Perinatal Outcomes and Neurodevelopment 1 Year after Birth in Discordant Twins According to Chorionicity.

Background and Objectives: This study aimed to compare maternal complications, perinatal outcomes, and neurodevelopment 1 year after the birth between concordant and discordant twins in monochorionic and dichorionic twins. Materials and Methods: This retrospective study included twin pregnancies delivered between 24 + 1 and 38 + 2 weeks of gestation between January 2011 and September 2019. Chorionicity was confirmed by ultrasonography and was categorized into monochorionic and dichorionic. Each was then divided into two groups (concordant and discordant) according to birth weight discordancy. Maternal complications and neonatal outcomes, including neurodevelopmental delays, were compared between the two groups. Results: A total of 298 pairs of twin pregnancies were enrolled, of which 58 (19.26%) women were pregnant with monochorionic diamniotic twins and 240 (80.54%) with dichorionic diamniotic twins. In both monochorionic and dichorionic twins, the discordant twins had a greater incidence of emergency deliveries because of iatrogenic causes than the concordant twins. Among dichorionic twins, discordant twins had lower birth weight rates and higher hospitalization rates and morbidities than concordant twins. Among monochorionic twins, discordant twins had a lower birth weight and higher neonatal mortality than concordant twins. The neonatal size was not a predictor of neurodevelopment in this group. Based on the logistic regression analysis, male sex, respiratory distress syndrome, and bronchopulmonary dysplasia were risk factors for the neurodevelopmental delay; birth weight discordancy was significant only in dichorionic twins. Conclusions: Perinatal outcomes in discordant twins may be poor, and neurodevelopment 1 year after birth was worse in discordant twins than in concordant twins. Discordancy in twins can be a risk factor for neurodevelopmental delay.

Clinical outcomes of hysterectomy for benign diseases in the female genital tract: 6 years' experience in a single institute.

BACKGROUND: Hysterectomy is one of the major gynecologic surgeries. Historically, several surgical procedures have been used for hysterectomy. The present study aims to evaluate the surgical trends and clinical outcomes of hysterectomy performed for benign diseases at the Yeungnam University Hospital. METHODS: We retrospectively reviewed patients who underwent a hysterectomy for benign diseases from 2013 to 2018. Data included the patients' demographic characteristics, surgical indications, hysterectomy procedures, postoperative pathologies, and perioperative outcomes. RESULTS: A total of 809 patients were included. The three major indications for hysterectomy were uterine leiomyoma, pelvic organ prolapse, and adenomyosis. The most common procedure was total laparoscopic hysterectomy (TLH, 45.2%), followed by open hysterectomy (32.6%). During the study period, the rate of open hysterectomy was nearly constant (29.4%-38.1%). The mean operative time was the shortest in the single-port laparoscopic assisted vaginal hysterectomy (LAVH, 89.5 minutes), followed by vaginal hysterectomy (VH, 96.8 minutes) and TLH (105 minutes). The mean decrease in postoperative hemoglobin level was minimum in single-port LAVH (1.8 g/dL) and VH (1.8 g/dL). Conversion to open surgery or multi-port surgery occurred in five cases (0.6%). Surgical complications including wound dehiscence, organ injuries, and conditions requiring reoperation were observed in 52 cases (6.4%). CONCLUSION: Minimally invasive approach was used for most hysterectomies for benign diseases, but the rate of open hysterectomy has mostly remained constant. Single-port LAVH and VH showed the most tolerable outcomes in terms of operative time and postoperative drop in hemoglobin level in selected cases.

Clinical and histopathologic analysis of gynecological cancer: a single institute experience over 7 years.

