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Background: The German federal parliament is discussing the implementation of a comprehensive tobacco advertising ban and whether that ban should include alternative nicotine delivery systems (ANDSs), such as e‑cigarettes and tobacco heaters. It would be important to know which outcome the general population, and in particular the users of tobacco/ANDSs, would prefer., Objective: Assessing public support for a comprehensive advertising ban on ANDSs in the German population, and particularly in tobacco and ANDSs users., Material and Methods: The German Study on Tobacco Use ("Deutsche Befragung zum Rauchverhalten", DEBRA) is an ongoing, representative household survey of persons aged 14 years and older. Data from the June/July 2019 survey wave (n = 2019) were analysed. Participants were interviewed regarding their tobacco smoking status and ANDS use, sociodemographic factors, and their support of an advertising ban on ANDSs. Prevalence rates and associations (odds ratio, OR) between support and sociodemographic factors or use of tobacco/ANDSs are reported., Results: Of the population, 57.0% (95% confidence interval (95%CI) = 54.7-59.1%) support a ban on ANDS advertising; 11.1% (95%CI = 9.8-12.6%) reject it. There is support for the ban from 46.0% (95%CI = 42.2-49.9%) of current tobacco smokers and 42.7% (95%CI = 35.9-49.6%) of ANDS users. Ex-smokers show the highest rates of support (64.8%, 95%CI = 58.9-70.3%). Acceptance among never- and ex-smokers is higher than among current smokers (adjusted OR 2.06, 95%CI = 1.64-2.59 and OR 1.65, 95%CI = 1.23-2.21)., Conclusions: The majority of the German population supports a comprehensive advertising ban on ANDSs. Tobacco smokers and ANDS users are also more in favour of than against such a ban. Thus, only little resistance will be expected within the population if a comprehensive tobacco advertising ban, as currently discussed in parliament, includes e‑cigarettes and heated tobacco products.

Smoking worsens tuberculosis (TB) outcomes. Persons with TB who smoke can benefit from smoking cessation. We report findings of a multi-country qualitative process evaluation assessing barriers and facilitators to implementation of smoking cessation behaviour support in TB clinics in Bangladesh and Pakistan. We conducted semi-structured qualitative interviews at five case study clinics with 35 patients and 8 health workers over a period of 11 months (2017-2018) at different time points during the intervention implementation phase. Interviews were conducted by trained researchers in the native languages, audio-recorded, transcribed into English and analysed using a combined deductive-inductive approach guided by the Consolidated Framework for Implementation Research and Theoretical Domains Framework. All patients report willingness to quit smoking and recent quit attempts. Individuals' main motivations to quit are their health and the need to financially provide for a family. Behavioural regulation such as avoiding exposure to cigarettes and social influences from friends, family and colleagues are main themes of the interviews. Most male patients do not feel shy admitting to smoking, for the sole female patient interviewee stigma was an issue. Health workers report structural characteristics such as high workload and limited time per patient as primary barriers to offering behavioural support. Self-efficacy to discuss tobacco use with women varies by health worker. Systemic barriers to implementation such as staff workload and socio-cultural barriers to cessation like gender relations, stigma or social influences should be dealt with creatively to optimize the behaviour support for sustainability and scale-up.

Smoking prevalence in Germany remains high at approximately 28%. We assessed public support for tobacco legislation and associations between level of support and smoking and socio-demographic characteristics. Data from 2087 people were collected as part of the German Study on Tobacco Use ("DEBRA"): a nationally representative, face-to-face household survey. Public support was measured on total ban of sale, raising the minimum age for sales, taxation of tobacco industry sales, research into e-cigarettes, and ban of smoking in cars when children are present. Associations were assessed with multivariate logistic regression. Over 50% of the German population support taxing industry profits (57.3%) and assessing e-cigarettes as an aid to quit smoking (55.5%). Over 40% support raising the legal age of sale (43.1%), and 22.9% support a total ban on tobacco sales. A smoking ban in cars when children are present was most popular (71.5%), even among current smokers (67.0%). There is public support for stricter tobacco control measures in Germany. A smoking ban in cars when children are present could be a feasible policy to implement., Competing Interests: L.S. has received honoraria for talks, an unrestricted research grant, and travel expenses to attend meetings and workshops by pharmaceutical companies that make smoking cessation products (Pfizer, Johnson & Johnson), and has acted as paid reviewer for grant awarding bodies and as a paid consultant for health care companies. Other research has been funded by the government, a community-interested company (National Centre for Smoking Cessation), and charitable sources. J.B. has received unrestricted smoking cessation research funding from Pfizer. The other authors declare no conflicts of interest. The funding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results. All authors declare no financial links with tobacco companies or e-cigarette manufacturers or their representatives.

Background: Current data on tobacco use are a necessary prerequisite for the study of the implementation of tobacco control measures in the general population. The German Study on Tobacco Use (Deutsche Befragung zum Rauchverhalten, DEBRA) provides previously lacking data on key indicators of smoking behavior and on the consumption of new products such as e-cigarettes. The continual acquisition and accumulation of data permits the analysis of trends and precise statistical evaluation., Methods: Data were obtained by repeated face-to-face interviews, at 2-month intervals, of representative samples of approximately 2000 persons across Germany aged 14 years and above. For this article, data from 12 273 persons that were acquired in 6 waves of the survey (June/July 2016 to April/May 2017) were aggregated and weighted., Results: The one-year prevalence of current tobacco consumption was 28.3% (95% confidence interval: [27.5; 29.1]) in the overall survey population and 11.9% [8.9; 14.9] among persons under age 18. Higher tobacco consumption was correlated with lower educational attainment and lower income. 28.1% of the smokers had tried to quit smoking in the past year; the most commonly used method of quitting was e-cigarettes (9.1%). Brief physician advice or pharmacotherapy for smoking cessation were tried by 6.1% and 7.0%, respectively. 1.9% of the overall survey population but only 0.3% of persons who had never smoked were current consumers of e-cigarettes., Conclusion: Tobacco consumption is very high in Germany compared to other countries in Western and Northern Europe, and its distribution across the population is markedly uneven, with a heavy influence of socioeconomic status.

