The profile of illegal advertising of tobacco and nicotine products on social networks in Brazil

Tobacco, nicotine and related products have and continue to change rapidly, creating new challenges for policies regulating their advertising, promotion, sponsorship and sales. This paper reviews recent commercial product offerings...

Tobacco and newer nicotine products pose significant risks to children. Data is needed on tobacco and nicotine use among children in Pakistan, given the evolving market and lack of regular surveillance. We conducted a cross-sectional survey of 10-16-year-olds in Pakistan. Using a multistage stratified random sampling strategy, we planned to recruit 9,000 school children from 180 schools and 4,320 out-of-school children from 72 enumeration blocks. We gathered data on their tobacco/nicotine use, exposure, access, and susceptibility. Descriptive analyses were performed to estimate frequencies and usage patterns. Between December 2023 and May 2024, 14,232 children were surveyed; one-third were out-of-school, with one-third girls. Overall, 9.1% (95%CI:8.5-9.6) of boys and 7.1% (95%CI:6.3-7.7) of girls reported using nicotine and/or tobacco products. Their use did not differ between school-going (8.3%; 95%CI:7.7-8.9) and out-of-school (8.5%; 95%CI:7.7-9.2) children. Reported use of e-cigarettes (boys=4.3%; girls=3.2%) and nicotine pouches (boys=3.4%; girls=2.7%) appeared higher than smoking (boys=2.1%; girls=0.7%) and smokeless tobacco use (boys=2.7%; girls=2.0%), though no statistical comparisons were conducted. More children stated that they would accept cigarettes (27%) and nicotine pouches (23.4%) than smokeless tobacco (18.5%) and electronic cigarettes (16.7%) when offered by a friend. A significant proportion could access tobacco shops near their schools (55.4%) and homes (43.1%); and 33.3% indicated they could buy these easily. In Pakistan, more children reported using e-cigarettes and nicotine pouches than smoking cigarettes, although these differences were not tested for statistical significance. Nonetheless, the observed prevalence underscores the need to regulate these products. The findings underscore the need for targeted regulatory actions to address youth use of tobacco and nicotine products in Pakistan. Comprehensive policies should consider restrictions on sales near schools, enforcement of smoke-free laws, and public awareness campaigns to prevent youth uptake and continued use of tobacco and nicotine products. Future research should build on these findings by exploring the social and behavioural drivers of children's nicotine use and evaluating interventions aimed at curbing product accessibility and appeal. This study sets a benchmark for future surveillance efforts and policy evaluations in Pakistan and similar settings.

New nicotine and tobacco products such as electronic cigarettes and oral nicotine products have increased in use and threaten to addict a new generation of youth. This review summarizes current literature on nicotine and tobacco products used by youth, epidemiology, health effects, prevention and treatment of nicotine dependence, and current policies and regulations. Electronic cigarettes and oral nicotine products are popular among youth, attracting adolescents through exposure to deceptive marketing and fruit, candy and dessert flavors. Electronic cigarettes and oral nicotine product use can lead to nicotine addiction and is associated with respiratory, cardiovascular, and oral health problems, although long-term health effects are not fully known. The Food and Drug Administration (FDA) has authority to regulate nicotine and tobacco products; however, thousands of unregulated and unauthorized products remain on the market. Millions of adolescents continue to use nicotine and tobacco products, which puts them at risk for health problems, including nicotine addiction. Pediatric providers can provide prevention messages, screen youth for tobacco and nicotine use, and offer appropriate treatment options. Regulation of tobacco and nicotine products by the FDA is critical to reverse this public health epidemic of youth nicotine and tobacco use.

