Waterpipe and Co-Use of Inhaled Nicotine and Tobacco Products: Findings from a Population-Based Cross-Sectional Household Survey in Germany

Non-combustible nicotine products (NCNPs), such as heated tobacco products (HTPs) and nicotine vaping products (NVPs) have gained a significant nicotine market share in South Korea. This descriptive study examined patterns of regular cigarette and NCNP use among South Korean adults. Data were from the 2020 International Tobacco Control Korea Survey and included 4016 adults (aged ≥19 years) in the Republic of Korea who were regularly (at least weekly) using at least one NCNP (NVP/HTP, n=2117) and/or smoked cigarettes (n=3763) at the time of the survey. Weighted descriptive estimates were computed to assess respondents' nicotine product use among all respondents (exclusive, dual, or triple use). Thereafter, we identified sociodemographic characteristics associated with NCNP use (n=2117). Among Korean adults who were smoking cigarettes, 83.1% (95% CI: 81.6-84.6) did so exclusively, and 16.9% (95% CI: 15.4-18.4) smoked cigarettes and used NCNPs. Among those who used HTPs (n=1877), 14.9% (95% CI: 11.5-18.4) did so exclusively, 59.6% used HTPs and smoked cigarettes (95% CI: 55.4-63.1), 4.2% used HTPs and vaped (95% CI: 11.5-18.4), and 21.6% (95% CI: 18.9-24.2) used all three products. Of adults who used HTPs and smoked cigarettes, 86.6% smoked daily. Among those who vaped (n=865), 13.3% did so exclusively (95% CI: 9.4-17.1), 55.6% (95% CI: 49.6-61.5) vaped and smoked cigarettes, 5.1% (95% CI: 1.7-8.6) used HTPs and vaped, and 26.1% (95% CI: 22.1-30.1) used all three products. Of adults who vaped and smoked cigarettes, 82.4% (95% CI: 77.1-87.7) smoked daily. Cigarettes remain the most commonly used nicotine product in South Korea, and among adults using heated tobacco and/or vaping products, the majority were also smoking. Research is urgently needed to assess whether adults who are using an NCNP are doing so to quit, or rather to complement their cigarette smoking.

Background In parallel with a decline in cigarette smoking in the previous decade, other tobacco and nicotine products (TNPs), that are often used concurrently, have gained popularity among adolescents. The purpose of this study was to identify patterns of tobacco and nicotine product use among Serbian adolescents. Methods Data for this study were obtained from Health Behavior in School-aged Children (HBSC), a WHO collaborative cross-national study of adolescent health and well-being, that was conducted in Serbia in 2022 on a sample of 3713 students 11,13 and 15 years old. Descriptive statistics was used as well as latent class analysis to classify students based on their past-month use of cigarettes, e-cigarettes, heated tobacco products, waterpipes, and oral tobacco/nicotine products. Results Among students 11,13 and 15 years old, 10.2% smoke cigarettes, 13% use e-cigarettes, 11.1% waterpipes, 3.7% oral tobacco/nicotine products, and 4.5% heated tobacco products with differences by age and sex. We found high percentages of dual use of TNPs among cigarette smokers. Among students who smoke cigarettes, 61.6% also use e-cigarettes, 36.2% smoke waterpipes, 30.2% heated tobacco products, and 24.1% oral tobacco/nicotine products. Latent class analysis identified three classes as optimal solution: (1) dual e-cigarette and cigarette users (6.9%); (2) minimal/non-users (83.2%) and (3) poly tobacco and nicotine products users (9.9%). Statistically significant differences between classes were found in age and sex. Conclusions Dual and poly-tobacco and nicotine use is common among Serbian adolescents and presents a challenge for monitoring and public health response. Findings contribute to a better understanding of patterns and heterogeneity of TNPs use among adolescents and might have implications for prevention and cessation interventions for youth. Key messages • Among students 11,13 and 15 years old, tobacco and nicotine products, other than cigarettes is gaining popularity and with the e-cigarettes being the most popular product. • Dual and poly tobacco and nicotine products use is new challenged that should be taken into account in tobacco and nicotine monitoring, cessation and prevention.