BACKGROUND: Approximately 100,000 women are diagnosed with cancer each year in Korea. According to a survey by the Korean central cancer registry in 2016, uterine cervical cancer, uterine corpus cancer, and ovarian cancer were the 5th, 7th, and 8th most prevalent cancers respectively among Korean women. The present study aims to review the clinico-pathologic characteristics of patients who were treated for major gynecological malignancies at Yeungnam University Medical Center. METHODS: Patients with invasive gynecological cancers from January 2012 to February 2019 were retrospectively identified. We analyzed the clinical features, demographic profiles, pathologic data, treatment modality used, adjuvant treatment used, complications, recurrence, and survival outcomes. RESULTS: A total of 287 patients (cervical cancer 115; corporal cancer 86; and ovarian, tubal, or primary peritoneal cancer 90) were included. Most cervical (82.7%) and corporal cancers (89.5%) were diagnosed in the early stages (stage I or II), while more than half (58.9%) the cases of ovarian, tubal or peritoneal cancers were diagnosed in the advanced stages (stage III or IV). Surgical complications were observed in 12.2% of cervical cancers, 16.3% of uterine corpus cancers, and 11.1% of ovarian, tubal, and peritoneal cancers, respectively. The 5-year overall survival rate was 94.1%, 91.0%, and 77.1% for cervical, corporal, and ovarian, tubal, or peritoneal cancers, respectively. CONCLUSION: Surgical treatment was satisfactory in terms of the incidence of complications, and survival outcomes were generally good. Clinicians should be aware of the clinical and histopathological characteristics of patients with gynecological cancers to be able to provide optimal strategies and counseling.

Measuring waterpipe tobacco smoking in survey research.

Waterpipe tobacco (WT) smoking remains a significant public health problem. However, few validated measures exist, presenting challenges for obtaining accurate prevalence estimates and making comparisons across studies. We identified items used to measure several WT smoking behaviours in eight US national surveys of youth and adults and two international studies, including the National Youth Tobacco Survey, National Adult Tobacco Survey, Population Assessment of Tobacco and Health Adult and Youth Surveys, Monitoring the Future, National Health Interview Survey, Health Styles, Tobacco Use Supplement: Current Population Survey, Global Adult Tobacco Survey and Global Youth Tobacco Survey. We also identified WT survey items across the first 14 Food and Drug Administration-funded Tobacco Centers of Regulatory Science. Constructs included product description and terminology, ever and current use, quantity and frequency, use of flavours and reasons for use. There was little consistency in WT measurement, highlighting the need for validated measures.

Impacts of Nicotine and Flavoring on the Sensory Perception of E-Cigarette Aerosol.

INTRODUCTION: To examine the interaction between an added flavoring (cherry) and nicotine on the perception of electronic cigarette (e-cigarette) aerosol and how this impacts the appeal of flavored liquids for e-cigarette (e-liquids). METHODS: A total of 19 subjects (13 male, 6 female) vaped six commercially available e-liquids with varying contents of nicotine (0, 6, 12 mg/mL) and cherry flavor (4.7% or 9.3% vol/vol). For each e-liquid, subjects first rated overall liking/disliking of the aerosol using the Labeled Hedonic Scale, followed by perceived intensities of sweetness, bitterness, harshness (irritation), and cherry flavor of the aerosol using the general version of Labeled Magnitude Scale. RESULTS: The main findings were that (1) added nicotine increased perceived irritation and bitterness, and decreased the perceived sweetness of the e-cigarette aerosol; (2) cherry flavoring added a characteristic "cherry flavor" and an increase in the flavoring concentration from 4.7% to 9.3% tended to increase perceived intensities of sweetness, harshness, and bitterness; and (3) hedonic ratings of the e-cigarette aerosol decreased as nicotine level increased, but were not affected by flavor level. CONCLUSIONS: Our findings indicate that the appeal of the e-cigarette aerosol decreases as nicotine concentration increases. Conversely, perceived sweetness improved liking. An increase in the concentration of cherry flavoring did not appear to impact any of the measured attributes to a significant degree. IMPLICATIONS: This work demonstrates that the perception of specific sensory attributes of e-cigarettes and their overall appeal are affected by the e-liquid constituents. Most significantly, the results suggest that nicotine decreases the sensory appeal of e-cigarettes by contributing to the perceived irritation and bitterness of the aerosol. These data have implications for the role that nicotine plays in the sensory perception and appeal of e-cigarettes aerosol and further how these sensory factors can be modulated by sweet flavoring.

