Standard smokeless tobacco packaging: potential impact on perceived attractiveness, warning label visibility and harm perceptions among adults in Bangladesh

BACKGROUND

In Bangladesh, smokeless tobacco (SLT) is available in a variety of pack shapes and sizes. Lack of standard packaging could limit compliance with pictorial health warning label (HWL) requirements. We explored Bangladeshi SLT users' and non-users' perceptions of a proposed standard pack shape for gul (tobacco powder) and zordha (chewing tobacco), including the role that HWL placement plays on harm perceptions.

METHODS

We conducted 28 focus groups across three regions of Bangladesh: Dhaka, Sylhet and Khulna. Groups were stratified equally by urban/rural residence, gender and SLT use. Trained facilitators used a standardised guide to discuss perceived attractiveness, noticeability of HWLs and perceived harm of current versus standard packs.

RESULTS

Most groups found bright colours, 'brand owner' portrait imagery, and strong, sturdy pack material of current packs attractive. Many of the same features increased perceived attractiveness of the standard packs. Pictorial HWLs on the standard packs appeared larger and increased the visibility and noticeability of HWLs compared with current packs. Lack of HWLs or limited visibility of HWL due to discolouration contributed to lower levels of perceived harm of the current packs. In contrast, HWL prominence and placement on both sides of the standard pack increased perceived harm of standard packs.

CONCLUSION

The findings suggest a standard shape and size for SLT sold in Bangladesh, coupled with proper implementation of HWLs per the law, could improve HWL noticeability and increase harm perceptions. Additional plain packaging policies that also standardise pack colour may be required to reduce attractive colours and branding.

Comparison between moyamoya disease and moyamoya syndrome in Israel

BACKGROUND AND AIMS

Moyamoya is a chronic brain vasculopathy involving the distal intracranial internal carotid artery (ICA) or proximal middle cerebral artery (MCA). Moyamoya patients can be divided into those with primary moyamoya disease (MMD) and those with moyamoya secondary to other known causes such as intracranial atherosclerosis (moymoya syndrome [MMS]). Our aim was to compare the characteristics of MMD patients to those of MMS patients in a sample of Israeli patients seen over the course of 20 years at a tertiary referral center.

METHODS

Included patients were diagnosed with either MMD or MMS based on typical imaging findings and the presence or absence of known concomitant vascular risk factors or associated disorders and vascular disease. Patients with MMS were compared to those with MMD. Demographics, symptoms, signs, and radiological data were compared between the groups. Treatment options and long-term rates of recurrent stroke and functional outcome were also studied.

RESULTS

Overall, 64 patients were included (25 MMD, 39 MMS). Patients with MMD were significantly younger (median IQR 20 (7-32) vs. 40 (19-52); p=0.035). Patients with MMS more often had vascular risk factors but there were no significant differences in clinical presentations or long-term disability rates between the groups and a similar proportion of patients underwent surgical interventions to restore hemispheric perfusion in both groups (48% vs. 44% MMS vs. MMD; p=0.7). Almost one in four patient had a recurrent stroke after the initial diagnosis in both groups. Most recurrences occurred in the pre-surgery period in the MMS group and in the post-surgery period in the MMD group.

CONCLUSIONS

There were no statistically significant differences in clinical or radiological presentations between the MMS and MMD patients. The course is not benign with recurrent stroke occurring in as many as 25%. More data is needed in order to identify those at high risk for stroke occurrence and recurrence.

Monday-Enhanced CEASE Program for Underserved Ethnic Minorities: a Mixed-Methods Study

BACKGROUND

Due to the persistence of tobacco-related health disparities in the U.S., there is a need for innovative strategies to reach the underserved ethnic minority populations who are most at risk. As contemplations for health behavior modification tend to surge on Mondays, we explored the feasibility and effect of a Monday-enhanced smoking cessation program on quitting outcomes in a low-income ethnic minority community.

AIMS

To compare a Monday-enhanced with a standard Communities Engaged and Advocating for a Smoke-free Environment (CEASE) program and understand the overall experiences of participants in the program.

METHODS

In this mixed-methods study, affordable housing complexes (n = 4) and a church were randomly assigned either a Monday-enhanced (n = 3) or standard (n = 2) CEASE smoking cessation program. CEASE comprised twelve weekly group counseling sessions facilitated by trained peer motivators plus nicotine replacement products. Participants in the Monday-enhanced arm were encouraged to pick Mondays as a quitting day. Quantitative and qualitative data were collected during the program and at 3-month post-graduation.

RESULTS

Seventy-seven participants were enrolled in the study arms. In both groups combined, tobacco consumption reduced from 7.7 to 5.6 cig/day (mean reduction, 2.1; 95% CI: 0.9 to 5.1, p = 0.08). Although no significant difference in quit rate was observed between the two arms, more participants completed the follow-up survey in the Monday-enhanced than standard CEASE program [82.4% vs. 36.0%, p < 0.05]. While qualitative data suggested an overall satisfaction of participants with the program, motivation for quitting was higher in the Monday-enhanced CEASE program compared to the standard CEASE program.

CONCLUSION

The Monday-enhanced program is promising and may enhance participants' engagement and willingness to quit smoking, particularly in low-income ethnic minority communities. Further research should include larger sample sizes to better assess the efficacy of a Monday-enhanced program across diverse populations.

Exposure to and Appeal of Tobacco Ads and Displays in China: A Qualitative Exploration of Chinese Youth Perceptions

INTRODUCTION

Adolescents are uniquely vulnerable to nicotine addiction, and smoking is common among male adolescents in China. Although China implemented a ban on cigarette and e-cigarette advertising in public places, Chinese youth remain exposed to this marketing, which may contribute to future use.

AIMS AND METHODS

From December 2021 to January 2022, we conducted 20 online focus group discussions with 119 adolescents in 10 Chinese cities to explore sources of tobacco marketing exposure, defined as exposure to cigarette and e-cigarette ads and product displays, and what features made marketing attractive.

RESULTS

All groups discussed exposure to tobacco ads/displays in public places, including locations near their home or school. Nearly all groups discussed that exposure to online tobacco ads was common, particularly exposure to e-cigarette commercial ads and posts made by classmates or friends selling e-cigarettes. Most groups identified how eye-catching colors, imagery, product packaging, and price promotions featured in e-cigarette ads/displays attracted their attention.

CONCLUSIONS

Results suggest Chinese adolescents are exposed to cigarette and e-cigarette ads and displays, many of which are placed in youth-friendly locations and contain youth-appealing features.

IMPLICATIONS

Only a handful of studies have examined the influence of cigarette and e-cigarette advertising on youth in the context of China. Prior research has established the relationship between youth exposure to tobacco marketing and increased susceptibility to future use. Our findings emphasize the importance of effectively enforcing and expanding restrictions on cigarette and e-cigarette marketing in order to protect youth from exposure and future smoking/vaping initiation.

Decisions of the FDA on premarket tobacco product applications: Changes in the number of unique devices and liquids used by US adults who frequently use electronic nicotine delivery systems, 2020-2023

INTRODUCTION

The majority of decisions on electronic nicotine delivery system (ENDS) premarket tobacco product applications (PMTAs) were made from October 2020 to February 2023; 99% (>25 million) had determinations by March 2023 and just twenty-three received marketing granted orders. We examined the unique devices and liquids used among US adults frequently using ENDS before, during, and after a majority of PMTA decisions were made.

METHODS

Data are from waves 1-5 (W1: May-Oct 2020, n=1179; W5: Feb-Apr 2023, n=1290) of a longitudinal survey of US adults (≥21 years) using ENDS ≥5 days/week. User-submitted photos of participants' most used devices and liquids were coded. Descriptive analyses and Wilcoxon signed-rank tests were used to understand the number and types of unique devices and liquids used in W1-W5, and the top brands in each wave.

RESULTS

From W1-W5, the number of unique ENDS device models and liquid products used by participants increased from 279 to 357 (p<0.001) and 546 to 695 (p<0.001), respectively. More unique devices in W5 versus W1 were disposable (W1: 16.5%; W5: 36.1%); fewer were disposable pod (W1: 6.5%; W5: 3.1%) or tank (W1: 53.8%; W5: 30.8%) devices. Liquids were primarily sweet-flavored (W1: 81.1%; W5: 82.0%). The median liquid nicotine concentration increased from 12 to 50 mg/mL. In W5, few participants used FDA-approved devices (n=17; 1.3%) or liquids (n=6; 0.5%), and Elf Bar was the most commonly used device and liquid brand. Results for all waves are reported.

