Quitting smoking with smoke? Unauthorized claims used by herbal cigarette manufacturers.

INTRODUCTION: Herbal cigarettes are made with non-tobacco plant materials (e.g., tea leaves, hemp), are typically sold pre-rolled in packs and with filters, and are combusted and smoked like tobacco cigarettes. Herbal cigarette manufacturers have a history of making misleading health claims and at least one company has previously settled with the US Federal Trade Commission over deceptive advertising. This study examined current claims and product characteristics of herbal cigarettes sold by a popular online retailer. METHODS: We searched Amazon.com for "herbal cigarettes" and "hemp cigarettes" and identified all herbal cigarette products sold on the first page of search results (n=51). Two coders independently content analyzed each product's Amazon page for claims (e.g., smoking cessation, health), product characteristics (e.g., flavors), and presence of disclaimers and warnings. RESULTS: Overall, 78.4% of product pages made smoking cessation claims (e.g., "A more scientific way to quit smoking", "…decreases nicotine craving symptom and helps to quit tobacco smoking"). Further, 45.1% of product pages included claims describing lower risk/exposure compared to tobacco products (e.g., "…without the addictive nicotine and toxic chemicals found in tobacco cigarettes"). Some herbal products were available in multiple flavors, including menthol (21.6%) and fruit (17.7%). Only 35.3% of products included visible health warnings on product packaging. CONCLUSIONS: Many herbal cigarette products sold on Amazon.com make unauthorized cessation and health claims. Regulatory agencies must act decisively to stop the misleading advertising of these products and develop appropriate warnings to educate the public about the potential harms of herbal cigarettes. IMPLICATIONS: This content analysis documents the use of unauthorized and misleading claims made in the marketing of herbal cigarettes.These findings highlight the need for enforcement of existing federal regulations, which prohibit deceptive advertising.Research is needed to inform the development of appropriate warning labels that can be used to inform consumers of the potential harms of smoking herbal cigarettes.

Effects of Modified Risk Tobacco Product Claims on Consumer Responses.

INTRODUCTION: US tobacco manufacturers can seek authorization from the US Food and Drug Administration (FDA) to market products using modified risk tobacco product (MRTP) claims. To inform regulatory decisions, we examined the impact of MRTP claim specificity and content, including whether the claims produced halo effects (ie, inferring health benefits beyond what is stated). AIMS AND METHODS: Participants were 3161 US adult cigarette smokers. Using a two (general vs. specific) × 2 (risk vs. exposure) plus independent control design, we randomized participants to view one message from these conditions: general risk claim (eg, "smoking-related diseases"), general exposure claim (eg, "chemicals in smoke"), specific risk claim (eg, "lung cancer"), specific exposure claim (eg, "arsenic"), or control. Claims described the benefits of completely switching from cigarettes to the heated tobacco product IQOS. RESULTS: MRTP claims of any sort elicited a higher willingness to try IQOS relative to control (d = 0.09, p = .043). Claims also elicited lower perceived risk of disease and exposure to harmful chemicals for completely switching from cigarettes to IQOS (d = -0.32 and -0.31) and partially switching (d = -0.25 and d = -0.26; all p < .05). Relative to specific MRTP claims, general MRTP claims led to lower perceived risk and exposure for complete switching (d = -0.13 and d = -0.16) and partial switching (d = -0.14 and d = -0.12; all p < .05). Risk and exposure MRTP claims had similar effects (all p > .05). DISCUSSION: MRTP claims led to lower perceived risk and exposure, and higher willingness to try IQOS. General claims elicited larger effects than specific claims. MRTP claims also promoted unintended halo effects (eg, lower perceived risk of disease and chemical exposure for partial switching). IMPLICATIONS: We found evidence that MRTP claims promoted health halo effects. In light of these findings, the FDA should require research on halo effects prior to authorization. Further, if an MRTP claim is authorized, FDA should require tobacco manufacturers to conduct post-market surveillance of how the claim affects consumer understanding, including partial switching perceived risk and exposure beliefs, as well as monitoring of dual-use behaviors.

