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There is strong evidence that cigarette smoking causes adverse outcomes in people with cancer. However, more research is needed regarding those effects and the effects of alternative tobacco products and of secondhand smoke, the effects of cessation (before diagnosis, during treatment, or during survivorship), the biologic mechanisms, and optimal strategies for tobacco dependence treatment in oncology. Fundamentally, tobacco is an important source of variation in clinical treatment trials. Nevertheless, tobacco use assessment has not been uniform in clinical trials. Progress has been impeded by a lack of consensus regarding tobacco use assessment suitable for cancer patients. The NCI-AACR Cancer Patient Tobacco Use Assessment Task Force identified priority research areas and developed recommendations for assessment items and timing of assessment in cancer research. A cognitive interview study was conducted with 30 cancer patients at the NIH Clinical Center to evaluate and improve the measurement items. The resulting Cancer Patient Tobacco Use Questionnaire (C-TUQ) includes “Core” items for minimal assessment of tobacco use at initial and follow-up time points, and an “Extension” set. Domains include the following: cigarette and other tobacco use status, intensity, and past use; use relative to cancer diagnosis and treatment; cessation approaches and history; and secondhand smoke exposure. The Task Force recommends that assessment occur at study entry and, at a minimum, at the end of protocol therapy in clinical trials. Broad adoption of the recommended measures and timing protocol, and pursuit of the recommended research priorities, will help us to achieve a clearer understanding of the significance of tobacco use and cessation for cancer patients. Clin Cancer Res; 22(8); 1907–13. ©2016 AACR.

This file contains the NCI-AACR tobacco use questionnaire and notes about its use.

This file contains detailed information about the methodology.

The topic of e-cigarettes is controversial. Opponents focus on e-cigarettes’ risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking. Most US health organizations, media coverage, and policymakers have focused primarily on risks to youths. Because of their messaging, much of the public—including most smokers—now consider e-cigarette use as dangerous as or more dangerous than smoking. By contrast, the National Academies of Science, Engineering, and Medicine concluded that e-cigarette use is likely far less hazardous than smoking. Policies intended to reduce adolescent vaping may also reduce adult smokers’ use of e-cigarettes in quit attempts. Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, many scientists, including this essay’s authors, encourage the health community, media, and policymakers to more carefully weigh vaping’s potential to reduce adult smoking-attributable mortality. We review the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation, concerns about youth vaping, and the need to balance valid concerns about risks to youths with the potential benefits of increasing adult smoking cessation.

BackgroundTo understand the state of tobacco control efforts across Africa, a first-ever survey was implemented to assess the nature and activities of tobacco control stakeholders across the African continent.MethodsA survey in English, Arabic, and French was made available to individuals and organizations to assess the types and scope of tobacco control efforts and experience with tobacco control programs based on FCTC articles/MPOWER components.ResultsThere were 219 respondents from 32 African and 6 non-African countries. Research and advocacy were the most reported activities, and several organizations emerged as network nodes for connecting tobacco control efforts across multiple African countries. The most common FCTC articles/MPOWER components worked on were (W) warning about the dangers of tobacco (58%), (M) monitor tobacco use and policies (49%), and (P) protection against secondhand smoke exposure (47%). Significant between-country differences were also found on some FCTC articles/MPOWER components: (1) (R) price and tax measures [Articles 6 and 15] (F=1.57, p=0.048), (2) industry interference [Article 5.3] (F=1.62, p=0.038), and (3) economically viable alternatives to tobacco growing [Article 17] (F=1.94, p=0.007).DiscussionThis study found a broad and robust tobacco control network across Africa, with multiple organizations serving those networks and having overlapping collaborations. There is considerable variability in tobacco control priorities and networking, and multiple barriers were identified to expanding the network and to fostering increased tobacco control efforts. The results point to important directions for increasing collaboration across FCTC articles/MPOWER components to improve tobacco control efforts; potential research opportunities, including an analysis of tobacco industry activities, an exploration of ways to help people quit tobacco, and approaches to elevate the cost of tobacco; and a solid tobacco control network foundation on which to build. However, exploring creative approaches to increase research most relevant to specific countries and their cultural characteristics is essential.

Background: Physician-led smoking cessation services are suboptimal in Nigeria. Objectives: This study evaluated a text messaging intervention designed to increase the knowledge and practices of physicians in Nigeria to help smokers quit. Methods: Using a pre-post study design, all physicians ( N = 946) in 3 tertiary care hospitals located in 3 geopolitical zones in Nigeria were sent 2–3 text messages weekly over a 13-week period to create awareness and improve cessation practices using the “Ask, Advise and Refer” (AAR) model. The primary outcomes were the awareness of AAR and the proportion of physicians who offered each of the components of the brief intervention (AAR) to at least half of eligible patients. Secondary outcomes included the attitudes and self-reported effects of the messages on motivation to offer AAR to patients who smoke. Results: Of the 946 eligible respondents, only 165 responded to both the before and after intervention surveys (17.4% participation rate). Participants were more likely to indicate awareness of the AAR approach after the intervention (60%) than before (21.2%). Overall, physicians’ practice of each component of the AAR changed significantly after the intervention ( P Conclusions: A brief and low-cost text messaging intervention to physicians increased the awareness and practice of AAR in those who participated in the study. However, the relatively low participation rate highlights the importance of new research to improve and expand text messaging as an intervention among physicians to help them foster tobacco treatment among their patients.

Author(s): Hatsukami, Dorothy K; Luo, Xianghua; Heskin, Alisa K; Tang, Mei Kuen; Carmella, Steven G; Jensen, Joni; Robinson, Jason D; Vandrey, Ryan; Drobes, David J; Strasser, Andrew A; al'Absi, Mustafa; Leischow, Scott; Cinciripini, Paul M; Koopmeiners, Joseph; Ikuemonisan, Joshua; Benowitz, Neal L; Donny, Eric C; Hecht, Stephen S | Abstract: AimA previous study showed significantly greater reductions in number of cigarettes smoked and biomarkers of toxicant and carcinogen exposure in smokers assigned to immediate reduction of nicotine in cigarettes to very low levels versus gradually over time or continued smoking of normal nicotine content cigarettes. This study examines the effects of these approaches on selected biomarkers associated with harmful biological effects.DesignThree-arm, randomized controlled trial.SettingTen United States academic institutional sites.ParticipantsDaily smokers uninterested in quitting smoking with a mean age of 45.1 [standard deviation (SD)n=n13.4)] years and smoking 17.1 (SDn=n8.5) cigarettes/day; 43.9% (549 of 1250) female; 60.6% (758 of 1250) white ethnicity.Interventions(1) Smoking cigarettes where nicotine content was immediately reduced to very low levels (nn=n503); (2) smoking cigarettes where nicotine content was gradually reduced, with dose changes occurring monthly (nn=n498); and (3) continued smoking with normal nicotine content cigarettes (nn=n249).MeasurementsSmokers were assessed at baseline while smoking their usual brand cigarettes, and again at 4, 8, 12, 16 and 20nweeks. Outcomes were areas under the concentration time curve (AUC) for the period of study of biomarkers of inflammation, oxidative stress and hematological parameters.FindingsNo consistent significant differences were observed across groups (Bayes factors showing data to be insensitive), with the only exception being red blood cell size variability, which was observed to be lower in the immediate versus gradual nicotine reduction [mean differencen=nn-0.11; 95% confidence interval (CI)n=n-0.18, -0.04, Pn=n0.004] and normal nicotine control groups (mean differencen=n-n0.15, 95% CIn=n-0.23, -0.06, Pn=n0.001).ConclusionIt remains unclear whether switching to very low nicotine cigarettes leads to a short-term reduction in biomarkers of tobacco-related harm.