CONCLUSIONS

Despite PMTA decisions, an increase in the number of unique device models and liquid products used among adults who frequently use ENDS was observed from 2020 to 2023. Few participants in 2023 were using FDA-approved devices or liquids. Further research and monitoring are needed to inform how FDA prioritizes enforcement actions and what types of enforcement actions are effective.

Testing messaging strategies to correct beliefs about nicotine and relative harm perceptions of non-cigarette tobacco products compared to cigarettes: A 2 × 2 factorial experiment of factsheets

INTRODUCTION

The misperception that nicotine is a major cause of cancer is common and may relate to inaccurate relative harm perceptions about tobacco products. To assess if messaging can correct these misperceptions, we tested factsheets that manipulated presences vs absence of (1) a causal alternative (i.e., combustion, not nicotine, causes disease) and/or (2) a reason for the misinformation (i.e., nicotine is the focus of many health messages).

METHODS

We used an online 2 × 2 factorial experiment of n = 193 adults who smoke and believe nicotine causes cancer to assess the effect of different message strategies on perceptions of tobacco products and switch intention. Pre-post differences and between-condition differences were assessed.

RESULTS

Strength of agreement with the statement that nicotine is a major cause of cancer decreased and switch intentions increased after message exposure. The proportion of participants with low relative harm perceptions increased for e-cigarettes and smokeless tobacco (p <.0001) and decreased for very low nicotine cigarettes compared to cigarettes. The message with both strategies decreased agreement that nicotine causes cancer more than the message with only the causal alternative. There was no significant effect of condition on relative harm beliefs or switch intentions.

CONCLUSIONS

Messages with both corrective strategies can reduce the belief that nicotine causes cancer to a greater extent than messaging that only contains a causal alternative. Belief accuracy increased after any message exposure, but these findings should be interpreted cautiously given the study design. Combined strategies should be further investigated in larger samples.

Menthol and Other Flavor Chemicals in Cigarettes from Vietnam and the Philippines

INTRODUCTION

Tobacco product flavors can increase product appeal, adolescent initiation and experimentation, and difficulty quitting. Flavored tobacco products are not restricted in Vietnam or the Philippines despite the high smoking prevalence among those 15 years of age and older (24% and 23%, respectively). There are no published reports to our knowledge on the levels of flavor chemicals in the cigarettes sold in these two countries.

METHODS

Cigarettes were purchased in Vietnam (32 brand variants) and the Philippines (19 brand variants) during 2020. Chemical analyses gave the mg/filter, mg/rod, and mg/stick (= mg/(filter + rod)) values for 180 individual flavor chemicals. Values were calculated for menthol, clove-related compounds, and "other flavor chemicals" (OFCs).

RESULTS

Five flavor groupings were found among the brand variants purchased in Vietnam: menthol + OFCs (n = 15), OFCs only (n = 8), nonflavored (n = 7), menthol + OFCs with a clove flavorant (n = 1) and menthol only (n = 1). Three flavor groupings were found among the brand variants purchased in the Philippines: menthol + OFCs (n = 10), nonflavored (n = 5), and menthol only (n = 4).

CONCLUSIONS

A range of flavored cigarette products are being offered by tobacco companies in Vietnam and the Philippines, presumably to maximize cigarette sales. Regulation of flavor chemicals should be considered in these two countries.

IMPLICATIONS

Article 9 of the WHO Framework Convention on Tobacco Control (FCTC), ratified by both Vietnam and the Philippines, states that "there is no justification for permitting the use of ingredients, such as flavoring agents, which help make tobacco products attractive." Flavors increase product appeal, adolescent initiation and experimentation, and difficulty quitting. These analyses found that cigarettes purchased in Vietnam and the Philippines contained menthol and other flavor chemicals. Tobacco companies are offering multiple flavor chemical profiles and nominally nonflavored versions in these countries; regulation of flavor chemicals should be considered in these two countries.

Culturally specific health-related features on cigarette packs sold in China

BACKGROUND

China is the country with the highest burden of tobacco-caused disease. We characterised the extent to which cigarette pack marketing features (eg, imagery, text, pack color) could potentially mislead consumers by suggesting products are healthy.

METHODS

We used two methods: group concept mapping and content analysis. First, we used a group concept mapping approach to generate and sort Chinese consumer responses to an open-ended prompt asking what marketing features suggest a product is 'healthy' or 'good for you'. Second, based on the concept mapping results, we developed a codebook of health-related features on cigarette packs that were relevant to the unique cultural context of product marketing in China. Two trained coders who were native Chinese speakers double-coded a sample of 1023 cigarette packs purchased in 2013 (wave 1) and 2017 (wave 2). We examined differences in the presence of features overall and over time.

RESULTS

Overall, 83.5% (n=854) of Chinese cigarette packs in our sample contained at least one 'healthy' or 'good for you' feature, and the presence of health-related features on packs remained constant between wave 1 (83.5%, n=354) and wave 2 (83.5%, n=500; p=1.00). Across both waves, the most common categories of culturally specific health features present related to recycling symbols, rare animal imagery, bright colours (eg, bright yellow) and botanical imagery (eg, bamboo, mint).

CONCLUSION

Health-related features on cigarette packs sold in China are common. Enhanced policies to address tobacco packaging, labelling and branding could support and facilitate a reduction in the high tobacco burden in China.

PMI-funded foundation for a smoke-free world: application of criteria to assess funding models that include financial support from the tobacco industry

Recent changes to the leadership and the terms of tobacco industry financing of the Foundation for a Smoke-Free World (FSFW) have called for a revisiting of a paper published in 2009 where we proposed criteria and other considerations to assess possible funding models for research that include financial support from the tobacco industry. This paper reviews and attempts to apply the elements laid out in 2009 to the current state of FSFW. After discussing each criterion and consideration we conclude that, at this point in time, conducting a thorough assessment using our 2009 paper is not possible because critical details related to FSFW governance, decision-making and process have not been announced. Nonetheless, we hope this paper will remind the tobacco control community that the 2009 criteria exist and highlight the information needed and questions that might be asked of FSFW to help form judgements about this new iteration of the foundation. We further hope this will put the FSFW on notice that they need to address each of these criteria and speak publicly about their plans regarding the specific issues raised in the 2009 paper.

Tobacco product litter as a form of postconsumption marketing: an observational study in India

BACKGROUND

Tobacco product litter may be a form of postconsumption marketing if the littered items are branded. We conducted an observational study in India to assess the presence of tobacco product litter and determine the proportion that included branding.

METHODS

During November-December 2022, we identified tobacco product litter (cigarette/bidi butts and packaging; smokeless tobacco packaging) in nine Indian cities: Bengaluru, Bhubaneswar, Chennai, Delhi, Guwahati, Hyderabad, Lucknow, Mumbai and Patna. In each city, we conducted observations along 15 different routes, each approximately 250 m in distance, for a total of 135 observational routes. Data collectors classified each piece of tobacco litter (product/packaging) and recorded if the litter had visible branding, such as brand names and/or logos.

RESULTS

The study identified 17 261 pieces of tobacco product litter; SLT packaging comprised the largest proportion of the sample (62%), followed by cigarette butts (26%), bidi butts (8%), cigarette packaging (3%) and bidi packaging (1%). Across the sample, 81% (n=13 924) of the litter was branded. A brand was visible on most packaging for cigarettes (98%), bidis (97%) and SLT (86%), and present on 82% of cigarette butts and 26% of bidi butts.

CONCLUSION

This study found that the majority of tobacco product litter in India is branded, which could function as a form of postconsumption marketing. Plain and standardised packaging and banning branding features on filters would reduce tobacco litter branding.

E-Cigarette Dependence and Depressive Symptoms Among Youth

INTRODUCTION

Although the relationship between smoking and depression has been well-established, little is known about the association between use of e-cigarette and depression, particularly among youth and young adults. This study proposes that e-cigarette dependence, rather than simply use, serves as a potential stressor and may interact with pre-existing vulnerabilities to contribute to depression in youth, consistent with the diathesis-stress theory. This study examines the longitudinal association of vaping dependence and vaping frequency on depression symptoms among youth and young adults who have never smoked cigarettes.

