IntroductionTobacco addiction remains a major public health challenge. Existing smoking cessation treatments require prolonged daily use with potentially poor adherence and reduced efficacy.MethodsThe phase II study was a multicenter, randomized, double-blind, placebo-controlled trial with a 1-year follow-up to assess the efficacy, safety, and immunogenicity of NFL-101 as a potential aid for smoking cessation. A total of 318 adult daily smokers were randomized to receive subcutaneous injections of NFL-101-100 μg, NFL-101-200 μg, or placebo on day 1 and day 8. The primary outcome was 6-week post-quit 28-day continuous abstinence (CA, day 15–day 43), validated by exhaled CO.ResultsCO verified 6-week post-quit CA was: NFL-101-100 μg: 31/108 (28.7%), 200 μg: 23/109 (21.1%), and placebo: 18/101 (17.8%), NFL-101-100 μg vs placebo, RR = 1.61, p = .063, and 200 μg vs placebo RR = 1.18, p = .5492. CA, when urinary cotinine was used, was: 26/108 (24.1%) for NFL-101-100 μg, 18/109 (16.5%) for 200 μg, and 13/101 (12.9%) for placebo. NFL-101-100 μg vs placebo showed an RR = 1.87, 95% confidence interval (CI): 1.02 to 3.44, p = .0378 and 200 μg vs placebo was RR = 1.28, 95%CI: 0.66 to 2.48, p = .4572. If individuals who used NRTs and/or e-cigarettes were classified as non-abstinent, then 29/108 (26.9%) were abstainers for NFL-101-100 μg and 14/101 (13.9%) for placebo (p = .0203). NFL-101-100 μg RR remained stable between 28 days and 12 months. At day 43, NFL-101-100 μg reduced craving (p < .05), with no significant difference for withdrawal symptoms. Abstainers experienced greater increases in anti-NFL-101-IgG concentrations compared to non-abstainers (p < .009). NFL-101 was well-tolerated.ConclusionsAlthough the prespecified primary endpoint was not statistically significant, if the primary outcome had been defined as nicotine abstinence, the results would have reached statistical significance. Efficacy, craving reduction, and minimal dosing regimen of NFL-101-100 μg support its potential as a promising smoking cessation therapy.ImplicationsIn this multicenter randomized clinical trial that included 318 smokers, effect sizes between groups were sufficiently large to suggest a meaningful clinical effect. NFL-101 at a dose of 100 μg increased 6-week post-quit 28-day continuous smoking abstinence that was confirmed by urinary cotinine concentrations and reduced craving, suggesting psychological benefits that could mitigate relapse risks. Abstainers experienced a significant increase in anti-NFL-101 IgG concentrations compared to those who continued to smoke.Findings from the present study offer support for an entirely new category of treatment that acts through immune modulation. Additional strengths include a subcutaneous route of administration in the form of two injections spaced a week apart (thus, enhances treatment adherence) and has demonstrated a safe profile with minimal adverse effects. These results support a follow-up phase III clinical trial.

IntroductionGlobally, tobacco use rates in Muslim communities, particularly among men, are significantly higher than in non-Muslim communities. In the United Kingdom, there are also low rates of help-seeking among British Muslims who use tobacco. Ramadan could be a “window of opportunity” to support tobacco use behavior change but we lack the voice of British Muslim communities on culturally tailored cessation support. We undertook a public and patient involvement and engagement (PPIE) project to gain views from representatives of these communities.Aims and MethodsDiscussions with 15 PPIE representatives from, or who worked with, a variety of British Muslim communities identified through gatekeepers, social media, and snowballing approaches. Key points and views from PPIE discussions were summarized into broad themes.ResultsOpportunities and challenges with culturally adapting tobacco cessation support to Ramadan were raised. “Light touch” positive religious messaging connected to tobacco cessation was recommended, and overemphasizing religion in messaging content to be avoided. Quitting during Ramadan was felt challenging due to fasting, precluding the use of nicotine replacement products or medication, and reinforcing tobacco use as part of fast-breaking routines. Instead, PPIE representatives suggested quitting in advance of Ramadan or promoting cessation afterward by capitalizing on tobacco reduction achieved during Ramadan. There was support for digital cessation approaches, but it was felt many in their communities would prefer traditional approaches, including interpersonal support and messaging through influential community members.Conclusions“Light touch” culturally tailored tobacco cessation support before or after Ramadan was felt more promising than supporting cessation initiation during Ramadan.ImplicationsMembers of British Muslim communities identified challenges with using Ramadan as a “window of opportunity” for tobacco behavior change and favored quitting ahead of time for Ramadan or capitalizing on tobacco behavior change achieved during Ramadan to promote a quit attempt afterward. Taking a “light touch” approach with religiously tailored messaging could help engage Muslim people who smoke in cessation support. However, avoiding any strong or negatively framed tobacco-related messages linked to religious phrases or imagery is important. This work reinforces the importance of engaging with communities when considering culturally adapting interventions to prevent misdirected adaptions.

