Associations between vaping and self-reported respiratory symptoms in young people in Canada, England and the US.

BACKGROUND: Prevalence of youth nicotine vaping has increased, heightening concerns around negative health effects. This study aimed to compare self-reported respiratory symptoms among youth by vaping behaviours. METHODS: Participants (n = 39,214) aged 16-19 from the 2020 and 2021 International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Surveys (Canada, England, US). Weighted multivariable logistic regression assessed associations between reporting any of five respiratory symptoms in the past week (shortness of breath, wheezing, chest pain, phlegm, cough) and: past 30-day smoking and/or vaping; lifetime/current vaping. Among past-30-day vapers (n = 4644), we assessed associations between symptoms and vaping frequency, use of nicotine salts, usual flavour and device type(s). RESULTS: Overall, 27.8% reported experiencing any of the five respiratory symptoms. Compared with youth who had only vaped, those who had only smoked had similar odds of symptoms [adjusted odds ratio, OR (95% confidence interval, CI): 0.97 (0.85-1.10)], those who both smoked and vaped had higher odds [1.26 (1.12-1.42)], and those who had done neither, lower odds [0.67 (0.61-0.72)]. Compared with those who had never vaped, past use, experimentation and current regular or occasional use were all associated with higher odds. Reporting usually using nicotine salts was associated with higher odds of symptoms [1.43 (1.22-1.68)] than non-salt but was often uncertain. Compared with tobacco flavour (including with menthol), menthol/mint and sweets flavours were associated with similar odds; fruit [1.44 (1.07-1.93)], multiple [1.76 (1.30-2.39)] and 'other' [2.14 (1.45-3.16)] flavours with higher odds. All device types were associated with similar odds. CONCLUSIONS: Among youth, vaping was associated with increased reporting of past-week respiratory symptoms. Among those who vaped, some flavour types and potentially nicotine salts were associated with respiratory symptoms.

Exposure to Tobacco-Specific Nitrosamines Among People Who Vape, Smoke, or do Neither: A Systematic Review and Meta-Analysis.

INTRODUCTION: Smoking exposes people to high levels of Tobacco-Specific Nitrosamines (TSNAs), which include potent carcinogens. We systematically reviewed TSNA exposure between people smoking, vaping, and doing neither. AIMS AND METHODS: Databases were searched between August 2017-March 2022, using vaping-related terms. Peer-reviewed articles reporting TSNA metabolites (NNAL, NNN, NAB, and NAT) levels in bio-samples among adults exclusively vaping, exclusively smoking, or doing neither were included. Where possible, meta-analyses were conducted. RESULTS: Of 12 781 identified studies, 22 were included. TSNA levels fell substantially when people who smoke switched to vaping in longitudinal studies and were lower among people who vaped compared to smoked in cross-sectional studies. Levels of TSNAs were similar when comparing people who switched from smoking to vaping, to those who switched to no use of nicotine products, in longitudinal studies. Levels were higher among people who vaped compared to people who neither vaped nor smoked in cross-sectional studies.When comparing people who vaped to smoked: pooled urinary NNAL was 79% lower across three randomized controlled trials and 96% lower across three cross-sectional studies; pooled NAB was 87% lower and NAT 94% lower in two cross-sectional studies. When comparing people who neither vaped nor smoked to people who vaped, pooled urinary NNAL was 80%, NAB 26%, and NAT 27% lower in two cross-sectional studies. Other longitudinal data, and NNN levels could not be pooled. CONCLUSIONS: Exposure to all TSNAs was lower among people who vaped compared to people who smoked. Levels were higher among people who vaped compared to people who neither vaped nor smoked. IMPLICATIONS: As well as TSNAs, there are many other toxicant exposures from smoking and vaping that can increase the risk of disease. However, it is likely that the reduced exposure to TSNAs from vaping relative to smoking reduces the risk to health of those who use vaping products to quit smoking. Future high-quality research, with robust definitions of exclusive vaping and smoking, and accounting for TSNAs half-lives, is needed to fully assess exposure to TSNAs among people who vape.

Associations between smoking and vaping prevalence, product use characteristics, and mental health diagnoses in Great Britain: a population survey.

