The latest medical research on Addiction Medicine

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Compliance of e-cigarette refill liquids with regulations on labelling, packaging and technical design characteristics in nine European member states.

Tobacco Control

To evaluate electronic cigarette (e-cigarette) product compliance with European regulations (Tobacco Products Directive (TPD), Implementing Decisions), with a focus on labelling/packaging practices and technical design/safety features.

Before the implementation of the TPD, in early 2016, we randomly selected e-cigarette refill liquids from the five top-selling companies in France, Poland, Germany, Netherlands, UK, Spain, Romania, Hungary and Greece. Identical products were purchased after the implementation of the TPD (early 2018) and assessment of compliance was performed on self-matched samples (n=107) using a prospective cohort design. Compliance with the Classification, Labelling and Packaging (CLP) regulations was also evaluated.

Following the implementation of the TPD, improvements were noted with regards to the existence of text-only warnings (32.7% pre vs 86.0% post, p<0.001), child-resistant fastenings (93.3% pre vs 100.0% post, p=0.016), tamper-proof vials (58.9% pre vs 86.9%, post p<0.001) and maximum refill volume ≤10 mL in vials (86.9% pre vs 94.4% post, p=0.008). Lower compliance was noted with regards to the inclusion of a leaflet (26.2% pre vs 53.3% post, p<0.001), refilling instructions (28.0% pre vs 51.4% post, p<0.001) and health warnings on the box, vial or leaflet (32.7% pre vs 86.0%, p<0.001). Overall, 86.0% of products had a warning label in the post-TPD phase in comparison to 32.7% of products before the implementation of the TPD (p<0.001). Compliance with the CLP regulations, also increased in the post TPD follow-up phase.

This is the first study to evaluate the level of implementation of the e-cigarette regulations in nine EU member states. Our results indicate that refill liquids had substantial but not full compliance in most of the characteristics evaluated. Further effort is needed to ensure complete compliance.

Big tobacco focuses on the facts to hide the truth: an algorithmic exploration of courtroom tropes and taboos.

Tobacco Control

To use methods from computational linguistics to identify differences in the rhetorical strategies deployed by defence versus plaintiffs' lawyers in cigarette litigation.

From 318 closing arguments in 159 Engle progeny trials (2008-2016) archived in the Truth Tobacco Industry Documents, we calculated frequency scores and Mann-Whitney Rho scores of plaintiffs versus defence corpora to discover 'tropes' (terms used disproportionately by one side) and 'taboos' (terms scrupulously avoided by one side or the other).

Defence attorneys seek to place the smoker on trial, using his or her friends and family members to demonstrate that he or she must have been fully aware of the harms caused by smoking. We show that 'free choice,' 'common knowledge' and 'personal responsibility' remain key strategies in cigarette litigation, but algorithmic analysis allows us to understand how such strategies can be deployed without actually using these expressions. Industry attorneys rarely mention personal responsibility, for example, but invoke that concept indirectly, by talking about 'decisions' made by the individual smoker and 'risks' they assumed.

Quantitative analysis can reveal heretofore hidden patterns in courtroom rhetoric, including the weaponisation of pronouns and the systematic avoidance of certain terms, such as 'profits' or 'customer.' While cigarette makers use words that focus on the individual smoker, attorneys for the plaintiffs refocus agency onto the industry. We show how even seemingly trivial parts of speech-like pronouns-along with references to family members or words like 'truth' and 'facts' have been weaponised for use in litigation.

Reactions to electronic nicotine delivery system (ENDS) prevention messages: results from qualitative research used to inform FDA's first youth ENDS prevention campaign.

Tobacco Control

Youth e-cigarette use is a major public health concern. Large-scale tobacco prevention campaigns are a proven strategy to prevent tobacco use. There is a gap in understanding what types of e-cigarette prevention messages might be most effective. This study addresses this gap by reporting youth reactions to health messages aimed at preventing e-cigarette use.

In 2018, twenty-four focus groups, with 159 teens (12-17) at risk for or experimenting with e-cigarettes were conducted in four cities across the USA. During focus groups, youth responded to creative concepts dealing with (1) the addictive nature of e-cigarettes, (2) the fact that e-cigarettes come in flavours, which may encourage youth initiation, and nicotine which may lead to addiction, or (3) that youth who use e-cigarettes are more likely to use cigarettes. Youth also gave feedback to specific facts about harmful and potentially harmful chemicals in e-cigarettes. Transcripts were analysed using thematic analysis.

