Leveraging the cigarette purchase task to understand relationships between cumulative vulnerabilities, the relative reinforcing effects of smoking, and response to reduced nicotine content cigarettes.

We examined if the relative-reinforcing effects of smoking increase with greater cumulative vulnerability and whether cumulative vulnerability moderates response to reduced nicotine content cigarettes. Participants were 775 adults from randomized clinical trials evaluating research cigarettes differing in nicotine content (0.4, 2.4, 15.8 mg/g). Participants were categorized as having low (0-1), moderate (2-3), or high (≥4) cumulative vulnerability. Vulnerabilities included rural residence, opioid use disorder, affective disorder, low educational attainment, poverty, unemployment, and physical disability. We used the cigarette purchase task (CPT) to assess the relative-reinforcing effects of participants' usual-brand cigarettes at baseline and study cigarettes during the 12-week trial. The CPT is a behavioral-economic task wherein participants estimate likely smoking (demand) over 24 h under escalating cigarette price. Demand is characterized by two factors: Amplitude (demand volume at zero/minimal price) and Persistence (demand sensitivity to price). Greater cumulative vulnerability was associated with greater demand Amplitude (F[2709] = 16.04,p < .0001) and Persistence (F[2709] = 8.35,p = .0003) for usual-brand cigarettes. Demand Amplitude for study cigarettes increased with increasing cumulative vulnerability (F[2619] = 19.59, p < .001) and decreased with decreasing nicotine content ([4879] = 5.45, p < .001). The only evidence of moderation was on demand Persistence (F[8867] = 2.00,p = .04), with larger reductions at the 0.4 mg/g compared to 15.8 mg/g doses among participants with low compared to moderate or high cumulative vulnerability. The relative-reinforcing effects of smoking clearly increase with greater cumulative vulnerability. Reducing nicotine content would likely reduce demand Amplitude across cumulative-vulnerability levels but reductions in demand Persistence may be more limited among those with greater cumulative vulnerability.

Genetic predispositions moderate the effectiveness of tobacco excise taxes.

BACKGROUND: Tobacco consumption is one of the leading causes of preventable death. In this study, we analyze whether someone's genetic predisposition to smoking moderates the response to tobacco excise taxes. METHODS: We interact polygenic scores for smoking behavior with state-level tobacco excise taxes in longitudinal data (1992-2016) from the US Health and Retirement Study (N = 12,058). RESULTS: Someone's genetic propensity to smoking moderates the effect of tobacco excise taxes on smoking behavior along the extensive margin (smoking vs. not smoking) and the intensive margin (the amount of tobacco consumed). In our analysis sample, we do not find a significant gene-environment interaction effect on smoking cessation. CONCLUSIONS: When tobacco excise taxes are relatively high, those with a high genetic predisposition to smoking are less likely (i) to smoke, and (ii) to smoke heavily. While tobacco excise taxes have been effective in reducing smoking, the gene-environment interaction effects we observe in our sample suggest that policy makers could benefit from taking into account the moderating role of genes in the design of future tobacco control policies.

There's no smoke without fire: Smoking in smoke-free acute mental health wards.

BACKGROUND: People who smoke with serious mental illness carry disproportionate costs from smoking, including poor health and premature death from tobacco-related illnesses. Hospitals in New Zealand are ostensibly smoke-free; however, some mental health wards have resisted implementing this policy. AIM: This study explored smoking in acute metal health wards using data emerging from a large sociological study on modern acute psychiatric units. METHODS: Eighty-five in-depth, semi-structured interviews were conducted with staff and service users from four units. Data were analysed using a social constructionist problem representation approach. RESULTS: Although high-level smoke-free policies were mandatory, most participants disregarded these policies and smoking occurred in internal courtyards. Staff reasoned that acute admissions were not the time to quit smoking, citing the sceptres of distress and possibly violence; further, they found smoking challenging to combat. Inconsistent enforcement of smoke-free policies was common and problematic. Many service users also rejected smoke-free policies; they considered smoking facilitated social connections, alleviated boredom, and helped them feel calm in a distressing environment - some started or increased smoking following admission. A minority viewed smoking as a problem; a fire hazard, or pollutant. No one mentioned its health risks. CONCLUSION: Psychiatric wards remain overlooked corners where hospital smoke-free policies are inconsistently applied or ignored. Well-meaning staff hold strong but anachronistic views about smoking. To neglect smoking cessation support for people with serious mental illness is discriminatory and perpetuates health and socioeconomic inequities. However, blanket applications of generic policy are unlikely to succeed. Solutions may include myth-busting education for service users and staff, local champions, and strong managerial support and leadership, with additional resourcing during transition phases. Smoke-free policies need consistent application with non-judgemental NRT and, potentially, other treatments. Smoking cessation would be supported by better designed facilities with more options for alleviating boredom, expressing autonomy, facilitating social connections, and reducing distress.

