A Cross-Sectional Survey on Oral Nicotine Pouches: Characterizing Use-Motives, Topography, Dependence Levels, and Adverse Events.

INTRODUCTION: Oral nicotine pouches (ONPs) contain a crystalized nicotine powder instead of tobacco leaves. ONPs come in a variety of flavors and are often marketed as "tobacco-free," but research on ONP use-motivations and related experiences is limited. AIMS AND METHODS: This cross-sectional web-based survey collected self-report data on ONP use-characteristics (eg, frequency), brands and flavors used, use-motivations, dependence (Fagerström Test for Nicotine Dependence-Smokeless Tobacco [FTND-ST]), and ONP-related adverse events (AEs) experienced. RESULTS: The sample included 118 adults who reported current (past 30-day) ONP use. On average (SD), participants reported ONP use on 13 (6) days during the past month. Most participants (% of the sample) also reported the use of tobacco cigarettes (74%) and/or electronic cigarettes (53%) during the past month. Zyn (27%) and Lucy (19%) were the most currently used ONP brands with mint (23%) and tobacco (16%) as the most currently used flavors. The availability of preferred flavors was the most frequently reported (31%) ONP use-motivation. The sample demonstrated significant dependence levels (FTND-ST = 7, SD = 2). Reported AEs included mouth lesions (48%), upset stomach (39%), sore mouth (37%), sore throat (21%), and nausea (9%). Results should be interpreted in the context of study limitations, including using a relatively small and homogeneous online convenience sample. Acknowledging the limitations, this sample was deemed appropriate to include considering the novelty of the findings, the dearth of related research, and the necessity of examining foundational ONP use-characteristics (eg, topography, AEs); however, future research should consider recruiting larger and more generalizable samples. CONCLUSIONS: The availability of preferred flavors was a key ONP use-motivation in this sample. Mint and tobacco were the most currently used flavors, with Zyn and Lucy being the most currently used ONP brands. Participants reported dependence and a substantial number of ONP-related AEs. Nationally representative surveys should investigate ONP use along with outcomes included in the current study (eg, AEs) to inform ONP surveillance and policy development efforts. IMPLICATIONS: This study is among the first to assess reasons for initiating/maintaining ONP use as well as other relevant use-experiences (eg, AEs, dependence). These results highlight the role of flavors and nicotine dependence in ONP use, which are important considerations for informing ONP regulations.

Transitions in device and liquid characteristic groupings among US adults frequently using electronic nicotine delivery systems (ENDS) over three timepoints, 2020-2021.

INTRODUCTION: Electronic nicotine delivery system (ENDS) and liquid characteristics affect nicotine and toxicant exposure and use behaviors. Little is known about how adults who frequently use ENDS transition between ENDS device/liquid groupings. METHODS: A total of 379 US adults (≥21 years) using ENDS frequently (≥5 days/week) self-reported and uploaded photos of their most used ENDS device and liquid in three waves of online surveys (May 2020 - November 2021). Device/liquid grouping was defined by device (i.e. disposable/refillable tank/refillable pod or cartridge/disposable pod or cartridge, adjustable/no adjustable settings) and liquid (i.e. salt/freebase) characteristics. Participants using the same grouping across waves were considered stable users. RESULTS: The most prevalent wave (W) 1 grouping was tank (freebase, adjustable settings; 36.8%). From W1 to W3, the number of disposable device (salt, no adjustable settings) users increased 156.4% and the number of disposable pod/cartridge (salt, no adjustable settings) users decreased 15.2%. In W2 and W3, compared to stable users, participants using tank (freebase, adjustable settings) in W1 and another grouping in W2 and/or W3 reported significantly higher nicotine concentrations (mg/mL) (W2: 15.1 vs 5.5, p<0.001; W3: 22.9 vs 5.6, p<0.001) and lower device power (watt) (W2: 46.8 vs 58.7, p=0.02; W3: 34.0 vs 57.2, p<0.001). CONCLUSIONS: Over a 1.5-year period, a rapid growth in disposable device (salt, no adjustable settings) use and a decrease in disposable pod/cartridge (salt, no adjustable settings) use were observed. Participants who transitioned from tank (freebase, adjustable settings) to other groupings were more likely to increase liquid nicotine concentration and reduce device power compared to stable users.

The association between viewing cigarette health warning labels and intention to quit smoking among Chinese adult smokers: support for including health outcome content and culturally specific messages.

