School of Public Health, The University of Hong Kong, Hong Kong, Hong Kong
| | - Man Ping Wang
- School of Nursing, The University of Hong Kong, Hong Kong, Hong Kong
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2
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Jung B, Lee JA, Kim YJ, Cho HJ. The smoking population is not hardening in South Korea: a study using the Korea Community Health Survey from 2010 to 2018. Tob Control 2024; 33:171-177. [PMID: 35851261 DOI: 10.1136/tc-2022-057332] [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: 02/10/2022] [Accepted: 07/08/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The hardening hypothesis proposes that the proportion of hardcore smokers increases when smoking prevalence declines. To evaluate whether such hardening occurs in South Korea, we examined the association between quitting behaviours, the number of cigarettes smoked per day and the proportion of hardcore smokers and smoking prevalence among local districts in South Korea. METHODS This study used the cross-sectional data from the Korea Community Health Survey (2010-2018) to examine local district-level associations between smoking prevalence and quit attempts, quit plans, quit ratios, cigarettes smoked per day and the proportion of hardcore smokers. Panel regression analysis was performed using the indicators of hardcore smoking (quit attempts, quit plans, quit ratios, cigarettes smoked per day and proportion of hardcore smokers) as the outcome variables, and prevalence of smoking, local districts, age and sex as predictor variables. RESULTS When the smoking prevalence of the districts decreased by 1%, quit attempts, quit plans and quit ratios increased by 0.24% (95% CI 0.11 to 0.37), 0.37% (95% CI 0.26 to 0.47) and 1.71% (95% CI 1.65 to 1.76), respectively. Cigarette consumption decreased by 0.17 cigarettes per day (95% 0.15 to 0.19), and the prevalence of hardcore smokers decreased by 0.88% (95% CI 0.78 to 0.98) when smoking prevalence decreased by 1%. CONCLUSION Hardening of smoking did not occur in South Korea when smoking prevalence declined, which suggests tobacco control policies in South Korea have been effective in reducing smoking prevalence without increasing the proportion of hardcore smokers.
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Affiliation(s)
- Boyoung Jung
- Jireh Clinic of Family Medicine, Seoul, The Republic of Korea
| | - Jung Ah Lee
- Workplace Health Institute, Total Health Care Center, Kangbuk Samsung Hospital, Jongno-gu, Seoul, The Republic of Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Songpa-gu, Seoul, The Republic of Korea
| | - Hong-Jun Cho
- Department of Family Medicine, Asan Medical Center. University of Ulsan College of Medicine, Songpa-gu, The Republic of Korea
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Miller CR, Xu SS, Smith DM, Sutanto E, Goniewicz ML, Quah ACK, Fong GT. Assessing use of inhalable nicotine products within complex markets: the dilemma of heated tobacco products. Tob Control 2023; 33:103-109. [PMID: 35680384 PMCID: PMC10804002 DOI: 10.1136/tobaccocontrol-2021-057081] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/27/2022] [Indexed: 11/04/2022]
Abstract
The introduction of electronic inhalable products, such as nicotine vaping products (NVPs) and heated tobacco products (HTPs), has further diversified the nicotine market landscape. This poses unique challenges in measuring self-reported nicotine use behaviours, which have been the hallmark of tobacco surveillance systems. This paper raises concerns of potential measurement error for electronic inhalable product use in surveys due to similarities in product design between NVPs and HTPs, as well as changing trends in cannabis administration. We identify several strategies for addressing this issue (eg, including descriptive preambles in surveys that differentiate product classes from one another; incorporating survey questions that probe beyond an initial question regarding product use). In the absence of comprehensive validation studies, caution is warranted when interpreting survey results that rely on self-reported HTP use.
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Affiliation(s)
- Connor Richard Miller
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Steve S Xu
- Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
| | - Danielle M Smith
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Edward Sutanto
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Maciej Lukasz Goniewicz
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Anne C K Quah
- Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
| | - Geoffrey T Fong
- Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
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Seo YG, Paek YJ, Kim JH, Kim JK, Noh HM. Relationship between heated tobacco product use and allergic rhinitis in Korean adults. Tob Induc Dis 2023; 21:146. [PMID: 37954489 PMCID: PMC10632938 DOI: 10.18332/tid/174130] [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: 05/19/2023] [Revised: 08/18/2023] [Accepted: 10/13/2023] [Indexed: 11/14/2023] Open
Abstract
INTRODUCTION Combustible cigarette (CC) smoking is a risk factor for chronic obstructive pulmonary disease (COPD) and asthma, and some studies reported that tobacco smoking might affect the development or symptom control of allergic rhinitis, sinusitis, and atopic dermatitis. However, evidence on the health risks of heated tobacco products (HTPs) is lacking. We investigated the prevalence of respiratory and allergic diseases according to tobacco use types in Korean adults. METHODS We used data from 18230 adults in the Korea National Health and Nutrition Examination Survey. Multiple logistic regression analyses were performed to assess the prevalence of respiratory and allergic diseases according to tobacco use types (current exclusive CC use, current exclusive HTPs use, and dual use of CC and HTPs). RESULTS The prevalence of exclusive CC users, exclusive HTPs users, dual users of CC and HTPs was 15% (n=2740), 1% (n=182), and 2.4% (n=435), respectively. The prevalence of COPD was higher among past tobacco users (AOR=2.37; 95% CI: 1.02-5.51) versus no tobacco use group. The prevalence of asthma was higher among past tobacco users or exclusive CC users (AOR=1.73; 95% CI: 1.26-2.38, and AOR=1.57; 95% CI: 1.08-2.26) versus non-users of tobacco. The prevalence of allergic rhinitis was higher among past tobacco users versus non-users of tobacco (AOR=1.33; 95% CI: 1.13-1.57), and the prevalence of allergic rhinitis was higher among exclusive HTPs users versus non-users of tobacco or exclusive CC users (AOR=1.60; 95% CI: 1.06-2.42, and AOR=1.74; 95% CI: 1.14-2.66). The adjusted odds of sinusitis and atopic dermatitis were not significantly different between tobacco use types. CONCLUSIONS Exclusive use of HTPs was associated with allergic rhinitis in Korean adults. Further longitudinal studies are needed to clarify the health risk of HTPs.
