December 2022
For quick navigation, please click on the titles below of the topics featured in this month's issue of Connections. Research Tobacco CessationPriority PopulationsE-Cigarettes and Heated Tobacco ProductsTechnologyTobacco UseJob and Conference Announcements
Highlighted Article
NEW REPORT: Priority Practices for State Quitlines to Implement by June 2023.
NAQC is pleased to release the “Priority Practices Report”. Building on the 2018 “Adoption of Recommended Best Practices among State Quitlines” issue paper which identified 21 best practices from 17 issue papers, the new report identifies six high priority best and promising practices for adoption by all state quitlines by June 2023. The criteria used to identify the priority practices reflect expectations within the quitline community for improving the quality of quitline services: Increase reach; improve impact; adapt to emerging issues; be feasible; and be sustainable.
In early 2023 NAQC plans to host an interactive webinar to review the priority practices, feature current relevant research, and facilitate discussion with the quitline community. More information on this opportunity for dialogue will be shared in the new year!
NAQC News
Thank you to NAQC Members and Happy Holidays to All!
Thank you to all organizations and individuals who renewed their NAQC membership or joined as new members this year! Your support allows us to provide resources, address important timely environmental changes and be more flexible as an organization in meeting changing member needs and requests.
Our very best wishes to all for a wonderful holiday season and a successful 2023!
FY2022 NAQC Annual Survey is Due December 22.
The FY2022 annual survey will close on Thursday, December 22nd. An invitation email was sent to the main contact for each state quitline on October 12, 2022 providing a link and instructions to the survey tool. Please contact us at annualsurvey@naquitline.org as soon as possible if you have any questions or need to request a deadline extension.
We Need your Recommendation for Candidates for NAQC’s Board of Directors!
In late January, NAQC will begin the nomination process for its Board of Directors. Please give some thought to who you would like to see in leadership positions!
Resources on Incentives to Help Quitline Participants Quit Tobacco.
NAQC has compiled literature on the use of incentives in tobacco cessation as a resource for quitlines considering the use of incentives. Additionally, NAQC hosted a webinar on incentives on November 30. The slides and recording of that webinar are available here.NAQC Membership FY2023 and Orientation/Refresher Webinar.
Thank you to every organization and individual who renewed their NAQC membership or joined as a new member! For questions regarding membership, please contact Natalia Gromov at 800-398-5489 ext. 701 or membership@naquitline.org. Join an orientation/refresher webinar to learn about existing programs and resources as well as about future projects. Please contact Natalia Gromov at 800-398-5489 ext. 701 or membership@naquitline.org if you will be interested in attending. Please submit any priority question before the webinar so staff can address it. Find more NAQC News in our Newsroom or go back to top.
Time-Sensitive News
NIH-Seeking Input: Innovative Approaches to Promote Mental Wellness in Populations Experiencing Health Disparities.
The NIH ADVANCE (Advancing Prevention Research for Health Equity) initiative is seeking input about interventions or strategies to prevent mental health problems and promote mental wellness in populations that experience health disparities (racial and ethnic minority groups, socioeconomically disadvantaged populations, underserved rural populations, and sexual and gender minorities).
NIH is particularly interested in interventions that move beyond the traditional approach of providing mental health treatment to instead address social determinants of health to prevent the development of mental health problems. You can find more information about potential topics of interest and learn how to submit a response in NIH Guide Notice NOT-OD-23-030.
Input from community-based service providers and other community-based organizations about promising or successful approaches in their communities is particularly encouraged.
Responses to the RFI should be submitted electronically on the RFI submission website by March 1, 2023, at 11:59 p.m. ET.
March 31, 2023 - Take Down Tobacco National Day of Action.
Take Down Tobacco, a fresh take on Kick Butts Day, is the Campaign for Tobacco-Free Kids’ signature platform for empowering people to stand up and speak out against the tobacco industry. The Take Down Tobacco program is a 365 day a year effort that culminates every spring with the Take Down Tobacco National Day of Action.
The next Take Down Tobacco National Day of Action will be held on March 31, 2023. This year also marks the 27th occurrence of this event, and there have been many important victories since the first Kick Butts Day was held in 1996.
» learn more
Find more Time-Sensitive News in our Newsroom or go back to top.
Cessation and Tobacco Control News Breaking News: A Global First - New Zealand Passes Tobacco Endgame Bill Package.
WASHINGTON, DC – DECEMBER 13, 2022 – Today, the New Zealand Parliament adopted the strongest anti-tobacco law in world history. Once implemented, the Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Bill is expected to phase out the tobacco epidemic in the country and set a global example of what is possible when policymakers, researchers and advocates unite to follow the data and protect their citizens. Other countries have already vowed to follow suit.
“Today, history was made for public health and for the generations of families who have lost loved ones to the preventable diseases caused by ordinary tobacco use,” said Action on Smoking and Health (ASH) Executive Director Laurent Huber. “New Zealand has single-handedly changed the course of what is possible in tobacco regulations and we stand ready to help other jurisdictions follow their groundbreaking lead.”
The Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Act includes three novel components attacking the tobacco epidemic from different angles.
First, it will ban the commercial sale of combustible tobacco products to anyone born on or after January 1, 2009. The concept, called “Smoke-Free Generation” or SFG, can also be characterized as a sales ban with a grandfather clause for existing adults who smoke. New Zealand will be only the third jurisdiction to pass such a law, following Balanga City in the Philippines – which has been unable to implement the law due to litigation – and Brookline, Massachusetts, which implemented a similar law (tobacco-free generation) in January 2021 and successfully defended an industry lawsuit in October 2022. Unlike New Zealand, Balanga City and Brookline banned sales to anyone born this century, and included all tobacco products, rather than a focus on combustibles.
