The prevalence and mortality risks of PRISm and COPD in the United States from NHANES 2007-2012.

BACKGROUND: We estimated the prevalence and mortality risks of preserved ratio impaired spirometry (PRISm) and chronic obstructive pulmonary disease (COPD) in the US adult population. METHODS: We linked three waves of pre-bronchodilator spirometry data from the US National Health and Nutritional Examination Survey (2007-2012) with the National Death Index. The analytic sample included adults ages 20 to 79 without missing data on age, sex, height, BMI, race/ethnicity, and smoking status. We defined COPD (GOLD 1, 2, and 3-4) and PRISm using FEV1/FVC cut points by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). We compared the prevalence of GOLD stages and PRISm by covariates across the three waves. We estimated adjusted all-cause and cause-specific mortality risks by COPD stage and PRISm using all three waves combined. RESULTS: Prevalence of COPD and PRISm from 2007-2012 ranged from 13.1%-14.3% and 9.6%-10.2%, respectively. We found significant differences in prevalence by sex, age, smoking status, and race/ethnicity. Males had higher rates of COPD regardless of stage, while females had higher rates of PRISm. COPD prevalence increased with age, but not PRISm, which was highest among middle-aged individuals. Compared to current and never smokers, former smokers showed lower rates of PRISm but higher rates of GOLD 1. COPD prevalence was highest among non-Hispanic White individuals, and PRISm was notably higher among non-Hispanic Black individuals (range 31.4%-37.4%). We found associations between PRISm and all-cause mortality (hazard ratio [HR]: 2.3 95% CI: 1.9-2.9) and various cause-specific deaths (HR ranges: 2.0-5.3). We also found associations between GOLD 2 (HR: 2.1, 95% CI: 1.7-2.6) or higher (HR: 4.2, 95% CI: 2.7-6.5) and all-cause mortality. Cause-specific mortality risk varied within COPD stages but typically increased with higher GOLD stage. CONCLUSIONS: The prevalence of COPD and PRISm remained stable from 2007-2012. Greater attention should be paid to the potential impacts of PRISm due to its higher prevalence in minority groups and its associations with mortality across various causes including cancer.

Comparison of smoking prevalence in Canada before and after nicotine vaping product access using the SimSmoke model.

OBJECTIVES: The public health impact of nicotine vaping products (NVPs) is subject to complex transitions between NVP and cigarette use. To circumvent the data limitations and parameter instability challenges in modeling transitions, we indirectly estimate NVPs' impact on smoking prevalence and resulting smoking-attributable deaths using the SimSmoke simulation model. METHODS: Canada SimSmoke uses age- and sex-specific data on Canadian population, smoking prevalence and tobacco control policies. The model incorporates the impact of cigarette-oriented policies on smoking prevalence but not the explicit contribution of NVPs. The model was calibrated from 1999 to 2012, thereby projecting smoking prevalence before NVPs were widely used in Canada. The NVP impact on smoking prevalence is inferred by comparing projected 2012-2020 smoking trends absent NVPs to corresponding trends from two Canadian national surveys. We further distinguish impacts before and after NVPs became regulated in 2018 and more available. RESULTS: Comparing 2012-2020 survey data of post-NVP to SimSmoke projected smoking prevalence trends, one survey indicated an NVP-related relative reduction of 15% (15%) for males (females) age 15+, but 32% (52%) for those ages 15-24. The other survey indicated a 14% (19%) NVP-related smoking reduction for ages 18+, but 42% (53%) for persons ages 18-24. Much of the gain occurred since Canada relaxed NVP restrictions. NVP-related 2012-2020 smoking reductions yielded 100,000 smoking-attributable deaths averted from 2012 to 2060. CONCLUSION: Smoking prevalence in Canada, especially among younger adults, declined more rapidly once NVPs became readily available. The emergence of NVPs into the Canadian marketplace has not slowed the decline in smoking.

