Predictors of perceived success in quitting smoking by vaping: A machine learning approach.

Prior research has suggested that a set of unique characteristics may be associated with adult cigarette smokers who are able to quit smoking using e-cigarettes (vaping). In this cross-sectional study, we aimed to identify and rank the importance of these characteristics using machine learning. During July and August 2019, an online survey was administered to a convenience sample of 889 adult smokers (age ≥ 20) in Ontario, Canada who tried vaping to quit smoking in the past 12 months. Fifty-one person-level characteristics, including a Vaping Experiences Score, were assessed in a gradient boosting machine model to classify the status of perceived success in vaping-assisted smoking cessation. This model was trained using cross-validation and tested using the receiver operating characteristic (ROC) curve. The top five most important predictors were identified using a score between 0% and 100% that represented the relative importance of each variable in model training. About 20% of participants (N = 174, 19.6%) reported success in vaping-assisted smoking cessation. The model achieved relatively high performance with an area under the ROC curve of 0.865 and classification accuracy of 0.831 (95% CI [confidence interval] 0.780 to 0.874). The top five most important predictors of perceived success in vaping-assisted smoking cessation were more positive experiences measured by the Vaping Experiences Score (100%), less previously failed quit attempts by vaping (39.0%), younger age (21.9%), having vaped 100 times (16.8%), and vaping shortly after waking up (15.8%). Our findings provide strong statistical evidence that shows better vaping experiences are associated with greater perceived success in smoking cessation by vaping. Furthermore, our study confirmed the strength of machine learning techniques in vaping-related outcomes research based on observational data.

Real-world vaping experiences and smoking cessation among cigarette smoking adults.

INTRODUCTION: E-cigarettes may have the potential to be an effective cessation aid for some cigarette smokers. However, the extent to which smokers' experiences using e-cigarettes (vaping) to quit smoking impact their cessation outcomes is unclear. In this cross-sectional survey study, we develop a multidimensional measure of vaping experiences in adults who quit smoking by vaping and test its association with perceived success in smoking cessation. METHODS: In 2019, recruitment invitations were emailed to adult past-year smokers who had accessed cessation services across Ontario, Canada. Respondents who tried vaping to quit smoking in the past year completed a detailed online survey. Factor analysis was performed on ratings of 45 vaping experiences items to identify dimensions of vaping experiences. Factor scores were entered into logistic regressions to test if vaping experiences dimensions had differential impact on perceived success in smoking cessation. RESULTS: Of the 889 participants, 56.0% were female, 81.1% were Caucasian, and the mean age was 37.7 ± 11.9 years. Twenty percent (19.6%) reported having successfully quit smoking by vaping in the past year. Among the six vaping experiences factors, better experiences in five factors-Relationships, Flexibility of Vaping, Side Effects, Vaping Devices, and Sensory Functions-were each independently and positively associated with improved odds of successful quitting. Notably, Relationships [OR = 2.01, 95% CI: 1.61-2.64] and Side Effects [OR = 1.95; 95% CI 1.54-2.29] were the strongest correlates of perceived success in smoking cessation. CONCLUSIONS: These findings indicate an opportunity to increase cessation rates by improving the experiences of smokers who vape to quit smoking.

Co-use and Mixing Tobacco With Cannabis Among Ontario Adults.

INTRODUCTION: The legalization of nonmedical cannabis in 2018 may have important implications for tobacco use in Canada. There is a risk of renormalizing tobacco use with co-use of tobacco and cannabis introducing nontobacco users to tobacco. Co-use is the use of both substances by the same individual at the same time or on different occasions, as well as mixed together. This study assessed the prevalence of co-use and mixing of tobacco and cannabis among Ontario adults and the characteristics of the users. AIMS AND METHODS: Data from the 1996 to 2017 cycles of the Centre for Addiction and Mental Health Monitor (n = 4481) were used to examine trends in prevalence and the proportion of Ontario adults co-using and mixing tobacco and cannabis. Logistic regression was used to study associations between user characteristics and co-use and mixing. RESULTS: Co-use of cigarettes and cannabis among cannabis users declined from 59.8% in 1996 to 41.7% in 2017. Past-year e-cigarette use was the only predictor of co-use. From 2015 to 2017, 31.1% (95% confidence interval 27.0, 35.9) of Ontario adults who used cannabis reported mixing it with tobacco in the past year. Being white, past-year e-cigarette use, having moderate or high nicotine dependence, and having moderate or high risk for cannabis problems were significant predictors of mixing among cannabis users. CONCLUSION: Given the well-established negative health effects associated with tobacco use, alongside a growing evidence base for negative health effects of cannabis smoking, co-use and mixing could pose a considerable public health concern in the context of legalization. IMPLICATIONS: Considerable effort has been expended to reduce tobacco smoking. However, current efforts to reduce tobacco smoking may be diminished since this study found the prevalence of mixing tobacco and cannabis among cannabis users in Ontario to be higher than expected. Mixing tobacco and cannabis may introduce nontobacco smokers to tobacco, exposing them to health risks associated with both cannabis and tobacco smoke. Therefore, there is a need to monitor changes in tobacco use and understanding implications for tobacco control and cessation programs within the changing environment of cannabis legalization in Canada and other jurisdictions.

