Andrea C. Villanti

Harm Minimization and Tobacco Control: Reframing Societal Views of Nicotine Use to Rapidly Save Lives

Inhalation of the toxic smoke produced by combusting tobacco products, primarily cigarettes, is the overwhelming cause of tobacco-related disease and death in the United States and globally. A diverse class of alternative nicotine delivery systems (ANDS) has recently been developed that do not combust tobacco and are substantially less harmful than cigarettes. ANDS have the potential to disrupt the 120-year dominance of the cigarette and challenge the field on how the tobacco pandemic could be reversed if nicotine is decoupled from lethal inhaled smoke. ANDS may provide a means to compete with, and even replace, combusted cigarette use, saving more lives more rapidly than previously possible. On the basis of the scientific evidence on ANDS, we explore benefits and harms to public health to guide practice, policy, and regulation. A reframing of societal nicotine use through the lens of harm minimization is an extraordinary opportunity to enhance the impact of tobacco control efforts.

Tobacco and nicotine delivery product use in a national sample of pregnant women

Monitoring use of tobacco products among pregnant women is a public health priority, yet few studies in U.S. national samples have been reported on this topic. We examined prevalence and correlates of using cigarettes, e-cigarettes, and other tobacco/nicotine delivery products in a U.S. national sample of pregnant women. Data were obtained from all pregnant women (≥18 years) in the first wave of the Population Assessment of Tobacco and Health (PATH, 2013-2014) Study (N=388). Prevalence of current and prior use of tobacco/nicotine products was examined overall and among current cigarette smokers. Multiple logistic regression was used to examine correlates of use of cigarettes, e-cigarettes, hookah and cigars. Overall prevalence was highest for cigarettes (13.8%), followed by e-cigarettes (4.9%), hookah (2.5%) and cigars (2.3%), and below 1% for all other products. Prevalence of using other tobacco products is much higher among current smokers than the general population, with e-cigarettes (28.5%) most prevalent followed by cigars (14.0%), hookah (12.4%), smokeless (4.7%), snus (4.6%), and pipes (2.1%). Sociodemographic characteristics (poverty, low educational attainment, White race) and past-year externalizing psychiatric symptoms were correlated with current cigarette smoking. In turn, current cigarette smoking and past year illicit drug use were correlated with using e-cigarettes, hookah, and cigars. These results underscore that tobacco/nicotine use during pregnancy extends beyond cigarettes. The results also suggest that use of these other products should be included in routine clinical screening on tobacco use, and the need for more intensive tobacco control and regulatory strategies targeting pregnant women.

Tobacco and nicotine delivery product use in a U.S. national sample of women of reproductive age.

This study examined prevalence and correlates of using cigarettes, e-cigarettes, and other tobacco/nicotine delivery products in a U.S. national sample of women of reproductive age. Weighted data were obtained from women aged 15-44u202fyears who were not currently pregnant in the first wave of the Population Assessment of Health and Tobacco (PATH, 2013-2014) study (Nu202f=u202f12,848). 20.1% of women were current cigarette smokers, 5.9% current e-cigarette users, 4.9% current cigar smokers, and 6.5% current hookah users. Prevalence of current use of other tobacco products was <1.0%. Current cigarette smoking was the strongest correlate of current e-cigarette use (ORu202f=u202f65.7, 95% CIu202f=u202f44.8-96.5), cigar smoking (ORu202f=u202f19.2, 95% CIu202f=u202f14.1-26.1), and hookah use (ORu202f=u202f6.6, 95% CIu202f=u202f5.1-8.5). Among former cigarette smokers, 3.8%, 6.9%, and 3.2% were also currently using e-cigarettes, hookah, and cigars, respectively. Use of other tobacco and nicotine delivery products was low among those who never smoked tobacco cigarettes: 2.5% used hookah and <1.0% used other products. Cigarette smoking prevalence remains relatively high among women of reproductive age and strongly correlated with use of other tobacco products. Monitoring tobacco and nicotine use in this population is important due to the additional risk of adverse health impacts should they become pregnant. Clinicians working with cigarette smokers should assess for use of other tobacco products. Among women of reproductive age, use of emerging tobacco and nicotine products appears to be largely, although not exclusively, restricted to current cigarette smokers.

