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

BACKGROUND: Tobacco product litter may be a form of postconsumption marketing if the littered items are branded. We conducted an observational study in India to assess the presence of tobacco product litter and determine the proportion that included branding. METHODS: During November-December 2022, we identified tobacco product litter (cigarette/bidi butts and packaging; smokeless tobacco packaging) in nine Indian cities: Bengaluru, Bhubaneswar, Chennai, Delhi, Guwahati, Hyderabad, Lucknow, Mumbai and Patna. In each city, we conducted observations along 15 different routes, each approximately 250 m in distance, for a total of 135 observational routes. Data collectors classified each piece of tobacco litter (product/packaging) and recorded if the litter had visible branding, such as brand names and/or logos. RESULTS: The study identified 17 261 pieces of tobacco product litter; SLT packaging comprised the largest proportion of the sample (62%), followed by cigarette butts (26%), bidi butts (8%), cigarette packaging (3%) and bidi packaging (1%). Across the sample, 81% (n=13 924) of the litter was branded. A brand was visible on most packaging for cigarettes (98%), bidis (97%) and SLT (86%), and present on 82% of cigarette butts and 26% of bidi butts. CONCLUSION: This study found that the majority of tobacco product litter in India is branded, which could function as a form of postconsumption marketing. Plain and standardised packaging and banning branding features on filters would reduce tobacco litter branding.

Assessing Electronic Nicotine Delivery Systems Device Type Accurately in Surveys.

INTRODUCTION: The electronic nicotine delivery systems (ENDS) market is highly heterogeneous and changing rapidly in the United States, making classification of devices complicated, especially for surveys. We assessed the percentage of concordant responses between self-reported device type and device type reported by manufacturer/retailer sites for three ENDS brands. AIMS AND METHODS: Population Assessment of Tobacco and Health Study wave 5 (2018-2019) asked adult ENDS users about their ENDS device type with the following multiple-choice question: "What kind of electronic nicotine product [is/was] it?" with response options: (1) A disposable device, (2) A device that uses replaceable prefilled cartridges, (3) A device with a tank that you refill with liquids (4) A mod system, and (5) Something else. Participants using only one ENDS device and reporting brands of JUUL (n = 579), Markten (n = 30), or Vuse (n = 47) were included. Responses were dichotomized as "concordant=1" (prefilled cartridge for these three brands) and "discordant = 0" (other responses) to assess the concordance. RESULTS: The overall concordance between self-reports and manufacturer/retail sites was 81.8% (n = 537). This percentage was 82.7% (n = 37) among Vuse users, 82.6% (n = 479) among JUUL users, and 69.1% (n = 21) among Markten users. Almost one in three people who use Markten did not indicate that their device uses replaceable prefilled cartridges. CONCLUSIONS: While at least 70% concordance could be acceptable, collecting more information about device type (eg, liquid container (pod/cartridge/tank), refillability; and submitting pictures) may improve the accuracy of the information. IMPLICATIONS: This study is particularly relevant for researchers analyzing smaller samples for example when examining disparities. Monitoring the characteristics of ENDS accurately in population-based studies is critical for regulatory authorities to understand ENDS toxicity, addiction, health effects, and use behaviors at the population level. There is evidence that higher concordance can be achieved with other questions- and methods. Adjusting survey questions about ENDS device type (eg, more descriptive response options, inclusion of separate questions asking about tank, pod, cartridge) and potentially including photos of participants' devices may help to classify ENDS device types more accurately.