Messages focusing on addiction alone did not resonate with participants. While youth found the idea that e-cigarettes may contain nicotine and can be addictive believable, with many describing personal experiences of addiction, they questioned how bad this really was, comparing addiction to e-cigarettes to things like being addicted to food. Participants wanted more information about negative consequences of vaping. Concepts paired with strong health effects messages resonated with participants.

These focus groups clarified which e-cigarette prevention messages might be most persuasive to teens. Youth in this study responded favourably to messages stating specific health consequences of e-cigarette use.

Systemic biomarkers of inflammation, oxidative stress and tissue injury and repair among waterpipe, cigarette and dual tobacco smokers.

Tobacco Control

Waterpipe tobacco (WPT) smoking is associated with deleterious effects on cardio-pulmonary systems which may have adverse repercussions in pathophysiology and progression of chronic lung and cardiovascular diseases. We compared the biomarkers of systemic inflammation, lipid mediators, injury/repair and oxidative stress between groups of non-smokers (NS), exclusive WPT smokers (WPS), exclusive cigarette smokers (CS) and dual WPS and CS (DS).

Two cohorts were recruited. Cohort I consisted of WPS (n=12), CS (n=26), DS (n=10) and NS (n=25). Cohort II consisted of WPS (n=33) and NS (n=24). Plasma and urine samples were collected and analysed for various systemic biomarkers.

Compared with NS, plasma levels of inflammatory mediators (interleukin (IL)-6, IL-8, IL1β and tumor necrosis factor-α) were significantly higher in WPS and CS, and were further augmented in DS. Endothelial biomarkers (intracellular adhesion molecule-1, prostaglandin E-2 and metalloproteinase-9) were significantly higher in CS. Most notably, pro-resolving lipid mediator (resolvin E1) and biomarkers of immunity, tissue injury, and repair were significantly lower in WPS and CS. Urinary levels of 8-isoprostane were significantly higher in all smoking groups in cohort I, while 8-isoprostane, myeloperoxidase, receptor for advanced glycation end products (RAGE), En-RAGE and matrix metalloproteinase-9 were significantly higher in all smoking groups in cohort II.

Biomarkers of inflammation, oxidative stress, immunity, tissue injury and repair were elevated in WPS and CS groups. Furthermore, concurrent use of WPT and cigarettes is more harmful than cigarette or WPT smoking alone. These data may help inform the public and policy-makers about the dangers of WPT smoking and dual use of tobacco products.

Waterpipe tobacco smoke toxicity: the impact of waterpipe size.

Tobacco Control

Waterpipe tobacco smoking continues to show increasing popularity, especially among individuals between 18 and 22 years old. Waterpipe tobacco smoke (WTS) is a mixture of particulates and gases formed from the combustion of the charcoal and volatilisation and humidification of the tobacco+humectant+flavouring substrate known as shisha or mu'assel. As such, variation in the configuration of the waterpipe may affect the particles produced. Our study focuses on the effects of waterpipe size on the physical properties and cytotoxicity of the smoke produced.

Shisha type and headspace volume were held constant and a modified Beirut puff protocol was followed while the size of the waterpipe was varied. Particle concentrations and size distributions were measured using a TSI Engine Exhaust Particle Sizer. Type II alveolar cells were exposed to smoke at the air-liquid interface and two metrics of cell health analysed.

In a 30 min session, we observed a decrease in total particle concentration (1014-1013) and mass (10 000-2800 mg/m3) and an increase in particle size (125-170 nm) as pipe height increases from 22 to 55 cm and bowl size from 300 to 1250 mL. Smoke from all pipe sizes caused decreases in lysosomal function (>40%) and membrane integrity (>60%) 24 hours post 57 min exposure, and meet the National Institutes of Health definition of a cytotoxic agent (≥30% decrease in cell viability).

Smoke from waterpipes of all sizes causes significant alveolar cellular harm, indicating that this device needs regulation as a hazard to human health.

Understanding why some Australian retailers have stopped selling tobacco, some might and some are unlikely.

Tobacco Control

Widespread availability of tobacco has been shown to contribute to ongoing smoking and make quitting harder. This study investigates why some retailers in three Australian states decided to stop selling tobacco, others might stop selling and why others continue to sell in a declining market.