Objectives: Our objective was to provide data contrasting commercial tobacco retailing in Tribal versus non-Tribal jurisdictions, in 3 states. These data may be relevant for US Food and Drug Administration regulation of Tribal retailing. Methods: With Tribal permission, observations were made on commercial tobacco advertising, product variety, pricing, and retail concept for stores within and just outside Tribal jurisdictions in areas of Arizona (AZ), California (CA), and Oklahoma (OK). Results: A total of 87 Tribal (20 AZ, 53 CA, 14 OK) and 67 (10, 43, 14) non-Tribal retailer visits were completed. There was substantial variation across tribes, with sales in AZ and most CA Tribal jurisdictions handled at convenience stores, whereas OK Tribal retailing was done mostly in specialized tobacco-specialty shops. Electronic cigarettes were ubiquitous across Tribal and non-Tribal outlets. Advertising and breadth of cigarette offerings was most extensive in the tobacco specialty retailers of Tribal OK. Surprisingly, Tribally manufactured cigarettes were found only at some CA Tribal retailers. Conclusions: Some Tribal commercial tobacco outlets actually price above their non-Tribal competitors and there is substantial variation in retailing strategy across Tribal jurisdictions. Tribal governments can continue to evaluate and reform commercial tobacco retailing so as to improve Tribal health.

This article presents a case study of a scientist–practitioner research network established by the National Cancer Institute’s State and Community Tobacco Control Research Initiative. While prior programs have focused on collaboration among scientists, a goal here was to encourage collaborations with non-university, practice-based partners. Two stages of analyses examine growth in the network and collaboration outcomes over a 2-year timeframe. First, visual and descriptive analyses were used to assess the network’s structure and characteristics. Second, regression modeling was used to assess the relationship between investigator characteristics on active collaboration with non-university partners in research and coauthorship. Network analysis revealed an increasing number of connections, low and decreasing density, increasing centralization and select individuals with high degree and betweenness centralities. Investigator seniority and experience did not predict the active partner connections. Rather, scientists’ betweenness centrality, or the extent to which they acted as bridges across the network, was the key predictor of collaboration. This finding suggests a novel way for dissemination-focused research programs to identify super-connector investigators to foster practitioner linkages.

Background Patient medical records are an objective tool for the systematic identification and treatment of tobacco users. The aim of this study was to assess brief intervention tobacco cessation activities documented by physicians in some select tertiary hospitals in Nigeria. Methods We conducted a cross-sectional descriptive study using information obtained from 1588 randomly selected patient records in six teaching hospitals participating in a study to capacitate physicians to deliver brief advice. Trained data collectors collected data using a uniform checklist prior to the training of the physicians in these hospitals. Results Of the audited health records, 33.1% of patients had documentation of physicians' inquiry of their tobacco use mostly during out-patient clinics (37%) and by a resident doctor/medical officer (42.9%). Among identified tobacco users, it was documented that 12.9% were offered some form of tobacco cessation advice; readiness to quit was recorded in 2.6%; assistance with quitting was documented for 1.5% of tobacco users, while only 0.8% showed documentation of patient follow-up. Males and patients admitted to the hospital were 1.86 times and 2.14 times respectively more likely to have records of physicians' inquiry of their tobacco use. Patients who had tobacco-related morbidities and the unemployed were also more likely to have records of inquiry of their tobacco use. Conclusions There was poor documentation of tobacco use by physicians in these hospitals and many opportunities for brief intervention activities were missed. Efforts to educate the physicians on the importance of documenting tobacco use in clinical notes are recommended. Implications This study provides empirical evidence showing that there is poor documentation of tobacco use inquiry and brief intervention among physicians in tertiary hospitals in Nigeria. Records showing implementation of the 5A's were abysmally low and opportunities for brief intervention may have been missed. In line with the World Health Organization recommendations of Article 14 of the Framework Convention on Tobacco Control, efforts to promote brief intervention among physicians in tertiary hospitals in Nigeria should include an emphasis on appropriate documentation of tobacco control interventions in patient clinical notes.

BACKGROUND Stopping the epidemic of e-cigarette use among youth has become the common goal of both regulatory authorities and health departments. JUUL is currently the most popular e-cigarette brand on the market. Young people usually obtain and exchange information about JUUL with the help of social media platforms. Along with the rising prevalence of JUUL, posts about underage JUUL buying and selling have appeared on social media platforms such as Reddit, which sharply increase the risk of minors being exposed to JUUL. OBJECTIVE This study aims to analyze Reddit messages about JUUL buying and selling among the users of the UnderageJuul subreddit, and to further summarize the characteristics of those messages. The findings and insights can contribute to a better understanding of the patterns of underage JUUL use, and help public health officials provide timely education and guidance to minors who have intentions of accessing JUUL. METHODS We used a novel cross-subreddit method to analyze the Reddit messages on 2 subreddits. From July 9, 2017, to January 7, 2018, we collected data from the UnderageJuul subreddit, which was created for underage JUUL use discussion. The data set included 716 threads, 2935 comments, and 844 Reddit users (ie, Redditors). We collected our second data set, comprising 23,840 threads and 162,106 comments posted between July 9, 2017, and January 8, 2019, from the JUUL subreddit. We conducted analyses including the following: (1) annotation of users with buying/selling intention, (2) posting patterns discovery and topic comparison, and (3) posting activeness observation of discovered Redditors. Term frequency–inverse document frequency and regular expression-enhanced keyword search methods were applied during the content analysis to extract the posting patterns. The public posting records of the discovered users on the JUUL subreddit during the year after the UnderageJuul subreddit was shut down were analyzed to determine whether they were still active and interested in obtaining JUUL. RESULTS Our study revealed the following: (1) Among the 716 threads on the UnderageJuul subreddit, there were 214 threads related to JUUL sale and 168 threads related to JUUL purchase, which accounted for 53.5% (382/714) of threads. (2) Among the 844 Redditors of the UnderageJuul subreddit, 23.82% (201/844) of users were annotated with buying intention, and 21.10% (178/844) of users were annotated with selling intention. There were 34 users with buying/selling intention that self-reported as being CONCLUSIONS There were overlapping users active in the JUUL and UnderageJuul subreddits. The buying/selling-related content appeared in multiple venues with certain posting patterns from July 9, 2017, to January 7, 2018. Such content might lead to a high risk of health problems for minors, such as nicotine addiction. Based on these findings, this study provided some insights and suggestions that might contribute to the decision-making processes of regulators and public health officials.

BACKGROUND: Cannabis concentrates, which are cannabis plant extracts that contain high concentrations of Δ-9-tetrahydrocannbinol (THC), have become increasingly popular among adults in the United States. However, no studies have reported on the prevalence or correlates of cannabis concentrate use in adolescents, who, as a group, are thought to be particularly vulnerable to the harms of THC. METHODS: Participants are a racially and ethnically diverse group of 47 142 8th-, 10th-, and 12th-grade students recruited from 245 schools across Arizona in 2018. Participants reported on their lifetime and past-month marijuana and cannabis concentrate use, other substance use, and risk and protective factors for substance use problems spanning multiple life domains (ie, individual, peer, family, school, and community). RESULTS: Thirty-three percent of all 8th-, 10th-, and 12th-graders reported lifetime cannabis use, and 24% reported lifetime concentrate use. Seventy-two percent of all lifetime cannabis users had used concentrates. Relative to adolescent cannabis users who had not used concentrates, adolescent concentrate users were more likely to use other substances and to experience more risk factors, and fewer protective factors, for substance use problems across numerous life domains. CONCLUSIONS: Most adolescent cannabis users have used concentrates. Based on their risk and protective factor profile, adolescent concentrate users are at higher risk for substance use problems than adolescent cannabis users who do not use concentrates. Findings raise concerns about high-risk adolescents’ exposure to high-THC cannabis.

