Does Self-Reported smoking cessation fatigue predict making quit attempts and sustained abstinence among adults who smoke Regularly?

BACKGROUND: Quitting smoking is difficult and many people who smoke experience cessation fatigue (CF) as a result of multiple failed attempts. This study examined the association of CF with making and sustaining a smoking quit attempt. METHODS: Data analysed were 4,139 adults (aged 18 years or older) who smoked daily or weekly and participated in the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping Surveys (ITC 4CV) conducted in Australia, Canada, England, and the US. CF was assessed at baseline using a single question: "To what extent are you tired of trying to quit smoking?" with response options: "Not at all tired"; "Slightly tired"; "Moderately tired"; "Very tired"; or "Extremely tired". We used binary logistic regression models to test the hypothesis that baseline CF would predict lower odds of both making a quit attempt and sustaining abstinence for a month or longer at follow-up adjusted for socio-demographic and smoking/vaping-related covariates. RESULTS: Persons who currently smoked and reported at least some CF were more likely to make a quit attempt, but less likely to sustain abstinence for at least one month, than those who reported no CF. These associations were independent of socio-demographic variables, and they did not differ by country. CONCLUSION: Contrary to expectation, CF was positively associated with making a quit attempt and non-linearly associated with lower rates of sustained abstinence at follow-up. While these findings should be replicated, they suggest that people with CF may benefit from targeted support to remain abstinent after a quit attempt.

A Pilot Study to Test the Feasibility for a Randomized Controlled Trial of E-cigarettes as Harm Reduction Tools Among People Who Smoke and Previously Failed to Quit with Pharmacotherapy.

INTRODUCTION: We conducted a pilot study to test the feasibility of a future randomized controlled trial comparing e-cigarettes to traditional pharmacotherapy among people who smoke daily, were motivated to quit, and failed to quit within the past 5 years using pharmacotherapy. METHODS: Eligible participants were assigned to either: 1) an e-cigarette (n=20) or 2) combination nicotine replacement therapy (patches and lozenges) (n=10). Participants received 5 weeks of product and selected a quit date 1 week later. Assessments were completed weekly, and electronic diaries were completed each day. As a pilot randomized controlled trial, outcomes focus on effects sizes and not statistical significance. RESULTS: Participants in the e-cigarette and NRT groups had a mean age of 51 (SD=13) and 50 (SD=10) years old, were 55% and 60% female, and were 15% and 0% non-white, respectively. At least 90% of participants completed each weekly assessment, and 77% of participants completed at least 80% of daily diaries. Mean cigarettes smoked per day reduced from 18 (SD=6.2) to 2.4 (SD=4.4) per day in the e-cigarette group and 16.5 (SD=8.5) to 4.9 (SD=5.9) per day in the NRT group. Rates of biochemically confirmed 7-day point prevalence abstinence at the end of treatment were numerically, but not statistically, higher in the e-cigarette group than the NRT group (35% vs. 10%, OR=4.8, 95% CI=0.5-46.5). CONCLUSIONS: Among current daily cigarette smokers who have previously tried to quit and failed using standard pharmacotherapies, provision of an e-cigarette is a feasible intervention. A larger adequately powered trial is warranted. IMPLICATIONS: This pilot study suggests that e-cigarettes may serve as an acceptable harm reduction intervention for people who smoke who cannot quit smoking with traditional pharmacotherapy, but adequately powered randomized controlled trials are needed.

E-Cigarette Characteristics and Cigarette Cessation Among Adults Who Use E-Cigarettes.