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Affiliation(s)
- Young-Gyun Seo
- Department of Family Medicine, Hallym University Sacred Heart Hospital, Hallym University, Anyang, Republic of Korea
| | - Yu-Jin Paek
- Department of Family Medicine, Hallym University Sacred Heart Hospital, Hallym University, Anyang, Republic of Korea
| | - Joo-Hee Kim
- Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hallym University, Anyang, Republic of Korea
| | - Jwa-Kyung Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Hallym University, Anyang, Republic of Korea
| | - Hye-Mi Noh
- Department of Family Medicine, Hallym University Sacred Heart Hospital, Hallym University, Anyang, Republic of Korea
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5
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Koh DH. The relationship between heated cigarette smoking and blood white blood cell count: a population-based cross-sectional study. Public Health 2023; 222:154-159. [PMID: 37544126 DOI: 10.1016/j.puhe.2023.07.006] [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: 11/30/2022] [Revised: 04/21/2023] [Accepted: 07/05/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES Conventional cigarette smoking increases inflammation and white blood cell (WBC) counts. However, there have been limited studies on the relationship between heated cigarette smoking and WBC counts. This study aimed to examine this relationship using nationally representative population-based health data. STUDY DESIGN This was a population-based cross-sectional study. METHODS The Korea National Health and Nutrition Examination Survey database was used to analyze this relationship. Data related to sex, age, body mass index (BMI), WBC count, and smoking history were obtained from the database. The smoking-related questionnaires included smoking status, smoking type (heated or conventional cigarettes), and smoking amount. The summary statistics of the WBC counts were calculated according to sex, smoking status, and smoking type. In addition, the exposure-response relationship between the smoking amount and WBC count was examined by smoking type, controlling for sex, age, and BMI. RESULTS In total, 9747 WBC measurements were used in the analyses. WBC count increased in conventional cigarette smokers, while there was no significant difference in WBC count between heated cigarette smokers and non-smokers. The WBC count showed a positive dose-response relationship with the smoking amount in both conventional and heated cigarette smokers. CONCLUSIONS The results confirm that conventional cigarette smoking increases WBC counts. Furthermore, the results suggest that heated cigarette smoking does not lead to a significant increase in WBC counts, although it indicates a potential dose-response relationship with WBC count. Further research with larger sample sizes is needed to confirm whether these results reflect true associations.
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Affiliation(s)
- D-H Koh
- Department of Occupational and Environmental Medicine, International St. Mary's Hospital, Catholic Kwandong University, Incheon, South Korea.
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6
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Won D, Jung W, Shin D. Comparison of the Smoking Cessation of Heated Tobacco Product Users and Conventional Cigarette Smokers in Korea. Korean J Fam Med 2023; 44:151-157. [PMID: 37225440 DOI: 10.4082/kjfm.22.0142] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 03/08/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Since the introduction of heated tobacco products (HTPs) in Korea in 2017, their annual sales have increased. Several studies have investigated the perceptions of HTPs and smoking cessation behaviors. For the first time, In 2019, questions focused on HTP use were introduced in the Korea National Health and Nutrition Examination Survey (KNHNES). This study aimed to compare smoking cessation behaviors between HTP users and conventional cigarette smokers using KNHANES data. METHODS Data of 947 current adult smokers from the 8th KNHNES (2019) were analyzed. Current smokers were divided into conventional cigarette (CC)-only, HTP-only, and dual-use groups. The general characteristics of the three groups were investigated. Differences in current intention to quit smoking and past attempts to quit smoking among the three groups were analyzed using multivariate logistic regression analysis by IBM SPSS ver. 25.0. RESULTS HTP-only users demonstrated fewer future smoking cessation plans (adjusted odds ratio [AOR], 0.398; 95% confidence interval [CI], 0.195-0.813; P=0.012) and fewer smoking cessation attempts in the past year (AOR, 0.533; 95% CI, 0.298-0.954; P=0.034) than CC-only smokers. However, there was no significant difference between dual-use (CC+HTP) and CC-only smokers. CONCLUSION While dual-use and CC-only smokers showed similar smoking cessation behaviors, HTP-only users had fewer previous attempts to quit smoking and were less likely to be currently ready to quit smoking. These findings can be explained by a decrease in the need to quit smoking due to the convenience of HTP and the perception that HTPs are less harmful than CC.
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Affiliation(s)
- Doyeon Won
- Department of Family Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wonyoung Jung
- Department of Family Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dongwook Shin
- Department of Family Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Science & Technology, Sungkyunkwan University, Seoul, Korea
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Cho YG. Is Using Heated Tobacco Products Helpful in Smoking Cessation? Korean J Fam Med 2023; 44:127-128. [PMID: 37225437 DOI: 10.4082/kjfm.44.3e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Affiliation(s)
- Young Gyu Cho
- Department of Family Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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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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Odani S, Tsuno K, Agaku IT, Tabuchi T. Heated tobacco products do not help smokers quit or prevent relapse: a longitudinal study in Japan. Tob Control 2023:tc-2022-057613. [PMID: 36849258 DOI: 10.1136/tc-2022-057613] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 01/27/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Heated tobacco products (HTPs) are often marketed as a safer alternative to help cigarette smokers quit. We investigated the link between HTP use and smoking cessation and relapse. METHODS 7044 adults (≥20 years old) with at least two observations over three waves (2019-2021) of a longitudinal, nationwide, internet-based survey were classified into current (past 30-day), former and never cigarette smokers. ≥1 month and ≥6 months smoking cessation and smoking relapse at 1-year follow-up were assessed in relation to current HTP use at baseline. Generalised estimating equation models were weighted to account for population differences between HTP users and non-users. Adjusted prevalence ratios (APRs) were computed within population subgroups. RESULTS At baseline, 17.2%, 9.1% and 6.1% of the respondents were current cigarette smokers, HTP users and dual users, respectively. Among current established smokers (having smoked regularly, n=1910), HTP use was significantly associated with a decreased likelihood of ≥1 month cessation within those who reported having used evidence-based cessation measures (APR=0.61), smoking 20+ cigarettes per day (APR=0.62), high school education or less (APR=0.73) and fair/poor health (APR=0.59). Negative associations were also seen for ≥6 months cessation among those aged 20-29 years (APR=0.56) and full-time workers (APR=0.56). Among former smokers (n=2906), HTP use was associated with smoking relapse within those who last smoked >1 year ago (APR=1.54), among women (APR=1.61), those aged 20-29 years (APR=2.09), those reporting high school education or less (APR=2.36), those who were unemployed/retired (AOR=3.31) and never/non-current alcohol users (APR=2.10). CONCLUSION HTP use did not help smokers quit or prevent former smokers from relapsing. HTPs should not be recommended as a cessation aid.
