Prevalence and correlates of e-cigarette source and use of e-cigarettes with nicotine: A case study of Mexico, where e-cigarettes are banned.

BACKGROUND: Low- and middle-income countries have increasingly banned e-cigarettes, as in Mexico. In these countries, little is known about where adults obtain e-cigarettes or who uses e-cigarettes with nicotine. METHODS: Data were analyzed from eight online surveys of Mexican adults who both smoked and used e-cigarettes (November 2018-March 2021; n = 2,060). For the e-cigarette they used most often, participants reported how they acquired it (social sources=reference; online purchase; vape shop purchase; other retail purchase) and if it contained nicotine (no=reference group; yes; don't know). Multinomial models regressed each of these outcomes on smoking- and e-cigarette-related factors, as well as sociodemographics. RESULTS: Almost half the sample (45.9 %) reported obtaining their e-cigarettes from social sources, with online purchase being the second most common source (28.7 %). Being male, having recently attempted to quit smoking, and more frequent e-cigarette use were positively associated with purchasing e-cigarettes (vs social sources) across all venues. Most reported that their e-cigarettes contained nicotine (58.2 %), a third reported using e-cigarettes without nicotine (35.9 %), and some did not know (5.8 %). More frequent smoking and e-cigarette use, using closed e-cigarette devices and purchasing e-cigarettes online were positively associated with using e-cigarettes with nicotine. CONCLUSIONS: Despite Mexico's e-cigarette ban, adults who smoke access e-cigarettes through multiple sources, including online and vape shop purchases. Most participants reported using e-cigarettes with nicotine, though many did not or did not know.

Association Between Cigarette and Bidi Purchase Behavior (Loose vs Pack) and Health Warning Label Exposure: Findings From the Tobacco Control Policy India Survey and In-Depth Interviews With People Who Smoke.

BACKGROUND: The sale of loose cigarettes or bidis can undermine the purpose of requiring health warning labels (HWLs) on cigarette packs and bidi bundles by diminishing their visibility and legibility. OBJECTIVE: This mixed-methods study aims to examine the association between purchase behavior (loose vs pack or bundle), HWL exposure, and responses to HWLs among Indian adults who smoke. METHODS: Data were analyzed from the 2018-2019 India Tobacco Control Policy Survey and from 28 in-depth interviews conducted with Indian adults who smoked in 2022. The Tobacco Control Policy Survey sample included tobacco users who bought cigarettes (n=643) or bidis (n=730), either loose or in packs or bundles at their last purchase. Ordinal regression models were fit separately for cigarettes and bidis, whereby HWL variables (noticing HWLs, reading and looking closely at HWLs, forgoing a cigarette or bidi because of HWLs, thinking about health risks of smoking, and thinking about quitting smoking cigarettes or bidis because of HWLs) were regressed on last purchase (loose vs packs or bundles). In-depth interviews with participants from Delhi and Mumbai who purchased loose cigarettes in the last month were conducted, and thematic analysis was used to analyze the interview data. RESULTS: Survey findings indicated that about 74.3% (478/643) of cigarette users and 11.8% (86/730) of bidi users reported having bought loose sticks at their last purchase. Those who purchased loose cigarettes (vs packs) noticed HWLs less often (estimate -0.830, 95% CI -1.197 to -0.463, P<.001), whereas those who purchased loose bidis (vs bundles) read and looked closely at HWLs (estimate 0.646, 95% CI 0.013-1.279, P=.046), thought about the harms of bidi smoking (estimate 1.200, 95% CI 0.597-1.802, P<.001), and thought about quitting bidi smoking (estimate 0.871, 95% CI 0.282-1.461, P=.004) more often. Interview findings indicated lower exposure to HWLs among those who purchased loose cigarettes, primarily due to vendors distributing loose cigarettes without showing the original cigarette pack, storing them in separate containers, and consumers' preference for foreign-made cigarette brands, which often lack HWLs. While participants were generally aware of the contents of HWLs, many deliberately avoided them when purchasing loose cigarettes. In addition, they believed that loose cigarette purchases reduced the HWLs' potential to deliver consistent reminders about the harmful effects of cigarette smoking due to reduced exposure, an effect more common among those who purchased packs. Participants also noted that vendors, especially small ones, did not display statutory health warnings at their point of sale, further limiting exposure to warning messages. CONCLUSIONS: Survey and interview findings indicated that those who purchased loose cigarettes noticed HWLs less often. Loose purchases likely decrease the frequency of exposure to HWLs' reminders about the harmful effects of smoking, potentially reducing the effectiveness of HWLs.

Knowledge and beliefs about blunts among youth in the United States.

