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• Vaping Prevention and Quit Resources: Top Tips for Parents and Schools.
• New Survey Shows Progress on Curbing Teen Vaping, but E-cigarette use Remains High as Access to Flavors, Risk of Nicotine Addiction, and Impact on Youth Mental Health Concerns Grow.
• CNN News Article: Cigarette Sales in America Were Falling. Then Covid Hit.
• More Than Half of Young People Consider Quitting Vaping in 2022, New Survey Finds.
• Truth Report: Nicotine on Demand.
• SCLC's I COVID QUIT Social Media Campaign.

Quitlines

Pradeep Kumar P C, Pratima Murthy, R P Lohit, Sudarshan Hegde, Prabhat Chand, Lakshmanan Sethuraman.
Impact of Covid-19 on Caller Characteristics and Quit Rates: An Experience from Regional Tobacco Quitline from India.
Nicotine & Tobacco Research, 2022;, ntac013, https://doi.org/10.1093/ntr/ntac013

Background. The tobacco epidemic is a major health concern amplified by Covid-19. We aimed to study differences in caller profiles to the regional tobacco quitline services of South India during the Covid-19 pandemic in comparison with the pre-pandemic.
Method. Using a descriptive cross-sectional research design, we examined registered caller profiles to the quitline between March and July 2019 (Pre-Pandemic N=7845) and the same months in 2020 (Covid-19 pandemic phase N=6447) phases.
Results. The proportion of registered callers with an expressed intent to quit tobacco increased by 1.73 times during pandemic (16.7% versus 9.6%). Health concerns were cited as the major reason (93.25%) to quit tobacco in 2020 as compared to 2019 (88.02%). Cough (28.50%) and psychological difficulties (14.20%) were reported significantly more by RCs in 2020. Self-reported quit rates were significantly higher among RCs in 2020 as compared to 2019 on the quit day (2019 - 47.37% & 2020 - 77.54%, P=0.001), at one week (2019 - 25.17% and 2020 - 56.06%, P=0.001) as was one-month continuous abstinence (2019 - 11.88% and 2020 - 39.60% P=0.001).
Conclusion. The pandemic resulted in a greater intent to quit among registered callers to the quitline. However, awareness about the quitline services as well as other tobacco cessation services needs to be expanded to reach more tobacco users.
Implication. Pandemics offer an opportunity to change health risk behaviours. During the Covid-19 pandemic, callers to the tobacco quitline were more motivated to quit tobacco and attributed it to concerns about the health risks from tobacco use, particularly during the pandemic. Quit rates also increased significantly during the pandemic as compared to before. These gains in encouraging tobacco cessation need to be maintained beyond the pandemic by strengthening existing quitlines and other supports for tobacco cessation.

Londoño T, Moore JR, Guerra ZC, Heydarian NM, Castro Y.
The Contribution of Positive Affect and Loneliness on Readiness and Self-efficacy to Quit Smoking among Spanish-speaking Mexican American Smokers.
Am J Drug Alcohol Abuse. 2021 Dec 21:1-10. doi: 10.1080/00952990.2021.1998513. Epub ahead of print. PMID: 34932409.

Background. The existing research on affective and interpersonal determinants of smoking cessation largely under-represents minority smokers, such as Latinos.
Objective. The current study examined associations between affective and interpersonal factors with intermediary smoking cessation variables among Mexican-American smokers (N = 290; 60% male).
Methods. Measures of positive and negative affect, social support, and loneliness were each examined for associations with measures of motivational readiness to quit smoking, and smoking abstinence self-efficacy. Significant predictors were entered into models simultaneously to examine their unique associations. Covariates included gender, age, and educational attainment.
Results. Negative affect (b = .68, SE b = .14, p < .001) and loneliness (b = .20, SE b = .09, p < .05) were independently associated with motivation. Negative affect (b = .20, SE b = .06, p < .01) and positive affect (b = .34 SE b = .07, p < .001) were independently associated with self-efficacy. In the final models, only negative affect was associated with motivation (b = .68, SE b = .17, p < .001); whereas negative (b = .17, SE b = .06, p < .01) and positive (b = . 32, SE b = .07, p < .001) affect were associated with self-efficacy.
Conclusion. Results highlight the importance of resilience factors (e.g., positive affect) among Mexican-American smokers. Cessation interventions regularly target negative affect among smokers; additional focus on positive affect in cessation interventions with this population may be warranted.