E-cigarette Unit Sales by Product and Flavor Type, and Top-Selling Brands, United States, 2020-2022.

E-cigarette products, related policies, and use patterns change rapidly. In the United States, the prevalence of e-cigarette use is markedly higher among youths and young adults than it is among adults overall. In 2021, 4.5% of all adults aged ≥18 years (an estimated 11.1 million) and 11.0% of young adults aged 18-24 years (an estimated 3.1 million) currently (≥1 day during the previous 30 days) used e-cigarettes; during 2022, 14.1% of high school students (an estimated 2.14 million) currently used e-cigarettes (1,2). E-cigarettes often contain high concentrations of nicotine. Nicotine is highly addictive and can harm the adolescent brain, which continues to develop through approximately age 25 years (3). Since 2020, the availability of e-cigarette products has changed in response to multiple factors, including local and state policies to address flavored e-cigarette sales, actions undertaken by the Food and Drug Administration (FDA), COVID-19-related closures, and global supply chain disruptions. To assess trends in unit sales of e-cigarettes in the United States, by product and flavor, and top-selling brands, the CDC Foundation, Truth Initiative,* and CDC analyzed retail scanner data during January 26, 2020-December 25, 2022, from Information Resources, Inc. (IRI), a U.S. data analytics and market research company. Overall, unit sales increased by 46.6% during the study period. The unit share of menthol-flavored product sales remained relatively stable during this period, whereas nonmenthol flavor unit shares changed. During January 26, 2020-December 25, 2022, unit shares of tobacco-flavored and mint-flavored products decreased (from 28.4% to 20.1% and from 10.1% to 5.9%, respectively), whereas shares of other flavor sales increased (from 29.2% to 41.3%). In addition, during January 2020-December 2022, unit shares of prefilled cartridges decreased from 75.2% to 48.0%, and disposable e-cigarette unit share increased from 24.7% to 51.8% of total unit sales. The five top-selling e-cigarette brands for the 4-week period ending December 25, 2022, were Vuse, JUUL, Elf Bar, NJOY, and Breeze Smoke. Analysis of information on e-cigarette retail sales can guide strategies to prevent youth access to and use of e-cigarettes, including restrictions on flavored tobacco products (4).

MRTP claim authorisation and General Snus sales in the USA: evidence from a difference-in-differences model.

BACKGROUND: The 2009 Tobacco Control Act granted the US Food and Drug Administration (FDA) regulatory authority over tobacco products, including the ability to authorise modified-risk tobacco product (MRTP) claims. In October 2019, the FDA authorised the first-ever MRTP claim for General Snus, which allowed the product to be marketed as reduced risk (relative to cigarettes). MRTP authorisation may increase otherwise low rates of snus use in the USA (<0.5% for children and adults). METHODS: Using 2017-2021 Nielsen sales data from 19 US states, we conducted a difference-in-differences analysis to determine whether logged unit sales of General Snus were affected by the MRTP authorisation, compared with (1) sales of other snus brands and (2) sales of non-snus smokeless products; we also examined (3) if sales of non-General Snus brands were affected by General Snus's MRTP authorisation, compared with sales of non-snus smokeless tobacco products. RESULTS: Although sales declined in absolute terms, sales of General Snus relative to other snus brands were unchanged after MRTP authorisation (-9.0%, 95% CI -19.6% to 1.60%, p=0.098). However, compared with non-snus smokeless brand sales, sales of General Snus (+14.7%, 95% CI 5.23% to 24.2%, p=0.002) rose after MRTP authorisation. Compared with non-snus smokeless products, sales of non-General Snus brands also rose after MRTP authorisation (+23.7%, 95% CI 9.5% to 38.0%, p=0.001). CONCLUSIONS: Although only General Snus received MRTP authorisation, this designation appears to have slowed declines for the entire snus category. This suggests consumers may make determinations regarding product risk to a product class rather than individual products.