Background: Blunts (i.e., cannabis rolled in cigar paper with or without tobacco) are a popular way of consuming cannabis. Little survey research has examined knowledge and beliefs about blunts, especially among youth who use cigars or are susceptible to cigar use. Methods: Participants were a convenience sample of N = 506 youth (ages 15-20) from the United States (US) recruited April-June 2023 who reported ever using little cigars or cigarillos (LCCs), past 30-day use of LCCs, or susceptibility to using LCCs. We used adjusted logistic and ordinal regression models to examine correlates of knowledge that blunts contain nicotine and, separately, relative addiction/harm perceptions for blunts vs. unmodified cigars containing only tobacco. Results: One-third of youth (32.1 %) thought that blunts do not contain nicotine. Around half of youth thought that blunts were "much less" or "slightly less" addictive (45.0 %) and "much less" or "slightly less" harmful (51.5 %) than unmodified cigars. Youth who identified as Black/African American (vs. white) had lower odds of knowledge that blunts contain nicotine (aOR = 0.51, 95 % CI: 0.30, 0.87). Youth who frequently used blunts were less likely to report that blunts were more addictive (aOR = 0.39; 95 % CI: 0.24, 0.63) and harmful (aOR = 0.31; 95 % CI: 0.19, 0.50 (vs. unmodified cigars) compared with youth who never used blunts. Conclusions: Our study with a sample of US youth-who have used or are susceptible to using LCCs-found that about 1 in 3 participants thought that blunts do not contain nicotine, and many believed blunts were less harmful and addictive than unmodified cigars.

Examining the influence of cigar and cannabis co-marketing on packaging perceptions: An experiment with a sample of US youth.

SIGNIFICANCE: Cigars are sometimes marketed with cannabis references because they are often used for smoking blunts (i.e., cannabis rolled in cigar paper with or without tobacco). However, little research exists on the impact of cannabis co-marketing on cigar perceptions. METHODS: Participants included 506 US youth (ages 15-20) recruited April-June 2023 through Qualtrics who reported ever using little cigars or cigarillos (LCCs), past 30-day use of LCCs, or susceptibility to using LCCs. We then conducted a between-subjects experiment, randomizing youth to view one of two cigarillo packages: 1) a package with cannabis co-marketing (i.e., the package included a cannabis-related flavor descriptor and the word "blunt" appeared in the brand name and product label) or 2) a package with no cannabis co-marketing. We assessed the effects of the packaging on perceptions of product ingredients, addictiveness and harm perceptions, product appeal, susceptibility to using the product shown, and purchase intentions. RESULTS: Packages with cannabis co-marketing were perceived as more likely to contain cannabis (OR: 5.56, 95 % CI: 3.73, 8.27) and less likely to contain tobacco (OR: 0.42, 95 % CI: 0.25, 0.70) or nicotine (OR: 0.57, 95 % CI: 0.40, 0.82). Cannabis co-marketing also led to higher susceptibility to using the product shown (B: 0.21, p = 0.02). We did not find evidence that cannabis co-marketing changed harm perceptions or purchase intentions. CONCLUSIONS: Among a sample of US youth, cannabis co-marketing on cigar packages may change perceptions of product ingredients and increase susceptibility to using such products, which could lead to the initiation of cigars and cannabis.

Young adults' attention to reduced exposure claims in IQOS advertising and associations with product perceptions and use intentions.

INTRODUCTION: Non-combusted tobacco products, particularly those authorized as modified risk tobacco products (MRTPs), may appeal to young adults. This cross-sectional study explored young adults' attention to reduced exposure claims in IQOS advertising and its associations with product perceptions and use intentions. METHODS: Fifty-one young adults aged 21-29 (mean age = 24.5 years old, 54.9% who smoked cigarettes, 47.1% male, 66.7% White) viewed an IQOS advertisement containing two reduced exposure claims (one large, one detailed) for 20 seconds during eye-tracking, then completed post-exposure questionnaires (risk beliefs, harm perceptions, attitudes, use intentions). We compared attention and questionnaire measures by smoking status and examined associations between attention to reduced exposure claims and questionnaire measures. RESULTS: Overall, the large (vs. detailed) reduced exposure claim attracted young adults' attention more quickly, but the detailed claim held attention longer than all other advertisement features (p's < .001). There were no differences by smoking status in how quickly either claim attracted or held initial attention, but young adults who smoked (vs. did not smoke) spent more cumulative time looking at the large claim and less time looking at the detailed claim (p's < .05). Among those who smoked, greater dwell time on the detailed reduced exposure claim was associated with more beliefs about reduced harm, lower perceived risk of addiction, and greater intentions to try IQOS (p's <.05). CONCLUSIONS: Detailed information on reduced exposure in IQOS advertising may convey reduced risk and potentially promote uptake of IQOS among young adults who smoke and attend to this content. IMPLICATIONS: Findings from this exploratory, single-exposure study demonstrate differences in young adults' attention to reduced exposure claims in an IQOS advertisement based on their smoking status. Among those who smoke, greater attention to detailed reduced exposure information was associated with reduced perceptions of harm compared to cigarettes, and greater intentions to try IQOS. Findings suggest that among young adults who smoke cigarettes and visually engage with this content, detailed text containing IQOS' authorized reduced exposure claims is interpreted as reduced risk information and may promote uptake of this product.