Tobacco smoking initiation among students in Samoa and health concerns.

BACKGROUND: High prevalence of tobacco smoking among young students remains a serious health concern given the positive association between smoking and NCDs. More recently, some studies also noted young smokers were more likely to get infected with COVID-19 compared to non-smokers. This study aims to assess the factors that influence smoking uptake among young students in Samoa. Findings from this study will provide valuable insight to policymakers and health authorities on policies and strategies to combat smoking among youth in Samoa and the Pacific Island Countries (PICs). METHODS: The 2017 Global Youth Tobacco Survey data of Samoa, available from the World Health Organization is used in the analysis. We use the multinominal logistic model to investigate the effects of socio-economic and demographics factors on young students' uptake of smoking in Samoa. RESULT: The main findings of this study indicate that sex, age, friendship, parental smoking, family discussion, outside influence, pocket money, and mother's education are important determinants of tobacco smoking initiation among youths in Samoa. CONCLUSION: Our findings contribute towards the evidence of the imperative health impact of friends, parents, and public smoking on students in Samoa. This warrants strategies that are effective in discouraging parents from smoking and implement measures that prevent smoking in public places. Moreover, educational efforts, particularly those that encourage more discussion at home settings on the harmful effects of smoking are strongly recommended. Parents are strongly encouraged to regularly monitor children's spending behaviour.

The Effectiveness of Health Education Using Audiovisual on the Santri Smokers' Motivation to Stop Smoking.

BACKGROUND AND OBJECTIVE: Low motivation to quit smoking affects individual smoking behavior. Health education using audiovisual media can increase smokers' motivation to quit smoking. The objective of this study was to determine the effectiveness of health education using audiovisuals on the Santri smokers' motivation to stop smoking. METHODS: This quasi-experimental study was carried out using a pretest-posttest design. The sample in this study included Santri smokers studying at the Traditional Islamic Boarding School in Aceh Besar . This study consisted of 4 groups. Three groups were given intervention (audiovisual health education with different themes) and one group received just health education. Groups were compered in terms of difference in the mean smokers' motivation to quit smoking. The data analysis was done by running paired t-test and one-way ANOVA. RESULTS: The results of statistical tests showed that there was a difference in the mean motivation to quit smoking before and after the intervention in each group (mean ± SD for group 1 to 4 was 11.52 ± 4.76, 15.39 ± 6.06, 22.57 ± 6.23, and 9.84 ± 6.42, respectively). The highest increase in the mean motivation to quit smoking was allocated to group 3 who received audiovisual health education with the theme of risk of developing cancer due to smoking. CONCLUSION: Health education using audiovisuals could increase the motivation of students to quit smoking, especially interventions on the risk of developing cancer due to smoking. Therefore, health workers are suggested to use audiovisuals to implement various intervention in order to change smoking behavior in students.

Smokers' cognitive and behavioural reactions during the early phase of the COVID-19 pandemic: Findings from the 2020 ITC Four Country Smoking and Vaping Survey.

