Use of infection control measures in people with chronic lung disease: mixed methods study.

Background: The introduction of community infection control measures during the COVID-19 pandemic was associated with a reduction in acute exacerbations of lung disease. We aimed to understand the acceptability of continued use of infection control measures among people with chronic lung disease and to understand the barriers and facilitators of use. Methods: Australian adults with chronic lung disease were invited to an online survey (last quarter of 2021) to specify infection control measures they would continue themselves post-pandemic and those they perceived should be adopted by the community. A subset of survey participants were interviewed (first quarter of 2022) with coded transcripts deductively mapped to the COM-B model and Theoretical Domains Framework. Results: 193 people (COPD 84, bronchiectasis 41, interstitial lung disease 35, asthma 33) completed the survey. Physical distancing indoors (83%), handwashing (77%), and avoidance of busy places (71%) or unwell family and friends (77%) were measures most likely to be continued. Policies for the wider community that received most support were those during the influenza season including hand sanitiser being widely available (84%), wearing of face coverings by healthcare professionals (67%) and wearing of face coverings by the general population on public transport (66%). Barriers to use of infection control measures were related to physical skills, knowledge, environmental context and resources, social influences, emotion, beliefs about capabilities and beliefs about consequences. Conclusions: Adults with chronic lung diseases in Australia are supportive of physical distancing indoors, hand hygiene, and avoidance of busy places or unwell family and friends as long-term infection control measures.

Navigating the COVID-19 pandemic: Experiences and self-management approaches adopted by people with interstitial lung disease.

BACKGROUND: People with interstitial lung disease (ILD) were deemed more vulnerable to the SARS-CoV-2 virus and isolated as a means of reducing risk of infection. This study examined the impact of the pandemic on daily life, psychological wellbeing and access to healthcare and identified approaches undertaken to remain safe. METHODS: Four specialist clinics in tertiary centres in Australia (Victoria: two sites; New South Wales: one site; Western Australia: one site) recruited patients with ILD during an 8-week period from March 2021. Semi-structured telephone interviews were conducted with transcripts analysed using principles of grounded theory. RESULTS: Ninety participants were interviewed between April and December 2021. Participants were predominantly female, former smokers with an average age of 66 years. IPF and connective tissue-ILD being the most common subtypes. Five main themes were identified: vulnerability reduced social interaction and isolation, access to healthcare services and support, staying active, emotional and psychological impact. Self-management strategies included staying active both physically and mentally. DISCUSSION: Self-management was key to managing the impact of the pandemic. In combination with advances in technology, implementation of strategies for monitoring wellbeing and support for self-management provides an opportunity to leverage the lessons learnt to ensure a more individualised model of care for people with ILD.

Associations between smokers' knowledge of causes of smoking harm and related beliefs and behaviors: Findings from the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey.

BACKGROUND: Most smokers know that smoking is harmful to health, but less is known about their understanding of what causes the harms. The primary aim was to examine smokers' perceptions of the relative contributions to smoking-related morbidity from combustion products, nicotine, other substances present in unburned tobacco, and additives. A secondary aim was to evaluate the association of these perceptions with nicotine vaping product use intentions, and quitting motivation/intentions. METHODS: Participants were current smokers and recent ex-smokers from Australia, Canada, England and the United States (N = 12,904, including 8511 daily smokers), surveyed in the 2018 International Tobacco Control Four Country Smoking and Vaping Survey. Respondents reported on how much they thought combustion products, nicotine, chemicals in the tobacco and additives in cigarettes contribute to smoking-related morbidity (none/very little; some but less than half; around half; more than half; all or nearly all of it; don't know). RESULTS: Overall, 4% of participants provided estimates for all four component causes that fell within the ranges classified correct, with younger respondents and those from England most likely to be correct. Respondents who rated combustion as clearly more important than nicotine in causing harm (25%) were the least likely to be smoking daily and more likely to have quit and/or to be vaping. Among daily smokers, all four cause estimates were independently related to overall health worry and extent of wanting to quit, but the relative rating of combustion compared to nicotine did not add to prediction. Those who answered 'don't know' to the sources of harm questions and those suggesting very little harm were consistently least interested in quitting. CONCLUSIONS: Most smokers' knowledge of specific causes of harm is currently inadequate and could impact their informed decision-making ability.