RéSUMé: OBJECTIFS: L'effet des produits de vapotage avec nicotine (PVN) sur la santé publique dépend des transitions complexes entre l'usage des PVN et l'usage de la cigarette. Pour contourner les problèmes du manque de données et de l'instabilité des paramètres dans la modélisation de ces transitions, nous avons estimé indirectement l'effet des PVN sur la prévalence du tabagisme et sur les décès attribuables au tabagisme qui en résultent à l'aide du modèle de simulation SimSmoke. MéTHODE: Le modèle SimSmoke pour le Canada utilise des données par âge et par sexe sur la population canadienne, la prévalence du tabagisme et les politiques antitabac. Il intègre l'effet des politiques axées sur la cigarette sur la prévalence du tabagisme, mais pas explicitement l'apport des PVN. Ce modèle a été étalonné de 1999 à 2012; il prédit donc la prévalence du tabagisme avant l'utilisation des PVN à grande échelle au Canada. Nous avons déduit l'effet des PVN sur la prévalence du tabagisme en comparant les tendances de consommation de tabac projetées pour 2012­2020 sans PVN aux tendances correspondantes de deux enquêtes nationales canadiennes. Nous établissons aussi une autre distinction entre les effets avant et après la réglementation des PVN en 2018 et leur plus grande disponibilité. RéSULTATS: Si l'on compare les données d'enquête de 2012­2020 post-PVN aux tendances de prévalence du tabagisme projetées par SimSmoke, une enquête fait état d'une baisse de 15 % (15 %) liée aux PVN chez les hommes (femmes) de 15 ans et plus, mais de 32 % (52 %) chez les 15 à 24 ans. L'autre enquête fait état d'une baisse du tabagisme de 14 % (19 %) liée aux PVN chez les 18 ans et plus, mais de 42 % (53 %) chez les 18 à 24 ans. Une grande partie de ce gain s'est produit depuis que le Canada a assoupli ses restrictions sur les PVN. Les baisses du tabagisme liées aux PVN survenues entre 2012 et 2020 donnent 100 000 décès attribuables au tabagisme évités entre 2012 et 2060. CONCLUSION: La prévalence du tabagisme au Canada, surtout chez les jeunes adultes, a baissé plus rapidement lorsque les PVN sont devenus facilement accessibles. L'émergence des PVN sur le marché canadien n'a pas ralenti la baisse du tabagisme.

The role of flavored electronic nicotine delivery systems in smoking cessation: A systematic review.

Background: Electronic nicotine delivery systems (ENDS) come in numerous flavors and may aid smoking cessation. This systematic review examines evidence on the role of ENDS flavors in smoking cessation. Methods: We searched EMBASE OVID, PsychInfo, and Medline databases for studies that: 1) examined cigarette cessation outcomes for persons using ENDS (intent, attempts, and success) and 2) reported results separated by respondent's ENDS flavor used. We extracted crude and adjusted odds ratios for associations between cessation outcomes and types of ENDS flavors used (nontobacco vs. tobacco/unflavored; nontobacco and nonmenthol vs. tobacco/unflavored and menthol). We did not consider cessation outcomes among people not using ENDS. We evaluated the evidence using the GRADE approach, focusing on consistency and reliability of findings across studies. Results: 29 studies met inclusion criteria, producing 36 odds ratios (ORs) comparing cessation outcomes across ENDS flavor groups. Three ORs examined quit intent, five examined quit attempts, and 28 examined quit success. Using GRADE, we reached Low levels of certainty that there was not an association between ENDS flavor use and intention to quit smoking or making a quit attempt. There were Very Low levels of certainty that nontobacco flavored versus tobacco/unflavored ENDS use was not associated with smoking cessation success, with similar findings for nonmenthol and nontobacco compared to tobacco and menthol flavored ENDS. Conclusion: The evidence about the role of different flavored ENDS use and smoking cessation outcomes is inconclusive, reflecting highly heterogeneous study definitions and methodological limitations. More high-quality evidence, ideally from randomized controlled trials, is required.

Eliciting Trade-Offs Between Equity and Efficiency: A Methodological Scoping Review.

OBJECTIVES: To identify differences in the approaches and results of studies that elicit equity-efficiency trade-offs that can inform equity-informative cost-effectiveness analysis for healthcare resource allocation. METHODS: We searched Ovid (Medline), EconLit, and Scopus prior to June 25, 2021. Inclusion criteria were: (1) peer-reviewed or (2) gray literature; (3) published in English; (4) survey-based; (5) parameterized a social welfare function to quantify inequality aversion or (6) elicited a trade-off in equity and efficiency characteristics of health interventions. Exclusion criteria were: (1) studies that did not conduct a trade-off or (2) theoretical studies. We abstracted details on study methods, results, and limitations. Studies were grouped by following approach: (1) social welfare function or (2) preference ranking and distributional weighting. We described findings separately for each approach category. RESULTS: Seventy-seven papers were included, 28 parameterized social welfare functions and 49 were classified as preference ranking and distributional weighting. Study methods were heterogeneous. Studies were conducted across 29 countries. Sample sizes and composition, survey methods and question framing varied. Preferences for equity were mixed. Across both approach categories: 39 studies were classified as clear evidence of inequality aversion; 33 found mixed evidence; and 4 had no evidence of aversion. Evidence of between and within-study heterogeneity was found. Preferences for equity may differ by gender, profession, political ideology, income, and education. CONCLUSIONS: Substantial variability in study methods limit the direct comparability of findings and their use in equity-informed cost-effectiveness analysis. Future researches using representative samples that explore within and between country heterogeneity is needed.