INTRODUCTION: COVID-19 is primarily a respiratory illness, and smoking adversely impacts the respiratory and immune systems; this confluence may therefore incentivize smokers to quit. The present study, conducted in four high-income countries during the first global wave of COVID-19, examined the association between COVID-19 and: (1) thoughts about quitting smoking; (2) changes in smoking (quit attempt, reduced or increased smoking, or no change); and (3) factors related to a positive change (making a quit attempt or reducing smoking) based on an adapted framework of the Health Belief Model. METHODS: This cross-sectional study included 6870 adult smokers participating in the Wave 3 (2020) ITC Four Country Smoking and Vaping Survey conducted in Australia, Canada, England, and United States (US). These four countries had varying responses to the pandemic by governments and public health, ranging from advising voluntary social distancing to implementing national and subnational staged lockdowns. Considering these varying responses, and the differences in the number of confirmed cases and deaths (greatest in England and the US and lowest in Australia), smoking behaviours related to COVID-19 may have differed between countries. Other factors that may be related to changes in smoking because of COVID-19 were also explored (e.g., sociodemographics, nicotine dependence, perceptions about personal and general risks of smoking on COVID-19). Regression analyses were conducted on weighted data. RESULTS: Overall, 46.7% of smokers reported thinking about quitting because of COVID-19, which differed by country (p<0.001): England highest (50.9%) and Australia lowest (37.6%). Thinking about quitting smoking because of COVID-19 was more frequent among: females, ethnic minorities, those with financial stress, current vapers, less dependent smokers (non-daily and fewer cigarettes smoked/day), those with greater concern about personal susceptibility of infection, and those who believe COVID-19 is more severe for smokers. Smoking behaviour changes due to COVID-19 were: 1.1% attempted to quit, 14.2% reduced smoking, and 14.6% increased smoking (70.2% reported no change). Positive behaviour change (tried to quit/reduced smoking) was reported by 15.5% of smokers, which differed by country (p = 0.02), where Australia had significantly lower rates than the other three countries. A positive behavioural smoking change was more likely among smokers with: lower dependence, greater concern about personal susceptibility to infection, and believing that COVID-19 is more severe for smokers. CONCLUSIONS: Though nearly half of smokers reported thinking about quitting because of COVID-19, the vast majority did not change their smoking behaviour. Smokers were more likely to try and quit or reduce their smoking if they had greater concern about susceptibility and severity of COVID-19 related to smoking. Smokers in Australia were least likely to reduce or try to quit smoking, which could be related to the significantly lower impact of COVID-19 during the early phase of the pandemic relative to the other countries.

Changes in Attitude to Waterpipe Tobacco Smoking among Youngsters in Eastern Province, Saudi Arabia: A Cross-Sectional Study.

BACKGROUND: A growing number of epidemiological evidence suggests a significant increase in waterpipe tobacco smoking, and its potential to become a major public health concern in most Arabic countries, including Saudi Arabia. METHODS: A cross-sectional study was carried out to assess the prevalence of intention to quit among ever users of waterpipe and intention to start among the never users. The study also investigated the barriers that may prevent users from quitting or trigger the nonusers to start waterpipe smoking. The study consisted of 464 university students from Eastern Province, Saudi Arabia. RESULTS: One hundred and sixty-eight (36.2%) participants were responded that they had WTS at least one time in the past. Among the ever users of WTS, 120 (71.4%) participants had made an attempt or more to quit WTS in the past, 64 (38.1%) had made more than one attempt, and nearly two-third expressed the intention to quit WTS in the future. Forty (13.5%) out of 296 never-users expressed their intention to start WTS in the future. The study further showed that peer influence, social acceptance, and risk perception were significant predictors of intention to start or stop WTS among students. CONCLUSION: It is promising that substantial users have the intention to discontinue WTS, though a fraction of never users wish to try WTS in the future.
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I am what I am: A meta-analysis of the association between substance user identities and substance use-related outcomes.

OBJECTIVE: Research indicates that a substance user identity (i.e., drinking, smoking, and marijuana identity) is positively correlated with substance use-related outcomes (e.g., frequency, quantity, consequences, and disorder symptoms). The current study aimed to meta-analytically derive single, weighted effect size estimates of the identity-outcome association as well as to examine moderators (e.g., substance use type, explicit/implicit assessment, demographic characteristics, and research design) of this association. METHOD: Random effects meta-analysis was conducted on 70 unique samples that assessed substance user identity and at least one substance use-related outcome (frequency, quantity, consequences, and/or disorder symptoms), and provided the necessary information for effect size calculations. RESULTS: Substance user identity was found to be a statistically significant moderate-to-large correlate of all substance use-related outcomes examined in the current study (r w = .365, p < .001, rw² = .133). The strongest associations were observed between identity and disorder symptoms (alcohol) and frequency of substance use (tobacco or marijuana). In terms of moderators of the identity-outcome association, the link between explicit drinking identity and alcohol use-related outcomes appeared to be stronger in magnitude than the relationship between implicit drinking identity and alcohol use-related outcomes; however, this difference appears to be largely due to the finding that implicit measures have lower reliability. The strongest identity-outcome association was observed among younger individuals. CONCLUSIONS: Substance user identity is clearly an important correlate of substance use-related outcomes and this association is stronger among younger individuals. Additional theoretical, empirical, and intervention research is needed to utilize knowledge gleaned from the current study on the identity-outcome association. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

An adapted smoking-cessation intervention for Turkish-speaking migrants in Switzerland: Predictors of smoking outcomes at one-year follow-up.