METHODS

People who used e-cigarettes in the past month who reported never smoking a cigarette (N=1,226) aged between 16 and 25 years were followed longitudinally every 3 months for up to 1 year beginning in 2020. The Penn State E-Cigarette Dependence Index at time t was used to predict depression symptoms assessed using the Center for Epidemiologic Studies Depression Scale at time t+1.

RESULTS

A total of 32.1% reported vaping in the past month with the Penn State E-Cigarette Dependence Index score (M=8.5) and a Center for Epidemiologic Studies Depression Scale score (M=15.8). Higher vaping dependence scores were significantly associated with increased depression symptoms scores at follow-up among youth and adults (β=0.08; 95% CI=0.01, 0.15), controlling for baseline depression symptom scores and covariates. Although vaping dependence was highly associated with vaping frequency level, no significant association between the frequency of vaping and depression was found (β= -0.33; 95% CI= 1.21, 0.54).

CONCLUSIONS

These results are consistent with the diathesis-stress model of the relationship between substance use and depression. Vaping dependence but not vaping frequency was associated with increased depressive symptoms among people who never smoked cigarettes.

Milestones in the natural course of the onset of e-cigarette dependence among adolescents and young adults: Retrospective study

INTRODUCTION

There is considerable controversy about the development of dependence among e-cigarette users. This study describes the average amount of time using e-cigarettes before dependence milestones emerge and the differences in developing dependence between e-cigarette users who smoke cigarettes compared to those who do not.

METHODS

Adolescents and young adults aged 16-25 living in Canada were recruited into an online survey in 2021. Current (past-month) e-cigarette users completed 15 items assessing dependence from the Penn-State Electronic Cigarette Dependence Index and the E-cigarette Dependence Scale for a total of 12 behavioural (e.g., difficulty refraining from vaping) and 3 frequency (e.g., using e-cigarette daily, weekly, or monthly) indicators of dependence milestones. Number of years after e-cigarette onset at which the cumulative probability of attaining each milestone was 25 % was computed.

RESULTS

Among 1205 participants, most (80.6 %) were female, 73.7 % were Caucasian, and 49.7 % resided in Ontario. Ten of the 12 e-cigarette use milestones were attained by 25 % of respondents 2 years after starting vaping except for daily cigarette use (2.5 years after onset) and waking at night to vape (5.6 years after onset). Within the entire study population, frequency milestones (weekly, monthly, daily e-cigarette use) were attained faster by ever-smokers (hazard ratio compared to attainment by never-smokers: 1.12, 1.21, and 1.28 respectively), whereas for at least monthly users, behavioural milestones were attained faster by never-smokers.

DISCUSSION

Many current e-cigarette users developed symptoms of e-cigarette dependence between two and five years since onset. Never smokers may be at higher risk of becoming e-cigarette dependent since they attained e-cigarette dependence milestones faster than smokers.

Heterogeneity in sociodemographic characteristics of people who use different ENDS devices

Background

The electronic nicotine delivery systems (ENDS) market is heterogeneous with a wide variety of devices and liquids available to consumers. People with distinct sociodemographic characteristics may have different ENDS device and liquid preferences.

Methods

1290 U.S. adults (21 + ) using ENDS 5 + days/week completed the Wave 5 (February-April 2023) VAPER study survey and submitted photos of their most used ENDS device and liquid. Latent class analysis (LCA) was performed based on sociodemographic characteristics and cigarette smoking status to identify groups among respondents. We examined the association between identified groups and the device (disposable device/disposable pod/refillable pod/tank, power/airflow/coil modifiability)/liquid (nicotine salt/freebase) groupings found by exploratory factor analysis.

Results

Among our sample, there were three groups of adults frequently using ENDS: (1) group of women who are older, heterosexual, and have smoked cigarettes (62 % of the sample); (2) group of men who are higher-income and heterosexual (23 % of the sample); and (3) group of women who are younger and LGBTQ+ (16 % of the sample). The third group was more likely to use non-adjustable disposable devices with a nicotine salt liquid and less likely to use adjustable tanks with a freebase liquid than the other two groups (p < 0.001).

Conclusions

We found three distinct groups of adults frequently using ENDS. The group of younger LGBTQ + women was different from the other two groups in use of device and liquid characteristics. Our findings can enhance understanding of people using ENDS and inform the expected impacts of ENDS regulatory efforts to protect public health.

Exploring Different Incentive Structures Among US Adults Who Use e-Cigarettes to Optimize Retention in Longitudinal Web-Based Surveys: Case Study

BACKGROUND

Longitudinal cohort studies are critical for understanding the evolution of health-influencing behaviors, such as e-cigarette use, over time. Optimizing follow-up rates in longitudinal studies is necessary for ensuring high-quality data with sufficient power for analyses. However, achieving high rates of follow-up in web-based longitudinal studies can be challenging, even when monetary incentives are provided.

OBJECTIVE

This study compares participant progress through a survey and demographics for 2 incentive structures (conditional and hybrid unconditional-conditional) among US adults using e-cigarettes to understand the optimal incentive structure.

METHODS

The data used in this study are from a web-based longitudinal cohort study (wave 4; July to September 2022) of US adults (aged 21 years or older) who use e-cigarettes ≥5 days per week. Participants (N=1804) invited to the follow-up survey (median completion time=16 minutes) were randomly assigned into 1 of 2 incentive structure groups (n=902 each): (1) conditional (US $30 gift code upon survey completion) and (2) hybrid unconditional-conditional (US $15 gift code prior to survey completion and US $15 gift code upon survey completion). Chi-square tests assessed group differences in participant progress through 5 sequential stages of the survey (started survey, completed screener, deemed eligible, completed survey, and deemed valid) and demographics.

RESULTS

Of the 902 participants invited to the follow-up survey in each group, a higher proportion of those in the conditional (662/902, 73.4%) than the hybrid (565/902, 62.6%) group started the survey (P<.001). Of those who started the survey, 643 (97.1%) participants in the conditional group and 548 (97%) participants in the hybrid group completed the screener (P=.89), which was used each wave to ensure participants remained eligible. Of those who completed the screener, 555 (86.3%) participants in the conditional group and 446 (81.4%) participants in the hybrid group were deemed eligible for the survey (P=.02). Of those eligible, 514 (92.6%) participants from the conditional group and 401 (89.9%) participants from the hybrid group completed the survey and were deemed valid after data review (P=.14). Overall, more valid completions were yielded from the conditional (514/902, 57%) than the hybrid group (401/902, 44.5%; P<.001). Among those who validly completed the survey, no significant differences were found by group for gender, income, race, ethnicity, region, e-cigarette use frequency, past 30-day cigarette use, or number of waves previously completed.

CONCLUSIONS

Providing a US $30 gift code upon survey completion yielded higher rates of survey starts and completions than providing a US $15 gift code both before and after survey completion. These 2 methods yielded participants with similar demographics, suggesting that one approach is not superior in obtaining a balanced sample. Based on this case study, future web-based surveys examining US adults using e-cigarettes could consider providing the full incentive upon completion of the survey.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/38732.

Tobacco retailers around schools in 10 cities across China

OBJECTIVE

This study explored the nature and extent of tobacco product availability at retailers near junior, senior and vocational high schools in rural and urban areas in 10 cities across China, including Shanghai, Beijing, Guangzhou, Chongqing, Shenyang, Jinan, Kunming, Guilin, Kaifeng and Baiyin.

METHODS

Tobacco sales at 1612 retailers around 904 schools (within 100 m for urban schools and within 250 m for rural schools) were observed by trained data collectors with an online observation form in 2021. Multistage sampling with simple random sampling at each stage was used to select schools from the city district-level/rural county-level divisions. χ2 tests and analyses of variance were used to analyse the data.

FINDINGS

Over half of urban schools (57.0%) and a large majority of rural schools (71.0%) had a cigarette retailer within a 100 m and a 250 m radius, respectively. Nearly all cigarette and electronic cigarette (e-cigarette) retailers displayed tobacco products inside. Majority of cigarette retailers (63.2%) sold flavoured cigarettes, of which 88.6% sold menthol/mint-flavoured cigarettes. Approximately half of these retailers did not display required signage prohibiting sales to minors. Overall, outcomes varied across cities and between urban and rural areas, but not by school type.