Introduction: Tuberculosis (TB) remains a significant public health problem in South Asia. Tobacco use increases the risks of TB infection and TB progression. The TB& Tobacco placebo-controlled randomised trial aims to (1) assess the effectiveness of the tobacco cessation medication cytisine versus placebo when combined with behavioural support and (2) implement tobacco cessation medication and behavioural support as part of general TB care in Bangladesh and Pakistan. This paper summarises the process and context evaluation protocol embedded in the effectiveness-implementation hybrid design., Methods and Analysis: We are conducting a mixed-methods process and context evaluation informed by an intervention logic model that draws on the UK Medical Research Council's Process Evaluation Guidance. Our approach includes quantitative and qualitative data collection on context, recruitment, reach, dose delivered, dose received and fidelity. Quantitative data include patient characteristics, reach of recruitment among eligible patients, routine trial data on dose delivered and dose received, and a COM-B ('capability', 'opportunity', 'motivation' and 'behaviour') questionnaire filled in by participating health workers. Qualitative data include semistructured interviews with TB health workers and patients, and with policy-makers at district and central levels in each country. Interviews will be analysed using the framework approach. The behavioural intervention delivery is audio recorded and assessed using a predefined fidelity coding index based on behavioural change technique taxonomy., Ethics and Dissemination: The study complies with the guidelines of the Declaration of Helsinki. Ethics approval for the study and process evaluation was granted by the University of Leeds (qualitative components), University of York (trial data and fidelity assessment), Bangladesh Medical Research Council and Bangladesh Drug Administration (trial data and qualitative components) and Pakistan Medical Research Council (trial data and qualitative components). Results of this research will be disseminated through reports to stakeholders and peer-reviewed publications and conference presentations., Trial Registration Number: ISRCTN43811467; Pre-results., Competing Interests: Competing interests: EK, KZ and AP received payment for clinical studies and educational activities from Pfizer. They received no funding from a cytisine producing pharmaceutical company. KS received a research grant from Pfizer (2015–2017) to study the effect of varenicline (a smoking cessation medicine) on waterpipe smoking cessation., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Tobacco smoking is the leading preventable cause of death worldwide, which makes it essential to stimulate smoking cessation. The financial cost of smoking cessation treatment can act as a barrier to those seeking support. We hypothesised that provision of financial assistance for people trying to quit smoking, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts. This is an update of the original 2005 review., Objectives: The primary objective of this review was to assess the impact of reducing the costs for tobacco smokers or healthcare providers for using or providing smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use or prescription of smoking cessation treatment, or both, and on the number of smokers making a quit attempt (quitting smoking for at least 24 hours). We also assessed the cost effectiveness of different financial interventions, and analysed the costs per additional quitter, or per quality-adjusted life year (QALY) gained., Search Methods: We searched the Cochrane Tobacco Addiction Group Specialised Register in September 2016., Selection Criteria: We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers, or both., Data Collection and Analysis: Two reviewers independently extracted data and assessed the quality of the included studies. We calculated risk ratios (RR) for individual studies on an intention-to-treat basis and performed meta-analysis using a random-effects model., Main Results: In the current update, we have added six new relevant studies, resulting in a total of 17 studies included in this review involving financial interventions directed at smokers or healthcare providers, or both.Full financial interventions directed at smokers had a favourable effect on abstinence at six months or longer when compared to no intervention (RR 1.77, 95% CI 1.37 to 2.28, I² = 33%, 9333 participants). There was no evidence that full coverage interventions increased smoking abstinence compared to partial coverage interventions (RR 1.02, 95% CI 0.71 to 1.48, I² = 64%, 5914 participants), but partial coverage interventions were more effective in increasing abstinence than no intervention (RR 1.27 95% CI 1.02 to 1.59, I² = 21%, 7108 participants). The economic evaluation showed costs per additional quitter ranging from USD 97 to USD 7646 for the comparison of full coverage with partial or no coverage.There was no clear evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%, 2311 participants).Full financial interventions increased the number of participants making a quit attempt when compared to no interventions (RR 1.11, 95% CI 1.04 to 1.17, I² = 15%, 9065 participants). There was insufficient evidence to show whether partial financial interventions increased quit attempts compared to no interventions (RR 1.13, 95% CI 0.98 to 1.31, I² = 88%, 6944 participants).Full financial interventions increased the use of smoking cessation treatment compared to no interventions with regard to various pharmacological and behavioural treatments: nicotine replacement therapy (NRT): RR 1.79, 95% CI 1.54 to 2.09, I² = 35%, 9455 participants; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%, 6321 participants; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65, I² = 75%, 9215 participants.There was evidence that partial coverage compared to no coverage reported a small positive effect on the use of bupropion (RR 1.15, 95% CI 1.03 to 1.29, I² = 0%, 6765 participants). Interventions directed at healthcare providers increased the use of behavioural therapy (RR 1.69, 95% CI 1.01 to 2.86, I² = 85%, 25820 participants), but not the use of NRT and/or bupropion (RR 0.94, 95% CI 0.76 to 1.18, I² = 6%, 2311 participants).We assessed the quality of the evidence for the main outcome, abstinence from smoking, as moderate. In most studies participants were not blinded to the different study arms and researchers were not blinded to the allocated interventions. Furthermore, there was not always sufficient information on attrition rates. We detected some imprecision but we judged this to be of minor consequence on the outcomes of this study., Authors' Conclusions: Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting. There was no clear and consistent evidence of an effect on smoking cessation from financial incentives directed at healthcare providers. We are only moderately confident in the effect estimate because there was some risk of bias due to a lack of blinding in participants and researchers, and insufficient information on attrition rates.

iOS and Android smartphone users may differ in ways that affect their use and likelihood of success when using a smoking cessation application (app). If so, it may be necessary to take the device type (iOS and Android) into account when designing smoking cessation apps and in studies evaluating app effectiveness. How do socio-demographic and smoking characteristics, potentially relevant to engagement and cessation outcomes, of the SF28 app users differ between those using the iOS version and those using the Android version? Data were collected between October 2013 and April 2015. The variables measured were age, gender, social grade, time since the most recent quit attempt, choice of medication use (nicotine replacement therapy or varenicline), weekly expenditure on cigarettes, cigarettes smoked per day, reason for using the app and quit date set. The alpha was set to p < 0.006 to adjust for multiple comparisons. A total of 1368 users were included in the analysis. iOS and Android device users were similar in terms of age, social grade, weekly expenditure on cigarettes and cigarettes smoked per day. Compared with Android users, iOS users were more likely to have downloaded the app for a serious quit attempt (74.3 versus 69.6%, p = 0.001), made a quit attempt within the last 12 months (59.6 versus 45.9%, p < 0.001) and set their quit date on the day of registration (61 versus 46.2%, p < 0.001). They were less likely to have used stop-smoking medication to support their quit attempt (31.5 versus 48.6%, p < 0.001). Differences between smokers using the iOS version of smoking cessation apps and those using the Android version may influence quit success.