Importance: Population-level health outcomes associated with e-cigarettes depend in part on the association between e-cigarettes and combustible cigarette cessation. The US Food and Drug Administration has authority to regulate e-cigarette characteristics, including flavor and device type. Objective: To investigate whether e-cigarette characteristics are associated with cigarette cessation behaviors among adults in the US population who use e-cigarettes. Design, Setting, and Participants: This cohort study was conducted using longitudinal data collected in 2014 to 2021 by the Population Assessment of Tobacco and Health Study, a population-based, US nationally representative study. Participants were sampled from the civilian noninstitutionalized population using a 4-staged, stratified sampling design. Data were weighted and analyzed from 1985 adults ages 21 or older who smoked cigarettes daily and had used e-cigarettes in the past 30 days. Data were analyzed in May 2021 to May 2024. Exposures: The following e-cigarette characteristics were assessed: use frequency (daily and nondaily), flavor type (tobacco, menthol or mint, sweet, and combination), device type (disposable, cartridge, and tank), and year of data collection as a proxy for the evolving e-cigarette marketplace. Main Outcomes and Measures: The following cigarette cessation behaviors were assessed: making a cigarette quit attempt, cigarette cessation among individuals who made a quit attempt, and overall cigarette discontinuation regardless of quit attempts. Associations were evaluated between e-cigarette characteristics (assessed at baseline in 1 approach and assessed at follow-up in another approach) and cigarette cessation outcomes, controlling for demographic, cigarette smoking, and other e-cigarette use characteristics. Results: The study sample consisted of 1985 participants representing adults in the population (mean age, 40.0 years [95% CI, 39.2-40.9 years]; 49.4% [95% CI, 46.3%-52.6%] male; 11.4% [95% CI, 9.6%-13.4%] Black, 80.7% [95% CI, 77.8%-83.3%] White, and 8.0% [95% CI, 6.3%-10.0%] other race; 9.2% [95% CI, 7.5%-11.2%] Hispanic). Daily vs nondaily e-cigarette use was associated with greater overall cigarette discontinuation rates (12.8% [95% CI, 9.1%-17.7%] vs 6.1% [95% CI, 4.8%-7.7%]; adjusted odds ratio [aOR], 2.26 [95% CI, 1.34-3.81]), and use of e-cigarettes in 2019 to 2021 vs 2014-2015 to 2015-2016 was also associated with greater overall cigarette discontinuation rates (12.0% [95% CI, 8.8%-16.0%] vs 5.3% [95% CI, 2.9%-9.3%]; aOR, 2.75 [95% CI, 1.13-6.67]). Use of menthol or mint vs tobacco flavor e-cigarettes was associated with greater overall cigarette discontinuation rates (9.2% [95% CI, 6.6%-12.8%] vs 4.7% [95% CI, 3.0%-7.1%]; aOR, 2.63 [95% CI, 1.32-5.27]) only when assessing e-cigarette use at baseline. E-cigarette device type was not associated with cigarette discontinuation rates in adjusted analyses. Conclusions and Relevance: In this study, daily e-cigarette use and use of e-cigarettes in 2019 to 2021 were consistently associated with greater cigarette discontinuation rates. These findings suggest that research focused on e-cigarettes marketed in recent years is needed to inform product regulation and public health policy decisions.

Implementation of an "opt-out" tobacco treatment program in six hospitals in South Carolina.

OBJECTIVE: Describe the screening, referral, and treatment delivery associated with an opt-out tobacco treatment program (TTP) implemented in six hospitals varying in size, rurality and patient populations. METHODS: Between March 6, 2021 and December 17, 2021, adult patients (≥ 18 years) admitted to six hospitals affiliated with the Medical University of South Carolina were screened for smoking status. The hospitals ranged in size from 82 to 715 beds. Those currently smoking were automatically referred to one of two tobacco treatment options: 1) Enhanced care (EC) where patients could receive a bedside consult by a trained tobacco treatment specialist plus an automated post-discharge follow-up call designed to connect those smoking to the South Carolina Quitline (SCQL); or 2) Basic care (BC) consisting of the post-discharge follow-up call only. An attempt was made to survey patients at 6-weeks after hospitalization to assess smoking status. RESULTS: Smoking prevalence ranged from 14 to 49% across the six hospitals; 6,000 patients were referred to the TTP.The delivery of the bedside consult varied across the hospitals with the lowest in the Charleston hospitals which had the highest caseload of referred patients per specialist. Among patients who received a consult visit during their hospitalization, 50% accepted the consult, 8% opted out, 3% claimed not to be current smokers, and 38% were unavailable at the time of the consult visit. Most of those enrolled in the TTP were long-term daily smokers.Forty-three percent of patients eligible for the automated post-discharge follow-up call answered the call, of those, 61% reported smoking in the past seven days, and of those, 34% accepted the referral to theSCQL. Among the 986 of patients surveyed at 6-weeks after hospitalization quit rates ranged from 20%-30% based on duration of reported cessation and were similar between hospitals and for patients assigned to EC versus BC intervention groups. CONCLUSION: Findings demonstrate the broad reach of an opt-out TTP. Elements of treatment delivery can be improved by addressing patient-to-staffing ratios, improving systems to prescribe stop smoking medications for patients at discharge and linking patients to stop smoking services after hospital discharge.