CONCLUSION

Display of tobacco products is very prevalent near schools in 10 cities across China. In contrast, compliance with posting 'no sales to minors' signs is low. Our findings suggest that effective enforcement of prohibiting tobacco retailers around schools and stronger restrictions on tobacco displays and flavoured cigarettes and e-cigarettes are needed to protect youth in China.

The Use of Packaging Descriptors in a Rapidly Growing Market for Capsule Cigarettes: Evidence From Mexico

INTRODUCTION

The global market for capsule cigarettes has grown rapidly, especially in Latin America. This research examined the sales trends and patterns as well as packaging characteristics of capsule cigarette in Mexico in recent years.

METHODS

National data on cigarette sales in Mexico between October 2018 and September 2021 licensed from NielsenIQ were supplemented with cigarette pack pictures and Internet searches to determine whether characterizing flavor, concept flavor, and action descriptors were used. Market share in sales value and volume was calculated by capsule and flavor status, descriptors, price tier, manufacturer, pack size, and cigarette length for the whole time period and for each month. Number of unique brand variants was also examined.

RESULTS

Capsule cigarette sales totaled US$4.29 billion or 30.99 billion sticks during the assessed period, comprising 37.7% of the cigarette market share in sales value or 35.5% in sales volume. Over half of capsule cigarettes sold during this time period had concept flavor descriptors, 17.8% contained characterizing flavor descriptors, and 15.1% contained action descriptors that were suggestive of the interactive aspects of capsules. The monthly market share of capsule cigarette sales volume among all cigarette sales in Mexico increased steadily from 33.3% in October 2018 to 37.3% in September 2021.

CONCLUSIONS

The expanding capsule cigarette market in Mexico is concerning, given the product's associated misconceptions of reduced harm and greater appeal among youth. Findings underline the need for enhanced regulations to address the public health threat posed by capsule cigarettes.

IMPLICATIONS

Capsule cigarettes have a substantial market share in Mexico, with increasing popularity. Descriptors and other product characteristics such as cigarette length might be used to increase the appeal and target particular populations. Policy makers should consider banning capsules and flavors in cigarettes including descriptors or other indication in product presentation that could be perceived as denoting a taste, aroma, or sensation, and making the appearance and design of tobacco products more commensurate with the harm they cause by adopting plain and standardized packaging.

Impact of Canada's menthol cigarette ban on quitting among menthol smokers: pooled analysis of pre-post evaluation from the ITC Project and the Ontario Menthol Ban Study and projections of impact in the USA

INTRODUCTION

Between 2015 and 2018, Canada banned menthol cigarettes. This study pooled data from two pre-post cohort studies (the Ontario Menthol Ban Study, and the International Tobacco Control Policy Evaluation (ITC) Canada Survey, conducted in seven provinces) to derive more precise estimates of the impact of Canada's menthol ban on quitting and to apply these estimates to project the impact of a menthol ban in the USA.

METHODS

Weighted multivariable logistic analyses compared post-ban quit success of menthol smokers with non-menthol smokers (for daily smokers and for all (daily + non-daily) smokers), controlling for sex, age, ethnicity, education, baseline smoking status, baseline cigarettes per day and study regions. Projections to the USA were created by multiplying the effect size of the Canadian menthol ban on quitting (percentage of increased quitting among menthol smokers) by the number of menthol smokers overall and among African Americans, from the 2019 National Survey on Drug Use and Health.

RESULTS

After the menthol cigarette ban, menthol smokers were more likely than non-menthol smokers to have quit smoking among daily smokers (difference=8.0%; 95% CI: 2.4% to 13.7%,p=0.005) and all (daily+non-daily) smokers (difference=7.3%; 95% CI: 2.1% to 12.5%,p=0.006). The projected number of smokers who would quit after a US menthol ban would be 789 724 daily smokers (including 199 732 African Americans) and 1 337 988 daily+non-daily smokers (including 381 272 African Americans).

CONCLUSIONS

This pooled analysis of Canada's menthol cigarette ban provides the foundation for estimating the impact of menthol bans in the USA and other countries. Projections suggest that a US menthol cigarette ban would have a substantial impact on increasing quitting.

Transitions in device and liquid characteristic groupings among US adults frequently using electronic nicotine delivery systems (ENDS) over three timepoints, 2020-2021

INTRODUCTION

Electronic nicotine delivery system (ENDS) and liquid characteristics affect nicotine and toxicant exposure and use behaviors. Little is known about how adults who frequently use ENDS transition between ENDS device/liquid groupings.

METHODS

A total of 379 US adults (≥21 years) using ENDS frequently (≥5 days/week) self-reported and uploaded photos of their most used ENDS device and liquid in three waves of online surveys (May 2020 - November 2021). Device/liquid grouping was defined by device (i.e. disposable/refillable tank/refillable pod or cartridge/disposable pod or cartridge, adjustable/no adjustable settings) and liquid (i.e. salt/freebase) characteristics. Participants using the same grouping across waves were considered stable users.

RESULTS

The most prevalent wave (W) 1 grouping was tank (freebase, adjustable settings; 36.8%). From W1 to W3, the number of disposable device (salt, no adjustable settings) users increased 156.4% and the number of disposable pod/cartridge (salt, no adjustable settings) users decreased 15.2%. In W2 and W3, compared to stable users, participants using tank (freebase, adjustable settings) in W1 and another grouping in W2 and/or W3 reported significantly higher nicotine concentrations (mg/mL) (W2: 15.1 vs 5.5, p<0.001; W3: 22.9 vs 5.6, p<0.001) and lower device power (watt) (W2: 46.8 vs 58.7, p=0.02; W3: 34.0 vs 57.2, p<0.001).

CONCLUSIONS

Over a 1.5-year period, a rapid growth in disposable device (salt, no adjustable settings) use and a decrease in disposable pod/cartridge (salt, no adjustable settings) use were observed. Participants who transitioned from tank (freebase, adjustable settings) to other groupings were more likely to increase liquid nicotine concentration and reduce device power compared to stable users.

Spinning a global web: tactics used by Big Tobacco to attract children at tobacco points-of-sale

Most of the published literature on cigarette advertising and promotion at points-of-sale is on research conducted in high-income countries. We report findings from monitoring cigarette advertising and promotion at points-of-sale near schools and playgrounds in 42 countries, the majority low-income and middle-income. Four strategies were detected across most of these countries: (1) display of cigarettes near snacks, sweets and sugary drinks, (2) placement of cigarette advertisements near the eye-level of children, (3) advertisements and display of flavoured cigarettes and (4) sale of single sticks of cigarettes. These advertising and promotional tactics target children and youth and demonstrate that multinational tobacco companies use similar strategies to promote cigarettes at points-of-sale. The widespread violations of existing laws and regulations, the exploitation of regulatory loopholes and lack of existing tobacco control policies that apply to points-of-sale call for adoption and enactment of provisions recommended by the WHO Framework Convention on Tobacco Control such as comprehensive bans on tobacco advertisement, promotion and sponsorship, bans on sale of single cigarette sticks and regulation of flavours. These strategies will help to protect children and youth from exposure to tobacco advertising.

Effects of tumor type on outcomes in patients with large vessel occlusion stroke and cancer

BACKGROUND

Large vessel occlusions (LVO) stroke is associated with cancer. Whether this association differs among patients with LVO that undergo endovascular thrombectomy (EVT) according to cancer type remains unknown.

PATIENTS AND METHODS

Data from consecutive patients that underwent EVT for LVO at three academic centers were pulled and analyzed retrospectively. Patients with LVO and solid tumors were compared to those with hematological tumors. Associations of cancer type with 90-day functional outcome and mortality were calculated in multivariable analyses.

RESULTS

Of the 154 patients with cancer and LVO that underwent EVT (mean age 74±11, 43% men, median NIHSS 15), 137 had solid tumors (89%) and 17 (11%) had hematologic tumors. Patients with solid cancer did not significantly differ from those with hematological malignancy in demographics, risk factor profile, stroke severity and subtype, and procedural variables. Outcome parameters including rates of favorable target recanalization and favorable outcome or mortality at discharge and 90 days post stroke were similar. Safety parameters including rates of symptomatic intracranial hemorrhage also did not differ between the groups. On regression analyses, controlling for various prognostic variables cancer type was not associated with mortality or favorable outcomes.