Is vaping cessation like smoking cessation? A qualitative study exploring the responses of youth and young adults who vape e-cigarettes.

INTRODUCTION: Young people are now seeking help to quit vaping. However, little is known about vaping cessation. To bridge the gap between the current state of research and the urgent need for interventions, practitioners have drawn upon smoking cessation models under the assumption that vaping and smoking are fairly similar. In this study, we sought to understand the nature and extent to which vaping is similar to smoking in order to inform the development of vaping cessation interventions for young people. METHODS: Seven focus groups were conducted between November 2019 and February 2020 among youth (ages 16-18) and young adults (ages 19-29) living in the Greater Toronto Area who self-identified as e-cigarette vapers and expressed interest in vaping cessation (n = 41). Focus groups were audio recorded, transcribed verbatim, and analyzed using thematic analysis methods. RESULTS: Perceived similarities between vaping and smoking emerged from participant narratives: three themes relating to barriers to quitting (social benefits, stress reduction, sensory and behavioural gratification), and three relating to reasons for quitting (financial loss, industry influence, dependence). However, there were also perceived differences that emerged: three themes relating to barriers to quitting vaping (enjoyment of flavours, convenience and discreetness, lack of self-awareness of vaping behaviours), and two relating to reasons for quitting vaping (lack of trusted information, perceived social acceptability). CONCLUSIONS: Although there is significant overlap between vaping and smoking, understanding perceived differences in barriers to quitting and reasons for quitting is critical to advancing vaping cessation research and practice among young people.

Perceived addiction to vaping among youth and young adult regular vapers.

BACKGROUND: The prevalence of e-cigarette use among youth and young adults has increased markedly in recent years; however, little is known about young people's perceptions of e-cigarette addiction. This study examines factors associated with self-reported addiction to e-cigarette use among this population. METHODS: In 2018, 1048 Canadians aged 16-25 years were recruited through online social media platforms to complete a survey. Quota sampling was used to oversample regular e-cigarette users (vaping at least weekly); these 578 regular users were included in this analysis. Self-perceived addiction was assessed by asking participants if they felt they were 'very', 'somewhat' or 'not at all' addicted to e-cigarettes. A proportional odds model was employed to identify factors associated with the ordinal outcome. RESULTS: Almost half of regular users perceived themselves to be 'not at all addicted', 41% felt they were 'somewhat addicted' and 13% felt they were very addicted to e-cigarettes. Women, former cigarette smokers, daily vapers and those vaping for more than a year were more likely to report higher levels of perceived addiction. Similarly, high sensation-seeking youth, those reading blogs and websites about vaping, those frequently dripping and those using higher nicotine strengths had a greater likelihood of higher perceived addiction than their respective counterparts. CONCLUSION: More than half of youth and young adult regular e-cigarette users felt they had some level of addiction. The findings identify possible opportunities for targeted programming for education and treatment, as well as potential opportunities for policy change such as maximum allowable nicotine strengths.

Predictors of E-Cigarette Initiation: Findings From the Youth and Young Adult Panel Study.

