An 8-year longitudinal study of long-term, continuous users of electronic cigarettes.

BACKGROUND AND AIMS: E-cigarettes have been available for over 15 years, but relatively little is known about long-term users. Our aim was to describe change over time in behaviours, attitudes and dependence in long-term users. DESIGN AND PARTICIPANTS: A longitudinal study of 375 e-cigarette users enrolled on the Internet in 2012-2016 and surveyed again in 2021 (8 years later on average), who continuously used e-cigarettes in the interval. FINDINGS: Fewer people in 2021 (11 %) than at baseline (33 %) had smoked tobacco in the past 31 days. Participants switched from second-generation models at baseline (e.g. Ego) to box mods in 2021 (e.g. iStick), they used larger refill bottles, they used home-made e-liquids twice as often, they used tobacco flavours less often and the nicotine concentration in e-liquids decreased from 12 to 6 mg/mL. There was no change over time in the time to the first e-cigarette puff of the day, but an e-cigarette dependence score of 0-100 decreased from 75 to 60, the frequency and strength of urges to vape decreased (from 31 % to 18 % of "strong" urges) and the proportion of people who said they would be likely to succeed if they tried to stop vaping increased. Compared to baseline, fewer people in 2021 reported vaping to cope with cravings or other smoking cessation symptoms, and fewer people reported vaping to quit smoking, to avoid relapse into smoking, or to reduce their tobacco consumption (p < 0.001 for all differences). CONCLUSIONS: In long-term, continuous users, over a period of 8 years, substantial changes were observed in the models of e-cigarettes used, in the flavours and strength of e-liquids, and in the reasons for vaping. Their level of nicotine dependence tended to decrease over time. These users were satisfied with e-cigarettes and vaped mostly because they felt that vaping was less dangerous than smoking, and for enjoyment.

Corrigendum: Comparing Tobacco and Alcohol Policies From a Health Systems Perspective: The Cases of the Philippines and Singapore.

[This corrects the article DOI: 10.3389/ijph.2022.1605050.].

Exploring key-stakeholder perceptions on non-communicable disease care during the COVID-19 pandemic in Kenya.

Introduction: over one third of total Disability-Adjusted-Life-Years lost in Kenya are due to non-communicable diseases (NCD). In response, the Government declared significant commitment towards improving NCD care. The COVID-19 pandemic increased the burden on the already overstretched health systems in Kenya. The aims of this study are to assess whether health care providers perceived NCD care to be optimal during the pandemic and explore how to improve responses to future emergencies. Methods: this cross-sectional online survey included healthcare personnel with non-clinical roles (public health workers and policy-makers) and those delivering health care (doctors and nurses). Respondents were recruited between May and September 2021 by random sampling, completed by snowball sampling. Results: among 236 participants (42% in clinical, 58% in non-clinical roles) there was an overall consensus between respondents on NCD care being disrupted and compromised during the pandemic in Kenya. Detracted supplies, funding, and technical resources affected the continuity of NCDs' response, despite government efforts. Respondents agreed that the enhanced personnel capacity and competencies to manage COVID-19 patients were positive, but noted a lack of guidance for redirecting care for chronic diseases, and advocated for digital innovation as a solution. Conclusion: this paper explores the perceptions of key stakeholders involved in the management of NCDs in Kenya to improve planning for future emergency responses. Gaps were identified in health system response and preparedness capacity during the pandemic including the perceived need to strengthen NCD services, with solutions offered to guide resilience efforts to protect the health system from disruption.

Predicting smoking cessation, reduction and relapse six months after using the Stop-Tabac app for smartphones: a machine learning analysis.

