Chinese ‘low-tar’ cigarettes do not deliver lower levels of nicotine and carcinogens

BackgroundLow-tar cigarette smoking is gaining popularity in China. The China National Tobacco Corporation (CNTC) promotes low-tar cigarettes as safer than regular cigarettes.MethodsA total of 543 male smokers smoking cigarettes with different tar yields (15 mg, regular cigarettes, 10-13 mg low-tar cigarettes and < 10 mg low-tar cigarettes) were recruited in Shanghai, China, who then completed a questionnaire on smoking behaviour and provided a urine sample for analysis of the nicotine metabolites cotinine and trans-3'-hydroxycotinine. A total of 177 urine samples were selected at random for the analysis of the carcinogens polycyclic aromatic hydrocarbon metabolites (PAHs) (1-hydroxypyrene, naphthols, hydroxyfluorenes and hydroxyphenanthrenes) and the tobacco specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-butanone (NNK) metabolites, 4-(methylnitrosamino)-1-(3-pyridyl)-butanol (NNAL) and NNAL-glucuronide. Values were normalised by creatinine to correct for possible distortions introduced by dilution or concentration of the urine.ResultsSmokers of low-tar cigarettes smoked fewer cigarettes per day (p=0.001) compared to smokers of regular cigarettes. Despite this lower reported consumption, levels of cotinine, trans-3'-hydroxycotinine and PAHs in urine of people smoking low-tar cigarettes were not correlated with nominal tar delivery of the cigarettes they smoked. Urine concentrations of NNAL were higher in smokers of lower tar than higher tar cigarettes.ConclusionsChinese low-tar cigarettes do not deliver lower doses of nicotine and carcinogens than regular cigarettes, therefore it is unlikely that there would be any reduction in harm. CNTC's promotion of low-tar cigarettes as 'less harmful' is a violation of the World Health Organization Framework Convention on Tobacco Control, which China ratified in 2005

Comparing identity, attitudes, and indicators of effectiveness in people who smoke, vape or use heated tobacco products: a cross-sectional study

Background: There is limited long-term and independent research on heated tobacco products (HTPs). We compared people who used HTPs with those who used nicotine vaping products (NVP) or cigarettes on smoker identity, indicators of effectiveness and, among NVP/HTP users, perceptions of these products. // Methods: Adults exclusive cigarette smokers (N=45) and ex-smokers with medium/long-term (>3months) NVP (N=46) or HTP use (N=45) were recruited in London, UK. Participants completed a questionnaire assessing socio-demographics, smoking characteristics, smoker identity, dependence, intention to stop and attitudes towards HTP/NVP. // Results: In adjusted analysis, people who used cigarettes (Mean Difference (MD)=1.4, 95%Confidence Intervals (CI) 0.7,2.0) and HTPs (MD=0.8, 95%CI 0.1,1.5) reported stronger smoker identities than those who used NVPs. Compared with smokers, HTP/NVP users had lower cravings for cigarettes (MD=3.0, 95%CI 1.6,4.3; MD=3.1, 95%CI 1.9,4.3, respectively), and higher intention to stop product use (MD=-0.8, 95%CI -1.7,-0.01; MD=-1.2, 95%CI -2.0,-0.3, respectively). People using HTPs or NVPs reported similar perceived product satisfaction (HTP:M=3.4, 95%CI 2.8,3.9; NVP:M=3.0, 95%CI 2.5,3.5), efficacy for smoking cessation (HTP:M=4.5, 95%CI 4.2,4.9; NVP:M=4.6, 95%CI 4.3,4.9) and safety (HTP:M=2.1, 95%CI 2.0,2.2; NVP:M=2.0, 95%CI 1.8,2.1). HTP users reported greater perceived addictiveness than NVPs (MD=0.3, 95%CI 0.2,0.6). // Conclusions: HTP and NVP users perceived products to be similarly acceptable and effective suggesting that HTPs, like NVPs, may support smoking cessation. However, since HTP use appears to maintain a stronger smoker identity and perceived addiction, this may suggest a more limited role of HTP for a permanent transition away from cigarettes

Examining acute psychopharmacological effects of nicotine vaping versus heated tobacco products in a randomised crossover study of product naïve adult smokers

Nicotine vaping products (NVPs) and heated tobacco products (HTPs) are designed to replicate the sensory and behavioural aspects of smoking cigarettes while avoiding combustion. The success of these products as harm reduction tools will partially depend on their ability to satisfy smokers and alleviate nicotine-related withdrawal symptoms. This study aims to compare short-term effects of NVPs (Juul and Aspire PockeX) versus HTPs (IQOS) on smoking-related withdrawal relief, product satisfaction, intention to switch to NVP/HTP, perceptions and attitudes in UK adult cigarette smokers naïve to these products. In a randomized cross-over study, 45 participants visited the lab twice, at each visit trying one of the two products (NVP/HTP) and completing a questionnaire. Responses were normalized on a 0–100% scale and mean differences (MD) between NVP and HTP scores computed, with positive and negative MD values indicating greater endorsement for NVP and HTP, respectively. Cigarette cravings were reduced similarly (~ 20.0%) by both products (MD = 4.5%, 95%Confidence Interval (CI) − 4.8, 13.8). Direct positive effects (MD = − 3.5%, 95%CI − 7.2, 0.2) and adverse side effects (MD = 1.8%, 95%CI − 0.3, 3.8) were comparable after each product use, though marginally favouring HTPs. HTPs were perceived as more satisfying overall (MD = − 13.2%, 95%CI − 20.3 − 6.1) than NVPs but both were perceived as similarly addictive (MD = 3.6%, 95%CI − 4.6, 11.8), relative to cigarettes. Intention to switch to either product was comparable (MD = 4.0%, 95%CI − 5.7, 13.8). Comparison of acute use of NVP versus HTP in a sample of UK smokers naïve to these products suggests that HTPs are perceived as more satisfying than NVPs, though still less satisfying than cigarettes

