Non-combustible Tobacco Research Articles

Demographic, psychosocial, and genetic risk associated with smokeless tobacco use among Mexican heritage youth

BackgroundDespite well-established negative health consequences of smokeless tobacco use (STU), the number and variety of alternative non-combustible tobacco products on the market have increased tremendously over the last 10 years, as has the market share of these products relative to cigarettes. While STU among non-Hispanic white youth has decreased over the last 10 years, the prevalence has remained constant among Hispanic youth. Here we examine demographic, psychosocial, and genetic risk associated with STU among Mexican heritage youth.MethodsParticipants (50.5 % girls) reported on psychosocial risk factors in 2008–09 (n = 1,087, mean age = 14.3 years), and smokeless tobacco use in 2010–11 (mean age = 16.7 years). Participants provided a saliva sample that was genotyped for genes in the dopamine, serotonin and opioid pathways.ResultsOverall 62 (5.7 %) participants reported lifetime STU. We identified five single nucleotide polymorphisms that increased the risk for lifetime use. Specifically, rs2023902 on SERGEF (OR = 1.93; 95 % CI: 1.05-3.53), rs16941667 on ALDH2 (OR = 3.14; 95 % CI: 1.65-5.94), and rs17721739 on TPH1 (OR = 1.71; 95 % CI: 1.00-2.91) in the dopamine pathway, rs514912 on TRH-DE (OR = 1.84; 95 % CI: 1.25-2.71) in the serotonin pathway, and rs42451417 on the serotonin transporter gene, SLC6A4 (OR = 3.53; 95 % CI: 1.56-7.97). After controlling for genetic risk, being male (OR = 1.86; 95 % CI: 1.02-3.41), obesity status (OR = 2.22; 95 % CI: 1.21-4.09), and both higher levels of anxiety (OR = 1.04; 95 % CI: 1.01-1.08) and social disinhibition (OR = 1.26; 95 % CI: 1.07-1.48) were associated with increased use. High subjective social status (OR = 0.78; 95 % CI: 0.64-0.93) was protective against use, while higher parental education (OR = 2.01; 95 % CI: 1.03-3.93) was associated with increased use.ConclusionsThese data suggest that use of genetic risk, along with psychosocial, demographic, and behavioral risk factors may increase our ability to identify youth at increased risk for STU, which in turn may improve our ability to effectively target prevention messages to Mexican heritage youth.

Gender differences influence overweight smokers' experimentation with electronic nicotine delivery systems

IntroductionOverweight and obese tobacco users possess increased risk of cancer, diabetes, heart disease and chronic tobacco-related disease. Efforts to prevent tobacco-related health risk in this comorbid population would be informed by better understanding and monitoring of trends in the concurrent use of electronic nicotine delivery systems (ENDS) among smokers in the US marketplace. MethodThe California Longitudinal Smokers Study (CLSS) established a cohort of current cigarette smokers in 2011 who were surveyed for tobacco use and health behavior at baseline and again in 2012 at follow-up. ResultsWe observed a large increase in reported experimentation with ENDS. As hypothesized, overweight or obese smokers were more likely to report experimentation with ENDS, an increase that was also observed among women. Experimentation with ENDS was not associated with a reduction in use of cigarettes or a decrease in cigarette dependence in this high risk population of smokers. ConclusionsContinued surveillance of this vulnerable population is needed to better understand how experimentation with new ENDS products may impact health, facilitate switching to non-combustible tobacco or facilitate persistent cigarette dependence.

Cancer-Related News from the CDC

Cancer-Related News from the CDC

Multiple tobacco product use among US adolescents and young adults

ObjectiveTo assess the extent to which multiple tobacco product use among adolescents and young adults falls outside current Food and Drug Administration (FDA) regulatory authority.MethodsWe conducted a web-based survey of...

Application of CE-MS to a metabonomics study of human urine from cigarette smokers and non-smokers.