BACKGROUND: Migrant populations usually report higher smoking rates. Among those migrant populations, Turkish- and Kurdish-speaking migrants are often overrepresented. Providing equal access to health services is one of the major challenges of our time. The need for adapted smoking-cessation treatments for Turkish-speaking populations to achieve equity in health led, in 2006, to the development and implementation of the Tiryaki-Kukla smoking-cessation program. The aims of the current study were to evaluate one-year quit rates for smoking-cessation courses held from 2006-2018 and investigate whether certain characteristics predict long-term smoking cessation or reduction. METHODS: Program evaluation included a pre/post questionnaire (session 1/ 3 months after the quit day) and a follow-up telephone call twelve months after the quit day. To elucidate factors associated with long-term smoking cessation and reduction, Cox regression analysis and Weighted Generalized Equation Models were used. RESULTS: Of the 478 who participated in smoking-cessation courses, 45.4% declared themselves non-smokers at one-year follow-up. This quit rate is higher than that achieved during the preliminary evaluation of the program involving 61 participants (37.7%). Predictors of long-term smoking cessation were course length (eight vs. six sessions) (95% CI = 1.04-1.36, p = .01), adherence to the course (95% CI = 0.98-0.99, p<0.01), use of pharmacotherapy or nicotine replacement therapy products (95% CI = 0.74-0.98, p = .02), and time passed in the morning until the first cigarette is smoked (95% CI5min = 1.17-1.77, p<0.001; 95% CI30min = 1.09-1.65, p<0.01). Predictors of change in cigarettes smoked per day among smokers were-the time passed until the first cigarette in the morning (5min p < .001; 30min p < .001; 60min p < .01)-, gender (p < .001), and level of motivation to quit at baseline (p = .04). CONCLUSIONS: Our findings are consistent with existing evidence supporting adapted smoking cessation interventions to reduce health inequity in migrant populations. However, achieving harm reduction in smokers with higher dependence scores remains challenging.

Trajectory of smoking behavior change among Chinese immigrant smokers.

BACKGROUND: The incidence and mortality rates of smoking-associated lung cancer are high among Chinese immigrant smokers. Coming from a country with different smoking policies, culture, and economic background than the U.S., Chinese smokers may change their smoking behaviors after immigrating to the U.S. OBJECTIVES: This study aims to explore the trajectory of smoking behavior change among Chinese immigrant smokers migrating to the U.S. METHODS: This qualitative study was guided by the Grounded theory. Semi-structured intensive individual interviews were conducted among 10 eligible participants. A purposive theoretical sampling method was used to recruit participants through a website. Individual interviews were conducted online, via telephone, or in-person in Mandarin. Data were transcribed verbatim in Mandarin, translated into English, and triangulated with follow-up interviews and dialogues among authors to enhance trustworthiness and consistency of the study. Process coding and content analysis were used to analyze data. RESULTS: A total of 10 participants, 7 males and 3 females, were interviewed. Results showed the trajectory of smoking behavior change among Chinese immigrant smokers went through three phases: 1) Beginning to smoke, which included learning to smoke from others, trying to smoke and learning to smoke, and hiding their smoking behaviors from others; 2) maintaining smoking, which included setting boundary around smoking, smoking as a facilitator or barrier to social interaction, feeling pressures related to smoking behavior, and making others happy: Collective smoking and controlling smoking desire; and 3) changing smoking behaviors, which included experiencing life events that were triggers to changing smoking behavior, boredom as a reason for relapses, personal will as a key to quitting smoking, and quitting smoking for a loved one. Although some differences existed between male and female Chinese immigrant smokers' smoking behaviors, their trajectories of smoking behavior change were generally similar. DISCUSSION: Findings from this study can help health care providers to extend their understanding toward smoking behavior change among Chinese immigrant smokers across different socio-cultural contexts.

Mental activities after dinner increase cigarettes consumption.

