Non-combustible Nicotine Products Research Articles

Association between Use of Combustible Cigarettes and Noncombustible Nicotine or Tobacco Products and Health-Related Quality of Life in Korean Men: A Nationwide Population-Based Study.

Although the association between smoking and health-related quality of life (HRQoL) has been established, the effects of tobacco products, including combustible cigarettes (CCs) and non-combustible nicotine or tobacco products (NNTPs), on HRQoL remain unclear. This study examined the association between tobacco use and HRQoL in Korean men. Data from the Korea National Health and Nutrition Examination Survey conducted between 2013 and 2020 were analyzed. A total of 16,429 male participants aged ≥19 years completed the European Quality of Life-5 Dimensions (EQ-5D). Impaired HRQoL was defined as scoring in the lowest 20% of the EQ-5D index and having some or extreme problems in the following five domains of the EQ-5D: mobility, self-care, usual activities, pain/ discomfort, and anxiety/depression. Multiple logistic regression was conducted to evaluate the risk of impaired HRQoL in current tobacco users. Current tobacco users exhibited a significantly higher risk of impaired HRQoL compared with never users (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.05-1.92). Compared to never users, current tobacco users reported more problems with mobility and pain/discomfort (all P<0.05). Moreover, compared with former tobacco users, current tobacco users had a higher risk of impaired HRQoL (OR, 1.60; 95% CI, 1.18-2.17). Compared to former tobacco users, current tobacco users reported more problems with mobility and pain/discomfort (all P<0.05). Use of CCs and NNTPs is associated with impaired HRQoL in Korean men. Therefore, further interventions for lifestyle modification and smoking cessation treatments are required to reduce the risk of impaired HRQoL among current tobacco users.

A Descriptive Analysis of Beliefs About Nicotine and Switching to Noncombustibles Among Adults Who Smoke Cigarettes and Believe Nicotine Causes Cancer

Introduction: Many people who smoke cigarettes report believing that nicotine causes cancer, a misperception that may reduce interest in switching to noncombustible nicotine products. Quantitative survey questions do not capture how this population thinks about nicotine and switching to noncombustible products. Methods: This study used an online convenience sample of 193 US adults who smoke cigarettes and reported that nicotine causes cancer. Respondents were asked if they thought nicotine was harmful (and why or why not) and if they would consider switching to a noncombustible product (and why or why not). Inductive and deductive coding were used, and descriptive statistics are reported. Results: Descriptions of nicotine directly causing disease (61%) were more common than descriptions of nicotine causing addiction to a harmful product (8%). One-third expressly stated that nicotine causes cancer, and 21% that nicotine causes lung disease. Interest in switching was moderate (mean 47.4 out of 100). When asked about switching, 34% described enjoying their current smoking experience, 23% described a perceived health benefit, 16% described a health concern, and 11% worried that switching would not address nicotine addiction. Discussion: Adults who smoke commonly perceived nicotine as a direct cause of cigarette-related disease, and harm and addictiveness perceptions were often mentioned as reasons for interest or disinterest in switching to a noncombustible. Future studies could explore strategies for correcting nicotine misperception, stigma related to addiction, and common concerns related to health as well as user experience.

Personal characteristics associated with switching from Cigarettes to Non-combustible tobacco and nicotine products among U.S. adults: Findings from PATH Study Wave 1 - Wave 5.

