IntroductionTobacco companies use social media to bypass marketing restrictions. Studies show that exposure to tobacco promotion on social media influences subsequent smoking behavior, yet it is challenging to monitor such content. We developed an artificial intelligence that can automatically identify tobacco-promoting content on social media.Aims and MethodsIn this mixed methods study, 177,684 tobacco-related tweets published on Twitter in Turkish were collected. Through inductive content analysis of a sample of 200 tweets, the main mechanisms by which tobacco is promoted on social media were identified. Then, a sample of 5000 tweets was deductively analyzed and labeled based on those mechanisms. A pre-trained transformer-based Large Language Model was fine-tuned using the labeled dataset. Then, tobacco promotion in all tweets was predicted using this model.ResultsThe main mechanisms of tobacco promotion on social media included modeling the behavior, expressing positive attitudes, recommending use, and marketing brands or vendors. The developed model identified tobacco-promoting social media content with 87.8% recall and 81.1% precision. The utility of the model was demonstrated in the analysis of tobacco promotion in tweets for a period of a month.ConclusionsThis tool makes it possible to monitor tobacco promotion in social media and creates new opportunities for tobacco control policy and practice, not only in surveillance and enforcement but also in health promotion.ImplicationsTobacco promotion in social media is a well-known yet hard-to-addressed problem due to the nature of social media. This study leverages a cutting-edge AI approach, Large Language Models, to identify tobacco promotion in social media content automatically and precisely. The developed model offers better prediction performance than previously proposed techniques. The study enables surveillance of tobacco-promoting content both for research purposes and enforcement of tobacco control measures. Furthermore, we suggest a range of health promotion opportunities this tool can help with from developing personal skills to creating supportive environments and strengthening community actions.

IntroductionDifferences in smoking prevalence across socioeconomic groups are a major driver of health inequalities. Although smoking prevalence continues to decline across most developed countries, socioeconomic inequalities in smoking still persist. While Ireland is among a small number of countries with a tobacco-endgame goal set to achieve a smoking prevalence of 5% by 2025, the challenge this presents by socioeconomic status is uncharted.Aims and MethodsWe analyzed how differences in smoking status across various socioeconomic groups have changed over time in the adult population in Ireland. We used cross-sectional smoking data from the national population-based Healthy Ireland Survey for 2015–2022 (n = 52 494). Educational attainment and area-based deprivation were used as socioeconomic indicators. Socioeconomic differences and changes in inequality over time were identified using the relative index of inequality (RII). Multinomial logistic regression was used to analyze the association between socioeconomic status and daily smoking, occasional smoking, former smoking, and never smoking with adjustment for sex, age, and survey year.ResultsWe observed the highest daily smoking rates among the least educated (OR = 11.62; 95% CI = 9.91, 13.63) and individuals living in the most deprived areas (OR = 4.23; 95% CI = 3.55, 5.04). Additionally, we identified significant relative smoking inequalities over the observation period continued to increase, among the least educated (RII = 2.86, 95%CI = 2.63, 3.09) and individuals living in the most deprived areas (RII = 2.64, 95% CI = 2.36, 2.93)ConclusionsDespite generally reducing smoking prevalence, socioeconomic inequalities continue to widen among the smoking population in Ireland.ImplicationsAs the tobacco endgame deadline of 2025 is fast approaching, this study highlights the urgent need to consider potential effects across the lowest socioeconomic status groups when implementing equity-oriented tobacco control policies.