Evidence of compensation among waterpipe smokers using harm reduction components.

OBJECTIVES: We examined two waterpipe tobacco smoking components advertised to reduce harm to determine if they result in lower levels of biomarkers of acute exposure. METHODS: We conducted a crossover study of 34 experienced waterpipe smokers smoking a research-grade waterpipe in three configurations ad libitum in a controlled chamber: control (quick-light charcoal), electric (electric heating) and bubble diffuser (quick-light charcoal and bubble diffuser). We collected data on smoking topography, environmental carbon monoxide (CO), subjective effects, heart rate, plasma nicotine and exhaled CO and benzene. RESULTS: Smokers' mean plasma nicotine, heart rate, and exhaled benzene and CO boost were all significantly lower for electric compared with control. However, smokers puffed more intensely and took significantly more and larger volume puffs for a larger total puffing volume (2.0 times larger, p<0.0001) when smoking electric; machine yields indicate this was likely due to lower mainstream nicotine. Smokers rated electric smoking experience less satisfying and less pleasant. For charcoal heating, the mean mass of CO emitted into the chamber was ~1 g when participants smoked for a mean of 32 minutes at a typical residential ventilation rate (2.3 hr-1). CONCLUSION: Waterpipe smokers engaged in compensation (i.e., increased and more intense puffing) to make up for decreased mainstream nicotine delivery from the same tobacco heated two ways. Waterpipe components can affect human puffing behaviours, exposures and subjective effects. Evidence reported here supports regulation of waterpipe components, smoking bans in multifamily housing and the use of human studies to evaluate modified or reduced risk claims.

A review of the cost-effectiveness of adult influenza vaccination and other preventive services.

The Centers for Disease Control and Prevention recommend annual influenza vaccination of persons ≥6 months old. However, in 2016-17, only 43.3% of U.S. adults reported receiving an influenza vaccination. Limited awareness about the cost-effectiveness (CE) or the economic value of influenza vaccination may contribute to low vaccination coverage. In 2017, we conducted a literature review to survey estimates of the CE of influenza vaccination of adults compared to no vaccination. We also summarized CE estimates of other common preventive interventions that are recommended for adults by the U.S. Preventive Services Task Force. Results are presented as costs in US$2015 per quality-adjusted life-year (QALY) saved. Among adults aged 18-64, the CE of influenza vaccination ranged from $8000 to $39,000 per QALY. Assessments for adults aged ≥65 yielded lower CE ratios, ranging from being cost-saving to $15,300 per QALY. Influenza vaccination was cost-saving to $85,000 per QALY for pregnant women in moderate or severe influenza seasons and $260,000 per QALY in low-incidence seasons. For other preventive interventions, CE estimates ranged from cost-saving to $170,000 per QALY saved for breast cancer screening among women aged 50-74, from cost-saving to $16,000 per QALY for colorectal cancer screening, and from $27,000 to $600,000 per QALY for hypertension screening and treatment. Influenza vaccination in adults appears to have a similar CE profile as other commonly utilized preventive services for adults. Efforts to improve adult vaccination should be considered by adult-patient providers, healthcare systems and payers given the health and economic benefits of influenza vaccination.

Development and psychometric validation of a novel measure of sensory expectancies associated with E-cigarette use.