BACKGROUND: Rates of diseases and death from tobacco smoking are substantially higher among those with a mental health condition (MHC). Vaping can help some people quit smoking, but little is known about vaping among people with MHCs or psychological distress. We assessed the prevalence and characteristics (heaviness, product type) of smoking and/or vaping among those with and without a history of single or multiple MHC diagnoses and with no, moderate or serious psychological distress. METHODS: Data from 27,437 adults in Great Britain surveyed between 2020 and 2022. Multinomial regressions analysed associations between smoking, vaping and dual use prevalence, smoking/vaping characteristics and (a) history of a single or multiple MHC and (b) moderate or serious psychological distress, adjusted for age, gender, and socioeconomic status. RESULTS: Compared with people who had never smoked, those who currently smoked were more likely to report a history of a single (12.5% vs 15.0%, AOR=1.62, 95% CI=1.46-1.81, p<.001) or multiple MHCs (12.8% vs 29.3%, AOR=2.51, 95% CI=2.28-2.75, p<.001). Compared with non-vapers, current vapers were more likely to report a history of a single (13.5% vs 15.5%, AOR=1.28, 95% CI=1.11-1.48, p<.001) or multiple MHCs (15.5% vs 33.4%, AOR=1.66, 95% CI=1.47-1.87, p<.001). Dual users were more likely to report a history of multiple MHCs (36.8%), but not a single MHC than exclusive smokers (27.2%) and exclusive vapers (30.4%) (all p<.05). Similar associations were reported for those with moderate or serious psychological distress. Smoking roll-your-own cigarettes and smoking more heavily, were associated with a history of single or multiple MHCs. There were no associations between vaping characteristics and a history of MHCs. Frequency of vaping, device type and nicotine concentration differed by psychological distress. CONCLUSIONS: Smoking, vaping and dual use were substantially higher among those with a history of MHC, especially multiple MHC, and experiencing past month distress than those not having a history of MHC or experiencing past month distress respectively. Analysis used descriptive epidemiology and causation cannot be determined.

How is nicotine vaping product (e-cigarette) use monitored in primary care electronic health records in the United Kingdom? An exploratory analysis of Clinical Practice Research Datalink (CPRD).

BACKGROUND: Electronic health records (EHRs) could identify long-term health effects of nicotine vaping. We characterised the extent to which vaping is recorded in primary care EHRs in the UK, on a population level. METHODS: We performed descriptive analysis of Clinical Practice Research Datalink (CPRD), primary care electronic health records of 25% of the UK population (~ 16 million patients). Patients aged ≥ 18 years whose vaping status was recorded using medical codes between 2006 and 2022 were identified. We reported the frequency of vaping codes; their distribution by patient age, gender, and ethnicity; trends in vaping recording over time (including interrupted time series analyses); and transitions in patient smoking status. RESULTS: Seven medical codes indicated current or former vaping, from 150,114 patients. When their vaping status was first recorded, mean patient age was 50.2 years (standard deviation: 15.0), 52.4% were female, and 82.1% were White. Of those recorded as currently vaping, almost all (98.9%) had records of their prior smoking status: 55.0% had been smoking, 38.3% had stopped smoking, 5.6% had never smoked. Of those who were smoking prior to being recorded as vaping, more than a year after the vaping record, over a third (34.2%) were still smoking, under a quarter (23.7%) quit smoking, 1.7% received a 'never smoked' status, and there was no smoking status for 40.4%. The 'e-cigarette or vaping product use-associated lung injury' (EVALI) outbreak was significantly associated with a declining trend in new records of current vaping between September 2019 and March 2020; and an immediate significant increase in new records of former vaping, followed by a declining trend. CONCLUSIONS: Few patients are being asked about vaping. Most who vape had smoked, and many quit smoking after starting vaping. To enable electronic health records to provide stronger evidence on health effects, we recommend improved completeness, accuracy and consistency.

Medium- and longer-term cardiovascular effects of e-cigarettes in adults making a stop-smoking attempt: a randomized controlled trial.

BACKGROUND: Smoking is a major risk factor for cardiovascular disease and smoking cessation reduces excess risk. E-cigarettes are popular for smoking cessation but there is little evidence on their cardiovascular health effect. Our objective was to compare the medium- and longer-term cardiovascular effects in smokers attempting to quit smoking using e-cigarettes with or without nicotine or prescription nicotine replacement therapy (NRT). METHODS: This was a single-center, pragmatic three-arm randomized (1:1:1) controlled trial, which recruited adult smokers (≥ 10 cigarettes/day), who were willing to attempt to stop smoking with support (n = 248). Participants were randomized to receive behavioral support with either (a) e-cigarettes with 18 mg/ml nicotine, (b) e-cigarettes without nicotine, and (c) NRT. Flow-mediated dilation (%FMD) and peak cutaneous vascular conductance (CVCmax) responses to acetylcholine (ACh) and sodium nitroprusside (SNP), mean arterial pressure (MAP), and other outcomes were recorded at baseline, 3, and 6 months after stopping smoking. Data were analyzed using generalized estimating equations (GEE). RESULTS: At 3- and 6-month follow-up, %FMD showed an improvement over baseline in all three groups (e.g., p < 0.0001 at 6 months). Similarly, ACh, SNP, and MAP improved significantly over baseline in all groups both at 3 and 6 months (e.g., ACh: p = 0.004, at 6 months). CONCLUSIONS: Smokers attempting to quit experienced positive cardiovascular impact after both a 3- and 6-month period. None of the groups (i.e., nicotine-containing and nicotine-free e-cigarettes or NRT) offered superior cardiovascular benefits to the others. TRIAL REGISTRATION: ClinicalTrials.gov NCT03061253 . Registered on 17 February 2017.