OBJECTIVES: Although previous studies have identified reasons why youth try e-cigarettes, longitudinal research is needed to identify predictors of e-cigarette initiation. This study assesses predictors of e-cigarette initiation among youth and young adults in the 2018-2019 Youth and Young Adult Panel Study. METHODS: This study examined the proportion of Canadian participants aged 16 to 25 (n = 137) reporting never use of e-cigarettes at baseline in 2018. Individuals were categorized as not initiated and initiated at 12-month follow-up. We examined demographic characteristics, substance use, health status, social influences and perception by initiation category. Adjusted odds ratios (AORs) were calculated using logistic regression models and multivariable logistic regression model. RESULTS: Among the 137 never e-cigarette users at baseline, 59% remained never users while 41% initiated use of e-cigarettes during the 12-month follow-up. The results of multivariable logistic regression analysis showed that regularly seeing anyone use e-cigarettes (AOR: 4.11; 95% CI: 1.04, 16.31) and seeing anyone use e-cigarettes very often or always at baseline (AOR: 4.54; 95% CI: 1.21, 17.01) is associated with initiating e-cigarette use among youth and young adults. CONCLUSION: The results revealed social influences to be the most important predictors of initiation among youth and young adults. Interventions to prevent youth and young adults from initiating e-cigarette use should expand from only focusing on peer use to reducing use in public space such as parks and recreational facilities.

Is blue the new green? Repackaging menthol cigarettes in response to a flavour ban in Ontario, Canada.

BACKGROUND: As of 1 January 2017, the Canadian province of Ontario banned the distribution and sale of menthol tobacco products. There is limited knowledge about how tobacco companies will adapt their packaging in response to a menthol ban. METHODS: We conducted a content analysis of preban traditional menthol (no capsule) and menthol capsule cigarette packs and their postban replacements. Preban and postban packs were matched using tobacco company descriptions of replacement brands in business-to-business marketing materials, advertising on cigarette pack cellophane and a tobacco company website. RESULTS: A total of 63 menthol (n=30) and 'non-menthol alternative' (n=33) cigarette packs were included in the analysis. Approximately half of the preban packs were menthol capsule cigarettes and half traditional menthol cigarettes. While some postban brands continued to convey menthol-like qualities via the colour and/or brand descriptor 'green', 'blue' was the most common colour and brand descriptor postban. Packs shifted from using 'menthol' and/or 'fresh' as taste descriptor preban to using 'smooth' postban; some postban packs had 'non-menthol alternative' or 'without menthol/capsules' written on their cellophane. The presence of innovative filter technologies continued in the postban samples. CONCLUSION: Results suggest that tobacco companies attempted to maintain menthol smokers in Ontario by aggressive preban promotion of menthol capsule cigarettes, continued promotion of innovative filter technologies and by directing smokers to non-menthol alternatives whose packaging both in text and in colour connoted menthol-like qualities (eg, green) and reduced harshness or harm (eg, blue, white, silver, smooth taste).

Marketing IQOS in a dark market.

INTRODUCTION: Phillip Morris International (PMI) is pushing hard to promote IQOS heat-not-burn cigarettes in Ontario, Canada. Canada regulates IQOS as a tobacco product so that the robust tobacco marketing ban creates challenges to its promotion. METHODS: We collected data on IQOS promotion in 49 retail outlets, and through interviews with clerks and observations outside an IQOS store. RESULTS: The dominant marketing channel is the visible availability of IQOS in a large number of tobacco retail outlets-1029 across Ontario. Several stores display the price of 'heated tobacco' on one of three price signs which are permitted despite Ontario's total display ban. IQOS boutique stores are the locus of aggressive promotion including exchanging a pack of cigarettes or lighter for an IQOS device, launch parties, 'meet and greet' lunches and after-hour events. Outside the store, promotion includes a prominent IQOS sign, a sandwich board sign reading 'Building a Smoke-Free Future' and sales representatives regularly smoking IQOS. Membership services: Upon acquiring an IQOS device one can register to access the IQOS website store5 and receive customer support services, a map of retail locations and a product catalogue. Members receive regular email invitations to complete surveys with opportunities to win prizes. CONCLUSIONS: These promotion activities have undoubtedly made substantial numbers of Ontarians aware of IQOS. Yet, the government has not provided guidance as to absolute and relative potential harms. Our observations of tactics to promote a new tobacco product in a dark market may inform government regulatory policy and non-governmental organisation efforts wherever heat-not-burn products are introduced.

Waterpipe use among high school students in Ontario: Demographic and substance use correlates.