Interaction Between State-Level Cigarette Prices and County-Level Tobacco 21 Coverage on Cigarette Smoking Outcomes Among US Adolescents.

PURPOSE: To examine whether Tobacco 21 (T21) law coverage moderated associations between cigarette prices and adolescent smoking and associated disparities. METHODS: We used nationally representative, repeated cross-sectional 2014-2020 Monitoring the Future study data (n = 20,547-96,083) to examine associations between state-level average cigarette price per pack and county-level T21 coverage (100% vs. < 100%) on past 30-day smoking participation, first and daily cigarette smoking initiation, and smoking intentions in US adolescents in eighth, 10th, and 12th grade. We implemented weighted, grade-stratified, modified Poisson regression models to test for interactions between price and T21 coverage for each outcome. We also tested for disparities by sex, race and ethnicity, parental education, and college educational expectations. RESULTS: Higher cigarette prices were associated with a lower probability of past 30-day smoking participation among eighth graders in counties with < 100% T21 coverage (average marginal effect = -0.003, 95% confidence interval = -0.006, 0.000) but not among eighth graders in counties with 100% T21 coverage (average marginal effect = 0.001, 95% confidence interval = -0.001, 0.004) (p for interaction = 0.005). There were no associations with other smoking outcomes or grades or evidence of differential associations by sociodemographic factors. DISCUSSION: Our findings suggested that higher cigarette prices were associated with lower adolescent smoking among eighth graders living in counties with < 100% T21 coverage. However, no such association was observed in other grades or smoking outcomes. Further investigation is necessary to determine the best combination of policies to reduce adolescent smoking, related sociodemographic disparities, and the use of other tobacco products in areas with fewer tobacco control policies.

To use or not to use electronic cigarettes? Reasons for use, stopping use and their behavioural sequelae among Mexicans who smoke.

INTRODUCTION: Reasons for using and stopping the use of e-cigarettes and their associations with transitions in nicotine product use are relatively unknown in countries with e-cigarette bans, such as Mexico. METHODS: Data comes from an open cohort of people who smoke in Mexico, surveyed every 4 months from November 2018 to November 2021. Those who smoked and used e-cigarettes at time t (n=904 individuals, 1653 observations) were categorised at 4-month follow-up (t+1): (1) continued 'dual use', (2) exclusive smoking, (3) exclusive use of e-cigarettes or neither product. For people who formerly used e-cigarettes at time t (n=332 individuals, 372 observations), follow-up categories were: (1) continued exclusive smoking; (2) re-initiated e-cigarette use. Multinomial and logistic models regressed follow-up status (ref=status at time t) on reasons for using or stopping e-cigarette use, respectively, at time t, adjusting for covariates. RESULTS: The most prevalent reasons for current e-cigarette use were 'they were less harmful to others' (40.5%) and 'enjoyable' (39.0%). Those who reported using e-cigarettes because they were less harmful to others (Adjusted Relative Risk Ratio (ARRR)=0.67), more enjoyable (ARRR=0.52), could help them to quit smoking (ARRR=0.65), or to control weight (ARRR=0.46) were less likely to return to exclusively smoking. Among people who formerly used e-cigarettes, lack of satisfaction was the primary reason for stopping e-cigarette use (32%) and those who reported this were less likely to start using e-cigarettes again at follow-up (Adjusted Odds Ratio (AOR)=0.58). CONCLUSIONS: Specific reasons for using and stopping e-cigarettes predict changes in smoking and e-cigarette use, and targeting these beliefs could promote desired behaviour changes.

Packaging of disposable vaping products and e-liquids in England, Canada and the United States: A content analysis.

