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A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Health Behavior, Chronic Disease and Health Promotion".

Deadline for manuscript submissions: closed (31 December 2018) | Viewed by 83286

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Special Issue Editors

Assoc. Prof. Coral Gartner

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Guest Editor

School of Public Health, University of Queensland, Cnr Wyndham Street and Herston Road, Herston, QLD 4006, Australia
Interests: tobacco control; tobacco harm reduction; alternative nicotine products; priority populations and health disparities; environmental health
Special Issues, Collections and Topics in MDPI journals

Dr. Ratika Sharma-Kumar

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Guest Editor

School of Public Health, University of Queensland, Cnr Wyndham Street and Herston Road, Herston, QLD 4006, Australia
Interests: tobacco cessation; tobacco harm reduction; priority populations and health disparities; health communication; online social media; dental public health

Dr. Kylie Morphett

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Guest Editor

School of Public Health, University of Queensland, Cnr Wyndham Street and Herston Road, Herston, QLD 4006, Australia
Interests: tobacco control; health communication; smoking cessation; addiction beliefs; lay understandings of health and illness

Special Issue Information

Dear Colleagues,

Tobacco Harm Reduction has been a controversial area in public health, largely due to the promotion by the tobacco industry of cigarette modifications that gave the appearance of reduced harm, without reducing health risk. This may have increased overall harm by discouraging smokers from quitting. However, there is now good evidence that switching from cigarettes to some alternate nicotine and tobacco products can reduce exposure to harmful constituents and reduce health risk. The Swedish experience with snus, a form of oral snuff manufactured to limit the formation of carcinogenic nitrosamines, is an example of an alternate tobacco product with long-term epidemiological evidence to support its much lower risk profile. Newer products, such as e-cigarettes and other vaping devices and heated tobacco products are generating substantial interest. While this is a rapidly advancing research field, the recent National Academies of Science, Engineering and Medicine Report on the Public Health Consequences of E-cigarettes has identified a number of priority areas for research to help fill some of the gaps in evidence on these alternate nicotine and tobacco products. This Special Issue of IJERPH on Tobacco Harm Reduction welcomes submissions on these priority research areas and other research that advances our understanding of the potential place of tobacco harm reduction within a comprehensive strategy to reduce the burden of smoking related disease and assists policy makers to determine what level of regulation is most appropriate.

Assoc. Prof. Coral Gartner
Dr. Ratika Sharma-Kumar
Dr. Kylie Morphett
Guest Editors

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Keywords

tobacco harm reduction
e-cigarettes
vaporized nicotine products
nicotine
smokeless tobacco
snus
heated tobacco
biomarkers
secondhand exposure
substitution
harmful and potentially harmful constituents
emissions
relative risk
dual use

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Published Papers (9 papers)

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13 pages, 317 KiB

Open AccessArticle

How Are Self-Reported Physical and Mental Health Conditions Related to Vaping Activities among Smokers and Quitters: Findings from the ITC Four Country Smoking and Vaping Wave 1 Survey

by Lin Li, Ron Borland, Richard J. O’Connor, Geoffrey T. Fong, Ann McNeill, Pete Driezen and K. Michael Cummings

Int. J. Environ. Res. Public Health 2019, 16(8), 1412; https://doi.org/10.3390/ijerph16081412 - 19 Apr 2019

