Flavored Cigarettes Research Articles

Adults’ E-Cigarette Flavor Use and Cigarette Quit Attempts: Population Assessment of Tobacco and Health Study Findings

Prevalence of use of e-cigarettes among youth 1 Cullen KA Gentzke AS Sawdey MD et al. E-cigarette use among youth in the United States, 2019. JAMA. 2019; 322: 2095-2103https://doi.org/10.1001/jama.2019.18387 Crossref PubMed Scopus (383) Google Scholar and adults 2 Creamer MR Wang TW Babb S et al. Tobacco product use and cessation indicators among adults - United States, 2018. MMWR Morb Mortal Wkly Rep. 2019; 68: 1013-1019https://doi.org/10.15585/mmwr.mm6845a2 Crossref PubMed Scopus (448) Google Scholar in the U.S. continues to rise, and flavored tobacco product use is associated with initiation and subsequent use of tobacco products. 3 Villanti AC Johnson AL Glasser AM et al. Association of flavored tobacco use with tobacco initiation and subsequent use among U.S. youth and adults, 2013-2015. JAMA Netw Open. 2019; 2e1913804 https://doi.org/10.1001/jamanetworkopen.2019.13804 Crossref PubMed Scopus (46) Google Scholar However, little data exist on whether flavored e-cigarettes are associated with cigarette-cessation behaviors, 4 National Academies of Sciences Engineering and MedicinePublic Health Consequences of e-Cigarettes. The National Academies Press, Washington, DC2018https://doi.org/10.17226/24952 Google Scholar including attempting to quit cigarette smoking and quit success among those who attempt to quit, 5 Kasza KA Edwards KC Tang Z et al. Correlates of tobacco product cessation among youth and adults in the USA: findings from the PATH study waves 1-3 (2013-2016). Tob Control. 2020; 29: s203-s215https://doi.org/10.1136/tobaccocontrol-2019-055255 Crossref PubMed Scopus (20) Google Scholar although Buu et al. 6 Buu A Hu YH Piper ME Lin HC The association between e-cigarette use characteristics and combustible cigarette consumption and dependence symptoms: results from a national longitudinal study. Addict Behav. 2018; 84: 69-74https://doi.org/10.1016/j.addbeh.2018.03.035 Crossref PubMed Scopus (29) Google Scholar found that among exclusive cigarette smokers, using flavored e-cigarettes 1 year later was associated with lower quantity of cigarette smoking. This study uses U.S. nationally representative data from the Population Assessment of Tobacco and Health (PATH) Study to report on e-cigarette flavor use among adult past 30–day dual users of e-cigarettes and cigarettes and to longitudinally evaluate the relationship between flavor use and attempting to quit cigarette smoking approximately 1 year later.

Cigarette Use Before and After the 2009 Flavored Cigarette Ban

PurposeOn September 22, 2009, the U.S. Food and Drug Administration's national ban on flavored cigarette products went into effect, barring the sale of flavored cigarettes with the exception of menthol. Flavored cigarettes largely appeal to and were disproportionately used by youth (under age 18 years). However, little research has evaluated the effects of the ban. This study examined past 30-day cigarette use among youth (12–17 years), young adults (18–25 years), adults (26–49 years), and older adults (≥50 years) before and after the implementation of this ban. MethodsAnalyses were conducted using 2002–2017 National Survey on Drug Use and Health (NSDUH) data (n = 893,226). Regression models—weighted for national representation—were used to examine past 30-day cigarette use before and after the flavored cigarette ban in different age groups, using a quasi-experimental design incorporating elements of interrupted time series and difference-in-differences design. This design was used to examine differences in pre- versus post-ban smoking within age groups and heterogeneous policy effects between age groups, to help adjust for the generally stronger tobacco control environment over time. ResultsThe flavor ban was associated with statistically significant immediate increases as well as reductions over time in youth and young adult use of any cigarettes and menthol cigarettes, compared to older adults. In 2017, the predicted probability of youth and young adult cigarette smoking were reduced by 43% and 27%, respectively, compared to the model predicted probability in absence of the ban. No such effect was observed for older adults. The predicted probability of menthol use was reduced by 60% and 55% for youth and young adults, respectively. ConclusionsFindings support the effectiveness of flavored cigarette bans at reducing cigarette use among young people and suggest a substitution effect between flavored tobacco products.