IntroductionAs cigarette smoking has decreased among youth and young adults (YAs) in the United States, the prevalence of other tobacco and nicotine product use has increased.MethodsThis study identified common past 30-day patterns of tobacco and nicotine product use in youth (grades 6–12) and YAs (aged 18–24). Using data from the 2011–2015 National Youth Tobacco Survey (NYTS) and corresponding years of the Truth Initiative Young Adult Cohort Study (TIYAC), past 30-day use of the following products was assessed: cigarettes, e-cigarettes, any type of cigar, smokeless tobacco, hookah, and other tobacco products (pipe, bidis, kreteks, dissolvable tobacco, and snus). A user-generated program in R was used to assess all possible combinations of product-specific and polytobacco use.ResultsThe top five patterns of past 30-day use in youth were exclusive cigarette use (12.0%), exclusive cigar use (10.3%), exclusive e-cigarette use (10.0%), dual use of cigarettes and cigars (6.1%), and exclusive hookah use (5.2%). In YAs, the top five patterns were exclusive cigarette use (46.5%), exclusive cigar use (10.0%), dual use of cigarettes and cigars (6.4%), exclusive hookah use (5.9%), and dual use of cigarettes and e-cigarettes (3.9%).ConclusionsAs noncigarette tobacco and nicotine products become increasingly popular among tobacco users, further research is needed to identify predictors and correlates of specific tobacco use patterns in youth and YAs. This analysis can inform tobacco prevention efforts focusing on emerging tobacco products such as e-cigarettes and hookah. Educational and other intervention efforts should focus on the diversity of products and use patterns in these age groups.ImplicationsThis study uses population-based data to provide new information on the most prevalent patterns of past 30-day nicotine and tobacco use over a 5-year period among youth and young adults. Study findings demonstrate that youth and young adults report using tobacco and nicotine products in different combinations, with varying popularity over time. Additionally, by examining young adults as a separate group, this study highlights the unique patterns of use not previously discussed in the adult literature.

#TobaccoExposed

At present, IQOS, Philip Morris’s (PM’s) heated tobacco product, is being test-marketed in 30 countries worldwide.1 Similarly to electronic cigarettes,2 regulation varies widely by country. In the USA, for example,...

New types of nicotine and tobacco products like electronic cigarettes (ECs), heated tobacco products or nicotine pouches have been discussed as less harmful alternatives to combustible cigarettes and other toxic forms of tobacco products. Their harm reduction potential lay in the efficient transition away from smoking to those new products. Numerous studies addressing the cessation efficacy of ECs have been published with contradictory outcomes. Yet, a comprehensive Cochrane review concluded with high certainty on the cessation efficacy of ECs. This prompted us to perform a review to identify weaknesses in common study designs and to summarize best practices for the study design on the potential of new nicotine products as cessation aids. 120 articles retrieved from Medline were found to be eligible. Most of the studies in the field were interventional trials while observational studies played a minor role in the evaluation of smoking cessation. Efficacy was predominantly assessed for ECs in 77% of the reports while heated tobacco (17%) and non-combustible products (11%) were less frequently investigated up to now. Measures to determine the efficacy were questionnaire-based assessments as well as use documentation/prevalence and abstinence rates. Studies varied largely in their duration and sample size with medians of 3 months and 156.5 participants, respectively.With the help of this review, we identified several weaknesses in the common study designs. One major limitation in longitudinal trials was the lack of compliance measures suited to verify the use status over longer time periods, relying solely on self-reports. Moreover, the motivation of the participants to quit was rarely defined and a profound familiarization period was not taken into account for the majority of the studies. To what extent such weaknesses influence the outcome of the studies was beyond the scope of this review. We encourage researchers to consider the recommendations which resulted from this review in order to determine the abuse liability and cessation efficacy of the products in a more robust manner. Finally, we like to call attention to the missing data for low- and middle-income countries which would require quitting strategies most urgently to combat the tobacco smoking epidemic.