Synthetic nicotine descriptors: awareness and impact on perceptions of e-cigarettes among US youth.

BACKGROUND: Electronic cigarettes (e-cigarettes) are being advertised and sold with synthetic nicotine. Little research has examined youth awareness of synthetic nicotine or the impact of synthetic nicotine descriptors on perceptions of e-cigarettes. METHODS: Participants were a sample of 1603 US adolescents (aged 13-17 years) from a probability-based panel. The survey assessed knowledge of nicotine source in e-cigarettes (from 'tobacco plants' or 'other sources besides tobacco plants') and awareness of e-cigarettes containing synthetic nicotine. Then, in a between-subjects experiment with a 2×3 factorial design, we manipulated descriptors on e-cigarette products: (1) nicotine label (inclusion of the word 'nicotine': present or absent) and (2) source label (inclusion of a source: 'tobacco-free', 'synthetic' or absent). RESULTS: Most youth were either unsure (48.1%) or did not think (20.2%) that nicotine in e-cigarettes comes from tobacco plants; similarly, most were unsure (48.2%) or did not think (8.1%) that nicotine in e-cigarettes comes from other sources. There was low-to-moderate awareness of e-cigarettes containing synthetic nicotine (28.7%), with higher awareness among youth who use e-cigarettes (48.0%). While no main effects were observed, there was a significant three-way interaction between e-cigarette status and the experimental manipulations. The 'tobacco-free nicotine' descriptor increased purchase intentions relative to 'synthetic nicotine' (simple slope: 1.20, 95% CI 0.65 to 1.75) and 'nicotine' (simple slope: 1.20, 95% CI 0.67 to 1.73) for youth who use e-cigarettes. CONCLUSIONS: Most US youth do not know or have incorrect beliefs about the sources of nicotine in e-cigarettes and describing synthetic nicotine as 'tobacco-free nicotine' increases purchase intentions among youth who use e-cigarettes.

U.S. public opinion toward policy restrictions to limit tobacco product placement and advertising at point-of-sale and on social media.

The Family Smoking Prevention and Tobacco Control Act granted the U.S. Food and Drug Administration authority to regulate tobacco advertising and promotion, including at the retail level, and preserved state, tribal, and local tobacco advertising and promotion authorities. Public health experts have proposed prohibiting point-of-sale tobacco advertisements and product displays, among other tobacco advertising restrictions. We examined the prevalence and correlates of public support, opposition, and neutrality toward proposed tobacco product placement and advertising restrictions at point-of-sale and on social media utilizing the National Cancer Institute's 2020 Health Information National Trends Survey (HINTS) (N = 3865), a cross-sectional, probability-based postal survey of U.S. addresses conducted from Feb 24, 2020 to June 15, 2020 (Bethesda, MD). Frequencies and unadjusted, weighted proportions were calculated for support, neutrality, and opposition toward the three policies under study, and weighted, adjusted multivariable logistic regression was employed to examine predictors of neutrality and opposition. Tests of significance were conducted at the p < 0.05 level. Sixty-two percent of U.S. adults supported a policy prohibiting tobacco product advertising on social media; 55% supported a policy restricting the location of tobacco product advertising at point-of-sale; and nearly 50% supported a policy to keep tobacco products out of view at the checkout counter. Neutrality and opposition varied by sociodemographic characteristics including age, sex, education, rurality, and presence of children in the household. Understanding public opinion toward tobacco product placement and advertising restrictions may inform policy planning and implementation.

Cigarette Promotions in U.S. Pharmacies.

