Patterns of use and biomarkers of exposure among ‘dual’ tobacco cigarette and electronic cigarette users in Canada.

Background: Tobacco use remains the leading risk factor for preventable disease in Canada. Although tobacco smoke is the direct cause of smoking-induced diseases, nicotine addiction sustains the use of tobacco. Electronic cigarettes (e-cigarettes) are battery-powered devices that deliver nicotine in an aerosol form. Despite a restriction on the sale of nicotine-containing e-cigarettes in Canada, products with and without nicotine are accessible to Canadians. Although e-cigarettes are likely to be much less harmful than tobacco cigarettes, empirical evidence of potential reduced risk at the individual level is limited. To date, behavioural switching studies involving tobacco cigarettes and e-cigarettes are limited by restrictions placed on e-cigarette user and product characteristics, and few have examined biomarkers of exposure among concurrent (dual) users of these products. Furthermore, although dual users constitute the majority of e-cigarette users in Canada, little is known about their behaviour. The current study seeks to fill several critical evidence gaps regarding dual users’ patterns of use and exposure to nicotine and tobacco smoke constituents in the Canadian context. Objectives: The study examined: 1) Patterns of use and perceptions of tobacco cigarettes and e-cigarettes among dual users. In the context of product switching, the study examined: 2) Exposure to nicotine and compensatory behaviour; 3) Exposure to tobacco smoke constituents; 4) Symptoms of nicotine withdrawal for tobacco cigarettes and e-cigarettes, respectively; 5) Self-efficacy for abstaining from smoking tobacco cigarettes and using e-cigarettes, respectively; and 6) Perceived respiratory health. Methods: An un-blinded within-subjects experiment was conducted with a sample of adult daily dual users (n=48) in Kitchener-Waterloo and Toronto, Ontario. Participants completed three consecutive seven-day periods in which the use of tobacco cigarettes and e-cigarettes was experimentally manipulated, resulting in four study conditions: dual use, exclusive use of tobacco cigarettes, exclusive use of e-cigarettes, and use of neither product. To control for order effects, the order in which participants experienced the study conditions was randomized. Participants’ behaviours and exposure to nicotine and tobacco smoke constituents were assessed following each study condition. Patterns of use and product perceptions were examined at baseline using descriptive statistics. Repeated measures models were used to examine the following outcomes: compensatory behaviour for nicotine, exposure to tobacco smoke constituents, symptoms of nicotine withdrawal, self-efficacy, and perceived respiratory health. Results: Dual users were 36 years of age, mostly male (71%), and exhibited low to moderate nicotine dependence (FTCD: 4.7 (SD=1.9)). Study participants had smoked and vaped daily for 17.4 (SD=12.2) and 1.2 (SD=0.9) years, respectively, and all reported initiating use of tobacco cigarettes prior to e-cigarettes. Although dual users reported similar daily consumption of tobacco cigarettes and e-cigarettes (13.7 (SD=5.6) tobacco cigarettes per day vs. 10.9 (SD=11.4) bouts of e-cigarette use, p=0.09), a greater proportion reported smoking tobacco cigarettes within the first hour of waking (98% vs. 59% for e-cigarettes; p<0.001). Virtually all dual users reported using tank systems (92%) and e-cigarettes with nicotine (94%). The most commonly reported reasons for using e-cigarettes included: to smoke fewer tobacco cigarettes (79%), to help with cravings for tobacco cigarettes (71%), and because of the belief that e-cigarettes are less harmful than tobacco cigarettes (71%). Compared to tobacco cigarettes, dual users considered e-cigarettes as more socially acceptable (65%), less satisfying (67%), less pleasurable (64%), less harmful (87%), and less expensive (81%). Findings from the product-switching experiment indicated that compared to dual use, levels of urinary cotinine were stable when participants exclusively smoked (p=0.524), but significantly decreased when they exclusively vaped (p=0.027), despite significant increases in e-cigarette consumption (p=0.001). Biomarkers of exposure, including exhaled carbon monoxide (CO), urinary 1-hydroxypyrene (1-HOP), and urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), were significantly lower when participants exclusively vaped, as compared to when they engaged in dual use (CO: -41%, p<0.001; 1-HOP: -31%, p=0.025; NNAL: -30%, p=0.017). A similar trend was observed among participants abstaining from both tobacco cigarettes and e-cigarettes, as compared to dual use (CO: -26%, p<0.001; 1-HOP: -14% (ns); NNAL: -35%, p=0.016). In addition, biomarkers of exposure showed an increasing trend among participants when they exclusively smoked as compared to dual use (CO: +21%, p=0.029; 1-HOP: +23%, p=0.048; NNAL: +8% (ns)). Study participants experienced significantly greater urges to smoke tobacco cigarettes when they were not permitted to do so (p=0.001). Although changes in participants’ self-efficacy for abstaining from tobacco cigarettes depended on the order in which they experienced study conditions, the self-efficacy of all participants at the end of the product-switching experiment did not differ significantly from their baseline values. In contrast, participants reported no significant changes in urges to use e-cigarettes (p=0.460) or in their self-efficacy to abstain from using e-cigarettes (p=0.150) across study conditions. Dual users reported significant improvements in various domains of respiratory health when they abstained from smoking tobacco cigarettes, including improvement in experiencing shortness of breath, cough, cough with phlegm, sounds emanating from the chest, and in perceived lung function (p<0.001 for all). Conclusions: The findings suggest that dual use behaviour is similar to that in other jurisdictions, despite Canada’s restrictive regulatory framework for these products. Tobacco cigarettes appear superior to e-cigarettes in their ability to deliver nicotine. Although abstaining from smoking tobacco cigarettes elicits cravings, it is also associated with significant improvements in perceived respiratory health. Consistent with other research, results from the current study demonstrate that abstaining from tobacco cigarettes is the most important factor in reducing exposure to tobacco smoke constituents. Therefore, dual use is likely to have public health benefit only to the extent that it leads to complete smoking cessation