The Use of Tobacco Industry Vaping Products in the UK and Product Characteristics: A Cross-Sectional Survey.

BACKGROUND: Tobacco industry (TI) companies have entered the UK e-cigarette ("vaping") market in recent years. However, their motives and ambitions are unclear. This study explored how popular TI vaping products are and who uses them, and how they differ from independent products. METHODS: Secondary analysis of data from a longitudinal web-based survey of smokers, ex-smokers, and vapers (n = 3883) in the UK in 2019. The main study sample consisted of daily and nondaily vapers, who were current or ex-cigarette smokers, and had stated the brand of their preferred e-cigarette device (n = 1202). Proportions using TI and independent brands were calculated and regression analysis assessed associations with sociodemographic and smoking/vaping characteristics between vapers of TI and independent products. Chi-square tests were used to analyze differences between TI and independent products. RESULTS: Overall, 53.4% used TI products. A university education (67.6%; adjOR = 1.54; 95% CI, 1.140-2.088), nondaily vaping (68.2%; adjOR = 1.39; CI, 1.029-1.880), and cigarette dependence (moderate, strong and very strong urges to smoke) were associated with using TI vaping brands. TI products used were less likely to be refillable ("open") than independent brands (60.9% vs. 18.3%, chi-square = 228.98, p < .001), more likely to use nicotine salts (16.7% vs. 8.6%, chi-square = 25.04, p < .001) and tobacco flavors (23.8% vs. 17.9%, chi-square = 12.65, p < .001). CONCLUSION: TI vaping products were popular in the UK, associations with product and user characteristics suggest that TI products may be less conducive to smoking cessation, although the findings were not always consistent. IMPLICATIONS: Consequences of regulations need to be carefully considered to ensure that independent producers are not more negatively impacted than tobacco industry producers, and to avoid reducing utility of products for smoking cessation.

The Effect of Tobacco Control Mass Media Campaigns on Smoking-Related Behavior Among People With Mental Illness: A Systematic Literature Review.

INTRODUCTION: Tobacco control mass media campaigns (MMCs) can be effective generally, but little is known about their effects among people with mental illness. The objectives of this study were to systematically review: (1) Whether tobacco control MMCs affect smoking-related outcomes among people with mental illness. (2) Cost-effectiveness. AIMS AND METHODS: Data sources: MEDLINE, Embase, PsycInfo, Web of Science, CINAHL, the Cochrane Library (searched March 2021), reference lists of included articles and relevant systematic reviews. Study eligibility criteria: Population: Adults with mental illness and experience of smoking tobacco and/or using other nicotine-containing products. Intervention/exposure: Tobacco control MMC messages. Comparator: No exposure, other tobacco control intervention(s), no comparator. Primary outcome: Changes in quitting behaviors. Study design: All primary research. Quantitative data were appraised using the EPHPP tool, qualitative data using CASP's Studies Checklist. Data were synthesized narratively. RESULTS: Eight studies were included, seven were at high risk of bias. There was inconclusive evidence of the effect of MMCs on quit attempts and intentions to quit among people with mental illness. Increasing advertisement exposure did not increase quit attempts or intentions to quit among those with mental illness, however, increased exposure to an advertisement that addressed smoking and mental health did. None of the studies assessed cost-effectiveness. CONCLUSIONS: Findings should be interpreted with caution as data are limited and of low or moderate quality. There is evidence to suggest that tobacco control MMCs have limited impact on those with mental illness, although campaigns that are specific to smoking and mental health may be effective. IMPLICATIONS: There is a paucity of good-quality evidence of the effect of tobacco control MMC messages among people with mental illness. Careful consideration should be given to the design of future studies that evaluate MMCs in order to minimize the risk of bias, establish causality, and ensure the findings reflect real-world implementation. Further research should examine the need for MMC messages that address mental health.

