The latest medical research on Addiction Medicine

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Twenty-year health and economic impact of reducing cigarette use: Minnesota 1998-2017.

Tobacco Control

Adult smoking prevalence in Minnesota fell from 21.8% in 1997 to 15.2% in 2016. This reduction improved heart and lung health, prevented cancers, extended life and reduced healthcare costs, but quantifying these benefits is difficult.

1.3 million individuals were simulated in a tobacco policy model to estimate the gains to Minnesotans from 1998 to 2017 in health, medical spending reductions and productivity gains due to reduced cigarette smoking. A constant prevalence scenario was created to simulate the tobacco harms that would have occurred had smoking prevalence stayed at 1997 levels. Those harms were compared with tobacco harms from a scenario of actual smoking prevalence in Minnesota from 1998 to 2017.

The simulation model predicts that reducing cigarette smoking from 1998 to 2017 has prevented 4560 cancers, 31 691 hospitalisations for cardiovascular disease and diabetes, 12 881 respiratory disease hospitalisations and 4118 smoking-attributable deaths. Minnesotans spent an estimated $2.7 billion less in medical care and gained $2.4 billion in paid and unpaid productivity, inflation adjusted to 2017 US$. In sensitivity analysis, medical care savings ranged from $1.7 to $3.6 billion.

Minnesota's investment in comprehensive tobacco control measures has driven down smoking rates, saved billions in medical care and productivity costs and prevented tobacco related diseases of its residents. The simulation method employed in this study can be adapted to other geographies and time periods to bring to light the invisible gains of tobacco control.

Effect of user puffing topography on total particulate matter, nicotine and volatile carbonyl emissions from narghile waterpipes.

Tobacco Control

Puffing topographies of waterpipe users vary widely as does the puff-to-puff topography of an individual user. The aim of this study was to determine if puff duration and flow rate have an effect on the characteristics of the mainstream emission from waterpipes, including total particulate matter (TPM), mass ratio of nicotine and mass concentration of volatile carbonyls.

Puffing parameters were chosen to encompass a significant portion of the perimeter space observed from a natural environment study. Tested conditions were 150, 200 and 250 mL sec-1; each run at 2, 3.5 and 5 s durations; 25 s interpuff duration and ~100 puffs per session. Each session was run in quadruplicate using the Programmable Emissions System-2 (PES-2) emissions capture system under identical conditions. Particulate matter, for quantification of TPM and nicotine, was collected on filter pads every ~5 L of aerosol resulting in 6 to 25 samples per session. Volatile carbonyls were sampled using 2,4-Dinitrophenylhydrazine (DNPH)-coated silica.

Mass concentration of TPM linearly decreased with increased flow rate, with no dependency on puff duration. Nicotine mass ratio was independent of topography, with average mass ratio of nicotine to TPM of 0.0027±0.0002 (mg/mg). The main carbonyls observed were acetaldehyde and formaldehyde. Puff duration increased emissions of some carbonyls (eg, formaldehyde) but not others (eg, acetaldehyde).

The results presented here highlight that topographies influence the emissions generated from waterpipes including TPM, total nicotine and volatile carbonyls. For laboratory studies to be representative of user exposure, a range of topographies must be studied. Using a range of topographies within a controlled laboratory environment will better inform regulatory policy.

Illicit cigarette trade in South Africa: 2002-2017.

Tobacco Control

Increasing cigarette excise taxes is widely recognised as the most effective measure to reduce the demand for cigarettes. The presence of illicit trade undermines the effectiveness of tax increases as both a public health and a fiscal measure, because it introduces cheaper alternatives to legal, full-priced cigarettes.

To assess trends in the size of the illicit cigarette market in South Africa from 2002 to 2017 using gap analysis.

Tax-paid cigarette sales are compared with consumption estimates from two nationally representative surveys: the All Media and Products Survey and the National Income Dynamics Study. We explore the size of the illicit cigarette market and its changes over the period 2002-2017.

Since 2009, illicit trade has increased sharply. We estimate that illicit trade is between 30% and 35% of the total market in 2017. The acceleration in the growth of the illicit market since 2015 corresponds with a turbulent time at the South African Revenue Service, when many of the enforcement functions were greatly reduced.

The current levels of illicit trade are extremely high and need to be addressed urgently by implementing effective control mechanisms such as a track and trace system to monitor the production, taxation, and sale of cigarettes.