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Affiliation(s)
- Satomi Odani
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
| | - Kanami Tsuno
- School of Health Innovation, Kanagawa University of Human Services, Kawasaki, Japan
| | - Israel T Agaku
- Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Takahiro Tabuchi
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
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Han M, Jeong S, Song J, Park SJ, Min Lee C, Lee K, Park SM. Association between the dual use of electronic and conventional cigarettes and NAFLD status in Korean men. Tob Induc Dis 2023; 21:31. [PMID: 36844383 PMCID: PMC9951190 DOI: 10.18332/tid/159167] [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: 08/27/2022] [Revised: 01/02/2023] [Accepted: 01/10/2023] [Indexed: 02/26/2023] Open
Abstract
INTRODUCTION This study investigated the association between smoking types, including dual use (usage of both combustible cigarettes and e-cigarettes), and non-alcoholic fatty liver disease (NAFLD) status in Korean men. METHODS Data from the 7th and 8th Korea National Health and Nutrition Examination Survey (KNHANES) 2016-2020 were used. The presence of NAFLD was defined by the respective cut-off values for the Hepatic Steatosis Index (HSI), NAFLD Ridge Score (NRS), and Korea National Health and Nutrition Examination Survey NAFLD score (KNS). Multivariate logistic regression analyses were used to determine the associations between smoking types and NAFLD as determined by HSI, NRS, and KNS. RESULTS After adjustment for confounders, an independent association was observed between dual use and NAFLD (HSI: AOR=1.47; 95% CI: 1.08-1.99, p=0.014; NRS: AOR=2.21; 95% CI: 1.70-2.86, p=0.000; KNS: AOR=1.35; 95% CI: 1.01-1.81, p=0.045). Cigarette only smokers also had significantly higher odds of NAFLD compared to never smokers for all of the NAFLD indices (HSI: AOR=1.22; 95% CI: 1.05-1.42, p=0.008; NRS: AOR=2.13; 95% CI: 1.87-2.42, p=0.000; KNS: AOR=1.33; 95% CI: 1.14-1.55, p=0.000). In subgroup analyses, no significant interaction effects were found for age, BMI, alcohol consumption, income, physical activity, and the diagnosis of T2DM. Moreover, cigarette only smokers and dual users differed significantly in terms of log-transformed urine cotinine and pack-years. The relationship between smoking type and pack-years was attenuated after stratification by age. CONCLUSIONS This study shows that the dual use of e-cigarettes and combustible cigarettes is associated with NAFLD. Age differences may explain why dual users, with a greater proportion of young people, appear to have fewer pack-years than cigarette only smokers. Further research should be conducted to investigate the adverse effects of dual use on hepatic steatosis.
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Affiliation(s)
- Minjung Han
- Department of Family Medicine, Myongji Hospital, Goyang, Republic of Korea
| | - Seogsong Jeong
- Department of Biomedical Informatics, CHA University School of Medicine, CHA University, Seongnam, Republic of Korea,Institute for Biomedical Informatics, School of Medicine, CHA University, Seongnam, Republic of Korea
| | - Jihun Song
- Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, Republic of Korea
| | - Sun Jae Park
- Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, Republic of Korea
| | - Cheol Min Lee
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea,Department of Family Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kiheon Lee
- Department of Family Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea,Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sang Min Park
- Department of Biomedical Sciences, Seoul National University Graduate School, Seoul, Republic of Korea,Department of Family Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea,Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Hwang JS, Lee K, Kim CY, Kim H, Kim S, Lee CM. JUUL preference among Korean adult tobacco users and its effect on attempts to quit tobacco: A follow-up survey four months post JUUL launch. Tob Induc Dis 2023; 21:39. [PMID: 36925566 PMCID: PMC10012008 DOI: 10.18332/tid/160163] [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: 08/03/2022] [Revised: 12/23/2022] [Accepted: 01/31/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION This study examined the various factors in the selection of JUUL (and/or), a pod-mod type electronic cigarette (EC), and the changes in EC patterns before and after the JUUL debut on 24 May 2019, using follow-up survey data of adult tobacco users in South Korea. METHODS This study examined transition outcomes among tobacco users and factors associated with future JUUL use. Convenience sample data were collected from adult tobacco users in South Korea, from March-April 2019 (baseline, n=2173) to September 2019 (follow-up, n=779). Results were obtained from the 779 respondents in the follow-up survey, and user data of one or more tobacco products were analyzed. The changes in the proportion of EC and JUUL use during this period were calculated, and multivariate logistic regression analysis was conducted to investigate the selection factors of JUUL. RESULTS Four months after the JUUL launch, the proportion of current EC and JUUL users among the whole sample increased by 10.3% (42.6-52.9%, p<0.001) and 17.7 % (4.0-21.7%, p<0.001), respectively, while the proportion of triple users doubled (18.7% vs 37.5%, p<0.001). Among current EC users, the percentage of quitting EC within one month decreased from 18.7% to 8.7%; this change was more pronounced among concurrent JUUL users than non-JUUL users (p<0.001). In the multivariate logistic analysis with adjustment for possible confounders, JUUL use was significantly associated with male sex, young and middle age, and metropolitan residency status at the baseline survey. CONCLUSIONS After the launch of JUUL in South Korea, EC users, including JUUL and triple users, increased significantly, but the intention to stop EC decreased significantly. Given the serious interests of the tobacco industry in these products, additional regulation is warranted.
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Affiliation(s)
- Ju Sam Hwang
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kiheon Lee
- Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Family Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Choon-Young Kim
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heejin Kim
- Department of Epidemiology and Health Promotion, Institute for Health Promotion, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
| | - Sungroul Kim
- Department of Environmental Health Sciences, Soonchunhyang University, Asan, Republic of Korea
| | - Cheol M Lee
- Department of Family Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea
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Acute Eosinophilic Pneumonia after Combined Use of Conventional and Heat-Not-Burn Cigarettes: A Case Report. Medicina (B Aires) 2022; 58:medicina58111527. [DOI: 10.3390/medicina58111527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/21/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Acute eosinophilic pneumonia (AEP) is a rare acute respiratory disease accompanied by fever, shortness of breath, and cough. Although the pathogenesis of the disease is not yet established, the patient’s condition improves with a rapid therapeutic response to systemic corticosteroids. Conventional cigarettes or heat-not-burn cigarettes are the most common cause of AEP among young people. Case Presentation: A 22-year-old woman with dyspnea, cough, and fever did not improve after visiting the local medical center and was admitted to the emergency room. The patient denied having any recent travel history or insect bites. She was treated with appropriate antibiotics according to the community acquired pneumonia, but there was no improvement. Chest radiography showed bilateral patches of pulmonary infiltration, and chest computed tomography revealed bilateral multifocal patchy consolidations with multiple small nodular ground-glass opacities and interlobular septal thickening. The bronchoalveolar lavage result was dominantly eosinophilic. The patient’s condition improved rapidly after the use of intravenous methylprednisolone and then a change to oral methylprednisolone. Finally, the patient was hospitalized for 9 days, and the duration of use of methylprednisolone including outpatient visits was 14 days. Results: The early treatment of AEP yields a good prognosis, but since the symptoms of AEP are similar to those of infectious diseases such as community-acquired pneumonia, physicians should be meticulous in differentiating AEP from other diseases. Conclusions: Since AEP shows a good response to steroids, early detection using an appropriate diagnostic method is recommended. In addition, there should be strong education against smoking in any form.
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13
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Yu H, Lee CM. Comparison of Tobacco Use and Cessation Behavior between Conventional Cigarette and Heated Tobacco Product Users: Based on the Analyses of the Eighth Korea National Health and Nutrition Examination Survey 2019. Korean J Fam Med 2022; 43:296-304. [PMID: 36168901 PMCID: PMC9532185 DOI: 10.4082/kjfm.21.0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/26/2022] [Indexed: 11/30/2022] Open
Abstract
Background After the advent of heated tobacco products (HTPs) in 2017, domestic cigarette sales declined until 2019, but have increased in South Korea since 2020. This study aimed to analyze tobacco use and cessation behavior among HTP users compared with conventional cigarette (CC) users. Methods We analyzed data from the eighth Korea National Health and Nutrition Examination Survey (2019). Of 6,188 study participants, 1,181 were current tobacco product users (single, dual, and triple), including all combinations of CCs, HTPs, and electronic cigarettes (ECs). Tobacco use and cessation behaviors among single and dual users of CCs and HTPs were assessed using various categorical methods. Results In 2019, proportions of HTP use in men and women aged ≥19 years in South Korea were 8.8% and 1.5%, respectively, and those of single, dual, and triple users were 23.6%, 58.0%, and 18.4%, respectively. Dual users had more tobacco use than CC only and HTP only users (all P<0.001). Each daily user accounted for a lower percentage of attempt and preparation stages for cessation than intermittent users (all P<0.001, except for dual users). Conclusion In this study, we analyzed the differences in tobacco use and cessation behavior among CC and HTP users in various populations in South Korea. Additionally, we found that all novel tobacco product users had already experienced CCs in adulthood. Further studies that address HTP’s harmful effects in humans are necessary.