Accountability and pediatric physician-researchers: are theoretical models compatible with Canadian lived experience?

Physician-researchers are bound by professional obligations stemming from both the role of the physician and the role of the researcher. Currently, the dominant models for understanding the relationship between physician-researchers' clinical duties and research duties fit into three categories: the similarity position, the difference position and the middle ground. The law may be said to offer a fourth "model" that is independent from these three categories

Cigarette brands with flavour capsules in the filter: Trends in use and brand perceptions among smokers in the USA, Mexico and Australia, 2012-2014

Objective To describe trends, correlates of use and consumer perceptions related to the product design innovation of flavour capsules in cigarette filters.&nbsp; Methods Quarterly surveys from 2012 to 2014 were analysed from an online consumer panel of adult smokers aged 18&ndash;64, living in the USA (n=6865 observations; 4154 individuals); Mexico (n=5723 observations; 3366 individuals); and Australia (n=5864 observations; 2710 individuals). Preferred brand varieties were classified by price (ie, premium; discount) and flavour (ie, regular; flavoured without capsule; flavoured with capsule). Participants reported their preferred brand variety's appeal (ie, satisfaction; stylishness), taste (ie, smoothness, intensity), and harm relative to other brands and varieties. GEE models were used to determine time trends and correlates of flavour capsule use, as well as associations between preferred brand characteristics (ie, price stratum, flavour) and perceptions of relative appeal, taste and harm.&nbsp; Results Preference for flavour capsules increased significantly in Mexico (6% to 14%) and Australia (1% to 3%), but not in the USA (4% to 5%). 18&ndash;24 year olds were most likely to prefer capsules in the USA (10%) and Australia (4%), but not Mexico. When compared to smokers who preferred regular brands, smokers who preferred brands with capsules viewed their variety of cigarettes as having more positive appeal (all countries), better taste (all countries), and lesser risk (Mexico, USA) than other brand varieties.&nbsp; Conclusions Results indicate that use of cigarettes with flavour capsules is growing, is associated with misperceptions of relative harm, and differentiates brands in ways that justify regulatory action

To "vape" or smoke? Experimental evidence on adult smokers.