INTRODUCTION: E-cigarette dependence measures largely focus on e-cigarette use ("vaping") that is linked to nicotine use, and measures assessing sensory aspects of vaping that may influence use (e.g., taste) are limited in scope. Thus, we developed the novel Sensory E-cigarette Expectancies Scale (SEES). METHODS: In Summer 2017, 610 adult e-cigarette users (48.7% male, 84.9% White, 37.41[±12.15] years old) completed an online survey that included 23 SEES items. Psychometric analyses included evaluating latent structure, internal consistency, measurement invariance, mean differences, and test-criterion relationships. RESULTS: Factor analyses supported a 9-item, 3-subscale structure (taste/smell, pleasure/satisfaction, vapor cloud production). Subscales evidenced internal consistency and scalar invariance by sex, race, smoking status (current/not), vaping status (daily/not), e-liquid nicotine content (yes/no), and device type (cig-a-likes/vape-pens/Advanced Personal Vaporizers [APVs]/Mods). Women and daily e-cigarette users reported stronger SEEs for taste/smell and pleasure than their counterparts. Non-white participants reported stronger SEEs for cloud production than White participants. Cig-a-like users reported the weakest SEEs for taste/smell and weaker SEEs linked to cloud production than APV/mod users. SEES scores evidenced convergence with nicotine dependence (mean r = .36). Finally, SEES scores predicted vaping frequency and habitual vaping concurrently and incrementally beyond nicotine dependence. CONCLUSIONS: The SEES evidenced good psychometric properties, suggesting that the measure can be used to assess sensory vaping expectancies in adults. Importantly, SEES scores indicated that sensory expectancies are related, yet distinct, from nicotine dependence. Future research should evaluate how SEEs relate to product characteristic preferences and patterns of vaping including the development and maintenance of addiction.

Adrenal metastasis in sequentially developed combined hepatocellular carcinoma-cholangiocarcinoma: A case report.

The incidence of combined hepatocellular carcinoma-cholangiocarcinoma (cHCC-CC) in a single patient accounts for only 0.4 to 14% of all primary liver cancer. However, the prognosis of its intrahepatic cholangiocarcinoma (ICC) component is poor. We experienced a unique case of a sequentially developed cHCC-CC with adrenal metastasis as the primary presentation and a hidden primary hepatocellular carcinoma. A 65-year-old female with a history of jaundice and abdominal discomfort was diagnosed with S4 ICC measuring 5 cm in diameter, and characterized histologically as papillary adenocarcinoma with intraductal growth, but without any evidence of malignant hepatocyte. S4 segmentectomy with hepaticojejunostomy revealed no additional masses. A follow-up CT scan 3 months after surgery showed a right adrenal mass with markedly increased serum AFP (4950 ng/mL), which was treated with right adrenalectomy. Histopathology revealed a metastatic hepatocellular carcinoma testing positive for AFP, glypican-3, and hepatocytes, but negative for CD-10, inhibin-α, EMA, S-100, and cytokeratin-7. Serum AFP level immediately plummeted to 4.1 ng/mL upon adrenal mass removal. A recurrent S7 liver mass was suspected 1 year later with serum AFP value of 7.6 ng/mL, and characteristic CT imaging of HCC. TACE was performed with good response. Adrenal metastasis may manifest as the primary focus of hepatocellular carcinoma in sequentially developed cHCC-CC patients with hidden primary HCC. cHCC-CC should be considered in the differential diagnosis of cholangiocarcinoma with elevated AFP.

Establishing consensus on survey measures for electronic nicotine and non-nicotine delivery system use: Current challenges and considerations for researchers.

The development and validation of survey measures for electronic nicotine and non-nicotine delivery system (ENDS) use has not kept pace with the burgeoning research on them. This, along with the diverse and evolving nature of ENDS, presents several unique measurement challenges and hampers surveillance and tobacco regulatory research efforts. In this commentary, we identify four important areas related to ENDS use (describing ENDS products; defining current use; evaluating frequency and quantity of use; and characterizing devices and e-liquids) and summarize a selective review of the measurement and definitions of these constructs across prominent national tobacco use surveys and 30 projects within the 14 federally-funded Tobacco Centers of Regulatory Science. Across these national, regional, and local studies, there was considerable variability and relatively little consensus in ENDS use measures - thus highlighting the need for caution when comparing findings across studies or over time until more research is available to evaluate the sensitivity of findings to differing measures. Drawing from the nascent ENDS use measurement research literature and our experiences, we conclude with general considerations for measuring ENDS use for tobacco researchers as an initial step towards the development of consensus measures.