Chemical Profiles and Toxicity of Electronic Cigarettes: An Umbrella Review and Methodological Considerations.

BACKGROUND: Electronic cigarettes (ECs) are often marketed as a safer alternative to combustible tobacco products. The global EC market has rapidly expanded since their introduction, creating an urgent need for research describing the toxicity and chemical composition of ECs. We conducted an umbrella review to summarize the evidence from existing systematic reviews (SRs). METHODS: The search for SRs was conducted across four electronic databases through 25 January 2022. Methodological quality was assessed using the AMSTAR-2 quality appraisal tool. RESULTS: Twenty-five SRs were included in our umbrella review. Chemical profiles widely varied across studies included in the reviews, which was mainly attributed to the lack of standardized protocols investigating the constituents, and differences in EC devices and e-liquids tested. Metals were more abundant in some EC aerosols than cigarettes, while carbonyls were typically found at lower levels. There was consistent evidence of in vitro toxicity from EC aerosol and e-liquid exposure. AMSTAR-2 revealed important limitations across reviews. CONCLUSIONS: While most reviews concluded that ECs were likely less harmful than cigarettes, there was hesitancy to draw clear conclusions due to variable analytical procedures and inconsistent findings among the included studies. Future SRs with improved methodology and reporting are needed to adequately inform tobacco regulatory actions.

The actual and anticipated effects of restrictions on flavoured electronic nicotine delivery systems: a scoping review.

OBJECTIVE: To synthesize the outcomes of policy evaluations of flavoured electronic nicotine delivery systems (ENDS) restrictions. DATA SOURCES: PubMed, Scopus, Embase and Web of Science before May 3, 2022. STUDY SELECTION: Studies that report sales, behaviour, or compliance outcomes related to implemented or hypothetical ENDS flavour restrictions. DATA EXTRACTION: Restriction details, whether implemented or hypothetical, whether additional products were restricted, jurisdictional level, study locations, and outcomes classified by sales, behaviour, and compliance. DATA SYNTHESIS: We included 30 studies. Of those, 26 were conducted exclusively in the US, two in India, and two surveyed respondents in multiple countries, including the US. Twenty-one evaluated implemented restrictions, while nine considered hypothetical restrictions. Five studies evaluated product sales, 17 evaluated behaviour, and 10 evaluated compliance, with two studies reporting multiple outcomes. Two studies reported an increase and one a reduction in cigarette sales following restrictions, while three reported reductions in ENDS sales. Behavioural studies presented a mixed view of the impacts of regulations on ENDS and cigarette use. However, the use of disparate outcomes limits the comparability of studies. Studies of hypothetical restrictions suggest decreased ENDS use, increased cigarette use, and increased use of illicit markets. Studies of compliance with flavoured product restrictions that included ENDS found that 6-39% of stores sold restricted flavoured products post-restrictions. Online stores remain a potential source of restricted products. CONCLUSION: Our findings highlight the need for additional research on the impacts of ENDS restrictions. Research should further evaluate the impact of restrictions on youth and adult use of nicotine and tobacco products in addition to the effects of restrictions in countries beyond the US to enable a robust consideration of the harm-benefit trade-off of restrictions.

A Decision-Theoretic Public Health Framework for Heated Tobacco and Nicotine Vaping Products.

Markets for nicotine vaping products (NVPs) and heated tobacco products (HTPs) have grown as these products became positioned as harm-reduction alternatives to combusted tobacco products. Herein, we present a public health decision-theoretic framework incorporating different patterns of HTP, NVP, and cigarette use to examine their impacts on population health. Our framework demonstrates that, for individuals who would have otherwise smoked, HTP use may provide public health benefits by enabling cessation or by discouraging smoking initiation and relapse. However, the benefits are reduced if more harmful HTP use replaces less harmful NVP use. HTP use may also negatively impact public health by encouraging smoking by otherwise non-smokers or by encouraging initiation or relapse into smoking. These patterns are directly influenced by industry behavior as well as public policy towards HTPs, NVPs, and cigarettes. While substantial research has been devoted to NVPs, much less is known about HTPs. Better information is needed to more precisely define the health risks of HTPs compared to cigarettes and NVPs, the relative appeal of HTPs to consumers, and the likelihood of later transitioning to smoking or quitting all products. While our analysis provides a framework for gaining that information, it also illustrates the complexities in distinguishing key factors.