Safe at home: prevention of pediatric unintentional injuries.

BACKGROUND: Unintentional injuries are the leading cause of death in children in the United States. Studies have shown that parent adherence to safety guidelines is improved when education is provided in conjunction with safety equipment. METHODS: This study surveyed parents about specific injury prevention behaviors regarding medication and firearm storage and provided education and safety equipment for safe practice of these behaviors. The project took place in a pediatric emergency department (PED) and partnered with the hospital foundation and the school of medicine. Inclusion criteria were families visiting a freestanding PED in a tertiary care center. Participants completed a survey conducted by a medical student approximately 5 min in length. The student then provided each family with a medication lock box (if children ≤ 5 years old lived in the home), firearm cable lock, and education for safe storage of medications and firearms in the home. RESULTS: The medical student researcher spent a total of 20 h in the PED from June to August 2021. 106 families were approached to participate in the study, of which 99 agreed to participate (93.4%). A total of 199 children were reached with ages ranging from less than 1 year old to 18 years old. A total of 73 medication lockboxes and 95 firearm locks were distributed. The majority (79.8%) of survey participants were the mother of the patient and 97.0% of participants lived with the patient > 50% of the time. For medication storage, 12.1% of families store medications locked and 71.7% reported never receiving medication storage education from a healthcare professional. Regarding firearms, 65.2% of participants who reported having at least 1 firearm in the home stored firearms locked and unloaded with various methods of storage. 77.8% of firearm owners reported storing ammunition in a separate location from the firearm. Of all participants surveyed, 82.8% reported never receiving firearm storage education from a healthcare professional. CONCLUSIONS: The pediatric ED is an excellent setting for injury prevention and education. Many families are not storing medications and firearms safely, demonstrating a clear opportunity to increase knowledge in families with young children.

Characterisation of vaping liquids used in vaping devices across four countries: results from an analysis of selected vaping liquids reported by users in the 2016 ITC Four Country Smoking and Vaping Survey.

OBJECTIVES: This study presents an analysis of vaping products (VPs) purchased in the USA, Canada, England and Australia and assesses whether differences in regulations were associated with differences in the chemical composition of the VPs. METHODS: April-September 2017, a total of 234 VP refill liquids and prefilled cartridges were purchased in convenience samples of retail locations in each country. Products were chosen from brands and styles most commonly reported by current VP users in the 2016 ITC Four Country Smoking and Vaping Survey. All products were tested for nicotine, tobacco-specific nitrosamines (TSNAs), minor tobacco alkaloids, organic acids and flavouring chemicals. RESULTS: Consistent with the laws in Canada and Australia at the time of product purchase, nicotine was not detected in any of the VPs (n=10 in Canada; n=15 in Australia). US liquids (n=54) had a mean nicotine concentration of 16.2 mg/mL, (range=0.0-58.6) and English liquids (n=166) had a mean concentration of 11.9 mg/mL ((range=0.0-31.2) F(3244)=12.32, p<0.001). About 5% of English samples exceeded the UK's 20 mg/mL nicotine limit. Substantial country differences were observed in levels ofTSNAs, with the USA being higher than elsewhere. Of all products tested, 18.8% contained at least one organic acid. Liquids purchased in England contained far more identifiable flavouring chemicals than those in the other countries. CONCLUSIONS: VP composition, particularly with respect to nicotine and flavouring, varies by country, likely reflecting both marketplace preferences and country-specific regulations. There are differences between nicotine levels claimed on the package and actual levels, particularly in England.

Smokers' awareness of filter ventilation, and how they believe it affects them: findings from the ITC Four Country Survey.