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Affiliation(s)
- Hyeree Yu
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
| | - Cheol Min Lee
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
- Corresponding Author: Cheol Min Lee Tel: +82-2-2112-5668, Fax: +82-2-2112-5635, E-mail:
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14
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Han M, Seo D, Kim Y, Seo HG, Cho SI, Lee S, Lim S, Kaai SC, Quah ACK, Yan M, Xu SS, Fong GT. Factors Associated with Quit Intentions among Adult Smokers in South Korea: Findings from the 2020 ITC Korea Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10839. [PMID: 36078553 PMCID: PMC9518068 DOI: 10.3390/ijerph191710839] [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: 07/22/2022] [Revised: 08/24/2022] [Accepted: 08/24/2022] [Indexed: 06/15/2023]
Abstract
Background: South Korea has made substantial progress on tobacco control, but cigarette smoking prevalence is still high. Previous studies were conducted before the use of nicotine vaping products (NVPs) or heated tobacco products (HTPs) became popular. Thus, whether the concurrent use of NVPs or HTPs affects quit intentions among Korean smokers remains a question that needs to be explored. This study aims to identify predictors of quit intentions among cigarette-only smokers and concurrent users of cigarettes and NVPs or HTPs. Methods: Data were from the 2020 International Tobacco Control Korea Survey. Included in the analysis were 3778 adult cigarette smokers: 1900 at-least-weekly exclusive smokers and 1878 at-least-weekly concurrent smokers and HTP or NVP users. Bivariate and multivariable logistic regression analyses were conducted. Results: Quit intentions were reported by 66.4% of respondents. Factors significantly associated with quit intentions included younger age, having a spouse/partner, lower nicotine dependence, reporting a past quit attempt, regretting starting smoking, believing that smoking had damaged health, worrying that smoking will damage future health, and perceiving health benefits of quitting. Current use of NVPs or HTPs was not significantly associated with quit intentions. Conclusions: This study contributes the following to current literature: intrinsic health-related beliefs were more important than societal norms in shaping quit intentions. These findings should be considered in shaping future smoking cessation policies, such as reinforcing education programs that emphasize the benefits of quitting for personal health reasons, lowering nicotine dependence, and encouraging multiple quit attempts and successful quitting.
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Affiliation(s)
- Minjung Han
- Department of Family Medicine, Myongji Hospital, Goyang 10475, Korea
| | - Donghee Seo
- Department of Family Medicine, National Cancer Center, Goyang 10408, Korea
| | - Yeol Kim
- Department of Family Medicine, National Cancer Center, Goyang 10408, Korea
- Department of Cancer Control, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang 10408, Korea
| | - Hong Gwan Seo
- Department of Family Medicine, National Cancer Center, Goyang 10408, Korea
- Department of Cancer Control, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang 10408, Korea
| | - Sung-il Cho
- Graduate School of Public Health, Seoul National University, Seoul 08826, Korea
| | - Sungkyu Lee
- Korea Center for Tobacco Control Research and Education, Seoul 04554, Korea
| | - Sujin Lim
- National Tobacco Control Center, Korean Health Promotion Institute, Seoul 04933, Korea
| | - Susan C. Kaai
- Department of Psychology, University of Waterloo, Waterloo, ON N2L 3G1, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Anne C. K. Quah
- Department of Psychology, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Mi Yan
- Department of Psychology, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Steve S. Xu
- Department of Psychology, University of Waterloo, Waterloo, ON N2L 3G1, Canada
| | - Geoffrey T. Fong
- Department of Psychology, University of Waterloo, Waterloo, ON N2L 3G1, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, ON N2L 3G1, Canada
- Ontario Institute for Cancer Research, Toronto, ON M5G 0A3, Canada
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15
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Heated Tobacco Product Use and Mental Health: Korean National Health and Nutrition Examination Survey (2018–2020). Int J Ment Health Addict 2022. [DOI: 10.1007/s11469-022-00907-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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16
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Aoike M, Mori Y, Hotta K, Shigeno Y, Aoyama Y, Tanaka M, Kouzai H, Kawamura H, Tsurudome M, Ito M. Evaluation of Japanese university students' perception of smoking, interest in quitting, and smoking behavior: An examination and public health challenges during the COVID-19 pandemic. Drug Discov Ther 2022; 16:118-123. [PMID: 35753801 DOI: 10.5582/ddt.2022.01041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study examined college students' perceptions of the association between smoking and novel coronavirus disease 2019 (COVID-19), changes in smoking behavior, and interest in quitting categorized by smoking device, to identify public health challenges. A questionnaire survey was conducted among 8,547 students in a Japanese university in March and April 2021. In response to "Awareness of the increased risk of COVID-19 infection due to smoking and the tendency to develop severe disease", current smokers (70.2%) were more aware of the risk than non-smokers (49.8%) (p < 0.001), with no significant difference according to smoking device (p = 0.213). "Interest in quitting smoking" (p = 0.323), and "Changes in smoking behavior during the COVID-19 pandemic" (p = 0.146) did not differ by smoking device. However, approximately 50% of the respondents answered that they were not interested in quitting smoking, while two-thirds reported that the number of cigarettes they smoked did not change during the pandemic. During the COVID-19 pandemic, college students were found to be less interested in quitting and not likely to change their smoking behavior, despite the knowledge of the increased risk of COVID-19 transmission and severity of disease from smoking, regardless of smoking device.
