All articles written by Ruth Canty unless otherwise attributed. Ideas and items for News Analysis should be sent to ruth. canty@flinders.edu.au
A new report, Behind Closed Doors: How the Tobacco Lobby Influences the European Union
The report reveals that industry influence...]]>
Although numerous studies have estimated the inhalation dose of metals emitted from electronic cigarettes (e-cigs), the impact of factors including aerosol size and the atomising power of e-cig aerosols on estimating the inhalation dose of metals remains underexplored. A comprehensive understanding of these determinants is essential to assess the health risks associated with inhaling e-cig aerosols, which may contain potentially harmful metals.
The aim of this study is to elucidate the mass and inhalation doses of potentially harmful metals in e-cig aerosols by different particle size and their association with the various atomising powers of e-cig devices and flavours.
Size-segregated e-cig aerosols were generated and collected in a exposure chamber, using an 11-stage cascade impactor for the analyses of aerosol mass and metals. The metal deposition dose in the human respiratory tract was calculated using a mathematical respiratory deposition estimation model and metal mass concentration by the size of aerosols.
In this study, the results showed that neither an increase in atomising power (from 5 to 20 W) nor e-cig flavours resulted in a significant increase in a metal deposition in the respiratory tracts. Although the factors did not significantly affect the calculated respiratory deposition of harmful metals under typical e-cig usage assumption, the estimated hazard index exceeded 1.0.
The calculated health risks suggest substantial risks of inhalation of metal aerosols from e-cig use.
The effectiveness of tax increases in reducing tobacco consumption relies on the tobacco retailers and producers passing on increases to consumers (tax pass-through). Previous UK research on supermarkets found heterogeneous levels of tax pass-through across the market segments and price distribution of tobacco products. This study uses data from small retailers across the UK to assess whether recent tax changes have been passed on to consumers and if this varies across the price distribution, between countries of the UK and by neighbourhood deprivation.
We use panel data quantile regression analysis of tobacco sales in small retailers in the UK from March 2017 to December 2021 combined with UK tax rates and store-level index of multiple deprivation (IMD). We calculated the rate of tax pass-through for factory-made cigarettes (FM) and roll-your-own tobacco (RYO).
Following increases in the duty payable on tobacco, we find evidence of overshifting across the entire price distribution for FM and RYO. For England, Scotland and Wales, the rate of the overshift in tax increased with product price. For Scotland, we find that stores in the least deprived IMD pass-through taxes at a higher rate.
Our evidence shows heterogeneous levels of tax pass-through by price, region and level of deprivation. The findings emphasise the importance of understanding the pricing strategies of the tobacco industry (TI) and how these vary across the UK to develop robust approaches to mitigate the pricing strategies of the TI.
To assess adolescents’ baseline knowledge of smoking health harms scheduled to be covered in future graphic health warnings (GHWs) and inform the content of future tobacco control public communication campaigns.
Cross-sectional survey of 8631 secondary school students (mean age=14.5 years) in Australia in 2022/2023 (weighted n=8655). Students were asked (a) for their agreement/disagreement that smoking causes each of nine harms (eg, lung cancer, stomach cancer and asthma), (b) to indicate where most of smoking’s harmful chemicals come from and (c) for their agreement/disagreement concerning the relative harmfulness of different tobacco product attributes (eg, menthol and roll-your-own). Multivariable logistic regression analyses examined associations between students’ knowledge and perceptions and their smoking status, controlling for demographics and school-level clustering.
Students had greater awareness of harms previously publicised in Australia. Among students who had never smoked, those open to future smoking had lower awareness of six smoking harms than those with a firm future intention not to smoke. Only 17.8% of all students were aware that most harmful chemicals came from burning the tobacco, with 37.8% not knowing and 34.6% attributing the source to additives. Three-quarters held misperceptions that roll-your-own cigarettes are less harmful than factory-made cigarettes or that cigarette smoke which feels light or smooth is less harmful than smoke that feels harsh. Only 25.9% of students were aware that menthol cigarettes are more addictive than non-menthol cigarettes.
New GHWs and public communication campaigns could improve student knowledge of previously unpublicised smoking harms and counter pervasive misperceptions about tobacco products.