IntroductionElectronic cigarettes (e-cigarettes) are considered a potential aid for smoking cessation. This study investigates the neurobiological mechanisms underlying the motivational properties of e-cigarettes compared to tobacco cigarettes and provides insights into their addictive potential and implications for smoking cessation.Aims and MethodsThe study included 47 daily e-cigarette users, the majority of whom were former smokers (n = 43), and 28 nicotine-naïve participants as controls. Among the e-cigarette users, 32 individuals currently used e-cigarettes exclusively, while 15 also used tobacco cigarettes (dual users). Functional magnetic resonance imaging was used to examine anticipatory brain activation to reward-predictive stimuli for money, e-liquid, or tobacco cigarettes, as well as the instrumental response to obtain each reward.ResultsExclusive e-cigarette users demonstrated increased activation in limbic regions, for example, the nucleus accumbens, during the anticipation of e-liquid and money over tobacco cigarettes. Prefrontal regions showed greater activation during the anticipation of money compared to e-liquid or tobacco cigarettes. Dual users showed greater activation for money compared to tobacco cigarettes in the hippocampal limbic system. No significant differences were observed in the anticipation of e-liquid and tobacco cigarettes among dual users.ConclusionsE-cigarettes are perceived as equally rewarding as money, highlighting their addictive potential. Among exclusive e-cigarette users, money and e-liquid have stronger motivational properties than tobacco cigarettes (even among former smokers), suggesting that e-cigarettes may be an effective tool for tobacco cessation. The comparable appeal of e-liquid and tobacco cigarettes among dual users may suggest that a complete switch to e-cigarettes may be more effective for smoking cessation.ImplicationsIt is important to understand the motivational properties of e-cigarettes, particularly compared to traditional tobacco products. E-cigarettes with little or no addictive potential might not be effective as a substitute for tobacco cigarettes; however, a high addictive potential would, conversely, pose a risk to nonsmokers. Our data suggest that e-cigarettes have a sufficiently high addictive potential to make them an attractive alternative for smokers, especially if they switch completely from tobacco to e-cigarettes.

IntroductionSnus is suggested as a risk factor for cardiometabolic disease, but little is known about health effects in young populations, particularly in women. We aimed to investigate associations between snus and cardiometabolic health markers among young men and women.Aims and MethodsThis study was conducted within the BAMSE (Swedish acronym for Children, Allergy, Environment, Stockholm, Epidemiology) birth cohort and included participants followed up around 24 years (n = 2256) and 26 years (n = 1011). Snus use was assessed at 24 years by questionnaires. Cardiometabolic health markers were recorded at clinical examinations at 24 and 26 years. Associations between snus use and cardiometabolic markers were assessed by multivariable linear regression.ResultsSnus was used by 6.4% (n = 81) among women and 21.9% (n = 219) among men. Compared to no tobacco use, daily exclusive snus use among women at 24 years was associated with higher body mass index (BMI) (adjusted β: 1.93 kg/m2, 95% confidence interval [CI] = 0.54, 3.33) and waist circumference (WC) (aβ: 3.80 cm, 95% CI = 0.41, 7.18) at 24 years, and with higher BMI (aβ: 2.73 kg/m2, 95% CI = 0.53 to 4.93) at 26 years. Among men, using ≥4 cans/week was associated with increased BMI (aβ: 2.48 kg/m2, 95% CI = 0.73, 4.24) and a tendency toward increased body fat (aβ: 2.31%, 95% CI = −0.53, 5.14) at 26 years. Snus use was not associated with glycemic status or blood pressure.ConclusionsOur results suggest that snus is associated with increased BMI, and possibly other measures of adiposity, among young women and heavy-using young men. Given the cross-sectional study design, the results should be interpreted with caution.ImplicationsWe found cross-sectional associations between snus use and measures of increased adiposity in a cohort of Swedish young adults, including BMI and WC among women and BMI among heavy snus-using men. We did not find associations between snus use and body fat %, glycemic status, or blood pressure. This is one of few studies to investigate the health effect of snus among both women and men as well as cardiometabolic health markers in young adults. Given the recent trends of increased snus use among young adults, our findings highlight the need for further research on snus on cardiometabolic health.