IntroductionVape use is increasing, particularly among young people who have never been cigarette smokers. Stealth vaping, that is, discrete use in places where it is prohibited, is also reported to be increasing. Regular vape use is high among those who identify as Māori, with the Tobacco Industry reported to be targeting Indigenous communities, thus continuing long-running harmful, colonial practices.Aims and MethodsThis qualitative study, using group interviews within a kaupapa Māori framework, explored stealth vaping with 19 young adults, of whom 18 identified as Māori in the Indigenous context in New Zealand.ResultsThe results showed that hiding vape use is enhanced by the features of devices, while the nicotine content drives the need to vape nearly anywhere.ConclusionsThe tobacco and nicotine endgame approach is favored by Māori leaders, meaning stricter regulation on vaping devices alone does not adequately protect young people. Instead, stronger measures must be implemented to reduce the appeal of vaping. Vaping does not align with Māori worldviews. Addiction and their easy concealment sustain their use, highlighting the tension between alternative nicotine products that benefit the Tobacco Industry, with the goals of Māori and other Indigenous peoples to eradicate nicotine entirely.ImplicationsThe study results reinforce that priority must be given to culturally led and culturally safe regulatory and policy changes and advocacy for both smoke- and vape-free environments. Regulating the features of devices to negate their stealth use, as their invisibility was facilitated by their manipulability, should enable the existing smoke-free environment spaces to again deter vape use. Advocates must understand Māori history and context to extend the spaces where the strength that comes from being Māori will overcome the need to vape.

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.

IntroductionE-cigarettes are an increasingly popular method of smoking cessation assistance; however, there is little research on whether this has affected the number of smokers who quit using “any” evidence-based cessation aid. This study examined trends in the use of cessation aids, including e-cigarettes and other evidence-based methods.Aims and MethodsData were cross-sectional surveys in 2016, 2018, and 2020 from the International Tobacco Control Four Country Smoking and Vaping Survey conducted in Canada, United States (US), England, and Australia. Respondents were adults (≥18) recruited by commercial panel firms who currently smoked, and/or quit smoking in the past 12 months. Respondents were asked about use of e-cigarettes, nicotine replacement therapies, prescription medications, quitlines, and counseling services during their last quit attempt (LQA). Generalized estimating equation regression models that were analyzed separately by country examined use of cessation assistance among 14 536 observations (Canada = 4880; US = 2917; England = 4846; and Australia = 1898).ResultsE-cigarettes (29.9%) and nicotine replacement therapy (29.8%) were popular methods of cessation assistance at LQA. Using e-cigarettes at LQA increased in Australia (2016 = 11.1%; 2020 = 25.1%; p=.002) and England (2016 = 37.1%; 2018 = 46.7%; p=.002), with no significant change in Canada or the US. Across all countries, there was little change over time in the overall use of evidence-based cessation assistance. Nearly half of respondents used some form of cessation assistance excluding e-cigarettes. Approximately two-thirds used “any” form of evidence-based cessation including e-cigarettes at LQA, which decreased in Canada (2016 = 64.0%, 2020 = 58.9%; p=.010).ConclusionsWhile e-cigarettes are a popular cessation aid, use of other evidence-based cessation assistance has remained comparatively stable among adults that tried to quit smoking.ImplicationsThe findings indicated that e-cigarettes are a popular cessation method among adults trying to quit smoking. Despite differences in e-cigarette use and regulatory environments in the four countries, rates of evidence-based cessation assistance were similar across countries and over time. E-cigarettes can be an effective method for stopping smoking; however, the current study suggests few, if any, changes in the proportion of adults who smoke using any evidence-based form of cessation assistance, despite changes in the use of e-cigarettes as a quit aid.