We investigated changes in the profile of persons who smoke (PWS) seeking assistance from smoking cessation services (SCS) in France between 2004 and 2018, aligning with national policies.
A prospective study of 131 280 adult PWS was conducted across three periods: 2004–2008 (during a 42% increase in tobacco prices), 2009–2013 (following a tobacco sales ban to minors) and 2014–2018 (marking the first national antismoking policy). Sociodemographic and medical characteristics, smoking behaviours and prescribed cessation medications were analysed cross-sectionally at the first consultation.
Between 2004–2008 and 2014–2018, the mean age of SCS attendees increased from 44 to 47 years (p<0.001). Concurrently, the proportion of PWS without a school diploma rose from 19% to 22%, and unemployed PWS from 13% to 22% (both p<0.001). Smoking-related cancer prevalence doubled from 3% to 6% (p<0.001). The proportion of PWS with no prior quit attempts increased from 31% in 2004–2008 to 35% in 2014–2018 (p<0.001). There was also a notable decline in those attending SCS on a personal initiative, dropping from 45% to 35% (p<0.001). Mean number of cigarettes smoked daily was stable at 23 between 2004 and 2018. Combination nicotine replacement therapy remained the most prescribed cessation medication, accounting for 44% of treatments during this period.
Despite tobacco control efforts between 2004 and 2018, challenges persist in reducing smoking behaviours in France. Increased SCS utilisation among older adults and individuals with lower socioeconomic status underscores the importance of enhancing SCS availability in France to support the various profiles of PWS.
Smoking rates have declined markedly in Australia over time; however, lesbian, bisexual and queer (LBQ) women continue to smoke at higher rates than heterosexual women. Understanding the factors influencing smoking in this population is crucial for developing targeted cessation interventions and other supports.
Experiences of and motivations for smoking among 42 LBQ cisgender and transgender women and non-binary people in Australia who currently or previously smoked were explored through semi-structured interviews. Participants were primarily white Australian cisgender women in their 30s–40s. Thematic analysis was used to identify common psychological, social and cultural influences on smoking.
While coping with minority stress was a common factor influencing some participants’ smoking behaviours, participants also described how smoking offered pleasurable opportunities for gender expression, affirmation and rebellion. Smoking also enabled participants to experience ‘marginalised connectivity’, a form of social solidarity fostered through the sharing of a stigmatised practice by an oppressed or stigmatised community.
This article identifies factors contributing to the ongoing socio-cultural relevance of smoking for some LBQ women in Australia. These specific psychological, social and cultural contexts remain salient for LBQ women’s smoking and must be factored into smoking cessation campaigns and programme designs for this population. Tailored messaging that emphasises alternative self-care strategies and the benefits of quitting in the context of supportive communities may be more effective in engaging LBQ women than long-term health risk messages.
Increasing intentions to quit e-cigarettes among youth and young adults can reduce usage rates by making quit attempts more likely. This study assessed the potential impacts of a national media campaign, focused on building knowledge of e-cigarette use risks and cessation resources, on intentions to quit and campaign-targeted beliefs about mental health and quitting.
A national sample from a repeated cross-sectional online survey was collected from March 2022 to August 2023, among youth and young adults who reported e-cigarette use in the past 30 days (N=5169). Regression models were used to assess associations between weekly campaign awareness and frequency of exposure on intentions to quit e-cigarette use within the next 6 months and targeted beliefs related to mental health and quitting.
Participants who were aware of both cessation and knowledge-building messaging were more likely to report intentions to quit e-cigarette use in the next 6 months (OR 1.43, (95% CI 1.21, 1.69)) and agree with quitting-related targeted beliefs (ORs 1.35–1.63) and a mental health targeted belief scale (b=1.14 (95% CI 0.69, 1.59)), relative those with no messaging awareness. The frequency of exposure to cessation messaging held a dose-response relationship with almost all outcomes.
Findings suggest that frequency and awareness of messaging that educates about e-cigarette harms to mental health and about cessation resources are associated with higher quitting intentions among young people who use e-cigarettes.
This study considers recent trends in combustible and e-cigarette use among US young adults who smoked cigarettes in adolescence, who are the originating source of most adults who smoke.