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

BACKGROUND: Few studies have evaluated Electronic Nicotine Delivery Systems (ENDS) in longitudinal studies, as a potential source of metals which may have carcinogenic, neurotoxic, and cardiotoxic effects. We evaluated metal body burden by ENDS use status in a longitudinal population-based national survey. METHODS: We used the Population Assessment of Tobacco and Health (PATH) Study wave 1 (2013-2014), wave 2 (2014-2015), and wave 3 (2015-2016) adult data to assess urinary concentrations of seven metals among (1) ENDS only users who never used any nonelectronic tobacco products (n = 50), (2) ENDS only users who were former users of any nonelectronic tobacco products (n = 123) and (3) Never users (n = 1501) of any tobacco product. RESULTS: Among ENDS only users who never used any nonelectronic tobacco products (n = 50), the geometric mean ratios (GMRs) of Cd and Pb were 1.25 (95%CI: 1.09-1.42) and 1.19 (95%CI: 1.05-1.34), respectively, compared to never users after adjustment for PATH Study wave, age, sex, race/ethnicity, education, region, secondhand smoke at home and work, and cannabis and other substance use. After the same adjustment, the corresponding GMRs were 1.48 (95%CI: 1.32-1.67) and 1.43 (95%CI: 1.28-1.60) for ENDS only users who were former users of any nonelectronic tobacco products (n = 123). No difference was observed in urinary concentrations of other metals comparing ENDS users to never users of any tobacco product. DISCUSSION: ENDS users show higher urinary levels of Cd and Pb, including lifetime exclusive ENDS users compared to never users of any tobacco product. These findings are limited by the small sample size and could be related to underreporting of past combustible tobacco use or other factors. Metals typical of ENDS such as nickel and chromium unfortunately are not available in PATH. Studies assessing metal exposure associated with long term lifetime exclusive ENDS use (≥5 years) with larger sample size are needed.

Effectiveness of ENDS, NRT and medication for smoking cessation among cigarette-only users: a longitudinal analysis of PATH Study wave 3 (2015-2016) and 4 (2016-2017), adult data.

BACKGROUND: Research is inconclusive on the effectiveness of electronic nicotine delivery systems (ENDS) as cigarette cessation aids compared with nicotine replacement therapy (NRT) or non-NRT medication. This study compared the cigarette cessation rates for ENDS, NRT and non-NRT medication. METHOD: Population Assessment of Tobacco and Health Study wave 3 cigarette-only users who used ENDS, NRT or non-NRT medication (varenicline and bupropion) to quit smoking between wave 3 and 4 were included. 'Cessation' was defined as being a former cigarette smoker in wave 4. χ2, logistic regression, and a sensitivity analysis with Bayes factor assessed the association between quitting smoking and method used. RESULTS: Among 6794 cigarette-only users, 532 used ENDS (n=75), NRT (n=289), non-NRT medication (n=68), or a combination of NRT and non-NRT medication (n=100) to quit smoking between wave 3 and 4. The percentages of quitting smoking among those who used ENDS, NRT, non-NRT medication, and a combination of NRT and non-NRT medication were 16.2% (n=14), 16.1% (n=47), 17.7% (n=13), and 14.8% (n=12), respectively (p=0.97). None of the cigarette-only users who used ENDS to quit smoking became ENDS-only users in wave 4; 37.6% became dual users of ENDS and cigarettes. CONCLUSION: No differences were found when cessation rates of ENDS, NRT or non-NRT medication were compared. Given uncertainty about the long-term health effect of ENDS and the likelihood of becoming dual users, people who smoke and need assistance quitting should be encouraged to use current Food and Drug Administration-approved cessation methods until more effective methods are developed.

Smoke-free Turkey: Evaluation of outdoor areas of public places.