The research reported here is an analysis of the evolution of the relationships that comprise a single public health network, focusing especially on the position of the network administrative organization (Provan and Kenis 2008) in the flow of knowledge among a large number of organizations providing similar services. Our study examines the North American Quitline Consortium (NAQC), a multi-sector network that spans the US and Canada and whose members provide telephone-based tobacco cessation services to anyone interested in quitting smoking. Data were collected using web-based surveys at three different points of time. Implications are discussed for network organizing, for both theory and practice, focusing especially on the importance of the network administrative organization in shaping the evolution of the whole network information flow.

Many American Indian (AI) healers are faced with a dilemma of how to maintain the ceremonial uses of traditional tobacco meant to encourage the restoration and balance of mind, body, and spirit, while discouraging commercial tobacco use and protecting against secondhand smoke exposure in ceremonial settings. To explore this dilemma and offer culturally informed solutions, researchers conducted qualitative interviews with Navajo healers who describe the history and role of commercial tobacco within ceremonial contexts. Healers understand the importance of their role on their community's health and expressed deep concern about the use of commercial tobacco in the ceremonial setting. Healers play an important role in curbing the use of commercial tobacco and limiting the exposure to secondhand smoke in ceremonial settings and beyond. Study implications include the importance of understanding traditional and cultural knowledge and its potential as a pathway to solve contemporary public health issues facing AI communities.

The past few decades have produced significant improvement and advances in health, economic development and growth, and standards of living on a global scale. Major achievements in global health have produced greater life expectancy, enhanced maternal and child health, and reduced the spread and impact of infectious diseases. Yet major barriers to human health and development persist, with noncommunicable diseases (NCDs) now the major cause of death and disability (World Health Organization, The global burden of disease: 2004 update. World Health Organization, Geneva, 2008a). Noncommunicable diseases, including cancer, now account for more than half of all global mortality (Beaglehole et al., Lancet 377:1438–1447, 2011a) and are an increasing burden on the health and wealth of countries regardless of income or level of development. Some of the same social and economic changes that have heralded improvement and advances have also resulted in the risk factors for NCDs becoming widespread.

Objective: There is a lack of consensus on whether e-cigarettes facilitate or threaten existing tobacco prevention strategies. This uncertainty is reflected in organizations' conflicting e-cigarette position statements. We conducted a scoping review of position statements in published and gray literature to map the range and frequency of e-cigarette use recommendations. Methods: We collected 81 statements from international health organizations. Two coders independently performed qualitative content analysis to categorize e-cigarette recommendations. We explored differences based on organization type, geography, and the year recommendations were published. Results: We identified 5 recommendation types: encourage smokers to use ecigarettes as a cessation aid or as an alternative source of nicotine (N = 5); support individuals who use e-cigarettes to quit smoking (N = 20); avoid using until more research is available (N = 19); restrict access based on available evidence (N = 30); and prohibit e-cigarette marketing and sale (N = 7). Conclusion: Organizations presented diverse e-cigarette use recommendations. The variation related to organizations' differing tobacco prevention priorities and level of confidence in current e-cigarette research. These differences may create confusion. Additional research can examine whether this variability influences stakeholders' attitudes or behavior.

BACKGROUND The popularity of JUUL (an e-cigarette brand) among youth has recently been reported in news media and academic papers, which has raised great public health concerns. Little research has been conducted on the age distribution, geographic distribution, approaches to buying JUUL, and flavor preferences pertaining to underage JUUL users. OBJECTIVE The aim of this study was to analyze social media data related to demographics, methods of access, product characteristics, and use patterns of underage JUUL use. METHODS We collected publicly available JUUL-related data from Reddit. We extracted and summarized the age, location, and flavor preference of subreddit UnderageJuul users. We also compared common and unique users between subreddit UnderageJuul and subreddit JUUL. The methods of purchasing JUULs were analyzed by manually examining the content of the Reddit threads. RESULTS A total of 716 threads and 2935 comments were collected from the subreddit UnderageJuul before it was shut down. Most threads did not mention a specific age, but ages ranged from 13 years to greater than 21 years in those that did. Mango, mint, and cucumber were the most popular among the 7 flavors listed on JUUL’s official website, and 336 subreddit UnderageJuul threads mentioned 7 discreet approaches to circumvent relevant legal regulations to get JUUL products, the most common of which was purchasing JUUL from other Reddit users (n=181). Almost half of the UnderageJuul users (389/844, 46.1%) also participated in discussions on the main JUUL subreddit and sought information across multiple Reddit forums. Most (64/74, 86%) posters were from large metropolitan areas. CONCLUSIONS The subreddit UnderageJuul functioned as a forum to explore methods of obtaining JUUL and to discuss and recommend specific flavors before it was shut down. About half of those using UnderageJuul also used the more general JUUL subreddit, so a forum still exists where youths can attempt to share information on how to obtain JUUL and other products. Exploration of such social media data in real time for rapid public health surveillance could provide early warning for significant health risks before they become major public health threats.

Background The objective is to assess cardiovascular (CV), malignancy, infectious, graft outcomes and tacrolimus levels for the Indigenous patients compared to Whites after kidney transplant (KTx). Methods 165 Indigenous and 165 White patients matched for the KTx year at Mayo Clinic Arizona from 2007–2015 were studied over a median follow-up of 3 years. Propensity score was calculated to account for baseline differences. Results Compared to Whites, Indigenous patients had the following characteristics: younger age, more obesity, diabetes, hypertension, and required dialysis prior to KTx (p Conclusions Compared to Whites, Indigenous patients have similar CV events, graft outcomes and infectious complications after accounting for baseline differences.

The Framework Convention on Tobacco Control (FCTC) set standards for global tobacco control, including the implementation of evidence-based tobacco dependence treatment. However, efforts to implement tobacco treatment programmes globally have been few. In order to expand tobacco treatment expertise and programmes, a new network called Global Bridges (GB) was established. This network provided training in tobacco treatment and opportunities to share best practices on implementation of tobacco dependence treatment and training programmes. In this analysis of the GB network, we found that 75% of the network members attended trainings, 60% disseminated knowledge gained through GB training, and network centralization was high (0.85). These results demonstrate initial success in network implementation, and create a foundation for expanded focus on tobacco treatment globally.

INTRODUCTION Cigarette smoking is a known risk factor for postoperative complications. Quitting or cutting down on cigarettes around the time of surgery may reduce these risks. This study aimed to determine the feasibility of using electronic nicotine delivery systems (ENDS) to help patients achieve this goal, regardless of their intent to attempt long-term abstinence. METHODS An open-label observational study was performed of cigarette smoking adults scheduled for elective surgery at Mayo Clinic Rochester and seen in the pre-operative evaluation clinic between December 2014 and June 2015. Subjects were given a supply of ENDS to use prior to and 2 weeks after surgery. They were encouraged to use them whenever they craved a cigarette. Daily use of ENDS was recorded, and patients were asked about smoking behavior and ENDS use at baseline, 14 days and 30 days. RESULTS Of the 105 patients approached, 80 (76%) agreed to participate; five of these were later excluded. Among the 75, 67 (87%) tried ENDS during the study period. At 30-day follow-up, 34 (51%) who had used ENDS planned to continue using them. Average cigarette consumption decreased from 15.6 per person/d to 7.6 over the study period (P < .001). At 30 days, 11/67 (17%) reported abstinence from cigarettes. CONCLUSION ENDS use is feasible in adult smokers scheduled for elective surgery and is associated with a reduction in perioperative cigarette consumption. These results support further exploration of ENDS as a means to help surgical patients reduce or eliminate their cigarette consumption around the time of surgery. IMPLICATIONS Smoking in the perioperative period increases patients' risk for surgical complications and healing difficulties, but new strategies are needed to help patients quit or cut down during this stressful time. These pilot data suggest that ENDS use is feasible and well-accepted in surgical patients, and worthy of exploration as a harm reduction strategy in these patients.