Data come from the Monitoring the Future study, which includes young adults aged 19–30 who were first surveyed in 12th grade as part of a nationally-representative sample. The analysis centres on 3623 observations from 2377 young adults surveyed from 2017 to 2022 who reported they had ever smoked a combustible cigarette in the initial, 12th grade survey.
Among young adults who had smoked in adolescence, the percentage who used a combustible cigarette currently (in the past 30 days) significantly declined from 45% in 2017–2018 to 35% in 2021–2022. The percentage who currently used nicotine hovered around 50%, as measured by current use of an e-cigarette or combustible cigarette and this percentage did not significantly trend over the study period. The percentage who currently used e-cigarettes exclusively and not combustible cigarettes tripled from 6% in 2017–2018 to 21% in 2021–2022. About half of this exclusive e-cigarette group deliberately used e-cigarettes to quit combustible cigarettes, in all years. Dual use of both e-cigarettes and combustible cigarettes significantly increased from 11% in 2017–2018 to 17% in 2021–2022. Trends were robust in multivariable regression analyses that controlled demographics.
Among young adults who had smoked in adolescence, a 10-point decline in cigarette prevalence from 2017 to 2022 coincided with a 7-point increase in the percentage who deliberately used e-cigarettes to quit combustible cigarettes.
Despite a strict vaping ban also covering purchase, use and possession, vaping has become more prevalent in Singapore. As more countries seek to regulate vaping, with no tailored services or guidelines for vaping cessation, clinicians may face additional challenges in identifying or treating vaping cases due to stigma or patients’ reluctance to disclose their vaping. Few studies have explored how clinicians identify or manage vaping cases in a context where vaping is heavily regulated or stigmatised.
We conducted semistructured interviews with 12 Singapore practitioners from pharmacy, psychology, respiratory medicine, smoking cessation or youth welfare settings, all of whom had encountered vaping cases in their practice. Interviews explored how they manage vaping cases. We analysed data using inductive thematic methods.
Patients were described as reluctant to disclose their vaping for fear of being reported to authorities, and some clinicians were unsure of their duty to report, making it challenging to identify vaping cases. Variability in usage patterns and inaccurate e-liquid labelling posed difficulties in estimating nicotine dependence, leaving practitioners to trial and error or to adapt from smoking cessation guidelines. Tailored quit support for people who vape was lacking, especially in the form of subsidised nicotine replacement therapy.
Even in contexts where vaping is heavily regulated, given the rising incidence of vaping globally, it is important to record patients’ vaping history as part of routine practice and to provide services to help people quit vaping without facing stigma or legal repercussions because of their vaping.
Pairing e-cigarettes with healthy lifestyle contexts in influencers’ promotional social media posts may increase e-cigarette use risk among young adults. This study examined the effects of e-cigarette and healthy lifestyle content on young adults’ perceptions of influencer credibility, harm perceptions of, and susceptibility to use, e-cigarettes.
In this survey-based online, repeated-measures experiment (2023), California young adults (N=1494, Mage=23 (SD=1.8); 63% female, 51% Hispanic) were randomly shown 10 (total) Instagram and TikTok videos, featuring influencers promoting e-cigarettes alongside healthy lifestyle activities (experimental group), or a healthy lifestyle activity alone (control). After watching each video, participants rated perceived influencer credibility (eg, honesty). After watching all videos, harm perceptions of e-cigarettes were assessed among all participants and susceptibility to e-cigarette use was assessed among e-cigarette never-users. Harm perceptions and susceptibility outcomes were compared between groups (experimental vs control) and between participants who perceived influencers as credible versus non-credible, using binomial generalised linear mixed effects models.
Participants in the experimental group were more likely to report lower harm perceptions (adjusted OR (AOR) 1.12; 95% CI 1.03; 1.21) and higher susceptibility to e-cigarette use (AOR 1.22, 95% CI 1.11; 1.34), than participants in the control condition. Similar results were found when influencers were perceived as credible, but not when they were perceived as non-credible.
Social media influencers’ posts promoting e-cigarette use along with healthy activities may contribute to young adult e-cigarette use. Decreasing perceived credibility of influencers could decrease the negative effects of their promotional posts.
Menthol-flavoured cigarettes remain unregulated in the USA and in many low- and middle-income countries (LMICs) despite their known impacts on smoking uptake and reduced cessation. Yet, evidence about whether menthol cigarettes are associated with higher disease risks than non-menthol cigarettes is inconclusive, and the industry has used this argument to lobby against regulation.