Prevalence of menthol cigarette use among adults who smoke from the United States by census division and demographic subgroup, 2002-2020: findings from the International Tobacco Control (ITC) project.

BACKGROUND: Targeted marketing of menthol cigarettes in the US influences disparities in the prevalence of menthol smoking. There has been no analysis of sub-national data documenting differences in use across demographic subgroups. This study estimated trends in the prevalence of menthol use among adults who smoke in the nine US census divisions by sex, age, and race/ethnicity from 2002 to 2020. METHODS: Data from 12 waves of the US ITC Survey were used to estimate the prevalence of menthol cigarette use across census divisions and demographic subgroups using multilevel regression and post-stratification (n = 12,020). Multilevel logistic regression was used to predict the prevalence of menthol cigarette use in 72 cross-classified groups of adults who smoke defined by sex, age, race/ethnicity, and socioeconomic status; division-level effects were fit with a random intercept. Predicted prevalence was weighted by the total number of adults who smoke in each cross-classified group and aggregated to divisions within demographic subgroup. Estimates were validated against the Tobacco Use Supplement to the Current Population Survey (TUS-CPS). RESULTS: Overall modeled prevalence of menthol cigarette use was similar to TUS-CPS estimates. Prevalence among adults who smoke increased in each division from 2002 to 2020. By 2020, prevalence was highest in the Middle (46.3%) and South Atlantic (42.7%) and lowest in the Pacific (25.9%) and Mountain (24.2%) divisions. Prevalence was higher among adults aged 18-29 (vs. 50+) and females (vs. males). Prevalence among non-Hispanic Black people exceeded 80% in the Middle Atlantic, East North Central, West North Central, and South Atlantic in all years and varied most among Hispanic people in 2020 (Pacific: 26.5%, New England: 55.1%). CONCLUSIONS: Significant geographic variation in the prevalence of menthol cigarette use among adults who smoke suggests the proposed US Food and Drug Administration (FDA) menthol cigarette ban will exert differential public health benefits and challenges across geographic and demographic subgroups.

Respiratory symptoms and outcomes among cigar smokers: findings from the Population Assessment of Tobacco and Health (PATH) study waves 2-5 (2014-2019).

BACKGROUND: The mechanisms by which cigarette smoking increases the risk of respiratory disease have been studied. However, less is known about risks of respiratory symptoms and outcomes associated with smoking cigars, and risks by cigar types have not been previously explored. The aim of this study was to examine associations between cigar use, including traditional cigars, cigarillos, filtered cigars, and dual cigar and cigarette use, and functionally important respiratory symptoms (FIRS), lifetime asthma diagnosis, uncontrolled asthma, and new cases of FIRS. METHODS: Data from Waves 2-5 (2014-19) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative longitudinal study, were analyzed in two ways. For cross-sectional analysis, the analytic sample included adults 18 and older at each wave, resulting in 44,040 observations. Separately, longitudinal analyses were assessed among adults 18 and older at Wave 2, resulting in 7,930 individuals. Both analyses excluded adults with chronic obstructive pulmonary disease (COPD) or non-asthma respiratory disease. RESULTS: Current established cigarillo smokers had higher odds of having FIRS (Adjusted odds ratio (AOR): 1.72; 95% CI: 1.08, 2.74) compared to never smokers of cigarillos and cigarettes, after adjusting for covariates. Current established filtered cigar smokers had higher odds of asthma diagnosis (AOR: 1.35; 95% CI: 1.10, 1.66) while current established dual smokers of filtered cigars and cigarettes had higher odds of uncontrolled asthma (AOR: 5.13; 95% CI: 1.75, 15.02) compared to never smokers of filtered cigars or cigarettes. Both current established cigar smokers and current established dual smokers of cigarettes and cigars had higher odds of new FIRS compared to never cigar or cigarette smokers (AORs: 1.62; 95% CI: 1.02, 2.60 for exclusive cigars and 2.55; 95% CI 1.57, 4.14 for dual smokers). CONCLUSIONS: This study provides evidence that cigar smokers or dual smokers of cigars and cigarettes have greater odds of FIRS, asthma, and uncontrolled asthma and that new incidence of FIRS is higher among any cigar smokers compared to never cigar or cigarette smokers. Understanding health impacts associated with cigar use provides information for supporting policy development, as well as for designing clinical interventions focused on smoking cessation for cigars.

