Alternative Tobacco Research Articles

E-Cigarettes for Smoking Cessation

Nicotine cessation medication, combined with behavioral support, is considered the “gold standard” treatment for tobacco cessation, but it is only successful in 20% to 30% of patients. New and alternate tobacco cessation strategies are needed to address patients who fail or are unwilling to use current evidence-based options for cessation. Electronic cigarettes are one such product gaining popularity for use as a smoking cessation aid. Robust evidence-based support of e-cigarettes for smoking cessation is lacking, but their use is likely less harmful than that of conventional cigarettes. As such, it is reasonable to support a quit attempt with e-cigarettes following failure of evidence-based cessation treatments and behavioral support, stressing the fact that it is safest to do so without continuing to smoke tobacco.

Gender differences in use of alternative tobacco products among daily and nondaily smokers

Gender differences in use of alternative tobacco products among daily and nondaily smokers

The changing face of tobacco use among United States youth.

Tobacco use, primarily in the form of cigarettes, is the leading cause of preventable morbidity and mortality in the United States (U.S.). The adverse effects of tobacco use began to be recognized in the 1940's and new hazards of active smoking and secondhand smoke (SHS) exposure from cigarettes continue to be identified to this day. This has led to a sustained and wide-ranging array of highly effective regulatory, public health, and clinical efforts that have been informed by extensive scientific data, resulting in marked decreases in the use of cigarettes. Unfortunately, the dramatic recent decline in cigarette use in the U.S., has been accompanied by an upsurge in adolescent and young adult use of new, non-cigarette tobacco and nicotine-delivery products, commonly referred to as alternative tobacco products (ATPs). Commonly used ATPs include hookah, cigars, smokeless tobacco, and electronic cigarettes. While there have been a number of review articles that focus on adult ATP use, the purpose of this review is to provide an overview of what is, and is not known about emerging ATP use among U.S. adolescents on a national scale; as well as to identify research gaps in knowledge, and discuss future health and policy needs for this growing public health concern. This paper is not meant to systemically review all published survey data, but to present clear depiction of selected ATP usage in youth populations using national survey data.

Midwakh/dokha tobacco use in the Middle East: much to learn

Many alternative tobacco products (ATPs), such as hookahs, have grown in popularity and use beyond their locale of origin and are therefore becoming a significant global public health concern. This...

Perceived Harm of Tobacco Products and Individual Schemas of a Smoker in Relation to Change in Tobacco Product Use Over One Year Among Young Adults

Introduction: Given increases in nondaily smoking and alternative tobacco use among young adults, we examined the nature of change of various tobacco product use among college students over a year and predictors of use at one-year follow-up. Methods: An online survey was administered to students at six Southeast colleges and universities (N = 4,840; response rate = 20.1%) in Fall 2010, with attempts to follow up in Fall 2011 with a random subsample of 2,000 participants (N = 718; response rate = 35.9%). Data were analyzed from 698 participants with complete data regarding tobacco, marijuana, and alcohol use over a one-year period, perceived harm of tobacco use, and schemas of a “smoker” (as per the Classifying a Smoker Scale). Results: Baseline predictors of current smoking at follow-up included being White (p = .001), frequency of smoking (p < .001), alternative tobacco use (p < .001), and perceived harm of smoking (p = .02); marginally significant predictors included marijuana use (p = .06) and lower scores on the Classifying a Smoker Scale (p = .07). Baseline predictors of current smoking at follow-up among baseline nondaily smokers included more frequent smoking (p = .008); lower Classifying a Smoker Scale score was a marginally significant predictor (p = .06). Baseline predictors of alternative tobacco use at follow-up included being male (p = .007), frequency of smoking (p = .04), alternative tobacco use (p < .001), and frequency of alcohol use (p = .003); marginally significant predictors included marijuana use (p = .07) and lower perceived harm of smokeless tobacco (p = .06) and cigar products (p = .08). Conclusions: Tobacco control campaigns and interventions might target schemas of a smoker and perceived risks of using various tobacco products, even at low levels.