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Affiliation(s)
- Makoto Aoike
- Graduate School of Life and Health Sciences, Chubu University, Aichi, Japan
| | - Yukihiro Mori
- Graduate School of Life and Health Sciences, Chubu University, Aichi, Japan.,Center for Nursing Practicum Support, Chubu University, Aichi, Japan
| | - Kiyoshi Hotta
- Center for Nursing Practicum Support, Chubu University, Aichi, Japan
| | - Yukihiro Shigeno
- Center for Emergency Medical Technician Practicum Support, Chubu University, Aichi, Japan
| | - Yuka Aoyama
- Department of Clinical Engineering, College of Life and Health Sciences, Chubu University, Aichi, Japan
| | - Mamoru Tanaka
- Department of Food and Nutritional Sciences, College of Bioscience and Biotechnology, Chubu University, Aichi, Japan
| | - Hana Kouzai
- Department of Food and Nutritional Sciences, College of Bioscience and Biotechnology, Chubu University, Aichi, Japan
| | - Hatsumi Kawamura
- Graduate School of Life and Health Sciences, Chubu University, Aichi, Japan
| | - Masato Tsurudome
- Graduate School of Life and Health Sciences, Chubu University, Aichi, Japan.,Department of Biomedical Sciences, College of Life and Health Science, Chubu University, Aichi, Japan
| | - Morihiro Ito
- Graduate School of Life and Health Sciences, Chubu University, Aichi, Japan.,Department of Biomedical Sciences, College of Life and Health Science, Chubu University, Aichi, Japan
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17
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Quah ACK, Lee S, Seo HG, Cho SI, Lim S, Kim Y, Xu SS, Grey M, Yan M, Boudreau C, Thompson ME, Driezen P, Fong GT. Methods of the 2020 (Wave 1) International Tobacco Control (ITC) Korea Survey. Tob Prev Cessat 2022; 8:13. [PMID: 35434426 PMCID: PMC8961692 DOI: 10.18332/tpc/146685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 11/24/2022]
Abstract
This article presents methods used in the 2020 International TC Korea Wave 1 (KRA1) Survey. To date, three cohorts of Korean respondents have participated in the larger ITC Korea Project (cohort 1: 2005-2014, cohort 2: 2016, and cohort 3: 2020-present). The overall objectives of the ITC KRA1 Survey were to examine the use of cigarettes, heated tobacco products (HTPs), e-cigarettes (ECs); whether HTPs might help smokers quit; and the effectiveness of tobacco control policies, such as large graphic warnings, high cigarette taxes, and smoking bans in public places. The KRA1 Survey measures were identical or functionally similar to those of the ITC Japan Survey and, to a lesser extent, those of other ITC countries. Key measures assessed sociodemographic characteristics of respondents; the use of combustible cigarettes, e-cigarettes, and heated tobacco products; and measures assessing policies of the WHO Framework Convention on Tobacco Control, including price and tax (Article 6), smoke-free laws (Article 8), health warnings (Article 11), education, communication and public awareness (Article 12), advertising, promotion, and sponsorship restrictions (Article 13), and support for cessation (Article 14). Adult tobacco and/or nicotine users aged ≥19 years in South Korea were recruited by a commercial survey firm from its online panel. Overall, 4794 respondents completed the KRA1 Survey. The cooperation rate was 97.4% and the response rate was 15.2%. The cohort design permits assessment of transitions in products used among users in South Korea and evaluations of the impact of policies on tobacco and/or nicotine products used and transitions in use.
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Affiliation(s)
- Anne C K Quah
- Department of Psychology, University of Waterloo, Waterloo, Canada
| | - Sungkyu Lee
- Korea Center for Tobacco Control Research and Education, Seoul, Republic of Korea
| | - Hong Gwan Seo
- National Cancer Center, Goyang-si, Republic of Korea
| | - Sung-Il Cho
- Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Sujin Lim
- National Tobacco Control Center, Korean Health Promotion Institute, Seoul, Republic of Korea
| | - Yeol Kim
- Center for Smoking Cessation, National Cancer Center, Goygang, Republic of Korea
| | - Steve S Xu
- Department of Psychology, University of Waterloo, Waterloo, Canada
| | - Matthew Grey
- Department of Psychology, University of Waterloo, Waterloo, Canada
| | - Mi Yan
- Department of Psychology, University of Waterloo, Waterloo, Canada
| | - Christian Boudreau
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Canada
| | - Mary E Thompson
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Canada
| | - Pete Driezen
- Department of Psychology, University of Waterloo, Waterloo, Canada.,School of Public Health Sciences, University of Waterloo, Waterloo, Canada
| | - Geoffrey T Fong
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Canada.,School of Public Health Sciences, University of Waterloo, Waterloo, Canada.,Ontario Institute for Cancer Research, Toronto, Canada
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18
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Hwang J. Subjective Changes in Tobacco Product Use among Korean Adults during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063272. [PMID: 35328959 PMCID: PMC8949246 DOI: 10.3390/ijerph19063272] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 02/05/2023]
Abstract
This study explored subjective changes in tobacco product use during the COVID-19 pandemic. The online survey included 828 tobacco product users and was implemented from 20 August to 27 August 2021. Participants were classified based on currently used products (cigarettes, heated tobacco products (HTPs), and e-cigarettes) and categorized as single, dual, or triple users. Subjective changes in product use over the past year were designated as “no chang”, “increase”, or “decreased”. Single use was most common, as reported by 447 participants (male 249, female 198), while 283 (male 164, female 119) and 98 (male 59, female 39) participants reported dual and triple use, respectively. Age, income, and triple use were associated with increased cigarette use, whereas living with family was associated with decreased use. Gender, age, income, and triple use were associated with the changed use of HTPs. No factors were significantly associated with an increase in e-cigarette use, whereas age and income were associated with decreased use. Similar to many COVID-19-related changes in cultural, social, and economic aspects of life, users’ patterns of tobacco product use have also changed. Increasing tobacco product taxes, effective messaging, and customized cessation services might help prevent or limit tobacco product usage.
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Affiliation(s)
- Jieun Hwang
- College of Health Science, Dankook University, 119, Dandae-ro, Dongnam-gu, Cheonan-si 31116, Chungnam, Korea
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19
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Kim CY, Lee K, Lee CM, Kim S, Cho HJ. Perceived relative harm of heated tobacco products and
electronic cigarettes and its association with use in smoke-free
places: A cross-sectional analysis of Korean adults. Tob Induc Dis 2022; 20:20. [PMID: 35280047 PMCID: PMC8859996 DOI: 10.18332/tid/145699] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/14/2021] [Accepted: 01/11/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs) are often considered to be less harmful and safer than combustible cigarettes (CCs). As a result, numerous tobacco product users opt to use e-cigarettes or HTPs as a safer alternative, though the safety of these products is not fully warranted. The present study aimed to assess the various attitudes towards e-cigarettes and/or HTPs among Korean tobacco product users and their associations with the practical use of e-cigarettes and/or HTPs in private or smoke-free public places. METHODS A cross-sectional study using self-administered questionnaires was conducted from March 2019 to July 2019 on 2971 adult tobacco product users. Attitude towards e-cigarettes and/or HTPs, as well as the relative harm perceptions, in association with their practical use in private or smoke-free areas, were also analyzed. RESULTS Among those surveyed, 46.8% were exclusive users (CC-only smokers 23.5%, e-cigarette-only users 10.7%, HTP-only users 12.7%), and 47.6% were poly-users. Compared with non-e-cigarette or non-HTP users, current e-cigarette or HTP users perceived e-cigarettes or HTPs as less harmful than CCs and they were more acceptable to e-cigarettes or HTPs being used indoors. Their positive attitudes were associated with their more frequent use at home or in their car. Less number of participants supported that the government should regulate e-cigarettes or HTPs in the same way as CCs, their attitude being associated with more frequent use in smoke-free public places. CONCLUSIONS E-cigarettes or HTPs users have more positive attitudes toward their tobacco products than non-e-cigarette or non-HTP users. Those with more positive attitudes toward e-cigarettes or HTPs are closely related to their use in smoke-free places.