Implementation, enrollment, and engagement in an opt-out telehealth pharmacist-assisted tobacco treatment program for patients seen in oncology outpatient clinics.

OBJECTIVE: To describe the workflow, reach, cost, and self-reported quit rates for an opt-out tobacco treatment program (TTP) for patients seen in 43 oncology outpatient clinics. METHODS: Between May 25, 2021, and December 31, 2022, adult patients (≥18 years) visiting clinics affiliated with the Medical University of South Carolina Hollings Cancer Center were screened for smoking status. Those currently smoking were referred to a telehealth pharmacy-assisted TTP. An attempt was made to contact referred patients by phone. Patients reached were offered free smoking cessation counseling and a 2-week starter kit of nicotine replacement medication. A random sample of 420 patients enrolled in the TTP were selected to participate in a telephone survey to assess smoking status 4 to 12 months after enrollment. RESULTS: During the reference period 35,756 patients were screened and 9.3% were identified as currently smoking. Among the 3319 patients referred to the TTP at least once, 2393 (72.1%) were reached by phone, of whom 426 (12.8%) were ineligible for treatment, 458 (13.8%) opted out of treatment, and 1509 (45.5%) received treatment. More than 90% of TTP enrollees smoked daily, with an average of 13.1 cigarettes per day. Follow-up surveys were completed on 167 of 420 patients, of whom 23.4% to 33.5% reported not smoking; if all nonresponders to the survey are counted as smoking, the range of quit rates is 9.3% to 13.3%. CONCLUSION: The findings demonstrate the feasibility of reaching and delivering smoking cessation treatments to patients from a diverse set of geographically dispersed oncology clinics.

The association between excise taxes and smoking and vaping transitions-Findings from the 2016-2020 ITC United States surveys.

BACKGROUND: While a growing number of studies examined the effect of e-cigarette (EC) excise taxes on tobacco use behaviors using cross-sectional surveys or sales data, there are currently no studies that evaluate the impact of EC taxes on smoking and vaping transitions. METHODS: Using data from the US arm of the 2016-2020 International Tobacco Control Four Country Smoking and Vaping Survey (ITC 4CV), we employed a multinomial logit model with two-way fixed effects to simultaneously estimate the impacts of cigarette/EC taxes on the change in smoking and vaping frequencies. RESULTS: Our benchmark model suggests that a 10 % increase in cigarette taxes led to an 11 % reduction in smoking frequencies (p < 0.01), while EC taxes did not have a significant effect on smoking frequencies. CONCLUSION: Our findings suggest that increasing cigarette taxes may serve as an effective means of encouraging people who smoke to cut back on smoking or quit smoking. The impact of increasing EC taxes on smoking transitions is less certain at this time.

How do users compare the costs between nicotine vaping products and cigarettes? Findings from the 2016-2020 International Tobacco Control United States surveys.

BACKGROUND AND AIMS: Nicotine vaping products (NVPs) can potentially help adult tobacco users quit smoking. This study evaluated how adult consumers compare the costs between NVPs and cigarettes. METHOD: We used data from the US arm of the 2016-2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) surveys to perform a multinomial logit model with two-way fixed effects to measure how perceived cost comparisons are associated with NVP and cigarette taxes, use patterns, NVP device types and individual sociodemographic factors. RESULTS: Higher cigarette taxes are associated with a greater likelihood of perceiving NVPs and cigarettes as costing the same for the overall population and among people who exclusively smoke, and a lower likelihood of perceiving NVPs as more expensive among people who exclusively vape, compared with lower cigarette taxes. Pre-filled cartridge and tank users are more likely to perceive NVPs as less expensive than cigarettes, compared with people who use other types of NVPs. The associations between taxes and perceived cost comparison were more pronounced among males, younger and low-income populations. CONCLUSIONS: Higher cigarette taxes are associated with perceived financial incentives for nicotine vaping products (NVPs) over cigarettes, whereas NVP taxes are not associated with perceived cost comparison between NVPs and cigarettes.

Relationship Between Tobacco Product Use and Health-Related Quality of Life Among Individuals With COPD in Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study.