SIGNIFICANCE: Secondhand tobacco smoke (SHS) exposure is a major cause of morbidity and mortality around the world. The objective of this study was to evaluate the presence of smoking in outdoor areas of public places in three largest Turkish cities (Istanbul, Ankara, and Izmir). METHOD: For this cross-sectional observational study, the Turkish Statistical Institute randomly selected 10 sampling points in each city. Around each sampling point, fieldworkers visited the closest bars/nightclubs, cafes, government buildings, hospitals, restaurants, schools, shopping malls, traditional coffee houses, universities, children's playgrounds, parks and open markets. We observed smoking, ashtrays, and cigarette butts at the outdoor areas of public venues within the urban districts of each city. The fieldwork was conducted in April-May 2016. RESULTS: 477 venues were observed, covering 1017 outdoor locations in which 17,737 people were observed. Smoking in outdoor areas ranged from 3.7% around schools to 90% in open markets. Ashtrays were almost ubiquitous in hospitals (95.6%), shopping malls (92.0%), and universities (90.9%). Cigarette butts were more often observed in open markets (100%), shopping malls (96%), universities (95.5%), and parks (93.3%). Smoking at outdoor areas around schools was significantly lower than around other venues. CONCLUSION: Smoking in outdoor areas was common in most public places in Turkey except schools. The current indoor SHS legislation should be extended to cover adjacent outdoor areas of public venues in order to effectively protect people from SHS exposure in Turkey.

The prevalence of illicit cigarette consumption and related factors in Turkey.

BACKGROUND: The tobacco industry claims that high cigarette taxes drive illicit trade and that governments should therefore not increase tobacco tax because it will increase the level of illicit trade. This study examines illicit cigarette consumption in Turkey after a tobacco tax increase and its related factors. METHOD: This national cross-sectional survey was conducted in March-June 2013 and 9717 people aged ≥18 years participated in the interviewer-administered survey. Smokers were asked to show their last used cigarette pack to the interviewers and price paid for their cigarettes. Factors associated with smoking cigarettes with a tobacco tax stamp and paying ≥5 TL (Turkish lira) for a pack of cigarettes were analysed with logistic regression. RESULTS: Among the observed cigarette packs, 12.1% did not have the Turkish tax stamp. More illicit cigarettes were observed in the East region than in other regions (p<0.001). The reported average amount paid for a pack of cigarettes was €2.12 (€2.15 for men and €1.97 for women, p<0.001). The amount paid for cigarettes with a tax stamp (€2.15) was higher than the amount paid for cigarettes without tax stamp (€1.08) (per cigarette pack) (p<0.001). CONCLUSION: Just over 1 in 10 smokers (12%) had an illicit cigarette pack about 5 months after the final tax increase; this was most common in the East region of Turkey. Estimates are comparable to those in previous studies and do not indicate that an increase occurred in the prevalence of illicit cigarette use compared with before the tobacco tax increase.

Compliance with smoke-free legislation within public buildings: a cross-sectional study in Turkey.

OBJECTIVE: To investigate public compliance with legislation to prohibit smoking within public buildings and the extent of tobacco smoking in outdoor areas in Turkey. METHODS: Using a standardized observation protocol, we determined whether smoking occurred and whether ashtrays, cigarette butts and/or no-smoking signs were present in a random selection of 884 public venues in 12 cities in Turkey. We visited indoor and outdoor locations in bars/nightclubs, cafes, government buildings, hospitals, restaurants, schools, shopping malls, traditional coffee houses and universities. We used logistic regression models to determine the association between the presence of ashtrays or the absence of no-smoking signs and the presence of individuals smoking or cigarette butts. FINDINGS: Most venues had no-smoking signs (629/884). We observed at least one person smoking in 145 venues, most frequently observed in bars/nightclubs (63/79), hospital dining areas (18/79), traditional coffee houses (27/120) and government-building dining areas (5/23). For 538 venues, we observed outdoor smoking close to public buildings. The presence of ashtrays was positively associated with indoor smoking and cigarette butts, adjusted odds ratio, aOR: 315.9; 95% confidence interval, CI: 174.9-570.8 and aOR: 165.4; 95% CI: 98.0-279.1, respectively. No-smoking signs were negatively associated with the presence of cigarette butts, aOR: 0.5; 95% CI: 0.3-0.8. CONCLUSION: Additional efforts are needed to improve the implementation of legislation prohibiting smoking in indoor public areas in Turkey, especially in areas in which we frequently observed people smoking. Possible interventions include removing all ashtrays from public places and increasing the number of no-smoking signs.