BackgroundFor novel tobacco products that potentially reduce the risk of tobacco harm, post-market surveillance is important to observe population usage and behaviours associated with everyday use. This pilot study was performed to examine the use of tobacco products in three Japanese urban regions.MethodsThis study was a cross-sectional epidemiological survey administered in Sendai, Tokyo and Osaka, Japan, from May 19th to June 25th, 2018. Participants were selected with a three-stage probability random sampling process that first identified primary sampling units, then households and finally individuals. Eligible participants were aged at least 20 years who were willing to participate after information about the study was provided. People younger than 20 years and those living in institutions were excluded. Questionnaires were paper based and administered door to door.ResultsResponses were obtained from 4154 participants. Sixty-five percent self-reported being never, 19% current and 16% former users of any tobacco product at the time of the survey. Combustible tobacco products (almost all being cigarette) were used most (16%) followed by HTPs (5%). In the categories of combustible tobacco users and HTP users, 70% and 16%, respectively, used these products exclusively. Dual use was reported by 11% of respondents. Compared with 12 months before the survey, 12% of sole combustible tobacco products users were using HTPs exclusively or as dual users and 6% had quit tobacco products completely; 94% of sole HTP users remained sole users and 4% had quit tobacco products completely; and amongst dual users 12% had reverted to exclusive use of combustible tobacco products, 14% had switched to sole use of HTPs and 4% had quit tobacco products completely.ConclusionHTPs seem to be accepted as an alternative tobacco product amongst combustible tobacco users. Given complex findings for dual use, improved understanding of the motivations underlying this behaviour would be of interest.

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.

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IntroductionEmerging 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.MethodsWe 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.ResultsAmong never users in the EU, 2.6% found e-cigarettes appealing, while 2.0% found HTPs appealing. Fifty-point eight percent 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.ConclusionWhile 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.ImplicationsAlthough 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 EU, 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.

Smoking negatively impacts aerobic capacity, primarily by reducing V̇O2max, the gold standard measure of cardiorespiratory fitness. While smoking cessation is known to improve vascular function, exercise performance, and oxygen uptake, its specific impact on V̇O2max remains underexplored. Specifically, no research has yet evaluated V̇O2max changes following a switch to electronic cigarettes (ECs) or heated tobacco products (HTPs). This is a secondary analysis of the CEASEFIRE trial, a 12-weeks randomized controlled switching trial comparing the impact of ECs or HTPs on changes in smoking behaviour. The trial offers a unique opportunity to prospectively examine the relationship between smoking behavior and aerobic capacity, and to examine—for the first time—the specific impact of exclusive EC or HTP use on V̇O2max. Changes in VO₂max were analized across three smoking phenotypes: continuous smokers, those who reduced smoking, and those who abstained from smoking Additionally, VO2max was also evaluated specifically in participants who completely abstained from smoking tobacco cigarettes, evaluating outcomes in exclusive EC and HTP users. Quitters showed the greatest improvement in VO2max at both week 4 (2.4 ± 1.7 mL kg−1 min−1) and week 12 (2.7 ± 1.9 mL kg−1 min−1). Reducers also exhibited significant VO2max increases (1.3 ± 1.9 mL kg−1 min−1 at week 4: 1.9 ± 1.8 mL kg−1 min−1 at week 12), while Failures (i.e. those who continued smoking) showed no change. Exclusive use of EC and HTP resulted in statistically significant and clinically relevant improvements in V̇O2max. Compared to baseline, V̇O2max significantly increased at week 4 (EC: 38.4 ± 5.9 to 41.0 ± 6.1 mL kg−1 min−1; HTP: 39.2 ± 6.7 to 41.4 ± 6.4 mL kg−1 min−1, both p < 0.0001) and week 12 (EC: 38.4 ± 5.9 to 41.4 ± 6.3; HTP: 39.2 ± 6.7 to 41.6 ± 6.5 mL kg−1 min−1, both p < 0.0001). No significant differences between EC and HTP were observed at either time point. Rapid improvements in V̇O2max can happen when healthy smokers switch to exclusive use of ECs or HTPs. These findings reinforce the potential cardiorespiratory benefits of smoking cessation and harm reduction strategies.

Background Tobacco smoke is a major risk factor to noncommunicable disease (NCD) and its role is under study in the Joint Action PreventNCD. This study assessed the impact of new tobacco and nicotine products, i.e., electronic cigarettes (e-cig) and heated tobacco products (HTP), on smoking prevalence in the adult population residing in Italy. Methods Istituto Superiore di Sanità (ISS) uses behavioral surveillance systems for monitoring purpose in PreventNCD. PASSI surveillance system data 2008-2023 amount 532,115 interviews on adults (aged 18-69) residing in Italy. From the weighted monthly series on smokers’ prevalence, interrupted time series (ITS) were analysed, with generalized least squares, accounting for autocorrelation (ARMA matrix). January 2024 (introduction of e-cig in data collection) was used as “first-interruption” month, and January 2018 (introduction of HTP) as “second-interruption” month. The analysis shows the difference between what occurred after the intervention and expected outcome in the hypothesis of no intervention. The exclusive or combined use of the three products was also evaluated. Results Cigarettes smokers trend decreased from 30% to 24%, but the ITS analysis shows how the introduction of new tobacco and nicotine products and consuming shift, mostly combined, interrupted the declining trend in cigarettes use in Italy. There is no reduction in the total amount of nicotine addict or tobacco users: since PASSI started investigating new electronic devices, we observe a constant decrease in the number of exclusive traditional cigarettes users (from 25% in 2014 to 20% in 2023), in favor of an increase in both traditional cigarettes and electronic devices (from 1.5% in 2014 to 4.4% in 2023) users. Exclusive electronic devices users also slowly increased, from 0.4% in 2014 to 3.3% in 2023. Conclusions Exclusive use of cigarettes decreased as combined use with e-cig increased; exclusive use of electronic devices slowly increased. Key messages • Combined use of traditional cigarettes and electronic devices represents a challenge for public health, as it increases health risks caused by exposure to higher nicotine and harmful chemicals levels. • Tobacco and nicotine users did not decrease with the introduction of new electronic devices.