BACKGROUND: Filter ventilation creates sensations of 'lightness' or 'smoothness' and is also highly effective for controlling machine-tested yields of tar, nicotine and carbon monoxide. Nearly all factory-made cigarettes (FMC) now have filter ventilation in countries such as Australia, Canada, the UK and the USA. Research conducted before 'light' and 'mild' labelling was banned found low smoker awareness of filter ventilation and its effects. This study explores current levels of awareness of filter ventilation and current understanding of its effects in these four countries. METHODS: We used data from the 2018 wave of the ITC Four Country Smoking and Vaping Survey with samples from USA, England, Canada and Australia. Analyses were conducted initially on a weighted sample of 11 844, and subsequently on 7541 daily FMC smokers. FINDINGS: Only 40.3% of all respondents reported being aware of filter ventilation. Among daily FMC smokers, only 9.4% believed their cigarettes had filter ventilation. Believing that their usual cigarettes are smoother was positively associated with believing they are also less harmful. Both these beliefs independently predict believing their cigarettes are ventilated (smoother OR=1.97 (95% CI 1.50 to 2.59) and less harmful OR=2.41 (95% CI 1.66 to 3.49) in relation to those believing each characteristic is average. INTERPRETATION: Awareness of filter ventilation is currently low, despite decades of public 'education efforts around the misleading nature of 'light' and 'mild" descriptors. Few smokers realise that their cigarettes almost certainly are vented. Smokers who believed their cigarettes have filter ventilation were more likely to believe they were both smoother and less harmful. Awareness of the technology appears to be insufficient to prevent smokers being deceived by it. Filter ventilation is inherently misleading to smokers and it is time to ban it.

'It's all the other stuff!' How smokers understand (and misunderstand) chemicals in cigarettes and cigarette smoke.

Many people understand chemicals as entities that do not occur naturally, and which are also invariably toxic. Tobacco control messages liberally use the term 'chemicals' to evoke these meanings and create concern among smokers. This may reinforce misunderstandings, potentially leading to smokers making harmful choices. To investigate smokers' understandings of chemicals, we conducted qualitative research using 18 individual interviews and three focus groups with Australian smokers and recently quit smokers. The research was guided by the 'mental models' framework and the recently developed Context, Executive, and Operational Systems theory. We discerned two clusters of mental models: the first cluster focused on combustion as the overarching cause of harm (and were largely consistent with the science) and the second cluster focused on additives as causes of harm. We found most participants displayed limited knowledge of the causes of harm from smoking and some held mutually incompatible beliefs. Most participants believed that cigarettes differ significantly in harmfulness according to whether or not they were believed to contain additives. Only a minority understood that the bulk of the toxicants to which smokers are exposed are combustion products. These findings are directly relevant to tobacco control but also have broader relevance to risk communications about toxic exposures.

Understandings of the component causes of harm from cigarette smoking in Australia.

INTRODUCTION AND AIMS: To investigate relationships between smoking-related behaviours and knowledge of the disease risks of smoking and the causes of smoking harms, using a four-way division of 'component causes': nicotine, other substances found in unburned tobacco, combustion products of tobacco and additives. DESIGN AND METHODS: The data were collected using an on-line survey in Australia with 1047 participants in three groups; young non-smokers (18 to 25), young smokers (18 to 25) and older smokers (26 and above). RESULTS: Most participants agreed that cancer and heart disease are major risks of smoking but only a quarter accurately quantified the mortality risk of lifetime daily smoking. Very few (two of 1047) correctly estimated the relative contributions of all four component causes. Post-hoc analyses reinterpreting responses as expressions of relative concern about combustion products and nicotine showed that 29% of participants rated combustion products above nicotine. We delineated six relative concern segments, most of which had distinctive patterns of beliefs and actions. However, higher levels of concern about combustion products were only weakly positively associated with harm reducing beliefs and actions. DISCUSSION AND CONCLUSIONS: Most smokers do not appear to understand the risks of smoking and their causes well enough to be able to think systematically about the courses of action open to them to reduce their health risk. To facilitate informed decision-making, tobacco control communicators may need to better balance the dual aims of creating fear/negative affect about smoking and imparting knowledge about the health harms and their mechanisms.

Smokers' risk perceptions and misperceptions of cigarettes, e-cigarettes and nicotine replacement therapies.