“It’s important to stress that the Smoke-Free Generation law applies only to sales of combustible tobacco,” stressed Huber from ASH, which has endorsed SFG for years. “The law does not outlaw individual purchase, possession or use – or the act of smoking. The problem here is the tobacco industry, not their victims.”
The second leg of the law is a drastic reduction in the number of retailers – researchers estimate that the final reduction may be as much as 95%. Numerous studies have shown that people who smoke – like people who face any addiction –– find it easier to kick their addiction if cigarettes aren’t staring them in the face in every store.
Finally, the new law includes reducing nicotine content in cigarettes to below-addictive levels. Nicotine addiction is the driving force of the tobacco epidemic. Reducing it will make it far less likely for children to start smoking and far easier for adults to quit.
New Zealand was the first of the so-called “ASPIRE” countries that have set bold tobacco endgame goals. In 2010, the New Zealand Ministry of Health announced its intention to drive smoking prevalence below 5% by 2025. After reviewing progress toward this goal a few years ago, researchers realized that demand-reduction measures like taxation and smoke-free air laws would not be enough to reach the goal.
“Many countries have set aggressive tobacco control goals over the years,” continued Huber. “They almost never achieve them, and simply set a new goal. New Zealand deserves enormous credit for instead changing their strategy and remaining committed to their goal.”
The Smokefree Aotearoa process was largely driven by the country’s native Maori community, who smoke at a far higher prevalence than the general population and face more consequences as a result. The most significant aspect of the new approach is a focus on supply rather than demand, spurred by a growing recognition that the blame for the tobacco epidemic falls squarely on the tobacco industry rather than the users of its products.
“Nearly all adults who smoke were intentionally addicted as children,” said Huber. “The industry has spent half a century perfecting the cigarette as an addiction machine. They are far more addictive – and therefore dangerous – than they were at the height of smoking in the U.S., in the 1960s.”
Other jurisdictions in the U.S. are expected to follow Brookline, MA now that they have successfully defended their law in court, and at least a dozen countries have voiced their intention to follow New Zealand’s approach, including Singapore, Malaysia and the European Union.
New Zealand has no doubt changed the public health landscape and set the new standard for regulating away the tobacco epidemic.
California Legislative Updates.
On December 12, 2022, Justice Elena Kagan, on behalf of the United States Supreme Court, denied a request by R.J. Reynolds and other tobacco interests for an emergency injunction to block implementation of California’s law restricting the sale of flavored tobacco products. As a result, nearly two years after the California law was approved by state lawmakers and one month after it was resoundingly upheld by 64 percent of the state’s voters, California’s retail flavor ban will take effect by December 21, 2022.
Read more about the R.J. Reynolds v. Bonta lawsuit, the California flavor law (SB 793), and Public Health Law Center’s take on the litigation.
» learn more
POSTPONED: Cigarette Health Warnings Effective Date.
On November 7, 2022, the U.S. District Court for the Eastern District of Texas issued an order in the case of R.J. Reynolds Tobacco Co. et al. v. United States Food and Drug Administration et al., No. 6:20-cv-00176, to further postpone the effective date of the “Required Warnings for Cigarette Packages and Advertisements” final rule. Additionally, the court stated in its order that it expects to make a decision on the case within the next 31 days.
Based upon the latest postponement of the rule's effective date by an additional 31 days, the new effective date of the final rule is November 6, 2023. Pursuant to the court order, any obligation to comply with a deadline tied to the effective date is similarly postponed. However, FDA strongly encourages entities to submit cigarette plans as soon as possible, and no later than January 9, 2023.
Additional details on the rule, as well as the new effective date and recommended date for submission of cigarette plans, can be found on FDA’s website.
» learn more
ASQ Holiday Promotion Ideas | Radio Script and Social Media Posts.
ASQ developed different creatives and hopes they are helpful for state quitlines plan to promote quitlines to Chinese-, Korean-, and Vietnamese-speaking communities on various platforms. All of the creatives are available in Traditional and Simplified Chinese or Cantonese & Mandarin, Korean and Vietnamese. These creatives can be used in any format. Please find them below.
15-second radio scripts:
Occasion: Anytime, Christmas, Lunar New Year (LNY)
Target Audiences: Smokers, Vapers, People who want to help others to quit (proxy clients)
https://www.asiansmokersquitline.org/free_material/15-second-dj-read-radio-scripts/
Holiday Social Media Creatives:
Occasion: Christmas and New Year
Target Audiences: Anyone
Message: holiday wishes with ASQ in-language logo
https://www.facebook.com/asiansmokersquitline/posts/pfbid0XvHurrscjbrtYSXcGjB9KArioHapWoPqE3NgUc88yhNMLonhNmYNRgYNp39VkKeul
CDC's 6|18 Initiative: State Improvements Related to Tobacco Cessation through Increased Collaboration Between Medicaid and Public Health.