Patterns of Single and Multiple Tobacco Product Use Among US Women of Reproductive Age

Abstract Introduction Understanding patterns of single and multiple tobacco product use among reproductive-aged women is critical given the potential for adverse health effects on mother and infant should a woman become pregnant. Methods Patterns of tobacco use over a 2-year period were examined among all women (18–44 years) who completed wave 1 (W1) and wave 2 (W2) of the US Population Assessment of Tobacco and Health (PATH, 2013–2014, 2014–2015) Study. We examined the most common patterns of single and multiple tobacco product use in W1, and longitudinal trajectories of women engaged in each of these patterns of use from W1 to W2, among women not pregnant in either wave (n = 7480), not pregnant in W1 and pregnant in W2 (n = 332), and pregnant in W1 and not pregnant in W2 (n = 325). Results The most prevalent patterns of tobacco use in W1 among all three subgroups were using cigarettes alone followed by using cigarettes plus e-cigarettes. In all three subgroups, women using multiple products in W1 were more likely to adopt new use patterns in W2 relative to single-product users, with the new patterns generally involving dropping rather than adding products. The majority of multiple product use included cigarettes, and transitions to single product use typically involved dropping the noncigarette product. The most common trajectory among tobacco users transitioning to or from pregnancy was to use cigarettes alone in W2. Discussion This study contributes new knowledge characterizing tobacco use patterns across time and reproductive events among reproductive-aged women.

The Effects of Varying Electronic Cigarette Warning Label Design Features On Attention, Recall, and Product Perceptions Among Young Adults

ABSTRACT This study was a 3 (Brand: Blu, MarkTen, Vuse) by 3 (Warning Size: 20%, 30%, or 50% of advertisement surface) by 2 (Warning Background: White, Red) experimental investigation of the effects of electronic cigarette (e-cigarette) warning label design features. Young adults aged 18–30 years (n = 544) were recruited online, completed demographic and tobacco use history measures, and randomized to view e-cigarette advertisements with warning labels that varied by the experimental conditions. Participants completed a task assessing self-reported visual attention to advertisements with a-priori regions of interest defined around warning labels. Warning message recall and perceived addictiveness of e-cigarettes were assessed post-exposure. Approximately half of participants reported attending to warning labels and reported attention was greater for warnings on red versus white backgrounds. Recall of the warning message content was also greater among those reporting attention to the warning label. Overall, those who viewed warnings on red backgrounds reported lower perceived addictiveness than those who viewed warnings on white backgrounds, and e-cigarette users reported lower perceived addictiveness than non-users. Among e-cigarette users, viewing warnings on white backgrounds produced perceptions more similar to non-users. Greater recall was significantly correlated with greater perceived addictiveness. This study provides some of the first evidence that e-cigarette warning label design features including size and coloring affect self-reported attention and content recall.

Managing nicotine without smoke to save lives now: Evidence for harm minimization

Tobacco control has made strides in prevention and cessation, but deaths will not decline rapidly without massive behavior change. Currently, inhaled smoke from combusting tobacco is chiefly responsible for prematurely killing 7.2 million people worldwide and 530,000 in the United States annually. An array of noncombustible nicotine products (NNPs) has emerged and has disrupted the marketplace. Saving lives more speedily will require societal acceptance of locating a sweet spot within a three-dimensional framework where NNPs are simultaneously: 1. Less toxic, 2. Appealing (can reach smokers at scale), and 3. Satisfying (adequate nicotine delivery) to displace smoking. For this harm minimization framework to eliminate smoking, a laser focus on smoking control (not general tobacco control) is needed. By adopting these economically viable NNPs as part of the solution, NNPs can be smoking controls valued ally. Synthesis of the science indicates that policy and regulation can sufficiently protect youth while speeding the switch away from smoking. Despite some risks of nicotine dependence that can be mitigated but not eliminated, no credible evidence counters the assertion that NNPs will save lives if they displace smoking. But scientific evidence and advocacy has selectively exaggerated NNP harms over benefits. Accurate communication is crucial to dispel the misperception of NNPs harms and reassure smokers they can successfully replace smoking cigarettes with NNPs. Saving more lives now is an attainable and pragmatic way to call for alignment of all stakeholders and factions within traditional tobacco control rather than perpetuate the unrealized and unrealizable perfection of nicotine prohibition.

Trend differences in men and women in rural and urban U.S. settings

BACKGROUNDnSmoking prevalence is declining at a slower rate in rural than urban settings in the United States (U.S.), and known predictors of smoking do not readily account for this trend difference. Given that socioeconomic and psychosocial determinants of health disparities accumulate in rural settings and that life-course disadvantages are often greater in women than men, we examined whether smoking trends are different for rural and urban men and women.nnnMETHODnWe used yearly cross-sectional data (nu202f=u202f303,311) from the U.S. National Survey on Drug Use and Health (NSDUH) from 2007 through 2014 to compare cigarette smoking trends in men and women across rural and urban areas. Current smoking status was modelled using logistic regression controlling for confounding risk factors.nnnRESULTSnRegression derived graphs predicting unadjusted prevalence estimates and 95% confidence bands revealed that whereas the smoking trends of rural men, urban men, and urban women significantly declined from 2007 to 2014, the trend for rural women was flat. Controlling for demographic, socioeconomic and psychosocial predictors of smoking did not explain rural womens significantly different trend from those of the other three groups.nnnCONCLUSIONnRural women lag behind rural men, urban men and urban women in decreasing smoking, a health disparity finding that supports the need for tobacco control and regulatory policies and interventions that are more effective in reducing smoking among rural women.

