K. Michael Cummings

Electronic Nicotine Delivery Systems: International Tobacco Control Four-Country Survey

BACKGROUND Electronic nicotine delivery systems (ENDS) initially emerged in 2003 and have since become widely available globally, particularly over the Internet. PURPOSE Data on ENDS usage patterns are limited. The current paper examines patterns of ENDS awareness, use, and product-associated beliefs among current and former smokers in four countries. METHODS Data come from Wave 8 of the International Tobacco Control Four-Country Survey, collected July 2010 to June 2011 and analyzed through June 2012. Respondents included 5939 current and former smokers in Canada (n=1581); the U.S. (n=1520); the United Kingdom (UK; n=1325); and Australia (n=1513). RESULTS Overall, 46.6% were aware of ENDS (U.S.: 73%, UK: 54%, Canada: 40%, Australia: 20%); 7.6% had tried ENDS (16% of those aware of ENDS); and 2.9% were current users (39% of triers). Awareness of ENDS was higher among younger, non-minority smokers with higher incomes who were heavier smokers. Prevalence of trying ENDS was higher among younger, nondaily smokers with a high income and among those who perceived ENDS as less harmful than traditional cigarettes. Current use was higher among both nondaily and heavy (≥20 cigarettes per day) smokers. In all, 79.8% reported using ENDS because they were considered less harmful than traditional cigarettes; 75.4% stated that they used ENDS to help them reduce their smoking; and 85.1% reported using ENDS to help them quit smoking. CONCLUSIONS Awareness of ENDS is high, especially in countries where they are legal (i.e., the U.S. and UK). Because trial was associated with nondaily smoking and a desire to quit smoking, ENDS may have the potential to serve as a cessation aid.

Predictors of cessation in a cohort of current and former smokers followed over 13 years

The present study attempted to identify predictors of smoking cessation in a cohort of cigarette smokers followed over 13 years. Data are reported on 6,603 persons who resided in one of 20 U.S. communities involved in the National Cancer Institutes Community Intervention Trial for Smoking Cessation (COMMIT) study, were current smokers in the COMMIT trial in 1988, and completed detailed tobacco use telephone surveys in 1988, 1993, and 2001. A person was classified as a former smoker if at the time of follow-up he or she reported not smoking for at least 6 months prior to the interview. Reasons and methods for quitting also were assessed in 1993 and 2001. Among smokers in 1988, 24% had stopped smoking by 1993 and 42% were not smoking by 2001. The most frequently cited reasons for quitting were health and cost reasons, while assisted methods to quit were more common in more recent years. Measures of nicotine dependence were much more strongly associated with cessation than measures of motivation. Other predictors included male gender, older age, higher income, and less frequent alcohol consumption, although the gender effect no longer existed when cessation from cigarettes as well as other tobacco products was considered as the outcome. The present study shows that nicotine dependence is a major factor predicting long-term cessation in smokers. This finding has implications for tobacco control policy and treatment approaches.

A Longitudinal Assessment of the Impact of Smoke-Free Worksite Policies on Tobacco Use

OBJECTIVES In this cohort study, we assessed the impact of smoke-free work-site policies on smoking cessation behaviors. METHODS Smokers were tracked as part of the Community Intervention Trial for Smoking Cessation. Telephone surveys were administered to 1967 employed smokers in 1993 and 2001. Data were gathered on personal and demographic characteristics, tobacco use behaviors, and restrictiveness of worksite smoking policies. RESULTS People who worked in environments that changed to or maintained smoke-free policies between 1993 and 2001 were 1.9 times more likely (odds ratio [OR] = 1.92; 95% confidence interval [CI] = 1.11, 3.32) than people whose worksites did not do so to have stopped smoking by 2001. Continuing smokers decreased their average daily consumption by 2.57 cigarettes. People working in environments that had smoke-free policies in place in both 1993 and 2001 were 2.3 times more likely (OR=2.29; 95% CI=1.08, 4.45) than people not working in such environments to have quit by 2001, and continuing smokers reported a decline in average daily consumption of 3.85 cigarettes. CONCLUSIONS Smoke-free worksite policies help employees reduce their cigarette consumption and stop smoking.