Crankshaw E, Gaber J, Guillory J, Curry L, Farrelly M, Saunders M, Hoffman L, Ganz O, Delahanty J, Mekos D, Alexander T.
Final Evaluation Findings for This Free Life, a 3-year, Multi-market Tobacco Public Education Campaign for Gender and Sexual Minority Young Adults in the United States.
Nicotine Tob Res. 2022 Jan 1;24(1):109-117. doi: 10.1093/ntr/ntab146. PMID: 34270739; PMCID: PMC8666114.

Introduction. This Free Life was the first multi-market, primarily digital campaign designed to change tobacco-related beliefs among lesbian, gay, bisexual, and transgender (LGBT) young adults. Our evaluation sought to determine whether campaign exposure resulted in changes in tobacco-related beliefs. We summarize awareness and receptivity at the conclusion of the campaign and assess the effect of campaign exposure on tobacco-related beliefs in campaign treatment markets compared with control markets.
Aims and methods. Twenty-four US designated market areas were selected to receive the campaign or serve as control markets. A baseline survey was conducted in 2016, with six follow-up surveys conducted approximately 6 months apart over the course of the 3-year campaign. 12 324 LGBT young adult survey participants were recruited via intercept interviews and social media. Campaign effects on outcomes were estimated using difference-in-difference panel regression models, with p-values corrected for multiple comparisons.
Results. Brand and ad awareness peaked in treatment markets approximately 2.5 years into the 3-year campaign and were significantly higher in treatment than control markets. Brand equity and ad receptivity were generally high and similar across LGBT subgroups. There were small but significant campaign effects on five tobacco-related beliefs, with difference-in-difference estimates ranging from 1.9 to 5.6 percentage points.
Conclusions. This Free Life, the first multi-market tobacco public education campaign for LGBT young adults, reached and resonated with a large and diverse population, and had a small effect on beliefs involving social aspects of smoking. These findings should inform future communication efforts aimed at reducing tobacco use among LGBT young adults.
Implications. Modest overall campaign effects suggest that further research on effective campaign messaging and delivery to LGBT young adults is needed. Campaign messaging style, delivery channels, and targeted outcomes likely contributed to these findings. Health communication efforts for LGBT young adults should consider the limitations of digital media in achieving sufficient exposure. Ad style and content optimized for a digital environment is an area that will benefit from further development.

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 Jan 6;1(1):CD013790. doi: 10.1002/14651858.CD013790.pub2. PMID: 34988969; PMCID: PMC8733777.

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.

Ramamurthi D, Chau C, Berke HY, et al.
Flavour Spectrum of the Puff Family of Disposable E-Cigarettes.
Tobacco Control Published Online First: 11 January 2022. doi: 10.1136/tobaccocontrol-2021-056780

Background. In January 2020, the US Food and Drug Administration prohibited the sale of flavours (except for menthol and tobacco) in prefilled pod devices such as JUUL to decrease youth vaping. Excluded from the prohibition were disposable devices.
Objectives. To determine the scope and scale of flavours marketed by Puff Bar, a leading disposable brand, and related products.
Methods. Disposable e-cigarette flavours were identified via online searches encompassing vendor websites, wholesale distributors, manufacturers (eg, made-in-china.com), and social media channel, Instagram, between June and August 2020.
Results. The ‘Puff’ brand name and iconic cloud logo appear on a variety of products of differing sizes and nicotine e-liquid volumes. Among Puff Bar and its copycats (Puff-a-Likes), 139 flavours were identified. Fruit flavours predominated comprising 82.2% of the flavour varieties (fruit 50%, fruit and menthol/mint 23.6%, and fruity drinks 8.6%). A prevalent new flavour category which combines fruit with menthol/mint (Ice) was offered in 33 varieties such as Lychee Ice, Lush Ice and Banana Ice. Disposable e-cigarette brands are undertaking measures to escape tobacco regulation (eg, non-tobacco-sourced nicotine) and flavour limitations via post-market flavour additions to unflavoured nicotine e-liquid.
Conclusions. The proliferation of flavoured disposable e-cigarette products, many of which are designed to emulate popular pod devices, illustrates that narrowly limited flavour regulations covering only a single category are destined to fail. To be effective in youth protection, flavour regulations need to apply to all recreational nicotine-containing products and need to include measures to counter post-market flavour addition.