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Affiliation(s)
- Choon-Young Kim
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kiheon Lee
- Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Family Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Cheol Min Lee
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sungroul Kim
- Department of Environmental Health Sciences, Soonchunhyang University, Asan, Republic of Korea
| | - Hong-Jun Cho
- Department of Family Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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20
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Tattan-Birch H, Hartmann-Boyce J, Kock L, Simonavicius E, Brose L, Jackson S, Shahab L, Brown J. Heated tobacco products for smoking cessation and reducing smoking prevalence. Cochrane Database Syst Rev 2022; 1:CD013790. [PMID: 34988969 PMCID: PMC8733777 DOI: 10.1002/14651858.cd013790.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Heated tobacco products (HTPs) are designed to heat tobacco to a high enough temperature to release aerosol, without burning it or producing smoke. They differ from e-cigarettes because they heat tobacco leaf/sheet rather than a liquid. Companies who make HTPs claim they produce fewer harmful chemicals than conventional cigarettes. Some people report stopping smoking cigarettes entirely by switching to using HTPs, so clinicians need to know whether they are effective for this purpose and relatively safe. Also, to regulate HTPs appropriately, policymakers should understand their impact on health and on cigarette smoking prevalence. OBJECTIVES To evaluate the effectiveness and safety of HTPs for smoking cessation and the impact of HTPs on smoking prevalence. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, and six other databases for relevant records to January 2021, together with reference-checking and contact with study authors and relevant groups. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which people who smoked cigarettes were randomised to switch to exclusive HTP use or a control condition. Eligible outcomes were smoking cessation, adverse events, and selected biomarkers. RCTs conducted in clinic or in an ambulatory setting were deemed eligible when assessing safety, including those randomising participants to exclusively use HTPs, smoke cigarettes, or attempt abstinence from all tobacco. Time-series studies were also eligible for inclusion if they examined the population-level impact of heated tobacco on smoking prevalence or cigarette sales as an indirect measure. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking at the longest follow-up point available, adverse events, serious adverse events, and changes in smoking prevalence or cigarette sales. Other outcomes included biomarkers of harm and exposure to toxicants/carcinogens (e.g. NNAL and carboxyhaemoglobin (COHb)). We used a random-effects Mantel-Haenszel model to calculate risk ratios (RR) with 95% confidence intervals (CIs) for dichotomous outcomes. For continuous outcomes, we calculated mean differences on the log-transformed scale (LMD) with 95% CIs. We pooled data across studies using meta-analysis where possible. MAIN RESULTS We included 13 completed studies, of which 11 were RCTs assessing safety (2666 participants) and two were time-series studies. We judged eight RCTs to be at unclear risk of bias and three at high risk. All RCTs were funded by tobacco companies. Median length of follow-up was 13 weeks. No studies reported smoking cessation outcomes. There was insufficient evidence for a difference in risk of adverse events between smokers randomised to switch to heated tobacco or continue smoking cigarettes, limited by imprecision and risk of bias (RR 1.03, 95% CI 0.92 to 1.15; I2 = 0%; 6 studies, 1713 participants). There was insufficient evidence to determine whether risk of serious adverse events differed between groups due to very serious imprecision and risk of bias (RR 0.79, 95% CI 0.33 to 1.94; I2 = 0%; 4 studies, 1472 participants). There was moderate-certainty evidence for lower NNAL and COHb at follow-up in heated tobacco than cigarette smoking groups, limited by risk of bias (NNAL: LMD -0.81, 95% CI -1.07 to -0.55; I2 = 92%; 10 studies, 1959 participants; COHb: LMD -0.74, 95% CI -0.92 to -0.52; I2 = 96%; 9 studies, 1807 participants). Evidence for additional biomarkers of exposure are reported in the main body of the review. There was insufficient evidence for a difference in risk of adverse events in smokers randomised to switch to heated tobacco or attempt abstinence from all tobacco, limited by risk of bias and imprecision (RR 1.12, 95% CI 0.86 to 1.46; I2 = 0%; 2 studies, 237 participants). Five studies reported that no serious adverse events occurred in either group (533 participants). There was moderate-certainty evidence, limited by risk of bias, that urine concentrations of NNAL at follow-up were higher in the heated tobacco use compared with abstinence group (LMD 0.50, 95% CI 0.34 to 0.66; I2 = 0%; 5 studies, 382 participants). In addition, there was very low-certainty evidence, limited by risk of bias, inconsistency, and imprecision, for higher COHb in the heated tobacco use compared with abstinence group for intention-to-treat analyses (LMD 0.69, 95% CI 0.07 to 1.31; 3 studies, 212 participants), but lower COHb in per-protocol analyses (LMD -0.32, 95% CI -1.04 to 0.39; 2 studies, 170 participants). Evidence concerning additional biomarkers is reported in the main body of the review. Data from two time-series studies showed that the rate of decline in cigarette sales accelerated following the introduction of heated tobacco to market in Japan. This evidence was of very low-certainty as there was risk of bias, including possible confounding, and cigarette sales are an indirect measure of smoking prevalence. AUTHORS' CONCLUSIONS No studies reported on cigarette smoking cessation, so the effectiveness of heated tobacco for this purpose remains uncertain. There was insufficient evidence for differences in risk of adverse or serious adverse events between people randomised to switch to heated tobacco, smoke cigarettes, or attempt tobacco abstinence in the short-term. There was moderate-certainty evidence that heated tobacco users have lower exposure to toxicants/carcinogens than cigarette smokers and very low- to moderate-certainty evidence of higher exposure than those attempting abstinence from all tobacco. Independently funded research on the effectiveness and safety of HTPs is needed. The rate of decline in cigarette sales accelerated after the introduction of heated tobacco to market in Japan but, as data were observational, it is possible other factors caused these changes. Moreover, falls in cigarette sales may not translate to declining smoking prevalence, and changes in Japan may not generalise elsewhere. To clarify the impact of rising heated tobacco use on smoking prevalence, there is a need for time-series studies that examine this association.