A telephone survey of 4527 randomly selected retailers was conducted in August 2018 (response rate=72.4%). This study examines responses to open-ended questions in the survey probing retailers' attitudes and beliefs regarding selling (or not selling) tobacco.

27.3% of the sample sold tobacco, and 13.3% had formerly sold. Outlets that had stopped selling most frequently mentioned minimal profit and/or sales as the reason for stopping selling (27.7% across all states). This was also the most frequent reason why retailers said they might stop selling. Uniquely in Western Australia (the only state in the study with a fee-based licensing scheme), 12.5% of former tobacco retailers named tobacco licensing as the reason for stopping sales-the second most frequent reason in Western Australia. Of current sellers who were unlikely to stop, the potential to lose sales was the most frequently named reason (31.0% across all states).

Retailers report being driven by the profitability of tobacco when deciding whether or not to stop selling, although only a small percentage discussed losing incremental sales if they stopped selling. An annual licence fee contributed to some retailers stopping selling, showing that a fee-based tobacco license can contribute to a decline in retail availability of tobacco.

Evaluating smoking control policies in the e-cigarette era: a modelling study.

Tobacco Control

In jurisdictions in which electronic cigarettes are currently prohibited, policy makers must weigh the potentially lower risk compared with conventional cigarettes against the risk of initiation of e-cigarettes among non-smokers.

We simulated a synthetic population over a 50-year time horizon with an open cohort model using data from Singapore, a country where e-cigarettes are currently prohibited, and data from the USA, the UK and Japan. Using the smoking prevalence and the quality-adjusted life year gained calculated, we compared tobacco control policies without e-cigarettes-namely, raising the minimum legal age (MLA), introducing a smoke-free generation (SFG) and tax rises on tobacco consumption-with policies legalising e-cigarettes, either taking a laissez-faire approach or under some form of restriction. We also evaluated combinations of these policies.

Regardless of the country informing the transition probabilities to and from e-cigarette use in Singapore, a laissez-faire e-cigarette policy could reduce the smoking prevalence in the short term, but it is not as effective as other policies in the long term. The most effective single policies evaluated were SFG and aggressive tax rises; the most effective combination of policies considered was MLA plus moderate tax rises and e-cigarettes on prescription.

Policy makers in jurisdictions in which e-cigarettes are not yet established may be advised not to prioritise e-cigarettes in their tobacco end-game strategy, unless their use can be restricted to current smokers seeking to quit.

Measuring waterpipe tobacco smoking in survey research.

Tobacco Control

Waterpipe tobacco (WT) smoking remains a significant public health problem. However, few validated measures exist, presenting challenges for obtain...

A discarded cigar package survey in New York City: indicators of non-compliance with local flavoured tobacco restrictions.

Tobacco Control

In 2009, New York City (NYC) restricted the sale of flavoured tobacco products. We assessed product availability as a proxy for potential non-compliance by analysing discarded cigar, cigarillo and blunt wrap packages in New York City.

A discarded cigar package survey was conducted in 2016, in a stratified random sample of 94 block groups in NYC resulting in the collection of 886 discarded cigar packages. Each package was coded for brand name, flavour description (explicit and implicit) and size.

Overall, 19.2% of the cigar packages were explicitly flavoured. An additional 9.4% of the packages reflected implicit flavours. Explicit flavoured cigar packages were at increased odds of being found in Staten Island (adjusted OR (AOR)=3.96, 95% CI=1.66 to 9.46), in packaging size of two or three (AOR=8.49, 95% CI=4.24 to 17.02) or four or more (AOR=4.26, 95% CI=1.95 to 9.30).

Nearly one out of three cigar packages were flavoured products suggesting a problematic level of non-compliance and continued availability. Potential non-compliance is likely fueled by licensed wholesalers and retailers who continue to sell restricted flavoured products. Some retailers may be unaware that implicitly named cigars are typically flavoured and are, therefore, illegal. This lack of awareness of implicit flavoured cigars may be exacerbated by NYC's lack of education or enforcement specific to implicitly flavoured tobacco products.

Active smoking, secondhand smoke exposure and serum cotinine levels among Cheyenne River Sioux communities in context of a Tribal Public Health Policy.