Objective Adolescent overweight and obesity and smoking continue to be very important health challenges because of their lasting effects on overall health. Weight gain after smoking cessation is a barrier to quitting as well as a negative consequence to health. This study reports changes in the body mass index (BMI) z-scores of adolescent smokers participating in a dose-ranging clinical trial of bupropion SR (150 mg/day and 300 mg/day) for smoking cessation. Methods A total of N = 296 adolescent smokers (placebo n = 100, 150 mg/day n = 101, 300 mg/day n = 95) with a BMI z-score of 0.5 (sd: 1.4), 0.5 (sd: 1.3), and 0.5 (sd: 1.2) in the placebo, 150 mg/day, and 300 mg/day groups, respectively, were followed for 6 months. Results Adolescents in the 300 mg/day group had a significant reduction in BMI z-score 6 weeks after quitting (β = −0.16, CI = (−0.29, −0.04), P-value = 0.01). This result was not sustained at the 6-month follow-up. Conclusions A reduction in BMI z-score during smoking cessation with bupropion has important implications for the future of adolescent smoking cessation. These results are particularly relevant for adolescents who have either overweight or obesity or who have reservations about quitting for fear of gaining weight or BMI.

Background Stopping the epidemic of e-cigarette use among youth has become the common goal of both regulatory authorities and health departments. JUUL is currently the most popular e-cigarette brand on the market. Young people usually obtain and exchange information about JUUL with the help of social media platforms. Along with the rising prevalence of JUUL, posts about underage JUUL buying and selling have appeared on social media platforms such as Reddit, which sharply increase the risk of minors being exposed to JUUL. Objective This study aims to analyze Reddit messages about JUUL buying and selling among the users of the UnderageJuul subreddit, and to further summarize the characteristics of those messages. The findings and insights can contribute to a better understanding of the patterns of underage JUUL use, and help public health officials provide timely education and guidance to minors who have intentions of accessing JUUL. Methods We used a novel cross-subreddit method to analyze the Reddit messages on 2 subreddits. From July 9, 2017, to January 7, 2018, we collected data from the UnderageJuul subreddit, which was created for underage JUUL use discussion. The data set included 716 threads, 2935 comments, and 844 Reddit users (ie, Redditors). We collected our second data set, comprising 23,840 threads and 162,106 comments posted between July 9, 2017, and January 8, 2019, from the JUUL subreddit. We conducted analyses including the following: (1) annotation of users with buying/selling intention, (2) posting patterns discovery and topic comparison, and (3) posting activeness observation of discovered Redditors. Term frequency–inverse document frequency and regular expression-enhanced keyword search methods were applied during the content analysis to extract the posting patterns. The public posting records of the discovered users on the JUUL subreddit during the year after the UnderageJuul subreddit was shut down were analyzed to determine whether they were still active and interested in obtaining JUUL. Results Our study revealed the following: (1) Among the 716 threads on the UnderageJuul subreddit, there were 214 threads related to JUUL sale and 168 threads related to JUUL purchase, which accounted for 53.5% (382/714) of threads. (2) Among the 844 Redditors of the UnderageJuul subreddit, 23.82% (201/844) of users were annotated with buying intention, and 21.10% (178/844) of users were annotated with selling intention. There were 34 users with buying/selling intention that self-reported as being Conclusions There were overlapping users active in the JUUL and UnderageJuul subreddits. The buying/selling-related content appeared in multiple venues with certain posting patterns from July 9, 2017, to January 7, 2018. Such content might lead to a high risk of health problems for minors, such as nicotine addiction. Based on these findings, this study provided some insights and suggestions that might contribute to the decision-making processes of regulators and public health officials.

Background: On May 5, 2016, the U.S. Food and Drug Administration (FDA) finalized a rule extending its authority to all tobacco products, including e-cigarettes, cigars, hookah tobacco and pipe tobacco, among others, which aims to help protect Americans from the dangers of tobacco and nicotine, especially the youth. The policy can be seen as a new intervention and become a hot discussion topic among the users in Twitter. Objective: This paper aims to examine the tweets related to the FDA's new policy in the social media, and gain a systematic understanding of users' responses to the intervention and the regulation. Methods: A total of 13864 tweets related to the policy from May 1st, 2016 to May 31st, 2016 were collected and analyzed, the support and opposition viewpoints about the six aspects including Regulation, Health, Industry, Democracy, Science, and Children were summarized, the time-sequence co-occurrence pattern of high-frequency words and the analysis of retweet and user dissemination network were analyzed. Results: Tweets are classified into six broad themes: Regulation, Health, Children, Industry, Science, and Democracy, the number of tweets about the six themes is 7547, 2764, 1678, 795, 670, 45. There are more supports on Regulation, Health, Science, and Children, the ratio of support(opposition) on the four themes are 80.6%(19.4%), 74.9%(25.1%), 85.9%(14.1%), 75.8%(24.2%), respectively, as for the themes of industry and democracy, most users hold the opposing view. The co-occurrence frequencies of "vaping" and "vape", "stocks" and "bigTobacco", "vapingsaveslives" and "ivapeivote" are 328, 61, 104. A network with 222 retweets and 361 replies is constructed. Among the 361 replies, there are 62 negative replies accounting for 17.2%, 120 positive replies accounting for 33.2%, and 179 neutral replies accounting for 49.6%. It shows clearly that social media such as Twitter can be employed to gather valuable user feedback effectively and response on the government regulation.

To measure carbonyl emissions from a heated tobacco product (IQOS) in comparison with an e-cigarette (Nautilus Mini) and a commercial tobacco cigarette (Marlboro Red).Regular and menthol variants of the heated tobacco product were tested. A tank-type atomizer was tested with a tobacco-flavoured liquid at 10 and 14 W. Aerosol and smoke were collected in impingers containing 2,4-dinitrophenylhydrazine. Health Canada Intense and two more intense puffing regimens were used.Analytical laboratory in Greece.Carbonyl levels in the aerosol and smoke.At the Health Canada Intense regimen, heated tobacco products emitted 5.0-6.4 μg/stick formaldehyde, 144.1-176.7 μg/stick acetaldehyde, 10.4-10.8 μg/stick acrolein, 11.0-12.8 μg/stick propionaldehyde and 1.9-2.0 μg/stick crotonaldehyde. Compared with the tobacco cigarette, levels were on average 91.6% lower for formaldehyde, 84.9% lower for acetaldehyde, 90.6% lower for acrolein, 89.0% lower for propionaldehyde and 95.3% lower for crotonaldehyde. The e-cigarette emitted 0.5-1.0 μg/12 puffs formaldehyde, 0.8-1.5 μg/12 puffs acetaldehyde and 0.3-0.4 μg/12 puffs acrolein, but no propionaldehyde and crotonaldehyde. At more intense puffing regimens, formaldehyde was increased in heated tobacco products, but levels were three-fourfold lower compared with the tobacco cigarette. Based on the findings from Health Canada Intense puffing regimen, use of 20 heated tobacco sticks would result in approximately 85% to 95% reduced carbonyl exposure compared with smoking 20 tobacco cigarettes; the respective reduction in exposure from use of 5 g e-cigarette liquid would be 97% to99%.The IQOS heated tobacco product emits substantially lower levels of carbonyls than a commercial tobacco cigarette (Marlboro Red) but higher levels than a Nautilus Mini e-cigarette.