Novel biomarkers of exposure and early adverse effects are needed for comparative studies of combustible and non-combustible tobacco products for regulatory authority evaluation. Metabolic biomarkers reflect both gene and environmental effects. CE-MS has been applied to human urine samples from non-smokers and smokers of cigarettes at two tar levels. Validated chemometric models were able to separate smokers from non-smokers, with discrimination mainly based on the presence of nicotine metabolites. With these removed, it still proved possible to discriminate smokers from non-smokers with models now based on endogenous metabolites. The biochemical relevance of these biomarkers is discussed. This proof-of-principle metabonomics study illustrates the potential of CE-MS to discover novel biomarkers in urine from tobacco users.

Prevalence, harm perceptions, and reasons for using noncombustible tobacco products among current and former smokers.

We provided estimates of noncombustible tobacco product (electronic nicotine delivery systems [ENDS]; snus; chewing tobacco, dip, or snuff; and dissolvables) use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use. We assessed awareness of, prevalence of, purchase of, harm perceptions of, and reasons for using noncombustible tobacco products among 1487 current and former smokers from 8 US designated market areas. We used adjusted logistic regression to identify correlates of noncombustible tobacco product use. Of the sample, 96% were aware of at least 1 noncombustible tobacco product, but only 33% had used and 21% had purchased one. Noncombustible tobacco product use was associated with being male, non-Hispanic White, younger, and more nicotine dependent. Respondents used noncombustible tobacco products to cut down or quit cigarettes, but only snus was associated with a higher likelihood of making a quit attempt. Users of noncombustible tobacco products, particularly ENDS, were most likely to endorse the product as less harmful than cigarettes. Smokers may use noncombustible tobacco products to cut down or quit smoking. However, noncombustible tobacco product use was not associated with a reduction in cigarettes per day or cessation.

Screening practices and attitudes of obstetricians-gynecologists toward new and emerging tobacco products

We examined screening practices and attitudes of obstetricians-gynecologists toward the use of noncombustible tobacco products (chewing tobacco, snuff/snus, electronic cigarettes, and dissolvables) during pregnancy. The authors mailed a survey in 2012 to 1024 members of the American College of Obstetricians and Gynecologists, including Collaborative Ambulatory Research Network (CARN) and non-CARN members. Stratified random selection was used to generate CARN and non-CARN samples. Response rates were 52% and 31% for CARN and non-CARN members, respectively. Of 252 total eligible respondents (those currently providing obstetrics care) 53% reported screening pregnant women at intake for noncombustible tobacco product use all or some of the time, and 40% reported none of the time. Respondents who reported that noncombustible products have adverse health effects during pregnancy, but are safer than cigarettes, ranged from 20.2% (dissolvables) to 29% (electronic cigarettes) and that the health effects are the same as those of cigarettes from 13.5% (electronic cigarettes) to 53.6% (chewing tobacco). Approximately 14% reported that electronic cigarettes have no adverse health effects; <1% reported no health effects for the remaining products. Two-thirds of the respondents wanted to know more about the potential health effects of noncombustible tobacco products; only 5% believed themselves to be fully informed. A large proportion of obstetrician-gynecologists reported never or inconsistently screening their pregnant patients for the use of noncombustible tobacco products. Responses regarding the harms of these products relative to cigarettes were mixed and most respondents wanted more information. Development and dissemination of guidance for providers is needed to improve decision-making regarding noncombustible tobacco products.

非燃焼吸引型嗅ぎたばこ使用時における室内環境中成分濃度の測定

非燃焼型たばこ製品（non-combusted tobacco product, NCTP）から発生する化学物質の室内空気中濃度を評価するため，試験チャンバーを用いて粉じん，CO，CO2，ホルムアルデヒド，ニコチンおよびアンモニアの測定を行った。試験チャンバーの換気量およびNCTPの吸引回数は，ASHRAEおよびSHASE（空気調和・衛生工学会）の規格に基づいて設定した。その結果，本実験条件下ではNCTPの使用に伴う試験チャンバー内の分析対象物質の濃度上昇は認められなかった。

Noncombustible Tobacco Product Advertising: How Companies Are Selling the New Face of Tobacco