Background: The prevalence of tobacco smoking in Germany is high (~27%). Monitoring of national patterns of smoking behaviour and data on the "real-world" effectiveness of cessation methods are needed to inform policies and develop campaigns aimed at reducing tobacco-related harm. In England, the Smoking Toolkit Study (STS) has been tracking such indicators since 2006, resulting in the adaptation of tobacco control policies. However, findings cannot be directly transferred into the German health policy context. The German Study on Tobacco Use (DEBRA: "Deutsche Befragung zum Rauchverhalten") aims to provide such nationally representative data., Methods/design: In June 2016, the study started collecting data from computer-assisted, face-to-face household interviews in people aged 14 years and older. Over a period of 3 years, a total of ~36,000 respondents will complete the survey with a new sample of ~2000 respondents every 2 months (=18 waves). This sample will report data on demographics and the use of tobacco and electronic (e-)cigarettes. Per wave, about 500-600 people are expected to be current or recent ex-smokers (<12 months since quitting). This sample will answer detailed questions about smoking behaviour, quit attempts, exposure to health professionals' advice on quitting, and use of cessation aids. Six-month follow-up data will be collected by telephone., Discussion: The DEBRA study will be an important source of data for tobacco control policies, health strategies, and future research. The methodology is closely aligned to the STS, which will allow comparisons with data from England, a country with one of the lowest smoking prevalence rates in Europe (18%)., Trial Registration: This study has been registered at the German Clinical Trials Register ( DRKS00011322 ) on 25th November 2016.

Background: Stimulating successful tobacco cessation among employees has multiple benefits. Employees who quit tobacco are healthier, more productive, less absent from work, and longer employable than employees who continue to use tobacco. Despite the evidence for these benefits of tobacco cessation, a successful method to stimulate employees to quit tobacco is lacking. The aim of this study is to evaluate whether adding a financial incentive to behavioral support (compared with no additional incentive) is effective and cost-effective in increasing abstinence rates in tobacco smoking employees participating in a smoking cessation group training., Methods/design: In this cluster-randomized trial employees in the intervention and control group both participate in a smoking cessation group training consisting of seven weekly counseling sessions of ninety minutes each. In addition to the training, employees in the intervention group receive a voucher as an incentive for being abstinent from smoking at the end of the training (€50), after three months (€50), after six months (€50), and after one year (€200). The control group does not receive any incentive. The primary outcome is carbon monoxide validated 12-month continuous abstinence from smoking (Russel's standard). Additionally, an economic evaluation is performed from a societal and an employer perspective., Discussion: The present paper describes the methods and design of this cluster-randomized trial in detail. We hypothesize that the financial incentive for abstinence in the form of vouchers increases abstinence rates over and above the group training. The results of this study can provide important recommendations for enhancement of employee tobacco cessation., Trial Registration: Dutch Trial Register: NTR5657 . First received 27-01-2016.

Background and Aims: Smartphone applications (apps) offer a potentially cost-effective and a wide-reach aid to smoking cessation. In 2012, a content analysis of smoking cessation apps suggested that most apps did not adopt behaviour change techniques (BCTs), which according to previous research had suggested would promote higher success rates in quitting smoking. This study examined whether or not, this situation had changed by 2014 for free smoking cessation apps available in the Apple App Store. It also compared the use of engagement and ease-of-use features between the two time points., Methods: 137 free apps available in the Apple App Sore in 2014 were coded using an established framework for the presence or absence of evidence-based BCTs, and engagement and ease-of-use features. The results from the 2014 data were compared with a similar exercise conducted on 83 free apps available in 2012., Results: BCTs supporting identity change, rewarding abstinence and advising on changing routines were less prevalent in 2014 as compared with 2012 (14.6% vs. 42.2%, 18.2% vs. 48.2%, and 17.5% vs. 24.1%, respectively). Advice on coping with cravings and advice on the use of stop-smoking medication were more prevalent in 2014 as compared with 2012 (27.7% vs. 20.5% and 14.6% vs 3.6%, respectively). The use of recognised engagement features was less common in 2014 than in 2012 (45.3% vs. 69.6%) while ease-of-use features remained very high (94.5% vs. 82.6%)., Conclusion: There was little evidence of improvement in the use of evidence-based BCTs in free smoking cessation iPhone-based apps between 2012 and 2014., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Smokers with chronic obstructive pulmonary disease (COPD) seem to be a special subgroup of smokers that have a more urgent need to quit smoking but might find it more difficult to do so. This study aimed to explore which justifications for tobacco smoking and experiences of quitting were commonly shared in smokers with and without COPD, and which, if any, were specific to smokers with COPD., Methods: In ten primary healthcare centres in the Netherlands, we conducted semi-structured, in-depth interviews in 10 smokers with and 10 smokers without COPD., Results: Three themes were generated: 'balancing the impact on health of smoking', 'challenging of autonomy by social interference', 'prerequisites for quitting'. All participants trivialized health consequences of smoking; those with COPD seemed to be less knowledgeable about smoking and health. Both groups of smokers found autonomy very important. Smokers with COPD were indignant about a perceived lack of empathy in their communication with doctors. Furthermore, smokers with COPD in particular had little faith in the efficacy of smoking cessation aids. Lastly, motivation for quitting was dominated by fluctuation and smokers with COPD specifically maintained that their vision of life was linked with quitting., Conclusions: The participants showed many similarities in their reasoning about smoking and quitting. The corresponding themes argue for a less paternalistic regime in the communication with smokers with attention required for the motivational stage and room made for smokers' own views, and with clear information and education. Furthermore, addressing social interactions, health perceptions and moral agendas in the communication with smokers with COPD may help to make smoking cessation interventions more suitable for them.