Background Nicotine replacement therapy (NRT) has been demonstrated to be an effective pharmacological treatment for smoking cessation, and most types of NRT have been approved as over-the-counter (OTC) medications. In an effort to create a fast-acting, flexible, and discreet NRT, a nicotine mouth spray (NMS) has been developed. This study was designed to assess the efficacy and safety of NMS in a naturalistic setting in the United States. Methods This was a multicenter, randomized, double-blind, placebo-controlled, parallel-group, 26-week study in 1198 smokers motivated to quit. The study was designed to resemble an OTC environment, and thus included limited intervention, limited motivational screening, and no behavioral support. The primary efficacy endpoint was carbon monoxide-verified, self-reported continuous abstinence from smoking from week 2 until week 6. The safety of NMS was assessed by measuring vital signs, visual mouth inspection, and collection of subject-reported adverse events (AEs). Results The percentage of subjects with carbon monoxide-verified continuous abstinence from week 2 to week 6 was statistically significantly greater in the NMS group compared with the placebo group (5.0% vs. 2.5%, p = .021). Statistically significant treatment effects for the NMS were maintained throughout the 26-week period. The study medications were generally well tolerated. The severity of AEs was similar for both treatment groups, and most AEs were of mild or moderate severity. Conclusions These study results demonstrate that the NMS is an effective and safe smoking cessation option for smokers motivated to quit, even in a naturalistic setting and without behavioral support. Implications This study demonstrated the safety, efficacy, and acceptability of an NMS in an OTC environment with no behavioral counseling or support. It provides an additional option for smokers motivated to quit. Trial registration ClinicalTrials.gov (number NCT02355665).

Objectives. We explored whether various key stakeholders considered cost sharing with state telephone-based tobacco cessation quitlines, because including tobacco cessation services as part of the required essential health benefits is a new requirement of the Patient Protection and Affordable Care Act (ACA). Methods. We analyzed qualitative data collected from interviews conducted in April and May of 2014 with representatives of state health departments, quitline service providers, health plans, and insurance brokers in 4 US states. Results. State health departments varied in the strategies they considered the role their state quitline would play in meeting the ACA requirements. Health plans and insurance brokers referred to state quitlines because they were perceived as effective and free, but in 3 of the 4 states, the private stakeholder groups did not consider cost sharing. Conclusions. If state health departments are going to initiate cost-sharing agreements with private insurance providers, then they will need to engage a broad array of stakeholders and will need to overcome the perception that state quitline services are free.

INTRODUCTION Research has documented growing availability and use of e-cigarettes in the United States over the last decade. METHODS We conducted a national panel survey of current adult cigarette smokers to assess attitudes, beliefs, and behaviors relating to e-cigarette use in the United States (N = 2,254). RESULTS Among current cigarette smokers, 20.4% reported current use of e-cigarettes on some days and 3.7% reported daily use. Reported reasons for e-cigarette use included: quit smoking (58.4%), reduce smoking (57.9%), and reduce health risks (51.9%). No significant differences in sociodemographic characteristics between e-cigarette users and nonusers were observed. Prior quit attempts were reported more frequently among e-cigarette users (82.8%) than nonusers (74.0%). Intention to quit was reported more frequently among e-cigarette users (64.7%) than nonusers (46.8%). Smokers intending to quit were more likely to be e-cigarette users than those not intending to quit (odds ratio [OR] = 1.90, CI =1.36-2.65). Those who used e-cigarettes to try to quit smoking (OR = 2.25, CI = 1.25-4.05), reduce stress (OR = 3.66, CI = 1.11-12.09), or because they cost less (OR = 3.42, CI = 1.64-7.13) were more likely to report decreases in cigarette smoking than those who did not indicate these reasons. Smokers who reported using e-cigarettes to quit smoking (OR = 16.25, CI = 8.32-31.74) or reduce stress (OR = 4.30, CI = 1.32-14.09) were significantly more likely to report an intention to quit than those who did not indicate those reasons for using e-cigarettes. CONCLUSIONS Nearly a quarter of smokers in our study reported e-cigarettes use, primarily motivated by intentions to quit or reduce smoking. These findings identify a clinical and public health opportunity to re-engage smokers in cessation efforts.

ObjectiveAs part of the Smoke-Free Illinois Act, smoking on the gambling floors of all commercial casinos in Illinois became prohibited. This study examined the effects of the Smoke-Free Illinois Act on casino admissions per-capita and real per-capita adjusted gross receipts using 18 years of data (10 years before and 8 years after the Illinois law went into effect).MethodsWe employed a difference-in-difference regression technique using monthly data for the states of Illinois, Indiana, Iowa and Missouri and control for numerous determinants expected to affect casino admissions and revenue.ResultsThe Smoke-free Illinois Act was found not to be a statistically significant determinant of per-capita casino admissions and of real per-capita gross adjusted receipts in all the models we estimated.ConclusionsThe estimates from this study clearly indicated that the Illinois law that banned smoking in casinos has had no significant negative economic consequences for casinos in terms of per-capita admissions or revenues.

This year marks the 50th anniversary of the 1964 Surgeon General's Report on Smoking and Health . This landmark publication found a definitive, causal link between smoking and lung cancer in men, and, along with the subsequent reports, spurred a series of important public health initiatives that

Tobacco use continues to be the leading preventable cause of mortality and morbidity in North America and Quitlines are one of the primary cessation resources available to assist tobacco users with quitting. Implementation of best practices is important to the success of quitlines, but unfortunately, it is a complex and elusive process often difficult to achieve. This study aims to better understand the implementation process by using qualitative methods to examine an evaluation practice in-depth and to elucidate the complex factors influencing its implementation and institutionalization in the North American Quitline network. Nineteen semi-structured interviews were conducted with decision-makers in the Quitline network. The interview data were analyzed using a thematic analysis approach, guided by a systems change framework. The findings suggest that a broad range of factors influenced implementation of the evaluation practice at different levels of the system. These factors included system norms, system resources and operations (i.e., policies), five key relationships (e.g., between the funder and service provider), and power placement in the system. Characteristics of the evaluation practice itself also influenced implementation and interacted with other factors in the system. This study demonstrates the complexity of implementing and institutionalizing evaluation in an inter-organizational network. It also demonstrates the value of using qualitative data to study implementation phenomena. The findings can be used to improve efforts to institutionalize evaluation in the Quitline network and inform future implementation research studies.

The network of North American quitlines is a loose confederation of telephone-based smoking cessation professionals, including smoking cessation counseling providers, funders, researcher and policy advocates. Each quitline has some leeway in the types of services it provides, and the purpose of this article is to identify factors that explain such choices. Representatives from quitline organizations responded to a survey regarding the importance of several items that were hypothesized to influence general intentions to adopt and implement new cessation methods. Results indicate that internal (to the quitline) constraints are positively associated with consensus processes and that implementation of practices in general was more likely if consensus processes were used. Unilateral decision making (one person within an organization makes decisions for the quitline on his/her own) was unrelated to either internal or external constraints and was negatively associated with adoption of quitline practices. Discussion focuses on factors that influence consensus decision-making processes beyond those investigated in the article.

Cigarette smoking has been implicated in causing many cancers and cancer deaths. There is mounting evidence indicating that smoking negatively impacts cancer treatment efficacy and overall survival. The NCCN Guidelines for Smoking Cessation have been created to emphasize the importance of smoking cessation and establish an evidence-based standard of care in all patients with cancer. These guidelines provide recommendations to address smoking in patients and outlines behavioral and pharmacologic interventions for smoking cessation throughout the continuum of oncology care.