This brief highlights 6|18’s role in strengthening partnerships to increase access to and use of evidence-based tobacco cessation services for Medicaid beneficiaries. It offers guidance based on the experience of seven 6|18 state teams – Alaska, Colorado, Minnesota, New York, North Carolina, Rhode Island, and South Carolina – and their tobacco cessation efforts. Their achievements and lessons learned emphasize the importance of: (1) collaborating to improve the collection, monitoring, and analysis of data; (2) facilitating changes in Medicaid coverage policy to increase access and remove barriers to tobacco cessation services; and (3) using promotional strategies to increase utilization of tobacco cessation benefits.
» learn more
2022 Monitoring the Future Survey Shows Youth E-cigarette Use up among 10th and 12th Graders.
The 2022 Monitoring the Future Survey (MTF) released today confirms that youth vaping remains a serious public health threat with noteworthy upticks among 10th and 12th graders and increases in daily use (30 days in the last month) across those who vape in all grades and doubling among 8th graders since 2020.
» learn more Find more Cessation and Tobacco Control News in our Newsroom or go back to top.
Research Tobacco CessationHartmann-Boyce J, Lindson N, Butler AR, et al. Electronic Cigarettes for Smoking Cessation. Cochrane Database Syst Rev. 2022;11(11):CD010216. Published 2022 Nov 17. doi:10.1002/14651858.CD010216.pub7 Background. Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, although some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review. Objectives. To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence. Search methods. We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2022, and reference-checked and contacted study authors. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and randomized cross-over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both. Data collection and analysis. We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants, or both. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta-analyses. Main results. We included 78 completed studies, representing 22,052 participants, of which 40 were RCTs. Seventeen of the 78 included studies were new to this review update. Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 50 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There was high certainty that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (RR 1.63, 95% CI 1.30 to 2.04; I<sup>2</sup> = 10%; 6 studies, 2378 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6). There was moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs was similar between groups (RR 1.02, 95% CI 0.88 to 1.19; I<sup>2</sup> = 0%; 4 studies, 1702 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.12, 95% CI 0.82 to 1.52; I<sup>2</sup> = 34%; 5 studies, 2411 participants). There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I<sup>2</sup> = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I<sup>2</sup> = 0%; 5 studies, 1840 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I<sup>2</sup> = 0%; 8 studies, 1272 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.66, 95% CI 1.52 to 4.65; I<sup>2</sup> = 0%; 7 studies, 3126 participants). In absolute terms, this represents an additional two quitters per 100 (95% CI 1 to 3). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that (non-serious) AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I<sup>2</sup> = 41%, low certainty; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.03, 95% CI 0.54 to 1.97; I<sup>2</sup> = 38%; 9 studies, 1993 participants). Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit. Authors' conclusions. There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status. Bold K, O'Malley S, Krishnan-Sarin S, Morean M. E-cigarette Use Patterns, Flavors, and Device Characteristics Associated with Quitting Smoking among a US Sample of Adults Using E-cigarettes in a Smoking Cessation Attempt. [published online ahead of print, 2022 Dec 3]. Nicotine Tob Res. 2022;ntac276. doi:10.1093/ntr/ntac276 Introduction. Many adults who smoke cigarettes use e-cigarettes to try to quit smoking, however some are not successful. Identifying factors that are associated with successfully quitting smoking using e-cigarettes is important for maximizing cigarette cessation. Methods. Online survey data were collected in 2021 from 857 adults in the U.S. who reported using e-cigarettes in a recent attempt to quit smoking. Survey items assessed patterns of e-cigarette use and device characteristics (flavors, device, nicotine) used when trying to quit smoking. Multivariable linear regression models examined characteristics associated with the longest duration of smoking abstinence when using e-cigarettes to try to quit. Results. The average duration of smoking abstinence when using e-cigarettes during a quit attempt was 65 days (SD=104). In the multivariable model, greater frequency of e-cigarette use when quitting and abruptly switching to e-cigarettes from cigarettes (vs. gradually reducing) were significantly associated with longer durations of abstinence (ps<.001). Preference for non-tobacco (relative to tobacco) flavors and nicotine concentration were not associated with duration of abstinence, although preference for rechargeable pod and mod device types (vs. cig-a-likes) was associated with longer durations of abstinence. Conclusions. Patterns of e-cigarette use were related to abstinence duration, which may provide guidance for adults who are using e-cigarettes to quit smoking to encourage complete substitution and maximize smoking cessation. Findings indicate non-tobacco e-cigarette flavors and nicotine strength are not related to longer durations of cessation success for adults, which may inform tobacco regulatory policies limiting these constituents to protect public health. Implications. This study provides important new information about characteristics of e-cigarettes used during an attempt to quit smoking among adults across the U.S. and identifies factors associated with quitting success. Patterns of e-cigarette use were associated with longer durations of abstinence. In contrast, few e-cigarette characteristics were associated with abstinence. Although preference for some pod and mod device types was associated with longer abstinence duration compared to earlier cig-a-like devices, preference for non-tobacco (vs. tobacco) flavor and nicotine concentration were not associated with abstinence. Findings may help inform guidance for adults using e-cigarettes to quit smoking and support tobacco regulatory policies. Lopes LC, Zhang Y, Ross S, et al. Varenicline for Tobacco-dependent Adults who are not Ready to Discontinue Use: A Systematic Review and Meta-analysis. Ann Am Thorac Soc. 