BACKGROUND: An analysis of predictors of smoking behaviour among users of smoking cessation apps can provide useful information beyond what is already known about predictors in other contexts. Therefore, the aim of the present study was to identify the best predictors of smoking cessation, smoking reduction and relapse six months after starting to use the smartphone app Stop-Tabac. METHOD: Secondary analysis of 5293 daily smokers from Switzerland and France who participated in a randomised trial testing the effectiveness of this app in 2020, with follow-up at one and six months. Machine learning algorithms were used to analyse the data. The analyses for smoking cessation included only the 1407 participants who responded after six months; the analysis for smoking reduction included only the 673 smokers at 6-month follow-up; and the analysis for relapse at 6 months included only the 502 individuals who had quit smoking after one month. RESULTS: Smoking cessation after 6 months was predicted by the following factors (in this order): tobacco dependence, motivation to quit smoking, frequency of app use and its perceived usefulness, and nicotine medication use. Among those who were still smoking at follow-up, reduction in cigarettes/day was predicted by tobacco dependence, nicotine medication use, frequency of app use and its perceived usefulness, and e-cigarette use. Among those who had quit smoking after one month, relapse after six months was predicted by intention to quit, frequency of app use, perceived usefulness of the app, level of dependence and nicotine medication use. CONCLUSION: Using machine learning algorithms, we identified independent predictors of smoking cessation, smoking reduction and relapse. Studies on the predictors of smoking behavior among users of smoking cessation apps may provide useful insights for the future development of these apps and future experimental studies. CLINICAL TRIAL REGISTRATION: ISRCTN Registry: ISRCTN11318024, 17 May 2018. http://www.isrctn.com/ISRCTN11318024 .

An Online Survey of the Perceptions of Clinical and Non-Clinical Professionals on Healthcare for Non-Communicable Diseases and COVID-19 Measures During the Pandemic in Malaysia.

Objectives: This study assesses the opinions of health professionals in Malaysia on the disruption of non-communicable disease (NCD) services during the COVID-19 pandemic from March 2020 to January 2022. Methods: We conducted a cross-sectional online survey with 191 non-clinical public health workers and clinical health service workers in Malaysia from November 2021 to January 2022. Participants were recruited by the Malaysian Ministry of Health using major networks including key experts and practitioners. Secondary respondents were subsequently enrolled through snowballing. Results: The most notable issues raised by the survey participants relate to NCD service disruption, the redirection of NCD care resources, and NCD care being overburdened post-pandemic. Respondents also reported accounts of resilience and prompt reaction from the healthcare system, as well as calls for innovation. Conclusion: Most respondents perceived that the challenges arising from COVID-19 were mostly managed well by the healthcare system, which was able to provide the necessary services to NCD patients during this health emergency. However, the study identifies gaps in the health system response and preparedness capacity, and highlights solutions for strengthening NCD services.

Predicting the Users' Level of Engagement with a Smartphone Application for Smoking Cessation: Randomized Trial and Machine Learning Analysis.

INTRODUCTION: Studies of the users' engagement with smoking cessation application (apps) can help understand how these apps are used by smokers, in order to improve their reach and efficacy. OBJECTIVE: The present study aimed at identifying the best predictors of the users' level of engagement with a smartphone app for smoking cessation and at examining the relationships between predictors and outcomes related to the users' level of engagement with the app. METHODS: A secondary analysis of data from a randomized trial testing the efficacy of the Stop-Tabac smartphone app was used. The experimental group used the "full" app and the control group used a "dressed down" app. The study included a baseline and 1-month and 6-month follow-up questionnaires. A total of 5,293 participants answered at least the baseline questionnaires; however, in the current study, only the 1,861 participants who answered at least the baseline and the 1-month follow-up questionnaire were included. Predictors were measured at baseline and after 1 month and outcomes after 6 months. Data were analyzed using machine learning algorithms. RESULTS: The best predictors of the outcomes were, in decreasing order of importance, intention to stop smoking, dependence level, perceived helpfulness of the app, having quit smoking after 1 month, self-reported usage of the app after 1 month, belonging to the experimental group (vs. control group), age, and years of smoking. Most of these predictors were also significantly associated with the participants' level of engagement with the app. CONCLUSIONS: This information can be used to further target the app to specific groups of users, to develop strategies to enroll more smokers, and to better adapt the app's content to the users' needs.

A critique of the Australian National Health and Medical Research Council CEO statement on electronic cigarettes.