Health Effects of Electronic Cigarettes: An Umbrella Review and Methodological Considerations.

E-cigarettes are often marketed as a safer alternative to combustible cigarettes. However, their health effects, especially those associated with long-term use, remain largely uncertain. We conducted an umbrella review of the cardiopulmonary and carcinogenic risks of e-cigarette use, distinguishing between short-term and long-term health effects. The search for systematic reviews was conducted across four electronic databases through 25 January 2022. Methodological quality was assessed using the AMSTAR-2 quality appraisal tool. Seventeen systematic reviews, including five meta-analyses, were included in our umbrella review. There was a clear underreporting of e-cigarette devices and e-liquid types, e-cigarette and cigarette exposure, and the health and smoking status of study participants. Overall, the findings suggest that short-term use of e-cigarettes may be associated with acute cardiopulmonary risks, although to a lesser extent than cigarette use. Long-term e-cigarette use may have pulmonary/respiratory benefits in those who switch from chronic cigarette smoking, particularly in individuals with asthma and chronic obstructive pulmonary disease (COPD). Evidence on intermediate and long-term carcinogenic effects is lacking. This umbrella review underscores the urgent need for systematic reviews with better adherence to established reporting guidelines, consistent definitions of duration of e-cigarette use, a focus on newer devices, and accounting for the impacts of former or current smoking.

An analysis of cigarette sales during Poland's menthol cigarette sales ban: small effects with large policy implications.

BACKGROUND: In May 2020, the European Union Tobacco Products Directive mandated that EU member states, including Poland, ban the sale of menthol cigarettes. With menthol making up 28% of cigarette sales before the ban, Poland is the country with likely the largest menthol cigarette sales share in the world to ban their sale. We analyze how this ban changed the Polish tobacco market. METHODS: We use monthly NielsenIQ data (May 2018-April 2021) on sales of cigarettes and roll-your-own tobacco by menthol and standard flavor in eight regions of Poland. We set up a bite-style regression model controlling for pre-ban menthol share, climate, border opening status, and Apple movement data to estimate the effect of the May 2020 menthol ban. RESULTS: We find menthol cigarette sales fell at least 97% after the menthol cigarette ban across Poland and standard cigarette sales replaced them. Regression modeling indicates that total cigarette sales fell, after the ban, an average of 2.2 sticks per capita per month, equal to a 2.9% decline, however, results were not significant (P = 0.199). The bite component of our model reveals total cigarette sales did decline significantly in the regions with the highest pre-ban menthol sales shares. Roll-your-own tobacco sales increased by a statistically insignificant 0.03 stick-equivalents after the ban (P = 0.798). Product prices also fell in the wake of the menthol ban. CONCLUSIONS: In Poland, the EU state with the one of the largest pre-ban menthol shares, we find mixed evidence that the ban is working as intended.

Tobacco Couponing: A Systematic Review of Exposures and Effects on Tobacco Initiation and Cessation.

INTRODUCTION: Tobacco couponing continues to be part of contemporary tobacco marketing in the United States. We performed a systematic review of the evidence of tobacco product coupon receipt and redemption to inform regulation. AIMS AND METHODS: We searched EMBASE OVID and Medline databases for observational (cross-sectional and longitudinal) studies that examined the prevalence of tobacco coupon receipt and coupon redemption across different subpopulations, as well as studies of the association between coupon receipt and redemption with tobacco initiation and cessation at follow-up. We extracted unadjusted and adjusted odds ratios for the associations between coupon exposure (receipt, redemption) and tobacco use outcomes (initiation, cessation) and assessed each studies' potential risk of bias. RESULTS: Twenty-seven studies met the criteria for inclusion. Of 60 observations extracted, 37 measured coupon receipt, nine measured coupon redemption, eight assessed tobacco use initiation, and six assessed cessation. Tobacco product coupon receipt and redemption tended to be more prevalent among younger adults, women, lower education individuals, members of sexual and gender minorities, and more frequent tobacco users. Coupon receipt at baseline was associated with greater initiation. Coupon receipt and redemption at baseline were associated with lower cessation at follow-up among tobacco users. Results in high-quality studies did not generally differ from all studies. CONCLUSIONS: Tobacco product coupon receipt and redemption are often more prevalent among price-sensitive subpopulations. Most concerning, our results suggest coupon receipt may be associated with higher tobacco initiation and lower tobacco cessation. Couponing thereby increases the toll of tobacco use and could prove to be a viable public health policy intervention point. IMPLICATIONS: A systematic review was conducted of the scientific literature about the receipt, redemption, and effects on tobacco initiation and cessation of tobacco product couponing. This review found that tobacco coupons are more often received by price-sensitive persons and these coupons serve to increase tobacco initiation and decrease tobacco cessation. Policy efforts to address these consequences may help curb tobacco's harms and address health inequities.