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Affiliation(s)
- Harry Tattan-Birch
- Department of Behavioural Science and Health, University College London, London, UK
| | - Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Loren Kock
- Department of Behavioural Science and Health, University College London, London, UK
| | - Erikas Simonavicius
- Department of Addictions, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Leonie Brose
- Department of Addictions, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Sarah Jackson
- Department of Behavioural Science and Health, University College London, London, UK
| | - Lion Shahab
- Department of Behavioural Science and Health, University College London, London, UK
| | - Jamie Brown
- Department of Behavioural Science and Health, University College London, London, UK
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21
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Choi S, Lee K, Park SM. Combined Associations of Changes in Noncombustible Nicotine or Tobacco Product and Combustible Cigarette Use Habits With Subsequent Short-Term Cardiovascular Disease Risk Among South Korean Men: A Nationwide Cohort Study. Circulation 2021; 144:1528-1538. [PMID: 34601948 DOI: 10.1161/circulationaha.121.054967] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The associations of changes in noncombustible nicotine or tobacco product (NNTP) and combustible cigarette (CC) use habits with subsequent cardiovascular disease (CVD) risk are still unclear. METHODS The study population consisted of 5 159 538 adult men who underwent health screening examinations during both the first (2014-2015) and second (2018) health screening periods from the Korean National Health Insurance Service database. All participants were divided into continual CC-only smokers, CC and NNTP users, recent (<5 years) CC quitters without NNTP use, recent CC quitters with NNTP use, long-term (≥5 years) CC quitters without NNTP use, long-term CC quitters with NNTP use, and never smokers. Propensity score matching analysis was conducted to further compare CVD risk among CC quitters according to NNTP use. Starting from the second health screening date, participants were followed up until the date of CVD event, death, or December 31, 2019, whichever came earliest. Multivariable Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% CIs for CVD risk according to changes in NNTP and CC smoking habits. RESULTS Compared with continual CC-only smokers, CC and NNTP users (aHR, 0.83 [95% CI, 0.79-0.88]) and initial CC smokers who quit CCs and switched to NNTP use only (recent CC quitters with NNTP use, aHR, 0.81 [95% CI, 0.78-0.84]) had lower risk for CVD. After propensity score matching, recent CC quitters with NNTP use (aHR, 1.31 [95% CI, 1.01-1.70]) had higher risk for CVD than recent CC quitters without NNTP use. Similarly, compared with long-term CC quitters without NNTP use, long-term CC quitters with NNTP use (aHR, 1.70 [95% CI, 1.07-2.72]) had higher CVD risk. CONCLUSIONS Switching to NNTP use among initial CC smokers was associated with lower CVD risk than continued CC smoking. On CC cessation, NNTP use was associated with higher CVD risk than CC quitting without NNTPs. Compared with CC smokers who quit without NNTP use, CC quitters who use NNTPs may be at higher future CVD risk.
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Affiliation(s)
- Seulggie Choi
- Department of Biomedical Sciences (S.C., S.M.P.), Seoul National University College of Medicine, South Korea
| | - Kiheon Lee
- Department of Family Medicine (K.L., S.M.P.), Seoul National University College of Medicine, South Korea
- Department of Family Medicine, Seoul National University Bundang Hospital, South Korea (K.L.)
| | - Sang Min Park
- Department of Biomedical Sciences (S.C., S.M.P.), Seoul National University College of Medicine, South Korea
- Department of Family Medicine (K.L., S.M.P.), Seoul National University College of Medicine, South Korea
- Department of Family Medicine, Seoul National University Hospital, South Korea (S.M.P.)
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22
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Miller CR, Sutanto E, Smith DM, Hitchman SC, Gravely S, Yong HH, Borland R, O'Connor RJ, Cummings KM, Fong GT, Hyland A, Quah ACK, Goniewicz ML. Characterizing heated tobacco product use among adult cigarette smokers and nicotine vaping product users in the 2018 ITC Four Country Smoking & Vaping Survey. Nicotine Tob Res 2021; 24:493-502. [PMID: 34669964 DOI: 10.1093/ntr/ntab217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Heated tobacco products (HTP) have diversified global tobacco markets, and user characteristics remain understudied. This study evaluated sociodemographic characteristics, nicotine-related perceptions and behaviors of current HTP users within a sample of adult (18+ years) nicotine users across four countries. METHODS Data were from current smokers or nicotine vaping product (NVP; known as "e-cigarettes") users from Canada, England, the United States and Australia (n=11,421) who participated in the 2018 ITC Four Country Smoking and Vaping Survey. Current (at-least-monthly) HTP users were characterized (n=441), and weighted multivariable logistic regressions examined correlates of HTP use. RESULTS Compared to non-users, current HTP users were younger (mean age: 44.4 vs 31.0 years; p<0.001) and had higher socioeconomic status (p<0.001). A majority of current HTP users used HTPs non-daily (daily: 40.3% vs non-daily: 59.7%). Most HTP users concurrently used both cigarettes and NVPs (90.5%). Among concurrent cigarette-HTP-NVP users, 36.2% used all three products daily. Use of other combusted tobacco products (cigars, cigarillos, pipe, waterpipe/hookah), cannabis, and binge drinking were each associated with current HTP use. HTP use was more common among smokers intending to quit within 6 months or reporting a quit attempt in the past 18 months, and vapers who had experienced negative side effects. CONCLUSION HTP users in this sample tended to be younger and more affluent. Most reported concurrent use of multiple nicotine products and other substances. Those cigarette smokers who used HTPs appeared more interested in smoking cessation, while some characteristics of concurrent HTP-NVP users were suggestive of dissatisfaction with NVPs. IMPLICATIONS Few studies have scrutinized characteristics of HTP early-adopters in emerging markets. Our results indicate that in 2018, characteristics of established nicotine users who adopted HTP use in four high-income Western countries mirror those of HTP users in East Asian markets (South Korea and Japan) where HTPs are popular. HTP users reported high levels of concurrent use of non-cigarette combusted tobacco products (e.g., cigars, pipe tobacco). These findings point to the need for future longitudinal studies of HTP use given the implications of those use patterns on the harm reduction potential of HTPs. HTP user characteristics may yield important information to consider in regulation of these products.
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Affiliation(s)
- Connor R Miller
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Edward Sutanto
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Danielle M Smith
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Sara C Hitchman
- Department of Addictions, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Shannon Gravely
- Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
| | - Hua-Hie Yong
- School of Psychology, Deakin University, Geelong, Victoria, Australia.,Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Ron Borland
- Cancer Council Victoria, Melbourne, Victoria, Australia.,School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Richard J O'Connor
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - K Michael Cummings
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Geoffrey T Fong
- Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada.,School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.,Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Andrew Hyland
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Anne C K Quah
- Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
| | - Maciej L Goniewicz
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
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23
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Laverty AA, Vardavas CI, Filippidis FT. Prevalence and reasons for use of Heated Tobacco Products (HTP) in Europe: an analysis of Eurobarometer data in 28 countries. THE LANCET REGIONAL HEALTH. EUROPE 2021; 8:100159. [PMID: 34557853 PMCID: PMC8454644 DOI: 10.1016/j.lanepe.2021.100159] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Heated Tobacco Products (HTP) are a relatively new class of tobacco products, with limited data on usage patterns. We assessed the prevalence and reasons for use among persons aged ≥15 years in 27 European Union member states and the United Kingdom·. METHODS The 2020 Eurobarometer (93·2) survey was analysed (n=28,300, aged ≥15). Multi-level regression analyses assessed socio-demographic differences in use while separate analyses investigated reasons for starting to use HTP. Results are presented as adjusted Odds Ratios (aOR) and weighted percentages with 95% Confidence Intervals (95%CI). FINDINGS Overall, 6·5% (95% CI 6·1;7·0) of participants had ever used a HTP. 1·3% (1·1%;1·5%) of participants were current users of HTP, and 0·7% (0·6% to 0·9%) daily users. Current and former tobacco smokers were more likely than never tobacco smokers to use HTP (aOR 36·3 (22·9;57·5), and 7·3 (4·3;12·3) respectively. Youth aged 15-24 years of age were substantially more likely to report use, e.g. aOR for ever use=7·77 (6·56;9·21) compared to those aged ≥55 years. 51·3% of ever HTP users reported at least weekly concurrent use of combustible tobacco. Among those who reported ever use of HTP, but not e-cigarettes, the most popular reason for use was the perception that HTP are less harmful than smoking tobacco (39·5%), followed by use by friends (28·4%) and stopping or reducing smoking (28·2%). INTERPRETATION Considerable numbers of people in the EU have ever used HTP, although current and daily use remains low. Current use is more common among younger people, and current and former smokers. FUNDING None.