Introduction: Combining behavioural support and pharmacotherapy is most effective for smoking cessation and recommended in clinical guidelines. Despite that smoking cessation assistance from the general practitioner can be effective, dissemination of clinical practice guidelines and efforts on upskilling has not lead to the routine provision of smoking cessation advice among general practitioners. Intensive counselling from the practice nurse could contribute to better smoking cessation rates in primary care. However, the effectiveness of intensive counselling from a practice nurse versus usual care from a general practitioner in combination with varenicline is still unknown., Materials and Methods: A pragmatic randomized controlled trial was conducted comparing: (a) intensive individual counselling delivered by a practice nurse and (b) brief advice delivered by a general practitioner; both groups received 12-weeks of open-label varenicline. A minimum of 272 adult daily smoking participants were recruited and treated in their routine primary care setting. The primary outcome was defined as prolonged abstinence from weeks 9 to 26, biochemically validated by exhaled carbon monoxide. Data was analysed blinded according to the intention-to-treat principle and participants with missing data on their smoking status at follow-up were counted as smokers. Secondary outcomes included: one-year prolonged abstinence, short-term incremental cost-effectiveness, medication adherence, and baseline predictors of successful smoking cessation., Discussion: This trial is the first to provide scientific evidence on the effectiveness, cost-effectiveness, and potential mechanisms of action of intensive practice nurse counselling combined with varenicline under real-life conditions. This paper explains the methodology of the trial and discusses the pragmatic and/or explanatory design aspects., Trial Registration: Dutch Trial Register NTR3067., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The prevalence of tobacco smoking in patients with chronic obstructive pulmonary disease (COPD) is high. It is assumed that this group of smokers has more difficulties quitting than smokers without COPD. In order to increase the effectiveness of smoking cessation treatments in smokers with COPD it is important to identify any smoking-related factors which are specific to this group of smokers., Objective: To compare smokers with COPD with smokers without COPD regarding factors associated with tobacco smoking and quitting., Methods: We conducted a questionnaire survey in all smoking patients with a recorded diagnosis of COPD from a large Dutch primary health care network. We compared this group with twice as many age-, sex- and health care centre-matched smokers without COPD., Results: Respondents were 107 smokers with COPD and 86 smokers without COPD. The number of attempts to quit was similar in both groups but more smokers with COPD had ever used pharmacological, behavioural and alternative smoking cessation treatments. Furthermore, smokers with COPD more often received triggers to quit from their environment and from their general practitioner, and they were more concerned about, and aware of, the health risks of smoking. Importantly, smokers with COPD reported higher levels of depression and cigarette dependence and a lower self-efficacy to refrain from smoking than smokers without COPD., Conclusion: Smokers with COPD differ from smokers without COPD on several factors which are associated with tobacco smoking and quitting. Taking into account these differences may help to increase the effectiveness of smoking cessation treatments for the specific group of smokers with COPD., (© 2015 S. Karger AG, Basel.)

Objective: To estimate the "real-world" effectiveness of commonly used aids to smoking cessation in England by using longitudinal data., Patients and Methods: We conducted a prospective cohort study in 1560 adult smokers who participated in an English national household survey in the period from November 2006 to March 2012, responded to a 6-month follow-up survey, and made at least 1 quit attempt between the 2 measurements. The quitting method was classified as follows: (1) prescription medication (nicotine replacement therapy [NRT], bupropion, or varenicline) in combination with specialist behavioral support delivered by a National Health Service Stop Smoking Service; (2) prescription medication with brief advice; (3) NRT bought over the counter; (4) none of these. The primary outcome measure was self-reported abstinence up to the time of the 6-month follow-up survey, adjusted for key potential confounders including cigarette dependence., Results: Compared with smokers using none of the cessation aids, the adjusted odds of remaining abstinent up to the time of the 6-month follow-up survey were 2.58 (95% CI, 1.48-4.52) times higher in users of prescription medication in combination with specialist behavioral support and 1.55 (95% CI, 1.11-2.16) times higher in users of prescription medication with brief advice. The use of NRT bought over the counter was associated with a lower odds of abstinence (odds ratio, 0.68; 95% CI, 0.49-0.94)., Conclusion: Prescription medication offered with specialist behavioral support and that offered with minimal behavioral support are successful methods of stopping cigarette smoking in England., (Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Electronic cigarettes (e-cigarettes) are rapidly increasing in popularity. Two randomized controlled trials have suggested that e-cigarettes can aid smoking cessation, but there are many factors that could influence their real-world effectiveness. This study aimed to assess, using an established methodology, the effectiveness of e-cigarettes when used to aid smoking cessation compared with nicotine replacement therapy (NRT) bought over-the-counter and with unaided quitting in the general population., Design and Setting: A large cross-sectional survey of a representative sample of the English population., Participants: The study included 5863 adults who had smoked within the previous 12 months and made at least one quit attempt during that period with either an e-cigarette only (n = 464), NRT bought over-the-counter only (n = 1922) or no aid in their most recent quit attempt (n = 3477)., Measurements: The primary outcome was self-reported abstinence up to the time of the survey, adjusted for key potential confounders including nicotine dependence., Findings: E-cigarette users were more likely to report abstinence than either those who used NRT bought over-the-counter [odds ratio (OR) = 2.23, 95% confidence interval (CI) = 1.70-2.93, 20.0 versus 10.1%] or no aid (OR = 1.38, 95% CI = 1.08-1.76, 20.0 versus 15.4%). The adjusted odds of non-smoking in users of e-cigarettes were 1.63 (95% CI = 1.17-2.27) times higher compared with users of NRT bought over-the-counter and 1.61 (95% CI = 1.19-2.18) times higher compared with those using no aid., Conclusions: Among smokers who have attempted to stop without professional support, those who use e-cigarettes are more likely to report continued abstinence than those who used a licensed NRT product bought over-the-counter or no aid to cessation. This difference persists after adjusting for a range of smoker characteristics such as nicotine dependence., (© 2014 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Background and Aims: Nicotine vaccination has been proposed as a possible treatment to aid smoking cessation. First efficacy results of the nicotine vaccine 3'-AmNic-rEPA (NicVAX) showed that only a subgroup of the top 30% antibody responders achieved higher abstinence rates than placebo. The present study examined the efficacy of adding NicVAX versus placebo to varenicline and behavioural support as an aid in smoking cessation and relapse prevention., Design: Randomized placebo-controlled trial., Setting: Two research centres (Maastricht University Medical Centre and Slotervaart Hospital) in the Netherlands., Participants: A total of 558 smokers were assigned randomly to six injections with NicVAX (n = 278) or placebo (n = 280) both co-administered with open label varenicline and behavioural support., Measures: Outcomes were prolonged carbon monoxide-validated abstinence from weeks 9 to 52 (primary) and weeks 37 to 52 (secondary). We also performed a pre-planned subgroup analysis in the top 30% antibody responders., Findings: There was no difference in abstinence rates between NicVAX and placebo from weeks 9 to 52 [27.7 versus 30.0%, odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.62-1.29] or weeks 37 to 52 (33.8 versus 33.2%, OR = 1.03, 95% CI = 0.73-1.46). The top 30% antibody responders, compared to the placebo group, showed a non-significant tendency towards higher abstinence rates from weeks 37 to 52 (42.2 versus 33.2%, OR = 1.47, 95% CI = 0.89-2.42)., Conclusion: The nicotine vaccine, NicVAX, does not appear to improve the chances of stopping smoking when given in addition to varenicline and behavioural support., (© 2014 Society for the Study of Addiction.)