Abstract 2354: Nasal gene expression reflects the physiologic response to potentially reduced exposure products

Abstract Rationale Potentially reduced exposure products (PREPs) are tobacco-based products that may yield lower toxicant levels as compared to traditional cigarettes thereby possibly mitigating tobacco-exposure related harm. Due to their increasing popularity, there is an urgent need to develop approaches for evaluating the biological impact of these products to determine their potential health risks. We have shown that gene expression profiling of intra- and extra-thoracic airway epithelium can serve as an indicator of physiological responses to cigarette smoke exposure. Our goal here is to establish whether this same approach might identify similarities and differences in the response to reduced exposure tobacco products. We therefore examined longitudinal gene-expression alterations upon switching from traditional cigarettes to a lower nicotine product (Xodus) in readily collected nasal epithelium and compared these transcriptomic alterations to those associated with smoking-cessation. Methods Nasal epithelial brushings were obtained from 13 active smokers who switched to Xodus cigarettes for 6 weeks and then were tobacco abstinent for the next 18 weeks. Nasal brushings were obtained at baseline and at 4, 6, 16, and 24-weeks. Alveolar carbon monoxide levels were used to confirm cigarette use at baseline, 4 and 6 weeks and tobacco abstinence at 16 and 24 weeks. RNA from the nasal brushings was processed and hybridized to Affymetrix Human Gene 1.0 ST Arrays. Gene expression alterations at each time point were identified using a mixed model ANOVA. Results Alterations in the expression levels of 161 genes were associated with either switching to PREPs or with complete smoking cessation (FDR&amp;lt;0.2). For a minority of genes, Xodus usage resulted in decreased expression levels that further decreased upon smoking cessation. These genes were primarily involved in xenobiotic metabolism (P&amp;lt;0.05). The majority of genes altered by smoking cessation time points do not change upon switching to this PREP product. Conclusion Our data indicate that some of the gene expression differences induced by switching to the PREP product are intermediate between traditional cigarette smoking and tobacco abstinence whereas majority of gene expression remain unaltered with Xodus use. These data suggest that the PREP product may only constitute partially reduced exposure. Our study further suggests that the nasal epithelium can serve as a minimally invasive tool to measure responses to alternative tobacco products and may ultimately serve as a biomarker to evaluate the potential disease risks associated with these products. Citation Format: Kahkeshan Hijazi, Bozena Bomalysz, Katrina Steiling, Ji Xiao, Gang Liu, Yuriy Alekseyev, Martine Dumas Yves, Louise A. Hertsgaard, Joni Jensen, Rachel Isaksson Vogel, Dorothy Hatsukami, George O'Connor, Daniel R. Brooks, Jennifer Beane, Avrum Spira. Nasal gene expression reflects the physiologic response to potentially reduced exposure products. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2354. doi:10.1158/1538-7445.AM2014-2354

Perceived Harm, Addictiveness, and Social Acceptability of Tobacco Products and Marijuana Among Young Adults: Marijuana, Hookah, and Electronic Cigarettes Win

Background: There has been an increase in non-daily smoking, alternative tobacco product and marijuana use among young adults in recent years. Objectives: This study examined perceptions of health risks, addictiveness, and social acceptability of cigarettes, cigar products, smokeless tobacco, hookah, electronic cigarettes, and marijuana among young adults and correlates of such perceptions. Methods: In Spring 2013, 10,000 students at two universities in the Southeastern United States were recruited to complete an online survey (2,002 respondents), assessing personal, parental, and peer use of each product; and perceptions of health risks, addictiveness, and social acceptability of each of these products. Results: Marijuana was the most commonly used product in the past month (19.2%), with hookah being the second most commonly used (16.4%). The least commonly used were smokeless tobacco products (2.6%) and electronic cigarettes (4.5%). There were high rates of concurrent product use, particularly among electronic cigarette users. The most positively perceived was marijuana, with hookah and electronic cigarettes being second. While tobacco use and related social factors, related positively, influenced perceptions of marijuana, marijuana use and related social factors were not associated with perceptions of any tobacco product. Conclusions/Importance: Marketing efforts to promote electronic cigarettes and hookah to be safe and socially acceptable seem to be effective, while policy changes seem to be altering perceptions of marijuana and related social norms. Research is needed to document the health risks and addictive nature of emerging tobacco products and marijuana and evaluate efforts to communicate such risks to youth.