This paper critically analyses a statement by Australia's National Health and Medical Research Council (NHMRC) on e-cigarettes in May 2022 that will be used to guide national policy. We reviewed the evidence and the conclusions drawn in the NHMRC Statement. In our view, the Statement is not a balanced reflection of the benefits and risks of vaping because it exaggerates the risks of vaping and fails to compare them to the far greater risks of smoking; it uncritically accepts evidence of harms from e-cigarettes while adopting a highly sceptical attitude towards evidence of their benefits; it incorrectly claims that the association between adolescent vaping and subsequent smoking is causal; and it understates the evidence of the benefits of e-cigarettes in assisting smokers to quit. The Statement dismisses the evidence that vaping is probably already having a positive net public health effect and misapplies the precautionary principle. Several sources of evidence supporting our assessment were published after the NHMRC Statement's publication and are also referenced. The NHMRC Statement on e-cigarettes does not present a balanced assessment of the available scientific literature and fails to meet the standard expected of a leading national scientific body.

Effects of large financial incentives on motivation to quit smoking and on cigarette dependence.

BACKGROUND: Financial incentives enhance long-term smoking cessation rates, but their effects on motivation to quit in those who fail to quit are not well documented. AIM: To test the effects of large financial incentives on motivation to quit smoking and on cigarette dependence in smokers who failed to quit despite receiving incentives. PARTICIPANTS: Low-income smokers in the general population in Geneva, Switzerland, in 2011-2013. METHODS: A randomised controlled trial with follow-up after three, six and 18 months. Participants were assigned to receive either booklets plus access to a smoking cessation website (control group, n = 404), or the same intervention plus financial incentives (intervention group, n = 401). Incremental financial rewards, to a maximum of CHF 1500 (USD 1650, GBP 1000), were offered for biochemically verified smoking abstinence. No in-person counselling, telephone counselling, or medications were provided. MEASUREMENTS: Intrinsic and extrinsic motivation to quit, intention to quit, cigarette dependence. FINDINGS: In smokers at 6-month follow-up, intrinsic motivation decreased in the control group (-0.24 SD units, p < 0.001), extrinsic motivation increased in the intervention group (+0.35 SD units, p = 0.001), and twice as many participants in the intervention group (35 %) than in the control group (17 %, p < 0.001) said they intended to quit smoking in the next 30 days. Quit attempts were more frequent and their duration was longer in the intervention group than in the control group. The intervention had no impact on cigarette dependence scores. CONCLUSIONS: Large financial incentives increased motivation to quit smoking in smokers who failed to quit smoking despite receiving incentives.

Future Strategic Priorities of the Swiss Decentralized Healthcare System: A COVID-19 Case Study.

The COVID-19 pandemic exposed a multitude of vulnerabilities in Switzerland's decentralized healthcare system and highlighted the urgent need to strengthen Switzerland's capacity to respond to health crises and disease outbreaks. In this article, we draw on three distinct areas of analysis of the current functioning of the Swiss healthcare system to examine its strengths and weaknesses, which can serve as a basis for future considerations and strategic priorities. First, we analyze the different levels of nine non-pharmaceutical interventions (NPIs), as defined by the ETH KOF Stringency Index and implemented in the Swiss cantons of Zurich, Vaud, and Ticino, compared with the rate of positive COVID-19 cases, hospitalizations, and deaths. We find that there was no strong correlation between the severity of the nine non-pharmaceutical interventions implemented and lower rates of positive COVID-19 cases, hospitalizations, and deaths. Second, we examine the challenges of Switzerland's decentralized healthcare system through a literature review and with empirical data obtained from semi-structured interviews with health professionals in Switzerland. We conclude our analysis with the role of central authorities during the COVID-19 pandemic. The results demonstrate that during a national emergency in Switzerland, taking into account other factors that influence the success of a pandemic strategy, there is an opportunity for a more unified, centralized response to reduce the social and economic toll of the pandemic without necessarily risking greater health damage. We recommend that the Swiss federal government use a combination of decentralized and centralized public health and policy approaches and promote greater private-public collaboration with direct communication channels among policymakers, public health stakeholders, and the public to improve pandemic preparedness and response.