‘It has candy. You need to press on it’: young adults’ perceptions of flavoured cigarettes in the Philippines

BackgroundThe Philippines has a high smoking prevalence and one of the largest tobacco menthol market shares in the world. Flavour capsule cigarettes were introduced to the Philippines in 2013, most...

Heterogeneity in Tobacco-Use Behaviors Among U.S. Blacks per Global Region of Origin.

Heterogeneity in tobacco-use behaviors among U.S. blacks by global region of origin and age at immigration was examined. Self-identified black participants from the 2006-2015 Tobacco Use Supplement to the Current Population Surveywere included (n = 47,857). Countries of origin were classified by global regions (U.S., Africa, Europe, West Indies). Multivariable logistic regression models, adjusted for sociodemographic characteristics, were used to examine the association of global region of origin and age at immigration with tobacco-use behaviors. Prevalence of current cigarette smoking among U.S. blacks varied significantly by global region of origin (U.S.-born = 17.4%, Europe-born = 17.7%, Africa-born = 4.7%, West-Indies-born = 4.9%; p < 0.01). Furthermore, foreign-born blacks were less likely than U.S.-born blacks to smoke menthol flavored cigarettes (p < 0.05). Participants who immigrated to the U.S. at ≥ 13years old were less likely than U.S.-born blacks to start regular smoking as minor (p < 0.05). Tobacco-use behaviors differ by global region of origin and age at immigration in the U.S. black population.

Widespread use of flavored e-cigarettes and hookah tobacco in the United States.

In 2009, the U.S. Food and Drug Administration banned the sale of flavored cigarettes (excluding menthol) in the U.S. However, the sale of flavored e-cigarettes (FE) and flavored hookah tobacco (FHT) is still legal. In this study (conducted in the US in the period from October 2018 to February 2019), we estimated the prevalence of use of FE and FHT across users' sociodemographic characteristics (e.g., age, sex, race/ethnicity) and identified the key characteristics of tobacco users associated with use of FE and FHT. We analyzed the 2014–2015 Tobacco Use Supplement to the Current Population Survey data for current e-cigarette (n = 3691) and hookah tobacco (n = 658) users. Among e-cigarette users, 65.5% used FE; and among hookah tobacco users, 87.3% used FHT. Among e-cigarette users, the prevalence of use of FE was significantly higher for 18–24 year-old than 45+ year-old adults; women than men; Southern than Northeastern residents; and never smokers of regular cigarettes than current smokers of regular cigarettes (all adjusted p's < 0.05). Among hookah tobacco users, the rates of FHT use were significantly higher for women than men, and never smokers of regular cigarettes than current smokers (all adjusted p's < 0.05). Because availability and accessibility of flavored tobacco products may promote tobacco use, revising regulatory guidelines concerning manufacturing and distribution of FE and FHT may help reduce the popularity of emerging tobacco products.ImplicationsAmong users of emerging tobacco products such as e-cigarettes and hookah tobacco, use of flavored products is very common. Among e-cigarette users, 66% consumed flavored e-cigarettes; and among users of hookah tobacco, 87% consumed flavored hookah tobacco. Use of flavored products was especially common among users who were young adults, women, or never and former smokers of regular cigarettes. Availability of emerging tobacco products in many different flavors could be a reason for tobacco use initiation and continued use of tobacco after cessation of regular-cigarette smoking.

Triangulating abuse liability assessment for flavoured cigar products using physiological, behavioural economic and subjective assessments: a within-subjects clinical laboratory protocol

IntroductionIn the USA, Food and Drug Administration regulations prohibit the sale of flavoured cigarettes, with menthol being the exception. However, the manufacture, advertisement and sale of flavoured cigar products are...

Trends in Unit Sales of Flavored and Menthol Electronic Cigarettes in the United States, 2012-2016.