The Use of Expert Elicitation among Computational Modeling Studies in Health Research: A Systematic Review.

BACKGROUND: Expert elicitation (EE) has been used across disciplines to estimate input parameters for computational modeling research when information is sparse or conflictual. OBJECTIVES: We conducted a systematic review to compare EE methods used to generate model input parameters in health research. DATA SOURCES: PubMed and Web of Science. STUDY ELIGIBILITY: Modeling studies that reported the use of EE as the source for model input probabilities were included if they were published in English before June 2021 and reported health outcomes. DATA ABSTRACTION AND SYNTHESIS: Studies were classified as "formal" EE methods if they explicitly reported details of their elicitation process. Those that stated use of expert opinion but provided limited information were classified as "indeterminate" methods. In both groups, we abstracted citation details, study design, modeling methodology, a description of elicited parameters, and elicitation methods. Comparisons were made between elicitation methods. STUDY APPRAISAL: Studies that conducted a formal EE were appraised on the reporting quality of the EE. Quality appraisal was not conducted for studies of indeterminate methods. RESULTS: The search identified 1520 articles, of which 152 were included. Of the included studies, 40 were classified as formal EE and 112 as indeterminate methods. Most studies were cost-effectiveness analyses (77.6%). Forty-seven indeterminate method studies provided no information on methods for generating estimates. Among formal EEs, the average reporting quality score was 9 out of 16. LIMITATIONS: Elicitations on nonhealth topics and those reported in the gray literature were not included. CONCLUSIONS: We found poor reporting of EE methods used in modeling studies, making it difficult to discern meaningful differences in approaches. Improved quality standards for EEs would improve the validity and replicability of computational models. HIGHLIGHTS: We find extensive use of expert elicitation for the development of model input parameters, but most studies do not provide adequate details of their elicitation methods.Lack of reporting hinders greater discussion of the merits and challenges of using expert elicitation for model input parameter development.There is a need to establish expert elicitation best practices and reporting guidelines.

Identifying Equitable Screening Mammography Strategies for Black Women in the United States Using Simulation Modeling.

BACKGROUND: Screening mammography guidelines do not explicitly consider racial differences in breast cancer epidemiology, treatment, and survival. OBJECTIVE: To compare tradeoffs of screening strategies in Black women versus White women under current guidelines. DESIGN: An established model from the Cancer Intervention and Surveillance Modeling Network simulated screening outcomes using race-specific inputs for subtype distribution; breast density; mammography performance; age-, stage-, and subtype-specific treatment effects; and non-breast cancer mortality. SETTING: United States. PARTICIPANTS: A 1980 U.S. birth cohort of Black and White women. INTERVENTION: Screening strategies until age 74 years with varying initiation ages and intervals. MEASUREMENTS: Outcomes included benefits (life-years gained [LYG], breast cancer deaths averted, and mortality reduction), harms (mammographies, false positives, and overdiagnoses), and benefit-harm ratios (tradeoffs) by race. Efficiency (benefits per unit resource), mortality disparity reduction, and equity in tradeoffs were evaluated. Equitable strategies for Black women were defined as those with tradeoffs closest to benchmark values for screening White women biennially from ages 50 to 74 years. RESULTS: Biennial screening from ages 45 to 74 years was most efficient for Black women, whereas biennial screening from ages 40 to 74 years was most equitable. Initiating screening 10 years earlier in Black versus White women reduced Black-White mortality disparities by 57% with similar LYG per mammogram for both populations. Selection of the most equitable strategy was sensitive to assumptions about disparities in real-world treatment effectiveness: The less effective treatment was for Black women, the more intensively Black women could be screened before tradeoffs fell short of those experienced by White women. LIMITATION: Single model. CONCLUSION: Initiating biennial screening in Black women at age 40 years reduces breast cancer mortality disparities and yields benefit-harm ratios that are similar to tradeoffs of White women screened biennially from ages 50 to 74 years. PRIMARY FUNDING SOURCE: National Cancer Institute at the National Institutes of Health.

An Expert Elicitation on the Effects of a Ban on Menthol Cigarettes and Cigars in the United States.