Nonsmokers' responses to new warning labels on smokeless tobacco and electronic cigarettes: an experimental study.

BackgroundGraphic warning labels are a tobacco control best practice that is mandated in the US for cigarettes under the 2009 Family Smoking Prevention and Tobacco Control Act. However, smokeless tobacco products are not required to carry graphic warning labels, and as of September 2014, electronic cigarettes in the US carry no warning labels and are aggressively marketed, including with “reduced harm” or “FDA Approved” messages.MethodsIn this online experiment, 483 US adult non-users of tobacco were randomized to view print advertisements for moist snuff, snus, and e-cigarettes with either warning labels (current warning label, graphic warning label) or “endorsements” (a “lower risk” label proposed by a tobacco company, an “FDA Approved” label) or control (tobacco advertisement with no label, advertisement for a non-tobacco consumer products). Main outcome measures included changes in perceived harm, positive attitudes towards, openness to using, and interest in a free sample of moist snuff, snus, and e-cigarettes.ResultsThe graphic warning label increased perceived harm of moist snuff and e-cigarettes. “Lower risk” and “FDA Approved” labels decreased perceived harm of moist snuff and snus respectively. Current warning label and graphic warning label significantly lowered positive attitudes towards e-cigarettes. In this sample of non-users of tobacco, 15% were interested in a free sample of alternative tobacco products (predominantly e-cigarettes). Proportion of participants interested in a free sample did not differ significantly across the conditions, but those interested in a free sample had significantly lower perceptions of harm of corresponding tobacco products.ConclusionsRegulatory agencies should not allow “lower risk” warning labels, which have similar effects to the “FDA Approved” label, which is prohibited, and should consider implementing graphic warning labels for smokeless tobacco products and e-cigarettes.

Alternative tobacco product use and smoking cessation among homeless youth in los angeles county.

Approximately 70% of homeless youth smoke cigarettes, but their use of alternative tobacco products (ATPs) is unknown. This paper reports on ATP use among past-month smokers in Los Angeles County, including whether it differs by demographic characteristics, homelessness severity, past-year quit attempts, and readiness to quit smoking. Given the growing popularity of e-cigarettes, we also report on perceptions of harm and reasons for using this product. We surveyed 292 unaccompanied homeless youth who were randomly sampled from street sites. Participants had smoked at least 100 cigarettes during their lifetime and 1 cigarette during the past month. Seventy-two percent of youth reported past-month ATP use (e-cigarettes = 51%; little cigars/cigarillos = 46%; hookah = 31%; other smokeless tobacco product = 24%; chewing tobacco/moist snuff = 19%). Current ATP use was unrelated to most demographic characteristics or having a past-year quit attempt. However, youth who planned to quit smoking in the next 30 days were significantly less likely to report current use of hookahs, other smokeless tobacco products, or e-cigarettes. Among lifetime e-cigarette users, the most common reasons for use included not having to go outside to smoke (38%) and being able to deal with situations or places where they cannot smoke (36%); it was less common to report using e-cigarettes to quit smoking (17%-18%). Dual use of ATPs among homeless youth smokers is common and is more likely among those who have no immediate plans to quit smoking. Effective and easily disseminable strategies for reducing all forms of tobacco use among homeless youth are urgently needed.

Judgments, awareness, and the use of snus among adults in the United States.

Alternative tobacco products, such as snus, are emerging in the U.S. market. Understanding correlates of awareness and use, particularly judgments about harm and addictiveness, can inform public health communications about these products. Data were collected from a web panel representative of the U.S. population in March 2013 (N = 2,067). The survey assessed awareness and use of snus among adults. Absolute and comparative snus judgments, intentions, smoking status, and sociodemographic variables were measured. Bivariate and multivariable logistic regression analyses were conducted to examine associations between these variables and snus awareness and use. Nearly 36% of the population was aware of snus, and 5.2% reported ever using snus. Current cigarette smokers were about 4 times more likely as nonsmokers to report snus awareness and use. Sociodemographic correlates of snus awareness and use included being male, employed full time, and younger. Compared with respondents who perceived snus to be as harmful and as addictive as cigarettes, those who perceived snus to be less harmful and less addictive than cigarettes were more likely to have used snus. Current smokers are more likely to be aware of and have used snus. Multiple tobacco product use poses a significant challenge for public health efforts to reduce tobacco-associated morbidity and mortality. Perceptions that snus is less harmful and less addictive compared with cigarettes are associated with snus use. These judgments can inform public health communications about emerging tobacco products and multiple product use.