IntroductionThe use of flavored tobacco products, including electronic cigarettes (e-cigarettes), is common in the United States, and flavored products are particularly appealing to young people. The objective of this study was to describe national and state trends in flavored and menthol e-cigarette unit sales.MethodsWe examined data on 4 types of e-cigarette products (rechargeables, disposables, prefilled cartridges, and e-liquid refills). We used Universal Product Code retail scanner data from 2 sources: 1) convenience stores and 2) all other outlets combined, including supermarkets, drug stores, mass merchandisers (including Walmart), dollar stores, club stores, and US Department of Defense commissaries. We aggregated data in 4-week periods for the 48 contiguous states and the District of Columbia for the 5-year period from 2012 through 2016. Data from vape shops and internet sales were not available. We used Joinpoint regression to assess trends.ResultsFrom 2012 through 2016, flavored e-cigarette sales as a percentage of all e-cigarette sales increased nationally (from 2.4% to 19.8%) and in all but 4 states (North Dakota, South Dakota, Utah, and Vermont). Nationally, flavored disposable and prefilled cartridge sales increased. Menthol e-cigarette sales were stable nationally at 35% to 40%, while the percentage of menthol disposable, prefilled cartridge, and e-liquid refill sales decreased. By state, menthol e-cigarette sales increased in 2 states (Idaho and Nebraska) and decreased in 7 states. During 2015–2016, the percentage of flavored sales decreased in one state (Rhode Island) and increased in 29 states.ConclusionThese findings demonstrate that sales of flavored e-cigarette products have increased dramatically since 2012, with variations by product type and state. Continued monitoring of sales trends at all retail outlets can inform federal, state, and local efforts to address flavored tobacco product use, including e-cigarettes, in the United States.

Effects of Menthol Flavor Cigarettes or Total Urinary Menthol on Biomarkers of Nicotine and Carcinogenic Exposure and Behavioral Measures.

The effects of either menthol flavor cigarettes or total urinary menthol on nicotine dependence, biomarkers of addictive and carcinogenic exposure, and behavioral measures may inform differences and similarities of these two approaches. Stratified recruitment by cigarette (menthol flavor or regular) and race (African American and white) yielded a balanced sample of 136 adult smokers in a 36-hour inpatient protocol. Exposure measures assessed during 24-hour data collection included urinary menthol, total NNAL [4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol], 10 polycyclic aromatic hydrocarbon metabolites, baseline plasma cotinine, plasma nicotine pre- and post-smoking, exhaled carbon monoxide pre- and post-smoking, and cigarette puff volumes. The latter three were measured at four specified timepoints throughout the day. There were no significant differences between menthol flavor and regular cigarette smokers in measures of nicotine dependence, biomarkers of addictive and carcinogenic exposures, or behavioral measures. Significant race × cigarette type interaction effects were found for two biomarkers: plasma nicotine and 3-hydroxyphenanthrene. Total urinary menthol was significantly associated with higher levels of nearly all dependent variables including puff volume, exhaled carbon monoxide, plasma nicotine and cotinine, NNAL, and polycyclic aromatic hydrocarbons. The significant effects of total urinary menthol were sustained after adjusting for menthol flavor and regular cigarette type and other covariates (eg, number of cigarettes per day, baseline cotinine, and baseline nicotine). Urinary menthol is an independent predictive biomarker for nicotine dependence, addictive and carcinogenic exposure, and behaviors. Comparison of the effects of menthol flavor and total urinary menthol on nicotine dependence, biomarkers of addictive and carcinogenic exposure, and behavioral measures emphasizes the important significant contribution of total urinary menthol concentrations in contrast to no significant associations by dichotomous cigarette type with these biomarkers.

Prevalence of flavored cigarettes and e-cigarettes&lt;i&gt; in Uruguay&lt;/i&gt;: findings from the Wave 5 of the ITC Uruguay survey

Prevalence of flavored cigarettes and e-cigarettes&lt;i&gt; in Uruguay&lt;/i&gt;: findings from the Wave 5 of the ITC Uruguay survey

Marketing of flavored cigarettes at the point-of-sale (POS) near schools in 5 Latin American cities

Marketing of flavored cigarettes at the point-of-sale (POS) near schools in 5 Latin American cities

Use of flavored cigarettes in the first few puffs: a step toward smoking initiation and nicotine addiction? Data from a national survey among Brazilian adolescents

Use of flavored cigarettes in the first few puffs: a step toward smoking initiation and nicotine addiction? Data from a national survey among Brazilian adolescents