Comparing Tobacco and Alcohol Policies From a Health Systems Perspective: The Cases of the Philippines and Singapore.

Objective: To provide a comparative analysis of current tobacco and alcohol control laws and policies in the Philippines and Singapore Methods: We used a public health law framework that incorporates a systems approach using a scorecard to assess the progress of the Philippines and Singapore in tobacco and alcohol control according to SDG indicators, the WHO Framework Convention on Tobacco Control and the WHO Global Strategy to Reduce Harmful Use of Alcohol. We collected data from the scientific literature and government documents. Results: Despite health system differences, both the Philippines (73.5) and Singapore (86.5) scored high for tobacco control, but both countries received weak and moderate scores for alcohol control: the Philippines (34) and Singapore (52.5). Both countries have policy avenues to reinforce restrictions on marketing, improve corporate social responsibility programs, protect policies from the influence of the industry, and reinforce tobacco cessation and preventive measures against alcohol harms. Conclusion: Using a health system-based scorecard for policy surveillance in alcohol and tobacco control helped set policy benchmarks, showed the gaps and opportunities in these two countries, and identified avenues for strengthening current policies.

The Stop-tabac smartphone application for smoking cessation: a randomized controlled trial.

AIMS: To test whether the Stop-tabac smartphone application (app) increased smoking cessation rates. DESIGN: A two-arm, parallel-group, individually randomized, double-blind, controlled trial. SETTING AND PARTICIPANTS: A total of 5293 daily smokers (Stop-tabac = 2639, control = 2654) enrolled on app stores and on the internet in 2019-20, who lived in France or Switzerland. INTERVENTION AND COMPARATOR: The Stop-tabac application includes immediate feedback during episodes of craving and withdrawal; individually tailored counseling messages with notifications sent during 6 months; a discussion forum; fact sheets; modules on nicotine replacement therapy and e-cigarettes; and calculators of cigarettes not smoked, money saved and days of life gained since quitting. The control application included five brief pages and calculators as above. MEASUREMENTS: Primary outcome: self-reported smoking cessation after 6 months (no puff of tobacco in the past 4 weeks), with non-responders counted as smokers. SECONDARY OUTCOME: self-reported use of nicotine medications. FINDINGS: Participants were aged 36 years on average; 66% were women who smoked 15 cigarettes/day, and 64% screened positive for depression. Stop-tabac participants used the app over a longer period than control participants (23 versus 11 days, P < 0.001). Smoking cessation rates after 6 months were 9.9% in the Stop-tabac group versus 10.3% in the control group (odds ratio = 0.96, 95% confidence interval = 0.80-1.45, P = 0.63). Rates of use of nicotine medications after entry in the study were 38 versus 30% after 6 months (χ2 = 8.3, P = 0.004) in the Stop-tabac and control groups. After 6 months, 26% of participants in the Stop-tabac group and 8% in the control group said that the app helped them 'a lot' or 'enormously' to quit smoking (χ2 = 113, P < 0.001). CONCLUSIONS: In smokers enrolled on the app stores and the internet, allocation to the Stop-tabac smoking cessation app did not increase smoking cessation rates, but increased rates of use of nicotine medications.

Counseling in Vape Shops: A Survey of Vape Shop Managers in Switzerland.

Vaporizers (e-cigarettes) are the most common smoking cessation aids in Switzerland, but we do not know what information customers receive in vape shops. We surveyed vape-shop managers to find out what recommendations they make to their customers. An interdisciplinary group developed the questionnaire. Respondents self-reported their smoking history, demographics, and the recommendations they thought they would give to hypothetical customers in clinical vignettes. We also queried if they collaborated with health care professionals. Of those contacted, 53.8% (70/130) of vape-shop managers responded, and 52.3% (68/130) were included in the final analysis. Managers were mostly male and ex-smokers who switched to vaporizers; 60.3% would encourage a hypothetical smoker with high nicotine dependence to start with the highest possible nicotine concentration when switching to vaporizers. For this smoker, 36.9% would recommend high (≥15 mg/mL), 32.3% medium (6-14 mg/mL), and 3.1% low (1-5 mg/mL) nicotine concentrations. The rest adapted their recommendations to fit the customer or device; 76.5% reported that physicians referred customers to them, and 78.8% would attend a course given by experts in the field of vaporizers and smoking cessation. Vape-shop managers varied widely in the recommendations they gave customers. Most reported ongoing collaboration with health care professionals and were interested in improving their counselling skills through training.