Background and Aims: There is a need for more evidence on the 'real-world' effectiveness of commonly used aids to smoking cessation from population-level studies. This study assessed the association between abstinence and use of different smoking cessation treatments after adjusting for key potential confounding factors., Design: Cross-sectional data from aggregated monthly waves of a household survey: the Smoking Toolkit Study., Setting: England., Participants: A total of 10 335 adults who smoked within the previous 12 months and had made at least one quit attempt during that time., Measurements: Participants were classified according to their use of cessation aids in their most recent quit attempt: (i) medication (nicotine replacement therapy, bupropion or varenicline) in combination with specialist behavioural support delivered by a National Health Service Stop Smoking Service; (ii) medication provided by the prescribing health-care professional without specialist behavioural support; (iii) nicotine replacement therapy (NRT) bought over the counter; and (iv) none of these. The main outcome measure was self-reported abstinence up to the time of the survey, adjusted for key potential confounders including tobacco dependence., Findings: Compared with smokers using none of the cessation aids, the adjusted odds of remaining abstinent up to the time of the survey were 3.25 [95% confidence interval (CI) = 2.05-5.15] greater in users of prescription medication in combination with specialist behavioural support, 1.61 (95% CI = 1.33-1.94) greater in users of prescription medication combined with brief advice and 0.96 (95% CI = 0.81-1.13) in users of NRT bought over the counter., Conclusions: After adjusting for major confounding variables such as tobacco dependence, smokers in England who use a combination of behavioural support and pharmacotherapy in their quit attempts have almost three times the odds of success than those who use neither pharmacotherapy nor behavioural support. Smokers who buy nicotine replacement therapy over the counter with no behavioural support have similar odds of success in stopping as those who stop without any aid., (© 2013 Society for the Study of Addiction.)

Background: A national smoking cessation campaign based on behaviour change theory and operating through both traditional and new media was launched across England during late 2012 ('Stoptober'). In addition to attempting to start a movement in which smokers would quit at the same time in response to a positive mass quitting trigger, the campaign set smokers the goal of being smoke-free for October and embodied other psychological principles in a range of tools and communications., Methods: Data on quit attempts were obtained from 31,566 past-year smokers during nationally representative household surveys conducted monthly between 2007 and 2012. The effectiveness of the campaign was assessed by the increase in national quit attempt rate in October relative to other months in 2012 vs. 2007-2011., Results: Relative to other months in the year, more people tried to quit in October in 2012 compared with 2007-2011 (OR=1.79, 95%CI=1.20-2.68). In 2012 there was an approximately 50% increase in quitting during October compared with other months of the same year (9.6% vs. 6.6%; OR=1.50, 95%CI=1.05-2.15), whereas in 2007-2011 the rate in October was non-significantly less than in other months of the same period (6.4% vs. 7.5%; OR=0.84, 95%CI=0.70-1.00). Stoptober is estimated to have generated an additional 350,000 quit attempts and saved 10,400 discounted life years (DLY) at less than £415 per DLY in the modal age group., Conclusions: Designing a national public health campaign with a clear behavioural target (making a serious quit attempt) using key psychological principles can yield substantial behaviour change and public health impact., (Copyright © 2013 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Background: There is paucity of data on the smoking habits of rural populations in developing countries. This study aimed to explore cigarette smoking practices of a rural community in Ethiopia., Methods: A community based cross-sectional study was conducted among 548 individuals from a random sample of households in a rural town and its surrounding rural districts. Descriptive statistics and logistic regression were performed., Results: Twenty-eight percent (95% CI: 24.3% - 31.6%) of the respondents were current smokers. A total of 105 (68%) smokers expressed an interest to quit while 37 (34%) had tried to quit previously but without success. There was high exposure to second-hand smoke: 285 (52%) homes allowed indoor smoking, and in 181 (33%) indoor smoking took place daily. Current smoking was strongly associated with male sex (OR = 83.0; 95% CI: 11.5 - 599.0), and being a student was found to be protective of smoking (OR = 0.04; 95% CI: 0.005 - 0.05)., Conclusion: Cigarette smoking is prevalent among the male rural town population in Ethiopia. In addition, a high level of exposure to indoor second-hand smoke exists. There is a need for investment in rural tobacco control, including educational campaigns and cost-effective smoking cessation services.