Heated tobacco products (HTPs) are increasingly used by individuals attempting to quit smoking, particularly in Japan where HTP use is prevalent; however, the effectiveness of HTPs in achieving complete tobacco abstinence remains unclear. This study aimed to estimate the likelihood of complete tobacco abstinence and combustible cigarette abstinence among exclusive HTP users and dual users compared with exclusive combustible cigarette users. A prospective cohort design using sequential annual follow-ups (2019-2023) from the Japan 'Society and New Tobacco' Internet Survey (JASTIS). Inverse probability-weighted Poisson generalized estimating equation models were used to estimate rate ratios for abstinence outcomes. Nationwide internet-based survey conducted in Japan. A total of 8969 Japanese adults aged 20 years and older who were current tobacco users at baseline were included. Participants were categorized as exclusive combustible cigarette users (55.6%), exclusive HTP users (16.3%) or dual users (28.0%). Exclusive HTP users were further categorized as established (daily use, ≥100 HTPs used, or >12 months of lifetime use) or non-established users. Primary outcomes were (1) complete tobacco abstinence-defined as no current use of any tobacco products used at baseline-and (2) combustible cigarette abstinence after one year. Abstinence required selecting "used regularly in the past but quit" for each relevant product. Compared with exclusive combustible cigarette users (as classified at baseline), the rate ratio (RR) for complete tobacco abstinence was 0.85 [95% confidence interval (CI) = 0.71-1.02] among exclusive HTP users and 0.49 (95% CI = 0.42-0.58) among dual users. When stratified, established HTP users had a statistically significantly lower likelihood of complete tobacco abstinence (RR = 0.57, 95% CI = 0.47-0.70), while non-established users showed a higher likelihood (RR = 2.41, 95% CI = 1.83-3.17). Compared with exclusive combustible cigarette users, the RR for combustible cigarette abstinence after one year was 0.93 (95% CI = 0.83-1.04) among dual users. In this one-year follow-up, dual use of cigarettes and heated tobacco products (HTP) and established exclusive HTP use were associated with lower rates of complete tobacco abstinence compared with exclusive cigarette use, while non-established exclusive HTP use showed higher abstinence rates. Overall, HTP use was not associated with higher tobacco abstinence rates.

Background:Concurrent use of tobacco products such as cigarettes and water pipes may be associated with increased risk of nicotine dependence and smoking-related complications. Accurate statistics are not available regarding the prevalence of water pipe use or concurrent use of cigarettes and water pipe in the Iranian population. Thus, this study sought to assess the prevalence of concurrent use of cigarettes and water pipes and their related factors in Iran.Materials and Methods:This cross-sectional study was conducted on Tehran residents over 15 years of age, who were selected via cluster, multi-stage randomized sampling, from different geographical districts of Tehran between November and December 2014. The data were collected using the water pipe section of the Global Adult Tobacco Survey (GATS) questionnaire.Results:A total of 1,830 individuals participated in this study, 243 (13.3%) of which exclusively used water pipes, 76 (4.2%) used both cigarettes and water pipes, and 120 (6.6%) exclusive smoked cigarettes. Of those who used both cigarettes and water pipes, 86.8% were men and 13.2% were women (P < 0.001). The mean age of those who only used water pipes was 28.01 ± 8.7 years while the mean age of those who used both water pipes and cigarettes was 33.1 ± 1.1 (P < 0.001). Male sex (adj. OR: 3.8) and older age (adj. OR: 1.06) increased the odds of using both tobacco products.Conclusion:The prevalence of concurrent use of cigarettes and water pipes and that of exclusive water pipe use were 4.2% and 13.3%, respectively. The prevalence of exclusive cigarette smoking was 6.1%. Those who smoked both cigarettes and water pipes had a higher mean age than those who exclusively used water pipes and they were mostly men. Among those who used cigarettes and water pipes, the mean age at which they began using water pipes was lower than the mean age at which they began smoking cigarettes. In other words, dual smokers started water pipe smoking sooner than cigarette smoking. Future studies with different methodologies are required to further scrutinize the relationship between water pipe and cigarette smoking. Smoking cessation programs must specifically target dual smokers.