BACKGROUND: Tailored themes of pictorial health warning labels (HWLs) that considers specific cultural dimensions and within a specific policy/historical context can motivate behavior change, such as provoking smokers to think about quitting. Currently in China, the HWLs on cigarettes are text-only. This study designed pictorial HWLs using different themes to explore and examine the association between viewing pictorial HWLs and participants' intention to quit smoking. The themes included: (1) Self-harm from using cigarettes, (2) Harming family or children with secondhand smoke, (3) Complying with existing smoke-free policies, and (4) Cigarette gift giving practices. METHODS: A cross-sectional randomized experimental survey was conducted among 1,625 smokers in Beijing (n = 545), Shanghai (n = 541), and Shenzhen (n = 539) during 2017. Before and after viewing eight pictorial HWLs of one theme, participants were asked if they had plans to quit smoking within the next month, within the next 6 months, beyond the next 6 months, or not at all. Ordinal logistic regression, Wilcoxon and Chi-square tests were used to analyze the data. RESULTS: After viewing the HWLs, 434 participants (26.9%) reported an intention to quit smoking sooner, 987 (61.2%) reported the same intention to quit, and 191 (11.8%) reported an intention to quit later. The pre-post change in intention to quit was statistically significant among all participants and participants under each theme (p > 0.05). Participants who rated the effectiveness of the HWL communicating how secondhand smoke harms children had 1.13 (95% CI 1.01-1.27) greater odds of reporting an intention to quit sooner compared to those viewing labels from the other themes, adjusting for covariates. Female participants and participants with annual household income more than 100,000RMB had 1.39 (95% CI 1.14-1.69) and 1.29 (95% CI 1.04-1.60) greater odds of reporting an intention to quit sooner compared to their counterparts across the entire sample. CONCLUSIONS: Findings of this study provide evidence of an association between all four pictorial HWL themes and smokers' intention to quit smoking. These findings can help inform what HWL themes might be appropriate when China implements pictorial health warning labels.

Electronic nicotine delivery system advertising in business-to-business publications, United States, 2015-2020.

INTRODUCTION: Tobacco retailers are a key target audience for tobacco product advertising, yet little is known about the messages and channels used to market electronic nicotine delivery systems (ENDS) to retailers. METHODS: We assessed expenditures for business-to-business print advertising for ENDS in the United States, by year and by advertiser, from 2015 to 2020; and the content of advertisements placed in 2020. RESULTS: The total number of ENDS brands placing business-to-business advertisements declined from 45 in 2015 to 6 in 2020; spending declined from $2.6 million in 2015 (for 283 occurrences) to $492,789 in 2020 (69 occurrences). Across years, the top-spending advertisers were Logic ($1.9 million), blu ($1.0 million), JUUL ($625,050), NJOY ($373,126) and Vuse ($322,075). Common messages of advertisements placed in 2020 included that products are not intended for minors; brand market share; health warnings; profitability or revenue potential for retailers; and flavours. DISCUSSION: This study suggests that ENDS companies anticipate that ENDS retailers are interested in stocking products that maximise profits, appeal to consumers and comply with regulatory requirements. Declines in the number of advertisers mirror the overall consolidation of the ENDS industry that occurred during the study period. CONCLUSIONS: Business-to-business print advertising represents an important channel in which ENDS brands communicate a variety of messages about their products directly to potential retailers.

#Nicotineaddiction on TikTok: A quantitative content analysis of top-viewed posts.

INTRODUCTION: TikTok, the video-sharing app popular among youth, is a source of user-generated content about nicotine addiction with the potential to endorse or deter nicotine use among young viewers. We systematically analyzed content and themes of TikTok posts tagged #nicotineaddiction. METHODS: We conducted a quantitative content analysis of the visual and textual content of the 149 top-viewed English-language TikTok posts tagged #nicotineaddiction as of 1 March 2021. Posts were double-coded using a shared codebook, noting content creator characteristics, nicotine products featured, references to quitting, and overall themes of #nicotineaddiction expressed. We assessed the prevalence of post characteristics and themes overall and by apparent age of content creators (aged ≥21 years versus <21 years). RESULTS: The 149 posts analyzed received a mean and median of 62433 and 15800 likes, respectively. E-cigarettes were referenced or featured in 75% of posts; 58% featured a specific nicotine product brand, most commonly Puff Bar (23% of total) and JUUL (19%). Overall, 22% of posts mentioned quitting nicotine. The top themes of #nicotineaddiction expressed were physical or psychological consequences (e.g. withdrawal symptoms, 46%), physical or psychological benefits (e.g. tasting good, feeling 'buzzed', 28%), and social benefits (e.g. bonding with fellow users, 28%). Compared to those aged ≥21 years, posts by content creators likely <21 years (26%) less commonly mentioned quitting (p<0.01), had fewer followers (p<0.01), were more commonly from Canada (p<0.01) and less commonly from the US (p<0.01), and more commonly featured JUUL (p<0.05). CONCLUSIONS: While reaching a large and engaged audience, TikTok content creators suggest a range of benefits and consequences of nicotine addiction. Future research is warranted to examine this content's potential to influence young people's intentions to use or quit nicotine products.