2022;19(12):2077-2086. doi:10.1513/AnnalsATS.202110-1122OC Rationale. Not all individuals with tobacco dependence are ready to give up smoking. Research reveals behavioral differences between adults ready to discontinue tobacco use and those who are not. Thus, the interventions applied to these populations might differ. However, the evidence of using varenicline in individuals who are not ready to discontinue tobacco use is uncertain. Objectives. To determine if, in tobacco-dependent adults who report not being ready to discontinue tobacco use, clinicians should begin treatment with varenicline or wait until subjects are ready to discontinue tobacco use. Methods. We conducted a systematic review to assess the effectiveness and safety of treatment with varenicline in tobacco-dependent adults who are not ready to discontinue tobacco use. We systematically searched the Cumulative Index to Nursing and Allied Health Literature, Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials comparing varenicline versus placebo for individuals who were not ready to discontinue tobacco use. Outcomes of interest include point prevalence abstinence during treatment or at six months or longer, smoking reduction, motivation to quit, adverse events, and withdrawal symptoms. Two authors independently extracted data and assessed eligibility and risk of bias using a standardized data collection form. We followed the Grading of Recommendations, Assessment, Development and Evaluations approach to assess the certainty of evidence. Results. Five trials met our inclusion criteria. All 2,616 participants were adults who were not ready to discontinue tobacco use at study entry. For 7-day point prevalence abstinence at six months or longer, high-certainty evidence suggested that varenicline increased abstinence compared with placebo (relative risk, 2.00 [95% confidence interval (CI), 1.70-2.35]; absolute risk reduction, 173 more per 1,000 [95% CI, 121 more to 234 more]). We identified moderate-certainty evidence suggesting that varenicline increased serious adverse events (relative risk, 1.75 [95% CI, 0.98-3.13]; absolute risk reduction, 12 more per 1,000 [95% CI, 0 fewer to 35 more]). For withdrawal, low-certainty evidence suggested that varenicline treatment was associated with a lower symptom score (mean difference, 1.54 points lower; 95% CI, 2.15-0.93 points lower; low certainty) assessed using the Brief Questionnaire of Smoking Urges. Conclusions. In tobacco-dependent adults who are not ready to discontinue tobacco use, initiating varenicline treatment results in a large increase in abstinence and likely results in a slight increase in serious adverse events. Shepard DS, Slade EP, Nighbor TD, et al. Economic Analysis of Financial Incentives for Smoking Cessation During Pregnancy and Postpartum. Prev Med. 2022;165(Pt B):107079. doi:10.1016/j.ypmed.2022.107079 Higgins and colleagues' recently-completed randomized controlled trial and pooled data with 4 related trials of smoking cessation in pregnant women in Vermont (USA) showed that abstinence-contingent financial incentives (FI) increased abstinence over control conditions from early pregnancy through 24-weeks postpartum. Control conditions were best practices (BP) alone in the recent trial and payments provided independent of smoking status (noncontingently) in the others. This paper reports economic analyses of abstinence-contingent FI. Merging trial results with maternal and infant healthcare costs from all Vermont Medicaid deliveries in 2019, we computed incremental cost-effectiveness ratios (ICERs) for quality-adjusted life years (QALYs) and compared them to established thresholds. The healthcare sector cost (±standard error) of adding FI to BP averaged $634.76 ± $531.61 per participant. Based on this trial, the increased probability per BP + FI participant of smoking abstinence at 24-weeks postpartum was 3.17%, the cost per additional abstinent woman was $20,043, the incremental health gain was 0.0270 ± 0.0412 QALYs, the ICER was $23,511/QALY gained, and the probabilities that BP + FI was very cost-effective (ICER≤$65,910) and cost-effective (ICER≤$100,000) were 67.9% and 71.0%, respectively. Based on the pooled trials, the corresponding values were even more favorable-8.89%, $7138, 0.0758 ± 0.0178 QALYs, $8371/QALY, 98.6% and 99.3%, respectively. Each dollar invested in abstinence-contingent FI over control smoking-cessation programs yielded $4.20 in economic benefits in the recent trial and $11.90 in the pooled trials (very favorable benefit-cost ratios). Medicaid and commercial insurers may wish to consider covering financial incentives for smoking abstinence as a cost-effective service for pregnant beneficiaries who smoke. Trial Registration: ClinicalTrials.gov identifier: NCT02210832. Yon B, Williams R, Wedin J, Underhill L, Kurti A. Incentivizing Pregnant Women to Quit Smoking in the Real World-A Community-based Pilot Intervention. [published online ahead of print, 2022 Nov 29]. Health Promot Pract. 2022;15248399221139299. doi:10.1177/15248399221139299 Smoking during pregnancy is a leading preventable cause of poor pregnancy outcomes. Financial incentives interventions yield quit rates of approximately 30% during pregnancy, versus ~4% in traditional smoking cessation programs. This pilot study assessed the feasibility of translating an efficacious University of Vermont research-based intervention into a rural community setting delivered by the Vermont Department of Health. Pregnant women using tobacco products were recruited from the Women, Infants and Children program and Rutland Women's Healthcare. Women were provided in-person tobacco cessation counseling during regularly scheduled meetings and received gift cards throughout pregnancy and 3 months postpartum contingent upon biochemically verified smoking abstinence. Cessation counseling and abstinence monitoring began with high frequency (three visits per week), tapering through postpartum to biweekly visits. Gift card values began at $15, increasing by $5 for consecutive negative samples, to $40 maximum. Participants completed three surveys (enrollment, 4-6 weeks postpartum, 6-12 months postpartum) assessing smoking habits, and barriers and facilitators of treatment engagement and success. From 2018 to 2020, we enrolled 20 pregnant women, of whom six self-reported quitting tobacco at some point during the intervention. At study completion, three reported sustained abstinence. Results suggest that it is feasible to translate a research-based smoking cessation program into a community setting. This article discusses the challenges faced and the lessons learned when implementing research in a rural community setting, recruiting and retaining participants, and adapting protocols during the Covid-19 pandemic. Priority PopulationsPatten CA, Koller KR, Sinicrope PS, et al.