With declining cigarette sales, increasing restrictions, and recent Food and Drug Administration (FDA) regulation of cigarettes, there has been a dramatic rise in the marketing of noncombustible tobacco products (NCPs). However, little is known about how NCPs are advertised and to whom. Two full-service advertising firms were used to systematically collect all U.S. advertisements for NCPs (e-cigarettes, snus, dissolvables, and chew/dip/snuff,) running between June 1 and September 1, 2012. The advertisement and associated metadata (brand, media channel, observations, spend, and estimated reach) were examined. Attributes of print advertisements were examined relative to target demographics of the publications in which they ran. Over 3 months, almost $20 million was spent advertising NCPs. Although the greatest amount spent was on the promotion of smokeless (~$8 million) and snus (~$10 million), e-cigarette advertisements were the most widely circulated. Print advertisements, the majority of which were e-cigarettes and chew/dip/snuff, were heavily tailored to middle-aged White males. Many e-cigarette print ads suggested harm reduction and use when one cannot smoke (poly-use), while chew/dip/snuff focused on masculinity. Robust ongoing surveillance of NCP advertising is critical to inform the FDA and to protect public health. Both commercial advertising and public health media campaigns must ensure that content is not misleading and that it educates consumers about harm based on the available science. The way messages are framed have the potential to decrease tobacco use by promoting rather than undermining cessation of combusted products and/or by encouraging exclusive use of less harmful NCPs rather than poly-use of combusted and NCPs.

Combustible and non-combustible tobacco product preparations differentially regulate human peripheral blood mononuclear cell functions

Natural killer (NK) cells and T cells play essential roles in innate and adaptive immune responses in protecting against microbial infections and in tumor surveillance. Although evidence suggests that smoking causes immunosuppression, there is limited information whether the use of smokeless tobacco (ST) products affects immune responses. In this study, we assessed the effects of two preparations of cigarette smoke, ST extract and nicotine on T cell and NK cell responses using Toll-like receptor-ligand stimulated human peripheral blood mononuclear cells (PBMCs). The tobacco product preparations (TPPs) tested included whole smoke conditioned media (WS-CM), total particulate matter (TPM) and a ST product preparation in complete artificial saliva (ST/CAS). The PBMCs were stimulated with polyinosinic:polycytidylic acid (poly I:C) and lipopolysaccharide (LPS). A marked reduction of the expression of intracellular IFN-γ and TNF-α was evident in NK cells and T cells treated with WS-CM and TPM. Consistently, attenuation of ligand-induced secretion of cytokines (IL-1β, IL-10, IL-12 and TNF-α) from PBMCs treated with WS-CM and TPM were observed. While the treatment with TPPs did not alter the expression of the maturation marker CD69, WS-CM and TPM inhibited the cytolytic activity of human PBMCs. Suppression of perforin by WS-CM was also detected. Although interference from the vehicle confounded the interpretation of effects of ST/CAS, some effects were evident only at high concentrations. Nicotine treatment minimally impacted expression of cytokines and cytolytic activity. Data presented herein suggests that the function of NK cells and T cells is influenced by exposure to TPPs (based on equi-nicotine units) in the following order: WS-CM>TPM>ST/CAS. These findings are consistent with the hypothesis put forward by others that chronic smoking leads to immunosuppression, an effect that may contribute to increased microbial infections and cancer incidence among smokers.

Ending tobacco-caused mortality and morbidity: the case for performance standards for tobacco products

The US Family Smoking Prevention and Tobacco Control Act and WHO Framework Convention on Tobacco Control provide us with powerful tools to reduce the death and disease caused by the...

Perceptions about the harm of secondhand smoke exposure among U.S. middle and high school students: findings from the 2012 National Youth Tobacco Survey

BackgroundIncreased knowledge of the harmful effects of SHS is an evidence-based key indicator for eliminating nonsmokers’ exposure to SHS. This study assessed the prevalence and predictors of perceptions about the harm of secondhand smoke (SHS) exposure among U.S. middle and high school students.FindingsData were obtained from the 2012 National Youth Tobacco Survey, a nationally representative school-based survey of U.S. students in grades 6–12. Respondents who reported that they thought breathing smoke from other people’s cigarettes or other tobacco products causes “some” or “a lot” of harm were considered to have the perception that SHS is harmful. Multivariate logistic regression was used to identify predictors of the perception that SHS is harmful. Predictors included sex, race/ethnicity, school grade level, current tobacco use, and whether the respondent currently lived with a tobacco user. Overall, 75.4% of students perceived SHS exposure as harmful. The adjusted odds of perceiving SHS exposure as harmful were higher among non-Hispanic Asians than among non-Hispanic whites, and among students in 10th-12th grades than among students in 8th grade. Adjusted odds were lower among boys than among girls, among non-Hispanic blacks than among non-Hispanic whites, among students living with a tobacco user than among those not, and among those who use combustible tobacco only or both combustible and non-combustible tobacco than among those who use no tobacco.ConclusionsMost middle and high school students perceive SHS exposure as harmful, but efforts are needed to increase the prevalence of this perception in certain subpopulations, particularly tobacco users.