Mental Health Symptoms and Associations with Tobacco Smoking, Dependence, Motivation, and Attempts to Quit: Findings from a Population Survey in Germany (DEBRA Study).

INTRODUCTION: This study aimed to estimate prevalence rates of mental health symptoms (anxiety, depression, and overall psychological distress) by tobacco smoking status, and associations between such symptoms and the level of dependence, motivation, and attempts to quit smoking in the German population. METHODS: Cross-sectional analysis of data from six waves of a nationally representative household survey collected in 2018/19 (N = 11,937 respondents aged ≥18). Mental health symptoms were assessed with the Patient Health Questionnaire-4. Associations with smoking status, dependence, motivation to quit, and ≥1 past-year quit attempt (yes/no) were analysed with adjusted regression models among the total group, and among subgroups of current (n = 3,248) and past-year smokers (quit ≤12 months ago, n = 3,357). RESULTS: Weighted prevalence rates of mental health symptoms among current, former, and never smokers were: 4.1%, 2.4%, 2.5% (anxiety), 5.4%, 4.7%, 4.0% (depression), and 3.1%, 2.5%, 2.4% (psychological distress). Current versus never smokers were more likely to report symptoms of anxiety and depression. Smokers with higher versus lower levels of dependence were more likely to report higher levels of all three mental health symptoms. Higher versus lower levels of overall psychological distress were associated with a higher motivation to quit smoking and, among past-year smokers, with higher odds of reporting a past-year quit attempt. CONCLUSIONS: We found various relevant associations between mental health symptoms and smoking behaviour. Healthcare professionals need to be informed about these associations and trained to effectively support this vulnerable group in translating their motivation into abstinence.

Vaping in Pregnancy: A Systematic Review.

INTRODUCTION: Smoking in pregnancy increases the risk of negative health outcomes. Vaping can be effective for smoking cessation in nonpregnant populations. We conducted a systematic review of vaping in pregnancy, covering prevalence, patterns of use, reasons for use, smoking cessation, and health effects. METHODS: Five academic databases were searched on 17 February 2020. Studies reporting prevalence, patterns, reasons, cessation, or health effects of vaping in pregnancy were included; animal and in vitro studies were excluded. A narrative review was used, with risk of bias assessed using Hoy and colleague's tool, the Newcastle-Ottawa scale, and the Consolidated Criteria for reporting Qualitative Research. RESULTS: Twenty-three studies were identified: 11 survey, 7 qualitative, 3 cohort, and 2 secondary analyses of randomized clinical trials. Prevalence of vaping in pregnancy (four studies) was between 1.2% and 7.0% overall, and <1% among nonsmokers. Twelve studies reported patterns of use, but findings were inconsistent. Twelve of 14 studies asking why pregnant women vaped reported that most vaped to reduce or quit smoking. Mixed findings were reported from six studies on smoking cessation. Of three studies with health-related outcomes, two were underpowered and one reported similar birthweights for babies born to nonsmokers and women who vaped, with both higher (p < .0001) than the birthweight of babies born to smokers. CONCLUSIONS: There were insufficient data to draw conclusions about prevalence, patterns, and effects of vaping in pregnancy on smoking cessation. The limited literature suggests that vaping in pregnancy has little or no effect on birthweight. IMPLICATIONS: Smoking causes many negative health outcomes for pregnant women and to babies born to people who smoke. There remains a paucity of research on the effects of vaping in pregnancy. There is, however, the potential for vaping products to reduce the negative health outcomes associated with smoking. More research is needed to develop an evidence base in this area.

Mental health and smoking cessation-a population survey in England.

BACKGROUND: To reduce inequalities between individuals with and without mental health problems, a better understanding is required of triggers and success of quit attempts among the third of smokers with mental health problems. The aim was to assess whether there are differences by mental health status in (i) triggers for quit attempts, (ii) use of evidence-based support (iii) and quit success. METHODS: Monthly cross-sectional household surveys of representative samples of the adult population in England. In 2016/2017, 40,831 adults were surveyed; 1956 who had attempted to stop smoking cigarettes in the past year were included. Logistic regressions assessed associations between mental health (ever diagnosis, past-year treatment, past-month distress), triggers, support used and quit success, adjusting for sociodemographic and smoking characteristics. RESULTS: Concern about future health, current health problems and expense of smoking were the most common triggers overall. For respondents with an ever diagnosis, past-year treatment or serious past-month distress, quit attempts were more frequently triggered by current health problems. Non-evidence-based support and e-cigarettes were used most often, and this did not differ by mental health status. Respondents with an ever diagnosis and moderate or serious distress were less likely to have used non-prescription nicotine replacement therapy (NRT). Respondents with past-year treatment or serious distress were more likely to have used prescription medication/behavioural support. Quit success did not differ by mental health status. Compared with non-evidence-based support, non-prescription NRT conferred no benefit. There was some evidence that prescription medication/behavioural support was beneficial (depending on outcome and adjustment, ORs ranged from 1.46, 95% CI 0.92-2.31, to 1.69, 1.01-2.86). E-cigarettes were associated with higher success rates after adjustment for different indicators of mental health (ORs ranged from 2.21, 1.64-2.98, to 2.25, 1.59-3.18). CONCLUSIONS: Smokers with mental health problems were more likely to have attempted to quit because of health problems and were more likely to have used gold standard support (medication and behavioural support) than other smokers. E-cigarettes were strongly associated with increased success and were used similarly by those with and without mental health problems, indicating that improved uptake of e-cigarettes for smoking cessation among smokers with mental health problems could help address inequalities.