Anti-tobacco control industry strategies in Turkey

BackgroundTransnational tobacco companies (TTCs) penetrated the Turkish cigarette market due to trade and investment liberalization in the post-1980 period and eventually secured full control. Despite tobacco control policies put in place in reaction to accelerating consumption, TTCs reinforced their market power through a variety of strategies. This paper explores industry strategies that counteract tobacco control policies in Turkey.MethodsThe study employs both qualitative and quantitative analyses to explore industry strategies in Turkey. Besides the content analyses of industry and market reports, descriptive analyses were conducted for the sub-periods of 1999–2015. The analyses focus on the market strategies of product innovation, advertisement-promotion, cost management and pricing.ResultsRising sales of low tar, ultra-low tar, slim, super-slim and flavoured cigarettes indicate that product innovation served to sustain consumption. Besides, the tobacco industry, using its strong distribution channels, the Internet, and CSR projects, were found to have promoted smoking indirectly. The industry also rationalized manufacturing facilities and reduced the cost of tobacco, making Turkey a cigarette-manufacturing base. Tobacco manufacturers, moreover, offered cigarettes in different price segments and adjusted net prices both up and down according to price categories and market conditions. In response to the successful effect of shifts in price margins, the market share of mid-priced cigarettes expanded while those within the economy category maintained the highest market share. As a result of pricing strategies, net sales revenues increased. Aside from official cigarette sales, the upward trends in the registered and unregistered sales of cigarette substitutes indicate that the demand-side tobacco control efforts remain inadequate.ConclusionsThe Turkish case reveals that the resilience of the tobacco industry vis-à-vis mainstream tobacco control efforts necessitates a new policy perspective. Rising market concentration by TTCs and the global nature of industry strategies require that the highly profitable manufacturing and trade of tobacco products should be discouraged on a basis of international collaboration. To reduce and eventually eradicate tobacco consumption, supply-side tobacco control measures are needed along with demand-side policies.

Attitudes towards Potential New Tobacco Control Regulations among U.S. Adults.

Favorable attitudes towards tobacco control policies can facilitate their implementation and success. We examined attitudes toward four potential U.S. Federal tobacco regulations (banning menthol from cigarettes, reducing nicotine levels in cigarettes, banning candy and fruit flavored electronic cigarettes, and banning candy and fruit flavored little cigars and cigarillos) and associations with individual and state variables. A nationally representative phone survey of 4337 adults assessed attitudes toward potential policies. Weighted logistic regression was used to assess relationships between attitudes and demographic factors, smoking behavior, beliefs about the government (knowledge, trust, and credibility), exposure to tobacco control campaigns, and state variables from the US Centers for Disease Control and Prevention (CDC) State Tobacco Activities Tracking and Evaluation (STATE) System. Most respondents supported three out of four policies. Respondents that were female, non-white, Latino, living below the poverty line, had less than high school education, were of older age, did not smoke, had higher trust in government, and were exposed to national tobacco control campaigns had higher odds of expressing favorable attitudes toward potential new tobacco regulations than did their counterparts. No state-level effects were found. While differences in attitudes were observed by individual demographic characteristics, behaviors, and beliefs, a majority of participants supported most of the potential new tobacco regulations surveyed.

Perceptions and Experiences with Flavored Non-Menthol Tobacco Products: A Systematic Review of Qualitative Studies.

Although a few countries have banned flavored cigarettes (except menthol), flavors in most tobacco products remain unregulated across the globe. We conducted a systematic review of qualitative studies examining perceptions of and experiences with flavored non-menthol tobacco products. Of 20 studies on flavored tobacco products included in our qualitative systematic review, 10 examined hookah, six examined e-cigarettes, two examined little cigars and cigarillos (LCCs), and three examined other tobacco products, including cigarettes. The majority of studies, regardless of product type, reported positive perceptions of flavored tobacco products, particularly among young adults and adolescents. In six studies that assessed perceptions of harm (including hookah, LCCs, and other flavored tobacco products), participants believed flavored tobacco products to be less harmful than cigarettes. In studies that examined the role of flavors in experimentation and/or initiation (including three studies on e-cigarettes, one hookah study and one LCC study), participants mentioned flavors as specifically leading to their experimentation and/or initiation of flavored tobacco products. Given that many countries have not yet banned flavors in tobacco products, these findings add to existing research on why individuals use flavored tobacco products and how they perceive harm in flavored tobacco products, providing further support for banning non-menthol flavors in most tobacco products.