Introduction: We examined the association between tobacco product use and health-related quality of life (HRQoL) among individuals with chronic obstructive pulmonary disease (COPD) in Waves 1-5 of the Population Assessment of Tobacco and Health (PATH) Study. Methods: Adults ≥40 years with an ever COPD diagnosis were included in cross-sectional (Wave 5) and longitudinal (Waves 1 to 5) analyses. Tobacco use included 13 mutually exclusive categories of past 30-day (P30D) single use and polyuse with P30D exclusive cigarette use and ≥5-year cigarette cessation as reference groups. Multivariable linear regression and generalized estimating equations (GEE) were used to examine the association between tobacco use and HRQoL as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 questionnaire. Results: Of 1670 adults, 79.4% ever used cigarettes; mean (standard error [SE]) pack years was 30.9 (1.1). In cross-sectional analysis, P30D exclusive cigarette use, and e-cigarette/cigarette dual use were associated with worse HRQoL compared to ≥5-year cigarette cessation. Compared to P30D exclusive cigarette use, never tobacco use and ≥5-year cigarette cessation were associated with better HRQoL, while e-cigarette/cigarette dual use had worse HRQoL. Longitudinally (n=686), e-cigarette/cigarette dual use was associated with worsening HRQoL compared to both reference groups. Only never tobacco use was associated with higher HRQoL over time compared to P30D exclusive cigarette use. Conclusions: E-cigarette/cigarette dual use was associated with worse HRQoL compared to ≥5-year cigarette cessation and exclusive cigarette use. Never use and ≥5-year cigarette cessation were the only categories associated with higher HRQoL compared to exclusive cigarette use. Findings highlight the importance of complete smoking cessation for individuals with COPD.

Support for nicotine reduction in cigarettes: findings from the 2016 and 2020 ITC Four Country Smoking and Vaping Surveys.

INTRODUCTION: The USA and New Zealand have sought to establish a product standard to set a maximum nicotine level for cigarettes to reduce their addictiveness. This study examined support for very low nicotine cigarettes (VLNCs) in Australia, Canada, England and the USA between 2016 and 2020. METHODS: Repeated cross-sectional data were analysed from participants who currently smoke, formerly smoked or vaped and/or currently vape in the 2016 (n=11 150) and/or 2020 (n=5432) International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. Respondents were asked if they would support a law that reduces the amount of nicotine in cigarettes to make them less addictive. Adjusted and weighted logistic regression analyses estimated the prevalence and predictors of support, such as country, age, sex, education, income, race and smoking/vaping status for VLNCs (support vs oppose/do not know). RESULTS: A majority of respondents supported a VLNC law, with support highest in Canada (69%; 2016 and 2020 combined), followed by England (61%), Australia (60%) and the USA (58%). Overall, support decreased from 62% in 2016 to 59% in 2020 (p=0.004), which did not differ by country. Levels of support differed by smoking/vaping status, where those who exclusively smoked daily showed the lowest level of support (59%) and those who exclusively vaped non-daily had the highest level of support (72%). CONCLUSION: More than half of respondents in all four countries-including those who smoked daily-supported a hypothetical VLNC standard to render cigarettes less addictive. It is important to examine if support is sustained after policies are implemented.

Trends in E-Cigarette and Tobacco Cigarette Purchasing Behaviors by Youth in the United States, Canada, and England, 2017-2022.

Objectives: This paper describes trends in youth e-cigarette (EC) and tobacco cigarette (TC) purchasing behaviors in Canada, England, and the United States (US) in relationship to changing minimum legal age (MLA) laws. Methods: Data are from eight cross-sectional online surveys among national samples of 16- to 19-year-olds in Canada, England, and the US conducted from 2017 to 2022 (N = 104,467). Average wave percentage change in EC and TC purchasing prevalence and purchase locations were estimated using Joinpoint regressions. Results: EC purchasing increased between 2017 and 2022, although the pattern of change differed by country. EC purchasing plateaued in 2019 for the US and in 2020 for Canada, while increasing through 2022 for England. TC purchasing declined sharply in the US, with purchasing from traditional retail locations declining, while purchasing from social sources increased. Vape shops were the most common location for EC purchasing, although declining in England and the US. Conclusion: Trends in EC and TC purchasing trends in the US are consistent with the expected impact of the federal MLA law increasing the legal age to 21 years in December 2019.

Perceived Truthfulness of Reduced Lung Cancer Risk Advertising Claims Influences Consumers' Intention to try and to Purchase Snus.