With increasing e-cigarette use among US adolescents and decreasing use of other tobacco products, it is unclear how total use of nicotine products, and its long-term health risks, have changed. The Centers for Disease Control and Prevention's standard measure-any tobacco product use in the past 30 days-considers neither frequency of use nor product risk implications. To investigate how nicotine product use, including frequency of use, and its associated risks have changed among middle school and high school students since 1999. This cross-sectional study used data from the 1999-2020 National Youth Tobacco Survey, an in-school survey of a nationally representative sample of students in grades 6 through 12; each survey recruited between 15 000 and 36 000 participants. Nicotine product use in the past 30 days. Use of nicotine products assessed by nicotine product days (NPDs), the number of days that the average student consumed these products in the past 30 days. Risk-adjusted NPDs account for differential long-term health risks of various products. This study included 16 years of cross-sectional survey data. Each survey recruited between 15 000 and 36 000 participants in grades 6 through 12 (male students: mean, 50.4% [minimum, 48.5%; maximum, 58.4%]; mean age, 14.5 years [minimum, 14.0 years; maximum, 14.7 years]). Nationally representative cross-sectional data for high school students showed that NPDs decreased steadily from 5.6 days per month in 1999 (95% CI, 5.0-6.2 days per month) to 2.2 days per month in 2017 (95% CI, 1.9-2.6 days per month), increased to 4.6 days per month in 2019 (95% CI, 4.1-5.1 days per month), and then decreased to 3.6 days per month in 2020 (95% CI, 3.0-4.1 days per month). For a risk weight of 0.1 for e-cigarettes, compared with combustible products, risk-adjusted NPDs decreased from 2.5 days per month in 2013 (95% CI, 2.2-2.9 days per month) (prior to the popularity of e-cigarettes) to 2.0 days per month in 2019 (95% CI, 1.6-2.5 days per month) and 1.4 days per month in 2020 (95% CI, 1.0-1.8 days per month). However, with a risk weight of 1.0 for e-cigarettes (identical to that of combustible products), risk-adjusted NPDs increased to 5.3 days per month in 2019 (95% CI, 4.4-6.2 days per month) and 3.9 days per month in 2020 (95% CI, 3.1-4.7 days per month). Similar trends were found for middle school students. This study suggests that NPDs represent an improvement, albeit an imperfect one, compared with any 30-day tobacco product use by incorporating the frequency of use of various products. By distinguishing products, NPDs permit consideration of the health consequences associated with different mixes of products over time. Health risks of adolescent nicotine product use could have decreased during vaping's popularity if assessment of the long-term risks associated with vaping compared with those of smoking is low. There is a need to closely monitor youth nicotine and tobacco product use patterns.

Sugars are naturally present in tobacco plants and are introduced as additives during the manufacturing of various tobacco- and nicotine-containing products. Product palatability and appeal are the primary reasons for manufacturers' attention to the sugar content in tobacco and nicotine products. However, because of the complex chemistry of sugars and their thermal decomposition, these versatile constituents are also contributing to the toxicity profile of tobacco and nicotine products. Using published empirical data, this non-systematic review summarizes the state of knowledge on the toxicologically relevant chemical transformations of sugars and artificial sweeteners in tobacco and nicotine products, including waterpipe tobacco, combustible and electronic cigarettes, heated tobacco products, and smokeless tobacco, and available research on the associated health effects of sugar-derived toxicants. Implications of sugar and sweetener content for abuse liability of various tobacco products are also discussed. Based on the findings of this review, research gaps are identified and policy recommendations are made for regulating sugars and artificial sweeteners in tobacco and nicotine products, including adding sugars and artificial sweeteners to the list of harmful and potentially harmful constituents (HPHCs).

Emerging tobacco and nicotine products, such as e-cigarettes and heated tobacco products (HTPs), are gaining popularity, particularly among young people. This study examines the perceptions of e-cigarettes and HTPs among nicotine-naive individuals and their variations across sociodemographic subgroups. We conducted a cross-sectional analysis of the Special Eurobarometer 99.3 (May-June 2023) among never users of tobacco or nicotine products in the European Union (EU) (n = 13 436). We estimated the weighted prevalence of perceptions of e-cigarettes and HTPs: appeal, perceived effectiveness for smoking cessation, support for them being regulated like cigarettes, and support for keeping them out of sight in points-of-sale. Multi-level Poisson regression models examined associations of sociodemographic factors with these perceptions. Among never users in the EU, 2.6% found e-cigarettes appealing, while 2.0% found HTPs appealing. 50.8% and 58.8% of participants supported strict regulations and point-of-sale restrictions for these products, respectively. Younger age groups were more likely to find e-cigarettes (Prevalence Ratio [PR] = 1.70, for ages 15-39 vs. 55+) and HTPs (PR = 1.88, PR = 1.54 for ages 15-24 and 25-39) appealing and view them as effective for smoking cessation. Support for regulations similar to cigarettes was higher among women, individuals with higher education, those living with children, and those without financial difficulties. While the appeal of these products to never users remained low overall, the study found that young people were more likely to find them appealing, posing a risk for experimentation. Meanwhile, over 50% of respondents supported stricter regulations, which could influence policy changes in this area. Although appeal of e-cigarettes and Heated Tobacco Products (HTPs) was relatively low among people who have never used e-cigarettes, HTPs or smoking tobacco in the European Union, appeal was higher among younger age groups, which are often targeted by the industry. We also found substantial support for stricter regulatory policies for e-cigarettes and HTPs across the EU. These findings might encourage governments to increase restrictions around these emerging nicotine and tobacco products.