Tobacco smoking is the main risk factor for many diseases such as chronic obstructive pulmonary disease as well as lung cancer and cigarettes. Smokers usually keep continuing to smoke during their mental activities in the evening between dinner and sleep time on work days. So it is critical to elucidate the relationship between cigarettes daily consumption and mental activities after dinner. A survey designed by ourselves was finished among 369 patients who came to our clinic for smoking cessation. Age, gender, BMI, cigarettes consumption were recorded and analyzed. Statistically, Pearson correlation test and general linear model test were used. Compared to ≤ 40 years' group, patients with mental activities after dinner consumed more cigarettes than those without mental activities (22.80 ± 10.86 vs. 30.88 ± 18.69, P value < 0.001). The Pearson correlation test showed no interact effects on age and BMI, and general linear model test showed that the cigarettes numbers between smokers with mental activities after dinner and smokers without mental activities after dinner are different (P value < 0.001). Mental activities from dinner finish to sleep time increase cigarettes consumption. It provides evidence that mental thinking activities after dinner is a risk factor of tobacco using.

A Meta-Analysis of Cue Reactivity in Tobacco Cigarette Smokers.

INTRODUCTION: The cue reactivity paradigm allows for systematic evaluation of motivational responses to drug-related cues that may elicit drug use. The literature on this topic has grown substantially in recent decades, and the methodology used to study cue reactivity has varied widely across studies. The present research provided a meta-analytic investigation of variables that have an impact on cue reactivity effects to enhance our understanding of this key feature of tobacco use disorders. METHODS: A total of 128 publications yielded 249 effect sizes, which were analyzed to investigate the magnitude of the cue reactivity effect and potential moderators. RESULTS: Craving generated a moderate-to-large effect size (Hedges' g = 0.71, p < .001), indicating that drug cues produced significantly greater craving than neutral cues. However, physiological variables yielded significantly lower or nonsignificant effect sizes. Analyses of a variety of empirically and theoretically relevant moderator variables showed that cue modality, cue personalization, cue reactivity environment, and the use of multiple assessments of cue reactivity were significantly associated with the magnitude of cue-specific craving effects (ps < .001). Effect sizes were not significantly related to abstinence status, gender, cigarettes per day, and treatment-seeking status. CONCLUSIONS: The results underscored the strength of self-reported craving as an index of cue reactivity across studies, which support theories that posit cue reactivity is core to the addictive process for daily tobacco cigarette smokers. The present research further elucidates the variables that alter the cue reactivity effects across studies and provides recommendations for future cue reactivity research. IMPLICATIONS: A core feature of addiction is that drug-related cues can have a major impact on motivational responses across multiple substance use disorders, including tobacco cigarettes. This paper describes a meta-analysis updating and synthesizing cue reactivity research with tobacco cigarette smokers over the last 20 years, a time of rapid growth for this literature. The study leads to a better understanding of the cue reactivity paradigm across different self-report and physiological variables and identifies factors that may modulate addictive motivation for tobacco cigarettes.

An international survey: Tobacco smoking cessation strategies within left ventricular assist device centers.

BACKGROUND: Tobacco smoking is a significant source of morbidity in patients with a durable left ventricular assist device. While various cessation strategies have been investigated, the ability of ventricular assist device centers to implement a successful tobacco cessation program remains uncertain. We explored various cessation strategies employed by ventricular assist device centers and assessed perspectives of their effectiveness, as well as institutional investment in these programs. METHODS: A 37-question online self-report survey was created using Survey Monkey® and distributed worldwide. We investigated (1) programmatic strategies utilized for smoking cessation, (2) the respondent's perspective on the effectiveness of these strategies, (3) the structure with which these therapies are administered, and (4) overall organizational support for these treatments. RESULTS: A total of 47 centers worldwide completed the survey. The most common methods of tobacco cessation were pharmacologic and nicotine replacement therapy (78% and 66%). However, only about half (47% and 50%, respectively) of the centers indicated that these strategies were effective. When asked whether a respondent's center perceives that tobacco smoking should be a deciding factor in destination therapy evaluations, nearly a third (15, 32%) responded in the affirmative. CONCLUSION: While significant overlap exists among centers regarding treatments used for smoking cessation with left ventricular assist device patients, the most common treatments are not thought to be effective. While the current recommendations require tobacco smoking cessation in only bridge-to-transplant patients and not destination therapy patients, a number of centers disagree with the national guidelines and believe smoking should be prohibited in both populations.

Healthcare Professionals' Beliefs, Attitudes, Knowledge, and Behavior Around Vaping in Pregnancy and Postpartum: A Qualitative Study.