Factors that influence attitude and enforcement of the smoke-free law in Turkey: a survey of hospitality venue owners and employees.

INTRODUCTION: In 2009, Turkey extended the smoke-free legislation to hospitality venues. Compliance, however, remains low in some hospitality venues. We identified characteristics associated with knowledge of health effects that can be prevented by the smoke-free law, the attitude towards and enforcement of the law. METHODS: In 2014, we conducted 400 interviews with hospitality venue owners and employees in 7 cities in Turkey. The venues were identified based on a random sampling strategy in a previous phase of the study. RESULTS: Over one-third (37.3%) of hospitality owners and employees had adequate knowledge of the health effects from secondhand smoke (SHS), 71.3% had a positive attitude towards the law and 19.5% had personally enforced the law. Participants who worked 70 hours or more per week were more likely to have a positive attitude towards the law. Older individuals, women, participants working in bars/nightclubs, venue owners receiving fines for non-compliance and current smokers were less likely to have a positive attitude towards the law. Participants working in traditional coffee houses, former smokers, and participants with a high school education or greater were more likely to enforce the law. Smokers who quit or reduced smoking because of the law were more likely to enforce the law compared with those who were not influenced by the law. CONCLUSIONS: Although the attitude towards the law was positive, interventions are needed to increase knowledge on the health effects of SHS and facilitate enforcement of the law, particularly among subgroups less likely to have a positive attitude and enforce the law.

THE PREVALENCE OF CONSANGUINEOUS MARRIAGES AND AFFECTING FACTORS IN TURKEY: A NATIONAL SURVEY.

This study was carried out by the Turkish Republic Ministry of Health to determine the prevalence of consanguineous marriage and its correlates with socio-demographic and obstetric risk factors in women in Turkey. The cross-sectional, national-level study was carried out from October to December 2013. The study population was composed of women between the ages of 15 and 65 years living in Turkey. The sample size was calculated as 9290 houses within Turkey's 81 provinces so as to improve the Turkish rural-urban expectations by means of systematic stack sampling according to the Turkish Statistical Institute's address-based vital statistics system. The target sample size was 6364, but only eligible 4913 women, who had been married, were included in the study. The consanguineous marriage frequency in the sample was found to be 18.5%, and of these 57.8% were first cousin marriages. Women living in an extended family and whose education level and first marriage ages were low, and whose perceived economic status was poor, had higher frequencies of consanguineous marriage (p<0.001). Consanguineous marriage frequencies were higher (p<0.001) for women who had spontaneous abortions and stillbirths or who had given birth to infants with a congenital abnormality. In this context, it is important to develop national policies and strategies to prevent consanguineous marriages in Turkey.

[Evaluation of smoking cessation services approaches of the patients applying to Hacettepe Adult Hospital]. / Hacettepe Eriskin Hastanesine basvuran hastalarin sigara birakma hizmetleri hakkindaki yaklasimlarinin degerlendirilmesi.

INTRODUCTION: This research was conducted to determine the views and information of the society about smoking cessation services and to find out the smoking status. MATERIALS AND METHODS: This descriptive study was conducted at Hacettepe University Adult Hospital. The questionnaire was conducted to the participants with face to face interview techniques between the dates 3-8 August 2011 and asked about socio-demographic characteristics, smoking status and the views on smoking cessation methods and services. In the analysis, descriptive statistics, chi-square and Fisher's exact chi-square test was used where necessary. p< 0.05 was accepted for statistical significance. RESULTS: The average age of 599 individuals participated to the research was 36.95 ± 12.80 years and 56.6% were male. The participants declared their smoking status that 48.9% do not smoke, 15.9% quit smoking, 35.2% stated as still smoking. Among current smokers 60.2% thought to quit smoking in the last 12 months. Of the participants 42.1% have tried to quit smoking in the past 12 months. 46% percent of smokers and 56.3% non-smokers stated that they are aware of smoking cessation outpatient clinics (p= 0.033). The percentage of awareness of smoking cessation line was 67.8%, and 46.9% are aware of AMATEMs. Same percentages are as 49.5% and 28.4% for the ones who quit smoking. 59.7% of smokers think that nicotine-free preparates and 17.4% think that nicotine preparates is successful; these percentages are 89.7% and 36.7% for non-smokers. CONCLUSION: Tendency to cessation among tobacco users and have awareness about the services that support cessation and believe that the law reduces the harms of tobacco use. However, more interventions are needed to reach those who are at low-income level. Also being a role model to the children in the society and to use attitudes and behaviors in smoking cessation campaigns are thought to be effective.