A survey of users of the IQOS tobacco vaporizer: perceived dependence and perceived effects on cigarette withdrawal symptoms.

BACKGROUND: Tobacco vaporizers are devices that heat tobacco without burning it. There is currently a scarcity of studies about the addictiveness of tobacco vaporizers or their effects on cigarette withdrawal symptoms. GOALS: To assess the perceived dependence of users of tobacco vaporizers and the perceived effects of these products on cigarette withdrawal symptoms. METHODS: Enrollment of participants through the internet from 2016 to 2018. Participants were self-selected visitors to an anti-addiction website, current and past users of tobacco vaporizers aged ≥18. RESULTS: We included 139 users of IQOS tobacco vaporizers. All participants were current (49.6%) or former cigarette smokers at the time when they began to use the tobacco vaporizer. Among the 135 current users, the median dependence on vaporizers was 80 on a scale from 0-100 (25th and 75th percentiles: 50 and 90), and 63.6% reported being somewhat to totally afraid of becoming dependent on the vaporizer. Half (51%) reported that they were less dependent on vaporizers than on combustible cigarettes, 43.8% were equally dependent on both products and 5.2% were more dependent on vaporizers than on cigarettes. Only one cigarette withdrawal symptom was reported by participants, "craving" for combustible cigarettes, and among respondents who experienced craving, 83.9% found that the IQOS vaporizer relieved it "a lot" to "totally". CONCLUSIONS: In this self-selected online sample of IQOS users, the perceived dependence on this tobacco vaporizer was relatively high and almost two thirds of respondents were afraid of becoming dependent on IQOS. Most participants perceived that IQOS relieved the craving to smoke combustible cigarettes.

Public attitudes towards e-cigarette regulations and policies in Taiwan.

Background: There are various approaches to e-cigarette regulation globally. In Taiwan, the term "e-cigarette" is not found in existing regulations, but health authorities apply explanatory notes derived from standing laws to e-cigarette. Taiwan health authority is in the process of regulative reform to include "e-cigarette" in standing tobacco law. Our objective was to investigate the public's attitudes towards potential policy options for e-cigarette regulations in Taiwan. Design and Methods: We conduct an anonymous online survey in the general public. A questionnaire in Mandarin was posted on the website Stop-tabac.ch between July and November 2017. Results: Participants (n=236) were mostly male, young, highly educated, employed, and smoked or had smoked cigarettes in the past. Half were e-cigarette users. Four measures banning ecigarettes, labelling content and nicotine level and establishing a maximum-allowable nicotine level were supported by more than 70% of participants. Vaping status was strongly associated with support for most measures after controlling for other factors in multivariate models. Conclusion: We documented attitudes of a self-selected sample of the general public in Taiwan regarding e-cigarette regulations and policies. These results may be useful to design studies in more representative samples and to inform e-cigarette regulations, policies and education campaigns.

The Stop-Tabac smartphone application for smoking cessation: study protocol for a randomized controlled trial in the general population.