Background: Many different measures of motivation to stop smoking exist but it would be desirable to have a brief version that is standard for use in population surveys and for evaluations of interventions to promote cessation. The aim of this study was to assess the predictive validity and accuracy of the single-item Motivation To Stop Scale (MTSS)., Methods: This study is part of the "Smoking Toolkit Study;" a monthly survey of representative samples of the English population. We used data from 2483 respondents to the surveys from November 2008 to January 2011, who were smokers, used the MTSS, and were followed up 6 months later to provide information on quit attempts since baseline. The MTSS consists of one item with seven response categories ranging from 1 (lowest) to level 7 (highest level of motivation to stop smoking)., Results: A total of 692 smokers (27.9% (95% CI=26.1-29.6)) made an attempt to quit smoking between baseline and 6-month follow-up. The odds of quit attempts increased linearly with increasing level of motivation at baseline (p<0.001) and were 6.8 (95% CI=4.7-9.9) times higher for the highest level of motivation compared with the lowest. The accuracy of the MTSS for discriminating between smokers who did and did not attempt to quit was ROC(AUC)=0.67 (95% CI=0.65-0.70)., Conclusions: The MTSS provides strong and accurate prediction of quit attempts and is a candidate for a standard single-item measure of motivation to stop smoking. Further research should assess the external validity of this measure in different smoking populations., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: A potential new treatment in smoking cessation and relapse prevention is nicotine vaccination which is based on active immunization against the nicotine molecule. This immunization will elicit the immune system to produce nicotine-specific antibodies that sequester nicotine in the blood stream, after inhaling tobacco products. The resulting antibody-antigen is too large to cross the blood-brain barrier and is therefore postulated to attenuate the rewarding effect of nicotine by preventing the latter from reaching its receptors in the brain and causing the release of dopamine. The aim of this paper is to describe the design of a phase IIb, multi-center, double blind, randomized, placebo controlled trial to assess the efficacy of the nicotine vaccine NicVAX® co-administered with varenicline (Champix®) and intensive counseling as an aid in smoking cessation and relapse prevention., Methods/design: Two centers will include a total of 600 smokers who are motivated to quit smoking. At week -2 these smokers will be randomized, in a 1:1 ratio, to either 6 injections of NicVAX® or placebo, both co-administered with 12-weeks of varenicline treatment, starting at week 0. The target quit day will be set after 7 days of varenicline treatment at week 1. Smokers will be followed up for 54 weeks. The primary outcome is defined as biochemically validated prolonged smoking abstinence from week 9 to 52. Secondary outcomes include safety, immunogenicity, smoking abstinence from week 37 to 52, abstinence from week 9 to 24, abstinence in the subset of subjects with the highest antibody response, and lapse/relapse rate., Discussion: This is the first study to assess the efficacy of a nicotine conjugate vaccine in combination with an evidence-based smoking cessation pharmacotherapy (varenicline) to quit smoking. Although NicVAX® is primarily designed as an aid to smoking cessation, our study is designed to explore its potential to maintain abstinence and prevent relapse. The results of this trial will give a unique insight in the potential of nicotine vaccination for relapse prevention., Trial Registration: ClinicalTrials.gov: (NCT00995033).

Expired-air carbon monoxide (CO) is often used to validate self-reported nonsmoking in clinical settings and research studies. It sometimes occurs that a person reports to have quit smoking, whereas the CO measurement classifies him/her as a smoker. This commentary summarizes possible explanations for this discrepancy and briefly discusses what to do when there is reason to believe that the CO measurement is incorrect.

Background: We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts., Objectives: The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use and/or prescription of smoking cessation treatment and on the number of smokers making a quit attempt., Search Methods: We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2012., Selection Criteria: We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers or both., Data Collection and Analysis: Two reviewers independently extracted data and assessed the quality of the included studies. Risk ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random-effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives., Main Results: We found eleven trials involving financial interventions directed at smokers and healthcare providers.Full financial interventions directed at smokers had a statistically significant favourable effect on abstinence at six months or greater when compared to no intervention (RR 2.45, 95% CI 1.17 to 5.12, I² = 59%, 4 studies). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.11, 95% CI 1.04 to 1.32, I² = 15%) and use of smoking cessation treatment (NRT: RR 1.83, 95% CI 1.55 to 2.15, I² = 43%; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65). There was no evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%). Comparisons of full coverage with partial coverage, partial coverage with no coverage, and partial coverage with another partial coverage intervention did not detect significant effects. Comparison of full coverage with partial or no coverage resulted in costs per additional quitter ranging from $119 to $6450., Authors' Conclusions: Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting.  The absolute differences are small but the costs per additional quitter are low to moderate. We did not detect an effect on smoking cessation from financial incentives directed at healthcare providers. The methodological qualities of the included studies need to be taken into consideration when interpreting the results.

Aims: There is a growing interest in very low rate [fewer than one cigarette per day (CPD)] and light (one to nine CPD) smokers and in some parts of the world their numbers appear to be increasing. This paper examined changes in prevalence over the past 5 years, cessation patterns, and smoking and demographic characteristics of very low rate, light and moderate-to-heavy (10+ CPD) smokers in England., Design: Cross-sectional and longitudinal data from aggregated monthly waves of a household survey: the Smoking Toolkit Study., Setting: England., Participants: A total of 23,245 smokers interviewed between November 2006 and May 2011 and 4147 who provided data at 6-month follow-up., Measurements: We compared the demographic and smoking characteristics between the three groups of smokers at baseline, and the rate of attempts to quit, use of aids to cessation and success of quit attempts at follow-up., Findings: Very low rate smoking remained extremely rare (1.9% of smokers in 2006 to 2.8% in 2011), but light smoking became increasingly common (23.9-32.8%). Compared with moderate-to-heavy smokers, very low rate and light smokers were younger, more often female and from a higher socio-economic background. They were more motivated to quit and enjoyed smoking less. During the 6-month follow-up period, light smokers, but not very low rate smokers, were more likely to attempt to quit than moderate-to-heavy smokers. When they tried to quit, very low rate and light smokers used aids to cessation less than moderate-to-heavy smokers but still used them to a substantial degree: 18%, 31% and 44% used over-the-counter nicotine replacement therapy in their most recent quit attempt for the three types of smoker, respectively. Even very low rate smokers had a substantial failure rate: 65% failed in their most recent quit attempt within 6 months., Conclusions: Very low rate (fewer than one cigarette per day) and light (one to nine cigarettes per day) smokers in England are at least as motivated to quit as heavier smokers. Although they use cessation medication less than heavier smokers and are more likely to succeed, they still use such medication and fail in quit attempts to a substantial degree., (© 2011 The Authors, Addiction © 2011 Society for the Study of Addiction.)