BACKGROUND AND AIMS: Vaping product packaging is varied and often features bright colours and novel designs, particularly among recently marketed disposable vapes. This study provides an overview of attributes found on the packaging of popular disposable vapes and e-liquid bottles in England, Canada and the United States (US) and assesses compliance with local packaging regulations. DESIGN: Content analysis. SETTING: Brick-and-mortar and online shops in England (London), Canada (Ontario) and the US (New Hampshire and South Carolina). CASES: 108 vaping products (including packaging) from 76 brands in a range of flavours and nicotine levels. Specifically, 48 disposable vapes (15 from England, 16 from Canada, 17 from the US) and 60 e-liquid bottles (20 per country). MEASUREMENTS: Textual and graphic branding and marketing elements, independently coded by two researchers and checked by a third. FINDINGS: Compliance with local packaging regulations varied across countries. Health warnings were present on the packaging of all but one nicotine-containing product, although 33% of disposables and 17% of e-liquids featuring the warning did not adhere to formatting requirements. Leaflets were seldom included with e-liquid bottles, even in England (45%) where mandatory, and omitted elsewhere. Labelling of nicotine type and batch numbers was inconsistent. Vaping product packaging featured claims relating to sensory perceptions (41%), most often flavours, and some (32%) featured youth-appealing content. Common graphic elements included stylised brand fonts (80%), brand logos (54%), product representations on the external packaging (47%) and abstract graphic elements (64%). Colours on packaging, disposable vapes and e-liquid bottles were associated with product flavour. CONCLUSIONS: In England, Canada and the United States, popular disposable vapes and e-liquid bottles appear to have varying compliance with local packaging regulations and inconsistent labelling of nicotine and product characteristics. The use of colourful designs, evocative descriptors and appealing graphics to promote flavours underscores the need for comprehensive packaging regulations and enforcement.

Does e-cigarette use predict short-term smoking cessation behaviors among adults who smoke in Mexico? A longitudinal study.

INTRODUCTION: This study assessed quit attempts among adults who use cigarettes either exclusively or with e-cigarettes in Mexico, where non-daily smoking predominates. METHODS: An open cohort of Mexican adults who smoke was surveyed every four months from November 2018 to March 2021. Participants followed to the next survey were analyzed (n = 2220 individuals, 4560 observations). Multinomial logistic models regressed smoking quit attempts reported at the followup survey (ref = no attempt; tried to quit; sustained attempt of ≥30 days) on e-cigarette use frequency (none = ref; 1-2 days/week; ≥3 days/week), adjusting for sociodemographics and smoking-related variables. Additional models subdivided e-cigarette users by intentions to quit smoking in the next six months (i.e., yes/no), use of nicotine (i.e., yes/no), and vaping device used (i.e., open/closed). RESULTS: At 4-month follow-up, 32.7 % had tried to quit, and 2.9 % had quit for 30 days or more. Compared to those who smoke exclusively, occasional, and frequent e-cigarette users were more likely to try to quit (Adjusted Relative Risk Ratio or ARRR = 1.26 and 1.66, respectively) but no more likely to sustain their quit attempt. Among those who intended to quit smoking, e-cigarette users were no more likely to either try or sustain quit attempts. Furthermore, use of e-cigarettes with nicotine (59.6 %) was unassociated with cessation except that those who frequently used e-cigarettes with nicotine were more likely to try to quit than those who smoke exclusively (ARRR = 1.88). Device type used was not differentially associated with outcomes. CONCLUSIONS: Mexicans who smoke and use e-cigarettes appear more likely than those who smoke exclusively to try to quit but not to sustain abstinence.

Examining the Role of Aguas Frescas in Assessment of Sugary-Drink Intake among Mexican and Mexican American Adults.

BACKGROUND: Aguas frescas are Mexican drinks that are typically made with water, sugar, and fruit. Aguas frescas may be a significant component of sugary-drink intake among Mexican and Mexican-American (MA) adults. However, it is unclear whether survey respondents report aguas frescas consumption when it is not specifically queried in standardized beverage frequency instruments. OBJECTIVES: This study examined the prevalence of aguas frescas consumption, the sociodemographic correlates of aguas frescas intake, and how specifically querying aguas frescas intake affects sugary-drink estimates among Mexican and MA adults. METHODS: Cross-sectional, online surveys were conducted in 2021 with 5377 Mexican and 3073 MA adults as part of the International Food Policy Study. Past 7-d consumption of sugar-sweetened beverages (SSBs), sugary drinks, and aguas frescas were assessed along with relevant covariates. Weighted analyses included logistic and linear regression, including models with correlation structure. RESULTS: An estimated 61.7% of Mexican and 28.7% of MA adults consumed aguas frescas. In Mexico, consumption was associated with females, low education, perceiving oneself as having about the right weight, being good to excellent health, and consuming an unhealthy amount of sugary drinks. For MAs, intake was associated with being younger, speaking Spanish, and perceiving oneself as being underweight or about the right weight. Among Mexican adults who consumed aguas frescas but did not report them unless specifically queried, the volume of SSB intake was 67.9% higher for females and 64.3% higher for males when aguas frescas were included. Among MAs, SSB intake was 56.9% higher for females and 44.1% higher for males. Most participants (79.9%-85.2%) remained in the same sugary-drink tertiles when including compared with excluding aguas frescas. CONCLUSIONS: Aguas frescas should be queried during beverage intake assessments, as they contribute a nontrivial amount of added sugars to the diets of many Mexican and MA adults.