Subjective Responses to Oral Tobacco Products: Scale Validation

Several noncombusted oral tobacco products have been introduced that are primarily marketed to cigarette smokers. An important component of evaluating these products involves assessment of subjective responses to the product. To date, few studies have been undertaken to examine the validity of subjective response questionnaires for oral tobacco products. The goal of this study is to examine the extent subjective responses to a product are related to product preference and extent of product use. Data from a study examining oral tobacco product preference were used. Smokers were asked to sample a variety of oral tobacco products that differed in formulation (snus versus dissolvables) and dose of nicotine. At the end of the sampling period, subjects were asked to choose the product that they would use to completely substitute for cigarettes for the next 2 weeks. During the sampling period, subjects completed a Product Evaluation Scale (PES) that describes subjective responses to the product. During the treatment phase, they kept record of amount of product use. Subjective responses to the product on the PES were related to product choice and to some extent, the amount of product use. Product choice was associated with different characteristics of the product and smoker needs. The PES may be a useful tool for the evaluation or oral tobacco products.

Differential cell-specific cytotoxic responses of oral cavity cells to tobacco preparations

To examine the effects of standardized (reference) tobacco preparations on human oral cavity cells, two oral squamous cell carcinoma cell lines (101A, 101B) and normal human gingival epithelial cells (HGEC) were treated with cigarette smoke total particulate matter (TPM), smokeless tobacco extracted with complete artificial saliva (ST/CAS), or whole-smoke conditioned media (WS-CM). EC-50 values, as determined by sulforhodamine B assays, varied among the cell types and agents. When normalized to nicotine content, cytotoxicity for WS-CM and TPM was higher compared to that observed with ST/CAS. Nicotine alone had no or only minimal cytotoxicity for all cell types in the applied range.Activation of pro-apoptotic caspase-3 was examined in all cell types at their respective EC-50 doses for the three agents. TPM, but not ST/CAS or WS-CM significantly activated caspase-3 in all three cell types. Fluorescence-activated cell sorting (FACS) for expression of the early apoptosis marker Annexin V and for nuclear staining by 7-aminoactinomycin (7-AAD) revealed different extents of apoptosis versus non-apoptotic cell death for the three agents.These data characterize differential responses of normal and malignant oral cells after exposure to TPM, ST/CAS, or WS-CM. They assist in understanding differential effects of combustible versus non-combustible tobacco products, and in identifying novel biomarkers for tobacco smoke exposure and effect in the oral cavity.

Toxicology of Smokeless Tobacco: Implications for Immune, Reproductive, and Cardiovascular Systems

The popularity of smokeless tobacco (ST), or noncombusted tobacco, usually placed within the mouth to be chewed, sucked, or swallowed, is growing rapidly and its prevalence of use is rising globally, due (in part) to greater convenience, as allowable cigarette smoking areas are rapidly decreasing, and increased social acceptability. Though data are limited, ST usage has been directly linked to a number of adverse health outcomes. The potential role that immune dysfunction, including dysregulation of immune cells and their components, may play in the progression of these adverse health outcomes is only just beginning to emerge. Evidence suggesting reproductive outcomes, such as perinatal mortality, preterm birth, and reduced sperm viability, also exists in conjunction with ST use. Cardiovascular health may also be impacted by ST use, resulting in increased blood pressure and endothelial dysfunction, both of which may potentially lead to cardiovascular diseases. This review describes the toxicological implications associated with ST use, with emphasis on immune, reproductive, and cardiovascular outcomes. Epidemiological studies are discussed with respect to experimental studies to help develop the relationship between ST and disease pathology. This review also summarizes the gaps in ST knowledge and potential future directions that are needed to more fully delineate the complex systems driving the adverse health outcomes associated with its use.