All-cause and cause-specific mortality risk was assessed according to baseline smoking status (current, former and never) and menthol flavour status (menthol and non-menthol) of the cigarette brand smoked for the longest period among 969 349 persons from Cancer Prevention Study-II, a population-based prospective cohort study enrolled in 1982–1983 with mortality follow-up of 6 years.
73 486 and 281 680 persons reported menthol brands and non-menthol brands, respectively, among whom 4071 and 20 738 deaths occurred, respectively. Currently smoking cigarettes, whether menthol or non-menthol brands, was associated with highest mortality risks (eg, all causes: about two times higher risk vs never smoking) but quitting substantially reduced risks for both types. Among persons who formerly smoked, menthol versus non-menthol smoking was associated with an elevated mortality risk of 12% from all-causes, 16% from all cardiovascular diseases, 13% from ischaemic heart disease, and 43% from other heart diseases Among individuals currently smoking, there was no difference in mortality risks for menthol versus non-menthol cigarettes except for elevated risk among those smoking≥40 cigarettes per day. Black persons currently smoking menthol versus non-menthol brands had an 88% elevated mortality risk for other heart diseases.
Findings of a unique excess mortality risk associated with menthol cigarettes provide additional scientific evidence—apart from their known impacts on initiation and cessation—in support of menthol flavour regulation in the USA and similar policies in LMICs. Public communication efforts must reiterate that quitting all cigarette types is the only safe option to reduce disease risk.
Preventing youth exposure to cigarette smoking is a public health priority. One of the most effective ways to reduce tobacco use is to increase the prices of tobacco products. Minimum floor price laws (MFPLs) are a relatively new but more feasible strategy that sets a price below which the product cannot be sold. We aim to examine the effects of minimum floor prices (MFPs) on tobacco use among youth in Virginia.
An agent-based modelling (ABM) was developed from bottom-up to evaluate the influence of increasing the cigarette MFPs on middle and high school students’ smoking behaviour in the state of Virginia. A rational-addiction model was integrated to model the smoking decision of youth under the dynamic utility maximisation framework within the ABM.
The model predicted that every 10% increase in the MFP in Virginia could prevent 2232 8th graders and 1890 12th graders from cigarette smoking, a 2.4% and 1.8% reduction in median smoking prevalence. For students who smoked, 8th and 12th graders would consume 0.36 and 0.45 fewer cigarettes per smoking day if experiencing a 10% increase in the MFP from the baseline US$7.50 to US$8.30. The MFP level that produces the maximal response was estimated to be between 10% and 30%.
MFPLs provide local jurisdictions with a potentially effective strategy to reduce tobacco use and mitigate-related harms among youth.
Electronic nicotine delivery systems (ENDS), such as e-cigarettes, have surged in popularity. While long-term risks remain unclear, known dangers include nicotine addiction, E-cigarette or Vaping Use-Associated Lung Injury and potential extrapulmonary effects on the heart, immune system and neurodevelopment. Addressing ENDS addiction may require strategies akin to smoking cessation. However, evidence is lacking; there are no currently approved vaping-cessation aids. The objective of this review is to summarise the available literature addressing interventions for vaping cessation.
A librarian-assisted search was conducted in MEDLINE, Embase and Scopus, as well as preprints in Europe PMC, Open Science Framework, and the grey literature searches until January 2024. Six included studies used self-report methods to determine the abstinence rate, while one study used cotinine-level-verified self-reported abstinence. We included randomised controlled trials (RCTs) that examine ‘rates of vaping cessation’ outcomes. An intention-to-treat approach was used for data extraction, and random-effects meta-analyses models were applied.
Seven RCTs were included, which studied pharmacological therapy, digital interventions and/or educational content. The primary meta-analyses demonstrated a statistically significant increase in the odds of achieving 7-day point prevalence abstinence (PPA) (OR 1.52, 95% CI 1.15 to 2.01, number of participants=3244, moderate-certainty) and continuous abstinence (OR 2.71, 95% CI 1.31 to 5.61, number of participants=164, low-certainty) following intervention. A non-significant increase in odds was noted at 30-day PPA (OR 1.32, 95% CI 0.72 to 2.42, number of participants=1994, very low certainty).