INTRODUCTION: Finding effective ways to help pregnant women quit smoking and maintain long-term abstinence is a public health priority. Electronic cigarettes (ie, vaping) could be a suitable cessation tool in pregnancy for those who struggle to quit; however, healthcare professionals (HCP) must be informed about these devices to offer appropriate advice. This study used the Capability, Opportunity, Motivation, and Behavior (COM-B) model and Theoretical Domains Framework (TDF) to explore HCP attitudes towards vaping in pregnancy and postpartum; beliefs about the health risks of vaping; perceived barriers and facilitators of vaping in pregnancy; knowledge of current guidelines and policies; and training needs. METHODS: Interviews (n = 60) were conducted with midwives (n = 17), health visitors (n = 10), general practitioners (n = 15) and stop smoking specialists (n = 18) across the United Kingdom. Interview transcriptions were analyzed thematically using the framework approach and the COM-B. RESULTS: Discussing vaping as a tool for quitting smoking in pregnancy was prevented by a lack of capability (limited knowledge of vaping, lack of training in smoking cessation); lack of opportunity (restricted by organizational policies and guidelines, lack of time and financial issues impacting on training), and negative social influences (sensationalist media and stigma associated with vaping in pregnancy); and lack of motivation (fear of future litigation and comebacks should adverse effects from vaping arise). CONCLUSIONS: Factors related to capability, opportunity, and motivation were identified that influence HCPs attitudes and behaviors towards vaping in pregnancy. Gaps in knowledge and training needs were identified, which could inform the development of targeted vaping training. IMPLICATIONS: Vaping could be suitable in pregnancy for those struggling to quit smoking. However, HCPs must be informed about these devices to offer appropriate advice. These data extend our knowledge of factors influencing HCP attitudes and behaviors towards vaping in pregnancy. Generally, vaping was perceived as safer than cigarettes, but a perceived lack of evidence, health and safety risks, dependency, and regulation issues were concerning. Considering our findings, greater efforts are needed to ensure HCPs are sufficiently informed about vaping and guidelines available. More importance should be placed on training for all HCPs who have contact with pregnant women.

Impact of the Revised European Tobacco Product Directive on the Quality of E-cigarette Refill Liquids in Belgium.

INTRODUCTION: Since its introduction, the e-cigarette has become a commonly used consumer product. In this study, we investigate whether regulatory changes had an impact on the quality of refill liquids (e-liquids) available on the Belgian market through analysis of their chemical composition. Hence, the nicotine concentration accuracy was investigated in samples before, during and after the implementation of the revised Tobacco Product Directive (TPD) as an indicator of good manufacturing practices. This is, however, not enough to assure the quality. Therefore, extra criteria were also assessed based on TPD requirements. METHODS: By using in-house validated methods, a total of 246 e-liquids purchased prior (2013-2015), during (2016) and after (2017-2018) the implementation of the TPD revisions, were analyzed for the presence of nicotine, nicotine-related impurities, volatile organic compounds (VOCs), caffeine and taurine, and the flavors diacetyl and acetylpropionyl. RESULTS: Although not all manufacturers managed to produce and label their products accurately, nicotine labeling discrepancies have decreased over time. Moreover, also the number of e-liquids, containing high-risk VOCs (10% in 2016 vs. none of the samples in 2017-2018), caffeine (16% in 2017 vs. 5% in 2018), and diacetyl and acetylpropionyl (50% in 2017 vs. 27% in 2018 of sweet-flavored samples) diminished over time. CONCLUSION: Our results demonstrate that the overall quality of the e-liquids has improved after the implementation of the revised TPD. However, the results also show that periodic quality control might be required to ensure further compliance to the TPD. IMPLICATIONS: This study clearly demonstrates that the implementation of the revised TPD has improved the quality of the e-liquids on the Belgian market. However, there are still e-liquids that are not in agreement with the TPD due to nicotine concentration label discrepancies, presence of e-liquid impurities and controversial flavors diacetyl and acetylpropionyl or the additive caffeine.

Tobacco Product Promotions Remain Ubiquitous and Are Associated with Use and Susceptibility to Use Among Adolescents.