Self-reported attention and responses to cigarette package labels at the end of a two-week randomized trial of cigarette package labeling configurations.

INTRODUCTION: Cigarette package inserts that describe quitting benefits and tips may promote cessation; however, research is needed to understand better their effects, including potentially enhancing the effects of pictorial health warning labels (PHWLs). METHODS: A randomized trial with a 2×2 factorial design was conducted with adult smokers (n=356) assigned to either small text-only health warning labels (HWLs; control); inserts with cessation messages, and the small text-only HWLs (inserts-only); large PHWLs (PHWLs-only); both inserts and PHWLs (inserts + PHWLs). Participants received a 14-day supply of their preferred cigarettes with packs labeled to reflect their group. Upon finishing the trial, participants reported their past 14-day frequency of noticing, reading, thinking about smoking harms and cessation benefits, talking about labels, and forgoing cigarettes because of the labels. Ordered logistic models regressed these outcomes on labeling groups, and mediation analyses assessed whether attention (i.e. noticing, reading) to labels mediated effects of labeling exposure on other outcomes (i.e. thinking about harms/benefits, talking, forgoing). RESULTS: The inserts + PHWLs group reported higher frequencies than the control group for all outcomes. Compared to the control group, both the inserts-only and PHWLs-only groups reported higher frequency of noticing (AOR=3.53 and 2.46, respectively) and reading labels (AOR=2.89 and 1.71), thinking about smoking risks because of the labels (AOR=1.93 and 1.82), and talking about labels (AOR=2.30 and 2.70). Participants in the inserts-only group also reported more frequent thinking about quitting benefits (AOR=1.98). Attention mediated all labeling effects except for the contrast between PHWLs only and control. CONCLUSIONS: Compared to text-only HWLS, cigarette labeling that involves inserts, PHWLs, or both appears more effective at drawing attention to warnings, which mediated the effects on cessation-related psychosocial and behavioral outcomes.

Differential responses to cigarette package labeling alternatives among adults who smoke: Results from a randomized trial.

INTRODUCTION: Little experimental research has evaluated whether the effects of cigarette package inserts with efficacy messages and/or pictorial health warning labels (PHWLs) differ across key subgroups of adults who smoke. METHODS: Adults who reported currently smoking (n=367) were randomly assigned to one of four groups: small text-only health warning labels (HWLs) on pack sides (control); inserts with efficacy messages and small HWLs (inserts-only); PHWLs showing harms of smoking (PHWLs-only); both (inserts+PHWLs). Participants received a 14-day supply of cigarettes labeled to reflect their group. Every evening over two weeks, participants reported forgoing and stubbing out cigarettes before they finished smoking over the prior 24 hours, combined into a binary indicator of either behavior (e.g., forgoing/stubbing). Separate mixed-effects logistic models were estimated to evaluate moderation of labeling group contrasts (i.e., PHWLs vs not; inserts vs. not; inserts-only vs. inserts+PHWLs; PHWLs-only vs. inserts+PHWLs) by baseline covariates (self-efficacy to quit, intention to quit, education, health literacy, time discounting), predicting day-level forgoing/stubbing. RESULTS: Education moderated PHWL effects, with PHWLs predicting more forgoing/stubbing only among those with low education (OR=4.68, p<0.001). Time discounting moderated insert effects, with inserts promoting fogoing/stubbing only among those with low time discounting (i.e., lower impulsivity; OR=4.35, p<0.001). CONCLUSIONS: Inserts with efficacy messages appear effective mostly among people with low time discounting, whereas PHWLs appear most effective amongst those with low education, suggesting their potential to address education-related disparities. Labeling strategies appeared equally effective across subgroups defined by self-efficacy to quit, quit intention, and health literacy. Combining inserts with PHWLs did not appear to mitigate moderation effects. IMPLICATIONS: This randomized trial with adults who smoke suggests that cigarette packs with inserts describing cessation benefits and tips can promote cessation-related behaviors (i.e., forgoing or stubbing out cigarettes) among those with low time discounting (i.e., low impulsivity). Alternative interventions may be needed for people with high time discounting, as found in cessation trials. Pictorial health warning labels (PHWLs) appear most effective among those with low education, potentially addressing education-related disparities. No differential effects were found for those with different levels of self-efficacy to quit, quit intentions, or health literacy. Combining inserts and PHWLs may not be more effective than either alone.

The Role of Harm Visibility for Pictorial Health Warning Labels on Cigars.