Cited by 12 | Viewed by 8216

Abstract

This study examines whether having health conditions or concerns related to smoking is associated with use of vaping products. Data came from the 2016 wave of the International Tobacco Control Four Country Smoking and Vaping Survey. Smokers and recent quitters (n = 11,344) were asked whether they had a medical diagnosis for nine health conditions (i.e., depression, anxiety, alcohol problems, severe obesity, chronic pain, diabetes, heart disease, cancer, and chronic lung disease) and concerns about past and future health effects of smoking, and their vaping activities. Respondents with depression and alcohol problems were more likely to be current vapers both daily (Adjusted odds ratio, AOR = 1.42, 95% confidence interval, CI 1.09–1.85, p < 0.05 for depression; and AOR = 1.52, 95% CI 1.02–2.27, p < 0.05 for alcohol) and monthly (AOR = 1.32, 95% CI 1.11–1.57 for depression, p < 0.01; and AOR = 1.43, 95% CI 1.06–1.90, p < 0.05 for alcohol). Vaping was more likely at monthly level for those with severe obesity (AOR = 1.77, 95% CI 1.29–2.43, p < 0.001), cancer (AOR = 5.19, 95% CI 2.20–12.24, p < 0.001), and concerns about future effects of smoking (AOR = 1.83, 95% CI 1.47–2.28, p < 0.001). Positive associations were also found between chronic pain and concerns about past health effects of smoking and daily vaping. Only having heart disease was, in this case negatively, associated with use of vaping products on their last quit attempt (AOR = 0.72, 95% CI 0.43–0.91, p < 0.05). Self-reported health condition or reduced health associated with smoking is not systematically leading to increased vaping or increased likelihood of using vaping as a quitting strategy. Full article

(This article belongs to the Special Issue Tobacco Harm Reduction)

14 pages, 1452 KiB

Open AccessArticle

Relative Risk Perceptions between Snus and Cigarettes in a Snus-Prevalent Society—An Observational Study over a 16 Year Period

by Karl Erik Lund and Tord Finne Vedoy

Int. J. Environ. Res. Public Health 2019, 16(5), 879; https://doi.org/10.3390/ijerph16050879 - 11 Mar 2019

Cited by 12 | Viewed by 13657

Abstract

Background: Most studies on perceived risks of smokeless tobacco products (SLT) have been conducted in the U.S., and the vast majority conclude that perceptions of the relative harmfulness of SLT versus cigarettes in the population are inconsistent with epidemiologically-based risk estimates, and typically conflated to that of cigarettes. We tested whether such inaccuracies also existed in Norway, where SLT-products are less toxic (Swedish snus) and SLT use is more prevalent than in the U.S. Methods: Over a 16 years period (2003–2018), 13,381 respondents (aged 16–79 years) answered questions about risk perceptions in Statistics Norway’s nationally representative survey of tobacco behavior. We applied an indirect measure of comparative harm where risk beliefs for eight nicotine products were assessed independently of other products and then compared the answers. The wording of the question was: “We will now mention a variety of nicotine products and ask you how harmful you think daily use of these are. Use a scale from 1 to 7, where 1 is slightly harmful and 7 is very harmful”. Mean scores with 95% confidence intervals were calculated. Results: The overall risk score for cigarettes was 6.48. The risk score for snus was 5.14–79.3% of the risk score of cigarettes. The relative risk scores for e-cigarettes (3.78) and NRT products (3.39) was 58.4% and 52.3% when compared to cigarettes. Perceptions of risk were stable over time. A strong association was observed between perceived risk of snus and having used snus in attempts to quit smoking. Conclusion: Perceptions of relative risk between snus and cigarettes is inconsistent with estimates from medical expert committees, which assess the overall health risk from use of Swedish snus to be minor when compared to the risk from smoking. Like the situation in the US, incorrect beliefs about SLT risks seem to be prevalent also in the snus-prevalent Norwegian setting. Accurate information on differential harms needs to be communicated. Future research should try to identify reasons why health authorities in the US and Scandinavia allow these well-documented misconceptions to persist. Full article

(This article belongs to the Special Issue Tobacco Harm Reduction)

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17 pages, 313 KiB

Open AccessArticle

Attitudes to E-Cigarettes and Cessation Support for Pregnant Women from English Stop Smoking Services: A Mixed Methods Study

by Sue Cooper, Sophie Orton, Katarzyna A. Campbell, Michael Ussher, Naomi Coleman-Haynes, Rachel Whitemore, Anne Dickinson, Andy McEwen, Sarah Lewis, Felix Naughton, Katharine Bowker, Lesley Sinclair, Linda Bauld and Tim Coleman