IntroductionThe harms of cigarette smoking are greater for those who smoke more heavily. This study aimed to provide up-to-date estimates of cigarette consumption across Great Britain and explore differences by socioeconomic position, the presence of children in the household, nation, and region.MethodsCross-sectional analysis of data from a nationally representative household survey of adults in Great Britain, 2022–2024 (n = 77 796). Main outcome measures were mean daily cigarette consumption and the proportion consuming more than 20 cigarettes per day (among those who smoked cigarettes) and average per-capita cigarette consumption (among adults).ResultsOverall, adults who smoked cigarettes consumed on average 10.4 [95%CI = 10.2%–10.6%] cigarettes per day, with 5.5% [5.0%–6.0%] smoking more than 20 per day. Average per-capita consumption was 528 [512–543] cigarettes per year, equating to a total consumption of 28.6 [27.8–29.5] billion cigarettes in Great Britain per year. Consumption was lower among those from more vs. less advantaged socioeconomic positions (mean consumption: 9.4 [9.1–9.7] vs. 11.0 [10.7–11.3] cigarettes per day; proportion smoking more than 20 per day: 4.6% [3.9%–5.2%] vs. 6.1% [5.4%–6.9%]). It was also lower among those with children in the household than those without (9.7 [9.3–10.0] vs. 10.7 [10.4–10.9]; 4.0% [3.2%–4.9%] vs. 6.1% [5.4%–6.7%]), although these differences appeared to be largely explained by the younger age of those with children in the household. Cigarette consumption also varied geographically, with the highest consumption in the North East of England (11.7 [10.6–12.8] cigarettes per day) and Scotland (11.7 [10.8–12.5]) and the lowest in London (8.4 [7.9–9.0]) and the South West (9.5 [8.9–10.1]).ConclusionsAn estimated 28.6 billion cigarettes are smoked in Great Britain each year. There are persistent disparities in cigarette consumption across socioeconomic groups, regions, and nations, reflecting broader patterns of health inequality.ImplicationsWhile smoking prevalence has declined and regional differences have narrowed over recent decades, strong socioeconomic and geographic disparities in consumption remain, with particularly high levels among less advantaged groups and in regions with historically poorer health outcomes, such as the North East and Scotland. Addressing these disparities through targeted public health efforts and cessation support could contribute meaningfully to reducing health inequalities across Great Britain.

IntroductionThis study examines trends in social norms toward cigarette smoking and e-cigarette use among US youth during 2015-2021, focusing on descriptive interpersonal norms (friends’ behavior) and injunctive norms at interpersonal (perceived important others’ negative view) and societal level (perceived public disapproval).MethodsRespondents were youth aged 12 to 17 from the Population Assessment of Tobacco and Health Study of the United States, Wave 3 (2015-2016) to Wave 6 (2021). Logistic regression models that adjusted for demographics and participation effects assessed norm changes over time and their association with use status in Wave 6.ResultsBetween 2015 and 2021, the probability of having friends who smoked cigarettes decreased (26.1% vs. 7.9%, adjusted odds ratio [aOR] = 0.81 [95% confidence interval = 0.72 to 0.91]), while having friends who use e-cigarettes generally decreased (31.6% vs. 22.3%, aOR = 0.46, [0.37-0.58]) despite an increase in 2018-2019. Perceived negative views from important others remained stable for both products during 2015-2019, peaked in 2020 (85.2% and 86.2%) before declining slightly in 2021. Perceived public disapproval increased to a peak in 2020 for both products (73.3% to 84.2% for cigarettes and 55.4% to 77.5% for e-cigarettes). In 2021, having friends who used e-cigarettes was associated with current e-cigarette use (relative risk ratio [RRR] = 15.07 [9.94-22.85]) and current dual use (RRR = 3.38 [1.41-8.13]), while important others’ negative view toward e-cigarette use reduced the likelihood of current e-cigarette use (RRR = 0.3 [0.2-0.44]).ConclusionsAmong US youth during 2015-2021, norms consistently indicated denormalization of cigarette smoking. e-cigarette norms showed greater variability, particularly during the coronavirus disease 2019 (COVID-19) pandemic.

IntroductionHigh rates of smoking among people with HIV (PWH) persist and may be due to HIV-associated neurocognitive disorders exacerbating abstinence-induced cognitive deficits, leading to higher risk of relapse. This study assessed differences in smoking abstinence rates and abstinence-induced cognitive deficits among PWH and people without (PWOH).MethodsIn this prospective observational design (NCT03169101), treatment-seeking adults completed two laboratory sessions during a pre-quit phase to assess cognition: once following 24h abstinence and once smoking-as-usual. Cognition was measured through response inhibition, working memory, and verbal memory tasks. All received standard smoking cessation treatment over 8 weeks (i.e., counseling, nicotine patch). Point-prevalence abstinence was assessed at end-of-treatment.ResultsOur sample included 210 participants (38.1% PWH; 61.9% PWOH), who were mostly male (59.5%) and Black/African-American (76.7%). No significant HIV status by abstinence condition interactions emerged for any cognitive outcome (all ps > .4). There were significant abstinence-induced deficits in response inhibition (p = .02), working memory response time (p = .005), and verbal memory (p=<.001). No significant differences emerged in abstinence rates between PWH and PWOH (31.2%, 32.3%, respectively; OR = 1.26, 95% CI: 0.67, 2.39, p = .48).ConclusionDespite prior research suggesting differences in abstinence rates and cognition between PWH and PWOH who smoke, hypotheses were not supported. However, this is one of a few studies to directly compare people with and without HIV in a rigorously designed mechanistic smoking cessation study. Given that cognition does not appear to play a primary role in smoking among PWH, more work is needed to understand the mechanisms driving disproportionate smoking rates among PWH.