Willingness to Try Electronic Cigarettes Among UK Adolescents

ABSTRACTPurpose: To investigate factors that lead to willingness to try electronic cigarettes among UK adolescents. Methods: A sample of 16- to 19-year-old pupils (N = 256) completed a questionnaire. Results: Smoking status significantly predicted more than one-third of the variance of willingness to try an electronic cigarette and a further 7.8% was significantly predicted by a positive prototype of a smoker (e.g., stylish) and a negative prototype of an electronic cigarette user (e.g., unattractive). Moreover, tobacco-flavored electronic cigarettes were less favorable than alternative flavors such as fruit, chocolate, and mint. Conclusions: Findings provide evidence that flavored electronic cigarettes are more appealing to all; adolescents, smokers, non-smokers, current and past electronic cigarette users, and never users.

Cigarette sales to minors via the internet: how the story has changed in the wake of federal regulation

ObjectiveTo assess how easily minors can purchase cigarettes online and online cigarette vendors’ compliance with federal age/ID verification and shipping regulations, North Carolina's 2013 tobacco age verification law, and federal...

Preventing smoking during pregnancy: the importance of maternal knowledge of the health hazards and of the treatment options available.

OBJECTIVE: To examine the pattern of tobacco use and knowledge about tobacco-related diseases, as well as to identify popular types of electronic media, in pregnant women, in order to improve strategies for the prevention or cessation of smoking among such women. METHODS: A cross-sectional study involving 61 pregnant women, seen at primary care clinics and at a university hospital, in the city of Botucatu, Brazil. For all subjects, we applied the Hospital Anxiety and Depression Scale. For subjects with a history of smoking, we also applied the Fagerström Test for Nicotine Dependence, and we evaluated the level of motivation to quit smoking among the current smokers. RESULTS: Of the 61 pregnant women evaluated, 25 (40.9%) were smokers (mean age, 26.4 ± 7.4 years), 24 (39.3%) were former smokers (26.4 ± 8.3 years), and 12 (19.8%) were never-smokers (25.1 ± 7.2 years). Thirty-nine women (63.9%) reported exposure to passive smoking. Of the 49 smokers/former smokers, 13 (26.5%) were aware of the pulmonary consequences of smoking; only 2 (4.1%) were aware of the cardiovascular risks; 23 (46.9%) believed that smoking does not harm the fetus or newborn infant; 21 (42.9%) drank alcohol during pregnancy; 18 (36.7%) reported increased cigarette consumption when drinking; 25 (51.0%) had smoked flavored cigarettes; and 12 (24.5%) had smoked a narghile. Among the 61 pregnant women evaluated, television was the most widely available and favorite form of electronic media (in 85.2%), as well as being the form most preferred (by 49.2%). CONCLUSIONS: Among pregnant women, active smoking, passive smoking, and alternative forms of tobacco consumption appear to be highly prevalent, and such women seem to possess little knowledge about the consequences of tobacco use. Educational programs that include information about the consequences of all forms of tobacco use, employing new and effective formats tailored to this particular population, should be developed, in order to promote smoking prevention and cessation among pregnant women. Further samples to explore regional and cultural adaptations should be evaluated.

Tobacco products sold by Internet vendors following restrictions on flavors and light descriptors.

The 2009 Family Smoking Prevention and Tobacco Control Act bans characterizing flavors (e.g., grape, strawberry) in cigarettes, excluding tobacco and menthol, and prohibits companies from using misleading descriptors (e.g., light, low) that imply reduced health risks without submitting scientific data to support the claim and obtaining a marketing authorization from the U.S. Food and Drug Administration. This observational study examines tobacco products offered by Internet cigarette vendors (ICV) pre- and postimplementation of the ban on characterizing flavors in cigarettes and the restriction on misleading descriptors. Cross-sectional samples of the 200 most popular ICVs in 2009, 2010, and 2011 were identified. Data were analyzed in 2012 and 2013. In 2011 the odds for selling cigarettes with banned flavors or misleading descriptors were 0.40 times that for selling the products in 2009 (95% confidence interval [CI] = 0.18, 0.88). However, 89% of vendors continued to sell the products, including 95.8% of international vendors. Following the ban on characterizing flavors, ICVs began selling potential alternative products. In 2010, the odds for selling flavored little cigars were 1.71 (95% CI = 1.09, 2.69) times that for selling the product in 2009 and, for clove cigars, were 5.50 (95% CI = 2.36, 12.80) times that for selling the product in 2009. Noncompliance with the ban on characterizing flavors and restriction on misleading descriptors has been high, especially among international vendors. Many vendors appear to be circumventing the intent of the flavors ban by selling unbanned flavored cigars, in some cases in lieu of flavored cigarettes.