Int. J. Environ. Res. Public Health 2019, 16(1), 110; https://doi.org/10.3390/ijerph16010110 - 3 Jan 2019

Cited by 21 | Viewed by 9430

Abstract

Smoking in pregnancy remains a public health problem. In the UK e-cigarettes are the most popular aid to quitting smoking outside of pregnancy, but we don’t know the extent of e-cigarette use in pregnancy or how English Stop Smoking Services (SSS) respond to pregnant women who vape. In 2015 we surveyed SSS managers about cessation support for pregnant women and responses to clients who vaped. Subsequently we interviewed a sub-sample of managers to seek explanations for the SSS’ position on e-cigarettes; interviews were thematically analysed. Survey response rate was 67.8% (72/106); overall managers reported 2.2% (range 1.4–4.3%) of pregnant clients were using e-cigarettes. Most SSS reported supporting pregnant women who already vaped, but would not recommend e-cigarette use; for women that were still smoking and not using e-cigarettes, 8.3% of SSS were likely/very likely to advise using e-cigarettes, with 56.9% of SSS unlikely/very unlikely to advise using them. Fifteen respondents were interviewed; interviewees were generally positive about the potential of e-cigarettes for cessation in pregnancy although concerns about perceived lack of evidence for safety were expressed and most wanted research on this. Clear guidance on e-cigarette use informed by pregnancy specific research will assist SSS to provide consistent evidence-based support. Full article

(This article belongs to the Special Issue Tobacco Harm Reduction)

11 pages, 951 KiB

Open AccessArticle

The Value of Providing Smokers with Free E-Cigarettes: Smoking Reduction and Cessation Associated with the Three-Month Provision to Smokers of a Refillable Tank-Style E-Cigarette

by Neil McKeganey, Joanna Astrid Miler and Farhana Haseen

Int. J. Environ. Res. Public Health 2018, 15(9), 1914; https://doi.org/10.3390/ijerph15091914 - 3 Sep 2018

Cited by 2 | Viewed by 10576

Abstract

Despite the uptake of tobacco smoking declining in the United Kingdom (UK), smoking is still the leading cause of preventable poor health and premature death. While improved approaches to smoking cessation are necessary, encouraging and assisting smokers to switch by using substantially less toxic non-tobacco nicotine products may be a possible option. To date, few studies have investigated the rates of smoking cessation and smoking reduction that are associated with the provision of free electronic-cigarettes (e-cigarettes) to smokers. In this exploratory study, the Blu Pro e-cigarette was given to a convenience sample of adult smokers (n = 72) to assist them in reducing and quitting over a 90-day period. The rates of smoking abstinence and daily smoking patterns were assessed at baseline, 30 days, 60 days, and 90 days. The response rate was 87%. After 90 days, the complete abstinence rate was 36.5%, up from 0% at baseline. The frequency of daily smoking reduced from 88.7% to 17.5% (p < 0.001), and the median consumption of cigarettes/day reduced from 15 to five (p < 0.001). The median number of days per month that participants smoked also reduced from 30 to 13 after 90 days (p < 0.001). On the basis of these results, there may be value in smoking cessation services and other services ensuring that smokers are provided with e-cigarettes at zero or minimal costs for at least a short period of time. Full article

(This article belongs to the Special Issue Tobacco Harm Reduction)

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21 pages, 1706 KiB

Open AccessArticle

About One in Five Novice Vapers Buying Their First E-Cigarette in a Vape Shop Are Smoking Abstinent after Six Months

by Karolien Adriaens, Dinska Van Gucht and Frank Baeyens

Int. J. Environ. Res. Public Health 2018, 15(9), 1886; https://doi.org/10.3390/ijerph15091886 - 31 Aug 2018