Reducing the disease burden from tobacco smoking may encompass switching to non-combustible (NCs), along with cessation. This study evaluates factors associated with switching to NCs (e-cigarettes, smokeless, snus) versus continued smoking, complete cessation, or dual use. Population Assessment of Tobacco and Health adult data were analyzed in three two-year wave pairs across 2013-2019 to assess product transitions among people who exclusively smoked tobacco. Generalized estimating equations examined demographics, smoking characteristics, perceptions, and messaging exposure as predictors of transitions from cigarette smoking. Ages 18-44 years (ref=65+; aORs=3.79-5.92), males (aOR=1.18, 95%CI[1.01,1.37]), and perceiving NCs as less harmful than smoking (ref=not; aOR=1.47, 95%CI[1.28,1.69]) were positively associated with switching to NCs versus continued smoking, while being Black (ref=White; aOR=0.36, 95%CI[0.26,0.48]) or Hispanic (ref=Non-Hispanic; aOR=0.59, 95%CI[0.45,0.78]) were negatively associated. Ages 18-64 years (aORs=2.49-5.89), noticing promotional ads (ref=not; aOR=1.34, 95%CI[1.14,1.58]), daily light or heavy smoking (ref=nondaily; aORs=2.33-3.72), and smoking within 30 mins of waking (ref=>30min; aOR=1.47, 95%CI[1.18,1.85]) were positively associated with switching to NCs versus cessation, while being Black (aOR=0.55, 95%CI[0.38,0.74]) or Hispanic (aOR=0.52, 95%CI[0.38,0.71]) were negatively associated.. Incomes of $10,000->$100,000 (ref=<$10,000; aORs=2.08-3.13) and daily heavy smoking (aOR=1.96, 95%CI[1.11,3.48]) were positively associated with switching to NCs versus dual use, while being male (aOR=0.44, 95%CI[0.29,0.65]) was negatively associated. Transitioning to NCs was unequally distributed among sociodemographic groups and smoking characteristics. The mere availability of NCs may not promote health equity. Continued market and regulatory efforts that promote both smoking cessation and transitioning to NCs among various populations may promote public health gains. This study examines factors associated with transitioning from smoking to non-combustible tobacco product use. We examined three different product use scenarios that may be associated with varied levels of exposure to harm. We observed that younger ages and perceiving NCs as less harmful than cigarettes were more likely to transition to NCs as compared to continued smoking and cessation, while Black or Hispanic individuals were less likely to transition to NCs. This highlights the need for more focused harm reduction efforts for racial and ethnic minority populations as a complementary strategy to cessation to reduce health disparities from smoking.

Characterising smoking and nicotine use behaviours among women of reproductive age: a 10-year population study in England

BackgroundTobacco smoking affects women’s fertility and is associated with substantial risks of adverse pregnancy outcomes. This study explored trends by socioeconomic position in patterns of smoking, use of non-combustible nicotine products, and quitting activity among women of reproductive age in England.MethodsData come from a nationally representative monthly cross-sectional survey. Between October 2013 and October 2023, 197,266 adults (≥ 18 years) were surveyed, of whom 44,052 were women of reproductive age (18–45 years). Main outcome measures were current smoking, vaping, and use of nicotine replacement therapy (NRT), heated tobacco products (HTPs), and nicotine pouches; mainly/exclusively smoking hand-rolled cigarettes and level of dependence among current smokers; past-year quit attempts among past-year smokers; and success of quit attempts among those who tried to quit. We modelled time trends in these outcomes, overall and by occupational social grade (ABC1 = more advantaged/C2DE = less advantaged).ResultsSmoking prevalence among women of reproductive age fell from 28.7% [95%CI = 26.3–31.2%] to 22.4% [19.6–25.5%] in social grades C2DE but there was an uncertain increase from 11.7% [10.2–13.5%] to 14.9% [13.4–16.6%] in ABC1. By contrast, among all adults and among men of the same age, smoking prevalence remained relatively stable in ABC1. Vaping prevalence among women of reproductive age more than tripled, from 5.1% [4.3–6.0%] to 19.7% [18.0–21.5%], with the absolute increase more pronounced among those in social grades C2DE (reaching 26.7%; 23.3–30.3%); these changes were larger than those observed among all adults but similar to those among men of the same age. The proportion of smokers mainly/exclusively smoking hand-rolled cigarettes increased from 40.5% [36.3–44.9%] to 61.4% [56.5–66.1%] among women of reproductive age; smaller increases were observed among all adults and among men of the same age. Patterns on other outcomes were largely similar between groups.ConclusionsAmong women of reproductive age, there appears to have been a rise in smoking prevalence in the more advantaged social grades over the past decade. Across social grades, there have been substantial increases in the proportion of women of reproductive age who vape and shifts from use of manufactured to hand-rolled cigarettes among those who smoke. These changes have been more pronounced than those observed in the general adult population over the same period.