Alternate Tobacco Product and Drug Use Among Adolescents Who Use Electronic Cigarettes, Cigarettes Only, and Never Smokers

PurposeTo determine whether use of alternative tobacco products (i.e., cigars, blunts, hookah, smokeless tobacco), alcohol, and marijuana differs among adolescents who currently use (1) electronic cigarettes (e-cigarettes); (2) cigarettes only; and (3) never smokers. MethodsAnalysis of a self-reported survey from four high schools in 2010–2011 (n = 3,102) with a subsample (n = 1,556) surveyed on alcohol and marijuana. Analyses were conducted with multinomial logistic regression models accounting for clustering by schools. ResultsThe sample contained 2.4% (n = 76) e-cigarette users, 12.4% (n = 386) cigarette smokers, and 85.1% (n = 3,197) never smokers. E-cigarette users were more likely than cigarette-only smokers to report blunt (adjusted odds ratio, 1.81; 95% confidence interval, 1.21–2.71) and hookah use (adjusted odds ratio, 3.12; 95% confidence interval, 1.90–5.13), but not cigar, smokeless tobacco, alcohol, or marijuana use. ConclusionsE-cigarette users are more likely than cigarette smokers to use hookah and blunts.

Physical, Behavioral, and Cognitive Effects of Prenatal Tobacco and Postnatal Secondhand Smoke Exposure

The purpose of this review is to examine the rapidly expanding literature regarding the effects of prenatal tobacco and postnatal secondhand smoke (SHS) exposure on child health and development. Mechanisms of SHS exposure are reviewed, including critical periods during which exposure to tobacco products appears to be particularly harmful to the developing fetus and child. The biological, biochemical, and neurologic effects of the small fraction of identified components of SHS are described. Research describing these adverse effects of both in utero and childhood exposure is reviewed, including findings from both animal models and humans. The following adverse physical outcomes are discussed: sudden infant death syndrome, low birth weight, decreased head circumference, respiratory infections, otitis media, asthma, childhood cancer, hearing loss, dental caries, and the metabolic syndrome. In addition, the association between the following adverse cognitive and behavioral outcomes and such exposures is described: conduct disorder, attention-deficit/hyperactivity disorder, poor academic achievement, and cognitive impairment. The evidence supporting the adverse effects of SHS exposure is extensive yet rapidly expanding due to improving technology and increased awareness of this profound public health problem. The growing use of alternative tobacco products, such as hookahs (a.k.a. waterpipes), and the scant literature on possible effects from prenatal and secondhand smoke exposure from these products are also discussed. A review of the current knowledge of this important subject has implications for future research as well as public policy and clinical practice.

Youth tobacco use type and associations with substance use disorders

To examine the associations between youth poly-tobacco use and substance use disorders. Analysis of data from the 2007-11 US National Survey on Drug Use and Health. Randomly selected, household-dwelling adolescents from the non-institutionalized, civilian population of the United States. A total of 91 152 adolescents (aged 12-17 years). Logistic regression models were used to examine the associations between type of tobacco user (non-user, users of alternative tobacco products only, users of cigarettes only and users of cigarettes plus alternative tobacco products) with past year alcohol, marijuana or other illicit drug use disorders, adjusting for demographic and social variables. Compared with non-users of tobacco, the greatest risk for substance use disorders was among users of cigarettes plus alternative tobacco products [alcohol disorder adjusted odds ratio (aOR) = 18.3, 95% confidence interval (CI) = 16.2-20.6; marijuana disorder aOR = 37.2, 95% CI = 32.5-42.7; other drug disorder aOR = 18.4, 95% CI = 15.4-21.8], followed by users of cigarettes only (alcohol disorder aOR = 9.6, 95% CI = 8.8-10.6; marijuana disorder aOR = 20.4, 95% CI = 18.1-23.0; other drug disorder aOR = 9.4, 95% CI = 7.8-11.4), then users of alternative tobacco products only (alcohol disorder aOR = 8.1, 95% CI = 6.7-9.6; marijuana disorder aOR = 9.2, 95% CI = 7.5-11.4; other drug disorder aOR = 3.2, 95% CI = 2.4-4.3). Tobacco use in adolescence is associated with higher rates of substance use disorders across all tobacco users, especially among those who use cigarettes plus other tobacco products.