Tobacco Use and Tobacco Dependence Management.

Tobacco use is a major public health problem and the leading cause of preventable deaths in the United States and worldwide. Tobacco dependence determines tobacco use and is largely due to nicotine addiction. Such dependence is a disease resulting in a strong desire or compulsion to take tobacco, with difficulty in cessation of tobacco, along with persistent use despite overtly harmful consequences.

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

INTRODUCTION: The prevalence of flavor use in Electronic Nicotine Delivery Systems (ENDS) has been assessed in numerous studies, but limited research has focused on flavor use trends and maintenance of flavor preference over time. This study investigated the general trends and maintenance of ENDS flavor use for youth (aged 12-17 years), young adults (aged 18-24 years), and older adults (aged ≥25 years) between 2014 and 2019. METHODS: Population Assessment of Tobacco and Health (PATH) Study Wave 2 (2014-2015), Wave 3 (2015-2016), Wave 4 (2016-2017), and Wave 5 (2018-2019) youth and adult data were used. Cross-sectional flavor use prevalence (trends) and flavor maintenance (using the same flavor category in at least three consecutive waves) were assessed. RESULTS: The most reported primary flavor category was fruit among all age groups in all waves. Candy/desserts in waves two, three, four, and menthol/mint in wave five were the second most reported flavor in all age groups. The highest increase was observed for menthol/mint use among youth between wave two (21.9%) and five (58.1%) (OR=5.33; 95% CI: 3.58-7.96). Overall, 37.6% of fruit flavor users, 25.3% of candy/desserts users, 32.0% of menthol/mint users, and 33.4% of tobacco flavor users, maintained use of the same flavor in at least three consecutive waves. CONCLUSIONS: Fruit flavor had the highest percentages of use and maintenance between 2014 and 2019. While the maintenance of fruit and candy/desserts flavors were higher among youth, adults had substantially higher maintenance percentages for menthol/mint and tobacco flavor. There was a substantial increase in menthol/mint use in wave five among youth, which may affect ENDS flavor maintenance patterns in the future. Understanding maintenance of flavors over time can inform regulation of ENDS flavors.

Nicotine/tobacco use disparities among transgender and gender diverse adults: Findings from wave 4 PATH data.

BACKGROUND: Transgender and Gender Diverse (TGD) populations have current cigarette/e-cigarette/cigar use rates ranging from 32.6% to 39.7%. Importantly, while some studies have reported tobacco use as significantly higher among TGD versus cisgender individuals in multivariate analyses, others have reported no significant differences. The present study used data from wave 4 of the Population Assessment of Tobacco and Health (PATH) study, a large, nationally representative U.S. study, to examine relationships among sociodemographic characteristics, internal and external factors, and tobacco use behaviors, with a focus on TGD individuals. METHODS: Data were from 33,628 adults from the PATH study's wave 4 (collected December 2016-January 2018). Multivariable logistic regression models examined differences in current tobacco use (cigarettes, electronic nicotine products, and cigars) between TGD and cisgender individuals through the replication of previous work using PATH data, as well as evaluating the role of other internal and external factors. RESULTS: TGD individuals were 2-3 times more likely than cisgender individuals to report current nicotine/tobacco use, even after adjustment for potential confounders. TGD individuals tended to have lower income and education and be more likely to endorse a sexual minority identity than their cisgender counterparts; meanwhile, lower income, less education, and lesbian/gay and bisexual identities were significant predictors of nicotine/tobacco use, independent of TGD identity. CONCLUSIONS: Present findings underscore the high rates of nicotine/tobacco use in the TGNC community and emphasize the necessity of TGD-focused research methods and measures, access to quality medical care, and policy aimed at minimizing marginalization and nicotine/tobacco use disparities experienced by TGD communities.