INTRODUCTION: The US Food and Drug Administration announced its intention to ban menthol in cigarettes. However, information is needed on how a federal ban would affect population health. AIMS AND METHODS: We conducted an expert elicitation to gauge the impact of a menthol cigarette and cigar ban in the United States. We developed and pilot tested a questionnaire that focused on tobacco use transitions of current smokers (age 18-24 menthol, age 35-54 menthol, and age 35-54 nonmenthol) and potential menthol smokers (age 12-24). Using a structured expert elicitation, we estimated mean net transitions under a ban from cigarette use to combustible tobacco product, smokeless tobacco, novel nicotine delivery product (NNDPs, such as e-cigarettes) use, or no tobacco use. RESULTS: Eleven experts provided responses. Of those ages 12-24 who would have initiated menthol cigarette use in the absence of a ban, the experts estimated that 41% would still initiate combustible products under a ban, while 18% would initiate with NNDPs and 39% would not initiate regular tobacco use. Combustible use by menthol smokers ages 35-54 was expected to decline by 20% postban relative to preban rates, half switching to NNDPs and half quitting all tobacco use. Menthol smokers ages 18-24 were expected to reduce combustible use by 30%, with 16% switching to NNDPs. Greater reductions in combustible use were estimated for African Americans across the three age groups. Negligible impacts were expected for current adult nonmenthol smokers. CONCLUSIONS: According to expert opinion, a menthol ban is expected to substantially reduce smoking initiation and combustible tobacco product use among current menthol smokers. IMPLICATIONS: The US Food and Drug Administration recently announced its intention to ban menthol in cigarettes, but information on the potential impact on smoking and other nicotine product use is limited. We conducted an expert elicitation to gauge the impact of a menthol cigarette and cigar ban in the United States. A panel of experts estimated that menthol smokers ages 35-54 would reduce combustible tobacco use by 20%, with half switching to e-cigarettes and half quitting all nicotine use. Larger reductions were expected at younger ages, and menthol smoking initiation was reduced by 59% with 18% instead using e-cigarettes. African Americans were expected to have greater reductions in combustible tobacco use than the rest of the population.

A comparison of tobacco product prevalence by different frequency of use thresholds across three US surveys.

BACKGROUND: With the increasing changes in tobacco use patterns, "current use" definition and the survey used may have important implications for monitoring population use trends. METHODS: Using three US surveys (2014/15 TUS-CPS, NHIS and PATH), we compared the adult (age 18+) prevalence of four product groups (cigarettes, other combustibles, smokeless tobacco, and e-cigarettes) based on three past 30-day frequency of use thresholds: 1+, 10+, and 25+ days. We also examined mutually exclusive single, dual, and polytobacco users as a percentage of total users for each product group. RESULTS: Regardless of threshold or product, the prevalence was higher in PATH followed by NHIS and TUS-CPS, in some cases by large percentages. The differences in cigarette and smokeless tobacco use prevalence in going from the 1+ to 10+ days and to the 25+ days threshold were minimal. Applying different frequency thresholds had the largest impact on other combustibles prevalence, with a 60% reduction with the 10+ days threshold and a 80% reduction with the 25+ days threshold, compared to the 1+ days threshold, followed by e-cigarettes with 40 and 60% reductions, respectively. The proportion of dual and polytobacco users decreased considerably when using the 10+ vs. the 1+ days threshold and polytobacco use was almost non-existent with the 25+ days threshold. CONCLUSION: The estimated prevalence of each tobacco product use depends largely on the survey and frequency of use threshold adopted. The choice of survey and frequency threshold merits serious consideration when monitoring patterns of tobacco use.

Cost-Effectiveness of Smoking Cessation Interventions in the Lung Cancer Screening Setting: A Simulation Study.

BACKGROUND: Guidelines recommend offering cessation interventions to smokers eligible for lung cancer screening, but there is little data comparing specific cessation approaches in this setting. We compared the benefits and costs of different smoking cessation interventions to help screening programs select specific cessation approaches. METHODS: We conducted a societal-perspective cost-effectiveness analysis using a Cancer Intervention and Surveillance Modeling Network model simulating individuals born in 1960 over their lifetimes. Model inputs were derived from Medicare, national cancer registries, published studies, and micro-costing of cessation interventions. We modeled annual lung cancer screening following 2014 US Preventive Services Task Force guidelines plus cessation interventions offered to current smokers at first screen, including pharmacotherapy only or pharmacotherapy with electronic and/or web-based, telephone, individual, or group counseling. Outcomes included lung cancer cases and deaths, life-years saved, quality-adjusted life-years (QALYs) saved, costs, and incremental cost-effectiveness ratios. RESULTS: Compared with screening alone, all cessation interventions decreased cases of and deaths from lung cancer. Compared incrementally, efficient cessation strategies included pharmacotherapy with either web-based cessation ($555 per QALY), telephone counseling ($7562 per QALY), or individual counseling ($35 531 per QALY). Cessation interventions continued to have costs per QALY well below accepted willingness to pay thresholds even with the lowest intervention effects and was more cost-effective in cohorts with higher smoking prevalence. CONCLUSION: All smoking cessation interventions delivered with lung cancer screening are likely to provide benefits at reasonable costs. Because the differences between approaches were small, the choice of intervention should be guided by practical concerns such as staff training and availability.