OBJECTIVE: To examine waterpipe use and its association with demographic factors, tobacco cigarette smoking, ever use of electronic cigarettes (e-cigarettes) and alcohol use among high school students. METHODS: Data were derived from the 2013 Ontario Student Drug Use and Health Survey, a school-based survey of 7th to 12th grade students. This province-wide survey was based on a stratified two-stage cluster design. Analyses were based on a subsample of 2,873 high school students and included adjustments for the complex sample design. RESULTS: Overall, 12.5% of high school students (grades 9-12) had used a waterpipe in the previous year. Awareness of waterpipes was high - 68.4% of students reported that they were aware of waterpipes but had not used one in the past year; 19.1% had never heard of waterpipes or hookah. The percentage of high school students reporting waterpipe use in the past year was similar to reports of tobacco cigarette use (12.5% and 11% respectively). Waterpipe use was highly associated with past-year tobacco cigarette and regular alcohol use as well as ever use of e-cigarettes. In multivariate analyses, males and females had similar odds of waterpipe use, and non-White students and those in higher grades had greater odds of use after controlling for other substance use. CONCLUSION: These findings suggest that waterpipe use among high school students should be of some concern and suggest the need for policy measures to address potential risks associated with use.

The effect of MPOWER on smoking prevalence.

OBJECTIVE: To examine the effect of varying levels of comprehensive tobacco control on smoking in a global context. METHODS: Using data from WHO's Reports on the Global Tobacco Epidemic, scatter plots were produced to visualise the relationship between comprehensive tobacco control policy (2008 MPOWER composite score) and change in current tobacco smoking between 2006 and 2009. Fixed-effect regression models assessed the effect of changes in each MPOWER measure on changes in current tobacco smoking between 2006 and 2009. All analyses were stratified by sex. RESULTS: Overall, countries with higher MPOWER composite scores experienced greater decreases in current tobacco smoking between the years 2006 and 2009. Regression analyses revealed that the M and R measures showed a negative association with current tobacco smoking over time. Current tobacco smoking decreased (1.07 percentage points for males, 1.04 percentage points for females) with each increase in score value for monitoring tobacco use (M). Also, current tobacco smoking decreased (0.95 percentage points for males, 0.41 percentage points for females) with each increase in score value for raising taxes on tobacco (R). The effect of the MPOWER measures on current tobacco smoking varied by country income status (P measure in the female analysis; p<0.05) and/or by WHO region (M, P and O measures in the male analysis; p<0.05). CONCLUSIONS: Higher levels of MPOWER combined, as well as continued and frequent monitoring of tobacco use (M) and increasing taxation (R), were associated with a decrease in current tobacco smoking over time.

Ever Use of Nicotine and Nonnicotine Electronic Cigarettes Among High School Students in Ontario, Canada.

INTRODUCTION: There are limited data on the use of electronic cigarettes (e-cigarettes) among youth, particularly with regard to the use of nicotine versus nonnicotine products. This study investigates ever use of nicotine and nonnicotine e-cigarettes and examines the demographic and behavioral correlates of e-cigarette use in Ontario, Canada. METHODS: Data for 2,892 high school students were derived from the 2013 Ontario Student Drug Use and Health Survey. This province-wide school-based survey is based on a 2-stage cluster design. Bivariate and multivariate analyses were used to investigate the factors associated with ever use of e-cigarettes. Ever use of e-cigarettes was derived from the question, "Have you ever smoked at least one puff from an electronic cigarette?" All analyses included appropriate adjustments for the complex study design. RESULTS: Fifteen percent of high school students reported using e-cigarettes in their lifetime. Most students who ever used e-cigarettes reported using e-cigarettes without nicotine (72%), but 28% had used e-cigarettes with nicotine. Male, White/Caucasian, and rural students, as well as those with a history of using tobacco cigarettes, were at greater odds of e-cigarette use. Seven percent of students who had never smoked a tobacco cigarette in their lifetime reported using an e-cigarette. Five percent of those who had ever used an e-cigarette had never smoked a tobacco cigarette. CONCLUSION: More students reported ever using e-cigarettes without nicotine than with nicotine in Ontario, Canada. This underscores the need for greater knowledge of the contents of both nicotine and nonnicotine e-cigarettes to better guide public health policies.

Energetic and cell membrane metabolic products in patients with primary insomnia: a 31-phosphorus magnetic resonance spectroscopy study at 4 tesla.