Combinations of electronic nicotine delivery system device and liquid characteristics among U.S. adults.

INTRODUCTION: The combination of electronic nicotine delivery systems (ENDS) device and liquid characteristics affect user nicotine and toxicant exposure, however population-level national survey studies have not reported device and liquid features jointly nor in detail. We examined combinations of characteristics of devices and liquids used by adult ENDS users. METHODS: U.S. adults (21+) using ENDS at least five days/week (n = 1,179) completed an online survey in 2020 and uploaded photos of their most used device and liquid. Device/liquid combinations were analyzed to determine and describe the most common pairings. Data were weighted to the U.S. population of adult daily ENDS users. RESULTS: Five device/liquid combinations accounted for 87 % of those reported. The most prevalent combination, reported by 36.2 %, was re-useable devices with adjustable settings and a tank refilled with a free-base nicotine liquid with a median nicotine concentration of 5.2 mg/mL. The second most frequent combination - re-usable devices with no adjustable settings and a nicotine salt liquid in a disposable pod or cartridge - was reported by 22.8 % and the median nicotine concentration was 49.4 mg/mL. Wattage, voltage and resistance varied across device/liquid combination. Overall, 66.5 % refilled their device's tank or pod and 64.2 % had the ability to manipulate device characteristics (power, airflow, and/or coil). CONCLUSIONS: Analyzing ENDS device/liquid combinations rather than each separately can allow researchers to better evaluate relationships between use and key outcomes, such as quitting cigarettes and abuse liability. Additional research may reveal whether certain combinations are more effective at helping smokers quit and which device/liquid combinations should remain on the market.

Association of cigarette and electronic nicotine delivery systems use with internalizing and externalizing problems among US adults: Findings from wave 3 (2015-2016) of the PATH study.

AIMS: Electronic Nicotine Delivery System (ENDS) use is increasing among US adults. While existing research has demonstrated higher cigarette smoking rates among people with mental health conditions, there is sparse information on the association between ENDS use and mental health such as internalizing and externalizing problems. The aim of this study was to evaluate associations between internalizing and externalizing problems for cigarette only, ENDS only, and dual users, as well as changes in mental health among those groups. METHOD: We used the U.S. Population Assessment of Tobacco and Health (PATH) Study Wave 3 adult data. Internalizing and externalizing problems were self-reported and assessed via the Global Appraisal of Individual Needs-Short Screener; response options were dichotomized to reflect past 12 months and any lifetime problems. Self-reported changes in mental health over the past 12 months were also assessed. Participants' tobacco use status was categorized as ENDS only use (n = 618), cigarette only use (n = 6,779), dual use (cigarettes and ENDS) (n = 681), and non-current use (n = 16,515). RESULTS: Lifetime and past 12 month internalizing problems were reported by 63.8% (n = 18,706) and 50.4% (n = 15,326), respectively, while lifetime and past 12 months externalizing problems were reported by 63.3% (n = 18,835) and 52.7% (n = 16,005), respectively. Six percent of participants reported worse mental health over the past 12 months. Compared to non-current use of any tobacco product, and adjusting for age, sex, race, education, and household income, those reporting ENDS use only had higher odds of ever (aOR = 1.52; 95%CI: 1.22-1.89) and past 12 months (aOR = 1.49; 95%CI: 1.22-1.84) internalizing, and externalizing problems (aOR = 1.32; 95%CI: 1.04-1.66 and aOR = 1.34; 95%CI: 1.07-1.67, respectively), and higher odds of reporting worse mental health over the past 12 months (aOR = 1.50; 95%CI: 1.05-2.12). CONCLUSION: Health care providers should be aware that internalizing and externalizing problems, and worsening mental health, are more common among adults who use ENDS, cigarettes, or both of these tobacco products.