Tobacco Use Patterns

Tobacco Use Patterns

Response to Glantz and Ling

Dear Editors We appreciate Dr. Glantz and Dr. Ling's interest in our review “Does Dual Use Jeopardize the Potential Role of Smokeless Tobacco in Harm Reduction?” We recognize that a role for smokeless tobacco in cigarette harm reduction remains controversial. However, it is clear that smokeless tobacco is substantially less hazardous than cigarette smoking (Fagerstrom & Ramstrom, 1998; Foulds, Ramstrom, Burke, & Fagerstrom, 2003; Kozlowski, 1989; Levy et al., 2004; Rodu & Cole, 1994; Zeller & Hatsukami, 2009) and that “on the continuum of risk, noncombustible tobacco products are more likely to reduce harm than a smoked form of tobacco for individuals who would otherwise be using conventional cigarettes” (Zeller & Hatsukami, 2009). As noted in our review, there are a variety of reasons why some adult cigarette smokers choose to use smokeless tobacco, including as an alternative to continued cigarette smoking; these individuals may undergo a transitional period involving concomitant use of both products (dual use). Our review assessed the potential impact of dual use in terms of health effects and trajectories of tobacco product usage.

Changing Smokeless Tobacco Products: New Tobacco-Delivery Systems

Smokeless or noncombusted oral tobacco use as a substitute for cigarette smoking has been gaining greater interest and attention by the public health community and the tobacco industry. In order for the product to appeal to smokers, tobacco companies have been manufacturing new noncombusted oral tobacco (i.e., moist snuff) that is lower in moisture content and nitrosamine levels, packaged in small sachets and “spitless.” While the primary motives of the major tobacco companies are to maintain or increase tobacco use, some members of the public health community perceive the use of noncombusted oral tobacco products as a harm reduction tool. Because cigarette smoking is associated with greater toxicant exposure compared to noncombusted oral tobacco, reduced mortality and morbidity are hypothesized to ensue, if cigarette smokers switched completely to these products. However, variability exists in levels of nicotine and toxicants and potential health consequences from use within and across countries. Therefore, promulgating noncombusted oral tobacco products as a safer alternative to smoking or as a substitute for smoking may engender more rather than less harm. To date, limited research is available on the effects of marketing noncombusted oral tobacco products to smokers, to support the use of these products as a harm reduction tool, and to determine the effects of varying levels of tobacco toxicants including nicotine on health. The need exists for manufacturing standards to lower toxicant levels of all noncombusted oral tobacco products, for the formulation of appropriate tobacco-product regulations and for the development of a strategic plan by the public health community to address this controversial topic.

Immunophenotype similarity and high frequency of co-existence of columnar cell lesions, lobular neoplasia, and low grade DCIS with invasive tubular carcinoma and invasive lobular carcinoma

The increasing availability of emerging non-combusted tobacco products (snus, dissolvables, and electronic nicotine delivery systems or ENDS) may have implications for pregnant women and women of reproductive age. We conducted 15 focus groups to explore how women perceive emerging non-combusted tobacco products and nicotine replacement therapy (NRT) in general, and during pregnancy. Sessions were held in 2013 in four U.S. cities. Participants were 18–40 years old and were pregnant smokers, pregnant quitters, or smokers planning a pregnancy. Responses were coded and analyzed to identify key themes using NVivo 10.0 qualitative software (QSR).Several themes emerged from focus groups. Participants generally found snus unappealing, but viewed dissolvables as a discreet and stigma-free way to use tobacco during pregnancy. Participants perceived NRT as ineffective and having undesired side effects. ENDS were thought to offer advantages over cigarettes, including use in smoke-free areas, lower cost, appealing flavors, and fewer health effects, and were seen by some as a potential quit aid. Some participants, however, worried that the lack of natural stopping point could lead to excessive use. Many participants felt that the use of any tobacco or NRT product is harmful during pregnancy.Women seeking to reduce health risks or stigma related to smoking during pregnancy may perceive advantages of using some emerging products over cigarettes. These findings can inform future public health efforts to reduce risks associated with tobacco product use among women of reproductive age.