Awareness of Changes in E-cigarette Regulations and Behavior Before and After Implementation: A Longitudinal Survey of Smokers, Ex-smokers, and Vapers in the United Kingdom.

INTRODUCTION: In line with the European Union's Tobacco Products Directive (TPD), new regulations for electronic cigarettes implemented in the United Kingdom between May 2016 and May 2017 included limiting refills to 10 mL, tank and cartridge sizes to 2 mL, and nicotine concentrations to 20 mg/mL. AIMS: To investigate the (1) awareness of new regulations, (2) product use before and after implementation, and (3) association between use of compliant products and subsequent smoking. METHODS: A UK online longitudinal survey of smokers, ex-smokers, and vapers was conducted between May and June 2016 (wave 4) and September 2017 (wave 5).The following methods were used: (1) to assess awareness of changes, proportions were calculated by smoking and vaping status (n = 1606). (2) Comparison of refill volume, tank and cartridge volumes, nicotine concentration at waves 4 and 5 (n = 199-388) was conducted. (3) Association was studied between number of TPD-compliant products used at wave 4 and smoking at wave 5, adjusted for wave 4 vaping status, age, gender, income, urges to smoke, and device type (n = 480). RESULTS: Awareness of regulations was highest for refill volume (10.1%; 37.4% among exclusive vapers) and nicotine concentration (9.5%; 27.3%). Higher proportions used TPD-compliant refill volumes (60.0%-73.7%, χ2(1) = 10.9, p = .001) and nicotine concentrations (89.2%-93.9%, χ2(1) = 7.41, p = .007) in wave 5 than wave 4, with little change for tank or cartridge volumes (77.1-75.5%, χ2(1) = 0.38, p = .540). The likelihood of smoking was similar for those using no or one TPD-compliant products as it was for those using two (OR = 1.10, 95% CI = 0.47-2.59) or three (OR = 1.56, 95% CI = 0.69-3.55). CONCLUSION: Several months after full implementation, awareness of new regulations was low and most vapers used TPD-compliant products. Use of compliant products was not associated with subsequent smoking. IMPLICATIONS: Using a longitudinal survey at the beginning and a few months after the end of the transition period for implementation of new regulation on electronic cigarettes, this is the first study to assess awareness of regulation and use of compliant products. After full implementation, awareness of changes was low overall (smokers, ex-smokers, and vapers combined) although higher among those who vaped. Nevertheless, most vapers (74%-94%) used products that were compliant with the new regulations and the use of products compliant with incoming regulations did not predict whether they were smoking cigarettes after implementation.

Mental health, smoking, harm reduction and quit attempts - a population survey in England.

BACKGROUND: Tobacco control strategies have engendered overall declines in smoking; however, a large gap remains between people with and without mental health problems, causing substantial health inequalities. Population-level information on barriers and opportunities for improvements is scarce. We aimed to assess mental health status of cigarette smokers and recent ex-smokers ('past-year smokers') in England, and smoking and harm reduction behaviour and quit attempts by mental health status. METHODS: Data were collected from 5637 current and 434 recent ex-smokers in 2016/17 in household surveys of representative samples of adults. We calculated weighted prevalence of different indicators of mental health problem: a) ever diagnosis, b) none, moderate, serious past-month distress, c) past-year treatment. We compared weighted smoking status, cigarette type, dependence, motivation to stop smoking, cutting down, use of nicotine replacement therapy or e-cigarettes, short-term abstinence, and quit attempts according to mental health status. RESULTS: Among past-year smokers: 35.9% ever had a diagnosis; 24.3% had experienced moderate, an additional 9.7% serious, past-month distress; 21.9% had had past-year treatment. Those with an indication of a mental health problem were more highly dependent and more likely to smoke roll-your-own cigarettes but also more likely to be motivated to stop smoking, to cut down, use nicotine replacement therapy or e-cigarettes and to have attempted to quit in the past year. CONCLUSIONS: About a third of cigarette smokers in England have mental health problems. Interventions should address their increased dependence and leverage higher prevalence of harm reduction behaviours, motivation to stop and attempts to stop smoking.