Trends in and Characteristics of Marijuana and Menthol Cigarette Use Among Current Cigarette Smokers, 2005-2014.

Background: Given increasing co-marijuana and tobacco use in the United States, this study aimed to explore the overlap between menthol cigarette use (MCU) and marijuana. Methods: Data came from past month US cigarette smokers 12 years and older responding to the National Survey on Drug Use and Health between 2005 and 2014 (N = 51 500). Prevalence, demographics and substance use characteristics from 2013 to 2014 were assessed across four groups, based on past month marijuana and tobacco use: cigarette smokers with marijuana and MCU, with marijuana but no MCU, with no marijuana but MCU, and with use of neither. Multivariable logistic regression explored the relationship between MCU, marijuana, and dependence. Linear and quadratic trends were assessed using logistic regression with orthogonal polynomials. Results: Past month marijuana/MCU among cigarette smokers was 8.3% in 2013-2014. Overall, marijuana/MCU was significantly higher among blacks versus whites (20.8% vs. 5.8%, p < .0001), though among 12-25 year olds, prevalence was significantly higher among whites versus blacks (6.3% vs. 0.9% for 12-17-year-olds; 39.2% vs. 26.8% for 18-25-year-olds). Marijuana/MCU increased significantly between 2005 and 2014 overall, and among whites and blacks. No adjusted associations were found between marijuana, MCU and nicotine or marijuana dependence. Conclusions: Past month marijuana/MCU among cigarette smokers is increasing in the United States, with specific racial and age-based disparities. Research about the implications of consuming both marijuana and menthol, and the potential overlap in consumption of flavors across the products is warranted to better inform future preventive and treatment approaches. Implications: This is the first study to assess the overlap between MCU and marijuana use among a nationally representative sample of US current smokers ages 12 and older. Findings from this study suggest that past month marijuana and menthol use among cigarette smokers is increasing in the United States, with specific racial/ethnic and age-based disparities. More research about the implications of consuming both marijuana and menthol, and the potential overlap in consumption of flavors in marijuana and tobacco products is warranted to better understand what preventive and treatment approaches may be needed.

E-Cigarettes Use Behavior and Experience of Adults: Qualitative Research Findings to Inform E-Cigarette Use Measure Development.

OBJECTIVES: To gain a better understanding of electronic cigarette (e-cigarette) use behavior and experience among adult e-cigarette users, with the goal of informing development of future e-cigarette use measures. METHODS: Between August and October 2014 six focus groups were conducted in Seattle. Participants (63% male; 60% >35 years old; 60% White): e-cigarette users who used combustible tobacco products either currently or in the past. E-cigarette discussion topics covered: their daily use pattern (eg, frequency), product-related characteristics (eg, nicotine levels), and perceptions about health risks and benefits. RESULTS: Participants' descriptions of daily use were so varied that no common "unit" of a "session" easily summarized frequency or quantity of typical e-cigarette use. Most users had difficulty in tracking their own use. Participants reported nicotine craving relief when using e-cigarettes, but described e-cigarettes use as less satisfying than combustible cigarettes. Valued characteristics included "ready availability" and the possibility of using indoors. A unique aspect of the e-cigarette use experience is the option of adding flavors and having the ability to exhale "big clouds" of vapor/aerosol. Most perceived e-cigarettes as a better and safer alternative to conventional cigarettes, yet still sought further information about health consequences and safety of e-cigarettes from trusted sources. CONCLUSIONS: E-cigarettes users are far from homogeneous in their behavior and motivation for adopting e-cigarettes. A range of use patterns arising from both hedonic and utilitarian factors, along with product characteristics (eg, variable nicotine levels and flavors) extending beyond those of conventional cigarettes, suggest that new, specific e-cigarette use measures must be developed. IMPLICATIONS: The current study provides timely information on adult e-cigarette use behavior, which is a crucial step in measuring this new phenomenon and assessing the risks associated with using e-cigarette products. Our findings reveal that vaping is not a mere replacement for combustible cigarette smoking and that many users of e-cigarettes enjoy product characteristics such as flavors and "clouds" that are unavailable in combustible cigarettes. Therefore, commonly available cigarette smoking measures are not well suited to measurement of e-cigarette use behavior, and indication that new measures need to be developed to accurately track e-cigarette use.