BACKGROUND: Smartphone-based support can reach thousands of smokers and help those who would otherwise try to quit smoking by themselves with little chance of success. Nicotine medications double the chances of quitting smoking, but few smokers use them, and they often use them for too short a time and at an insufficient dose. It is therefore important to increase access to support for smoking cessation and compliance with nicotine therapy. The objectives of this study are to assess whether the Stop-Tabac application (app) is effective for smoking cessation and to examine whether the outcome is influenced by the personal characteristics of participants. METHODS: Trial design: this is a two-arm, parallel-group, superiority, individually randomized, "placebo" controlled trial in 5200 smokers, with follow up after 1 week, 1 month and 6 months. The participants are adult daily smokers (N = 5200) enrolled on the Internet, living in France or Switzerland. The intervention is the Stop-tabac fully-automated app for smartphones, which was launched in 2012 and continuously improved thereafter. It includes fact sheets; calculators of cigarettes not smoked, money saved, and years of life gained; an interactive "coach" that provides automated, individually tailored counseling messages based on the user's personal profile, sent regularly for 6 months; immediate feedback during episodes of craving and tobacco withdrawal symptoms; a discussion forum ("The Tribe") where participants provide and receive social support; a quiz that informs users in a playful way; and a module on nicotine therapy that includes personalized feedback and follow up. The outcome is self-reported smoking cessation after 6 months (no puff of tobacco in the past 4 weeks), and after 1 week and 1 month (no puff in the past 7 days). Participants will be randomized automatically based on a list of random numbers. Participants, assistants in charge of collecting follow-up data and data analysts will be blinded to allocation. Funding is provided by the Swiss National Science Foundation, CHF 194,942 (EUR 182,200, USD 200,700), grant 32003_179369. JFE's salary is paid by the University of Geneva, YK's salary is paid by the Lausanne University Hospitals. DISCUSSION: There is little evidence from randomized trials of the impact of health apps in general and of smoking cessation apps in particular. This study will fill this gap. TRIAL REGISTRATION: ISRCTN Registry: ISRCTN11318024. Registered on 17 May 2018.

Withdrawal Symptoms From E-Cigarette Abstinence Among Adult Never-Smokers: A Pilot Experimental Study.

INTRODUCTION: Use of e-cigarettes among never-smokers has substantially increased; yet there are few descriptions of the consequences of such use. We assessed whether adult never-smokers can have withdrawal from cessation of e-cigarettes. METHODS: In an un-blinded pre-post clinical trial, 30 never-smoker daily e-cigarette users used their own nicotine-containing e-cigarette for 7 days followed by 6 days of biologically confirmed abstinence. Participants monitored symptoms of nicotine withdrawal nightly via an Interactive Voice Response system. They attended three lab visits/week to provide expired carbon monoxide and urine samples to determine compliance. FINDINGS: Abstinence increased all the DSM5 symptoms of tobacco withdrawal and this occurred in the majority of participants. The increase in severity of withdrawal was small and rarely impaired functioning. CONCLUSIONS: Our finding suggests that withdrawal symptoms can occur in never-smokers who stop e-cigarettes abruptly. However, the severity of withdrawal appears to be small and may not be of clinical or regulatory significance. Although our sample size was small and thus replication tests of our results are indicated, it may be prudent to warn never-smokers that withdrawal symptoms may occur. IMPLICATIONS: This study indicates that withdrawal symptoms can occur in never-smokers who are daily e-cigarette users. However, the severity of withdrawal from e-cigarette abstinence in never-smokers appears to be small and may not be of clinical or regulatory significance. Given our small sample size, replication of our results is warranted. Nevertheless, it might be prudent to warn never-smokers of addiction to e-cigarettes.Clinical Trial Registration = NCT02825459.

Withdrawal Symptoms From E-Cigarette Abstinence Among Former Smokers: A Pre-Post Clinical Trial.

INTRODUCTION: The major aim of this study was to test whether abstinence from e-cigarettes causes withdrawal symptoms in former smokers. METHODS: We conducted an unblinded, within-participants, pre-post clinical trial in which 109 former smokers who were current daily electronic cigarette (e-cigarette) users used their own e-cigarette for 7 days followed by 6 days of biologically confirmed abstinence engendered via an escalating contingency payment system. Participants monitored symptoms of nicotine withdrawal daily via an Interactive Voice Response system. They also attended three laboratory visits per week for carbon monoxide and cotinine testing to verify abstinence. RESULTS: Half of participants completely abstained for a week. All the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) tobacco withdrawal symptoms, craving for e-cigarettes, craving for tobacco cigarettes, and the four possible new withdrawal symptoms (anhedonia, impulsivity, mood swings, and positive affect) increased during abstinence. Weight increased and heart rate decreased with abstinence. Symptoms showed the prototypical inverted U time pattern of a withdrawal state. The magnitude of withdrawal appeared to be somewhat less than that in a prior study of abstinent daily tobacco cigarette smokers. More severe withdrawal on the first 2 days of abstinence did not predict abstinence on the last day of the study. CONCLUSIONS: Former smokers who are daily e-cigarette users transfer physical dependence on tobacco cigarettes to dependence on e-cigarettes. The severity of withdrawal from e-cigarettes appears to be only somewhat less than that from daily tobacco cigarette use. Replication tests that include placebo controls, testing for pharmacological specificity, and including never-smokers, non-daily e-cigarette users and dual users are indicated. IMPLICATIONS: Our results indicate e-cigarettes can maintain physical dependence. This adverse effect should be included in any risk vs. benefit calculation. Also, potential and current e-cigarette users should be informed that abrupt cessation of e-cigarettes can cause withdrawal symptoms. TRIAL REGISTRATION: NCT02825459.