A growing share of the United States population uses e-cigarettes but the optimal regulation of these controversial products remains an open question. We conduct a discrete choice experiment to investigate how adult tobacco cigarette smokers' demand for e-cigarettes and tobacco cigarettes varies by four attributes: (i) whether e-cigarettes are considered healthier than tobacco cigarettes, (ii) the effectiveness of e-cigarettes as a cessation device, (iii) bans on use in public places, and (iv) price. We find that adult smokers' demand for e-cigarettes is motivated more by health concerns than by the desire to avoid smoking bans or higher prices

Adolescent awareness and use of electronic cigarettes: A review of emerging trends and findings

Adult electronic cigarette (e-cigarette) use is increasing globally, and early studies have suggested that similar trends may be observed among the adolescent population, albeit at lower levels. The current literature review presents data collected since 2014 from 21 cross-sectional studies and one cohort study that were all published in English. In particular, it focuses on awareness, ever use, past 30-day use, and regular use of e-cigarettes. The article suggests that adolescents are nearing complete awareness of e-cigarettes. Furthermore, in relation to ever use and past 30-day use, higher prevalence rates continue to be reported across time, especially in the United States. Nonetheless, reported regular use of e-cigarettes remains much lower than past 30-day use, although conclusions are limited due to inconsistencies with measurement and consequent lack of cross-cultural applicability. The majority of studies do not report whether adolescents use non-nicotine e-cigarettes. There is a current absence of longitudinal studies that explore any association between e-cigarettes and tobacco use and little qualitative data that may illuminate how and why adolescents use e-cigarettes. Through addressing these methodological limitations, future research will be able to inform health care and policy more effectively

E-cigarettes and urologic health: a collaborative review of toxicology, epidemiology, and potential risks

Context: Use of electronic cigarettes (ECs) is on the rise in most high-income countries. Smoking conventional cigarettes is a known risk factor for urologic malignancy incidence, progression, and mortality, as well as for other urologic health indicators. The potential impact of EC use on urologic health is therefore of clinical interest to the urology community. Objective: To review the available data on current EC use, including potential benefits in urologic patients, potential issues linked to toxicology of EC constituents, and how this might translate into urologic health risks. Evidence acquisition: A Medline search was carried out in August 2016 for studies reporting urologic health outcomes and EC use. Snowballing techniques were also used to identify relevant studies from recent systematic reviews. A narrative synthesis of data around EC health outcomes, toxicology, and potential use in smoking cessation and health policy was carried out. Evidence synthesis: We found no studies to date that have been specifically designed to prospectively assess urologic health risks, even in an observational setting. Generating such data would be an important contribution to the debate on the role of ECs in public health and clinical practice. There is evidence from a recent Cochrane review of RCTs that ECs can support smoking cessation. There are emerging data indicating that potentially harmful components of ECs such as tobacco-specific nitrosamines, polyaromatic hydrocarbons, and heavy metals could be linked to possible urologic health risks. Conclusions: ECs might be a useful tool to encourage cessation of conventional cigarette smoking. However, data collection around the specific impact of ECs on urologic health is needed to clarify the possible patient benefits, outcomes, and adverse events. Patient summary: While electronic cigarettes might help some people to stop smoking, their overall impact on urologic health is not clear. While electronic cigarettes might help some people to stop smoking, it is not clear if they may be bad for urologic health