ABSTRACTThis article provides a snapshot of the market structure and regulatory approaches around novel and emerging tobacco and nicotine products, both globally and in Latin America, with a focus on excise taxation. Using data from leading market research companies, the WHO Report on the Global Tobacco Epidemic 2021, and country laws and decrees, the article analyses the evolution and market structure of heated tobacco products (HTPs), electronic nicotine delivery systems (ENDS), and electronic non-nicotine delivery systems (ENNDS). This is followed by a summary review of regulatory approaches adopted by countries toward these products, with a particular focus on excise tax policies currently implemented. Based on the well-established knowledge about tobacco taxation best practices and on WHO’s recent recommendations on the taxation of novel and emerging tobacco and nicotine products, the authors then discuss possible elements of a good tax policy approach for countries to consider.

Summary Providing data on usage patterns is key to assessing the reduced-risk potential of novel tobacco and nicotine products as compared to conventional cigarettes at a population level. A pilot cross-sectional survey was conducted in 2018 across 3 areas of Japan (Tokyo, Osaka, and Sendai) to assess tobacco and nicotine product use after the introduction of Heated Tobacco Products (HTPs). Following successful completion of the pilot study, two nationwide cross-sectional surveys were conducted using the general population in Japan to assess use patterns after the introduction of HTPs. The first (Wave 1) was conducted in 2019, and the second in 2020. In Wave 2, the concern of this publication, additional population-level data was obtained on use patterns and behaviour relating to tobacco and nicotine products in Japan. Eligible participants were Japanese residents, aged 20 years or older who consented to complete the survey. A 3-stage probability sampling method was applied that was geographically stratified by street blocks proportionate to population density. Respondents self-reported patterns of product use and reasons for HTP use. Complete responses were available from 5307 individuals, of whom 889 (16.7%) were current users, 1012 (19.1%) were former users, and 3407 (64.2%) were never users of tobacco products (weighted respondent totals). Of current tobacco users, 63.5% smoked cigarettes exclusively and 17.9% used HTPs exclusively. HTP dual use in combination with conventional cigarettes was 12.7%. The remaining 5.9% of users were categorised as poly users (i.e., use of 2 or more tobacco products). The most common reasons reported for HTP use were perceived reduction in harm to others and self - compared to cigarettes. These findings are consistent across pilot and Wave 1 conducted in Japan as part of this survey programme. Cigarettes were still the most frequent tobacco product used (13.4% in the pilot to 15.5% in Wave 1) within the general population, the usage prevalence for HTPs (5.3% to 5.4%) being considerable in comparison to other tobacco or nicotine-containing products like cigars, cigarillos, pipe, kiseru, and oral tobacco, where usage prevalence was close to zero. As with the previous Waves, no gateway effect (use of non-traditional combustible tobacco use – such as e-cigarettes and in this case HTP use – leading to subsequent tobacco smoking) was observed in this study. The findings presented here are indicative of the results from the initial study in 2018 and the nationwide Wave 1 study in 2019 but with a larger population, where the market is now more established with new-generation products. In conclusion, the prevalence of cigarette use in Japan is decreasing and HTPs seem to be increasingly used as an alternative to cigarette smoking.