CONCLUSIONS

Our study suggests that the safety and efficacy of EVT in patients with malignancy does not depend on cancer type. Patients with malignancy should be considered for EVT regardless of cancer type.

Device and liquid characteristics used with sweet, menthol/mint, and tobacco ENDS liquid flavors: The population-based VAPER study

INTRODUCTION

Electronic nicotine delivery system (ENDS) device and liquid characteristics (e.g., wattage, nicotine concentration) are diverse and important in determining product appeal, aerosol volume/nicotine levels, and toxicity. Little is known about how device and liquid characteristics vary by flavor; we address this gap to identify potential regulatory implications.

METHODS

Data are from a longitudinal cohort study (Waves 2 and 3; December 2020-December 2021) of adult (≥21 years) U.S. ENDS users (≥5 days of use/week). Participants (n = 1809) reported on and submitted photos of their most used device and liquid. Participants were categorized into flavor groups of high prevalence in our sample and in prior literature: sweet, menthol/mint, or tobacco. Participants using liquids without nicotine or flavors other than sweet, menthol/mint, or tobacco were excluded (n = 320). Data were analyzed cross-sectionally. Chi-square and linear regression (n = 1489) were used to examine device and liquid characteristics by flavor.

RESULTS

Sweet flavors were most common (n = 1135; 76.2%), followed by menthol/mint (n = 214, 14.4%) and tobacco (n = 140, 9.4%). Sweet flavors were less common among participants using reusable devices with disposable pods/cartridges (nicotine salt) than those using other device-liquid groupings (5.2% vs 86.5-93.9%; p < 0.001). Sweet flavors were less common among those using ENDS for non-flavor reasons vs the flavor (73.5% vs 90.4%; p < 0.001). Sweet flavors correlated with lower nicotine concentrations, higher wattages, and lower ages of ENDS first use (p < 0.001).

CONCLUSIONS

Regulatory agencies must consider how regulations on device and liquid characteristics may affect ENDS users' behaviors (e.g., limiting availability of sweet flavors may encourage use of non-sweet flavors and lower wattages).

Assessing Electronic Nicotine Delivery Systems Device Type Accurately in Surveys

INTRODUCTION

The electronic nicotine delivery systems (ENDS) market is highly heterogeneous and changing rapidly in the United States, making classification of devices complicated, especially for surveys. We assessed the percentage of concordant responses between self-reported device type and device type reported by manufacturer/retailer sites for three ENDS brands.

AIMS AND METHODS

Population Assessment of Tobacco and Health Study wave 5 (2018-2019) asked adult ENDS users about their ENDS device type with the following multiple-choice question: "What kind of electronic nicotine product [is/was] it?" with response options: (1) A disposable device, (2) A device that uses replaceable prefilled cartridges, (3) A device with a tank that you refill with liquids (4) A mod system, and (5) Something else. Participants using only one ENDS device and reporting brands of JUUL (n = 579), Markten (n = 30), or Vuse (n = 47) were included. Responses were dichotomized as "concordant=1" (prefilled cartridge for these three brands) and "discordant = 0" (other responses) to assess the concordance.

RESULTS

The overall concordance between self-reports and manufacturer/retail sites was 81.8% (n = 537). This percentage was 82.7% (n = 37) among Vuse users, 82.6% (n = 479) among JUUL users, and 69.1% (n = 21) among Markten users. Almost one in three people who use Markten did not indicate that their device uses replaceable prefilled cartridges.

CONCLUSIONS

While at least 70% concordance could be acceptable, collecting more information about device type (eg, liquid container (pod/cartridge/tank), refillability; and submitting pictures) may improve the accuracy of the information.

IMPLICATIONS

This study is particularly relevant for researchers analyzing smaller samples for example when examining disparities. Monitoring the characteristics of ENDS accurately in population-based studies is critical for regulatory authorities to understand ENDS toxicity, addiction, health effects, and use behaviors at the population level. There is evidence that higher concordance can be achieved with other questions- and methods. Adjusting survey questions about ENDS device type (eg, more descriptive response options, inclusion of separate questions asking about tank, pod, cartridge) and potentially including photos of participants' devices may help to classify ENDS device types more accurately.

How Media Stories in Low- and Middle-Income Countries Discussed the U.S. Food and Drug Administration's Modified Risk Tobacco Product Order for IQOS

INTRODUCTION

In 2020, the U.S. Food and Drug Administration authorized the marketing of IQOS as a modified risk tobacco product (MRTP) with reduced exposure information (reduces exposure to harmful chemicals compared to cigarettes) but prohibited Philip Morris International from making reduced risk claims (reduces risk of disease compared to cigarettes). We aimed to assess how news media in low- and middle-income countries (LMICs) discussed this authorization and whether articles discussed IQOS as a reduced exposure versus reduced risk product.

AIMS AND METHODS

News articles published between July 7, 2020 and January 7, 2021 were obtained by searching Tobacco Watcher (www.tobaccowatcher.org), a surveillance platform for tobacco-related news. Articles were eligible if they were published in an LMIC and mentioned the IQOS MRTP order. Non-English language articles were professionally translated. Articles were double coded to identify country of origin, reduced risk and reduced exposure language, discussions of potential impacts of the authorization on regulations in LMICs, and quotes from tobacco industry and public health stakeholders.

RESULTS

We identified 50 eligible articles published in 20 LMICs. Twenty-six (52%) and 40 (80%) included reduced risk and reduced exposure language, respectively. Twenty-two (44%) discussed potential impacts of the MRTP order on regulations in LMICs. Thirty (60%) included quotes from tobacco industry representatives, 6 (12%) included quotes from public health or medical professionals, and 2 (4%) included both.

CONCLUSIONS

News articles in LMICs frequently misreported the MRTP order by using reduced risk language. The authorization is potentially being used to shape perspectives on tobacco regulations in LMICs. Tobacco control experts need to more frequently share their perspectives with the news media.

IMPLICATIONS

News articles from LMICs frequently misrepresented the IQOS MRTP order by using reduced risk language (reduces harm compared to cigarettes) rather than only using reduced exposure language (reduces exposure to harmful chemicals compared to cigarettes). Many articles referred to IQOS as a "better alternative" to cigarettes without specifically referencing reduced risk. Few articles included perspectives from public health or medical professionals, while most included tobacco industry quotes, suggesting that tobacco control experts need to more frequently engage with the news media. These findings also highlight how the U.S. FDA's actions can potentially shape perspectives on tobacco product regulations in LMICs.

Shared perceptions of flavored cigarette pack design among young adults who smoke in Mexico and the Philippines

INTRODUCTION

Tobacco industry documents reveal companies' knowledge of a similar young adult market across countries in terms of attitudes and lifestyle aspirations. Some tobacco companies, therefore, use similar marketing approaches across different jurisdictions. We examined young adults' perceptions of flavored cigarette packs, including those containing flavor capsules, in Mexico and the Philippines.

METHODS

We conducted a secondary analysis of five focus groups held in Mexico and four in the Philippines with young adults who smoke (aged 18-24 years), separated by gender, in which participants interacted with cigarette packs purchased locally. Transcribed and translated data were thematically analyzed and compared between countries.

RESULTS

Three major themes were identified: 1) Flavor capsules cigarettes are recognizable via pack design through imagery on the pack that is understood to signify capsules; 2) Colors signal flavor and make the pack attractive; and 3) Young adults who smoke identify the target audience for these products as young people and those who are beginning to smoke.

CONCLUSIONS

Young adults who smoke in Mexico and the Philippines interpreted flavored cigarette pack design similarly and thought that young people are the main audience for these products. This suggests a successful marketing approach creating shared perceptions of flavored cigarette packs in different world regions. It is likely that similar tactics are used in other countries around the world. Therefore, jurisdictions might use evidence from other jurisdictions to support the implementation of evidence-based tobacco control policies. These findings also support the implementation of plain and standardized packaging and flavor bans that would also limit product innovation such as capsules.

Effects of cigarette price and packaging on hypothetical quit-smoking behaviour: a discrete choice experiment among Vietnamese adults who smoke

INTRODUCTION

Raising cigarette prices, increasing graphic health warning label (HWL) coverage and requiring plain packaging could reduce cigarette smoking in Vietnam. This discrete choice experiment estimates the potential impact of these policies on smoking behaviour.