INTRODUCTION: The sale of tobacco products within American pharmacies has generated controversy for several decades, leading two U.S. states and 45 municipalities to adopt tobacco-free pharmacy policies. While previous research has reported cheaper cigarette prices in pharmacies, compared to other retailers, little is known about cigarette promotions in pharmacies, which are associated with increased youth smoking and unplanned cigarette purchases among adults. AIMS AND METHODS: Between May and August 2015, trained data collectors conducted store audits at 2128 tobacco retailers located within 97 U.S. counties in 40 states. Observations were made for three types of cigarette promotions: special price (e.g., $0.30 off/pack), multi-pack promotions (e.g., buy one pack, get one free), and cross-product promotions (e.g., buy a pack of cigarettes and a get free can of snus). We calculated weighted estimates of the proportion of pharmacies and other retailer types with cigarette promotions and used weighted multivariable logistic regression to compare cigarette promotions by tobacco retailer type, accounting for clustering at the county level and controlling for county-level demographic characteristics. RESULTS: Cigarette promotions were observed in 94.0% of pharmacies, more than any other retailer type (e.g., convenience stores: 82.0%, tobacco stores: 77.0%). All retailer types had lower odds of promotions for Marlboro, Newport, Camel, menthol, or any interior cigarette promotion, compared to pharmacies. CONCLUSIONS: Nearly all pharmacies offered in-store cigarette promotions and pharmacies had greater odds of offering cigarette promotions than all other retailer types. Whether voluntarily or legislatively, tobacco-free pharmacies would eliminate a prevalent retail source of cigarette promotions. IMPLICATIONS: This is the first known national study to examine prevalence of cigarette promotions in U.S. pharmacies compared to other retailer types. Nearly all pharmacies offered in-store cigarette promotions and pharmacies had greater odds of offering cigarette promotions than all other retailer types. These findings underscore the inherent contradiction of pharmacies serving both as an important component of the health care system, but also as purveyors and promotors of addictive and lethal tobacco products. Whether voluntarily or legislatively, tobacco-free pharmacy policies would eliminate a prevalent retail source of cigarette promotions.

Public Support for Cigarette Pack Pictorial Health Warnings Among US Adults: A Cross-sectional Analysis of the 2020 Health Information National Trends Survey.

INTRODUCTION: The US Food and Drug Administration issued a final rule requiring new warnings for cigarette packages and advertisements. This study examines population-level characteristics of support for-versus neutrality or opposition toward-cigarette pack warnings that use text and images to portray the negative health effects of smoking. METHODS: We used nationally representative cross-sectional data of US adults age 18 and older from the 2020 Health Information National Trends Survey (n = 3865). Frequencies and weighted proportions were calculated for neutrality toward, opposition to, and support for pictorial warnings across sociodemographics and other predictors. Weighted, multivariable logistic regression examined predictors of being neutral or opposed versus supportive of pictorial warnings. RESULTS: In 2020, an estimated 69.9% of US adults supported pictorial warnings, 9.1% opposed, and 20.9% neither supported nor opposed them. In fully adjusted models, current smokers had almost twice the odds of being neutral or opposed to pictorial warnings as never smokers (odds ratio [OR] = 1.99, confidence interval [CI] 1.12, 3.52). Adults 75 years and older (vs. 18-34) (OR = 0.55, CI 0.33, 0.94) and those with children under 18 in their household (vs. no children) (OR = 0.67, CI 0.46, 0.98) were less likely to be neutral or opposed. CONCLUSIONS: In advance of the Food and Drug Administration's implementation of pictorial warnings on cigarette packages, nearly 70% of American adults support this policy. Disseminating information about the effectiveness of pictorial warnings may further strengthen support among current smokers who are less supportive than never smokers. Furthermore, framing messages around the benefits of pictorial warnings for protecting youth may increase public support. IMPLICATIONS: While public support for pictorial warnings on cigarette packages is high in the United States, it may increase further after policy implementation and be strengthened by utilizing information campaigns that convey the evidence that pictorial warnings are an effective public health strategy.

Inferences beyond a claim: a typology of potential halo effects related to modified risk tobacco product claims.