IntroductionAdolescent usage of electronic cigarettes has increased globally. Inconsistent, or absent, labeling of nicotine and other ingredients requires chemical analysis to accurately determine the chemical composition of these products.Aims and MethodsElectronic cigarettes confiscated from public and private high school students (N = 598) were provided for analysis from three regions in New South Wales, Australia. The products were examined for brand, model, and flavor and a subset was further analyzed for chemical composition (n = 410) quantifying nicotine, synthetic cooling agents, flavoring chemicals, and prohibited ingredients by gas chromatography–mass spectrometry (GC–MS).ResultsThe majority of samples provided were fruit-flavored disposable e-cigarettes across three main brands (IGET, HQD, and Gunnpod). Nicotine was quantified in 97.3% of disposable samples with an average concentration of 40.0 mg/mL, while one refill e-liquid was found to contain nicotine at a low concentration. Almost all samples contained the coolant WS-23 in relatively high concentrations compared to other flavoring chemicals present. Chemicals prohibited under the TGO110 (Australian e-cigarette product standard) were identified in 3.4% of the samples which were chemically analyzed. This included the presence of ethylene glycol in moderately high concentrations (up to 13.2 mg/mL).ConclusionsAustralian students’ preferences for fruity, disposable e-cigarettes were identified regardless of region with the vast majority containing high concentrations of nicotine. WS-23 was found in most disposable e-cigarettes, potentially to reduce throat irritation from nicotine and other flavoring chemicals. The inhalational safety of the samples is of concern due to health risks associated with detected prohibited compounds, particularly ethylene glycol.ImplicationsThis is the first study to quantify nicotine, coolants, and flavoring chemicals in e-cigarette products seized from Australian high school students and has significant implications for future policy development. Students appear to be almost exclusively using disposable e-cigarettes with high nicotine concentrations and predominately fruity flavors. WS-23 may potentially be added to disposable e-cigarettes to facilitate the uptake of these products by adolescents unaccustomed to the throat irritation from nicotine and intense flavors. The e-cigarette coils were found to have degraded over time, potentially affecting the composition of the aerosol and leaching of metals.

IntroductionIn December 2022, a California law banned the retail sale of most flavored tobacco products (including e-cigarettes). This investigation evaluates adolescents’ use of flavored tobacco before and after enactment.Aims and MethodsThe Teens Nicotine and Tobacco Project included online surveys of California adolescents (age 12–17) in 2022 (N = 5127) and 2023 (N = 5015) that assessed past 30-day use of various tobacco products, flavored product use, and perceived access to flavored e-cigarettes. Eight focus groups conducted in 2023 and 2024 (total N = 35) queried flavored tobacco experiences and perceptions.ResultsAmong participants who used specific products, the prevalence of flavored product use declined for cigarettes (2022: 72.0%; 2023: 57.2%), cigars (2022: 87.2%; 2023: 67.4%), and smokeless tobacco (2022: 93.1%; 2023: 83.1%) but not for e-cigarettes (2022: 91.0%; 2023: 90.7%) or hookah (2022: 88.1%; 2023: 85.6%; the flavor law exempted some hookah sales). In 2023, 10.2% of all participants used any flavored tobacco product (2022: 10.0%), primarily flavored e-cigarettes (2022: 8.6%; 2023: 8.8%). In 2023, 22.0% of all participants were aware of the statewide flavor ban, including 44.1% of participants who reported tobacco use. Few focus group participants were aware of the statewide law or perceived difficulties accessing flavored e-cigarettes.ConclusionsShortly following a statewide flavor ban, adolescent use of flavored cigarettes, cigars, and smokeless tobacco declined, but flavored e-cigarette use was unchanged. More time for implementation and enforcement may be needed to see full policy impact.ImplicationsThese findings suggest that a statewide flavored tobacco policy in California was followed shortly by declines in adolescent use of some flavored tobacco products. Additional time for implementation and enforcement, along with potential further actions, such as greater restrictions on online sales, could be necessary to curb youth access to flavored e-cigarettes.

IntroductionHospital emergency departments (ED) offer an opportunity to engage with large numbers of people who smoke to prompt cessation, although the acceptability of opportunistic intervention in this context has been questioned. This process evaluation study was embedded into the Cessation of Smoking Trial in the Emergency Department (COSTED) randomized controlled trial and sought to explore the context of intervention delivery within the ED.Aims and MethodsQualitative interviews were conducted with participants and staff across six EDs participating in the COSTED randomized controlled trial. Interview data were thematically analyzed specifically exploring contextual influences. Data were triangulated with ethnographic observations.ResultsIn participant interviews (N = 34), it was acceptable overall to receive a brief opportunistic smoking cessation intervention in the ED. Contextual factors are impacted at a range of levels. At the micro level participant views and experiences combined with staff tailoring were important. Being given an e-cigarette starter kit by a “credible source” helped to legitimize vaping for smoking cessation and gave confidence in personal ability to switch away from tobacco. At the meso level, adaptations to intervention delivery were made in response to the context of the ED. Stop smoking advisors (N = 11) had to adapt and deliver the intervention flexibly depending on space and clinical need. At the macro level, hospital policies supportive of vaping legitimized the approach.ConclusionsSmoking cessation outcomes reported in the main trial across sites were very similar because of the high credibility, acceptability, and flexible approach to delivering the COSTED intervention in the ED.ImplicationsAttending a hospital ED is the right time and place to receive smoking cessation intervention, even for those not motivated to quit. People are willing to receive intervention, and clinical staff are willing to support intervention delivery. Despite challenges, overall the context is helpful in supporting people to switch away from tobacco. The intervention, with flexible and tailored implementation, is adaptable to different ED contexts. This suggests that wider implementation across NHS Trusts of the effective COSTED intervention is feasible and will ultimately support smoking cessation for people attending EDs, who may not otherwise have sought support.