Role of sweet and other flavours in liking and disliking of electronic cigarettes.

OBJECTIVE: To examine the extent to which the perception of sweet and other flavours is associated with liking and disliking of flavoured electronic cigarettes (e-cigarettes). METHODS: 31 participants (13 females/18 males; 12 sole/19 dual users) vaped 6 commercially available flavours of blu Tanks: Classic Tobacco (CT), Magnificent Menthol (MM), Cherry Crush (CC), Vivid Vanilla (VV), Piña Colada (PC) and Peach Schnapps (PS); all 'medium' strength, 12 mg/mL nicotine concentration. For each flavoured e-cigarette, participants first rated liking/disliking on the Labeled Hedonic Scale, followed by perceived intensities of sweetness, coolness, bitterness, harshness and specific flavour on the generalised version of the Labeled Magnitude Scale. The psychophysical testing was conducted individually in an environmental chamber. RESULTS: PC was perceived as sweetest and liked the most; CT was perceived as least sweet and liked the least. Across all flavours, liking was correlated with sweetness (r=0.31), coolness (r=0.25), bitterness (r=-0.25) and harshness (r=-0.29, all p<0.001). Specifically, liking was positively correlated with sweetness of PS (r=0.56, p=0.001) and PC (r=0.36, p=0.048); and with coolness of MM, CT and VV (r=0.41-0.52, p<0.05). In contrast, harshness was negatively correlated with liking for CC, PC and PS (r=0.37-0.40, p<0.05). In a multivariate model, sweetness had the greatest positive impact on liking followed by coolness; harshness had the greatest negative impact on liking. CONCLUSIONS: Our findings indicate that bitterness and harshness, most likely from nicotine, have negative impacts on the liking of e-cigarettes, but the addition of flavourants that elicit sweetness or coolness generally improves liking. The results suggest that flavours play an important role in e-cigarette preference and most likely use.

Using Electrophysiological Measures to Assess the Consumer Acceptability of Smokeless Tobacco Products.

INTRODUCTION: Adequate evaluation of novel tobacco products must include investigation of consumers' psychological response to such products. Traditionally, subjective scales of product liking have been used to assess consumer acceptability of tobacco products. However, subjective scales may miss cognitive changes that can only be captured by direct neurophysiological assessment. The present investigation explored the viability of using electroencephalography (EEG), in combination with traditional subjective measures, to assess consumer acceptability of five smokeless tobacco products. Given previous work linking product liking to arousal/attentional (executive function) enhancement, we focused on EEG measures of attention/arousal to objectively characterize cognitive changes associated with tobacco product use. METHODS: During five separate laboratory visits, smokeless tobacco users used Verve discs, Ariva dissolvables, Skoal snuff, Camel snus, or Nicorette lozenges. The N2 and P3b event-related potential components elicited by an oddball task were used to index attentional changes before/after product usage. Additionally, resting state alpha band EEG activity was analyzed before/after product usage to index cortical arousal. RESULTS: Although analyses of the subjective results provided limited inference, analyses of the electrophysiological measures, particularly the alpha suppression measure, revealed robust differences between products. Skoal elicited significantly enhanced alpha suppression compared to all four other products tested. Additionally, alpha suppression was found to correlate positively with subjective measures of satisfaction and psychological reward, but was unrelated to perceived aversion. CONCLUSIONS: The present results provide evidence that electrophysiological measures can yield important insights into consumer acceptability of novel tobacco products and are a valuable complement to subjective measures. IMPLICATIONS: This study is the first to employ a combination of electrophysiological measures and traditional subjective assays in order to assess the consumer acceptability of smokeless tobacco products. The results highlight the importance of adopting a multidimensional/multi-method approach to studying the consumer acceptability of tobacco products.