STUDY OBJECTIVES: Primary insomnia (PI) is a sleep disorder characterized by difficulty with sleep initiation, maintenance, and/or the experience of nonrestorative sleep combined with a subsequent impairment of daytime functioning. The hyperarousal hypothesis has emerged as the leading candidate to explain insomnia symptoms in the absence of specific mental, physical, or substance-related causes. We hypothesized that the cellular energetic metabolites, including beta nucleoside triphosphate, which in magnetic resonance spectroscopy approximates adenosine triphosphate (ATP), and phosphocreatine (PCr), would show changes in PI reflecting increased energy demand. DESIGN AND SETTING: Matched-groups, cross-sectional study performed at two university-based hospitals. PATIENTS: Sixteen medication-free individuals (eight males, eight females; mean ± standard deviation (SD) age = 37.2 ± 8.4 y) with PI and 16 good sleepers (nine males, seven females; mean ± SD age = 37.6 ± 4.7 y). MEASUREMENTS: Diagnosis was established for all individuals by unstructured clinical interview, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID), sleep diary, and actigraphy. Polysomnography was collected in individuals with PI. Phosphorous magnetic resonance spectroscopy (31P MRS) data were collected on all individuals at 4 Tesla. We assessed cell membrane (anabolic precursors and catabolic metabolites) and bioenergetic (ATP, phosphocreatine) metabolites in gray matter and white matter to determine their relationship to the presence and severity of PI. RESULTS: Individuals with PI showed lower phosphocreatine in gray matter and an unexpected decrease of phosphocholine, a precursor of the cell membrane compound phosphatidylcholine, in white matter. In addition, there was a trend toward a negative association between polysomnographically determined wake after sleep onset and gray matter beta-nucleoside triphosphate and white matter phosphocholine in the primary insomnia group. CONCLUSIONS: These results support the hyperarousal hypothesis in PI based on lower phosphocreatine in gray matter in the PI group.

Changes in retail tobacco promotions in a cohort of stores before, during, and after a tobacco product display ban.

We used a longitudinal design to investigate the impact of a government policy banning the display of tobacco products at the point of sale. The extent of tobacco promotions in 481 randomly selected stores was documented at 4 points in time (2005-2009). Tobacco promotions were greatly reduced after implementation of the display ban. A ban on the display of tobacco products and other signage and promotions at retail is a critical tobacco-control policy to reduce people's exposure to tobacco marketing.

Tobacco promotions at point-of-sale: the last hurrah.

OBJECTIVES: The retail environment provides important opportunities for tobacco industry communication with current, former, and potential smokers. This study documented the extent of tobacco promotions at the retail point-of-sale and examined associations between the extent of tobacco promotions and relevant city and store characteristics. METHODS: In each of 20 Ontario cities, 24 establishments were randomly selected from lists of convenience stores, gas stations, and grocery stores. Trained observers captured the range, type and intensity of tobacco promotions from April to July 2005. The extent of tobacco promotions was described using weighted descriptive statistics. Weighted t-tests and ANOVAs, and hierarchical linear modeling, were used to examine the relationships between tobacco promotions and city and store characteristics. RESULTS: Extensive tobacco promotions were found in Ontario stores one year prior to the implementation of a partial ban on retail displays, particularly in chain convenience stores, gas station convenience stores and independent convenience stores. The multivariate hierarchical linear model confirmed differences in the extent of tobacco promotions by store type (p < 0.01); in addition, tobacco promotions were found to be higher among stores close to a school (p = 0.01) and in neighbourhoods with lower median household incomes (p < 0.01). Independent convenience stores with a greater number of employees had more tobacco promotions; however, the relationship was reversed for grocery stores. DISCUSSION: Tobacco promotions were extensive at the point-of-sale. Public health messages about the harms of tobacco use may be compromised by the pervasiveness of these promotions.

A call for action to support best practices in evaluation of comprehensive tobacco control evaluation strategies.

The National Tobacco Control Best Practices Working Group convened a two-day workshop to support best practices in evaluation of comprehensive tobacco control strategies. A Better Practices Model, aimed at developing a self-correcting system for best practices, guided the workshop content and process. Organizers intended to identify a common surveillance and monitoring framework for tobacco control strategies in Canada by first building strong working relationships between 44 decision-makers, practitioners and researchers from 12 Canadian jurisdictions. Participants identified needs and recommendations related to increased understanding and use of uniform evaluation strategies, building capacity, and recognition of the complexity of the task of evaluating comprehensive tobacco control strategies. The workshop highlighted the need for increased communication to facilitate understanding across the different sectors of participants. It also identified the potential benefits of harmonization in evaluation of tobacco control strategies across jurisdictions. Priority actions include forming a national team to agree on a model for evaluation, conducting an environmental scan for indicators, planning evaluation / monitoring and research agendas and determining roles for various stakeholders.