Epidemiology of menthol cigarette use

Approximately one-fourth of all cigarettes sold in the United States are mentholated. An understanding of the consequences, patterns, and correlates of menthol cigarette use can guide the development and implementation of strategies to reduce smoking prevalence and smoking-attributable morbidity and mortality. This paper summarizes the literature on the health effects of mentholated cigarettes and describes various patterns of use as indicated by consumption and survey data from the United States and other nations. The epidemiological literature on menthol cigarettes and cancer risk is inconclusive regarding whether these cigarettes confer a risk for cancer above that of nonmentholated varieties. Available data indicate that mentholated cigarettes are at least as dangerous as their nonmentholated counterparts. In addition, because mentholation improves the taste of cigarettes for a substantial segment of the smoking population and appears to mask disease symptoms, this additive may facilitate initiation or inhibit quitting. Menthol market share is high in the Philippines (60%), Cameroon (35%-40%), Hong Kong (26%), the United States (26%), and Singapore (22%). Newport has become the leading menthol brand in the United States. Surveys from four nations indicate that menthol use among adult smokers is more common among females than males. Among U.S. smokers, 68.9% of Blacks, 29.2% of Hispanics, and 22.4% of Whites reported smoking a mentholated variety. Research is needed to better explain factors that may influence menthol preference, such as marketing, risk perceptions, brand formulation, and taste preferences. Such research would guide the development of potentially more effective programs and policies.

Compliance of pediatric and adolescent cancer patients

Compliance with self‐administered therapy in pediatric and adolescent patients is not always complete. Noncompliance may result in erroneous conclusions about the efficacy of a given therapy and lead to unnecessary tests and alteration of treatment regimens. To examine the causes of noncompliance, 46 cancer patients aged 2.5 to 23 years (mean age, 6.85 years) and 40 parents were extensively interviewed at 2 weeks, 20 weeks, and 50 weeks post‐diagnosis. The results of self‐reported compliance were corroborated by serum bioassay of the prescribed medications. A significant correlation between the age of patient and compliance with chemotherapeutic agents and nonchemotherapeutic medications was found (P < 0.05 and P < 0.02, respectively), with adolescent patients being compliant less often. Over the course of therapy, compliance among patients decreased, but not significantly. A significant negative correlation was found between compliance and the number of children in the family. Compilers and noncompliers did differ significantly in how well they understood instructions concerning how to take their medication (P = 0.04). No significant correlations between compliance and stage of the disease, number or type of drugs used, complexity of the regimen, degree of satisfaction with information given to the patient, understanding of disease, treatment, or belief in medication efficacy were found. The main reasons given for noncompliance were forgetfulness, busy schedules, and nonavailability of medication. More compilers than noncompliers were in agreement with their parents regarding who was responsible for the administration of the medication. Compliance is a complex and multifaceted issue which interrelates with a large number of medical and social factors. Cancer 58:1179‐1184, 1986.

Smoking at diagnosis and survival in cancer patients.

The effect of smoking on survival in cancer patients is limited by the lack of structured prospective assessments of smoking at diagnosis. To assess the effect of smoking at diagnosis on survival, structured smoking assessments were obtained in a cohort of 5,185 cancer patients within 30 days of a cancer diagnosis between 1982 and 1998. Hazard ratios (HRs) or odds ratios were generated to analyze the effects of smoking at diagnosis on overall mortality (OM) and disease‐specific mortality (DSM) in a patient cohort from 13 disease sites containing at least 100 patients in each disease site. With a minimum of 12 years of follow‐up, current smoking increased OM risk versus recent quit (HR 1.17), former (HR 1.29) and never smokers (HR 1.38) in the overall cohort. Current smoking increased DSM risk versus former (HR 1.23) and never smokers (HR 1.18). In disease sites with proportionately large (>20%) recent quit cohorts (lung and head/neck), current smoking increased OM and DSM risks as compared with recent quit. Current smoking increased mortality risks in lung, head/neck, prostate and leukemia in men and breast, ovary, uterus and melanoma in women. Current smoking was not associated with any survival benefit in any disease site. Data using prospective structured smoking assessments demonstrate that current smoking increased long‐term OM and DSM. Standardized smoking assessment at diagnosis is an important variable for evaluating outcomes in cancer patients.

Tobacco-Product Use by Adults and Youths in the United States in 2013 and 2014.