Electronic cigarettes: the new face of nicotine.

* Abbreviations: e-cigarette — : electronic cigarette FDA — : US Food and Drug Administration A rugged actor with a prematurely lined face and raspy voice expounds on the virtues of regaining our freedom. A flaxen-haired actress waxes poetic on the sex appeal of puffing up in a bar. These are not images pulled from the archives of the golden age of television, when advertising tobacco products on the airwaves was unregulated, but rather from a new, and relatively unregulated, chapter in the saga of nicotine-containing products: electronic cigarettes.1 Electronic cigarettes, or “e-cigarettes,” have been on the market since 2007 and are catapulting into the mainstream. As their popularity skyrockets, however, so too does the need for product and marketing regulations at the federal level and sales restrictions to minors at the state and local levels. In lieu of tobacco, e-cigarettes consist of a liquid cartridge, which typically contains nicotine derived from tobacco, with an atomizer and a rechargeable battery; when the user draws on the device, it atomizes the liquid and delivers a vapor, in lieu of smoke, to the user. E-cigarette users “vape” the atomized contents of the cartridge, which can have flavors ranging from “plain tobacco” to bubble gum or peach schnapps. (Of note, the sale of flavored cigarettes [other than menthol] has been banned since the 2009 Family Smoking Prevention and Tobacco Control Act because of their known appeal to young buyers.) Once rare, these products have become much more visible over the past few years, particularly with the aid of television commercials for “blu eCigs” (owned by the Lorillard Tobacco Company), filling a … Address correspondence to Emily K. Duffy, MD, Department of General Pediatrics, Pediatric Residency Program, Suite 9NW55, The Children’s Hospital of Philadelphia, 3400 Civic Center Blvd, Philadelphia, PA 19103. E-mail: duffye1{at}email.chop.edu

Use of flavoured cigarettes in Poland: data from the global adult tobacco survey (2009–2010)

BackgroundNowadays the European Union faces a debate on the ban of sale of flavoured cigarettes. There is growing evidence that certain subgroups of smokers are more vulnerable to the use of flavoured cigarettes. However in some European countries, figures on the use of these cigarettes are still scarce. The aim of the study was to assess the prevalence of flavoured cigarettes use in Poland, and examine whether its use among adults varies by socio-demographic characteristics.MethodsData on tobacco use including flavoured cigarettes and other characteristics were derived from the Global Adult Tobacco Survey (GATS). GATS is a cross-sectional, household survey implemented in Poland between 2009 and 2010. GATS provided data on a representative sample of 7,840 individuals covering 2,254 current smokers. Logistic regression model was used to obtain odds ratios (ORs) and 95% confidence interval (CI) of the selected socio-economic variables on the use of flavoured cigarettes.ResultsAmong females the aromatized cigarettes use was 26.1% compared to 10.5% in males (OR = 2.3; 95% CI: 1.62–3.2; p ≤ 0.001). Respondents aged 20–29 years had an increased likelihood of using flavoured cigarettes compared to subjects aged 60 years or older (OR = 2.7; 95% CI: 1.1–6.5; p ≤ 0.001). Respondents aware of negative health consequences of smoking had OR = 1.4 95% CI: 1.1–2.1 (p ≤ 0.05) of smoking aromatized cigarettes compared to those who were unaware. Participants who perceived some kinds of cigarettes less harmful than others were also more likely to use flavoured cigarettes compared to subjects who were convinced that all cigarettes are equally harmful (OR = 1.4; 95% CI: 1.1–1.8; p ≤ 0.01). High educational attainment, living in large cities, being non-economically active was also associated with use of flavoured cigarettes.ConclusionOur results are consistent with majority of epidemiology studies on this topic to date and should be considered in the enactment of tobacco control legislation at the national as well as European levels. For combating tobacco epidemic, further efforts need to be made to prevent smoking uptake. Ban of flavoured cigarettes could considerably support achieving this goal.