Association between e-cigarette use and parents' report of attention deficit hyperactivity disorder among US youth.

INTRODUCTION: There is paucity of literature that evaluates e-cigarette use rates among the youth with attention deficit hyperactivity disorder (ADHD). The aim of this study is to compare the rates of cigarette only, e-cigarette only, dual use, and initiation age of regular use and trying to quit cigarettes or e-cigarettes among the youth with and without ADHD. METHODS: We used Population Assessment of Tobacco and Health (PATH) study Wave 3 (2015-2016) youth data, a nationally representative cross-sectional study in the US. The main outcome was tobacco use status of youth and ADHD diagnosis was based on parent report. RESULTS: The survey included 11801 youth (50%, 12-14 years; 49% female). Compared to youth without ADHD, the relative risk ratio (RRR) was 1.79 (95% CI: 1.02-3.21) for cigarette only use, 1.41 (95% CI: 1.01-2.21) for e-cigarette only use, 3.40 (95% CI: 1.69-6.84) for dual use, 1.75 (95% CI: 0.92-3.35) for cigarette and other product(s) use, 1.48 (95% CI: 0.58-3.77) for e-cigarette and other product(s) use, and 3.37 (95% CI: 1.88-6.17) for poly use among youth with ADHD, after adjusting for age group, sex, and race/ethnicity. CONCLUSIONS: Cigarette only use, e-cigarette only use, dual use of cigarettes and e-cigarettes, and poly use of cigarettes, e-cigarettes, and other product(s) were significantly associated with parent report of an ADHD diagnosis. It is critical for healthcare providers to be screening youth for e-cigarette use, especially youth who are diagnosed with ADHD.

The youth e-cigarette epidemic: New estimates of JUUL Labs' revenue from youth users in the US.

INTRODUCTION: Past 30-day e-cigarette use increased by 78% among high school students from 2017 to 2018, an increase attributable to pod-style devices. JUUL Labs (JUUL) insists they do not market their product to teenagers. We created several scenarios to estimate the percentages of JUUL's net revenue from adults and youth in the US in 2018. METHODS: We used the number of youth (aged 12-17 years) and adults (aged ≥18 years) who reported using JUUL in the nationally representative Population Assessment of Tobacco and Health (PATH) Study wave 4 (Dec 2016-Jan 2018) to estimate the youth proportion of JUUL users. As a sensitivity analysis, we also used data from the nationally representative Truth Longitudinal Cohort (TLC) study to estimate the youth proportion of JUUL users. Based on this percentage, we then applied several scenarios to estimate JUUL's net revenue from youth in the US in 2018. RESULTS: From the PATH Study, 31% of JUUL users were youth (aged 12-17 years). In the TLC study, 30% of current JUUL users were aged 15-17 years. Given that JUUL's net revenue was $1.3 billion in 2018, we calculated that JUUL made between $130 million and $650 million of its net revenue from youth, depending on consumption scenarios. CONCLUSIONS: A substantial proportion of JUUL's profits in 2018 were a result of use by youth. It could be required that all e-cigarette companies actively ensure that use by youth is below a pre-determined small fraction of their sales, requiring that a high penalty be paid by those that fail to do so.

Desirability of medicine as a profession in developing countries: the case of Turkey.

Medicine has always been an appealing profession. However, some studies have shown that the medical profession in Turkey appeared to lose some of its appeal around the 1990s. The purpose of this study was to determine to what extent young people currently prefer the medical profession in Turkey as an example for developing countries. This descriptive study aims to evaluate and compare the selection and preferences of candidates between medical and industrial engineering programs in state universities between 1985 and 2009. The main indicators used in this study was the success rank" of the candidates, that refers to the candidate's placement in the list of student-scores sorted in descending order, and further grouped into 100. The data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 15, and percentage distribution and chi-square tests were applied. There were 21 medical faculties in state universities in 1985; this number reached 53 in 2009. The success rank of registered students decreased between 1985 and 2000 and then increased continuously thereafter. A significant difference between faculties in terms of the registration rate of the students who scored in the top 3% was determined in all years evaluated in this study (p < 0.05). This study clearly shows that although medicine was less popular among university candidates before 2000, it gradually gained in popularity, reaching its highest levels in 2008 and 2009.