Cited by 10 | Viewed by 13127

Abstract

Background: E-cigarette use is rising with the majority of vapers purchasing their e-cigarettes in vape shops. We investigated the smoking/vaping trajectories and quit-smoking success rates of smokers deciding to start vaping for the first time and buying their e-cigarette in brick-and-mortar vape shops in Flanders. Methods: Participants filled out questionnaires assessing smoking/vaping behaviour at three moments (intake, after three and six months) and smoking status was biochemically verified using eCO measurements. Results: Participants (n = 71) were regular smokers (M_eCO-intake = 22 ppm), half of whom reported a motivation to quit smoking in the near future. Participants bought 3rd/4th generation e-cigarettes and e-liquid with a nicotine concentration averaging 7 mg/mL. A smoking reduction of 53% (17 cigarettes per day (CPD) at intake to 8 CPD after six months) was observed, whereas eCO decreased to 15 ppm. Eighteen percent of participants had quit smoking completely (eCO = 2 ppm), another 25% had at least halved CPD, whereas 57% had failed to reduce CPD by at least 50% (including 13% lost to follow-up). Quitters consumed more e-liquid than reducers and those who continued to smoke. Conclusions: Around one in five smoking customers buying their first e-cigarette in a brick-and-mortar vape shop had quit smoking completely after six months. Full article

(This article belongs to the Special Issue Tobacco Harm Reduction)

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14 pages, 1589 KiB

Open AccessArticle

Influence of Coil Power Ranges on the E-Liquid Consumption in Vaping Devices

by Sébastien Soulet, Marie Duquesne, Jean Toutain, Charly Pairaud and Hélène Lalo

Int. J. Environ. Res. Public Health 2018, 15(9), 1853; https://doi.org/10.3390/ijerph15091853 - 28 Aug 2018

Cited by 23 | Viewed by 6231

Abstract

As electronic cigarettes (e-cigarettes) represent a new constantly evolving product category, the systematic analysis of the developed devices and the e-liquid vaporization is challenging. Indeed, understanding how e-cigarettes work and the role of key parameters in the process are major issues. This work focuses on an experimental study of how the power supplied by the battery to the atomizer coil influences e-liquid consumption. The reproducibility and the repeatability of e-liquid consumption were investigated over 20 series of 20 puffs for one of the tested atomizers. Then, the reproducibility and the repeatability of the e-liquid consumption was investigated over five series of 20 puffs for each tested atomizer. The wire behavior according to the supplied power could be separated into three regimes: under-heating (insufficient power to generate an aerosol), optimal vaporization characterized by a linear trend (vaporization of the e-liquid proportional to the supplied energy) and over-heating (dry-burn occurs). Using a controllable and repeatable energy supply, the reproducibility of the quantity of vaporized e-liquid was verified for each of the five series of 20 puffs programed for all the atomizers except one. Finally, the influence of the supplied power on the vaporization and the consumption of the e-liquid as well as the optimal power ranges were investigated and discussed. The results showed that atomizers with resistance ranging from 1 Ω to 1.8 Ω are efficient using all the energy supplied by the battery to vaporize the e-liquid and reducing the energy lost in the cotton or in the metal part of atomizer coil. Full article

(This article belongs to the Special Issue Tobacco Harm Reduction)

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5 pages, 253 KiB

Open AccessArticle

A Comparison of Dependence across Different Types of Nicotine Containing Products and Coffee

by Karl Fagerstrom

Int. J. Environ. Res. Public Health 2018, 15(8), 1609; https://doi.org/10.3390/ijerph15081609 - 30 Jul 2018