The debate over weight- versus price-based taxation of snuff in the United States' state legislatures.

Discount snuff, known for its cheap price, high nicotine content, and popularity among youth, has increased substantially in market share in the United States. As a likely result, the leading manufacturer of premium snuff has supported legislation changing the basis for taxing snuff from price to weight. To determine which public health issues arose in legislative debates, we transcribed 17 of 52 bills from US state legislatures and coded for arguments broadly categorized into public health, fair taxation, tax revenue, tax efficiency, and anti-competitiveness. State legislators expressed frustration that equitable taxation, revenue generation, and prevention of youth tobacco use were frequently conflated in the debates. Public health advocates expressed concerns over youths' incentives to purchase low-weight snuff, but seldom discussed youths' growing preference for discount snuff. The evolving market of moist snuff is a critical consideration for US state legislators as well as policy makers from other countries who may evaluate taxation methods for alternate tobacco products.

Alternative Tobacco Use among College Students: Who is at Highest Risk?

To examines smoking status, substance use, sociodemographics, and psychosocial characteristics in relation to alternative tobacco use among college students. Current tobacco use (cigarettes, cigar-like products, hookah, chew, snus) and correlates (sociodemographics, sensation-seeking, attitudes toward tobacco and smokers, social factors) were assessed among students aged 18-25 at 6 Southeastern US colleges using an online survey. Those who were younger, male, black, cigarette and marijuana users, and demonstrating at-risk psychosocial factors were at increased risk of alternative tobacco product use (p < .001). Among current smokers, never daily nondaily smokers were 3 times as likely as former daily non-daily smokers and daily smokers to use alternative tobacco products (p < .001). Important risk factors for alternative tobacco use included important sociodemographic and psychosocial characteristics.

The association between senior student tobacco use rate at school and alternative tobacco product use among junior students in Canadian secondary schools.

BackgroundThe use of alternative tobacco products (ATPs) has grown in popularity among Canadian youth. This study examined the association between a school-level characteristic (the senior student tobacco use rate) and the current use of manufactured cigarettes, little cigars or cigarillos, cigars, roll-your-own cigarettes, smokeless tobacco (SLT), and a hookah among junior students.MethodsThis study used nationally representative Canadian data from 29,495 students in grades 9 to 12 as part of the 2010/2011 Youth Smoking Survey. For each ATP, we described rates of senior and junior tobacco use, calculated the variance attributed to school-level factors, and examined the association between the senior student (grades 11 and 12) tobacco use rate and the current use of each ATP among junior students (grades 9 and 10) while accounting for relevant student-level characteristics. SAS 9.3 was used for all analyses.ResultsOver half of schools sampled had senior students that reported using each ATP. School-level differences accounted for between 14.1% and 29.7% of the variability in ATP current use among junior students. Each one percent increase in the number of senior students at a school that currently use manufactured cigarettes, SLT, or a hookah was significantly independently associated with an increased likelihood that a junior student at that school currently used manufactured cigarettes (OR 1.04, 95% CI 1.01 to 1.06), SLT (OR 1.14, 95% CI 1.06 to 1.24), or a hookah (OR 1.09, 95% CI 1.03 to 1.14).ConclusionsCharacteristics of the school environment a junior student attends appear to play an important role in ATP use, and tobacco control programs and policies should be designed to ensure that they include strategies to curb the use of all tobacco products. Additional evidence is needed for the impact of comprehensive school-based tobacco control approaches.

Toxicity of Gutkha, a Smokeless Tobacco Product Gone Global: Is There More to the Toxicity than Nicotine?