Design and Validation of a Research-Grade Waterpipe Equipped With Puff Topography Analyzer.

INTRODUCTION: Worldwide, commercially available waterpipes vary widely in design and durability, including differences in fabrication materials, degree of leak-tight fit, and flow path diameter. Little is known about how the components of the waterpipe may influence puffing behavior and user's exposure to toxins. To systematically evaluate exposure, it is necessary to use a standardized research-grade waterpipe (RWP) when conducting clinical and laboratory-based trials. METHODS: We developed a RWP that is configured with an in-line topography system which allows real-time measurement and recording of the smoke volume drawn through the RWP. The RWP was calibrated across the flow rate range expected for waterpipe tobacco smoking and the calibration was verified for known puff volumes using a smoking machine. Operation of the RWP was qualified in a cohort of experienced waterpipe smokers, each smoker using the RWP ad libitum in a laboratory setting while smoker topography and subjective effects data were collected. RESULTS: RWP machine smoking was highly reproducible and yielded puff volumes that agreed well with true values. User acceptance was comparable, and puffing behavior was similar in pattern, with more frequent puffing in the beginning of the session, but significantly different in intensity from that used to estimate the majority of toxicant exposure reported in the literature. CONCLUSIONS: The RWP operates with known precision and accuracy and is well accepted by experienced smokers. This tool can be used to determine the extent to which puffing behaviors are affected by the waterpipe design, components, and/or accessories, tobacco nicotine content, sweet flavorings and/or additives known to increase addictiveness. IMPLICATIONS: This study describes a standardized RWP, equipped with a puffing topography analyzer, which can operate with known precision and accuracy, and is well-accepted by experienced smokers in terms of satisfaction and reward. The RWP is an important tool for determining if puffing behaviors, and thus estimated toxin exposures, are affected by the waterpipe design, components, and/or accessories, tobacco nicotine content, sweet flavorings, and/or additives that are known to increase addictiveness.

Variability in Puff Topography and Exhaled CO in Waterpipe Tobacco Smoking.

OBJECTIVES: We examined intra-individual variability in puff topography and CO measures collected during laboratory waterpipe (WP) tobacco smoking using a research-grade waterpipe (RWP). METHODS: WP smoking topography and exhaled CO measures were obtained from 10 established WP smokers in a single-blind, crossover design. Using a previously validated RWP, each participant smoked "Two Apples" WP tobacco ad libitum with a single quick-light charcoal to satiation in 3 laboratory sessions spaced at least one week apart. To examine the intra-individual variability, the intraclass correlation coefficient (ρ) for topography and CO measures were estimated. Results: The majority of the topography and CO measures were stable. Most stable were puff frequency (ρ = 0.88), number of puffs (ρ = 0.86), and puff duration (ρ = 0.80). Less stable were peak flow (ρ = 0.57) and total puff volume (ρ = 0.52). CONCLUSIONS: The results provide the first set of empirical evidence that most topography and CO measurements collected using the RWP from a single laboratory smoking session are stable such that they can be representative of a smoker's puffing behaviors and reproducible among 3 sessions spread equally across 3 weeks.