Electronic cigarettes for smoking cessation

Background Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol formed by heating an e‐liquid. Some people who smoke use ECs to stop or reduce smoking, but some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit and if they are safe to use for this purpose. This is an update of a review first published in 2014. Objectives To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke achieve long‐term smoking abstinence. Search methods We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 February 2021, together with reference‐checking and contact with study authors. Selection criteria We included randomized controlled trials (RCTs) and randomized cross‐over trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. To be included, studies had to report abstinence from cigarettes at six months or longer and/or data on adverse events (AEs) or other markers of safety at one week or longer. Data collection and analysis We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow‐up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included changes in carbon monoxide, blood pressure, heart rate, blood oxygen saturation, lung function, and levels of known carcinogens/toxicants. We used a fixed‐effect Mantel‐Haenszel model to calculate the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data from these studies in meta‐analyses. Main results We included 56 completed studies, representing 12,804 participants, of which 29 were RCTs. Six of the 56 included studies were new to this review update. Of the included studies, we rated five (all contributing to our main comparisons) at low risk of bias overall, 41 at high risk overall (including the 25 non‐randomized studies), and the remainder at unclear risk. There was moderate‐certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.69, 95% confidence interval (CI) 1.25 to 2.27; I2 = 0%; 3 studies, 1498 participants). In absolute terms, this might translate to an additional four successful quitters per 100 (95% CI 2 to 8). There was low‐certainty evidence (limited by very serious imprecision) that the rate of occurrence of AEs was similar) (RR 0.98, 95% CI 0.80 to 1.19; I2 = 0%; 2 studies, 485 participants). SAEs occurred rarely, with no evidence that their frequency differed between nicotine EC and NRT, but very serious imprecision led to low certainty in this finding (RR 1.37, 95% CI 0.77 to 2.41: I2 = n/a; 2 studies, 727 participants). There was moderate‐certainty evidence, again limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non‐nicotine EC (RR 1.70, 95% CI 1.03 to 2.81; I2 = 0%; 4 studies, 1057 participants). In absolute terms, this might again lead to an additional four successful quitters per 100 (95% CI 0 to 11). These trials mainly used older EC with relatively low nicotine delivery. There was moderate‐certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 3 studies, 601 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 0.60, 95% CI 0.15 to 2.44; I2 = n/a; 4 studies, 494 participants). Compared to behavioral support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.70, 95% CI 1.39 to 5.26; I2 = 0%; 5 studies, 2561 participants). In absolute terms this represents an increase of seven per 100 (95% CI 2 to 17). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was no evidence that the rate of SAEs differed, but some evidence that non‐serious AEs were more common in people randomized to nicotine EC (AEs: RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants; SAEs: RR 1.17, 95% CI 0.33 to 4.09; I2 = 5%; 6 studies, 1011 participants, very low certainty). Data from non‐randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued use. Very few studies reported data on other outcomes or comparisons and hence evidence for these is limited, with confidence intervals often encompassing clinically significant harm and benefit. Authors' conclusions There is moderate‐certainty evidence that ECs with nicotine increase quit rates compared to ECs without nicotine and compared to NRT. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the size of effect, particularly when using modern EC products. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, though evidence indicated no difference in AEs between nicotine and non‐nicotine ECs. Overall incidence of SAEs was low across all study arms. We did not detect any clear evidence of harm from nicotine EC, but longest follow‐up was two years and the overall number of studies was small. The evidence is limited mainly by imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up‐to‐date information, this review is now a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status

Exposure to Food and Beverage Advertising on Television among Canadian Adolescents, 2011 to 2016

Adolescents represent a key audience for food advertisers, however there is little evidence of adolescent exposure to food marketing in Canada. This study examined trends in Canadian adolescents&rsquo; exposure to food advertising on television. To do so, data on 19 food categories were licensed from Nielsen Media Research for May 2011, 2013, and 2016 for the broadcasting market of Toronto, Canada. The average number of advertisements viewed by adolescents aged 12&ndash;17 years on 31 television stations during the month of May each year was estimated using television ratings data. Findings revealed that between May 2011 and May 2016, the total number of food advertisements aired on all television stations increased by 4%, while adolescents&rsquo; average exposure to food advertising decreased by 31%, going from 221 ads in May 2011 to 154 in May 2016. In May 2016, the advertising of fast food and sugary drinks dominated, relative to other categories, accounting for 42% and 11% of all exposures, respectively. The findings demonstrate a declining trend in exposure to television food advertising among Canadian adolescents, which may be due to shifts in media consumption. These data may serve as a benchmark for monitoring and evaluating future food marketing policies in Canada