Vaping cessation interventions increase 7-day PPA rates at 1–12 months follow-up and this was consistent across prespecified subgroup analyses of the intervention type, outcome and duration of follow-up. More high-quality studies with reproducible findings are needed to enhance the certainty of the evidence and guide clinical interventions.
CRD42022383670.
To systematically review available data on the effects of heated tobacco products (HTPs) on biomarkers of potential harm (BoPH) and adverse events, including comparison to cigarettes, e-cigarettes and smoking abstinence.
Web of Science, Scopus, MedRxiv, ClinicalTrials.gov, ICTRP database and HTP manufacturer libraries were searched from January 2010 to December 2024.
Included studies were interventional clinical trials of any design that measured BoPH or adverse events in adults assigned a marketed HTP and another assigned either cigarettes, e-cigarettes or smoking abstinence.
Two reviewers independently extracted data into a predesigned form and assessed risk of bias using Cochrane’s Risk of Bias tool version 1.
BoPH data were synthesised using effect direction plots. A random-effects model was used to calculate pooled risk ratios for adverse event data. 40 studies (10 independent, 29 industry-affiliated and 1 of unclear affiliation) were included. Only nine studies lasted longer than 5 days. 19 involved using the intervention just once. Risk of bias was high for 32 studies and unclear for 8. Data on 143 BoPH indicated short-term HTP use had mixed effects compared with cigarettes, e-cigarettes and smoking abstinence. The rate of adverse event reporting was not significantly different between HTP and any comparator group.
Despite a growing evidence base, significant limitations hinder interpretation of the data, which do not yet provide clear indication of harm or benefit, even compared with cigarettes. Longer, better quality studies independent of tobacco industry funding are needed to determine the health impacts of HTPs.
Tax non-compliance by online vaping retailers undermines excise taxes designed to reduce vaping rates and fund prevention efforts. Despite California’s 12.5% Electronic Cigarette Excise Tax and federal mandates under the Prevent All Cigarette Trafficking Act, online vaping retailers’ adherence to excise taxes remains unclear. This study assessed excise tax compliance among online vaping retailers shipping products to California consumers.
156 purchase attempts were made from n=78 online vaping retailers shipping to San Diego residential addresses. 16 buyers used their personal billing information and residential addresses. Receipts obtained from their purchases were analysed to determine if retailers charged the required 12.5% tax. Retailer licensing status was verified by comparing retailer information to the state’s licensed business list using geolocation and approximate string matching. Differences in compliance rates were compared using 2 and Fisher’s exact tests.
Of the n=58 retailers with receipts, 84.5% did not charge the required excise tax. In-state retailers were more likely to be (p<0.001) licensed than out-of-state (4.0%) or international (0.0%), but tax compliance rates did not significantly differ by retailer location (p=0.57)—intrastate (19.2%), interstate (16.7%) or international (0.0%). Licensed retailers had higher tax compliance (27.3%) than unlicensed ones (9.1%); however, overall compliance was low.
Many online vape retailers fail to comply with California’s excise tax and licensing laws. Low compliance rates indicate existing enforcement mechanisms are not optimised for online sales. Enhancing oversight and enforcement of excise tax laws for online retailers is crucial to reduce tax non-compliance, prevent revenue loss and support public health.
FDA enforcement of e-cigarette regulations is widely regarded as failing.
We used data from eight waves of the Prevention Radar study (https://www.praeventionsradar.de/). The (online) questionnaire survey is conducted annually between November and February in a convenience sample of general secondary schools in 14 federal states of Germany. Prevalence estimates of monthly e-cigarette and cigarette use from winter 2016/2017 to winter 2023/2024 for early adolescence (11–14 years) and late adolescence (15–17 years)
An interrupted time series (ITS) design was used.
The importance of the retailing...]]>
In the UK, HTPs are regulated as a novel tobacco product,
Authenticity is a core component for creating a distinguished and successful global brand.
Produced by Korean Tomorrow and Global (KT&G)—South Korea’s market leader and the fifth-largest tobacco company globally—Bohem Signature cigars highlight ‘authenticity’ in its marketing communication to romanticise smoking (