Exploring the Perceived Effectiveness and Cultural Acceptability of COVID-19 Relevant Social Media Intervention Content among Alaska Native People who Smoke: The CAN Quit Study.
Prev Med Rep. 2022;30:102042. doi:10.1016/j.pmedr.2022.102042
Social media platforms have potential for reach and effectiveness to motivate smoking cessation and use of evidence-based cessation treatment, even during the worldwide COVID-19 pandemic. This study builds on our prior community participatory approach to developing content postings for the CAN Quit Facebook intervention among Alaska Native (AN) people who smoke. With input from a community advisory committee, we selected new content on COVID-19 preventive practices (e.g., masking) and evaluated them using a validated, six-item perceived effectiveness scale and a single item assessing cultural relevance. We obtained feedback on six content postings (two videos and four text/pictures) from an online survey administered to 41 AN people (14 men, 27 women; age range 22-61 years) who smoke in Alaska statewide with 49 % residing in rural Alaska. Perceived effectiveness scale scores were high across postings, ranging from 3.9 to 4.4 out of a maximum score of 5.0. Cultural relevance item scores ranged from 3.9 to 4.3. We found no appreciable differences by sex, age, or rural/urban location for either score. This study adds new information on the adaptation, acceptability, and perceived effectiveness of content on COVID-19 preventive practices for future inclusion in a social media-based intervention for smoking cessation specifically tailored for AN people.
Donaldson CD, Stupplebeen DA, Wilkinson ML, Zhang X, Williams RJ.
Intersectional Disparities in Youth Tobacco Use by Sexual and/or Gender Minority Status and Race/Ethnicity.
[published online ahead of print, 2022 Nov 17]. Nicotine Tob Res. 2022;ntac264. doi:10.1093/ntr/ntac264
Introduction. The current study applied an intersectional lens to examine societal factors, individual psychological outcomes, and youth combustible tobacco and vape use at the intersection of sexual and/or gender minority (SGM) status and race/ethnicity.
Methods. Data were drawn from 133,969 youth respondents surveyed in the 2019-2020 California Student Tobacco Survey, a representative school-based survey of 8 th and 10 th grade public school students throughout California. The impact of multiple marginalized group membership using four mutually exclusive intersectional positions (non-SGM White, SGM White, racial minority only, and both SGM and racial minority), in addition to specific differences across ten SGM by race/ethnicity groups (e.g., non-SGM Black/African American, SGM Black/African American, etc.) were assessed.
Results. Compared to heterosexual/cisgender White youth, SGM and racial minority adolescents were shown to experience poorer school tobacco education quality and cessation support, lower school and family connectedness, and higher anxiety/depression symptoms. SGM and racial minority youth had a higher prevalence of ever combustible tobacco use but were less likely to be current vape users compared to non-SGM White respondents. In examining specific group differences, results revealed that SGM teens had the highest risk of ever combustible tobacco use. This disparity was amplified for those belonging to multiple marginalized groups, with Black/AA SGM teens evidenced to be at the highest risk of current combustible tobacco.
Conclusions. Information from this study has useful implications for SGM measurement in surveillance systems and highlights the usefulness of adopting an intersectional approach to inform equity driven public health policy and intervention.
Implications. This representative study of California youth supports that identifying as a sexual and/or gender minority (SGM) is an important risk factor for combustible tobacco use. Particularly, observed SGM disparities were magnified for youth belonging to marginalized groups, as Black/African American SGM teens were shown to be at the highest risk of current combustible tobacco use. Findings support that Intersectionality Theory represents a useful framework for examining tobacco-related disparities and underscores the importance of assessing how the intersection of multiple social categories impacts youth tobacco use.
Zavala-Arciniega L, Meza R, Hirschtick JL, Fleischer NL.
Disparities in Cigarette, E-cigarette, Cigar, and Smokeless Tobacco Use at the Intersection of Multiple Social Identities in the U.S. Adult Population. Results from the TUS-CPS 2018-2019 Survey.
[published online ahead of print, 2022 Nov 16]. Nicotine Tob Res. 2022;ntac261. doi:10.1093/ntr/ntac261
Introduction. Sociodemographic disparities in tobacco use are prevalent and persistent in the US. Nevertheless, few studies have examined disparities in tobacco use from an intersectionality perspective. We developed a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of multiple social identities.
Methods. We used the 2018-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) to estimate the prevalence of tobacco product use at the intersection of age (18-34, 35-54, 55+ years), sex (male, female), race/ethnicity (Non-Hispanic [NH] White, NH Black, Hispanic, NH Other), and annual household income (<$50,000, $50,000-$99,999, ≥$100,000). Estimates accounted for the complex survey design.
Results: For cigarettes, the most defining characteristic was income, with the highest prevalence among low-income NH White male adults aged 35-54 years (30.7%) and low-income NH White female adults aged 35-54 years (29.7%). For e-cigarettes, the most defining characteristic was age, with adults 18-34 years old having the highest prevalence. High prevalence groups for cigars included young- and middle-aged NH Black and NH White males, while NH White males had the highest prevalence of smokeless tobacco use.