INTRODUCTION: The decline in tobacco smoking among US adolescents has been exceeded by the exponential rise in nicotine vaping with an overall net gain in youth tobacco product use. While cigarette companies are restricted from advertising on television/radio, vaping promotions have been largely unrestricted. This study examined exposure to tobacco product promotions in a US sample of 1003 adolescents and its associations with product use and susceptibility to use. AIMS AND METHODS: Adolescents (13-17) were recruited online and anonymously surveyed in 2019 about their ever and current (past 30 days) tobacco smoking (cigarette and cigar) and nicotine vaping behaviors, and among never-users, susceptibility to vaping. Multivariate models tested associations with past-month exposure to tobacco product promotions controlling for demographic features, harm perceptions, and family and peer influences. RESULTS: Tobacco product use was 34% ever-use and 20% current-use. Most had seen cigarette (91%) and nicotine vaping (80%) product promotions in the past 30 days. A majority reported exposure at point-of-sale and on major (television and cinema) and social media. In adjusted multivariate models, greater exposure to tobacco product promotions was significantly associated with ever and current smoking and vaping; and among never-users, susceptibility to vaping (all p < .01, effect sizes 1.03-1.05). Family/peer use and attitudes also were significant correlates. CONCLUSIONS: Tobacco product promotions remain ubiquitous and are significantly associated with adolescents' tobacco product use and susceptibility to vape. Peers and family are important social influences and may reflect indirect channels of tobacco marketing. Stricter regulatory restrictions on tobacco marketing to young people are warranted. IMPLICATIONS: This study adds to mounting evidence showing that tobacco marketing remains pervasive and is associated with tobacco use and susceptibility to use. Most youth report seeing cigarette and nicotine vaping product promotions, with notable differences by channel: traditional media predominate for cigarettes and social media/email for e-cigarettes. Greater exposure to tobacco promotions is significantly associated with ever and current smoking and vaping, and among never-users, susceptibility to vaping. The accumulating findings support stricter regulatory restrictions on marketing of tobacco products in media channels accessed by youth.

The Impact of COVID-19 on Smoking Patterns in Pakistan: Findings From a Longitudinal Survey of Smokers.

INTRODUCTION: We investigated the influence of COVID-19 on smoking patterns in Pakistan. METHODS: In a longitudinal survey, we asked cigarette smokers in Pakistan about their smoking behaviors before and since COVID-19. Smokers were recruited before COVID-19 using two-stage random probability sampling. Since COVID-19, three subsequent waves were conducted over the telephone, asking additional questions on social determinants, mental health, and well-being. Based on the first two waves, we estimated the proportion of smokers who stopped, decreased, maintained, or increased smoking. We also explored any factors associated with the change in smoking patterns. In those who stopped smoking soon after COVID-19, we estimated the proportion relapsed in subsequent waves. We estimated all proportions based on complete-case analysis. RESULTS: We recruited 6014 smokers between September 2019 and February 2020; of these, 2087 (2062 reported smoking outcomes) were followed up in May 2020 after COVID-19. Since COVID-19, 14% (290/2062) smokers reported quitting. Among those who continued smoking: 68% (1210/1772) reduced, 14% (239/1772) maintained, and 18% (323/1772) increased cigarette consumption; 37% (351/938) reported at least one quit attempt; 41% (669/1619) were more motivated; while 21% (333/1619) were less motivated to quit. Changes in smoking patterns varied with nicotine dependence, motivation to quit, and financial stability since COVID-19. Among those reporting quitting soon after COVID-19, 39% (81/206) relapsed in the subsequent months (June-July 2020). CONCLUSIONS: There have been significant bidirectional changes in smoking patterns since COVID-19 in Pakistan. Although many people stopped, reduced, or tried quitting smoking, some increased smoking and some relapsed after quitting. IMPLICATIONS: We observed significant and complex changes in people's smoking patterns, which are likely to be attributable to the COVID-19 pandemic and replicated in similar events in the future. Assessing these changes is essential for most low- and middle-income countries like Pakistan, where the vast majority of tobacco users live, but cessation support is still rudimentary. If provided routinely, smoking cessation interventions can potentially support millions of highly motivated individuals in quitting successfully both in general and in global events like COVID-19, in particular.

Vaping Restrictions: Is Priority to the Young Justified?