The popularity of smokeless tobacco (ST) is growing rapidly and its prevalence of use is rising globally. Consumption of Gutkha, an addictive form of ST, is particularly common amongst South Asian communities throughout the World. This includes within the US, following large-scale immigration into the country. However, there exists a lack of knowledge concerning these alternative tobacco products. To this end, a study was carried out to determine the toxicity of gutkha, and what role, if any, nicotine contributes to the effects. Adult male mice were treated daily for 3-week (5 day/week, once/day), via the oral mucosa, with equal volumes (50 μL) of either sterile water (control), a solution of nicotine dissolved in water (0.24 mg of nicotine), or a solution of lyophilized guthka dissolved in water (21 mg lyophilized gutkha). Serum cotinine, measured weekly, was 36 and 48 ng/mL in gutkha- and nicotine-treated mice, respectively. Results demonstrated that exposure to nicotine and gutkha reduced heart weight, while exposure to gutkha, but not nicotine, decreased liver weight, body weight, and serum testosterone levels (compared to controls). These findings suggest that short-term guhtka use adversely impacts growth and circulating testosterone levels, and that gutkha toxicity may be driven by components other than nicotine. As use of guthka increases worldwide, future studies are needed to further delineate toxicological implications such that appropriate policy decisions can be made.

A Multiyear Assessment of Hookah Use Prevalence Among Florida High School Students

The purpose of this study was to assess the prevalence of hookah use among Florida high school students over time. Alternative tobacco products, including hookah, pose a public health threat to tobacco prevention efforts, especially among adolescents. Florida Youth Tobacco Survey data, representing all public high school students in the state, were analyzed to assess the prevalence of lifetime and current hookah use and were compared by demographic groups. Multiple years of data (2007-2012) were examined to assess changes over time. During the past 6 years, there was an increase in lifetime hookah use among Florida high school students. While males remained at a higher rate overall, female adolescents increased at a faster rate. Hispanic and non-Hispanic White respondents reported increased trends as well. Current use trends did not change over 4 years, remaining at about 8%. Hookah is a new tobacco product in the United States that appears attractive to youth, with dramatic increases among the state population. While cigarette use among youth is declining in Florida, the increasing uptake of alternative tobacco products may lessen the overall public health gains for tobacco use. There is a need for continued monitoring of hookah use among the adolescent population, for both prevention and cessation efforts as well as policy interventions to address this emerging trend.

The Land of 10 000 Tobacco Products: How Minnesota Led the Way in Regulating Tobacco Products

As state and local governments increase restrictions on cigarette smoking, tobacco manufacturers have shifted to marketing alternative tobacco products. Tobacco control laws need to be updated to reflect this shifting marketplace. With the 2010 enactment of the Tobacco Modernization and Compliance Act, Minnesota addressed regulatory gaps and created a model law for other states. We have detailed the updated definitions of tobacco and tobacco products and identified ways that future laws could be strengthened.

Prevalence and Harm Perceptions of Various Tobacco Products Among College Students

Although use of non-cigarette alternative tobacco products (ATPs) is increasingly prevalent in the United States, little is known about the varying patterns of tobacco use among college students. This study examined prevalence of ATP use and differences across 4 groups of students (nontobacco, cigarette-only, polytobacco, and ATP-only users) on perceptions of danger and beliefs about government safety evaluation of tobacco products. An online survey was administered to 5,028 students attending 7 public universities within a larger university system (M age = 20.5 years, 59.6% female, 54.6% Hispanic/Latino). Multivariate analyses were conducted to investigate differences between the 4 groups on perceived danger of tobacco products and beliefs regarding government safety evaluation of these products. Prevalence of ATP use among the sample ranged from 0.4% for dissolvable tobacco to 10.8% for hookah. Group membership was significantly associated with perceived danger of each tobacco product, whereby cigarette-only and ATP-only users reported significantly higher levels of perceived danger for most ATPs than did polytobacco users. Furthermore, cigarette-only, polytobacco, and ATP-only users were significantly more likely than nonusers to believe that the government evaluates some tobacco products for safety. ATP use among young adult college students is prevalent. Furthermore, students who use ATPs in conjunction with cigarettes (i.e., polytobacco users) appear to be at highest risk for the continuation and subsequent dependence on nicotine, given their danger perceptions and beliefs of government evaluation. Future research examining trajectories of use, particularly among polytobacco users, is needed.