The association of waterpipe tobacco smoking with later initiation of cigarette smoking: a systematic review and meta-analysis exploring the gateway theory.

Tobacco Control

There is a concern that waterpipe tobacco smoking (WTS) can lead to the later initiation of cigarette smoking, a concept referred to as the 'gateway theory'. The objective of the study was to systematically review the literature for the association of WTS with later initiation of cigarette smoking.

We searched Medline, Embase and ISI Web of Science in April 2018 without using any language or date restrictions. We selected eligible studies, abstracted data and assessed the risk of bias using a duplicate and independent approach. We meta-analysed the ORs across eligible studies using the inverse variance method and the random-effects model. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation methodology.

We included eight papers reporting on six eligible prospective cohort studies with a total of 21 224 participants, belonging to the adolescent and young adult age categories. The pooled adjusted OR for the association between ever waterpipe user (compared with never waterpipe user) at baseline, with 'cigarette smoking initiation' (ever cigarette use) was 2.54 (95% CI 1.60 to 4.02) at 6 months to 3 years follow-up (moderate certainty evidence). The pooled adjusted OR for the association between ever waterpipe user (compared with never waterpipe user) at baseline, with 'current cigarette smoking' (past 30-day cigarette use) was 2.04 (95% CI 1.32 to 3.15) at 1-2 years follow-up (moderate certainty evidence). The pooled adjusted OR for the association between past 30-day waterpipe user (compared with never waterpipe user) at baseline, with current cigarette smoking (past 30-day cigarette use) 2.46 (95% CI 1.73 to 3.49) at 6 months to 1 year follow-up (high certainty evidence).

Our findings indicate that WTS is associated with more than doubling of the odds of later initiation of cigarette smoking, supporting the gateway theory. Strengthening WTS policies is a priority and further research is needed on the development and evaluation of appropriate clinical and public health interventions.

Tobacco control in Nepal during a time of government turmoil (1960-2006).

Tobacco Control

Nepal was a monarchy, then a dictatorship, then a democracy. This paper reviews how tobacco control progressed in Nepal in the context of these changes in government from 1950 through 2006.

We triangulated tobacco industry documents, newspaper articles and key informant interviews.

Until 1983, the tobacco industry was mostly state owned. Transnational tobacco companies entered the Nepalese market through ventures with Surya Tobacco Company Private Limited (with Imperial Tobacco Company and British American Tobacco) in 1983 and Seti Cigarette Factory Limited (with Philip Morris International [PMI]) in 1985. Seminars and conferences on tobacco, celebrations of World No Tobacco Day (WNTD) and efforts by WHO helped promote tobacco control in Nepal beginning in the 1970s. Tobacco advocates in Nepal pushed the government to issue executive orders banning smoking in public places in 1992 and tobacco advertising in electronic media in 1998, and to introduce a tobacco health tax in 1993. The tobacco industry lobbied against these measures and succeeded in keeping the tobacco tax low by challenging it in court. Tobacco advocates sued the government in 2003 and 2005, resulting in a June 2006 Supreme Court decision upholding the smoking and advertising bans and requiring the government to enact a comprehensive tobacco control law.

Political instability, conflict, weak governance and the dictatorship significantly affect tobacco control activities in low-income and middle-income countries. Nepal shows that tobacco control advocates can take advantage of global events, such as WNTD, and use domestic litigation to maintain support from civil societies and to advocate for stronger tobacco control policies.

Changes in cigar sales following implementation of a local policy restricting sales of flavoured non-cigarette tobacco products.

Tobacco Control

On 3 January, 2013, the city of Providence, Rhode Island, began enforcing a restriction on the retail sale of all non-cigarette tobacco products with a characterising flavour other than tobacco, menthol, mint or wintergreen. We assessed the policy impact on cigar sales-which comprise 95% of flavoured non-cigarette tobacco products sold through conventional tobacco retail outlets (eg, convenience stores, supermarkets) in Providence-over time and in comparison to the rest of the state (ROS).

Weekly retail scanner sales data were obtained for January 2012 to December 2016. Cigar sales were categorised into products labelled with explicit-flavour (eg, Cherry) or concept-flavour (eg, Jazz) names. Regression models assessed changes in prepolicy and postpolicy sales in Providence and ROS.