Toxicity of Waterpipe Tobacco Smoking: the Role of Flavors, Sweeteners, Humectants, and Charcoal

Waterpipe tobacco (WPT) smoking is a public health concern, particularly among youth and young adults. The global spread of WPT use has surged since the introduction of pre-packaged flavored and sweetened WPT, which is widely marketed as a safer tobacco alternative. Besides flavorants and sugars, WPT additives include humectants, which enhance the moisture and sweetness of WPT, act as solvents for flavors, and impart smoothness to the smoke, thus increasing appeal to users. In the United States (U.S.), unlike cigarette tobacco flavoring (with the exception of menthol), there is no FDA product standard or policy in place prohibiting sales of flavored WPT. Research has shown that the numerous fruit, candy, and alcohol flavors added to WPT entice individuals to experience those flavors, putting them at an increased risk of exposure to WPT smoke-related toxicants. Additionally, burning charcoal briquettes-used as a heating source for WPT-contributes to the harmful health effects of WPT smoking. This review presents existing evidence on the potential toxicity resulting from humectants, sugars, and flavorants in WPT, and from the charcoal used to heat WPT. The review discusses relevant studies of inhalation toxicity in animal models and of biomarkers of exposure in humans. Current evidence suggests that more data are needed on toxicant emissions in WPT smoke to inform effective tobacco regulation to mitigate the adverse impact of WPT use on human health

E-cigarette puffing patterns associated with high and low nicotine e-liquid strength: effects on toxicant and carcinogen exposure

Contrary to intuition, use of lower strength nicotine e-liquids might not offer reduced health risk if compensatory puffing behaviour occurs. Compensatory puffing (e.g. more frequent, longer puffs) or user behaviour (increasing the wattage) can lead to higher temperatures at which glycerine and propylene glycol (solvents used in e-liquids) undergo decomposition to carbonyl compounds, including the carcinogens formaldehyde and acetaldehyde. This study aims to document puffing patterns and user behaviour associated with using high and low strength nicotine e-liquid and associated toxicant/carcinogen exposure in experienced e-cigarette users (known as vapers herein)

A Review of the Toxicity of Ingredients in E-Cigarettes, Including Those Ingredients Having the Fda\u27s generally Recognized As Safe (GRAS) Regulatory Status for Use in Food.

Some firms and marketers of electronic cigarettes (e-cigarettes; a type of electronic nicotine delivery system (ENDS)) and refill liquids (e-liquids) have made claims about the safety of ingredients used in their products based on the term GRAS or Generally Recognized As Safe (GRAS). However, GRAS is a provision within the definition of a food additive under section 201(s) (21 U.S.C. 321(s)) of the U.S. Federal Food Drug and Cosmetic Act (FD&C Act). Food additives and GRAS substances are by the FD&C Act definition intended for use in food, thus safety is based on oral consumption; the term GRAS cannot serve as an indicator of the toxicity of e-cigarette ingredients when aerosolized and inhaled (i.e., vaped). There is no legal or scientific support for labeling e-cigarette product ingredients as GRAS . This review discusses our concerns with the GRAS provision being applied to e-cigarette products and provides examples of chemical compounds that have been used as food ingredients but have been shown to lead to adverse health effects when inhaled. The review provides scientific insight into the toxicological evaluation of e-liquid ingredients and their aerosols to help determine the potential respiratory risks associated with their use in e-cigarettes

Biomarkers of Electronic Nicotine Delivery Systems (ENDS) use

This perspective summarizes available evidence on biomarkers of exposure in electronic nicotine delivery system (ENDS) users to aid the overall assessment of the health consequences of using ENDS. Identification of novel biomarkers of exposure specific to ENDS use remains challenging because chemicals emitted from ENDS devices have many familiar sources. The biomarker levels of many tobacco-related toxicants measured in biological samples collected from ENDS users did not differ significantly from non-users, except for nicotine metabolites and a small number of biomarkers of exposure to volatile organic compounds and tobacco-specific tobacco nitrosamines. Several studies have shown that while exposed to nicotine, long-term exclusive ENDS users showed significantly lower levels of toxicant biomarkers than cigarette smokers. Studies have also shown that concurrent users of ENDS and combustible cigarettes (‘dual users’) are not reducing overall exposure to harmful toxicants compared to exclusive cigarette smokers. Because of an absence of validated ENDS-specific biomarkers, we recommend combining several biomarkers to differentiate tobacco product user groups in population-based studies and monitor ENDS compliance in randomized controlled trials. Using a panel of biomarkers would provide a better understanding of health effects related to ENDS use