Association between Combustible Cigarettes and Noncombustible Nicotine or Tobacco Products and Generalized Anxiety Disorder Based on Data from the 8th Korea National Health and Nutrition Examination Survey 2021.

Despite the increasing prevalence of anxiety disorders in Korea, there have been no nationwide studies on the association between tobacco status and generalized anxiety disorder (GAD). Furthermore, despite the increasing number of people using noncombustible nicotine or tobacco products (NNTPs), the association between NNTP use and GAD remains unclear. Therefore, this study investigated the association between tobacco use and GAD. This nationwide study used data from the 8th Korea National Health and Nutrition Examination Survey (2021) and included 5,454 adults aged ≥19 years who self-reported on the tobacco use and mental health sections. Multivariable logistic regression analysis was performed to investigate the odds ratios (ORs) of GAD (Generalized Anxiety Disorder-7 score ≥10) according to tobacco status among Korean adults. The severity of anxiety was assessed using the Generalized Anxiety Disorder-7 scale. Compared to never tobacco users, the ORs of GAD for combustible cigarette smokers and NNTP users were 2.74 (95% confidence interval [CI], 1.66-4.50) and 2.11 (95% CI, 1.16-3.83), respectively. The OR of GAD for former tobacco users was 1.63 (95% CI, 0.98-2.72). Tobacco use (combustible cigarettes and NNTP) was positively associated with GAD. However, in former tobacco users, there was no significant association with GAD when compared with never tobacco users. Given the OR of GAD among tobacco users, it is crucial to pay attention to screening for GAD and implement appropriate early interventions.

Association of transitioning from combustible cigarettes to noncombustible nicotine or tobacco products with subsequent cancer risk: a nationwide cohort study in South Korea

Association of transitioning from combustible cigarettes to noncombustible nicotine or tobacco products with subsequent cancer risk: a nationwide cohort study in South Korea

Patterns of cigarette, heated tobacco product, and nicotine vaping product use among Korean adults: Findings from the 2020 ITC Korea Survey.

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

Applications of biomarkers of exposure and biological effects in users of new generation tobacco and nicotine products: Tentative proposals.

Despite efforts to eliminate smoking, more than 1 billion people worldwide continue to use combustible cigarettes through choice or inability to quit. With an associated 8 million deaths, the provision of noncombustible tobacco and nicotine products that smokers will accept to replace combustible cigarettes can lessen harm. However, most of these products have entered the market only in the past 20 years. Therefore, particularly for some smoking-related diseases, epidemiological studies to test harm reduction potential are only now becoming feasible. For cancer and chronic obstructive pulmonary disease, around two decades of data might be required. In this article, we discuss how the use of biomarkers might be applied to supplement epidemiological research for regulators. We further discuss how health providers and insurers can keep up with the rapid changes in biomarker research and recognize these reduced risks.

Oral Nicotine Product Awareness and Use Among People Who Smoke and Vape in the U.S.

Tobacco-free oral nicotine products are an emerging class of noncombustible nicotine products. Oral nicotine product sales have increased since 2016, although little research has investigated consumer awareness, use, or correlates of oral nicotine product use. The purpose of this analysis was to assess the prevalence and correlates of oral nicotine product awareness and use. This paper is a cross-sectional analysis of 2,507 U.S. participants from Wave 3 (February-June 2020) of the International Tobacco Control Four Country Smoking and Vaping Survey, a population-based survey of current and former cigarette smokers and nicotine vaping product users in the U.S. Oral nicotine product awareness and use prevalence were compared with those of heated tobacco products. Analyses conducted in late 2021 assessed the correlates of oral nicotine product awareness and use such as demographic characteristics, tobacco use (cigarettes, nicotine vaping products, smokeless tobacco), and tobacco quit attempts. Almost 1 in 5 respondents claimed to have heard of oral nicotine products, 3.0% reported ever use, and 0.9% were current users, all of which were lower than for heated tobacco products. Ever use of oral nicotine products was more common among younger adults (e.g., aged 18-24 years), males, and current users of smokeless tobacco. Oral nicotine product prevalence was higher among those who reported having made attempts to stop smoking or vaping. Oral nicotine product use was low among current and former smokers and nicotine vaping product users. Oral nicotine product users were demographically similar to use among individuals who smoke/vape and also use smokeless tobacco. Future studies are needed to understand emerging oral nicotine products, particularly whether they are being used as product supplements (dual use), replacements (switching), or cessation aids (quitting).