A comparison of product dependence among cigarette only, ENDS only, and dual users: Findings from Wave 3 (2015-2016) of the PATH study.

INTRODUCTION: Little is known about differences in tobacco product dependence among people who use two tobacco products versus one. Self-reported product dependence among individuals using cigarettes only, electronic nicotine delivery systems (ENDS) only, and both cigarettes and ENDS (dual users) was compared. METHOD: PATH Wave 3 data were collected between 2015 and 2016. We used 11 Wisconsin Inventory of Smoking Dependence Motives items to assess cigarette and ENDS dependence, averaged to generate Cigarette Dependence (CD) and ENDS Dependence (ED) scores. Linear regression models were used to assess the association between tobacco use groups and the two dependence scores. RESULTS: Our analytic sample included 5538 (91.5 %) cigarette only, 399 (6.7 %) ENDS only, and 108 (1.8 %) dual users. There was no difference in CD between cigarette only and dual users. ENDS only users' ED (2.11, SE = 0.05) was higher than dual users' ED (1.67, SE = 0.04) (p < 0.05). Dual users' mean ED (1.70, SE = 0.09) was significantly lower than their CD (3.03, SE = 0.11) (p < 0.001), and ENDS only users' ED (2.34, SE = 0.05) was significantly lower than cigarette only users' CD (2.94, SE = 0.02) (p < 0.001). CONCLUSION: While there was no difference in CD between dual and cigarette only users, dual users' ED was lower than that for ENDS only users. ENDS appeared to produce less dependence than cigarettes among dual users. Given the high nicotine concentration ENDS products that entered the market after PATH Wave 3 data were collected, future research should examine ED among ENDS only and dual users.

Evaluation of Secondhand Smoke Using PM2.5 and Observations in a Random Stratified Sample in Hospitality Venues from 12 Cities.

BACKGROUND: Turkey passed a law banning smoking in all indoor public places in 2008. In response to the indoor smoking restriction, many smokers may have relocated to outdoor areas of venues. The aim of this study was to evaluate air pollution related to SHS exposure in indoor and outdoor areas of hospitality venues in 12 cities in Turkey. METHOD: In this cross-sectional study, we evaluated hospitality venues in 12 cities in Turkey. In each visited venue, we evaluated a pre-specified number of study locations such as the outdoor area of the main entrance, indoor areas, and patios or other outdoor dining areas, completely or partially covered with window walls. We measured particulate matter 2.5 (PM2.5) in those areas. RESULTS: The fieldworkers visited 72 randomly selected hospitality venues and measured PM2.5 concentrations in 165 different locations (indoor, outdoor, and patios) of those venues. Overall, 2573 people were observed, 909 of them smoking. The median (IQR) PM2.5 concentrations were 95 (39-229) µg/m3 indoors, 25 (13-48) µg/m3 outdoors, and 31 µg/m3 (16-62) in the patios (p < 0.001). After adjustment, each additional smoker was associated with a 2% increase in PM2.5 concentrations in patio air (GMR (95% CI): 1.02 (1.00, 1.05), and a 4% increase in indoor air (GMR (95% CI): 1.04 (1.02, 1.05). CONCLUSIONS: There were unhealthy levels of smoking-caused PM2.5 concentrations, not only indoors, but also in the patios of hospitality venues. Legislative efforts to expand the smoke-free legislation to outdoor areas adjacent to indoor public places and an action plan to increase compliance with the smoke-free policy are urgently needed in Turkey.