Alternative nicotine products such as electronic nicotine delivery systems (ENDS) and tobacco heating systems have gained worldwide popularity. Findings suggest ENDS to be probably less harmful than combustible cigarettes, but evidence on long-term health effects is still lacking. The potential risk reduction by using tobacco heating systems instead of combustible cigarettes has largely been studied by tobacco industry-sponsored research. Evidence on the extent of risk reduction is key for risk-adapted taxation policies, which will be discussed soon in the Swiss parliament. Evidence on the effects of tax policies in the USA shows that the level of taxation of ENDS, tobacco heating systems and combustible cigarettes has an effect on switches between these products. Therefore, excise taxes influencing one another need to be considered. In Switzerland, tobacco heating systems are currently taxed at a level of 12%, whereas ENDS are not subject to tobacco excise taxation as yet, because they do not meet the legal definition of a tobacco product. This article analyses approaches for imposing taxes on tobacco and nicotine products and possible outcomes, depending on the intended public health goals. At least three tax models can be considered. Tax model A would apply a very small tax on ENDS and a higher tax for tobacco products, which could increase incentives for smokers to switch to vaping but comes with risks of increased vaping initiation among the youth and subsequent switch to or dual use of tobacco products. In contrast, model B would levy a moderate tax on ENDS and an increased tax on tobacco products, which could limit initiation among youth, incentivise to switch from smoking to vaping and discourage dual use. In model C, a comparable tax level for ENDS, tobacco heating systems and combustible cigarettes is levied. This could have overall positive effects in reducing tobacco- and nicotine-associated burden of disease by discouraging initiation in youth, overall consumption and dual use, but could discourage switching to less harmful products. When applying these tax models to current sales prices of these products we found that no public health goal, such as protecting youth and reducing tobacco-associated morbidity and mortality can be achieved. The price of tobacco products is too low to achieve any price differentiation that reflects the different risks associated with ENDS and tobacco products. In order to achieve any public health goal with one of these tax models, prices for tobacco products need to be increased substantially.

Thinking about the unthinkable: a <i>de facto</i> prohibition on smoked tobacco products

This study explores patterns of use of non-cigarette tobacco and nicotine products among adult cigarette smokers and recent ex-smokers. Along with cigarette smoking status we explore differences as a function of countries with different product regulations, gender, and age. Data came from the ITC Four Country Smoking and Vaping Wave 3 Survey conducted between February-June 2020. The analytic sample consisted of 9112 current cigarette smokers (at least monthly) and 1184 recent ex-smokers (quit cigarettes ≤ 2 years) from Australia, Canada, England, and the United States. Respondents were asked about their cigarette smoking and current use of the following non-cigarette products: combustible tobacco (cigars, cigarillos, pipe, waterpipe); noncombustible tobacco (smokeless tobacco, and heated tobacco products [HTPs]); and non-tobacco nicotine products (nicotine vaping products [NVPs], nicotine replacement therapy [NRT], and nicotine pouches). Overall, NVPs (13.7%) and NRT (10.9%) were the most reported nicotine products used, followed by cigars (5.3%), cigarillos (4.2%), and HTPs (3.5%). More than 21% current and recent ex-smokers of cigarettes reported using a non-tobacco nicotine product and noncombustible product, with respondents in England reporting the highest levels of use (>26%). Males, younger respondents, and current non-daily cigarette smokers were more likely to use non-cigarette nicotine products. Notably, 11.6% of ex-cigarette smokers were using other combustible tobacco. Considerable percentages of current cigarette smokers and ex-smokers use non-cigarette nicotine products, and there are unexpectedly high levels of use of other combustible products by those recent ex-smokers of cigarettes which is concerning and has important implications for definitions of smoking cessation. The tobacco product market has evolved to include new products which add to existing non-cigarette tobacco products creating a much more diverse nicotine market. This brief report provides a snapshot of use of various combustible and noncombustible nicotine-containing products among current cigarette smokers and recent ex-smokers in four western countries. Our results indicate that use of non-cigarette tobacco and nicotine products among these cigarette smokers and recent ex-smokers is not low, particularly among males, younger and non-daily cigarette smokers. Use of other combustible tobacco among respondents that recently quit cigarette smoking is concerning and has important implications for definitions of smoking cessation. Increased emphasis on researching non-cigarette nicotine product use is warranted in tobacco control generally and smoking cessation in particular.