Prevalence and characteristics of ever regular use of non-combustible nicotine for 1 year or more: a population survey in England

IntroductionUp-to-date monitoring of non-combustible nicotine products (e.g. e-cigarettes, nicotine replacement therapies (NRT), heated tobacco products (HTP); NNP) is important to assess their impact. To date, there is little evidence on the association between ever regular use (defined here as 1 year or more) of NNP and current smoking status.Aims/methodsThe purpose of this study was to examine the prevalence, and sociodemographic, alcohol and smoking status correlates, of ever regular use of NNP in England in 2020. A cross-sectional survey of adults in England was conducted between February and June 2020.ResultsA total of 8486 adults were surveyed; 94.9% (8055) were complete cases. The weighted prevalence of ever regular NNP use was 5.4% (n = 436; 95% CI 5.0–6.0), of which 82% (n = 360; 95% CI 78.7–85.8) was single and 18% (n = 79; 95% CI 14.8–22) multiple product use. Amongst ever regular NNP users, the prevalence of ever regular NRT, e-cigarette and HTP use was 64.7% (95% CI 60.1–69), 43.4% (95% CI 38.8–48) and 2.5% (95% CI 1.4–4.5), respectively. In adjusted analysis, ever regular NNP use was associated with smoking status, being significantly higher among current (22.3%; adjusted OR (aOR) 34.9, 95% CI 24.0–50.8) and ex-smokers (12.7%, aOR 19.8, 95% CI 11.1–14.4) than among never-smokers (0.6%). More advantaged occupational grade (aOR, 1.27 95% CI 1.02–1.57) and at least hazardous alcohol use (aOR, 1.38 95% CI 1.06–1.78) were associated with greater prevalence of ever regular NNP use.ConclusionsEver regularly using NNP was highest among smokers and ex-smokers and rare among never-smokers. Among people who have ever regularly used NNP, NRT is the most popular.

Epigenetic Analyses of Alcohol Consumption in Combustible and Non-Combustible Nicotine Product Users

Alcohol and tobacco use are highly comorbid and exacerbate the associated morbidity and mortality of either substance alone. However, the relationship of alcohol consumption to the various forms of nicotine-containing products is not well understood. To improve this understanding, we examined the relationship of alcohol consumption to nicotine product use using self-report, cotinine, and two epigenetic biomarkers specific for smoking (cg05575921) and drinking (Alcohol T Scores (ATS)) in n = 424 subjects. Cigarette users had significantly higher ATS values than the other groups (p < 2.2 × 10−16). Using the objective biomarkers, the intensity of nicotine and alcohol consumption was correlated in both the cigarette and smokeless users (R = −0.66, p = 3.1 × 10−14; R2 = 0.61, p = 1.97 × 10−4). Building upon this idea, we used the objective nicotine biomarkers and age to build and test a Balanced Random Forest classification model for heavy alcohol consumption (ATS > 2.35). The model performed well with an AUC of 0.962, 89.3% sensitivity, and 85% specificity. We conclude that those who use non-combustible nicotine products drink significantly less than smokers, and cigarette and smokeless users drink more with heavier nicotine use. These findings further highlight the lack of informativeness of self-reported alcohol consumption and suggest given the public and private health burden of alcoholism, further research into whether using non-combustible nicotine products as a mode of treatment for dual users should be considered.

Oral and periodontal implications of tobacco and nicotine products.

Tobacco use contributes to more mortality and morbidity globally than any other behavioral risk factor. Adverse effects do not spare the oral cavity, with many oral diseases more common, and treatments less successful, in the tobacco-using patient. Many of the oral health effects of cigarette smoking are well established, but other forms of tobacco, including cigars and smokeless tobacco, merit dental professionals' attention. Recently, an expanding variety of new or emerging tobacco and/or nicotine products has been brought to market, most prominently electronic cigarettes, but also including heated tobacco and other noncombustible nicotine products. The use of cannabis (marijuana) is increasing and also has risks for oral health and dental treatment. For the practicing periodontist, and all dental professionals, providing sound patient recommendations requires knowledge of the general and oral health implications associated with this wide range of tobacco and nicotine products and cannabis. This review provides an overview of selected tobacco and nicotine products with an emphasis on their implications for periodontal disease risk and clinical management. Also presented are strategies for tobacco use counselling and cessation support that dental professionals can implement in practice.