Smokers who have not tried alternative nicotine products: a 2019 survey of adults in Great Britain.

AIMS: Switching from smoking to using nicotine replacement therapy (NRT), electronic cigarettes (e-cigarettes) or heated tobacco products can reduce tobacco-related health risks. However, not all smokers in Great Britain have tried these products. This study aimed to identify and describe smokers who have never tried alternative nicotine products. METHODS: We analysed cross-sectional survey data of smokers (n = 1777) from a representative adult sample from Great Britain. The online survey was run in March 2019. The proportion of smokers who had never used alternative nicotine products was measured. A multivariate logistic regression assessed the association between never having used alternative nicotine products and sociodemographic and smoking characteristics and motivation to stop smoking. RESULTS: One in four smokers (27.8%, 95% CI 25.8-29.9%) had never tried NRT, e-cigarettes or heated tobacco products. These smokers were more commonly from Black and Minority than White ethnic groups (AOR = 1.55; 95% CI 1.02-2.31), were more likely to smoke up to 10 versus more cigarettes per day (AOR = 1.52; 95% CI 1.14-2.03) and to report low versus moderate or high motivation to stop smoking (AOR = 1.79; 95% CI 1.20-2.74). CONCLUSION: Light smokers, those unmotivated to stop and smokers from Black and Minority ethnic groups are less likely to have ever tried alternative nicotine products. Different approaches are needed to facilitate harm reduction and smoking cessation among these groups of smokers.

How did smokers respond to standardised cigarette packaging with new, larger health warnings in the United Kingdom during the transition period? A cross-sectional online survey.

INTRODUCTION: In the United Kingdom, standardised packaging for cigarettes was phased in between May 2016 and May 2017. We assessed whether there was an association between using standardised packs and warning salience, thoughts about the risks of smoking, thoughts about quitting, and awareness and use of stop-smoking websites. METHODS: We conducted a cross-sectional online survey with current smokers aged 16 and over (N = 1865) recruited in two regions of England between February-April 2017, when both standardised and fully-branded packs were on the market. Participants were asked about use of standardised packs, warning salience (noticing, reading closely), and whether the packs they were using increased thoughts of the risks of smoking and quitting. They were also asked about awareness of stop-smoking websites, source of awareness (including warnings on packs), and whether they had visited a stop-smoking website. RESULTS: Most participants reported currently using standardised packs (76.4%), 9.3% were not currently using them but had previously used them, and 14.3% had never used them. Compared with never users, current users were more likely to have noticed the warnings on packs often/very often (AOR (95%CI) = 2.76 (2.10, 3.63)), read them closely often/very often (AOR(95%CI) = 2.16 (1.51, 3.10)), thought somewhat/a lot about the health risks of smoking (AOR(95%CI) = 1.92 (1.38, 2.68)), and thought somewhat/a lot about quitting (AOR(95%CI) = 1.90 (1.30, 2.77)). They were also more likely to have noticed a stop-smoking website on packs. CONCLUSIONS: Consistent with the broad objectives of standardised packaging, we found that it was associated with increased warning salience and thoughts about risks and quitting.

Heat-not-burn tobacco products: a systematic literature review.

OBJECTIVE: To review peer-reviewed evidence on heat-not-burn tobacco products (HnB), their secondhand emissions and use by humans; to identify differences between independent and industry-funded studies. DATA SOURCES: Medline, Embase, PsycINFO, ProQuest, Scopus and Web of Science databases were searched up to 6 November 2017 for studies on HnB published after December 2009; reference lists were screened and other researchers contacted, yielding 637 records. STUDY SELECTION: Thirty-one publications on HnB secondhand emissions (n=16) or use by humans (n=15) were selected by two reviewers with excellent agreement (k=0.75). DATA EXTRACTION: Data on authors' affiliations, HnB products, secondhand emissions and human exposure were extracted by one reviewer. Two reviewers assessed the quality of experimental HnB studies using the Effective Public Health Practice Project tool. DATA SYNTHESIS: Twenty out of 31 studies were affiliated with tobacco industry. Studies on secondhand emissions varied by methodology, products and comparators. Compared with cigarettes, HnB delivered up to 83% of nicotine and reduced levels of harmful and potentially harmful toxicants by at least 62% and particulate matter by at least 75%. Experimental HnB use studies were limited to one product, reductions of human exposure to toxicants varied between 42% and 96%. HnB use suppressed urges to smoke, but participants rated HnB less satisfying than cigarettes. While limited by methodological heterogeneity, findings were largely similar for independent and industry-funded studies. CONCLUSIONS: Studies on HnB secondhand emissions and human use were heterogeneous and largely affiliated with the manufacturers. HnB exposed users and bystanders to toxicants, although at substantially lower levels than cigarettes.