When tobacco products are marketed with modified risk tobacco product (MRTP) claims, consumers may infer additional health benefits not directly stated in the claims. We propose a typology of seven potential 'halo effects' (ie, an unintended generalisation) that may occur with MRTP marketing. Evidence currently exists that some of these types of halo effects occur after exposure to MRTP claims. These generalisations are likely unavoidable in certain situations and may sometimes produce accurate inferences. However, some halo effects may be problematic if they mislead consumers into false inferences and result in unintended consequences that have a negative public health impact (eg, reinitiation, dual tobacco product use). To help mitigate unintended consequences and guide regulatory decisions about MRTP claims, we encourage researchers studying MRTP claims to test for halo effects. Regulatory agencies should include potential unintended consequences associated with halo effects when assessing individual-level and population-level health impacts of MRTP claims. Moreover, tobacco manufacturers should be required to report both premarket and postmarket surveillance of halo effects to relevant regulatory agencies. If MRTP claims are to play a role in tobacco harm reduction, it is imperative that they be communicated and interpreted in ways that minimise harms and maximise public health benefits.

Knowledge and Awareness of Added Sugar in Cigarettes.

INTRODUCTION: Sugars naturally occur in tobacco leaf but are also commonly added to cigarettes by tobacco companies. Added sugar increases levels of toxic chemicals in cigarette smoke. Little is known about smokers' knowledge of added sugar in cigarettes and awareness of its effects. METHODS: Adult cigarette smokers were recruited through Amazon Mechanical Turk to participate in an online experiment on electronic cigarette advertising. After completing the experiment, participants (N = 4351) answered two items assessing knowledge and awareness of added sugar in cigarettes. Participants had the option of providing open-ended comments about the overall study, and two reviewers read and independently coded comments pertaining to the sugar items. RESULTS: Only 5.5% of participants responded "yes" to the question: "Is sugar added to cigarettes?", and only 3.8% of participants indicated being aware that added sugar increases toxins in cigarette smoke. Forty-eight participants mentioned the sugar items when asked to comment about the overall questionnaire. Fifty-two percent of these comments expressed an interest in obtaining more information about added sugar, and 23% described the sugar items as interesting or informative. Three participants commented that learning about added sugar motivated them to quit or cut down on smoking. CONCLUSIONS: Among a large sample of smokers, few reported knowledge of added sugar in cigarettes and awareness of its effects. Further, several smokers expressed an interest in learning more about added sugar. Messages about added sugar in cigarettes may be a promising new angle for campaigns to discourage smoking. IMPLICATIONS: Few American smokers are aware that sugar is added to cigarettes, and some participants expressed a desire to learn more about this additive. Given such low awareness, the interest among smokers, and increased popular concerns about added sugar in foods and beverages, messaging about added sugar in cigarettes should be developed and tested for inclusion in public health media campaigns.

Air quality and presence of air ventilation systems inside waterpipe cafés in North Carolina.

BACKGROUND: After North Carolina (NC) fire inspectors detected unsafe carbon monoxide (CO) levels inside several waterpipe cafés, the state fire code was amended to include provisions regulating waterpipe cafés, adding a requirement for air ventilation. These regulations apply to new buildings constructed after 1 January 2016, but can be enforced for older buildings where there exists a distinct hazard to life. We measured air quality at a sample of waterpipe cafés before and after the starting date of this regulation and collected information on presence of air ventilation. METHODS: Air quality (CO, fine particulate matter (PM2.5)) monitoring was conducted inside and outside of six waterpipe cafés in NC in September of 2015 (time 1) and September of 2016 (time 2). In addition, questionnaires were administered to managers from each waterpipe café at time 2 to determine the presence of air ventilation systems. RESULTS: Elevated levels of CO and PM2.5 were found inside waterpipe cafés at time 1 (median CO=42 ppm; median PM2.5=379.3 µg/m3) and time 2 (median CO=65 ppm; median PM2.5=484.0 µg/m3), with no significant differences between time periods (p>0.05). Indoor levels were significantly higher than levels outside cafés at both time periods (p<0.05). All waterpipe cafés reported having an air ventilation system that was installed prior to time 1 air monitoring. CONCLUSIONS: Unsafe levels of CO and PM2.5 were observed in waterpipe cafés in NC, despite reported use of air ventilation systems. Prohibiting indoor waterpipe smoking may be necessary to ensure clean air for employees and patrons.