The objective of the current study was to evaluate the impact of a reduced risk claim about lung cancer, presented in various formats, on smokers' and non-smokers' interest in trying Camel Snus and intention to purchase Camel Snus. We varied claim formats by varying advertising messages for Camel Snus in 4 ways (1) text only; (2) bar chart; (3) text/testimonial; and (4) bar chart/testimonial. 3001 participants were recruited from a web-based consumer specialty panel via an email invitation. In 2015, a second study was conducted, using similar methods, where 3001 additional participants were recruited. Overall, controlling for other factors, the presence of an MRTP claim was not significantly related to interest in trying snus [X2 (4) = 8.567, P = .073], or purchase intentions [X2 (4) = 1.148, P = .887]. Relative to a control ad where no explicit health risk claim was made, the Graphic + testimonial [OR = 1.29] or Text only [OR = 1.41] claims did significantly increase interest in trying Camel Snus. However, the adverting format did not impact interest in purchasing Camel Snus. While current smokeless tobacco users (95%) and smokers (59%) expressed interest in trying Camel Snus, non-tobacco users (7%) showed low interest in trying or purchasing Camel Snus (P < .001). Interest in trying Camel Snus was stronger in younger smokers compared to older smokers. Among current smokers, worry about lung cancer (the key focus of the reduced risk claim) was not associated with interest in trying Camel Snus or with purchase intention [OR = .91, 95% CI: .72, 1.14] or intention to purchase snus [OR = 1.07, 95% CI: .86, 1.32]. Future research should evaluate how claim and messaging formats influence perceived truthfulness and whether this effect differs among sub-groups of consumers, such as adolescents, those with tobacco-related disease, and former smokers. It will also be helpful to understand whether perceptions of ad truthfulness result in changes in product use patterns over time. In sum, giving people truthful, credible information about relative product risks, such as through authorized MRTP claims, is important, but such information is likely insufficient to get smokers to switch.

Effect of unguided e-cigarette provision on uptake, use, and smoking cessation among adults who smoke in the USA: a naturalistic, randomised, controlled clinical trial.

Background: As summarised in the most recent Cochrane review, the few clinical trials on e-cigarettes are largely focused on smoking cessation. We aimed to determine the naturalistic uptake, use, and impact of e-cigarettes among adults who may or may not want to stop smoking. Methods: In this naturalistic, randomised, controlled clinical trial, adult smokers, across the motivational spectrum and with minimal history of e-cigarette use, were recruited online from the general community within 11 cities across the USA. Participants were randomly assigned (2:1) to either receive either a free 4-week supply of flavoured, tank-style e-cigarette, or not. E-cigarette group participants received a battery and device with up to 30 pre-filled tanks, offered among five flavours, with minimal instructions on use. The study's primary purpose was to descriptively assess naturalistic uptake and usage of the e-cigarette, and to secondarily assess its impact on smoking behavior. The latter, assessed through six months of follow-up, included: a) self-reported 7-day point prevalence abstinence, b) incidence of quit attempts, and c) smoking reduction. This trial is registered at ClinicalTrials.gov, NCT03453385. Findings: Between 5/2018 and 3/2022, 638 adult smokers were enrolled and randomly assigned (427 in the e-cigarette group and 211 in the no-product control group). Uptake of e-cigarettes was robust: approximately 70% of participants used the product, with average usage exceeding 4 days per week during the initial 30 days. Based on an intent-to-treat approach where missing data is imputed as smoking, almost all behavioral outcomes favored the e-cigarette group relative to no-product control, including point prevalence abstinence at six months (Odds Ratio [OR] = 1.8; 95% Confidence Interval [CI] = 1.0-3.1), cumulative incidence of 24-hr quit attempts (OR = 1.5; 95% CI = 1.0-2.2), and having reduced smoking by at least 50% since baseline (OR = 1.8; 95% CI = 1.2-2.7). Results were similar under an alternative imputation. Interpretation: Complementing cessation-focused trials, results suggest that unguided e-cigarette use also leads to smoking cessation, allaying the notion that causal effects of e-cigarettes on cessation are not reflective of real-world scenario of self-determined use. For smokers who may not be able to quit using existing pharmacologic approaches, e-cigarettes may be considered to achive that purpose. Funding: National Cancer Institute.

Implementation of an "Opt-Out" Tobacco Treatment Program in Six Hospitals in South Carolina.