Average weekly unit sales of flavoured cigars decreased prepolicy to postpolicy by 51% in Providence, while sales increased by 10% in ROS (both p<0.01). The Providence results are due to a 93% reduction in sales of cigars labelled with explicit-flavour names (p<0.01), which did not change significantly in ROS. Sales of cigars labelled with concept-flavour names increased by 74% in Providence and 119% in ROS (both p<0.01). Sales of all cigars-flavoured and otherwise-decreased by 31% in Providence (p<0.01). We detected some evidence of product substitution and cross-border purchasing.

The Providence policy had a city-specific impact on retail sales of flavoured cigars, which was attenuated by an increase in sales of concept flavour-named cigars. Products with concept-flavour names may avoid enforcement agency detection, and their continued sale undermines the intent of the policy.

UK tobacco price increases: driven by industry or public health?

Tobacco Control

Tobacco companies claim that higher taxes will force smokers into buying illicit tobacco, but if they were truly concerned about increasing illicit sales with higher prices they would only increase retail prices in line with changes in taxation. In this paper, we explore UK pricing of both factory-made cigarettes (FM) and roll-your-own tobacco (RYO) to explore the extent to which price increases were due to government tax rises or industry strategies to increase profit per pack.

Nielsen commercial data on UK tobacco sales data (2010-2015) were combined with official UK data on inflation and tax rates, to identify the source of real price increases.

Between 2010 and 2012, when there were unexpected large tax increases, industry driven price changes were small (16% of the price rise in FM and 20% in RYO), and changes were similar between market segments. Between 2013 and 2015, when tax increases were smaller and expected, industry behaviour generally accounted for a larger share of price rises (33% FM, 48% RYO), but changes varied considerably by segment.

The industry has increased its prices beyond that required by tax changes, even when tax rises were larger and unexpected, although were notably smaller in such conditions. This suggests (1) that the industry is not actually concerned by the threat of illicit, especially since RYO had the highest levels of industry driven price increases despite higher levels of illicit, and (2) there remains scope for further tax increases, which should be relatively large and unexpected.

Correction: Global economic cost of smoking-attributable diseases.

Tobacco Control

[This corrects the article DOI: 10.1136/tobaccocontrol-2016-053305.].

Waterpipe (hookah) tobacco use in pregnancy: use, preferences and perceptions of flavours.

Tobacco Control

Waterpipe tobacco (WPT; hookah) use is common in pregnant and reproductive-age women. Sweet flavours contribute to the appeal of WPT and are a potential regulatory target. This study investigated use, preferences and perceptions of WPT flavours in pregnant WPT users, and the impact of flavour preferences on preconception/prenatal WPT use and exposure biomarkers.

58 pregnant WPT users (mean age=27 years) completed a detailed interview regarding their WPT flavours use, preferences and perceptions. Biomarkers of nicotine and carcinogen exposure (eg, cotinine, benzene, butadiene) were also collected.

55% of participants were dual/poly WPT users (ie, reported use of one or more other tobacco products in addition to WPT). Pregnant WPT users reported nearly exclusive use of flavoured WPT, with greater use of menthol/mint (68%) followed by fruit flavours (48%) (p<0.001), and greater preferences for fruit followed by menthol/mint flavours (ps<0.05). Harm perceptions did not differ among flavours. Compared with dual/poly WPT users, WPT-only users reported more total WPT use events, greater use of and preference for menthol/mint flavoured WPT (ps<0.001), and decreased exposure biomarkers (ps≤0.040). Preference for menthol/mint and fruit flavours predicted more flavoured WPT use events during preconception and pregnancy; preference for menthol/mint predicted detectable cotinine and benzene levels but not butadiene.

This is the first study of WPT flavour use, preferences and perceptions in pregnant women. Use of and preference for menthol/mint and fruit WPT flavours in this vulnerable population could be considered in regulating WPT flavours to protect the health of women and children.

Comparison of e-cigarette marketing and availability in tobacco retail outlets among diverse low-income communities in California.

Tobacco Control

Research examining marketing and availability of electronic cigarettes (e-cigarettes) within tobacco retail stores is limited, especially among vulnerable communities. However, tobacco retailers tend to be the first point of access to e-cigarette exposure, especially among youth. In response, store observations were conducted among tobacco retailers across five ethnically diverse, low-income communities.