Liber AC, Cahn Z, Diaz MC, et al.
The EVALI Outbreak and Tobacco Sales in the USA, 2014–2020.
Tobacco Control Published Online First: 15 December 2021. doi: 10.1136/tobaccocontrol-2021-056807

Background. The E-cigarette, or Vaping Product-Use Associated Lung Injury (EVALI) Outbreak of 2019 hospitalised thousands and killed dozens of people in the USA and raised perceptions of the dangers posed to health by electronic cigarettes (e-cigarettes). These illnesses along with continued increases in youth vaping rates lead to the passage of many state and federal laws intended to curtail the sale of flavoured e-cigarettes. Little is known about the impact of these events on US e-cigarette and cigarette retail sales.
Methods. Using Nielsen Scantrack sales data from January 2014 to January 2020 for 23 US states, we evaluate the effect of the EVALI outbreak. First-differenced state-panel regressions tracking unit sales of total-level and category-level e-cigarettes and cigarette sales controlling for price, Tobacco 21 policy coverage, product distribution, seasonality, EVALI-attributable deaths, and state-level e-cigarette policies affecting the availability of e-cigarettes (non-tobacco flavoured and total) were employed.
Results. Dollar sales of e-cigarettes declined 29% from their pre-EVALI peak by January 2020. Total sales of e-cigarettes declined in response to EVALI deaths and the total e-cigarette sales ban put in place in Massachusetts adopted in its wake. Cigarette sales were largely unchanged by either the direct or indirect policy effects of the EVALI outbreak, except for in Massachusetts, where cigarette sales—particularly those smoked by young people—rose temporarily after a total ban on e-cigarette sales.
Conclusion. Sales of e-cigarettes declined in response to the EVALI outbreak and from the most restrictive regulatory policies that were adopted in response, while sales of cigarettes were affected less.

Tobacco Use

Jackson RA, Ren C, Coleman B, et al.
Transitions to Smokeless Tobacco use Among Adult Cigarette Smokers in the Population Assessment of Tobacco and Health (PATH) Study, Waves 3–5 (2015–2019).
Tobacco Control Published Online First: 22 December 2021. doi: 10.1136/tobaccocontrol-2021-056907

Objective. Examine patterns of dual use of cigarettes and smokeless tobacco and complete switching over time among adult current cigarette smokers using data from the Population Assessment of Tobacco and Health Study Wave 3 (2015–2016), Wave 4 (2016–2018) and Wave 5 (2018–2019).
Methods. We examined four tobacco use states among 6834 exclusive smokers and 372 dual users at Wave 3 with two waves of follow-up data: exclusive cigarette use, exclusive smokeless tobacco use, dual use and use of neither product.
Results. Among exclusive smokers at Wave 3, only 1.6% (95% CI: 1.3% to 2.1%) transitioned to dual use at Wave 4, and 0.1% (95% CI: 0.07% to 0.2%) switched to exclusive smokeless tobacco use. Among exclusive smokers who switched to dual use, 53.1% (95% CI: 40.9% to 64.9%) returned to exclusive cigarette smoking, 34.3% (95% CI: 23.8% to 46.6%) maintained dual use and 12.6% (95% CI: 7.0% to 21.7%) did not smoke cigarettes after an additional wave of follow-up. Dual users at Wave 3 were likely to maintain their dual use status at Wave 4, 51.2% (95% CI: 46.1% to 56.3%) and Wave 5, 47.9% (95% CI: 40.1% to 55.8%).
Conclusions. Very few cigarette smokers transition to smokeless tobacco use, and among those who do, dual use is more common than exclusive smokeless tobacco use. Further, the majority of exclusive cigarette smokers who transition to dual use at Wave 4 continue smoking cigarettes at Wave 5, either as dual users or as exclusive smokers.

Maki KG, Liao K, Lowenstein LM, Lopez-Olivo MA, Volk RJ.
Factors Associated with Obtaining Lung Cancer Screening among Persons who Smoke.
MDM Policy Pract. 2021 Dec 17;6(2):23814683211067810. doi: 10.1177/23814683211067810. PMID: 34993342; PMCID: PMC8725001.