Characteristics of "American Snus" and Swedish Snus Products for Sale in Massachusetts, USA.

Introduction: Snus may present lower health risks than cigarettes, but its harm reduction potential may be undermined if used dually with cigarettes. The likelihood of exclusive snus use compared with dual use may depend in part on the capacity of snus to deliver nicotine in doses that are satisfactory to smokers. We examined characteristics of "American snus" products, including nicotine levels, and compared to snus products that are more typical of Sweden. Methods: Tobacco industry reports for snus products submitted to the Massachusetts Department of Public Health for the year 2014 were used to assess moisture (%), pH, total nicotine, and unionized (free) nicotine (both mg/g and percent of total). A total of 14 ("American") snus products made by American manufacturers Philip Morris USA (n = 6), R.J. Reynolds Tobacco Company (n = 6), and US Smokeless Tobacco Company (n = 2), were compared with Swedish-style ("Swedish") snus products (n = 10) made by Swedish Match North America. Results: Compared with Swedish snus, American snus brands contained significantly lower concentrations of unionized nicotine (median: 0.52 mg/g vs. 6.52 mg/g; p < .001) and proportion of unionized nicotine (median: 3.17% vs. 81.8%; p < .001). American snus brands also had significantly lower pH (median: 6.54 vs. 8.68; p < .001) and moisture (median: 30.3% vs. 53.4%; p < .001). Conclusions: Swedish-made snus has higher unionized nicotine, measured by concentration and proportion of total nicotine, compared with snus products made by American manufacturers. These findings suggest that American snus products have lower addiction potential than Swedish snus, and may be more likely to be used dually with cigarettes than as a sole source of nicotine. Implications: American snus products contain significantly lower unionized nicotine, lower pH, and lower moisture, compared with Swedish snus products. Snus addiction potential and patterns of usage, including co-use with cigarettes, may differ between American and Swedish snus products due to differences in snus product characteristics.

Is initiating tanning bed use as a minor associated with increased risky tanning behaviors and burning? An exploratory study.

Tanning bed use is most common among youth and young adults, and is associated with an increased risk of skin cancer. Recently, numerous states have adopted restrictions on minors' access to tanning beds; however, little has been reported on how such policies may impact tanning behaviors and burning. The purpose of this study was to examine the associations between age of indoor tanning initiation and risky tanning behaviors and burning. Female students (n=567) attending a large southeastern public university completed a questionnaire (spring of 2015) assessing tanning bed use history, including age of initiation. The analytic sample was limited to participants reporting past year indoor tanning (n=134). Multivariable logistic regression was used to compare the odds of risky tanning behaviors and burning among those initiating indoor tanning before and after their 18th birthday. Participants initiating indoor tanning as a minor had significantly (ps<0.05) greater odds of using a tanning bed 10 or more times in the previous year, typically indoor tanning for ≥10min, ever indoor tanning without wearing goggles, and ever fallen asleep inside a tanning bed. Further, those that initiated as a minor had significantly greater odds of ever burning from indoor tanning (p<0.05). Indoor tanning initiation as a minor was associated with several risky tanning behaviors and burning. Youth access restrictions may help reduce the harms caused by tanning beds.

Differences in the design and sale of e-cigarettes by cigarette manufacturers and non-cigarette manufacturers in the USA.