Associations between vaping and relapse to smoking: preliminary findings from a longitudinal survey in the UK.

BACKGROUND: Most smokers attempting to quit relapse. There is little evidence whether the use of e-cigarettes ('vaping') increases or decreases relapse. This study aimed to assess 1) whether vaping predicted relapse among ex-smokers, and 2) among ex-smokers who vaped, whether vaping characteristics predicted relapse. METHODS: Longitudinal web-based survey of smokers, recent ex-smokers and vapers in the UK, baseline in May/June 2016 (n = 3334), follow-up in September 2017 (n = 1720). Those abstinent from smoking ≥ 2 months at baseline and followed up were included. Aim 1: Relapse during follow-up was regressed onto baseline vaping status, age, gender, income, nicotine replacement therapy use and time quit smoking (n = 374). Aim 2: Relapse was regressed onto baseline vaping frequency, device type, nicotine strength and time quit smoking (n = 159). RESULTS: Overall, 39.6% relapsed. Compared with never use (35.9%), past/ever (45.9%; adjOR = 1.13; 95% CI, 0.61-2.07) and daily vaping (34.5%; adjOR = 0.61; 95% CI, 0.61-1.89) had similar odds of relapse, for non-daily vaping evidence of increased relapse was inconclusive (65.0%; adjOR = 2.45; 95% CI, 0.85-7.08). Among vapers, non-daily vaping was associated with higher relapse than daily vaping (adjOR = 3.88; 95% CI, 1.10-13.62). Compared with modular devices (18.9% relapse), tank models (45.6%; adjOR = 3.63; 95% CI, 1.33-9.95) were associated with increased relapse; evidence was unclear for disposable/cartridge refillable devices (41.9%; adjOR = 2.83; 95% CI, 0.90-8.95). Nicotine strength had no clear association with relapse. CONCLUSION: Relapse to smoking is likely to be more common among ex-smokers vaping infrequently or using less advanced devices. Research into the effects of vaping on relapse needs to consider vaping characteristics.

Recommended core items to assess e-cigarette use in population-based surveys.

A consistent approach using standardised items to assess e-cigarette use in both youth and adult populations will aid cross-survey and cross-national comparisons of the effect of e-cigarette (and tobacco) policies and improve our understanding of the population health impact of e-cigarette use. Focusing on adult behaviour, we propose a set of e-cigarette use items, discuss their utility and potential adaptation, and highlight e-cigarette constructs that researchers should avoid without further item development. Reliable and valid items will strengthen the emerging science and inform knowledge synthesis for policy-making. Building on informal discussions at a series of international meetings of 65 experts from 15 countries, the authors provide recommendations for assessing e-cigarette use behaviour, relative perceived harm, device type, presence of nicotine, flavours and reasons for use. We recommend items assessing eight core constructs: e-cigarette ever use, frequency of use and former daily use; relative perceived harm; device type; primary flavour preference; presence of nicotine; and primary reason for use. These items should be standardised or minimally adapted for the policy context and target population. Researchers should be prepared to update items as e-cigarette device characteristics change. A minimum set of e-cigarette items is proposed to encourage consensus around items to allow for cross-survey and cross-jurisdictional comparisons of e-cigarette use behaviour. These proposed items are a starting point. We recognise room for continued improvement, and welcome input from e-cigarette users and scientific colleagues.

Waterpipe tobacco smoking prevalence among young people in Great Britain, 2013-2016.