Are we guilty of errors of omission on the potential role of electronic nicotine delivery systems as less harmful substitutes for combusted tobacco use

Two of the more controversial tobacco control and regulatory strategies in recent years are the nicotine reduction and tobacco harm reduction (THR) strategies. They have become inextricably intertwined as a successful nicotine reduction policy might only be possible in an environment in which alternative, noncombusted forms of nicotine like electronic nicotine delivery systems (ENDS) are available to address the needs of those who were unable or unwilling to completely give up nicotine. Unfortunately, ENDS have emerged as particularly controversial, in part, because they are the first product to carry reduced risk potential while being broadly appealing to cigarette smokers across demographic groups and subpopulations, and to a much smaller extent nonsmokers including, and most controversial, adolescents. In an effort to better understand some of the reasons that make this a controversial topic, we review some of the relevant history and discuss a broader dilemma that faces practitioners and policy developers of medical and public health interventions, namely, weighing the potential consequences of errors of commission versus omission. Commission errors involve a salient, direct link between an action and associated adverse or unintended consequences while omission errors are typically less salient with a more indirect link between inaction and associated adverse consequences. Decision-making research demonstrates that humans have a bias towards avoidance of commission errors and insensitivity to omission errors. This bias may be contributing to some of the aforementioned difficulties in finding common ground regarding the potential contribution of ENDS to reducing the harm of combusted tobacco use.

Co-occurring vulnerabilities and menthol use in U.S. young adult cigarette smokers: Findings from Wave 1 of the PATH Study, 2013–2014

This study incorporates intersectionality theory to address potential effects of age on other documented risk factors for current smoking and menthol cigarette use in young adults aged 18-34 using Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2014). We explored known correlates of current cigarette and menthol cigarette smoking and interaction analyses by age group (18-24 vs. 25-34), accounting for survey weighting. Use of non-cigarette tobacco products and e-cigarettes was characterized among current cigarette smokers. Young adults experience multiple vulnerabilities to smoking beyond age and some of these known risk factors for smoking place those aged 18-24 at different risk of cigarette smoking compared to their 25-34u202fyear old counterparts. These include lower odds of cigarette smoking by age for sex (female; AORu202f=u202f0.62 in those aged 18-24 vs. 0.72 in those aged 25-34) and Hispanic ethnicity (vs. White; AORu202f=u202f0.77 vs. 0.45), and higher odds of smoking among past 30-day alcohol users aged 18-24 vs. 25-34 (AORu202f=u202f1.62 vs. 1.32). Correlations between lower education and smoking were nearly two-fold higher in 25-34 than 18-24u202fyear olds. Having any medical comorbidity had opposite effects on current smoking by age (18-24 positive correlation, AORu202f=u202f1.17; 25-34 negative correlation, AORu202f=u202f0.84). Lower education was correlated with menthol cigarette use among young adult smokers. This study suggests that higher smoking prevalence among young adults is associated with the intersection of multiple vulnerabilities to smoking.

Response to reduced nicotine content cigarettes among smokers differing in tobacco dependence severity

This study examines whether tobacco dependence severity moderates the acute effects of reducing nicotine content in cigarettes on the addiction potential of smoking, craving/withdrawal, or smoking topography. Participants (Nu202f=u202f169) were daily smokers with mild, moderate, or high tobacco-dependence severity using the Heaviness of Smoking Index. Following brief abstinence, participants smoked research cigarettes varying in nicotine content (0.4, 2.4, 5.2, 15.8u202fmgu202fnicotine/g tobacco) in a within-subject design. Results were analyzed using repeated measures analysis of co-variance. No main effects of dependence severity or interactions with nicotine dose were noted in relative reinforcing effects in concurrent choice testing or subjective effects on the modified Cigarette Evaluation Questionnaire. Demand for smoking in the Cigarette Purchase Task was greater among more dependent smokers, but reducing nicotine content decreased demand independent of dependence severity. Dependence severity did not significantly alter response to reduced nicotine content cigarettes on the Minnesota Tobacco Withdrawal Scale nor Questionnaire of Smoking Urges-brief (QSU) Factor-2 scale; dependence severity and dose interacted significantly on the QSU-brief Factor-1 scale, with reductions dependent on dose among highly but not mildly or moderately dependent smokers. Dependence severity and dose interacted significantly on only one of six measures of smoking topography (i.e., maximum flow rate), which increased as dose increased among mildly and moderately but not highly dependent smokers. These results suggest that dependence severity has no moderating influence on the ability of reduced nicotine content cigarettes to lower the addiction potential of smoking, and minimal effects on relief from craving/withdrawal or smoking topography.