BACKGROUND: Three categories of e-cigarette brands have emerged within the US market: e-cigarette brands developed by cigarette manufacturers, brands acquired by cigarette manufacturers and brands with no cigarette manufacturer affiliation. In the absence of federal regulatory oversight of e-cigarettes, we assessed differences in e-cigarette products and sales practices across these categories. METHODS: Brand websites for top-selling e-cigarette brands from each of these categories were examined in October of 2015 to compare website access restrictions, online sales practices and products sold, including e-cigarette model type (eg, 'cigalike' vs advanced systems) and options available (eg, flavoured, nicotine free). RESULTS: Website access to brands developed by cigarette manufacturers was restricted to users aged 21 years or older, and one website required user registration. In addition, these brands were exclusively reusable/rechargeable 'cigalikes.' Limited flavour options were available for these products, and nicotine-free options were not sold. In contrast, brands acquired by cigarette manufacturers and brands with no cigarette manufacturer affiliation generally required website visitors to be 18, offered a nicotine-free option, and most offered disposable products and an array of flavoured products (eg, fruit/candy flavours). CONCLUSIONS: This exploratory study finds differences in e-cigarette products and sales practices across these three e-cigarette brand categories, with brands developed by cigarette manufacturers adopting a particularly distinctive product and sales strategy. Anticipated regulation of e-cigarettes in the USA may be influencing these product and sales decisions.

Secondhand smoke emission levels in waterpipe cafes in Doha, Qatar.

BACKGROUND: Exposure to the emissions of a tobacco waterpipe is associated with increased health risks among its users as well as those exposed to its secondhand smoke. Waterpipe use is an emerging concern to the tobacco control community, particularly among countries of the Eastern Mediterranean Region. In 2002, Qatar adopted legislation that prohibited cigarette smoking inside public venues, but exempted tobacco waterpipe smoking. To inform the development and enforcement of effective policy, the impact of cigarette and waterpipe use on indoor air quality was monitored in waterpipe cafes in Doha, Qatar. METHODS: Particulate matter (PM2.5) levels were measured inside and outside of a sample of 40 waterpipe cafes and 16 smoke-free venues in Doha, Qatar between July and October 2012. In addition, the number of waterpipes being smoked and the number of cigarette smokers were counted within each venue. Non-paired and paired sample t tests were used to assess differences in mean PM2.5 measurements between venue type (waterpipe vs smoke-free) and environment (indoor vs outdoor). RESULTS: The mean PM2.5 level inside waterpipe venues (476 µg/m(3)) was significantly higher than the mean PM2.5 level inside smoke-free venues (17 µg/m(3); p<0.001), and significantly higher than the mean PM2.5 level found immediately outside waterpipe venues (35 µg/m(3); p<0.001). In smoke-free venues, the outside mean PM2.5 level (30 µg/m(3)) did not differ significantly from the mean PM2.5 inside levels inside these venues (p=0.121). CONCLUSIONS: Elevated levels of particulate pollution were found in waterpipe cafes in Doha, Qatar, potentially endangering the health of employees and patrons. To protect the public from the dangers of secondhand tobacco smoke, and to change social norms around tobacco use, smoke-free policies that apply to all forms of combusted tobacco products, including the waterpipe, are needed.

Coverage of Indoor Smoking and Vaping Restrictions in the US, 1990-2021.

INTRODUCTION: Secondhand smoke exposure increases the risk of premature death and disease in children and non-smoking adults. As a result, many US states and local jurisdictions have enacted comprehensive indoor smoking restrictions (ISR). Indoor vaping restrictions (IVR) have also been adopted to protect against exposure to secondhand e-cigarette aerosol. This study aimed to quantify state and national US coverage of policies restricting indoor cigarette and e-cigarette use over time. METHODS: Data from the American Nonsmokers Rights' Foundation on US ISR from 1990 to 2021 and IVR from 2006 to 2021 were analyzed. Combining these data with 2015 US Census population estimates, the percentage of state and national residents covered by partial and comprehensive restrictions in bars, restaurants, and workplaces, were calculated (analysis in 2023-2024) over time. RESULTS: Between 1990-2021, national coverage of comprehensive ISR increased for bars (0% to 67.3%), restaurants (0% to 78.2%), and workplaces (0% to 77.5%). Partial ISR coverage decreased for bars (14.8% to 13.9%), restaurants (40.2% to 15.4%) and workplaces (40.2% to 22.5%). From 2006 to 2021, comprehensive IVR coverage increased for bars (0% to 43.5%), restaurants (0% to 51.5%), and workplaces (0% to 53.2%). Despite these increases in coverage, by the end of 2021, <50% of the population was protected by comprehensive ISR for bars, restaurants, and workplaces in 19, 12, and 14 states, respectively. CONCLUSIONS: The percentage of the US population protected by ISR and IVR has increased over time. However, gaps in coverage remain, which may contribute to disparities in tobacco-related disease and death.