Stakeholders' Views on E-cigarette Legislation: A Qualitative Study in Taiwan.

Objectives: Little is known about stakeholders' opinions on e-cigarette legislation in Taiwan. Our aim is to understand the perspectives of stakeholders regarding the current legal system and measures that could be included in future e-cigarette legislation in Taiwan. Materials and Methods: We conducted in-depth interviews with 14 Taiwanese stakeholders, using semi-structured questionnaires, either face-to-face or via telephone, in 2016-2017. All interviews were transcribed. Results: The current legal system is applied to e-cigarettes even though it does not mention them specifically, this system carries risks and faces challenges from anti-tobacco and vaper groups. Some weaknesses in the current legislative framework were noted, including the facts that e-cigarettes are sold without government approval, that there are no manufacturing standards, no inspections or monitoring, and no regulations for usage or advertising. There was wide acceptance among stakeholders that e-cigarettes should be better regulated, particularly e-cigarettes containing nicotine. Most interviewees agreed that there is a need to restrict e-cigarette use by teenagers and in public places where tobacco smoking is prohibited. Most interviewees also would like to restrict marketing, ban sales in vending machines, via mail order, and over the internet; label content and nicotine levels; and introduce health warnings and taxation. Conclusions: Almost all interviewees agreed that there is a need for a specific legal framework for e-cigarettes in Taiwan, and that e-cigarettes should be regulated in the same way as combustible cigarettes.

Learning to assist smokers through encounters with standardized patients: An innovative training for physicians in an Eastern European country.

OBJECTIVES: A lack of physician training is a major obstacle for effective tobacco dependence treatment. This study assessed the feasibility of an active learning training program and its effects on smoking cessation counselling skills of medical residents in Armenia, an Eastern European country with high smoking prevalence. STUDY DESIGN: The study used a pre-post assessment of smoking cessation counselling activities and a course evaluation survey to assess the feasibility of the intervention in a different environment. METHODS: We adapted an active learning training model developed in Switzerland. Residents were trained in Yerevan, Armenia, using video-taped counselling sessions, role plays, standardized patients (actors), group discussions and immediate feedback. The training evaluation was done using a semi-structured anonymous questionnaire. The study assessed the physicians' self-reported smoking cessation counselling activities before and 6 months after the training. A non-parametric Mann-Whitney test was used to assess pre-post differences in physicians' counselling skills measured on ordinal scale. RESULTS: Of the 37 residents trained, 75% were female, 89% aged 20-29 years and 83% were never-smokers. Twenty-eight trainees (76%) returned the course evaluation survey and 32 (86%) answered a questionnaire on skills self-assessment at 6 months follow-up. The majority agreed the course was successful in achieving its learning objectives (64%-96%) and increased their confidence in assisting their patients to quit (74%). After 6 months, the physicians were more likely than at baseline to adhere to evidence-based counselling strategies, including assessing the smoking status and dependence and matching the advice to the patient motivation. The training did not, however, improve the prescription of tobacco dependence medications. CONCLUSIONS: Six months after the training, several self-reported smoking cessation counselling activities had significantly improved compared to baseline. This training model is acceptable for medical residents in Yerevan, Armenia and offers a promising approach in addressing the lack of physician counselling skills in similar settings and populations.