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.

THE EVOLUTION OF INFORMATION TECHNOLOGY GOVERNANCE AT THE NIH CLINICAL CENTER.

An information technology governance (ITG) program has helped the National Institutes of Health (NIH) Clinical Center (CC) in the implementation of many systems and has guided the organization through the maturity of its project management methodology. The NIHCC Department of Clinical Research Informatics (DCRI) maintains an electronic health record (EHR) called the clinical research information system (CRIS) along with many clinical information systems (CIS) and research information systems, supporting approximately 3,200 users. ITG involves establishing processes to guide the review, selection, implementation, management, and setting of the IT strategy representing the business owners, stakeholders, and IT.1 Research conducted by Levstek, Hovelja, and Pucihar2 identified that different organizations may need different ITG structures, frameworks, and strategies. The path to achieving strong ITG is a continuous journey. This paper reviews the evolution of the NIHCC IT governance strategy.

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.

Enforcement agencies and smoke-free policy compliance: An observational study in Qingdao, China.

INTRODUCTION: In recent years, tobacco control policy initiatives have emerged at the subnational level in China. In 2013, for example, Qingdao enacted a 100% smoke-free policy that gave regulatory authority to multiple enforcement agencies. Given that little is known about the extent of smoke-free policy compliance in smaller Chinese cities, this study assessed compliance with Qingdao's Tobacco Control Regulation and whether compliance differed by enforcement agency. METHODS: A cross-sectional observational study was undertaken between October and November 2018. Venues were selected based on enforcement agency and included restaurants, retail stores, schools, government buildings, hospitals, business offices, and other hospitality venues. Comprehensive lists of venues were identified where they existed, and a random sample of venues were subsequently selected. For venue categories for which there were no comprehensive lists, a walking protocol was used. Observational data included evidence of smoking, the presence of no-smoking signage, and designated smoking areas (DSAs). Descriptive statistics were obtained. Subsequently, logistic regression models were used to determine the association between enforcement agency and policy compliance. RESULTS: A total of 694 venues were observed. For all venue types, 64.7% were compliant with the composite indicator 'evidence of smoking'. Findings also showed that smoke-free compliance varied by enforcement agency (p<0.001). Venues with evidence of smoking and not posting of no-smoking signs at the main entrance were lowest among venues that fall under Public Security Bureau. Compliance with posting no-smoking signs inside was lowest in venues that fall under the Industry and Commercial Administration (I&C). While Qingdao's smoke-free policy prohibits DSAs, our findings showed that 2% of venues that fall under the jurisdiction of I&C had DSAs. CONCLUSIONS: An effective coordination mechanism that can ensure a consistent and standardized approach is urgently needed in Qingdao. With such a concerted effort, it will be possible to achieve the target of 100% smoke-free indoor places in Qingdao.

Availability and advertising of electronic cigarettes in two Russian cities following implementation of comprehensive tobacco advertising restrictions.

INTRODUCTION: Electronic cigarettes (e-cigarettes) continue to gain popularity globally. Jurisdictions with comprehensive tobacco control policies, which limit the use and availability of combustible tobacco products but do not regulate e-cigarettes (as in Russia), may be vulnerable to the expansion of the e-cigarette market. METHODS: Using McNemar's test conducted in STATA, this observational study assessed changes between 2014 and 2016 in the availability of e-cigarettes across 239 retail outlets in Moscow and St Petersburg. Also, this study characterized the presence of retail advertising and promotion of e-cigarettes in 2016. RESULTS: Between 2014 and 2016, the availability and display of e-cigarettes increased within traditional tobacco product retail venues (27.6% in 2014 vs 51.9% in 2016; p<0.01). CONCLUSIONS: Observations indicate that there has been an increase in the proportion of retailers selling and displaying e-cigarettes.