The actual and anticipated effects of a menthol cigarette ban: a scoping review.

BACKGROUND: The United States (US) Food and Drug Administration (FDA), under the 2009 Family Smoking Prevention and Tobacco Control Act, banned characterizing flavors in cigarettes; however, mentholated tobacco products were exempt. Since 2009, over 20 US jurisdictions and numerous countries around the world have extended this restriction to menthol. Currently, the FDA is reconsidering its position on a nation-wide menthol cigarette ban. However, the effects of such a ban remain unclear. We conducted a scoping review to explore the impact of a menthol cigarette ban on individual behaviors (initiation, cessation, and product switching), sales, and compliance. METHODS: We conducted a search of the international literature using PubMed, EBSCO, and Web of Science (to November 25, 2019). We retrieved articles relevant to the impacts of an implemented or hypothetical menthol ban. We also included studies of flavored tobacco product bans due to their potential relevance in gauging compliance and product substitutability. RESULTS: The search identified 493 articles, of which 24 were included. Studies examined the effects of implemented menthol bans (n = 6), hypothetical menthol bans (n = 12) and implemented flavor bans that exclude menthol (n = 6). Menthol bans were found to reduce sales and increase smoking cessation with only partial substitution for non-menthol cigarettes. US smokers' reactions to a hypothetical ban indicate that about 25-64% would attempt to quit smoking and 11-46% would consider switching to other tobacco products, including 15-30% to e-cigarettes. Flavor ban studies indicate reductions in initiation of 6%. Ban compliance was high, but studies indicate that the tobacco industry and retailers have attempted to circumvent their impact via packaging changes and online sales. CONCLUSION: Our review finds that extending the US cigarette flavor ban to menthol products would promote smoking cessation and reduce initiation. This evidence supports further action by the FDA towards mentholated tobacco products. However, few studies have been conducted in the vaping era.

Potential Impact of Cessation Interventions at the Point of Lung Cancer Screening on Lung Cancer and Overall Mortality in the United States.

INTRODUCTION: Annual lung cancer screening with low-dose computed tomography is recommended for adults aged 55 to 80 years with a greater than or equal to 30 pack-year smoking history who currently smoke or quit within the past 15 years. The 50% who are current smokers should be offered cessation interventions, but information about the impact of adding cessation to screening is limited. METHODS: We used an established lung cancer simulation model to compare the effects on mortality of a hypothetical one-time cessation intervention and annual screening versus annual screening only among screen-eligible individuals born in 1950 or 1960. Model inputs were derived from national data and included smoking history, probability of quitting with and without intervention, lung cancer risk and treatment effectiveness, and competing tobacco-related mortality. We tested the sensitivity of results under different assumptions about screening use and cessation efficacy. RESULTS: Smoking cessation reduces lung cancer mortality and delays overall deaths versus screening only across all assumptions. For example, if screening was used by 30% of screen-eligible individuals born in 1950, adding an intervention with a 10% quit probability reduces lung cancer deaths by 14% and increases life years gained by 81% compared with screening alone. The magnitude of cessation benefits varied under screening uptake rates, cessation effectiveness, and birth cohort. CONCLUSIONS: Smoking cessation interventions have the potential to greatly enhance the impact of lung cancer screening programs. Evaluation of specific interventions, including costs and feasibility of implementation and dissemination, is needed to determine the best possible strategies and realize the full promise of lung cancer screening.

Simulation of Chemotherapy Effects in Older Breast Cancer Patients With High Recurrence Scores.