Conclusions. Our intersectionality visualization tool is helpful to uncover complex patterns of tobacco use, facilitating the identification of high-risk groups.
Implications. We created a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of age, sex, race/ethnicity, and income. Our visualization tool helps uncover complex patterns of tobacco use, facilitating the identification of high-risk population groups that would otherwise be masked. These results can be used to implement tobacco control policies targeted at factors that promote or sustain tobacco use disparities.
E-Cigarettes and Heated Tobacco Products Gorukanti AL, Kimminau KS, Tindle HA, et al.
Cross-sectional Online Survey of Clinicians' Knowledge, Attitudes and Challenges to Screening and Counselling Adolescents and Young Adults for Substance Use.
BMJ Open. 2022;12(11):e059019. Published 2022 Nov 22. doi:10.1136/bmjopen-2021-059019
Objective. To examine adolescent healthcare clinicians' self-reported screening practices as well as their knowledge, attitudes, comfort level and challenges with screening and counselling adolescents and young adults (AYA) for cigarette, e-cigarette, alcohol, marijuana, hookah and blunt use.
Design. A 2016 cross-sectional survey.
Setting. Academic departments and community-based internal medicine, family medicine and paediatrics practices.
Participants. Adolescent healthcare clinicians (N=771) from 12 US medical schools and respondents to national surveys. Of the participants, 36% indicated male, 64% female, mean age was 44 years (SD=12.3); 12.3% of participants identified as Asian, 73.7% as white, 4.8% as black, 4.2% as Hispanic and 3.8% as other.
Primary and secondary outcome measures. Survey items queried clinicians about knowledge, attitudes, comfort level, self-efficacy and challenges with screening and counselling AYA patients about marijuana, blunts, cigarettes, e-cigarettes, hookah and alcohol.
Results. Participants were asked what percentage of their 10-17 years old patients they screened for substance use. The median number of physicians reported screening 100% of their patients for cigarette (1st, 3rd quartiles; 80, 100) and alcohol use (75, 100) and 99.5% for marijuana use (50,100); for e-cigarettes, participants reported screening half of their patients and 0.0% (0, 50), (0, 75)) reported screening for hookah and blunts, respectively. On average (median), clinicians estimated that 15.0% of all 10-17 years old patients smoked cigarettes, 10.0% used e-cigarettes, 20.0% used marijuana, 25.0% drank alcohol and 5.0% used hookah or blunts, respectively; yet they estimated lower than national rates of use of each product for their own patients. Clinicians reported greater comfort discussing cigarettes and alcohol with patients and less comfort discussing e-cigarettes, hookah, marijuana and blunts.
Conclusions. This study identified low rates of screening and counselling AYA patients for use of e-cigarettes, hookahs and blunts by adolescent healthcare clinicians and points to potential missed opportunities to improve prevention efforts.
Abadi MH, Shamblen SR, Thompson K, et al.
Socio-temporal Contextual and Community Factors Associated with Daily Exclusive ENDS Use and Dual Use with Tobacco Cigarettes among Adolescent Vapers: an Ecological Momentary Assessment Study.
BMC Public Health. 2022;22(1):2289. Published 2022 Dec 7. doi:10.1186/s12889-022-14787-1
Background. Adolescents who dual use ENDS with tobacco cigarettes are more likely to have an increased risk of developing dependence. Yet, little is understood about the factors driving dual use among adolescents. The current study sought to reveal the day-to-day socio-temporal contextual and community factors associated with adolescents' use of electronic nicotine delivery systems (ENDS), and how these factors predict dual use with tobacco cigarettes.
Methods. We collected ecological momentary assessments (EMA) from a sample of 50 adolescent past two-week vapers (ages 14-17 years old) over 14 days. Daily EMA data were collected on ENDS and tobacco cigarette use, as well as a range of contextual (i.e., motivations to vape, location of vaping, who with when vaping) and community factors (i.e., exposure to peers vaping, to adults vaping, to ENDS advertising, to ENDS warning messages). Our primary analyses were multilevel regressions, accounting for daily observations nested within individuals (N = 700 observations).
Results. Participants used ENDS exclusively on 44% of days and dual used ENDS and tobacco cigarettes on 8% of the days. Dual use days (versus exclusive ENDS use days) were associated with "vaping because tobacco use was prohibited" (OR = 34.65, p < .05). Also, dual use days (versus no use days) were associated with greater exposure to adults vaping (OR = 5.59, p < .05), peers vaping (OR = 7.48, p < .05), and (c) ENDS advertisements or promotions (OR = 2.12, p < .01), whereas exclusive use days (versus no use days) were only associated with greater exposure to peers vaping (OR = 2.58, p < .01).
Conclusions. Results showed that exposure to peers and adults vaping and exposure to ENDS marketing were associated with same day dual use behaviors. And, that adolescents who dual used were motivated to use ENDS because they were easy to conceal. Findings support stricter regulation of ENDS marketing and for smoke-free air laws that include ENDS. In addition, these findings support prioritizing family- and school-based prevention programming that effectively communicates risk associated with ENDS use, including heightened risk of dual use and dependence. Such efforts can reduce the number of adolescents who use ENDS as well as the number who transition to tobacco cigarette use.
Helgertz S, Kingsbury J.
Teens Less Susceptible to Vaping When Restricted to Tobacco-flavored E-cigarettes: Implications for Flavored Tobacco Policies.