METHODS

In February-May 2022, we conducted a phone-based, cross-sectional survey of 1494 Vietnamese adults who smoke. Participants were randomly assigned to view four individual cigarette pack images, varied on price (15 000 (reference group); 20 000; 30 000 or 40 000 Vietnamese dong (VND)) and packaging (branded pack with 50% graphic HWL (reference group); branded pack with 85% graphic HWL; plain pack with 50% graphic HWL or branded pack without HWL). Participants responded if they would quit or continue smoking if they could only purchase the pack shown. We used binomial logistic regressions to estimate the relative risk (RR) of price and packaging on hypothetical quitting.

RESULTS

Participants were more likely to report they would quit when presented with 30 000 VND (RR 1.20, 95% CI 1.07 to 1.35) and 40 000 VND packs (RR 1.40, 95% CI 1.23 to 1.58) vs the 15 000 VND pack. Participants were also more likely to report they would quit when shown the branded pack with 85% HWL (RR 1.30, 95% CI 1.18 to 1.42) and plain pack with 50% HWL (RR 1.34, 95% CI 1.21 to 1.49) vs the branded pack with 50% HWL coverage. Participants had significantly lower quit likelihood (RR 0.41, 95% CI 0.35 to 0.48) when shown the branded pack without a HWL.

CONCLUSIONS

Results suggest raising cigarette prices to at least 30 000 VND, implementing larger graphic HWLs or plain packaging could decrease smoking rates in Vietnam.

Tobacco companies' creation of additional communication space: a content analysis of cigarette pack inserts and onserts

OBJECTIVES

Pack inserts and onserts-removable items placed inside or on the outside of packs-are a communicative strategy used by tobacco companies that provide them with additional marketing space. A content analysis of these items was conducted across several years, countries and brands to assess how these items are used to communicate with consumers.

METHODS

Between 2013 and 2020, cigarette packs were systematically collected using the Tobacco Pack Surveillance System protocol. Packs with inserts or onserts (n=178) were identified from 11 low and middle-income countries. Packs were coded for tobacco company strategies, physical pack characteristics and imagery and lexical marketing appeals.

RESULTS

Of the 5903 packs, 3% (n=178) had an insert or onsert. 171 of these (96%) were inserts. While most (78%) pack exteriors were entirely in English, over half (51%) of the inserts/onserts were entirely in the local (non-English) language from where the pack was collected. The most common appeals on the inserts/onserts were product dependability (64%), luxury/aspirational (55%) and machinery/technology (37%). Product images were prevalent as well as images or words mentioning filters (22%). The most used appeals involved featuring aspects of a product (66%), addressing customers directly (52%) and informing customers about new aspects of a product (31%).

CONCLUSIONS

Cigarette pack inserts/onserts are unregulated in many countries and provide additional space for tobacco companies to extend and innovate their advertising. Tobacco advertising and packaging policies such as plain and standardised packaging should expand to address inserts/onserts to protect consumers more fully from industry promotion of deadly products.

Efficacy of WeChat-based online smoking cessation intervention ('WeChat WeQuit') in China: a randomised controlled trial

Background

China has approximately 300 million current smokers, and smoking cessation services are limited. This study aimed to assess the efficacy of a Cognitive Behavioral Theory-based smoking cessation intervention ('WeChat WeQuit') via the most popular social media platform in China, WeChat.

Methods

A parallel, single-blind, two-arm randomised controlled trial was conducted via WeChat between March 19, 2020 and November 16, 2022. Chinese-speaking adult smokers (n = 2000) willing to quit within one month were recruited and randomised in a 1:1 ratio. The intervention group (n = 1005) received the 'WeChat WeQuit' program and the control group (n = 955) received control messages for 14 weeks (2-week prequit and 12-week postquit). Participants were followed up to 26 weeks after the quit date. The primary outcome was self-reported continuous smoking abstinence rate, biochemically validated at 26 weeks. The secondary outcomes were self-reported 7-day and continuous abstinence rates at 6 months. All analyses were by intention to treat. The trial is registered at ClinicalTrials.gov (NCT03169686).

Findings

By intention-to-treat analysis, the biochemically verified 26-week continuous abstinence rate was 11.94% in the intervention group and 2.81% in the control group (OR = 4.68, 95% CI: 3.07-7.13, p < 0.0001). The self-reported 7-day abstinence rates ranged from 39.70% at week 1-32.04% at week 26 for the intervention group and 14.17%-11.86% in the control group for weeks 1 and 26, respectively; the self-reported continuous abstinence rates at weeks 1 and 26 ranged from 34.33% to 24.28% and 9.65% to 6.13% in the intervention group and the control group respectively (all p < 0.0001). Participants with low nicotine dependence or previous quit attempts were more likely to successfully quit smoking.

Interpretation

The 'WeChat WeQuit' intervention significantly increased smoking abstinence rates at 6 months and should be considered for treatment-seeking smokers in China.

Funding

The research is supported by the Natural Science Foundation of Hunan Province (2020JJ4794, YLiao), the K.C. Wong Postdoctoral Fellowship for YLiao to study at King's College London, and China Medical Board (CMB) Open Competition Program (grant no. 15-226, 22-485, YLiao).

Electronic Nicotine Delivery System flavor use over time by age group in the US: A longitudinal analysis

INTRODUCTION

The prevalence of flavor use in Electronic Nicotine Delivery Systems (ENDS) has been assessed in numerous studies, but limited research has focused on flavor use trends and maintenance of flavor preference over time. This study investigated the general trends and maintenance of ENDS flavor use for youth (aged 12-17 years), young adults (aged 18-24 years), and older adults (aged ≥25 years) between 2014 and 2019.

METHODS

Population Assessment of Tobacco and Health (PATH) Study Wave 2 (2014-2015), Wave 3 (2015-2016), Wave 4 (2016-2017), and Wave 5 (2018-2019) youth and adult data were used. Cross-sectional flavor use prevalence (trends) and flavor maintenance (using the same flavor category in at least three consecutive waves) were assessed.

RESULTS

The most reported primary flavor category was fruit among all age groups in all waves. Candy/desserts in waves two, three, four, and menthol/mint in wave five were the second most reported flavor in all age groups. The highest increase was observed for menthol/mint use among youth between wave two (21.9%) and five (58.1%) (OR=5.33; 95% CI: 3.58-7.96). Overall, 37.6% of fruit flavor users, 25.3% of candy/desserts users, 32.0% of menthol/mint users, and 33.4% of tobacco flavor users, maintained use of the same flavor in at least three consecutive waves.

CONCLUSIONS

Fruit flavor had the highest percentages of use and maintenance between 2014 and 2019. While the maintenance of fruit and candy/desserts flavors were higher among youth, adults had substantially higher maintenance percentages for menthol/mint and tobacco flavor. There was a substantial increase in menthol/mint use in wave five among youth, which may affect ENDS flavor maintenance patterns in the future. Understanding maintenance of flavors over time can inform regulation of ENDS flavors.

The problematic use of cultural symbols on Chinese cigarette packs

INTRODUCTION

China is the world's largest tobacco-consuming nation. With minimal packaging regulations, the Chinese tobacco industry can use many appeals to promote their products, including calling upon traditions and culture to make positive connections between consumers and harmful products. We analyzed the nature and extent of cultural appeals on Chinese cigarette packs.

METHODS

A total of 610 unique cigarette packs were collected in 2017 from five major Chinese cities (Beijing, Guangzhou, Shanghai, Kunming, and Chengdu) following a systematic protocol. Two trained independent coders knowledgeable about Chinese culture and language coded the packs in accordance with a specially developed codebook encompassing important Chinese cultural symbols. The prevalence of identified elements was determined and interpreted.

RESULTS

Overall, 60.7% (n=370) of the analyzed Chinese cigarette packs in our sample contained at least one culturally specific appeal. The most common cultural appeals included written arts (n=131; 21.5%), celebratory red as the primary pack color (n=119; 19.5%), visual arts (n=70; 11.4%), and special occasions (n=60; 9.9%). There was a diverse range of cultural appeals present on the packs.

CONCLUSIONS

Cultural appeals are common on Chinese tobacco packaging, with over 60% of all analyzed packs containing at least one culturally specific element. With China's packaging policies requiring health warning labels to occupy only 35% of the pack, the tobacco industry is allowed plenty of package space to incorporate cultural elements among other appeals. A plain and standardized packaging policy would eliminate the ability for Chinese tobacco companies to use cultural appeals on their cigarette packs.