Most studies on lung function heritability have been conducted in smokers and non-smokers using cross-sectional study design. Smoking patterns may, however, confound the contribution of genetic factors. We investigated heritability of forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio longitudinally, excluding the effects of smoking. A sample of never smoking female twins (n = 374), aged 63-76 at baseline, answered health questionnaires and attended spirometry in years 2000 and 2003. Bivariate structural equation modeling, restricted to adequate spirometry performances (baseline n = 339, follow-up n = 252), was used to estimate genetic and environmental influences on consecutive measurements of FEV1, FVC, and FEV1/FVC. The best-fitting models included additive genetic and non-shared environmental effects. Heritability estimates of 32% and 36% for FEV1, 41% and 37% for FVC, while 46% and 16% for FEV1/FVC were found at baseline and at follow-up. Genetic correlation between FEV1 and FEV1/FVC heritability estimates approached unity, whereas correlation between FVC estimates was 0.80. Environmental correlations were 0.69 for FEV1, 0.62 for FVC, and 0.07 for FEV1/FVC. In never smokers, additive genetic and non-shared environmental effects explain the inter-individual variations in FEV1, FVC, and FEV1/FVC. One third of the variation in FEV1 and FVC is explained by genetic and two thirds by environmental effects. Between 2000 and 2003, environmental effects on FEV1/FVC changed, and the proportion of variance explained by environmental effects increased remarkably. Genetic effects on FEV1 and FEV1/FVC are common to consecutive measurements, whereas at follow-up, new genetic factors explained 14% of the observed variance in FVC.

Background: Case-finding of chronic obstructive pulmonary disease (COPD) using spirometry may deter people with normal lung function from stopping smoking. The objective of this study was to observe the percentage of smokers screened with normal lung function that quit smoking., Methods: As part of a study on early detection of COPD, 518 smokers were screened with normal lung function (post-bronchodilator FEV(1)/FVC ≥ 70%). They were invited for a follow-up measurement after an average of 2.4 years. Non-smoking was validated by carbon monoxide (<10 ppm), and respiratory health related quality of life was measured with the Clinical COPD Questionnaire (CCQ)., Results: A total of 255 participants were followed up (49%). The point prevalence rate of non-smoking at follow-up was 18% (N = 47), and 9% assuming that all non-respondents were smokers. This rate was not lower than the expected rate of quitting in the Dutch population (8-9%) and primary "care as usual" in smokers screened with abnormal lung function (10%; p > 0.05 for all comparisons). The average decline in post-bronchodilator FEV(1) was 26 mL/year, which was unrelated to smoking status at follow-up. Non-smokers showed a clinically meaningful and statistically significant (p < 0.001) improvement in CCQ respiratory symptoms (-0.96) and total score (-0.51)., Conclusions: Our results do not suggest that early detection of airflow limitation to motivate smoking cessation reduces the rate of quitting in smokers shown to have normal lung function. Such smokers should be advised to quit smoking on the grounds that they are likely to improve their respiratory health in the short term and reduce their risk for smoking related diseases in the long term., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: Spirometry for early detection of chronic obstructive pulmonary disease (COPD) and smoking cessation is criticised because of the potential negative effects of labelling with disease., Aim: To assess the effects of opinions of smokers with mild to moderate COPD on the effectiveness of spirometry for smoking cessation, the justification of early detection of airflow limitation in smokers and the impact of confrontation with COPD., Design: Qualitative study with data from a randomised controlled trial., Setting: General population of Dutch and Belgian Limburg., Methods: Semistructured ethical exit interviews were conducted with 205 smokers who were motivated to quit smoking and had no prior diagnosis of COPD but were detected with airflows limitation by means of spirometry. They received either (1) counselling, including labelling with COPD, plus with nortriptyline for smoking cessation, (2) counselling excluding labelling with COPD, plus nortriptyline for smoking cessation or (3) care as usual for smoking cessation by the general practitioner, without labelling with COPD., Results: Of the participants, 177 (86%) agreed or completely agreed that it is justified to measure lung function in heavy smokers. These participants argued that measuring lung function raises consciousness of the negative effects of smoking, helps to prevent disease or increases motivation to stop smoking. Most of the 18 participants who disagreed argued that routinely measuring lung function in smokers would interfere with freedom of choice., Conclusions: Labelling with disease is probably a less important issue in the discussion about the pros and cons of early detection of COPD.

Aims: To assess factors associated with the use of smoking cessation aids among smokers trying to quit in a country where these aids are widely available and free or cheap to access., Design: Cross-sectional household survey, the 'Smoking Toolkit Study'., Setting: England., Participants: A total of 3767 respondents who smoked and made at least one serious quit attempt in the past 12 months were interviewed from November 2006 to April 2008., Measurements: We analysed differences across socio-demographic and smoking characteristics in the use of nicotine replacement therapy (NRT) over the counter or on prescription, bupropion, varenicline, telephone support and the National Health Service Stop Smoking Service (NHS-SSS) which combines behavioural support with medication., Findings: More than half of smokers trying to quit (51.2%) had used any kind of treatment; 48.4% had used some form of medication but only 6.2% had used the NHS-SSS. The use of some form of smoking cessation treatment was higher in female than in male smokers [odds ratio (OR): 1.24, 95% confidence interval (CI): 1.08, 1.43] and increased with age (OR: 1.19, 95% CI: 1.14,1.25) and cigarettes smoked per day (OR = 1.05, 95% CI = 1.04,1.06). There was no association with social grade. Smokers who planned their quit attempt were more likely to have used all types of smoking cessation treatments, except for telephone support., Conclusions: In England, half of all attempts to quit smoking are aided by some form of pharmacological or behavioural treatment. However, the use of the most effective treatment option (the NHS-SSS) is low, despite it being free of charge. Factors associated with an increased use of aids to cessation were female sex, older age, more cigarettes smoked per day and planning a quit attempt. Research is needed into how to increase utilization rates, particularly among males and younger smokers.

Objective: Smokers from more deprived socioeconomic groups are less likely to become ex-smokers. This study examined how far this is attributable in England to a social gradient in quit attempts, use of aids to cessation and/or the success of quit attempts., Design: Cross-sectional household survey., Setting: England., Participants: 6950 respondents aged 16+ who had smoked in the past year, of whom 2983 had tried to stop in the past year and 469 reported having stopped at the time of the survey., Main Outcome Measures: Reported attempts to stop smoking in the past year; the use of stop-smoking medications (nicotine replacement therapy, bupropion or varenicline); use of behavioural support offered by the National Health Service Stop Smoking Services; current smoking status., Results: There was a large difference in success rates of quit attempts: 20.4% in social grade AB versus 11.4% in social grade E of those who made attempts were still not smoking by the time of the survey (p<0.001). However, there was no difference across social grades in the rate of attempts to stop (42.7% in social grade AB to 41.3% in E), use of medications to aid cessation (46.7% of those making quit attempts in AB to 50.9% in E) or use of NHS Stop Smoking Services (7.0% of those making quit attempts in AB to 4.8% in E)., Conclusions: Smokers in more deprived socioeconomic groups are just as likely as those in higher groups to try to stop and use aids to cessation but there is a strong gradient across socioeconomic groups in success, with those in the lowest group being half as likely to succeed compared with the highest. Determining the cause of, and counteracting, this gradient is paramount in reducing health inequalities.