[published online ahead of print, 2022 Dec 1]. Nicotine Tob Res. 2022;ntac272. doi:10.1093/ntr/ntac272
Introduction. Flavors added to tobacco products increase their appeal to youth and contribute to the youth vaping epidemic. To address this problem, over 340 localities have implemented various policies to restrict access to flavored tobacco products. Few studies have examined the extent to which restricting available e-cigarette flavors might affect e-cigarette initiation or cessation among youth.
Methods. A representative sample of Minnesota teens were asked about their use of e-cigarettes, symptoms of e-cigarette dependence and their willingness to use an e-cigarette under four flavor conditions: unspecified (any flavor); menthol, tobacco, or unflavored. Respondents with data on all four flavor conditions were included in the analysis (N=2,151).
Results. Cochran's Q, McNemar, and exact binomial tests revealed that susceptibility to e-cigarette use was highest when the flavor was unspecified (38.2%), lower for unflavored (29.7%) and menthol-flavored e-cigarettes (26.7%), and lowest when the flavor was tobacco (21.0%). Among the subsets of students who had never tried e-cigarettes and students who reported signs of e-cigarette dependence, the largest decrease in susceptibility from unspecified flavor e-cigarettes was observed for tobacco flavor, a decrease of 12.7 and 19.6 percentage points, respectively.
Conclusions. Whether teens had no experience using e-cigarettes or showed signs of dependence, the percentage of teens who were susceptible to using e-cigarettes was significantly lower when the flavor available was restricted. Susceptibility was lower for tobacco- and menthol-flavored than unflavored e-cigarettes, suggesting that teens consider these flavors aversive.
Implications. These results suggest that policies that eliminate all e-cigarette flavors except tobacco may be a powerful tool for advancing youth e-cigarette prevention and cessation goals by reducing the appeal of e-cigarettes to teens with different levels of experience with them, including teens who have never tried e-cigarettes and those who may find it difficult to quit using them.
Michael F. Pesko, K. Michael Cummings, Clifford E. Douglas
United States Public Health Officials Need to Correct E-cigarette Health Misinformation.
Addiction. First published: 12 December 2022. https://doi.org/10.1111/add.16097.
United States public health officials need to correct e-cigarette health misinformation (Editorial)
Summary: Health misinformation is harmful as it can cause confusion and sow mistrust regarding the adoption of public health recommendations and policies. Authors provide examples of e-cigarette misinformation promoted by the United States public health officials, which have persisted despite new data challenging the validity of the original assertions.
Technology
Marler JD, Fujii CA, Utley MT, Balbierz DJ, Galanko JA, Utley DS.
Outcomes of a Comprehensive Mobile Smoking Cessation Program with Nicotine Replacement Therapy in Adult Smokers: Pilot Randomized Controlled Trial.
JMIR Mhealth Uhealth. 2022;10(11):e41658. Published 2022 Nov 24. doi:10.2196/41658
Background. Cigarette smoking remains the leading cause of preventable illness and death, underscoring ongoing need for evidence-based solutions. Pivot, a US Clinical Practice Guideline-based mobile smoking cessation program, comprises a personal carbon monoxide breath sensor; a smartphone app; in-app, text-based human-provided coaching; nicotine replacement therapy; and a moderated web-based community. Promising Pivot cohort studies have established the foundation for comparative assessment.
Objective. This study aimed to compare engagement, retention, attitudes toward quitting smoking, smoking behavior, and participant feedback between Pivot and QuitGuide, a US Clinical Practice Guideline-based smoking cessation smartphone app from the National Cancer Institute.
Methods. In this remote pilot randomized controlled trial, cigarette smokers in the United States were recruited on the web and randomized to Pivot or QuitGuide. Participants were offered 12 weeks of free nicotine replacement therapy. Data were self-reported via weekly web-based questionnaires for 12 weeks and at 26 weeks. Outcomes included engagement and retention, attitudes toward quitting smoking, smoking behavior, and participant feedback. The primary outcome was self-reported app openings at 12 weeks. Cessation outcomes included self-reported 7- and 30-day point prevalence abstinence (PPA), abstinence from all tobacco products, and continuous abstinence at 12 and 26 weeks. PPA and continuous abstinence were biovalidated via breath carbon monoxide samples.
Results. Participants comprised 188 smokers (94 Pivot and 94 QuitGuide): mean age 46.4 (SD 9.2) years, 104 (55.3%) women, 128 (68.1%) White individuals, and mean cigarettes per day 17.6 (SD 9.0). Engagement via mean "total app openings through 12 weeks" (primary outcome) was Pivot, 157.9 (SD 210.6) versus QuitGuide, 86.5 (SD 66.3; P<.001). Self-reported 7-day PPA at 12 and 26 weeks was Pivot, 35% (33/94) versus QuitGuide, 28% (26/94; intention to treat [ITT]: P=.28) and Pivot, 36% (34/94) versus QuitGuide, 27% (25/94; ITT: P=.12), respectively. Self-reported 30-day PPA at 12 and 26 weeks was Pivot, 29% (27/94) versus QuitGuide, 22% (21/94; ITT: P=.32) and Pivot, 32% (30/94) versus QuitGuide, 22% (21/94; ITT: P=.12), respectively. The biovalidated abstinence rate at 12 weeks was Pivot, 29% (27/94) versus QuitGuide, 13% (12/94; ITT: P=.008). Biovalidated continuous abstinence at 26 weeks was Pivot, 21% (20/94) versus QuitGuide, 10% (9/94; ITT: P=.03). Participant feedback, including ease of setup, impact on smoking, and likelihood of program recommendation were favorable for Pivot.