The association between viewing cigarette health warning labels and intention to quit smoking among Chinese adult smokers: support for including health outcome content and culturally specific messages

BACKGROUND

Tailored themes of pictorial health warning labels (HWLs) that considers specific cultural dimensions and within a specific policy/historical context can motivate behavior change, such as provoking smokers to think about quitting. Currently in China, the HWLs on cigarettes are text-only. This study designed pictorial HWLs using different themes to explore and examine the association between viewing pictorial HWLs and participants' intention to quit smoking. The themes included: (1) Self-harm from using cigarettes, (2) Harming family or children with secondhand smoke, (3) Complying with existing smoke-free policies, and (4) Cigarette gift giving practices.

METHODS

A cross-sectional randomized experimental survey was conducted among 1,625 smokers in Beijing (n = 545), Shanghai (n = 541), and Shenzhen (n = 539) during 2017. Before and after viewing eight pictorial HWLs of one theme, participants were asked if they had plans to quit smoking within the next month, within the next 6 months, beyond the next 6 months, or not at all. Ordinal logistic regression, Wilcoxon and Chi-square tests were used to analyze the data.

RESULTS

After viewing the HWLs, 434 participants (26.9%) reported an intention to quit smoking sooner, 987 (61.2%) reported the same intention to quit, and 191 (11.8%) reported an intention to quit later. The pre-post change in intention to quit was statistically significant among all participants and participants under each theme (p > 0.05). Participants who rated the effectiveness of the HWL communicating how secondhand smoke harms children had 1.13 (95% CI 1.01-1.27) greater odds of reporting an intention to quit sooner compared to those viewing labels from the other themes, adjusting for covariates. Female participants and participants with annual household income more than 100,000RMB had 1.39 (95% CI 1.14-1.69) and 1.29 (95% CI 1.04-1.60) greater odds of reporting an intention to quit sooner compared to their counterparts across the entire sample.

CONCLUSIONS

Findings of this study provide evidence of an association between all four pictorial HWL themes and smokers' intention to quit smoking. These findings can help inform what HWL themes might be appropriate when China implements pictorial health warning labels.

Exposure to metals among Electronic Nicotine Delivery System (ENDS) users in the path study: A longitudinal analysis

BACKGROUND

Few studies have evaluated Electronic Nicotine Delivery Systems (ENDS) in longitudinal studies, as a potential source of metals which may have carcinogenic, neurotoxic, and cardiotoxic effects. We evaluated metal body burden by ENDS use status in a longitudinal population-based national survey.

METHODS

We used the Population Assessment of Tobacco and Health (PATH) Study wave 1 (2013-2014), wave 2 (2014-2015), and wave 3 (2015-2016) adult data to assess urinary concentrations of seven metals among (1) ENDS only users who never used any nonelectronic tobacco products (n = 50), (2) ENDS only users who were former users of any nonelectronic tobacco products (n = 123) and (3) Never users (n = 1501) of any tobacco product.

RESULTS

Among ENDS only users who never used any nonelectronic tobacco products (n = 50), the geometric mean ratios (GMRs) of Cd and Pb were 1.25 (95%CI: 1.09-1.42) and 1.19 (95%CI: 1.05-1.34), respectively, compared to never users after adjustment for PATH Study wave, age, sex, race/ethnicity, education, region, secondhand smoke at home and work, and cannabis and other substance use. After the same adjustment, the corresponding GMRs were 1.48 (95%CI: 1.32-1.67) and 1.43 (95%CI: 1.28-1.60) for ENDS only users who were former users of any nonelectronic tobacco products (n = 123).No difference was observed in urinary concentrations of other metals comparing ENDS users to never users of any tobacco product.

DISCUSSION

ENDS users show higher urinary levels of Cd and Pb, including lifetime exclusive ENDS users compared to never users of any tobacco product. These findings are limited by the small sample size and could be related to underreporting of past combustible tobacco use or other factors. Metals typical of ENDS such as nickel and chromium unfortunately are not available in PATH. Studies assessing metal exposure associated with long term lifetime exclusive ENDS use (≥5 years) with larger sample size are needed.

Eugenol, menthol and other flavour chemicals in kreteks and 'white' cigarettes purchased in Indonesia

BACKGROUND

Flavoured tobacco products are not restricted in Indonesia, a country with about 68 million adults who smoke. Most use clove-mixed tobacco cigarettes ('kreteks'); non-clove ('white') cigarettes are also available. Although the use of flavour chemicals has been identified by WHO as promoting tobacco use, little has been reported for Indonesia about the levels of flavourants in either kreteks or 'white cigarettes'.

METHODS

22 kretek brand variants and nine 'white' cigarette brand variants were purchased in Indonesia during 2021/2022; one of the kretek packs contained three colour-coded variants, giving a total sample number of 24 for the kreteks. Chemical analyses gave the mg/stick (=mg/(filter+rod)) values for 180 individual flavour chemicals that included eugenol (a clove-flavoured compound), four other clove-related compounds and menthol.

RESULTS

Eugenol was present at significant levels in all 24 kreteks (2.8-33.8 mg/stick), but was essentially absent in all of the cigarettes. Menthol was present in 14 of 24 kreteks, with levels ranging from 2.8 to 12.9 mg/stick, and in five of the nine cigarettes, with levels ranging from 3.6 to 10.8 mg/stick. Other flavour chemicals were also found in many of the kretek and cigarette samples.

CONCLUSIONS

In this small sample, we found numerous variations of flavoured tobacco products offered by multinational and national companies in Indonesia. Given the body of evidence that flavours make tobacco products more appealing, regulation of clove-related compounds, menthol and other flavour chemicals should be considered in Indonesia.

Colours, capsules and concept flavour names on cigarette packs appeal to youth in Mexico

BACKGROUND

Flavoured cigarettes are popular in Mexico. We examined how cigarette packaging design features used to communicate flavour influence perceptions of appeal, harm, perceived interest and pack preference among Mexico City residents.

METHODS

We conducted an experimental survey. Participants aged 13-34 years were randomly assigned to one of three conditions, viewed packs with systematically manipulated design features (colour, capsule image and flavour name) and answered questions on appeal, perceived harm, perceived interest and pack preference. Data were analysed using mixed effects and conditional logistic regression.

RESULTS

1500 adolescents and 950 adults participated. Regardless of flavour, cigarette packs with a background colour and capsule image were more appealing to adolescents (OR=13.19, 95% CI 11.53 to 15.10; OR=1.68, 95% CI 1.45 to 1.88) and adults (OR=4.18, 95% CI 3.73 to 4.69; OR=1.66, 95% CI 1.49 to 1.85) than packs without. Among adolescents, 'Tropical Burst' named packs were more appealing (OR=1.43, 95% CI 1.20 to 1.72) than packs without a flavour name and among adults, 'Arctic Air' named packs were more appealing (OR=1.20, 95% CI 1.02 to 1.14). Adolescents and adults reported a preference for trying packs that displayed a flavour name, background colour or capsule image (b=0.104, b=0.702, b=1.316, p<0.001 and b=0.126, b=0.619, b=0.775, p<0.001).

CONCLUSIONS

Colours and flavour capsule images appeal to adolescents and adults in Mexico. Mexico should consider adopting plain packaging to reduce appeal and interest.

The Vaping and Patterns of e-Cigarette Use Research Study: Protocol for a Web-Based Cohort Study

BACKGROUND

In total, 3.2% of American adults report using e-cigarettes every day or some days. The Vaping and Patterns of E-cigarette Use Research (VAPER) Study is a web-based longitudinal survey designed to observe patterns in device and liquid use that suggest the benefits and unintended consequences of potential e-cigarette regulations. The heterogeneity of the e-cigarette devices and liquids on the market, the customizability of the devices and liquids, and the lack of standardized reporting requirements result in unique measurement challenges. Furthermore, bots and survey takers who submit falsified responses are threats to data integrity that require mitigation strategies.

OBJECTIVE

This paper aims to describe the protocols for 3 waves of the VAPER Study and discuss recruitment and data processing experiences and lessons learned, including the benefits and limitations of bot- and fraudulent survey taker-related strategies.