Tobacco Control

American Indians and Alaska Natives face disproportionately high rates of smoking and secondhand smoke (SHS) exposure. The Cheyenne River Sioux Tribe (CRST) is among the few Tribal Nations controlling commercial tobacco exposures in public and work places. We had an opportunity to explore effects of the new commercial tobacco-free policy (implemented in 2015) in an environmental health study (2014-2016) that collected information about commercial tobacco use and SHS prevalence and examined predictor variables of serum cotinine concentrations.

Self-reported survey data were used in quantile regression statistical modelling to explore changes in cotinine levels, based on smoking status, smokeless tobacco consumption and SHS exposure.

From enrolled 225 adults, 51% (N=114) were current smokers. Among 88 non-tobacco users, 35 (40%) reported current SHS exposure. Significant differences in cotinine median concentrations were found among participants with and without current SHS exposure. Extremely high cotinine concentrations (~100 times larger than the median) were detected in some non-tobacco users. After implementing the new smoke-free air Tribal policy, cotinine decreased in participants with intermediate (3-15 ng/mL, non-tobacco users with SHS exposure) and high (>15 ng/mL, mainly tobacco users) cotinine levels showing association with an abatement of opportunities for SHS exposure. Significant predictors of cotinine levels were sampling year, current smoking and tobacco chewing. No gender differences were observed in cotinine.

Our results show decrease in cotinine concentrations in CRST participants since implementation of their 'Smoke-Free Clean Air Act' in 2015.

Communicating about chemicals in cigarette smoke: impact on knowledge and misunderstanding.

Tobacco Control

The USA must publicly share information about harmful and potentially harmful constituents (chemicals) in tobacco products. We sought to understand whether webpages with chemical information are "understandable and not misleading to a lay person."

Participants were a national probability sample of US adults and adolescents (n=1441, 18% smokers). In an online experiment, we randomly assigned participants to view one of the developed webpages (chemical names only, names with quantity ranges, names with visual risk indicators) or no webpage in phase one (between subjects). Participants completed a survey assessing knowledge, misunderstanding, perceived likelihood, perceived severity of health effects from smoking and quit intentions (smokers only). In phase two (within subjects), participants viewed all three webpage formats and reported webpage perceptions (clarity, usability, usefulness) and perceived impact (affect, elaboration, perceived effectiveness).

In phase one, viewing any webpage led to more knowledge of chemicals (48%-54% vs 28% no webpage, ps<0.001) and health harms (77% vs 67% no webpage, ps<0.001). When exposed to any webpage, 5%-23% endorsed misunderstandings that some cigarettes are safer than others. Webpage format did not affect knowledge or reduce misunderstandings. Viewing any webpage led to higher perceived likelihood of experiencing health effects from smoking (p<0.001) and, among smokers, greater intentions to quit smoking (p=0.04). In phase two, where participants viewed all formats, a visual risk indicator led to the highest perceived impact.

Knowledge of chemicals and health effects can increase after viewing a website. Yet, websites may not correct the misunderstanding that some cigarettes are safer.

Modelling the impact of menthol sales restrictions and retailer density reduction policies: insights from tobacco town Minnesota.

Tobacco Control

Tobacco control policies focused on the retail environment have the potential to reduce tobacco use and tobacco-related health disparities through increasing direct and indirect costs. Recently, national and subnational governments have begun to restrict the sale of menthol products and reduce tobacco retailer density.

We developed an agent-based model to project the impact of menthol cigarette sales restrictions and retailer density reduction policies for six types of communities and three priority populations. During each simulated day, agents smoke cigarettes, travel in the community and make purchase decisions-whether, where and which product type to purchase-based on a combination of their own properties and the current retail environment.

Of the policies tested, restricting all cigarette sales or menthol cigarette sales to tobacco specialty shops may have the largest effect on the total (direct and indirect) costs of purchasing cigarettes. Coupling one of these policies with one that establishes a minimum distance between tobacco retailers may enhance the impact. Combining these policies could also make the costs of acquiring cigarettes more equal across communities and populations.

Our simulations revealed the importance of context, for example, lower income communities in urban areas begin with higher retailer density and may need stronger policies to show impact, as well as the need to focus on differential effects for priority populations, for example, combinations of policies may equalise the average distance travelled to purchase. Adapting and combining policies could enhance the sustainability of policy effects and reduce tobacco use.