Introduction Smokers are asking health practitioners for guidance about using e-cigarettes as an aid to quitting. Several studies have surveyed physicians. However, in North America many smokers seek help from telephone quitlines rather than physicians. The objective of the current study was to assess quitline counselors’ perceptions of e-cigarettes and what they tell callers about these products. Methods An online cross-sectional survey, conducted in 2014 with 418 quitline counselors in the U.S. and Canada, measured perceptions of e-cigarettes: (1) use as a quitting aid; (2) safety; (3) professional guidance given and organizational guidance received; (4) regulation. The response rate was 90.1%. Analyses included calculating standard errors and 95% confidence intervals around summary statistics. Results Nearly 70% of counselors believed that e-cigarettes are not effective quitting aids. Most believed e-cigarettes are addictive (87%) and that secondhand exposure to vapor is harmful (71%). Counselors reported that callers ask for advice about e-cigarettes, but few counselors recommended e-cigarettes (4%). Counselors (97%) reported being instructed by quitline employers to explain to clients that e-cigarettes are not FDA-approved; 74% were told to recommend approved quitting aids instead. Most counselors (> 87%) believed e-cigarettes should be regulated like cigarettes in terms of advertising, taxation, access by minors, and use in public places. Conclusions Quitline counselors view e-cigarettes as ineffective quitting aids, potentially dangerous, and in need of greater regulations. Counselors can influence how treatment seekers view e-cigarettes, therefore it is imperative that quitlines stay abreast of emerging data and communicate about these products in ways that best serve clients.

Introduction Indigenous worldviews and research approaches are fundamental to make meaning of complex health issues and increase the likelihood of identifying existing cultural protective factors that have contributed to the resilience and survival of Indigenous people worldwide. Objective We describe the process for applying the Dine (Navajo) paradigm of Są’ah Naaghai Bik9eh Hozhoo (SNBH), a belief system that guides harmonious living, and demonstrate how the application of SNBH enhances understanding of Navajo principles for well-being. Specifically, we juxtapose this analysis with a conventional qualitative analysis to illuminate and interpret Dine perspectives on the health and economic impact of commercial secondhand smoke and smoke-free policy. Methods Focus groups were conducted throughout Navajo Nation to assess the appeal and impact of several evidence-based messages regarding the health and economic impact of smoke-free policy. Results Dine perspectives have shifted away from family and cultural teachings considered protective of a smoke-free life, and struggle to balance the ethical and economics of respect for individual and collective rights to live and work in smoke-free environments. Conclusions Indigenous-centred approaches to public health research and policy analysis contribute to understanding the cultural knowledge, practices and beliefs that are protective of the health and well-being of Indigenous people.

There is strong evidence that cigarette smoking causes adverse outcomes in people with cancer. However, more research is needed regarding those effects and the effects of alternative tobacco products and of secondhand smoke, the effects of cessation (before diagnosis, during treatment, or during survivorship), the biologic mechanisms, and optimal strategies for tobacco dependence treatment in oncology. Fundamentally, tobacco is an important source of variation in clinical treatment trials. Nevertheless, tobacco use assessment has not been uniform in clinical trials. Progress has been impeded by a lack of consensus regarding tobacco use assessment suitable for cancer patients. The NCI-AACR Cancer Patient Tobacco Use Assessment Task Force identified priority research areas and developed recommendations for assessment items and timing of assessment in cancer research. A cognitive interview study was conducted with 30 cancer patients at the NIH Clinical Center to evaluate and improve the measurement items. The resulting Cancer Patient Tobacco Use Questionnaire (C-TUQ) includes “Core” items for minimal assessment of tobacco use at initial and follow-up time points, and an “Extension” set. Domains include the following: cigarette and other tobacco use status, intensity, and past use; use relative to cancer diagnosis and treatment; cessation approaches and history; and secondhand smoke exposure. The Task Force recommends that assessment occur at study entry and, at a minimum, at the end of protocol therapy in clinical trials. Broad adoption of the recommended measures and timing protocol, and pursuit of the recommended research priorities, will help us to achieve a clearer understanding of the significance of tobacco use and cessation for cancer patients. Clin Cancer Res; 22(8); 1907–13. ©2016 AACR.

Objectives. This study was designed to better understand how the network of quitlines in the North American Quitline Consortium (NAQC) interact and share new knowledge on quitline practices. Methods. Network relationship data were collected from all 63 publicly funded quitlines in North America, including information sharing, partner trust, and reputation. Results. There was a strong tendency for US and Canadian quitlines to seek information from other quitlines in the same country, with few seeking information from quitlines from the other country. Quitlines with the highest reputation tended to more centrally located in the network, but the NAQC coordinating organization is highly central to the quitline network—thus demonstrating their role as a broker of quitline information. Conclusions. This first “snapshot” of US and Canadian quitlines demonstrated that smoking cessation quitlines in North America are not isolated, but are part of an interconnected network, with some organizations more central than others. As quitline use expands with the inclusion of national toll-free numbers on cigarette packs, how quitlines share information to improve practice will become increasingly important.

Tobacco use is the primary avoidable cause of morbidity and premature mortality in the United States and is attributed to 435,000 deaths annually.1 According to the 2004 Surgeon General’s report, millions of future premature deaths linked to smoking can be prevented through a reduction in tobacco use and abstinence.2 First implemented in 1990, quitlines are widely cited as an effective method to deliver behavioral support for tobacco cessation in the United States.3–5 Most often free to callers, quitlines are telephone-based coaching programs that assist smokers in achieving abstinence. These behavioral support programs have several advantages over other cessation models in that they are convenient, can facilitate treatment progress quickly, have the potential to reinforce engagement through proactive counseling, and often follow a structured protocol to ensure quality of service.6 Despite the demonstrable efficacy, quitlines serve less than 2% of all tobacco users annually.7,8 Given the low reach of most quitlines and the need to attain sustained abstinence for those smokers who do call, research focusing on which mode of entry into quitlines leads to improved quit rates is crucial. Proponents of tobacco control have widely cited health care providers as an effective source of promotion and referrals to quitlines.9 Many smokers receive care from a health care provider annually,10,11 which uniquely positions him or her to act as a bridge between hard-toreach tobacco users and cessation treatment services.9 Moreover, the US Public Health Service (USPHS) guidelines emphasize the positive relationship between provider referrals, treatment enrollment rates, and by extension, quit rates.3 USPHS guidelines recommend that all providers implement the 5A’s during patient visits: (1) ask about tobacco use; (2) advise to quit; (3) assess willingness to quit; (4) assist in quit attempt; and (5) arrange for follow-up.3 A fundamental problem with the 5A’s, however, is that even though the first 2 steps of this process are frequently implemented,12,13 few smokers have reported further assistance from their health care providers.10,13,14 In response to infrequent implementation of the full 5A’s by health care providers, the Wisconsin Tobacco Quitline implemented in 2003 the first fax-to-quit program in the United States.15 In fax-to-quit programs (including Arizona’s QuitFax program), with permission from the patient, a smoker’s health care provider refers the smoker to the quitline via a fax form so that the quitline can implement the last 2 of the 5A’s (ie, assist in quit attempt and follow the progress of the smoker). The fax-to-quit model situates quitline services into existing health care delivery systems and relies upon trained health care staff and the integration of quitline referral systems into various practice settings in order to better facilitate smoking cessation.15 However, to date there are a dearth of published studies that compare the effectiveness of physician-initiated referrals that result from fax-to-quit programs with other sources of referrals such as quitline-initiated promotions (eg, direct mail, radio, television promotions) or client self-referrals. All quitline promotion types and referral sources are potential modes of entry for tobacco users into existing quitline treatment services. In many respects, as extensions of quitline services, these various modes of entry are best described as direct links to one of the 2 primary categories of proactive or reactive quitline services. Proactive cessation services consist of quitline-initiated first and/or follow-up contacts with clients (ie, outbound services). A reactive service, on the other hand, consists of contacts with quitline coaches solely initiated by clients (ie, inbound services). Most proactive quitlines offer both comprehensive tobacco cessation services through scheduled outbound calls as well as reactive assistance such as that when a tobacco user initiates calls for service.16 Research shows that the likelihood of success in quitting tobacco through the use of proactive telephone counseling services, such as those provided by quitlines, is greatly increased when compared with the use of minimal interventions such as self-help materials or brief advice.4 Meta-analysis of 13 randomized, controlled trials have demonstrated the efficacy of proactive interventions with results showing a 56% increase in quit rates when compared with other types of cessation efforts.4 In an effort to establish and disseminate best practices for tobacco cessation, the USPHS and the US Centers for Disease Control (CDC) both recommend proactive telephone counseling as a method to improve quit rates.16,17 Given the prevailing consensus within tobacco control communities on the need to expand cessation services through increased quitline reach,18,19 as well as the varied mechanisms employed to accomplish this task, a greater understanding of the most effective modes of entry into quitlines that are related to abstinence is critical. Hence, in order to inform the development of initiatives aimed at increasing quitline reach, smoking cessation, and abstinence, we analyzed differences in abstinence rates as a function of referral type to the Arizona Smoker’s Helpline (ASHLine).