Objective: To describe the implementation an opt-out tobacco treatment program (TTP) in 6 diverse hospitals located in different regions of South Carolina. Methods: Between March 8, 2021 and December 17, 2021, adult patients (≥ 18 years) admitted to 6 hospitals affiliated with the Medical University of South Carolina (MUSC) were screened for their cigarette status. Patients who smoked cigarettes were referred to an TTP offering a brief bedside consult and automated post-discharge follow-up calls with an opportunity to receive a referral to the South Carolina Quitline (SCQL). The hospitals included in this study ranged in size from 82 to 715 beds with diverse patient populations. Herein, we report on the results of screening and referring patients to the TTP, delivery of smoking cessation treatments, and patient smoking status assessed in a sample of patients followed 6-weeks after discharge from the hospital. Results: Smoking prevalence ranged from 14-49% across the 6 hospitals. Among eligible patients reached, 85.6% accepted the bedside consult. Only 3.4% of patients reached were deemed ineligible because they claimed not to be currently smoking cigarettes. The automated post-discharge follow-up calls were answered by 43% of patients, with about a third of those who had relapsed back to smoking accepting the offer of a referral to the SCQL. Overall, about half of the 6,000 patients referred to the TTP received some type of treatment. Self-reported smoking abstinence rates assessed 6-weeks after discharge were similar across the five acute care hospitals ranging from about 20-30%. Conclusion: The findings demonstrate the broad reach of implementing an opt-out TTP for patients in hospitals of varying size, rurality and patient populations.

Comparison of smoking prevalence in Canada before and after nicotine vaping product access using the SimSmoke model.

OBJECTIVES: The public health impact of nicotine vaping products (NVPs) is subject to complex transitions between NVP and cigarette use. To circumvent the data limitations and parameter instability challenges in modeling transitions, we indirectly estimate NVPs' impact on smoking prevalence and resulting smoking-attributable deaths using the SimSmoke simulation model. METHODS: Canada SimSmoke uses age- and sex-specific data on Canadian population, smoking prevalence and tobacco control policies. The model incorporates the impact of cigarette-oriented policies on smoking prevalence but not the explicit contribution of NVPs. The model was calibrated from 1999 to 2012, thereby projecting smoking prevalence before NVPs were widely used in Canada. The NVP impact on smoking prevalence is inferred by comparing projected 2012-2020 smoking trends absent NVPs to corresponding trends from two Canadian national surveys. We further distinguish impacts before and after NVPs became regulated in 2018 and more available. RESULTS: Comparing 2012-2020 survey data of post-NVP to SimSmoke projected smoking prevalence trends, one survey indicated an NVP-related relative reduction of 15% (15%) for males (females) age 15+, but 32% (52%) for those ages 15-24. The other survey indicated a 14% (19%) NVP-related smoking reduction for ages 18+, but 42% (53%) for persons ages 18-24. Much of the gain occurred since Canada relaxed NVP restrictions. NVP-related 2012-2020 smoking reductions yielded 100,000 smoking-attributable deaths averted from 2012 to 2060. CONCLUSION: Smoking prevalence in Canada, especially among younger adults, declined more rapidly once NVPs became readily available. The emergence of NVPs into the Canadian marketplace has not slowed the decline in smoking.

RéSUMé: OBJECTIFS: L'effet des produits de vapotage avec nicotine (PVN) sur la santé publique dépend des transitions complexes entre l'usage des PVN et l'usage de la cigarette. Pour contourner les problèmes du manque de données et de l'instabilité des paramètres dans la modélisation de ces transitions, nous avons estimé indirectement l'effet des PVN sur la prévalence du tabagisme et sur les décès attribuables au tabagisme qui en résultent à l'aide du modèle de simulation SimSmoke. MéTHODE: Le modèle SimSmoke pour le Canada utilise des données par âge et par sexe sur la population canadienne, la prévalence du tabagisme et les politiques antitabac. Il intègre l'effet des politiques axées sur la cigarette sur la prévalence du tabagisme, mais pas explicitement l'apport des PVN. Ce modèle a été étalonné de 1999 à 2012; il prédit donc la prévalence du tabagisme avant l'utilisation des PVN à grande échelle au Canada. Nous avons déduit l'effet des PVN sur la prévalence du tabagisme en comparant les tendances de consommation de tabac projetées pour 2012­2020 sans PVN aux tendances correspondantes de deux enquêtes nationales canadiennes. Nous établissons aussi une autre distinction entre les effets avant et après la réglementation des PVN en 2018 et leur plus grande disponibilité. RéSULTATS: Si l'on compare les données d'enquête de 2012­2020 post-PVN aux tendances de prévalence du tabagisme projetées par SimSmoke, une enquête fait état d'une baisse de 15 % (15 %) liée aux PVN chez les hommes (femmes) de 15 ans et plus, mais de 32 % (52 %) chez les 15 à 24 ans. L'autre enquête fait état d'une baisse du tabagisme de 14 % (19 %) liée aux PVN chez les 18 ans et plus, mais de 42 % (53 %) chez les 18 à 24 ans. Une grande partie de ce gain s'est produit depuis que le Canada a assoupli ses restrictions sur les PVN. Les baisses du tabagisme liées aux PVN survenues entre 2012 et 2020 donnent 100 000 décès attribuables au tabagisme évités entre 2012 et 2060. CONCLUSION: La prévalence du tabagisme au Canada, surtout chez les jeunes adultes, a baissé plus rapidement lorsque les PVN sont devenus facilement accessibles. L'émergence des PVN sur le marché canadien n'a pas ralenti la baisse du tabagisme.