The aim of the present study was to determine the external validity of a recently developed questionnaire for the identification of patients at increased risk of airflow limitation in smokers from the general population in the provinces of Dutch and Belgian Limburg (regions surrounding Maastricht, the Netherlands). As part of a study on the early detection of airflow limitation and subsequent smoking cessation treatment (International Standard Randomised Controlled Trial Number: 64481813), the recently developed chronic obstructive pulmonary disease (COPD) diagnostic questionnaire was used in current smokers aged 40-70 yrs, with a smoking history of >or=10 pack-yrs, who reported one or more respiratory symptom (cough, sputum production or dyspnoea), but who had no diagnosis of a respiratory disease (COPD or asthma). Spirometry performed according to American Thoracic Society/European Respiratory Society criteria served as a reference test. Of the 676 subjects who entered the analyses, 398 showed normal lung function and 278 had a diagnosis of COPD (post-bronchodilator forced expiratory volume in one second/forced vital capacity of <0.70). The ability of the COPD diagnostic questionnaire to discriminate between subjects with and without COPD was poor (area under the receiver operating characteristic curve of 0.65). In a high-risk population consisting of middle-aged current smokers with a smoking history of >or=10 pack-yrs, the chronic obstructive pulmonary disease diagnostic questionnaire is probably not useful as a diagnostic tool for the identification of patients with an increased risk of airflow limitation.

Study Objectives: To assess and compare the smoking cessation practices and smoking behavior of Dutch general practitioners (GPs), cardiologists, and lung physicians., Methods: We conducted questionnaire surveys among a random sample of 2000 Dutch GPs, all Dutch cardiologists (N=594), and all Dutch lung physicians (N=375)., Results: In total, 834 GPs (41.7%), 300 cardiologists (50.5%), and 258 lung physicians (68.8%) filled out and returned the questionnaire. The prevalence of current smokers was 8.2% among GPs, 4.3% among cardiologists, and 3.5% among lung physicians. Of the pharmacological aids for smoking cessation, physicians recommended bupropion most frequently, followed by nicotine patches and nicotine gum. More lung physicians recommended the use of these three aids (67.0%, 36.3% and 18.2%, respectively) than GPs (65.7%, 18.7% and 9.8%, respectively), and than cardiologists (31.6%, 19.7% and 13.2%, respectively). A higher proportion of lung physicians (69.3%) had referred at least one smoker to a nurse for smoking cessation treatment than cardiologists (25%), and than GPs (11.3%)., Conclusions: Based on this national survey, one may conclude that the prevalence of current smoking among Dutch physicians is relatively low and has further decreased since 1988. Dutch GPs, cardiologists, and lung physicians mainly use interventions for smoking cessation that are easy to administer and are not very time consuming. Furthermore, more lung physicians than GPs and cardiologists recommend the use of bupropion, nicotine patch, and nicotine gum. When designing interventions for smoking cessation, one should take into account that physicians are often reluctant to provide interventions which demand much time. Therefore, intensive counseling of smokers who want to quit smoking may be more feasible for trained non-physicians, such as nurses.

Recreational cannabidiol (CBD) is frequently promoted as a medicinal or therapeutic cannabis product worldwide. Nationwide population-based data on awareness and use of recreational CBD are currently lacking. This study estimates the prevalence of recreational CBD awareness and use among the population in Germany. It also explores potential associations with socio-demographic characteristics, tobacco smoking, and e-cigarette use. We used data from a cross-sectional household survey (German Study on Tobacco Use, DEBRA) fielded across two waves in October-November 2020 and February-March 2021. Data were collected using computer-assisted face-to-face interviews among participants aged ≥14 years (n = 4026). Outcome variables were CBD awareness (yes/no) and CBD ever use (yes/no). The sample was weighted to ensure representativeness of the prevalence estimates. Associations with socio-demographic variables, tobacco smoking, and e-cigarette use were assessed using multivariable logistic regression. Approximately half of the population in Germany (48.3%, 95% CI: 46.8-49.9) was aware of recreational CBD products, and 4.3% (95% CI: 3.7-5.0) had ever used them (including 1.1% current users). Awareness was associated with younger age, higher education levels, female sex, living in urban regions, no migration background, tobacco smoking, and e-cigarette use. Ever use was associated with higher education levels, living in urban regions, tobacco smoking, and e-cigarette use. Awareness of recreational CBD products is high but ever use is currently low in Germany. Given the uncertain legal framework regarding the marketing of recreational CBD products, the changing retail landscape, and potential harms of CBD use, structured monitoring is warranted for public health purposes. [ABSTRACT FROM AUTHOR]

Background: The federal government of Germany is planning to liberalize the recreational cannabis market for adults. We aimed to collect key baseline data on frequency of use, routes of administration, and co-use of cannabis and inhaled nicotine or tobacco products in the population. Methods: Based on data from a national survey of 9644 people aged >14 years, we analyzed self-reported use of cannabis in the past 12 months and preferred route of administration (single choice: smoked with tobacco; smoked without tobacco; inhaled without tobacco; consumed with food; consumed in another form). Results: The prevalence of past-year cannabis use was 4.6% (95% CI [4,2; 5,1%]), with higher rates among 14-24- (11.4%) and 25-39-year-olds (8.2%) as well as among co-users of inhaled nicotine or tobacco products, particularly waterpipe users (27.0%). Smoking cannabis with or without tobacco was the preferred route of administration, reported by 92.4% (95% CI [89,6; 94,6%]). It was most frequently reported by 14-24-year-olds and by co-users of inhaled nicotine or tobacco products. Conclusion: Smoking remains the predominant form of using cannabis--especially among younger users, who are at greatest risk of cannabis-related consequences. The true prevalence of cannabis use may have been underestimated in our study, however, as not all participants answered the questions on cannabis. Nevertheless, preventive and harm reduction efforts are needed to reduce the harm from using cannabis. Continuous monitoring is required to evaluate the effects of the forthcoming law changes in Germany. [ABSTRACT FROM AUTHOR]