Content analysis of online product descriptions from cannabis retailers in six US states.

BACKGROUND: As the purchase of cannabis becomes legalized in US states, cannabis marketing presents an unexplored regulatory landscape. Research examining other consumer products indicates marketing informs consumer product perceptions, use expectancies, and behavior. The current study examined how cannabis products are described on US cannabis retailer websites. METHODS: We used the National Cannabis Industry Association website to identify 27 retailers, linked to brick-and-mortar locations in six states, who advertised cannabis flower products online, and thematically coded descriptions of each product sold (N=428). RESULTS: Cannabis strain product descriptions fell into six categories: psychoactive effects, physical effects, social effects, sensory profile, therapeutic and curative claims, and negatives/warnings. Relaxation/stress relief (47.4%) and happiness (43.9%) were the most commonly described psychoactive effects, and relaxation/sedation was the most common physical effect (41.6%). Many products noted sensory characteristics, such as fruity (38.1%) or sweet (31.3%) taste/smell. A significant number of retailers claimed that strains could relieve pain and depression. Reports of potential side effects or warnings were less common. CONCLUSION: Online cannabis retailers are making potentially unsubstantiated product claims. Future work should examine the potential for these claims to inform consumer behavior. Regulations should ensure that cannabis labeling does not mislead consumers or promote unsafe use.

The Effectiveness of Cigarette Pack Health Warning Labels with Religious Messages in an Urban Setting in Indonesia: A Cross-Sectional Study.

This study sought to assess the effectiveness of religious cigarette health warning labels (HWLs) in Indonesia, a country with a high public health burden from tobacco use. The study tested different religious and nonreligious messages related to suicide, secondhand smoke (SHS) and gangrene. Participants were smokers and non-smokers from Surabaya, Indonesia (n = 817). Participants rated each HWL for its effectiveness on a scale of 1 to 10 (1 = "not at all", 10 = "extremely") with respect to 10 items. Nonreligious HWLs were marginally superior for SHS and suicide while religious HWLs were marginally superior for gangrene. Given the close rating scores between religious and nonreligious HWLs, they were functionally equal in effectiveness. With proper assessment of potential unintended consequences, the implementation of religious HWLs could be considered for a proportion of HWLs.

The prevalence of fire and CO safety amenities in Airbnb venues that permit smoking - Findings from 17 countries.

Airbnb hosts rent their homes to guests as an alternative to traditional hospitality settings. Airbnb venues are not uniformly regulated for allowing smoking or requiring fire-safety amenities. This study quantified the reported prevalence of fire-safety amenities in 413,339 Airbnb venues that allow smoking in 43 cities in 17 countries. Proportions of host-reported smoke detectors and carbon monoxide (CO) alarms, and those that allow smoking were calculated. Across the entire sample 9.3% (n = 38,525) allowed smoking. An overall evaluation of those venues shows that 46% (n = 17,569) had smoke detectors compared to 64% of the 374,814 venues that do not allow smoking, a statistically significant difference (X2 = 5277 p < 0.01). A similar difference is found between venues that allow smoking and had CO alarms (19%, n = 7176) and the 33% of venues that prohibit smoking (X2 = 3442, p < 0.01). Among this sample, most Airbnb venues that allow smoking are less likely to have safety amenities.

Identifying behavioural characteristics of tobacco product and e-cigarette use clusters: A repeat cross-sectional analysis.

BACKGROUND: Youth may use a variety of tobacco products and e-cigarettes. However, there is a lack of evidence for the combinations of tobacco products and e-cigarettes commonly used by youth in Canada and whether youth from different usage classes share similar characteristics. METHODS: A cohort of 9th grade students from Ontario, Canada was identified at baseline (2013-14) of the COMPASS study (n = 4651). Classes of youth that currently use similar combinations of tobacco products and e-cigarettes were identified at baseline, one (FY1) and two years later (FY2) using latent class analysis. Multinomial logistic regression models identified demographic and behavioural characteristics (e.g., environmental influences, substance use behaviours, etc.) of youth in current tobacco and e-cigarette use classes relative to youth in non-current use classes. RESULTS: At baseline, a three-class model was identified as best, while a four-class model was identified at FY1 and FY2. A non-current use group and an all-product use group were identified every year. Students that reported having friends that smoked cigarettes, binge drinking, and using marijuana were more likely to be classified into a current use class. CONCLUSIONS: Tobacco cigarettes were more likely to be used with other products than on their own. An all-product use group was identified across all three survey waves and the prevalence of this group increased over time. Given that many youth in this study used more than one tobacco product or e-cigarette and commonly reported binge drinking and using marijuana, prevention and cessation activities should address the use of multiple products.