Background. Screening with low-dose computed tomography scans can reduce lung cancer deaths but uptake remains low. This study examines psychosocial factors associated with obtaining lung cancer screening (LCS) among individuals.
Methods. This is a secondary analysis of a randomized clinical trial conducted with 13 state quitlines' clients. Participants who met age and smoking history criteria were enrolled and followed-up for 6 months. Only participants randomized to the intervention group (a patient decision aid) were included in this analysis. A logistic regression was performed to identify determinants of obtaining LCS 6 months after the intervention.
Results. There were 204 participants included in this study. Regarding individual attitudes, high and moderate levels of concern about overdiagnosis were associated with a decreased likelihood of obtaining LCS compared with lower levels of concern (high levels of concern, odds ratio [OR] 0.17, 95% confidence interval [CI] 0.04-0.65; moderate levels of concern, OR 0.15, 95% CI 0.05-0.53). In contrast, higher levels of anticipated regret about not obtaining LCS and later being diagnosed with lung cancer were associated with an increased likelihood of being screened compared with lower levels of anticipated regret (OR 5.59, 95% CI 1.72-18.10). Other potential harms related to LCS were not significant.
Limitations. Follow-up may not have been long enough for all individuals who wished to be screened to complete the scan. Additionally, participants may have been more health motivated due to recruitment via tobacco quitlines.
Conclusions. Anticipated regret about not obtaining screening is associated with screening behavior, whereas concern about overdiagnosis is associated with decreased likelihood of LCS.
Implications. Decision support research may benefit from further examining anticipated regret in screening decisions. Additional training and information may be helpful to address concerns regarding overdiagnosis.

Marynak K, Emery S, King BA.
Nicotine Pouch Unit Sales in the US From 2016 to 2020—Reply.
JAMA. 2021;326(22):2331. doi:10.1001/jama.2021.19056

Manufacturers are currently marketing nicotine pouches and e-cigarettes with synthetic nicotine in the US. Whether derived from tobacco plants or synthetically developed in a laboratory, nicotine is an addictive drug with known adverse consequences for fetal development and adolescent brain development.
Given public health considerations, synthetic nicotine products warrant urgent attention from policy makers, clinicians, and researchers. Sufficient scientific evidence about nicotine’s harmful effects exists to caution young people and pregnant adults against use of synthetic nicotine and to justify inclusion of synthetic nicotine products in existing regulatory efforts.

Xu Wang, Yoonsang Kim, Mateusz Borowiecki, Michael A Tynan, Sherry Emery, Brian A King.
Trends in Cigar Sales and Prices, by Product and Flavor Type—the United States, 2016–2020.
Nicotine & Tobacco Research, 2021;, ntab238, https://doi.org/10.1093/ntr/ntab238

Introduction. Cigar smoking has increased in recent decades as the cigar product landscape has diversified. This study assessed trends in US cigar sales during 2016–2020.
Aims and Methods. Unit sales and average unit price for cigars were assessed during January 3, 2016–June 13, 2020, overall and by product and flavor type, for the 48 contiguous US states and D.C. Assessed cigar types were large cigars, little cigars, and cigarillos; assessed flavor types were tobacco/unflavored, candy/sweets, fruit, menthol, alcohol, coffee, other flavors, and no flavor stated. A joinpoint regression model was used to assess the magnitude and significance of sales trends.
Results. During January 3, 2016–June 13, 2020, unit sales of cigarillos increased (average monthly percentage change [AMPC] = 0.7%, p < .001), while unit sales of large cigars (AMPC = −0.8%, p < .001) and little cigars decreased (AMPC = −0.2%, p < .001). The average price of cigarillos gradually decreased since mid-August 2017 (AMPC = −0.1%, p < .001), and the average price of little cigars decreased from mid-June 2016 to mid-June 2019 (AMPC = −0.3%, p < .001). In contrast, the average price of large cigars increased during the entire study period (AMPC = 0.6%, p < .001). Irrespective of cigar type, tobacco-flavored/unflavored products were the most commonly sold cigars during the assessed period; however, sales of other flavors varied by cigar type.
Conclusions. Cigar sales and price vary by type over time in the United States, including sales of cigarillos (94.2% of unit sales) increasing as their prices have decreased in recent years. Public health strategies are warranted to address the full scope of cigar types being used in the United States.
Implications. Surveillance of cigar sales data, including product characteristics, can provide a timely complement to self-reported survey data of cigar use. This study assessed trends in US cigar sales during 2016–2020, including by product and flavor type. The findings indicate that sales of cigarillos, which comprise most cigar sales in the United States during the assessed period, increased as their prices decreased. Sales of certain flavors, such as candy/sweet cigarillos and coffee large cigars, increased significantly. These findings reinforce the importance of evidence-based strategies, including increasing price and restricting flavors, to reduce the affordability and consumption of cigars in the United States.

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