Although smoking is a known risk factor for problem gambling, the relationship between heated tobacco products (HTPs), emerging tobacco products that are widely used in Japan, and problem gambling has not yet been examined. This study investigated the association between smoking behaviour, including HTP use, and problem gambling. We conducted a cross-sectional study using data from a large-scale online survey conducted from January 24 to February 27, 2024. Respondents who reported gambling within the past year were included in this study. Exclusive cigarette use, exclusive HTP use, and dual use were defined as smoking variables based on current smoking patterns in Japan. Problem gambling was defined as a score of 8 or higher on the Problem Gambling Severity Index. Multivariable weighted logistic regression models were fitted to examine the adjusted odds ratios (AORs) of smoking status for problem gambling. In total, 12,222 respondents (7,649 men and 4,573 women) were included in the study. The proportion of problem gambling differed; it was 4.6% among individuals who did not use tobacco products, 13.8% among those who exclusively used combustible cigarettes, 15.2% among those who exclusively used HTP, and 41.9% among those who used both. Compared to non-use/non-current use of tobacco products, exclusive combustible cigarette use (AOR, 2.89 [95% CI, 2.36-3.53]), exclusive HTP use (AOR, 2.34 [95% CI, 1.81-2.99]), and dual use (AOR, 10.52 [95% CI, 8.89-12.47]) were associated with problem gambling. Smoking behaviours, including heated tobacco product use, were associated with problem gambling.

Purpose Despite the advent of heated tobacco products (HTPs), their relationship to mental health remains unclear. This study aimed to determine associations between the use of combustible cigarettes (CCs) and HTPs with depressive symptoms. Methods This descriptive-analytical cross-sectional study was conducted in March 2023. Using the 8th Korea National Health and Nutrition Examination Survey, 5,349 adults aged 19 years or older were classified into four groups: non-users, CC-only users, HTP-only users, and dual users. Relationships between exclusive or dual use of CCs and HTPs and depressive symptoms were analyzed using item scores and total scores of the Patient Health Questionnaire-9 (PHQ-9). To examine associations between exclusive or dual use of CCs and HTPs and depressive symptoms, a multinomial regression analysis was performed using the PHQ-9 total score. Results HTP-only users had the highest proportion of those with anhedonia and depressed mood. CC-only users had the highest proportion of individuals with trouble sleeping, while dual users had a higher proportion of those with fatigue and appetite problems. After adjusting for general characteristics, compared to non-users, CC-only users were more likely to have mild and moderate to severe depressive symptoms. HTP-only users and dual users were also more likely to have moderate to severe depressive symptoms. Conclusions All smokers have a higher risk of depression than non-smokers. Health care providers should closely monitor depressive symptoms, especially in HTP users and dual users of tobacco products.

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...

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.

Ontologies are ways of representing information that improve clarity and the ability to connect different data sources. This paper proposes an initial version of an ontology of tobacco, nicotine and vaping products with the aim of reducing ambiguity and confusion in the field. Terms related to tobacco, nicotine and vaping products were identified in the research literature and their usage characterised. Basic Formal Ontology was used as a unifying upper-level ontology to describe the domain, and classes with definitions and labels were developed linking them to this ontology. Labels, definitions and properties were reviewed and revised in an iterative manner until a coherent set of classes was agreed by the authors. Overlapping, but distinct classes were developed: 'tobacco-containing product', 'nicotine-containing product' and 'vaping device'. Subclasses of tobacco-containing products are 'combustible tobacco-containing product', 'heated tobacco product' and 'smokeless tobacco-containing product'. Subclasses of combustible tobacco-containing product include 'cigar', 'cigarillo', 'bidi' and 'cigarette' with further subclasses including 'manufactured cigarette'. Manufactured cigarettes have properties that include 'machine-smoked nicotine yield' and 'machine-smoked tar yield'. Subclasses of smokeless tobacco product include 'nasal snuff', 'chewing tobacco product', and 'oral snuff' with its subclass 'snus'. Subclasses of nicotine-containing product include 'nicotine lozenge' and 'nicotine transdermal patch'. Subclasses of vaping device included 'electronic vaping device' with a further subclass, 'e-cigarette'. E-cigarettes have evolved with a complex range of properties including atomiser resistance, battery power, properties of consumables including e-liquid nicotine concentration and flavourings, and the ontology characterises classes of product accordingly. Use of an ontology of tobacco, nicotine and vaping products should help reduce ambiguity and confusion in tobacco control research and practice.