Comparison of True and Smoothed Puff Profile Replication on Smoking Behavior and Mainstream Smoke Emissions.

To estimate exposures to smokers from cigarettes, smoking topography is typically measured and programmed into a smoking machine to mimic human smoking, and the resulting smoke emissions are tested for relative levels of harmful constituents. However, using only the summary puff data--with a fixed puff frequency, volume, and duration--may underestimate or overestimate actual exposure to smoke toxins. In this laboratory study, we used a topography-driven smoking machine that faithfully reproduces a human smoking session and individual human topography data (n = 24) collected during previous clinical research to investigate if replicating the true puff profile (TP) versus the mathematically derived smoothed puff profile (SM) resulted in differences in particle size distributions and selected toxic/carcinogenic organic compounds from mainstream smoke emissions. Particle size distributions were measured using an electrical low pressure impactor, the masses of the size-fractionated fine and ultrafine particles were determined gravimetrically, and the collected particulate was analyzed for selected particle-bound, semivolatile compounds. Volatile compounds were measured in real time using a proton transfer reaction-mass spectrometer. By and large, TP levels for the fine and ultrafine particulate masses as well as particle-bound organic compounds were slightly lower than the SM concentrations. The volatile compounds, by contrast, showed no clear trend. Differences in emissions due to the use of the TP and SM profiles are generally not large enough to warrant abandoning the procedures used to generate the simpler smoothed profile in favor of the true profile.

Custom Mentholation of Commercial Cigarettes for Research Purposes.

In the U.S. menthol remains the sole permitted characterizing cigarette flavor additive in part because efforts to link menthol cigarette use to increased tobacco-related disease risk have been inconclusive. To perform definitive studies, cigarettes that differ only in menthol content are required, yet these are not commercially available. We prepared research cigarettes differing only in menthol content by deposition of L-menthol vapor directly onto commercial nonmenthol cigarettes, and developed a method to measure a cigarette's menthol and nicotine content. With our custom-mentholation technique we achieved the desired moderately high menthol content (as compared to commercial brands) of 6.7 ± 1.0 mg/g (n = 25) without perturbing the cigarettes' nicotine content (17.7 ± 0.7 mg/g [n = 25]). We also characterized other pertinent attributes of our custom-mentholated cigarettes, including percent transmission of menthol and nicotine to mainstream smoke and the rate of loss of menthol over time during storage at room temperature. We are currently using this simple mentholation technique to investigate the differences in human exposure to selected chemicals in cigarette smoke due only to the presence of the added menthol. Our cigarettes will also aid in the elucidation of the effects of menthol on the toxicity of tobacco smoke.

The national "smoking cessation clinics" program in the republic of Korea: socioeconomic status and age matter.

BACKGROUND: Between 1998-2009 South Korea experienced significant progress in reducing the male smoking rate from 66.3% to 46.9%. As part of a significant government effort in the area of smoking cessation intervention, the Korean government implemented the national "Smoking Cessation Clinics (SCC) " program in 2004. MATERIALS AND METHODS: Data covered 804,334 adult male smokers participating in SCC program at 253 public health centers between 2006-2009. We examined participant cessation rates with the SCC program, their characteristics and program intervention components using health insurance status as a socioeconomic status (SES) indicator. Multivariate logistic regression analyses were performed correcting for intra-class correlations within public health centers. RESULTS: The overall 6-month quit rate was high (46.8%). Higher odds of smoking cessation were positively associated with higher levels of behavioral counseling sessions, but not nicotine replacement therapy (NRT). Cessation rates were lower for Medicaid participants than for regular health insurance participants. Disadvantaged younger smokers were less likely to participate in the program. Older smokers were more likely to quit regardless of SES. Stress was cited as major reason for failure. CONCLUSIONS: SES inequalities across different age groups exist in smoking cessation among Korean adult male smokers. There is a need for intervention programs specifically targeting sub-populations of SES by different age groups.