Background: One percent of adults in Great Britain use waterpipe tobacco at least monthly, however national epidemiological evidence among young people is absent. This study aims to assess waterpipe tobacco prevalence and correlates among young people in Great Britain. Methods: Data were analyzed from online surveys conducted annually from 2013 to 2016 with weighted national samples of 11 to 18-year olds in Great Britain (annual n = 1936-2059). Primary outcome measures were at least monthly waterpipe tobacco use and lifetime waterpipe tobacco use. Binary logistic regression models tested the association between these outcomes and age, sex, country of residence and other tobacco consumption. Results: Between 2013 and 2016, 1.7% (95% CI 1.5-2.1%) used waterpipe tobacco at least monthly and 9.9% (95% CI 9.2-10.7%) used waterpipe in their lifetime. There were no changes in prevalence over time. At least monthly use was associated with older age groups [16-18 years vs. 11-15 years, adjusted odds ratio (AOR) 2.63, 95% CI 1.55-4.46], male sex (AOR 1.82, 95% CI 1.23-2.71) and other tobacco consumption (e.g. lifetime cigarette use AOR 10.30, 95% CI 5.22-20.29). Lifetime use had similar correlates, but was not associated with male sex (AOR 0.97, 95% CI 0.80-1.17). Conclusions: One in 10 young people in Great Britain have tried waterpipe tobacco, though more frequent use appears low. We found no evidence of increasing or decreasing prevalence of waterpipe use between 2013 and 2016. Being male, older and a concurrent user of other tobacco products were correlated with waterpipe tobacco use.

Depression and Smoking Cessation: Evidence from a Smoking Cessation Clinic with 1-Year Follow-Up.

BACKGROUND: Smoking is more prevalent among people with depression. Depression may make cessation more difficult and cessation may affect depression symptoms. PURPOSE: The aims of this study were to assess the associations between (1) baseline depression and 1-year smoking abstinence and (2) abstinence and change in depression. METHODS: Observational study using data collected routinely in a smoking cessation clinic in the Czech Republic from 2008 to 2014. Aim 1: N = 3775 patients; 14.3% reported mild and 15.4% moderate/severe baseline depression levels measured using Beck's Depression Inventory (BDI-II). Logistic regressions assessed if depression level predicted 1-year biochemically verified abstinence while adjusting for patient and treatment characteristics. Aim 2: N = 835 patients abstinent at 1 year; change in depression was analysed using Chi-square statistics, t test and mixed method analyses of variance. RESULTS: Rate of abstinence was lower for patients with mild (32.5%, OR = 0.68; 95% CI: 0.54 to 0.87, p = 0.002) and moderate/severe depression (25.8%; OR = 0.57, 95% CI: 0.45 to 0.74, p < 0.001) compared with patients without depression (40.5%). Across abstinent patients, the majority with baseline depression reported lower depression levels at follow-up. Overall mean (SD) BDI-II scores improved from 9.2 (8.6) to 5.3 (6.1); t(834) = 14.6, p < 0.001. There were significant main effects of time (F(1832) = 880.8, p < 0.001, partial η2 = 0.51) and baseline depression level (F(2832) = 666.4, p < 0.001, partial η2 = 0.62) on follow-up depression and a significant depression * time interaction (F(2832) = 296.5, p < 0.001, partial η2 = 0.42). CONCLUSIONS: In this effective smoking cessation clinic, depression at the start of treatment predicted reduced smoking abstinence 1 year later. Patients abstinent from smoking experienced considerable improvement in depression.

Support for e-cigarette policies: a survey of smokers and ex-smokers in Great Britain.

INTRODUCTION: E-cigarette regulations are the topic of extensive debate. Approaches vary worldwide, and limited evidence is available on public support for specific policies or what influences support. The present study aimed to assess smokers' and ex-smokers' support for 3 e-cigarette policies: (1) equal or higher availability relative to cigarettes, (2) advertising, (3) use in smoke-free places, and to assess changes in support over time and associations with respondent characteristics. METHODS: Smokers and ex-smokers (n=1848) provided 3279 observations over 2 waves (2013 and 2014) of a longitudinal web-based survey in Great Britain. Multivariable logistic regressions fitted using generalised estimating equations assessed change in policy support over time, and associations between support and demographics (age, gender and income), smoking and e-cigarette use status, nicotine knowledge and perceived relative harm. RESULTS: Equal or higher relative availability was supported by 79% in 2013 and 76% in 2014; advertising by 66% and 56%, respectively; neither change was significant in adjusted analyses. Support for use in smoke-free places decreased significantly from 55% to 45%. Compared with ex-smokers, smokers were more likely to support advertising and use in smoke-free places. Respondents using e-cigarettes, those who perceived e-cigarettes as less harmful than cigarettes, and those with more accurate knowledge about nicotine were more likely to support all 3 policies. CONCLUSIONS: Less restrictive e-cigarette policies were more likely to be supported by e-cigarette users, and respondents who perceived e-cigarettes to be less harmful than cigarettes, or knew that nicotine was not a main cause of harm to health.