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Affiliation(s)
- Anthony A. Laverty
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, United Kingdom
| | - Constantine I. Vardavas
- Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, MA, USA
- School of Medicine, University of Crete, Greece
| | - Filippos T. Filippidis
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, United Kingdom
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24
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Lee J. Nicotine Dependence of Electronic Cigarette, Dual Combustible and Electronic Cigarette Users. Korean J Fam Med 2021; 42:189-190. [PMID: 34038986 PMCID: PMC8164930 DOI: 10.4082/kjfm.42.3e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jungun Lee
- Department of Family Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea
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25
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Yi J, Lee CM, Hwang SS, Cho SI. Prevalence and predictors of heated tobacco products use among male ever smokers: results from a Korean longitudinal study. BMC Public Health 2021; 21:316. [PMID: 33557796 PMCID: PMC7871562 DOI: 10.1186/s12889-021-10344-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 01/27/2021] [Indexed: 12/04/2022] Open
Abstract
Background This study examined sociodemographic and tobacco-related factors of heated tobacco products (HTPs) use among adult ever smokers in South Korea where the sales of HTPs have been rapidly increasing since their launch in June 2017. Methods Before the launch of HTPs in Korea, participants comprised male ever smokers (234 current smokers and 37 quitters) who participated in the Korea National Health and Nutrition Examination Survey from 2015 to 2017 through one-to-one interview survey and agreed to participate in the follow-up surveys through telephone in December 2017. Data were analyzed using logistic regression, to explore sociodemographic and smoking behavior-related factors of HTPs use. Results Overall, 10.7% (29/271) of participants responded to using HTPs and 8.1% (22/271) were current HTPs users at the time of the follow-up survey. Multivariate analysis showed that HTPs use is associated with middle age (36 to 49 years old) (aOR = 3.72, CI = 1.16–12.0) (vs. ≥ 50 years), higher income (4Q vs 1Q: aOR = 2.71, CI = 1.16–6.34), and higher educational level (college or higher: aOR = 2.40, CI = 0.87–6.60). Also, vaping experience at baseline was highly associated with HTPs use (aOR = 3.11, CI = 1.22–7.93 for the former experience; aOR = 9.14, CI = 2.34–35.6 for current). However, smoking amount and level of motivation for smoking cessation were not found to be predictors of future HTPs use when limited to current smokers at baseline. Conclusions The results showed that vaping experience regardless of current smoking behavior and higher socioeconomic status were found to be associated with subsequent HTPs use among ever smokers. Further studies are required to explore whether this association is causal.
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Affiliation(s)
- Jeeeun Yi
- Division of Public Health Science, Graduate School of Public Health, Seoul National University, 1, Gwanak-ro, Gwanak-gu, Seoul, Republic of Korea
| | - Cheol Min Lee
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, 39th Fl, Gangnam Finance Center, 152, Teheran-ro, Gangnam-gu, Seoul, 06236, Republic of Korea.
| | - Seung-Sik Hwang
- Division of Public Health Science, Graduate School of Public Health, Seoul National University, 1, Gwanak-ro, Gwanak-gu, Seoul, Republic of Korea
| | - Sung-Il Cho
- Division of Public Health Science, Graduate School of Public Health, Seoul National University, 1, Gwanak-ro, Gwanak-gu, Seoul, Republic of Korea
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26
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Kim JY. Directions and Challenges in Smoking Cessation Treatment. Tuberc Respir Dis (Seoul) 2020; 83:S1-S5. [PMID: 33261242 PMCID: PMC7837376 DOI: 10.4046/trd.2020.0150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 12/02/2020] [Indexed: 02/01/2023] Open
Abstract
Raising the tax on tobacco-related products is the most effective and sustainable intervention for smoking cessation. The 2015 tobacco-tax increase resulted in a decreased smoking rate among Korean adult men. However, participation in the government-sponsored smoking-cessation programs developed after the 2015 tobacco tax increase has declined sharply since 2018. The popularity of electronic cigarettes (e-cigarettes) seems to be an important factor in this decline. Indeed, the market share of e-cigarettes has increased steadily since 2007, when the e-cigarette was introduced in Korea as a vaporizer. The introduction of the tobacco-heating device IQOS in 2017 resulted in the skyrocketing popularity of e-cigarettes, especially among the young generation of Koreans. The U.S. Food and Drug Administration (FDA) authorized marketing of IQOS as a “reduced exposure” tobacco product on July 7, 2020, further complicating smoking-cessation efforts. The agency announced that IQOS produces fewer or lower levels of some toxins than combustible cigarettes. However, FDA authorization does not mean that these products are safe. There is no evidence that reducing the harmful chemical components leads to health benefits. Clinicians need to maintain the position that those who smoke, regardless of tobacco-product type, should be counseled for smoking cessation and prescribed appropriate proven pharmacologic agents.
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Affiliation(s)
- Jae Yeol Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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27
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Lee CM, Kim CY, Lee K, Kim S. Are Heated Tobacco Product Users Less Likely to Quit than Cigarette Smokers? Findings from THINK (Tobacco and Health IN Korea) Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8622. [PMID: 33233606 PMCID: PMC7699694 DOI: 10.3390/ijerph17228622] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 01/08/2023]
Abstract
Since the advent of heated tobacco products in June 2017 in South Korea, the sale of heated tobacco products accounted for 10.5% of total tobacco sales in 2019. However, the decreasing trend in total tobacco sales is gradually weakening and the number of visitors using stop smoking services has also dropped. This study examines the association between the use of new tobacco products and related products and cessation behaviors. A cross-sectional study using a self-administered questionnaire was conducted from March 2019 to July 2019 for 2831 adult tobacco users. The difference in rates of quit attempts using the type of tobacco products and related products in the past year were noted (55.6% (any cigarette smoker), 46.7% (any e-cigarette user), and 39.6% (any heated tobacco product user)). About a 30% increase in quit attempts was observed for the triple users of either conventional cigarette or heated tobacco product than exclusive users. Exclusive heated tobacco product and e-cigarette users were approximately 40% and 20% less likely to quit the product they used than exclusive cigarette smokers, respectively. These findings can explain recent occurrences in South Korea, such as the reduction of visitors at smoking cessation clinics and the attenuation of the decline in tobacco sales.
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Affiliation(s)
- Cheol Min Lee
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul 06236, Korea;
| | - Choon-Young Kim
- Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea;
| | - Kiheon Lee
- Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea;
- Department of Family Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Sungroul Kim
- Department of Environmental Health Sciences, Soonchunhyang University, Asan 31538, Korea;
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