INTRODUCTION: Pictorial health warning labels (HWLs) can communicate the harms of tobacco product use, yet little research exists for cigars. We sought to identify the most effective types of images to pair with newly developed cigar HWLs. AIMS AND METHODS: In September 2021, we conducted an online survey experiment with US adults who reported using little cigars, cigarillos, or large cigars in the past 30 days (n = 753). After developing nine statements about health effects of cigar use, we randomized participants to view one of three levels of harm visibility paired with each statement, either: (1) an image depicting internal harm not visible outside the body, (2) an image depicting external harm visible outside of the body, or (3) two images depicting both internal and external harm. After viewing each image, participants answered questions on perceived message effectiveness (PME), negative affect, and visual-verbal redundancy (VVR). We used linear mixed models to examine the effect of harm visibility on each outcome, controlling for warning statement. RESULTS: Warnings with both and external harm depictions performed significantly better than the internal harm depictions across all outcomes, including PME (B = 0.21 and B = 0.17), negative affect (B = 0.26 and B = 0.25), and VVR (B = 0.24 and B = 0.17), respectively (all p < .001). Compared to both, the external depiction of harm did not significantly change PME or negative affect but did significantly lower VVR (B = -0.07, p = .01). CONCLUSIONS: Future cigar pictorial HWLs may benefit from including images depicting both or external harm depictions. Future research should examine harm visibility's effect for other tobacco pictorial HWLs. IMPLICATIONS: The cigar health warning labels (HWLs) proposed by the US Food and Drug Administration are text-only. We conducted an online survey experiment among people who use cigars to examine the effectiveness of warnings with images depicting different levels of harm visibility. We found HWLs with images depicting both an internal and external depiction of cigar harm, or an external depiction of harm alone, performed better overall than images portraying internal depictions of harm. These findings provide important regulatory evidence regarding what type of images may increase warning effectiveness and offer a promising route for future cigar HWL development.

Self-reported decreases in the purchases of selected unhealthy foods resulting from the implementation of warning labels in Mexican youth and adult population.

BACKGROUND: Front-of-package nutritional warning labels (WLs) are designed to facilitate identification and selection of healthier food choices. We assessed self-reported changes in purchasing different types of unhealthy foods due to WLs in Mexico and the association between the self-reported reductions in purchases of sugary beverages and intake of water and sugar-sweetened beverages. METHODS: Data came from 14 to 17 year old youth (n = 1,696) and adults ≥ 18 (n = 7,775) who participated in the Mexican arm of the 2020-2021 International Food Policy Study, an annual repeat cross-sectional online survey. Participants self-reported whether the WLs had influenced them to purchase less of each of nine unhealthy food categories due to WLs. Among adults, a 23-item Beverage Frequency Questionnaire was used derive past 7-day intake of water and sugary beverages analyzed to determine the relationship between self-reported reductions in purchasing sugary drinks due to the WLs. Multilevel mixed-effects logistic regression models were fitted to estimate the percentage of participants who self-reported reducing purchases within each food group, and overall. Sociodemographic characteristics associated with this reduction were investigated as well. RESULTS: Overall, 44.8% of adults and 38.7% of youth reported buying less of unhealthy food categories due to the implementation of WL, with the largest proportion reporting decreased purchases of cola, regular and diet soda. A greater impact of WLs on the reported purchase of unhealthy foods was observed among the following socio-demographic characteristics: females, individuals who self-identified as indigenous, those who were overweight, individuals with lower educational levels, those with higher nutrition knowledge, households with children, and those with a significant role in household food purchases. In addition, adults who reported higher water intake and lower consumption of sugary beverages were more likely to report reduced purchases of sugary drinks due to the WLs. Adults who reported greater water intake and lower sugary beverages intake were significantly more likely to report buying fewer sugary drinks due to the WLs. CONCLUSION: Our findings suggest that implementation of WLs has reduced perceived purchases of unhealthy foods in Mexico. These results underscore the potential positive impact of the labeling policy particularly in subpopulations with lower levels of education and among indigenous adults.

"The ban is there, but it is not there": perceptions of cigarette users and tobacco vendors regarding ban on the sale of loose cigarettes in India.