A conceptual framework for assessing the public health effects from snus and novel non-combustible nicotine products.

Objective:The tobacco industry plans to base their future earnings on the production of non-combustible nicotine products. These might replace or come in addition to the more harmful cigarettes that historically have dominated the nicotine market in the Nordic countries. The authorities in each country must decide whether the products should have market access and, in that case, how strictly they should be regulated. Our aim is to present a framework that can assist the health authorities to make a regulation where benefits will outweigh the harms.Method:In a public health perspective, health gains from substitution must be weighed against the health loss from additional use. The main elements of the weighing will be based on the information about the absolute risk of the products, their relative risk compared to conventional cigarettes and how the users are composed according to smoking status. We apply the framework on snus as used in Norway – a product with an established usage pattern and epidemiologically assessed health risks.Results:The framework consists of (i) a comprehensive set of specific user patterns that may result in health deterioration and user patterns that may result in health benefits, (ii) an estimation of the number of people with health-augmenting and health-impairing user patterns, respectively, and (iii) an estimation of the degree of health deterioration or health benefit that will affect the persons with the different user patterns.Conclusion:The net effect on public health will appear as an overall result of the number of people with positive and negative user patterns, respectively, in combination with the magnitude of the change in health status these people will experience. The use of an explicit framework highlights how a political decision may affect nicotine use and health-related outcomes. The framework breaks open a large and complex question into smaller pieces and requires the authorities to expose and explain the kind of evidence and reasoning behind regulations of novel nicotine products.

Evidence From the Scientific Assessment of Electronic Cigarettes and Their Role in Tobacco Harm Reduction

Summary While smoking remains a main global cause of preventable morbidity and mortality, a potential inflection point has arrived where it could become possible for non-combustible nicotine products to displace cigarettes and reduce risk for smokers who transition completely from smoking. These have proven consumer satisfaction and are now widely and increasingly available globally. One of the most prominent of these nicotine products are electronic cigarettes (ECs), which are used daily by millions of current and former smokers. The category is not without controversy as these products are not risk free and can cause nicotine dependence. The differing interpretation of science assessing ECs has transpired into inconsistent regulation and product standards, providing an environment for its fragmented manufacturing base which allows for variable product quality and in turn, product quality variability has impacted on how they are viewed. In this review, we assess published scientific evidence to evaluate whether, on balance, ECs fulfil a tobacco harm reduction role by reducing health risks relative to smoking and providing a viable alternative for smokers while having limited appeal to non-smokers.

The Kentucky SimSmoke Tobacco Control Policy Model of Smokeless Tobacco and Cigarette Use.

Background: Smokeless tobacco (SLT) prevalence was decreasing in Kentucky before 2007, but has since increased. This study examines the impact of policies on cigarette and SLT use by applying the SimSmoke tobacco control policy simulation model. Methods: Using data from the large-scale Tobacco Use Supplement of the Current Population Survey (TUS-CPS) and information on state-specific tobacco policies, Kentucky SimSmoke is updated and extended to incorporate exclusive SLT and dual cigarette and SLT use. The model is validated using survey data through 2017. The model was used to estimate the impact on smoking and SLT prevalence and attributable deaths of policies implemented between 1993 and 2018 and the impact of stronger future policies implemented in 2018 and maintained through 2060. Results: SimSmoke generally reflects trends in exclusive cigarette use from the TUS-CPS and the Behavioral Risk Factor Surveillance System (BRFSS), but underestimated the increase in SLT prevalence in recent years. SimSmoke projects that policies implemented between 1993 and 2018 reduced male and female cigarette use by 23.7% and 23.0%, and male and female SLT use by 4.9% by 2018, averting 9018 tobacco-attributable deaths by 2018, increasing to 89 547 by 2060. The largest reductions in cigarette and SLT use were attributed to cigarette price increases. Strengthening tobacco control policies could reduce smoking prevalence by 41% and 40%, and reduce SLT prevalence by 33% and 25% for males and females by 2060. Conclusion: Our results suggest that cigarette-oriented policies were effective in reducing SLT use but have been less successful in recent years. Future use rates can be further reduced through more restrictive statewide policies, which also target non-combustible nicotine products.