BACKGROUND: Tumor genomic expression profile data are used to guide chemotherapy choice, but there are gaps in evidence for women aged 65 years and older. We estimate chemotherapy effects by age and comorbidity level among women with early-stage, hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancers and Oncotype DX scores of 26 or higher. METHODS: A discrete-time stochastic state transition simulation model synthesized data from population studies and clinical trials to estimate outcomes over a 25-year horizon for subgroups based on age (65-69, 70-74, 75-79, and 80-89 years) and comorbidity levels (no or low, moderate, severe). Outcomes were discounted at 3%, and included quality-adjusted life-years (QALYs), life-years, and breast cancer and other-cause mortality with chemoendocrine vs endocrine therapy. Sensitivity analysis tested the effect of varying uncertain parameters. RESULTS: Women aged 65-69 years with no or low comorbidity gained 0.16 QALYs with chemo-endocrine and reduced breast cancer mortality from 34.8% to 29.7%, for an absolute difference of 5.1%; this benefit was associated with a 12.8% rate of grade 3-4 toxicity. Women aged 65-69 years with no or low or moderate comorbidity levels, and women aged 70-74 years with no or low comorbidity had small chemotherapy benefits. All women aged 75 years and older experienced net losses in QALYs with chemo-endocrine therapy. The results were robust in sensitivity analyses. Chemotherapy had greater benefits as treatment effectiveness increased, but toxicity reduced the QALYs gained. CONCLUSION: Among women aged 65-89 years whose tumors indicate a high recurrence risk, only those aged 65-74 years with no or low or moderate comorbidity have small benefits from adding chemotherapy to endocrine therapy. Genomic expression profile testing (and chemotherapy use) should be reserved for women aged younger than 75 years without severe comorbidity.

Smoking cessation interventions for potential use in the lung cancer screening setting: A systematic review and meta-analysis.

OBJECTIVES: Current guidelines recommend delivery of smoking cessation interventions with lung cancer screening (LCS). Unfortunately, there are limited data to guide clinicians and policy-makers in choosing cessation interventions in this setting. Several trials are underway to fill this evidence gap, but results are not expected for several years. METHODS AND MATERIALS: We conducted a systematic review and meta-analysis of current literature on the efficacy of smoking cessation interventions among populations eligible for LCS. We searched PubMed, Medline, and PsycINFO for randomized controlled trials of smoking cessation interventions published from 2010-2017. Trials were eligible for inclusion if they sampled individuals likely to be eligible for LCS based on age and smoking history, had sample sizes >100, follow-up of 6- or 12-months, and were based in North America, Western Europe, Australia, or New Zealand. RESULTS: Three investigators independently screened 3,813 abstracts and identified 332 for full-text review. Of these, 85 trials were included and grouped into categories based on the primary intervention: electronic/web-based, in-person counseling, pharmacotherapy, and telephone counseling. At 6-month follow-up, electronic/web-based (odds ratio [OR] 1.14, 95% CI 1.03-1.25), in-person counseling (OR 1.46, 95% CI 1.25-1.70), and pharmacotherapy (OR 1.53, 95% CI 1.33-1.77) interventions significantly increased the odds of abstinence. Telephone counseling increased the odds but did not reach statistical significance (OR 1.21, 95% CI 0.98-1.50). At 12-months, in-person counseling (OR 1.28 95% CI 1.10-1.50) and pharmacotherapy (OR 1.46, 95% CI 1.17-1.84) remained efficacious, although the decrement in efficacy was of similar magnitude across all intervention categories. CONCLUSIONS: Several categories of cessation interventions are promising for implementation in the LCS setting.

Change in Survival in Metastatic Breast Cancer with Treatment Advances: Meta-Analysis and Systematic Review.

BACKGROUND: Metastatic breast cancer (MBC) treatment has changed substantially over time, but we do not know whether survival post-metastasis has improved at the population level. METHODS: We searched for studies of MBC patients that reported survival after metastasis in at least two time periods between 1970 and the present. We used meta-regression models to test for survival improvement over time in four disease groups: recurrent, recurrent estrogen (ER)-positive, recurrent ER-negative, and de novo stage IV. We performed sensitivity analyses based on bias in some studies that could lead earlier cohorts to include more aggressive cancers. RESULTS: There were 15 studies of recurrent MBC (N = 18 678 patients; 3073 ER-positive and 1239 ER-negative); meta-regression showed no survival improvement among patients recurring between 1980 and 1990, but median survival increased from 21 (95% confidence interval [CI] = 18 to 25) months to 38 (95% CI = 31 to 47) months from 1990 to 2010. For ER-positive MBC patients, median survival increased during 1990-2010 from 32 (95% CI = 23 to 43) to 57 (95% CI = 37 to 87) months, and for ER-negative MBC patients from 14 (95% CI = 11 to 19) to 33 (95% CI = 21 to 51) months. Among eight studies (N = 35 831) of de novo stage IV MBC, median survival increased during 1990-2010 from 20 (95% CI = 16 to 24) to 31 (95% CI = 24 to 39) months. Results did not change in sensitivity analyses. CONCLUSION: By bridging studies over time, we demonstrated improvements in survival for recurrent and de novo stage IV MBC overall and across ER-defined subtypes since 1990. These results can inform patient-doctor discussions about MBC prognosis and therapy.