METHODS

American adults (aged ≥21 years) who use e-cigarettes ≥5 days per week are recruited from up to 404 Craigslist catchment areas covering all 50 states. The questionnaire measures and skip logic are designed to accommodate marketplace heterogeneity and user customization (eg, different skip logic pathways for different device types and customizations). To reduce reliance on self-report data, we also require participants to submit a photo of their device. All data are collected using REDCap (Research Electronic Data Capture; Vanderbilt University). Incentives are US $10 Amazon gift codes delivered by mail to new participants and electronically to returning participants. Those lost to follow-up are replaced. Several strategies are applied to maximize the odds that participants who receive incentives are not bots and are likely to possess an e-cigarette (eg, required identity check and photo of a device).

RESULTS

In total, 3 waves of data were collected between 2020 and 2021 (wave 1: n=1209; wave 2: n=1218; wave 3: n=1254). Retention from waves 1 to 2 was 51.94% (628/1209), and 37.55% (454/1209) of the wave 1 sample completed all 3 waves. These data were mostly generalizable to daily e-cigarette users in the United States, and poststratification weights were generated for future analyses. Our data offer a detailed examination of users' device features and specifications, liquid characteristics, and key behaviors, which can provide more insights into the benefits and unintended consequences of potential regulations.

CONCLUSIONS

Relative to existing e-cigarette cohort studies, this study methodology has some advantages, including efficient recruitment of a lower-prevalence population and collection of detailed data relevant to tobacco regulatory science (eg, device wattage). The web-based nature of the study requires several bot- and fraudulent survey taker-related risk-mitigation strategies, which can be time-intensive. When these risks are addressed, web-based cohort studies can be successful. We will continue to explore methods for maximizing recruitment efficiency, data quality, and participant retention in subsequent waves.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38732.

Perceived effectiveness of four different cigarette health warning label themes among a sample of urban smokers and non-smokers in China

OBJECTIVE

This study, conducted in China, evaluated the effectiveness of four different themes of health warning labels (HWLs) that used both text and pictures: (1) self-harm from using cigarettes, (2) harming family or children with secondhand smoke, (3) reinforcing compliance with existing smoke-free policies and (4) anticigarette gift giving practices.

METHODS

A cross-sectional randomised experimental survey was conducted among 3247 adult (aged 18+ years) participants in Beijing, Shanghai and Shenzhen in 2017, using quotas for age group, gender and smoking status. Participants were randomly assigned to one of the four HWL themes. Each participant viewed eight HWLs and rated how effective these themed-labels were in terms of credibility, raising awareness of health harms of smoking on family and children, improving compliance with public smoking bans, stopping the practice of gifting cigarettes, thinking about quitting and preventing smoking using a 10-point scale, with 10 being most effective. Analysis of variance and independent t-tests were used to analyse these data.

FINDINGS

All four HWL themes performed well for each outcome with average ratings >6.5. Harming family or children with secondhand smoke was the theme that received the highest ratings for each outcome, with credibility (8.0, 95% CI 7.86 to 8.09) and prevention of smoking (8.8, 95% CI 8.63 to 8.91) outcomes being significantly higher (p<0.05). Overall, analysis of ratings by gender, income and education did not impact outcomes.

CONCLUSION

All four HWL themes tested could be effective in China; the theme of secondhand smoke harming family or children may be a particularly credible/effective theme.

Smoking, e-cigarettes and the effect on respiratory symptoms among a population sample of youth: Retrospective cohort study

INTRODUCTION

E-cigarettes have been steadily increasing in popularity, both as cessation methods for smoking and for recreational and social reasons. This increase in vaping may pose cardiovascular and respiratory risks. We aimed to assess respiratory symptoms in youth users of e-cigarettes and cigarettes.

METHODS

A retrospective survey design was utilized to assess Canadian youth aged 16-25 years. Participants were recruited from the Ontario Tobacco Research Unit Youth and Young Adult Research Registration Panel November 2020 to March 2021. A total of 3082 subjects completed the baseline survey. Of these, 2660 individuals who did not have asthma were included in the analysis. The exposure of interest was pack-equivalent years, a novel measure of vaping exposure equivalent conceptually to cigarette pack years incorporating number of puffs per day, number of days vaped per month, and number of years vaped. Respiratory symptoms were measured using the five-item Canadian Lung Health Test. Poisson regression analyses were performed while adjusting for demographic confounders, stratified by smoking status. A non-stratified model tested the interaction of status and vaping dose and the effect of vaping device used was assessed among ever vapers. Analyses controlled for demographic characteristics, use of cannabis and alcohol, and survey date.

RESULTS

Each additional puff year increased the rate ratio (RR) of respiratory symptoms by a factor of 11.36 (95% CI: 4.61-28.00; p<0.001) for never smokers, but among current daily smokers higher pack-equivalent years were not associated with more respiratory symptoms (RR=0.83; 95% CI: 0.23-3.11). Among current vapers, those using pod-style devices were more likely to have more respiratory symptoms (RR=1.25; 95% CI: 1.08-1.45) after adjusting for dose.

CONCLUSIONS

Vaping is associated with an increased risk of reporting respiratory symptoms among never smoking youth and non-daily ever cigarette smokers. Use of e-cigarettes among non-smokers should be discouraged.

Covid-19 associated free hanging clots in acute symptomatic carotid stenosis

BACKGROUND

Thrombotic complications including stroke were previously described following Covid-19. We aim to describe the clinical and radiological characteristics of Covid-19 related with acutely symptomatic carotid stenosis (aSCS).

METHOD

All patients presenting with an aSCS were prospectively enrolled in an ongoing institutional database. Inclusion criteria for the Covid-19-aSCS group were a combination of both antigen test and a positive reverse-transcriptase (PCR) test for Covid-19 upon admission. Patients with additional potential etiologies for stroke including cardioembolism, carotid dissection or patients with stenosis of <50% on CTA were excluded. A cohort of non-Covid-19 related aSCS patients admitted to the same institution before the pandemic during 2019 served as controls.

RESULTS

Compared to controls (n = 31), Covid-19-aSCS (n = 8), were younger (64.2 ± 10.7 vs 73.5 ± 10, p = 0.027), and less frequently had hypertension (50% vs 90%, p = 0.008) or hyperlipidemia (38% vs 77%, p = 0.029) before admission. Covid-19-aSCS patients had a higher admission NIHSS score (mean 9 ± 7 vs 3 ± 4, p = 0.004) and tended to present more often with stroke (88% vs 55%, p = 0.09) rather than a TIA. Covid-19-aSCS patients had higher rates of free-floating thrombus and clot burden on CTA (88% vs 6.5%, p = 0.002). Covid-19 patients also less often achieved excellent outcomes, with lower percentage of mRS score of 0 after 90-days (13% vs 58%, p = 0.022).

CONCLUSION

Covid-19- aSCS may occur in a younger and healthier subpopulation. Covid-19- aSCS patients may have higher tendencies for developing complex clots and less often achieve excellent outcomes.

Disparities in self-reported exposure to tobacco marketing among youth and young adults from low-socioeconomic status neighbourhoods in Mexico City

Exposure to tobacco marketing is positively associated with smoking initiation and behaviours. There is limited literature examining disparities among reported exposure in low- and middle-income countries. This study sought to fill this gap with a survey among 1427 adolescents and 889 adult smokers in Mexico City in 2020. Data were analysed using chi-square and hierarchical regression models. Two-thirds of adolescents noticed cigarette pack displays in stores. Participants from low- and mid-socioeconomic status (SES) neighbourhoods were more exposed to tobacco marketing than their counterparts through several channels. After addressing the shared variance among participants from the same household nested in neighbourhood SES level and controlling for gender, adolescent non-smokers and adult smokers who noticed pack displays were more likely to be susceptible to smoking (OR = 1.8, 95% CI 1.4-2.4) and to smoke more (OR = 1.7, 95% CI 1.21-2.47); adult smokers who noticed tobacco marketing at more places were less likely to be certain about smoking risks (OR = 0.9, 95% CI 0.8-0.9). The results suggest that the tobacco industry targets youth and individuals from low-SES neighbourhoods through several channels. Greater exposure to tobacco marketing was associated with increased susceptibility to smoking and decreased risk perception. These findings support a comprehensive ban on tobacco marketing in Mexico.