Conclusions. In this randomized controlled trial comparing the app-based smoking cessation programs Pivot and QuitGuide, Pivot participants had higher engagement and biovalidated cessation rates and more favorable user feedback at 12 and 26 weeks. These findings support Pivot as an effective, durable mobile smoking cessation program.
Tobacco Use
Cassidy RN, Tidey JW, Jackson KM, et al.
The Impact of Reducing Nicotine Content on Adolescent Cigarette Smoking and Nicotine Exposure: Results from a Randomized Controlled Trial.
[published online ahead of print, 2022 Dec 9]. Nicotine Tob Res. 2022;ntac279. doi:10.1093/ntr/ntac279
Introduction. As the science base around the potential benefits of a reduced-nicotine standard for cigarettes grows, information on the potential effects on adolescent smokers is a high priority. The aim of this randomized trial was to test the influence of three-week exposure to reduced nicotine cigarettes in a sample of adolescent daily smokers.
Methods. In this double-blind, two-arm, randomized controlled trial (NCT0258731), following a one-week baseline, adolescent daily smokers not currently intending to quit (ages 15-19, n=66 randomized) were urn randomized to use either very low nicotine content (VLNC; 0.4 mg/g; n=33) or normal nicotine content (NNC, 15.8 mg/g; n=33) research cigarettes for three weeks. Participants attended 5 study sessions at our clinical laboratory. The primary outcome was average total cigarettes smoked per day (CPD; including both study and non-study cigarettes) at week 3.
Results. Stepwise regression results demonstrated that compared with NNC cigarettes (n=31), assignment to VLNC cigarettes (n=29), was associated with 2.4 fewer CPD on average than NNC assignment (p<.05).week 3 when controlling for covariates (p<.01, Cohen's d= 0.52 n=60 completed all procedures). VLNC cigarettes were also associated with lower levels of craving reduction than NNC cigarettes (QSU Factor 2, p<.05). No group differences were found for secondary outcomes.
Conclusions. Adolescent participants assigned to VLNC use for 3 weeks smoked fewer total cigarettes smoked per day relative to the NNC group. Overall, data suggest that a VLNC policy would reduce cigarette smoking in adolescents who smoke, but high rates of incomplete adherence that youth may seek alternative sources of nicotine in this scenario.
Implications. The US Food and Drug Administration may enact a reduced-nicotine product standard that would affect all commercially-available cigarettes. One important population affected by this policy would be adolescents who smoke. This study, the first clinical trial of very low nicotine content (VLNC) cigarettes in adolescents, demonstrates that adolescents switched to VLNC cigarettes for three weeks reduced their cigarettes smoked per day relative to the normal-nicotine cigarette control group, without leading to increased respiratory symptoms or increased withdrawal. Biomarkers indicated use of other sources of nicotine, suggesting that such a policy will need to consider approaches to assist in transitioning away from smoking.
Job and Conference AnnouncementsIf you have any job openings that would interest tobacco control professionals, please send them to us at naqc@naquitline.org.The University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI) is Seeking a Director. The University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI) is seeking a Director. Please read about the position opening here. Postdoctoral Fellowship in Digital Health at Truth Initiative. The Innovations Center is a cross-functional team that builds, evaluates, and disseminates digital tools for tobacco cessation including BecomeAnEX, EX Program, and This Is Quitting. Fellows will receive mentorship and be encouraged to transform existing data sets into publications, presentations, and grants through secondary data analysis and new data collection. This is an excellent opportunity to conduct research and gain experience working in a live, digital production environment. Successful candidates will have a strong background in quantitative skills for data analysis and a passion for making a direct impact on public health. Details are available at https://truthinitiative.applytojob.com/apply/UnkGUJVARj/Postdoctoral-Fellow-Innovations-Center. Please distribute to anyone who you think might be a good candidate. Feel free to reach out to me ( agraham@truthinitiative.org) or Dr. Michael Amato ( mamato@truthinitiative.org) with any questions. The State of Oklahoma is Seeking Tobacco Control Consultant. Posting end date of December 21. This position will serve as a Tobacco Control Consultant for Tobacco Settlement Endowment Trust (TSET) grantees providing information, training and consultation to grantees statewide to prevent/reduce tobacco use and secondhand smoke exposure. Efforts will utilize evidence-based or evidence-informed interventions and focus on policy, systems and environmental changes with various local organizations. Learn more here. March 1-4, 2023: Society for Research on Nicotine & Tobacco Annual Meeting in San Antonio, TX. SRNT is offering five pre-conference workshops. All pre-conference workshops are three (3) hours and run concurrently. Learn more here. May 9-11, 2023: The NNPHI Annual Conference is Headed to DC!The National Network of Public Health Institutes (NNPHI) is proud to announce its 22nd Annual Conference will be held May 9-11, 2023 in Washington, DC. Learn more here. Find more Job and Conference Announcements in our Newsroom or go back to top.
Funding for Connections is provided solely through a cooperative agreement from the Centers for Disease Control and Prevention (5 NU58DP006704-04-00). We thank them for their support of this publication. Information and links are provided solely as a service to NAQC members and partners and do not constitute an endorsement of any organization by NAQC, nor should any be inferred. |
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