Trained community health workers recorded the presence of e-cigarette products, marketing, self-service displays, product pricing and product placement in the tobacco retail environment across American-Indian Tribal lands in California (n=96) and low-income African-American, Hispanic/Latino (HL), Korean-American (KA) and Non-Hispanic White (NHW) communities in Southern California (n=679) from January 2016 to January 2017. Store characteristics and pricing were analysed by ethnic community.

Compared with retailers in NHW communities, retailers across all other communities were less likely to sell e-cigarette and flavoured e-cigarette products and were less likely to have self-service displays. Compared with retailers in NHW communities, retailers across all other communities were less likely to have e-cigarettes placed near youth-friendly items, while retailers in KA and HL communities were less likely to have exterior advertising compared with retailers in NHW communities.

Findings indicate differences in e-cigarette availability and marketing by ethnic community. In addition, placement of products and marketing that expose youth to e-cigarette and other tobacco products within the retail environment should be restricted and regulated by policymakers and tobacco regulatory agencies to reduce the burden of tobacco-related diseases among vulnerable populations.

Effect of flavour manipulation on low and high-frequency waterpipe users' puff topography, toxicant exposures and subjective experiences.

Tobacco Control

Flavoured tobacco is one of the major factors behind the popularity of waterpipe (WP) smoking in the USA and internationally. The current study examined the impact of flavour manipulation on satisfaction, puff topography and toxicant exposure among high-frequency and low-frequency WP users.

This cross-over study was conducted among 144 current (past month) WP smokers reporting WP smoking less than once a week (low-frequency users; n=69) or at least once a week (high-frequency users; n=75) in the past 6 months. Participants attended two counterbalanced 45 min ad libitum smoking sessions that differed by flavour (preferred flavoured vs unflavoured tobacco), preceded by ≥12 hours of tobacco use abstinence. Outcome measures included puff topography, expired carbon monoxide (eCO), plasma nicotine and subjective measures.

Both high-frequency and low-frequency WP users reported an enhanced smoking experience and greater interest in future use after smoking the flavoured compared with unflavoured tobacco (p<0.05 for all). High-frequency users, however, were more keen on smoking the flavoured tobacco in the future, had higher puffing parameters in general compared with low-frequency users (p<0.05 for all) and had no differences in eCO and plasma nicotine concentrations between the flavoured and unflavoured tobacco conditions (p>0.05 for all). On the other hand, low-frequency users had significantly greater eCO and plasma nicotine concentrations following smoking the unflavoured compared with flavoured tobacco condition (p<0.05 for all).

Our results indicate that removing flavours will likely negatively affect WP satisfaction and future use and that such an effect will be more pronounced among high-frequency compared with low-frequency WP smokers.

Waterpipe device cleaning practices and disposal of waste associated with waterpipe tobacco smoking in homes in the USA.

Tobacco Control

To quantify postsmoking waterpipe tobacco (WPT) waste and describe postsmoking waterpipe (WP) device cleaning practices and disposal of associated waste in home settings.

We analysed data from a US convenience sample of 50 exclusive WPT smokers, mean age 25.3 years. Data were collected at a home visit during which participants smoked one WPT head and completed a self-administered questionnaire on WP cleaning practices and disposal of waste associated with WPT use. Research assistants provided and prepared a WP for participants by weighing and loading 10 g of WPT in the WP head and placing 470 mL of water in the WP bowl. At the completion of the smoking session, research assistants measured the remaining WPT and water. Descriptive analyses were performed.

Of the 10 g of fresh WPT used for each smoking session, 70.1% (mean=7.01 g) was discarded postsmoking as waste; for each 470 mL of water used in the WP bowl, 94.3% (mean=443 mL) was discarded. WP device cleaning practices ranged from never cleaning the device to cleaning it after each smoking session. Respondents reported discarding smoked WPT residue in the trash (81.6%) or the kitchen sink (14.3%) and discarding postsmoking charcoal in the trash (57.6%), the kitchen sink (27.3%) or backyard soil (9.1%). Respondents reported discarding smoked WP water in the kitchen sink (76.5%), bathroom sink (14.7%), toilet (2.9%) and backyard soil (5.9%).

Interventions and regulations are needed to inform proper WP device cleaning practices and disposal of waste associated with WPT use.