IntroductionAn estimated 78% of the total deaths attributable to smoking tobacco use occurred in low- and middle-income countries (LMICs) in 2019. In addition, smokeless tobacco increases the risk of all-cause mortality, all cancers, including upper aero-digestive tract cancer, stomach cancer, ischemic heart disease and stroke, with 88% of the mortality burden being borne by the South-East Asian region. Evidence-based interventions from high-income countries (HICs) are not easily transferable to LMICs, as patterns of tobacco use, health beliefs associated with tobacco use, and awareness of specific health risks vary substantially.MethodsWe synthesized the effectiveness of behavioral interventions for tobacco cessation in LMICs through a systematic review and meta-analysis. Interventional studies which delivered individual behavioral intervention and assessed abstinence from tobacco use were included. We examined the pooled intervention effect at 6 months postintervention follow-up.ResultsFor continuous abstinence at 6 months, the intervention was superior to the active comparator (RR 2.32; 95% CI 1.78 to 3.02) and usual care (RR 4.39; 95% CI 2.38 to 8.11). For point prevalence abstinence at six months, the intervention was superior to the active comparator (RR 1.76; 95% CI 1.28 to 2.44), and usual care (RR 2.37; 95% CI 1.47 to 3.81). The statistical heterogeneity was substantial to considerable for all comparisons. Only six studies had an overall low risk of bias. Publication bias was observed for all comparisons except for 6-month continuous outcomes.ConclusionsImplementation research is needed to understand factors for programme sustainability and equity of the impact of behavioral interventions in reducing tobacco use in LMICs.ImplicationsOur review is an important step towards understanding the effectiveness of behavior interventions for tobacco cessation suited for LMICs and which are responsive to the contextual needs of such countries.

IntroductionAustralian survey and seizure data suggest a growing illicit tobacco market. As an illicit product, accurately tracking trends in illicit tobacco growing, manufacture, and sales is challenging. We examined trends in Australian illicit tobacco-related crimes using a content analysis of news articles.Aims and MethodsWe analyzed Australian news articles identified in the Factiva database and government press releases describing Australian illicit tobacco-related crimes reported between January 2000 and December 2023. Sources were coded for crime type, location, product type, dollar value of seized products, methods of distribution or storage, agencies involved, and other crimes involved.ResultsWe identified 447 crimes reported in 389 sources. The number of illicit tobacco-related crimes reported increased between 2000 and 2023. The most common crimes were possession of illicit tobacco (n = 196/43.7%) and smuggling (n = 187/41.8%), and the most common product type was “illicit cigarettes” (n = 197/44.1%). The most common distribution/storage method reported was via residential premises (n = 98/21.9%). One-hundred and twenty incidents involved other crimes such as financial crimes involving money laundering (n = 59/13.2%). Across all included news articles, the quantity of seized products totaled 827 529 307 cigarette sticks, 76 185 cartons, 668 687 packs, 239 hectares (of land growing tobacco plants), and 2 149 000 plants of illicit tobacco between 2000 and 2023. The median value (worth; AUD) of each seizure was $1 500 000 (range $43 to $67 000 000).ConclusionsAustralian media reporting on illicit tobacco-related crimes increased over the past two decades, particularly since 2018. These findings highlight a need for improved border detection measures, investment in enforcement, and other deterrent activities.ImplicationsThis media analysis complements trends identified in national survey data that indicate a growing illicit tobacco market in Australia since 2013 with a marked increase since 2018. While survey data suggests that the Australian tobacco tax policy, which has included regular large tax increases since 2010, has decreased consumer demand for tobacco overall, it may have also incentivized criminal networks to supply illicit tobacco products due to it being a “low risk” and “high reward” activity. Controlling the Australian illicit tobacco market should be a policy priority.