The vast majority of smokers become dependent on nicotine in youth. Preventing dependence has therefore been crucial to the recent decline in youth smoking. The advent of vaping creates an opportunity for harm reduction to existing smokers (mostly adults) but simultaneously also undermines prevention efforts by becoming a new vehicle for young people to become dependent on nicotine, creating an ethical dilemma. Restrictions to access to some vaping products enacted in response to the increase in vaping among youth observed in the United States since 2018 have arguably prioritized prevention of new cases of dependence-protecting the young-over harm reduction to already dependent adults. Can this prioritization of the young be justified? This article surveys the main bioethical arguments for prioritizing giving health benefits to the young and finds that none can justify prioritizing dependence prevention over harm reduction: any reasons for prioritizing the current cohort of young people at risk from vaping will equally apply to current adult smokers, who are overwhelmingly likely to have become nicotine-dependent in their own youth. Public health authorities' current tendency to prioritize the young, therefore, does not seem to be ethically justified. IMPLICATIONS: This article argues that commonsense reasons for prioritizing the young do not apply to the ethical dilemma surrounding restricting access to vaping products.

Smoking-related cue reactivity in a virtual reality setting: association between craving and EEG measures.

BACKGROUND: Cue-reactivity is the array of responses that smokers exhibit when exposed to conditioned and contextual stimuli previously associated to substance use. The difficulty to experimentally recreate the complexity of smokers' spatial experience and context requires more ecological models. Virtual reality (VR) creates a state of immersion close to reality allowing controlled assessments of behavioral responses. To date, no studies investigated brain activation associated to smoking cue-reactivity in VR using electroencephalography (EEG). AIMS: To investigate whether a VR cue-reactivity paradigm (a) may increase smoking craving, (b) is feasible with EEG recording, and (c) induces craving levels associated to EEG desynchronization. METHODS: Smokers (N = 20) and non-smokers (N = 20) were exposed to neutral and smoking-related VR scenarios, without and with smoking conditioned stimuli, respectively. EEG was recorded from occipital and parietal leads throughout the sessions to assess alpha band desynchronization. Smoking and food craving and presence visual analogue scales (VAS) were assessed during the session. RESULTS: To be smoker, but not non-smoker, significantly influenced smoking craving VAS induced by smoking cue VR but not by neutral VR. No significant food craving changes was observed during the VR sessions. The new finding was that EEG alpha band power in posterior leads was significantly increased by the smoking context scenario only in smokers, and that the degree of smoking (i.e., heavy vs. light) was significantly associated to this neurophysiological measure. CONCLUSIONS: This study demonstrated, for the first time, the feasibility of EEG recording in a VR setting, suggesting that EEG desynchronization may be a neurophysiological marker of smoking cue-reactivity.

Testing Augmented Reality for Eliciting Cue-Provoked Urges to Smoke: Toward Moving Cue-Exposure Into the Real World.

BACKGROUND: Cue exposure for extinguishing conditioned urges to smoking cues has been promising in the laboratory, but difficult to implement in natural environments. The recent availability of augmented reality (AR) via smartphone provides an opportunity to overcome this limitation. Testing the ability of AR to elicit cue-provoked urges to smoke (ie, cue reactivity [CR]) is the first step to systemically testing the efficacy of AR for cue exposure therapy. OBJECTIVES: To test CR to smoking-related AR cues compared to neutral AR cues, and compared to in vivo cues. METHODS: A 2 × 2 within-subject design comparing cue content (smoking vs. neutral) and presentation modality (AR vs. in vivo) on urge response. Seventeen smokers viewed six smoking-related and six neutral cues via AR smartphone app and also six smoking and six neutral in vivo cues. Participants rated their urge to smoke and reality/co-existence of the cue. RESULTS: Average urge to smoke was higher following smoking-related AR images (Median = 7.50) than neutral images (Median = 3.33) (Z = -3.44; p = .001; d = 1.37). Similarly, average urge ratings for in vivo smoking-related cues (Median = 8.12) were higher than for neutral cues (Median = 2.12) (Z = -3.44; p = .001; d = 1.64). Also, greater CR was observed for in vivo cues than for AR cues (Z = -2.67, p = .008; d = .36). AR cues were generally perceived as being realistic and well-integrated. CONCLUSIONS: CR was demonstrated with very large effect sizes in response to AR smoking cues, although slightly smaller than with in vivo smoking cues. This satisfies the first criterion for the potential use of AR for exposure therapy. IMPLICATIONS: This study introduces AR as a novel modality for presenting smoking-related stimuli to provoke cue reactivity, and ultimately to conduct extinction-based therapy. AR cues presented via a smartphone have the advantage over other modes of cue presentation (pictures, virtual reality, in vivo, etc.) of being easily transportable, affordable, and realistic, and they can be inserted in a smokers' natural environment rather than being limited to laboratory and clinic settings. These AR features may overcome the generalizability barriers of other methods, thus increasing clinical utility for cue exposure therapies.