Introduction: Banning the sales of loose cigarettes is recommended by Article 16 of the World Health Organization - Framework Convention on Tobacco Control. This study aims to understand the perceptions of cigarette users and tobacco vendors regarding such a ban. Methods: Using a systematic recruitment and interview protocol, we interviewed cigarette users (n = 28) and tobacco vendors (n = 28) from two Indian cities where sales of loose cigarettes were banned (Mumbai) or not banned (Delhi). Separate semi-structured interview guides were used for users and vendors. Interview questions focused on reasons for purchasing loose cigarettes, preference for buying and selling loose vs. packs, thoughts on the necessity of banning loose cigarettes, and the perceived impact of the policy ban for vendors and cigarette users. We performed thematic analysis and used NVivo for organizing transcript coding. Results: The main reasons users cited for purchasing loose cigarettes were financial constraints, social restrictions (fear of getting caught), and limiting cigarette consumption. In Mumbai, awareness of the existing ban was poor among both users and vendors. Those who were aware did not think the policy had been implemented. Users thought that loose cigarettes promoted smoking initiation and prevented them from quitting. Both users and vendors reported that a ban on loose cigarettes would reduce cigarette consumption and promote quit attempts as it would not be possible for everyone to purchase packs because of financial and social reasons. Conclusion: Users in both cities reported easy access to and widespread availability of loose cigarettes. Low awareness of the ban in Mumbai suggested inadequate enforcement. A country-wide ban on the sale of loose cigarettes could be highly effective in preventing smoking initiation and promoting quitting.

Heated tobacco product use frequency, smoking quit attempts, and smoking reduction among Mexican adult smokers.

INTRODUCTION: Heated tobacco products (HTPs) are promoted as less harmful than cigarettes; nonetheless, whether HTPs help smokers quit is uncertain. METHODS: Data from 4067 Mexican adult smokers surveyed longitudinally every four months (November 2019-March 2021) were analyzed. Mixed-effects multinomial models regressed HTP use frequency (no use=reference; monthly; weekly; and daily use) on sociodemographics and tobacco/nicotine-related variables. Among participants who completed at least two surveys (n=2900) over four months, the duration of their longest smoking quit attempt (SQA) between surveys (SQAs: <30 days; ≥30 days; no SQA=reference) was regressed on HTP use frequency, and changes in the number of cigarettes smoked per day were regressed on HTP initiation between surveys, adjusting for covariates. RESULTS: Consistent predictors of all HTP use frequencies (monthly, weekly, or daily vs no use) were daily smoking >5 cigarettes (ARRR=1.69 [95% CI: 1.12-2.55], 1.88 [95% CI: 1.26-2.81] and 6.46 [95% CI: 3.33-12.52], respectively); e-cigarette use (ARRR =5.68 [95% CI: 3.38-9.53], 6.54 [95% CI: 4.06-10.55] and 2.59 [95% CI: 1.26-5.30]); lower HTP risk perceptions (ARRR=2.12 [95% CI: 1.50-30.00], 2.25 [95% CI: 1.63-3.10] and 2.00 [95% CI: 1.25-3.22]); exposure to HTP information inside (ARRR=2.13 [95% CI: 1.44-3.15], 2.13 [95% CI: 1.49-3.05] and 3.72 [95% CI: 2.28-6.09]) and outside stores (ARRR=2.36 [95% CI: 1.56-3.57], 2.32 [95% CI: 1.65-3.25] and 2.44 [95% CI: 1.41-4.24]) where tobacco is sold; having family (ARRR=2.46 [95% CI: 1.54-3.91], 2.90 [95% CI: 1.93-4.37] and 2.96 [95% CI: 1.52-5.77]) and friends (ARRR=5.78 [95% CI: 3.60-9.30], 4.98 [95% CI: 3.22-7.72] and 6.61 [95% CI: 2.91-15.01]) who use HTPs. HTP use frequency was not associated with quit attempts, except for monthly HTP use predicting SQAs lasting ≥30 days (ARRR=2.12 [95% CI: 1.17-3.85]). Initiation of HTP use was not associated with changes in smoking frequency. Limiting analysis to those who intend to quit smoking also yielded null results. CONCLUSIONS: Among Mexican adult smokers, frequency of HTP use was mostly not associated with either cessation behaviors or changes in cigarette consumption, suggesting that HTPs have limited to no effectiveness for smoking cessation.

The potential impact of removing a ban on electronic nicotine delivery systems using the Mexico smoking and vaping model (SAVM).