Background Collaborative networks of health organizations have received a great deal of attention in recent years as a way of enhancing the flow of information and coordination of services. However, relatively little is known about how such networks are formed and evolve, especially outside a local, community-based setting. This article is an in-depth discussion of the evolution of the North American Quitline Consortium (NAQC). The NAQC is a network of U.S. and Canadian organizations that provide telephone-based counseling and related services to people trying to quit smoking. Methodology The research draws on data from interviews, documents, and a survey of NAQC members to assess how the network emerged, became formalized, and effectively governed. Findings The findings provide an understanding of how multiregional public health networks evolve, while building on and extending the broader literature on organizational networks in other sectors and settings. Specifically, we found that the network form that ultimately emerged was a product of the back-and-forth interplay between the internal needs and goals of those organizations that would ultimately become network members, in this case, state-, and provincial-level tobacco quitline organizations. We also found that network formation, and then governance through a network administrative organization, was driven by important events and shifts in the external environment, including the impact and influence of major national organizations. Practice implications The results of the study provide health care leaders and policy officials an understanding of how the activities of a large number of organizations having a common health goal, but spanning multiple states and countries, might be coordinated and integrated through the establishment of a formal network.

Tobacco product testing is a critical component of the Family Smoking Prevention and Tobacco Control Act (FSPTCA), which grants the Food and Drug Administration the authority to regulate tobacco products. The availability of methods and measures that can provide accurate data on the relative health risks across types of tobacco products, brands, and subbrands of tobacco products on the validity of any health claims associated with a product, and on how consumers perceive information on products toxicity or risks is crucial for making decisions on the product's potential impact on public health. These tools are also necessary for making assessments of the impact of new indications for medicinal products (other than cessation) but more importantly of tobacco products that may in the future be marketed as cessation tools.To identify research opportunities to develop empirically based and comprehensive methods and measures for testing tobacco and other nicotine-containing products so that the best science is available when decisions are made about products or policies.Literature was reviewed to address sections of the FSPTCA relevant to tobacco product evaluation; research questions were generated and then reviewed by a committee of research experts.A research agenda was developed for tobacco product evaluation in the general areas of toxicity and health risks, abuse liability, consumer perception, and population effects.A cohesive, systematic, and comprehensive assessment of tobacco products is important and will require building consensus and addressing some crucial research questions.

IMPORTANCE: The optimal temporal approach for reducing nicotine to minimally or nonaddictive levels in all cigarettes sold in the United States has not been determined. OBJECTIVES: To determine the effects of immediate vs gradual reduction in nicotine content to very low levels and as compared with usual nicotine level cigarettes on biomarkers of toxicant exposure. DESIGN, SETTING, AND PARTICIPANTS: A double-blind, randomized, parallel-design study with 2 weeks of baseline smoking and 20 weeks of intervention was conducted at 10 US sites. A volunteer sample of daily smokers with no intention to quit within 30 days was recruited between July 2014 and September 2016, with the last follow-up completed in March 2017. INTERVENTIONS: (1) Immediate reduction to 0.4 mg of nicotine per gram of tobacco cigarettes; (2) gradual reduction from 15.5 mg to 0.4 mg of nicotine per gram of tobacco cigarettes with 5 monthly dose changes; or (3) maintenance on 15.5 mg of nicotine per gram of tobacco cigarettes. MAIN OUTCOMES AND MEASURES: Between-group differences in 3 co-primary biomarkers of smoke toxicant exposure: breath carbon monoxide (CO), urine 3-hydroxypropylmercapturic acid (3-HPMA, metabolite of acrolein), and urine phenanthrene tetraol (PheT, indicator of polycyclic aromatic hydrocarbons) calculated as area under the concentration-time curve over the 20 weeks of intervention. RESULTS: Among 1250 randomized participants (mean age, 45 years; 549 women [44%]; 958 [77%] completed the trial), significantly lower levels of exposure were observed in the immediate vs gradual reduction group for CO (mean difference, −4.06 parts per million [ppm] [95% CI, −4.89 to −3.23]; P < .0055), 3-HPMA (ratio of geometric means, 0.83 [95% CI, 0.77 to 0.88]; P < .0055), and PheT (ratio of geometric means, 0.88 [95% CI, 0.83 to 0.93]; P < .0055). Significantly lower levels of exposure were observed in the immediate reduction vs control group for CO (mean difference, −3.38 [95% CI, −4.40 to −2.36]; P < .0055), 3-HPMA (ratio of geometric means, 0.81 [95% CI, 0.75 to 0.88]; P < .0055), and PheT (ratio of geometric means, 0.86 [95% CI, 0.81 to 0.92]; P < .0055). No significant differences were observed between the gradual reduction vs control groups for CO (mean difference, 0.68 [95% CI, −0.31 to 1.67]; P = .18), 3-HPMA (ratio of geometric means, 0.98 [95% CI, 0.91 to 1.06]; P = .64), and PheT (ratio of geometric means, 0.98 [95% CI, 0.92 to 1.04]; P = .52). CONCLUSIONS AND RELEVANCE: Among smokers, immediate reduction of nicotine in cigarettes led to significantly greater decreases in biomarkers of smoke exposure across time compared with gradual reduction or a control group, with no significant differences between gradual reduction and control.