Inequalities, harm reduction and non-combustible nicotine products: a meta-ethnography of qualitative evidence

BackgroundWe sought to review qualitative evidence on how smokers in different socioeconomic groups engage with non-combustible nicotine products (NCNP), including electronic cigarettes and nicotine replacement therapies, in order to provide insight into how these products might impact on smoking inequalities.MethodsWe searched ten electronic databases in February 2017 using terms relating to NCNP and socioeconomic status. We included qualitative studies that were published since 1980 and were available in English. We used guidelines adapted from the Critical Appraisal Skills Programme for appraising qualitative research.ResultsThe review only identified studies exploring the attitudes of socioeconomically disadvantaged smokers towards NCNP for harm reduction or cessation purposes (i.e. we did not identify any relevant studies of more advantaged socioeconomic groups). Using a lines-of-argument meta-ethnographic approach, we identified a predominantly pessimistic attitude to NCNP for harm reduction or cessation of smoking due to: wider circumstances of socioeconomic disadvantage; lack of a perceived advantage of alternative products over smoking; and a perceived lack of information about relative harms of NCNP compared to smoking. Optimistic findings, although fewer, suggested the potential of NCNP being taken up among smokers experiencing socioeconomic disadvantage.ConclusionsOverall, our review highlights the importance of considering the social, cultural and economic circumstances that influence experiences of smoking and of alternative product use.

The use of human induced pluripotent stem cells to screen for developmental toxicity potential indicates reduced potential for non-combusted products, when compared to cigarettes

devTOX quickPredict (devTOXqP) is a metabolomics biomarker-based assay that utilises human induced pluripotent stem (iPS) cells to screen for potential early stage embryonic developmental toxicity in vitro. Developmental toxicity potential is assessed based on the assay endpoint of the alteration in the ratio of key unrelated biomarkers, ornithine and cystine (o/c).This work aimed to compare the developmental toxicity potential of tobacco-containing and tobacco-free non-combustible nicotine products to cigarette smoke. Smoke and aerosol from test articles were produced using a Vitrocell VC10 smoke/aerosol exposure system and bubbled into phosphate buffered saline (bPBS). iPS cells were exposed to concentrations of up to 10% bPBS. Assay sensitivity was assessed through a spiking study with a known developmental toxicant, all-trans-retinoic acid (ATRA), in combination with cigarette smoke extract.The bPBS extracts of reference cigarettes (1R6F and 3R4F) and a heated tobacco product (HTP) were predicted to have the potential to induce developmental toxicity, in this screening assay. The bPBS concentration at which these extracts exceeded the developmental toxicity threshold was 0.6% (1R6F), 1.3% (3R4F), and 4.3% (HTP) added to the cell media. Effects from cigarette smoke and HTP aerosol were driven largely by cytotoxicity, with the cell viability and o/c ratio dose–response curves crossing the developmental toxicity thresholds at very similar concentrations of added bPBS. The hybrid product and all the electronic cigarette (e-cigarette) aerosols were not predicted to be potential early developmental toxicants, under the conditions of this screening assay.

The Effects of Nicotine on Development.

Recently, there has been a significant increase in the use of noncombustible nicotine-containing products, including electronic cigarettes (e-cigarettes). Of increasing popularity are e-cigarettes that can deliver high doses of nicotine over short periods of time. These devices have led to a rise in nicotine addiction in adolescent users who were nonsmokers. Use of noncombustible nicotine products by pregnant mothers is also increasing and can expose the developing fetus to nicotine, a known teratogen. In addition, young children are frequently exposed to secondhand and thirdhand nicotine aerosols generated by e-cigarettes, with little understanding of the effects these exposures can have on health. With the advent of these new nicotine-delivery systems, many concerns have arisen regarding the short- and long-term health effects of nicotine on childhood health during all stages of development. Although health studies on nicotine exposure alone are limited, educating policy makers and health care providers on the potential health effects of noncombustible nicotine is needed because public acceptance of these products has become so widespread. Most studies evaluating the effects of nicotine on health have been undertaken in the context of smoke exposure. Nevertheless, in vitro and in vivo preclinical studies strongly indicate that nicotine exposure alone can adversely affect the nervous, respiratory, immune, and cardiovascular systems, particularly when exposure occurs during critical developmental periods. In this review, we have included both preclinical and clinical studies to identify age-related health effects of nicotine exposure alone, examining the mechanisms underlying these effects.