IntroductionThis study evaluated whether e-liquid nicotine concentration and non-tobacco flavor availability affected very low nicotine content (VLNC) and normal nicotine content (NNC) cigarette purchasing within an online experimental tobacco marketplace (ETM).Aims and MethodsAdults who smoked daily (n = 67) completed four study visits. At each visit, using a pre-allocated balance, participants completed successive ETM shopping trips to purchase a week’s worth of cigarettes, e-cigarette e-liquid, and nicotine gum. In one trip, the only cigarettes available had VLNC. In others, both NNC and VLNC cigarettes were available, with the price of NNC cigarettes escalating across trips ($0.12 to $2.00 / cigarette) while VLNC cigarette price remained constant ($6.00 / pack). Across visits, e-liquid available in the ETM varied by nicotine concentration (50 mg/mL, 25 mg/mL) and flavor availability (multiple flavors, one tobacco flavor). We compared cigarette purchasing by a linear mixed model with a random effect for subject.ResultsWhen the only cigarettes available had VLNC, participants purchased fewer cigarettes when multiple e-liquid flavors (vs. one tobacco flavor) were simultaneously available in the ETM (−8.55 cigarettes, 95% confidence interval [CI] = −15.85, −1.25). The nicotine concentration of available e-liquid (50 vs. 25 mg/mL) did not significantly affect cigarette purchasing. NNC cigarette demand across escalating prices was similar regardless of e-liquid condition, except average maximum expenditure was lower when multiple e-liquid flavors were available (−$2.54, 95% CI = −$4.08, −$1.00).ConclusionsWithin an ETM where NNC cigarettes were unavailable, participants purchased fewer VLNC cigarettes when non-tobacco e-liquid flavors were available versus only a tobacco flavor.ImplicationsAccess to a variety of non-tobacco (eg, fruit, mint, and dessert) flavored e-liquids could moderate initial VLNC cigarette and nicotine e-liquid purchasing if a low nicotine product standard for cigarettes is implemented. Future studies should investigate how the nicotine concentration, the flavor variety, and risk perceptions of vaping products affect VLNC cigarette purchasing and use over time.

IntroductionEvidence on the mortality burden of tobacco use remains fragmented for low- and middle-income countries like India, and does not fully use Indian-specific datasets. We estimated mortality fractions attributable to different tobacco types (smoked, smokeless, and mixed tobacco use) for India by sex and state-and-union territories over time.Aims and MethodsWe applied a direct prevalence approach to estimate mortality fractions attributable to tobacco types among men (35–54 years) and women (35–49 years) over time across 36 Indian states. We used national- and state-level prevalence estimates from the National Family Health Survey (1998–1999, 2005–2006, 2015–2016, and 2019–2021) and estimated Indian-specific relative risks (RRs) of all-cause mortality by tobacco type and sex by applying Cox proportional hazards models to data from the Mumbai Cohort Study.ResultsRRs and sex differences therein differed by tobacco use type. Smoking exhibited the highest RR among men, while mixed tobacco use was highest among women. In 2019–2021, 45.7% and 2.5% of all deaths among Indian men and women, respectively, were related to tobacco use, driven by smoking-attributable mortality among men (28%) and smokeless tobacco-attributable mortality among women (2.1%). Tobacco-attributable mortality shares declined between 1998–1999 and 2019–2021, more strongly for women than men, with an increase in different tobacco types for men and in smoking for women until 2005–2008. State differences in tobacco-attributable mortality shares varied by sex and tobacco types, with higher shares for smoking in the Northeast region, and for smokeless tobacco in East India.ConclusionsLevels, sex and state differences, and time trends in mortality fractions attributable to tobacco use in India differed substantially by tobacco type.ImplicationsOur findings highlight the importance of further strengthening tobacco control initiatives by shifting to a target-oriented approach comprising different actions for each tobacco use type, aimed particularly at men and the Northeast Indian states, to enable India to achieve its Sustainable Development Goals by 2030.