Objective: To develop the Mexico Smoking and Vaping Model (Mexico SAVM) to estimate cigarette and electronic nicotine delivery systems (ENDS) prevalence and the public health impact of legalizing ENDS use. Methods: SAVM, a cohort-based discrete-time simulation model, compares two scenarios. The ENDS-Restricted Scenario estimates smoking prevalence and associated mortality outcomes under the current policy of an ENDS ban, using Mexico-specific population projections, death rates, life expectancy, and smoking and e-cigarette prevalence. The ENDS-Unrestricted Scenario projects smoking and vaping prevalence under a hypothetical scenario where ENDS use is allowed. The impact of legalizing ENDS use is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the ENDS-Restricted and Unrestricted scenarios. Results: Compared to a national ENDS ban, The Mexico SAVM projects that legalizing ENDS use could decrease smoking prevalence by 40.1% in males and 30.9% in females by 2049 compared to continuing the national ENDS ban. This reduction in prevalence would save 2.9 (2.5 males and 0.4 females) million life-years and avert almost 106 (91.0 males and 15.5 females) thousand deaths between 2025 and 2049. Public health gains decline by 43% to 59,748 SVADs averted when the switching rate is reduced by half and by 24.3% (92,806 SVADs averted) with a 25% ENDS risk level from that of cigarettes but increased by 24.3% (121,375 SVADs averted) with the 5% ENDS risk. Conclusions: Mexico SAVM suggests that greater access to ENDS and a more permissive ENDS regulation, simultaneous with strong cigarette policies, would reduce smoking prevalence and decrease smoking-related mortality. The unanticipated effects of an ENDS ban merit closer scrutiny, with further consideration of how specific ENDS restrictions may maximize public health benefits.

Consolidated guidance for behavioral intervention pilot and feasibility studies.

BACKGROUND: In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences. METHODS: To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of a well-known PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences. RESULTS: A total of 496 authors were invited to take part in the three-round Delphi survey (round 1, N = 46; round 2, N = 24; round 3, N = 22). A set of twenty considerations, broadly categorized into six themes (intervention design, study design, conduct of trial, implementation of intervention, statistical analysis, and reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading. CONCLUSION: We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.

Prevalence and perceptions of flavour capsule cigarettes among adults who smoke in Brazil, Japan, Republic of Korea, Malaysia and Mexico: findings from the ITC surveys.

INTRODUCTION: The global market of flavour capsule cigarettes (FCCs) has grown significantly over the past decade; however, prevalence data exist for only a few countries. This study examined prevalence and perceptions of FCCs among adults who smoke across five countries. METHODS: Cross-sectional data among adults who smoked cigarettes came from the International Tobacco Control Policy Evaluation Project Surveys-Brazil (2016/2017), Japan (2021), Republic of Korea (2021), Malaysia (2020) and Mexico (2021). FCCs use was measured based on reporting one's usual/current brand or favourite variety has flavour capsule(s). Perceptions of the harmfulness of one's usual brand versus other brands were compared between those who used capsules versus no capsules. Adjusted logistic regression models examined correlates of FCC use. RESULTS: There were substantial differences in the prevalence of FCC use among adults who smoke across the five countries: Mexico (50.3% in 2021), Republic of Korea (31.8% in 2021), Malaysia (26.5% in 2020), Japan (21.6% in 2021) and Brazil (6.7% in 2016/2017). Correlates of FCC use varied across countries. Capsule use was positively associated with being female in Japan and Mexico, younger age in Japan, Republic of Korea and Malaysia, high education in Brazil, Japan and Mexico, non-daily smoking in Republic of Korea, and having plans to quit in Japan and Republic of Korea. There was no consistent pattern of consumer perceptions of brand harmfulness. CONCLUSION: Our study documented the high prevalence of FCCs in some countries, pointing to the need to develop and implement regulatory strategies to control these attractive products.

Independent and combined effects of very low nicotine cigarette messages and e-cigarette messages: a randomised clinical trial.

BACKGROUND: USA is considering reducing nicotine in cigarettes to non-addictive levels, coupled with promoting alternative nicotine delivery products (eg, e-cigarettes). However, effective communication is needed to reduce misperceptions about very low nicotine cigarettes (VLNCs) being less harmful than regular cigarettes. METHODS: In 2022-2023, we conducted a four-group randomised clinical trial with a national probability sample from an online panel (971 adults who smoked cigarettes exclusively, 472 adults who dual used cigarettes and e-cigarettes and 458 adults aged 18-29 who had never smoked). Participants were randomised (parallel assignment) to one message condition: (1) VLNCs as harmful but easier to quit than regular cigarettes (n=468), (2) those who are not ready to quit should consider switching to e-cigarettes as less harmful alternatives (n=484), (3) combined (VLNC and e-cigarette messages; n=476) or (4) control condition (ie, water ads), n=473. The primary outcome was perceived absolute harm of VLNCs. RESULTS: Perceived harm of VLNCs was higher in the VLNC condition compared with the e-cigarette and control conditions, and higher in the combined condition compared with the e-cigarette condition (adjusted p<0.05). Among adults who dual used, intention to switch to e-cigarettes was higher in the VLNC condition than the e-cigarette, combined or control conditions (adjusted p<0.05). CONCLUSIONS: VLNC messages reduced the misperception that VLNCs are less harmful than cigarettes, but adding messages about e-cigarettes did not enhance desired outcomes. These VLNC messages can be considered during the rollout of a reduced nicotine policy. TRIAL REGISTRATION: NCT05506046.