Background: E-liquid is one of the main components in electronic nicotine delivery systems (ENDS). ENDS review comments could serve as an early warning on use patterns and even function to serve as an indicator of problems or adverse events pertaining to the use of specific e-liquids—much like types of responses tracked by the Food and Drug Administration (FDA) regarding medications. Objective: This study aimed to understand users’ “vaping” experience using sentiment opinion summarization techniques, which can help characterize how consumers think about specific e-liquids and their characteristics (eg, flavor, throat hit, and vapor production). Methods: We collected e-liquid reviews on JuiceDB from June 27, 2013 to December 31, 2017 using its public application programming interface. The dataset contains 27,070 reviews for 8058 e-liquid products. Each review is accompanied by an overall rating and a set of 4 aspect ratings of an e-liquid, each on a scale of 1-5: flavor accuracy, throat hit, value, and cloud production. An iterative dichotomiser 3 (ID3)-based influential aspect analysis model was adopted to learn the key elements that impact e-liquid use. Then, fine-grained sentiment analysis was employed to mine opinions on various aspects of vaping experience related to e-liquids. Results: We found that flavor accuracy and value were the two most important aspects that affected users’ sentiments toward e-liquids. Of reviews in JuiceDB, 67.83% (18,362/27,070) were positive, while 12.67% (3430/27,070) were negative. This indicates that users generally hold positive attitudes toward e-liquids. Among the 9 flavors, fruity and sweet were the two most popular. Great and sweet tastes, reasonable value, and strong throat hit made users satisfied with fruity and sweet flavors, whereas “strange” tastes made users dislike those flavors. Meanwhile, users complained about some e-liquids’ steep or expensive prices, bad quality, and harsh throat hit. There were 2342 fruity e-liquids and 2049 sweet e-liquids. There were 55.81% (1307/2342) and 59.83% (1226/2049) positive sentiments and 13.62% (319/2342) and 12.88% (264/2049) negative sentiments toward fruity e-liquids and sweet e-liquids, respectively. Great flavors and good vapors contributed to positive reviews of fruity and sweet products. However, bad tastes such as “sour” or “bitter” resulted in negative reviews. These findings can help businesses and policy makers to further improve product quality and formulate effective policy. Conclusions: This study provides an effective mechanism for analyzing users’ ENDS vaping experience based on sentiment opinion summarization techniques. Sentiment opinions on aspect and products can be found using our method, which is of great importance to monitor e-liquid products and improve work efficiency.

Executive Summary The evidence against tobacco use is clear, incontrovertible, and convincing; so is the need for urgent and immediate action to stem the global tide of tobacco-related death and suffering and to improve public health. The American Association for Cancer Research makes an unequivocal call to all who are concerned about public health to take the following immediate steps:Increase the investment in tobacco-related research, commensurate with the enormous toll that tobacco use takes on human health, to provide the scientific evidence to drive the development of effective policies and treatments necessary to dramatically reduce tobacco use and attendant disease.Develop new evidence-based strategies to more effectively prevent the initiation of tobacco use, especially for youth and young adults.Promote the further development of evidence-based treatments for tobacco cessation, including individualized therapies, and ensure coverage of and access to evidence-based behavioral and pharmacological treatments.Develop evidence-based strategies for more effective public communication to prevent, reduce, and eliminate tobacco use and to guide health policies and clinical practice.Develop effective, evidence-based policies to reduce disparities across the tobacco continuum among social groups and developed and developing nations.Implement to the fullest extent existing evidence-based, systems-wide tobacco control programs to prevent initiation and foster cessation. Adapt and implement appropriate approaches to reduce the growing burden of tobacco use in the developing world.Enhance and coordinate surveillance efforts, both in the United States and globally, to monitor tobacco products, tobacco use, and tobacco-related disease, including tobacco use in oncology clinical trials.Establish a comprehensive, science-based regulatory framework to evaluate tobacco products and manufacturers' claims.Promote research that addresses the following: the potential harms of current and new tobacco products; the impact of altering the levels of addictive components in tobacco products; the identification of risk and risk-reduction measures for current and former tobacco users; enhanced early detection methods for tobacco-related cancers; and effective treatments against tobacco-related cancers tailored to the unique effects of tobacco on cancer.Pursue domestic and international economic policies that support tobacco control.Urge the United States to ratify the World Health Organization Framework Convention on Tobacco Control. Foster global scientific efforts to support the Framework.Work together with stakeholders worldwide, including federal agencies, to develop and implement effective tobacco control strategies and to deter counter-tobacco control efforts by the tobacco industry. Only such concerted global actions by scientists, policymakers, and advocates together can prevent the invidious impact of tobacco, the use of which is cutting wide swathes of death and disease around the world. Cancer Res; 70(9); 3419–30. ©2010 AACR.

Much has been discussed and written about the purposes, outcomes and ethics related to tobacco industry funding of research.1–9 The issue is controversial because of tobacco industry funding mechanisms that have been used by the tobacco industry to gain credibility and to advance the industry’s interests, which may come at the expense of public health;6 at the same time others have argued that, given the scarcity of funding from other sources, tobacco industry support may be defensible, at least under some circumstances.10 These concerns raise the question of whether there could be a model of tobacco company funding that would be acceptable to the tobacco control research community. This paper presents a set of criteria for evaluating funding models and applies them to four diverse models. While tobacco consumption and prevalence rates have declined in many developed countries over the past 40 years, the projections are that worldwide tobacco-related deaths will increase in the 21st century.11 Despite the disproportionate toll tobacco use takes, there remains only a modest investment in research to better understand tobacco products, tobacco product marketing, addiction, treatment and consumer behaviour. For example, in the USA, where tobacco causes almost 30% of all cancer deaths, only 2.3% of the National Cancer Institute’s 2003 budget was spent on tobacco-related research funding.12 This level of research investment is inadequate relative to the magnitude of the damage caused by tobacco use.13 14 At the same time, the tobacco industry has funded tobacco and health related research at universities. In the current context of limited funding, individuals and institutions may welcome additional sources of support. However the evidence is now clear that the tobacco industry participated in a long-standing conspiracy to defraud the public regarding the health risks of smoking. In 2006, the …

Improving population health requires understanding and changing societal structures and functions, but countervailing forces sometimes undermine those changes, thus reflecting the adaptive complexity inherent in public health systems. The purpose of this paper is to propose systems thinking as a conceptual rubric for the practice of team science in public health, and transdisciplinary, translational research as a catalyst for promoting the functional efficiency of science. The paper lays a foundation for the conceptual understanding of systems thinking and transdisciplinary research, and will provide illustrative examples within and beyond public health. A set of recommendations for a systems-centric approach to translational science will be presented.

Recent epidemiologic data on the stabilization of adult and youth smoking rates underscore the need for vigorous research across the cancer control spectrum on tobacco use interventions. The steady decline in adult rates of smoking has stalled for the first time in 8 years, and certain race, ethnic, and population groups are disproportionately at risk to tobacco-related cancers because of disparities in tobacco use or access to effective interventions. Although substantial progress has been made across levels of basic through applied research, tobacco-control research across the discovery and delivery continuum must be accelerated to further reduce the cancer burden. Following a brief review of the prevalence and trends affecting tobacco use initiation and cessation, we identify and describe four domains of extraordinary research opportunities: genetics and gene-environment interactions, bioinformatics and health informatics, disparities and disproportionate risk, and prevention and treatment. Evolutionary scientific changes, like rapidly advancing technology and emphasis on the paradigm of team science research approaches, provide both a challenge as well as unparalleled opportunities for scientific advancement and public health progress. (Cancer Epidemiol Biomarkers Prev 2007;16(6):1077–80)

Clinicians are in a unique position to reduce cardiovascular morbidity and mortality by helping their patients quit smoking. At each visit, clinicians should document smoking status, provide strong and clear advice to quit, and recommend and prescribe pharmacotherapy for patients who are motivated to quit, which can double the odds of success. Effective pharmacotherapies include nicotine replacement, bupropion, and varenicline, which was recently approved by the Food and Drug Administration. Behavioral counseling to develop a quit plan and extended follow-up are critical to maximize quit rates but are rarely provided by clinicians due to time constraints and lack of expertise. As an alternative, the authors recommend referral to telephone quitlines that provide no-cost behavioral counseling by specialists. Hospitals should implement systemwide procedures to ensure that smokers are identified at admission and trained staff is available to provide smoking cessation consults that include a minimum of 20 minutes of inpatient counseling with follow-up for at least 1 month.