Association of metformin use and cancer incidence: a systematic review and meta-analysis.

BACKGROUND: Metformin is among the most widely used antidiabetics medications because of its minimal toxicity, favorable safety profile, availability, and low cost. In addition to its role in diabetes management, metformin may reduce cancer risk. METHODS: We conducted a comprehensive systematic review and meta-analysis to investigate the association between metformin use and cancer risk, with evaluation by specific cancer type when possible. Applicable studies were identified in PubMed/MEDLINE, Embase, Cochrane Library, Web of Science, and Scopus from inception through March 7, 2023, with metformin use categorized as "ever" or "yes" and a cancer diagnosis as the outcome. Article quality was evaluated using National Heart, Lung, and Blood Institute guidelines, and publication bias was evaluated using the Egger test, Begg test, and funnel plots. Pooled relative risk (RR) estimates were calculated using random-effects models, and sensitivity analysis was completed through leave-one-out cross-validation. RESULTS: We included 166 studies with cancer incidence information in the meta-analysis. Reduced risk for overall cancer was observed in case-control studies (RR = 0.55, 95% confidence interval [CI] = 0.30 to 0.80) and prospective cohort studies (RR = 0.65, 95% CI = 0.37 to 0.93). Metformin use was associated with reduced gastrointestinal (RR = 0.79, 95% CI = 0.73 to 0.85), urologic (RR = 0.88, 95% CI = 0.78 to 0.99), and hematologic (RR = 0.87, 95% CI = 0.75 to 0.99) cancer risk. Statistically significant publication bias was observed within the studies (Egger P < .001). CONCLUSIONS: Metformin may be associated with a decreased risk of many cancer types, but high heterogeneity and risk of publication bias limit confidence in these results. Additional studies in populations without diabetes are needed to better understand the utility of metformin in cancer prevention.

Availability and range of tobacco products for sale in Massachusetts pharmacies.

OBJECTIVE: New tobacco control policies have been introduced in Massachusetts which restrict tobacco product sales in pharmacies. The purpose of this investigation was to outline the scope of pharmacy involvement in the tobacco market by assessing the availability and range of tobacco products sold in Massachusetts pharmacies. METHODS: Public listings of licenced pharmacies and tobacco retailers in Massachusetts were examined to determine the proportion of pharmacies licenced to sell tobacco, and the proportion of tobacco retailers possessing a pharmacy licence. Telephone interviews were conducted with a random sample (n=70) of pharmacies possessing a tobacco licence to assess the availability and range of tobacco products for sale. The availability of nicotine replacement therapy (NRT) products was assessed as a comparison. RESULTS: The majority of pharmacies in Massachusetts possessed a tobacco licence (69%), and pharmacies made up 9% of licenced tobacco retailers. Among pharmacies surveyed that reported selling tobacco (90%), cigarettes were the most available tobacco product for sale (100%), followed by cigars (69%), little cigars/cigarillos (66%), moist snuff (53%), pipe tobacco (49%), roll-your-own tobacco (34%), snus (14%), dissolvable tobacco (11%) and electronic cigarettes (2%). Nearly all pharmacies selling tobacco offered the nicotine patch (100%), gum (100%) and lozenge (98%). CONCLUSIONS: Tobacco-free pharmacy policies would affect a majority of Massachusetts pharmacies and remove a variety of tobacco products from their store shelves. Further, nearly one in ten tobacco retailers would be eliminated by prohibiting tobacco sales in Massachusetts pharmacies statewide.