Cited by 6 | Viewed by 7236

Abstract

Introduction: Few studies have compared the dependence to different tobacco and nicotine products. Even less is known about how it relates to dependence on other common drugs, e.g., caffeine. In this study degree of dependence was compared between snus, cigarettes, nicotine replacement (NR), electronic cigarettes and coffee. Methods: A random sample of Swedish citizens belonging to an internet panel were contacted from September to October 2017. The responders were asked among other related things about their use of snus, NR, traditional cigarette or e-cigarette use and coffee consumption. The indicators of dependence used were: (A) the Heavy Smoking Index, (B) The proportions that used within 30 min after raising in the morning, (C) rating the first use in the morning as the most important and (D) Stating that it would be very hard to give up entirely. Results: Significantly fewer coffee drinkers started use within 30 min of awakening compared with all other products. The first use of the day was found to be more important for snus users compared with other products. On HSI there was no difference between snus and cigarettes. Snus and cigarettes were rated as being more difficult to give up than NR and coffee. Conclusion: Dependence to traditional cigarettes and snus seem to be relatively similar while NR was rated lower and coffee lowest. Since the prevalence of caffeine use in all forms is so much more prevalent than nicotine there might be more persons in the society heavily dependent on caffeine. Implication: Tobacco products are likely more dependence forming than NR products and coffee although there might be more people dependent on caffeine. The addiction to coffee or caffeine is seldom discussed in the society probably because of the little or no harm it causes. Funding: The Snus Commission in Sweden (snuskommissionen) funded the data collection. No funding used for the analysis and writing of manuscript. Full article

(This article belongs to the Special Issue Tobacco Harm Reduction)

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5 pages, 238 KiB

Open AccessCommentary

Truth Telling about Tobacco and Nicotine

by Rachelle Annechino and Tamar M.J. Antin

Int. J. Environ. Res. Public Health 2019, 16(4), 530; https://doi.org/10.3390/ijerph16040530 - 13 Feb 2019

Cited by 3 | Viewed by 7900

Abstract

Research suggests that many people in the US are misinformed about the relative harms of various tobacco and nicotine products. Concerns about public misinformation have often been framed as relevant only to the degree that public health institutions agree to prioritize conventional approaches to tobacco harm reduction. We argue that while the information priorities of public health professionals are important, ethical and credible information sharing also requires consideration of broader issues related to public trust. To promote trust, public health institutions must develop truth telling relationships with the communities they serve and be genuinely responsive to what people themselves want to know about tobacco and nicotine products. Full article

(This article belongs to the Special Issue Tobacco Harm Reduction)

13 pages, 302 KiB

Open AccessFeature PaperConcept Paper

Vape Club: Exploring Non-Profit Regulatory Models for the Supply of Vaporised Nicotine Products

by Coral Gartner, Marilyn Bromberg, Tanya Musgrove and Kathy Luong

Int. J. Environ. Res. Public Health 2018, 15(8), 1744; https://doi.org/10.3390/ijerph15081744 - 14 Aug 2018

Cited by 2 | Viewed by 4289

Abstract

Vaporised nicotine products (VNPs) that are not approved as therapeutic goods are banned in some countries, including Australia, Singapore, and Thailand. We reviewed two non-profit regulatory options, private clubs and the Australian Therapeutic Goods Administration Special Access Scheme (SAS) that have been applied to other controlled substances (such as cannabis) as a potential model for regulating VNPs as an alternative to prohibition. The legal status of private cannabis clubs varies between the United States, Canada, Belgium, Spain, and Uruguay. Legal frameworks exist for cannabis clubs in some countries, but most operate in a legal grey area. Kava social clubs existed in the Northern Territory, Australia, until the federal government banned importation of kava. Access to medical cannabis in Australia is allowed as an unapproved therapeutic good via the SAS. In Australia, the SAS Category C appears to be the most feasible option to widen access to VNPs, but it may have limited acceptability to vapers and smokers. The private club model would require new legislation but could be potentially more acceptable if clubs were permitted to operate outside a medical framework. Consumer and regulator support for these models is currently unknown. Without similar restrictions applied to smoked tobacco products, these models may have only a limited impact on smoking prevalence. Further research could explore whether these models could be options for regulating smoked tobacco products. Full article

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