Background Noncigarette tobacco products are evolving rapidly, with increasing popularity in the United States. Methods We present prevalence estimates for 12 types of tobacco products, using data from 45,971 adult and youth participants (≥12 years of age) from Wave 1 (September 2013 through December 2014) of the Population Assessment of Tobacco and Health (PATH) Study, a large, nationally representative, longitudinal study of tobacco use and health in the United States. Participants were asked about their use of cigarettes, e‐cigarettes, traditional cigars, cigarillos, filtered cigars, pipe tobacco, hookah, snus pouches, other smokeless tobacco, dissolvable tobacco, bidis, and kreteks. Estimates of the prevalence of use for each product were determined according to use category (e.g., current use or use in the previous 30 days) and demographic subgroup, and the prevalence of multiple‐product use was explored. Results More than a quarter (27.6%) of adults were current users of at least one type of tobacco product in 2013 and 2014, although the prevalence varied depending on use category. A total of 8.9% of youths had used a tobacco product in the previous 30 days; 1.6% of youths were daily users. Approximately 40% of tobacco users, adults and youths alike, used multiple tobacco products; cigarettes plus e‐cigarettes was the most common combination. Young adults (18 to 24 years of age), male adults and youths, members of racial minorities, and members of sexual minorities generally had higher use of tobacco than their counterparts. Conclusions During this study, 28% of U.S. adults were current users of tobacco, and 9% of youths had used tobacco in the previous 30 days. Use of multiple products was common among tobacco users. These findings will serve as baseline data to examine between‐person differences and within‐person changes over time in the use of tobacco products. (Funded by the National Institute on Drug Abuse and the Food and Drug Administration.)

Tobacco Outlet Density and Demographics in Erie County, New York

Economic literature shows that smokers are responsive to the price of cigarettes and that African American and lower-income smokers are particularly price sensitive.1–4 Tobacco control policies that effectively restrict access and use of cigarettes will raise the cost of the cigarettes themselves as a result of increased costs in obtaining and using cigarettes. For example, zoning restrictions on the number of tobacco outlets in a given area will require smokers to travel greater distances, which has a cost associated with it, to obtain cigarettes. Studies in the alcohol literature indicate that reductions in the physical availability of alcohol products are associated with positive health and behavioral outcomes,5–8 especially in low socioeconomic areas.9,10 No such studies have been performed concerning tobacco retail outlet densities. Given this deficiency in the tobacco literature, we set out to determine whether tobacco outlets were more densely concentrated in areas with lower incomes and more African Americans.

Use of and beliefs about light cigarettes in four countries: Findings from the International Tobacco Control Policy Evaluation Survey

This study examined reported use of, and beliefs about, so-called light cigarettes among adult smokers in four countries: Australia (Aus), Canada (Can), the United Kingdom (U.K.) and the United States (U.S.). The method used was parallel telephone surveys among 9,046 smokers across the four countries. The results indicated that more than half of all smokers in each country except the U.K. reported smoking light cigarette brands. A majority of smokers surveyed in each country except Canada continue to believe that light cigarettes offer some health benefit compared to regular cigarettes (Canada 43%, U.S. 51%, Australia 55%, U.K. 70%). A majority of smokers in all four countries believed that light cigarettes are smoother on the throat and chest than regular cigarettes. Predictors of use of light cigarettes and beliefs about possible benefits were very similar in the four countries. These results demonstrate an ongoing need for public education about why light cigarettes do not reduce harm and do not make quitting easier. The results provide further evidence for the need for regulatory measures in all four countries to prohibit the use of misleading light and mild descriptors including package imagery in product marketing (as prescribed in Article 11 of the Framework Convention on Tobacco Control), abandon the use of standard FTC/ISO tar and nicotine yields as consumer information, and adopt policies to regulate deceptive design features of cigarettes, such as ventilated filters.

Smokers' beliefs about the relative safety of other tobacco products: Findings from the ITC Collaboration

Most tobacco control efforts in western countries focus on the factory-made, mass-produced (FM) cigarette, whereas other tobacco products receive relatively little attention. Noncombusted tobacco products (i.e., referred to as smokeless tobacco), particularly Swedish-style snus, carry lower disease risks, compared with combusted tobacco products such as cigarettes. In this context, it is important to know what tobacco users believe about the relative harmfulness of various types of tobacco products. Data for this study came from random-digit-dialed telephone surveys of current smokers aged 18 or older in Australia, Canada, the United Kingdom, and the United States. Three waves of data, totaling 13,322 individuals, were assessed. Items assessed use of and beliefs about the relative harms of cigars, pipes, smokeless tobacco, and FM and roll-your-own cigarettes, as well as sociodemographics and smoking behaviors. Cigars (2.8%-12.7%) were the other tobacco products most commonly used by current cigarette smokers, followed by pipes (0.3%-2.1%) and smokeless tobacco (0.0%-2.3%). A significant minority of smokers (12%-21%) used roll-your-own cigarettes at least some of the time. About one-quarter of smokers believed that pipes, cigars, or roll-your-own cigarettes were safer than FM cigarettes, whereas only about 13% responded correctly that smokeless tobacco was less hazardous than cigarettes. Multivariate analyses showed that use of other tobacco products was most strongly related to beliefs about the reduced harm of these other products. Use of other tobacco products was low but may be growing among smokers in the four countries studied. Smokers are confused about the relative harms of tobacco products. Health education efforts are needed to correct smoker misperceptions.