Cost and Threshold Analysis of the FinishIt Campaign to Prevent Youth Smoking in the United States.

In 2014, Truth Initiative launched the national FinishIt campaign to prevent smoking initiation among youth and young adults. The significant changes in the communications landscape requires further analysis to determine resource requirements for public education campaigns relative to their impact. This analysis estimates the cost of the FinishIt campaign based on data from expenditure records and uses published estimates of the lifetime treatment costs and quality-adjusted life years associated with smoking. The total cost of the FinishIt campaign for 2014⁻2016 was $162 million. Under assumptions associated with the pessimistic base-case (no medical care costs saved through prevention), 917 smoking careers would need to be averted for the campaign to be cost-effective. Assuming smoking leads to increased medical care costs, 7186 smoking careers would need to be averted for the campaign to be cost-saving. Given these thresholds (917 and 7186) and the estimate of the impact of the previous truth campaign, the investments in the Truth Initiative's FinishIt campaign are likely warranted for preventing smoking careers among youth and young adults.

The Relationship Between Neighborhood Disorder and Barriers to Cessation in a Sample of Impoverished Inner-City Smokers in Baltimore, Maryland, United States.

Introduction: Economic disparities in rates of smoking have been well documented in many countries. These disparities exist on an individual and geographic or neighborhood level. This cross-sectional study examined the relationship between neighborhood physical and social disorder and barriers to smoking cessation among an impoverished urban sample. Methods: A sample of current smokers were recruited through street outreach, posted advertisements, and word of mouth from impoverished neighborhoods in Baltimore, Maryland, USA for a study of psychosocial factors and smoking behaviors. Neighborhood disorder was assessed with a 10-item scale from the Block Environmental Inventory and barriers to cessation with a 9-item scale. Results: In the multiple logistic regression model, perceived stress (aOR = 1.60, 95% CI = 1.32 to 1.95), neighborhood disorder (aOR= 1.34, 95% CI = 1.11 to 1.63), and level of nicotine dependence (aOR = 1.97), 95% CI = 1.62 to 2.40) were all strongly associated with barriers to cessation. Conclusion: The results of this study suggest that neighborhood disorder may lead to barriers to cessation among low-income populations. The findings also indicate that tobacco control interventions should examine and address social and physical aspects of impoverished neighborhoods. Implications: In many countries, tobacco control programs and policies have been less effective among low-income populations as compared to more affluent populations. Little is known about how neighborhood factors influence smoking cessation. This study examined the relationship between neighborhood disorder and barriers to cessation among a low-income population. We recruited a convenience sample of hard-to-reach cigarette smokers from low-income neighborhoods. Even after controlling for level of nicotine dependence and stress, neighborhood disorder was found to be associated with barriers to cessation. The findings suggest the important role of neighborhood disorder as a barrier to smoking cessation.

The Relationship between Neighborhood Disorder, Social Networks, and Indoor Cigarette Smoking among Impoverished Inner-City Residents.

Impoverished urban neighborhoods tend to have higher rates of smoking and higher rates of exposure to secondhand smoke as compared to more affluent neighborhoods. Contextual factors of neighborhood disorder and social network and household composition may have an impact on indoor smoking behaviors. The TIDE study examined psychosocial factors associated with smoking behaviors among impoverished inner-city smokers in Baltimore, Maryland. Among a community-recruited sample of 413 smokers who lived with others, most (73%) reported that they or others smoked in their residence. Cohabitation with children, elderly, and those with asthma and other respiratory condition was not associated with indoor smoking. Neighborhood disorder, the proportion of social network members who smoked with the study participant, and the proportion of household members who smoked were all independently associated with smoking indoors. The study findings suggest the importance of addressing neighborhood and social network factors when developing programs for promoting indoor smoking bans as well as cessation and prevention programs.