Tobacco Litigation, E-Cigarettes, and the Cigarette Endgame

Among his many contributions to the field of public health law, Professor Richard Daynard is perhaps best known for (a) advancing the idea that affirmative litigation, particularly against the tobacco industry, can serve as an effective public health tool, (b) introducing the discussion of an “endgame,” in which the commercial sale of cigarettes—the most deadly form of tobacco use—is phased out. This article unites these two topics and analyzes the potential for affirmative litigation to hasten the end of commercial cigarette sales. In recent years, the major tobacco companies have suggested that they support moving towards a “smoke-free world,” with non-combustible nicotine products such as e-cigarettes gradually replacing more harmful cigarette smoking. Though this rhetoric is deeply cynical—these same companies continue to spend heavily to promote their cigarette brands—it may nonetheless create a window of opportunity for litigants. Past litigation against tobacco companies has foundered on the absence of a “reasonable alternative design” for cigarettes. Today, the tobacco companies’ own statements can be used to show the availability of such alternatives. More importantly, now-public documents from the tobacco industry’s archives help establish the case for treating e-cigarettes as a “reasonable alternative design” for cigarettes. These documents show that the major tobacco companies developed the essential components of e-cigarette technology decades ago, but they chose not to commercialize these products because they feared they would prove to be viable alternatives to cigarettes. This article reviews how the introduction of e-cigarettes may reinvigorate products liability litigation against the manufacturers of conventional cigarettes. Building on the work of Professor Daynard, it also considers how these lawsuits, even if ultimately unsuccessful in court, might nonetheless benefit public health by pressuring the tobacco industry to live up to its public statements and by catalyzing legislative efforts to phase out the sale of cigarettes.

Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: a systematic review and synthesis of best available evidence

BackgroundWhile some experts have emphasised the potential for e-cigarettes to facilitate cessation among smokers with low socioeconomic status (SES), there is limited evidence of their likely equity impact. We assessed the potential for electronic cigarettes and other non-combustible nicotine-containing products (NCNPs) to reduce inequalities in smoking by systematically reviewing evidence on their use by SES in countries at stage IV of the cigarette epidemic.MethodsTen electronic databases were searched in February 2017 using terms relating to e-cigarettes, smokeless tobacco and nicotine replacement therapy (NRT); and SES. We included studies published since 1980 that were available in English and examined product use by SES indicators such as income and education. Data synthesis was based on those studies judged to be of medium- to high-quality using guidelines adapted from the Critical Appraisal Skills Programme.ResultsWe identified 54 studies describing NCNP use by SES across 12 countries, of which 27 were judged of sufficient quality to include in data synthesis. We found mixed patterns of e-cigarette current use by SES, with evidence of higher use among low-income adults but unclear or mixed findings by education and occupation. In contrast, smokeless tobacco current use was consistently higher among low SES adults. There was very limited evidence on the SES distribution of NRT in adults and of all NCNPs in young people.ConclusionsThe only NCNP for which there are clear patterns of use by SES is smokeless tobacco, where prevalence is higher among low SES groups. While this suggests a potentially positive impact on inequalities in smoking (if NCNP use displaces smoked tobacco use), this has not been seen in practice. These findings do not support the suggestion that e-cigarettes have the potential to reduce social inequalities in smoking, since i) current evidence does not show a clear trend of higher e-cigarette use in population groups with higher tobacco consumption, and ii) the experience of smokeless tobacco suggests that – even where NCNP use is higher among low SES groups – this does not necessarily replace smoked tobacco use in these groups.