Potential Implications for Tobacco Industry Transformation of the Acquisition of Swedish Match by Philip Morris International.

Philip Morris International's recent purchase of Swedish Match may prove to be a vital tobacco industry development. We focus on PMIs potential progress in moving from primarily selling cigarettes toward primarily selling noncombustible nicotine delivery products (NCNDPs). We also consider the potential contribution of the acquisition to industry transformation whereby other cigarette firms may potentially move toward primarily selling NCNDPs. We examine the potential impact on noncombustible nicotine delivery product use, including nicotine pouches (a major Swedish Match product), e-cigarettes, heated tobacco products, and, most importantly, on sales of the industry's staple, combustible cigarettes. We focus on the United States as a special case, where PMI is limited from entering the cigarette market. Implications: Philip Morris International's purchase of Swedish Match and policies regarding nicotine pouches (NPs) have been overlooked in the tobacco control literature. The acquisition indicates the importance of the NP market to the largest nonstate-owned tobacco company. The acquisition has the potential through pricing and marketing tactics to either encourage or discourage the use of NPs, e-cigarettes, heated tobacco products, and most importantly cigarettes. Due to its inability to sell cigarettes in the United States, PMI will have incentives to use its alternative nicotine delivery products, including its newly acquired NPs, to reduce the sale of cigarettes by other companies. However, the potential effects in other countries, where PMI does sell cigarettes, are less clear. Monitoring and analyzing tobacco company acquisitions is essential to studying future transitions in using different kinds of tobacco products, especially from cigarettes to lower-risk alternative nicotine delivery products.

Gender differences in cigarette smoking cessation attempts among adults who smoke and drink alcohol at high levels: Findings from the 2018-2020 International Tobacco Control Four Country Smoking and Vaping Surveys.

BACKGROUND: This study examined the association between alcohol consumption and smoking cessation behaviour of adults who smoke in four countries. METHODS: Data came from 4275 adults (≥18 years) who smoked tobacco ≥ monthly and participated in the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping Surveys (Australia: n = 720; Canada: n = 1250; US: n = 1011; England: n = 1294). The 2018 Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) survey data coded into three levels ('never/low', 'moderate' or 'heavy' consumption) were analysed using multivariable logistic regression models to predict any smoking cessation attempts and successful cessation by 2020 survey, and whether this differed by gender and country. RESULTS: Compared to never/low alcohol consumers, only those who drink heavily were less likely to have made a quit smoking attempt (40.4 % vs. 43.8 %; AOR = 0.69, 95 % CI = 0.57-0.83, p < .001). The association differed by gender and country (3-way interaction, p < .001), with females who drink heavily being less likely to attempt to quit smoking in England (AOR = 0.27, 95 % CI = 0.15-0.49, p < .001) and Australia (AOR = 0.38, 95 % CI = 0.19-0.77, p = .008), but for males, those who drink moderately (AOR = 2.18, 95 % CI = 1.17-4.06, p = .014) or heavily (AOR = 2.61, 95 % CI = 1.45-4.68, p = .001) were more likely to make a quit attempt in England only. Alcohol consumption did not predict quit success. CONCLUSION: Heavy alcohol use among adults who smoke appears to only undermine the likelihood of trying to quit smoking with some variation by gender and country of residence, but not their chances of succeeding if they tried.