INTRODUCTION AND AIMS: To identify the range and coherence of smokers and recent ex-smokers' general beliefs about the harms associated with smoking and the implications of these beliefs for their assessments of the relative harms and addictiveness of various nicotine containing products. DESIGN AND METHODS: The study consisted of 18 single participant interviews with current smokers or vapers (13 M, 5 F) and three focus groups (15 M, 14 F) with current smokers/vapers and recent quitters. Both individual interviews and focus groups included semi-structured discussions of how nicotine and cigarette smoke cause disease and addiction, and a structured task involving rating the relative harmfulness and addictiveness of 17 nicotine products against a reference, popular, cigarette. RESULTS: Most participants were able to give adequate accounts of what makes cigarette smoking harmful and addictive but this general knowledge was not consistently applied to making harmfulness and addictiveness judgements about specific products. Many participants applied simple affect-based heuristics to harmfulness and addictiveness judgments, even when they had apparently demonstrated more sophisticated knowledge earlier. Most used binary safe/dangerous thinking, with addictiveness and harmfulness strongly linked and a decoupling of satisfaction and addictiveness. DISCUSSION AND CONCLUSIONS: Many smokers appear to have reasonable general knowledge of the risks of smoking but cannot reliably apply this knowledge to practical risk judgements. We need to rethink how we communicate with the public about the risks of smoking, and using other nicotine products, in ways that allow them to make more informed decisions about their smoking.

Clinical Outcomes of Transplanted Modified Bone Marrow-Derived Mesenchymal Stem Cells in Stroke: A Phase 1/2a Study.

BACKGROUND AND PURPOSE: Preclinical data suggest that cell-based therapies have the potential to improve stroke outcomes. METHODS: Eighteen patients with stable, chronic stroke were enrolled in a 2-year, open-label, single-arm study to evaluate the safety and clinical outcomes of surgical transplantation of modified bone marrow-derived mesenchymal stem cells (SB623). RESULTS: All patients in the safety population (N=18) experienced at least 1 treatment-emergent adverse event. Six patients experienced 6 serious treatment-emergent adverse events; 2 were probably or definitely related to surgical procedure; none were related to cell treatment. All serious treatment-emergent adverse events resolved without sequelae. There were no dose-limiting toxicities or deaths. Sixteen patients completed 12 months of follow-up at the time of this analysis. Significant improvement from baseline (mean) was reported for: (1) European Stroke Scale: mean increase 6.88 (95% confidence interval, 3.5-10.3; P<0.001), (2) National Institutes of Health Stroke Scale: mean decrease 2.00 (95% confidence interval, -2.7 to -1.3; P<0.001), (3) Fugl-Meyer total score: mean increase 19.20 (95% confidence interval, 11.4-27.0; P<0.001), and (4) Fugl-Meyer motor function total score: mean increase 11.40 (95% confidence interval, 4.6-18.2; P<0.001). No changes were observed in modified Rankin Scale. The area of magnetic resonance T2 fluid-attenuated inversion recovery signal change in the ipsilateral cortex 1 week after implantation significantly correlated with clinical improvement at 12 months (P<0.001 for European Stroke Scale). CONCLUSIONS: In this interim report, SB623 cells were safe and associated with improvement in clinical outcome end points at 12 months. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01287936.

Relationship of cigarette-related perceptions to cigarette design features: findings from the 2009 ITC U.S. Survey.

INTRODUCTION: Many governments around the world have banned the use of misleading cigarette descriptors such as "light" and "mild" because the cigarettes so labeled were found not to reduce smokers' health risks. However, underlying cigarette design features, which are retained in many brands, likely contribute to ongoing belief that these cigarettes are less harmful by producing perceptions of lightness/smoothness through lighter taste and reduced harshness and irritation. METHODS: Participants (N = 320) were recruited from the International Tobacco Control U.S. Survey conducted in 2009 and 2010, when they answered questions about smoking behavior, attitudes and beliefs about tobacco products, and key mediators and moderators of tobacco use behaviors. Participants also submitted an unopened pack of their usual brand of cigarettes for analysis using established methods. RESULTS: Own-brand filter ventilation level (M 29%, range 0%-71%) was consistently associated with perceived lightness (p < .001) and smoothness (p = .005) of own brand. Those whose brand bore a light/mild label (55% of participants) were more likely to report their cigarettes were lighter [71.9% vs. 41.9%; χ(2)(2) = 38.1, p < .001] and smoother than other brands [75.5% vs. 68.7%; χ(2)(2) = 7.8, p = .020]. CONCLUSION: Product design features, particularly filter ventilation, influence smokers' beliefs about product attributes such as lightness and smoothness, independent of package labels. Regulation of cigarette design features such as filter ventilation should be considered as a complement to removal of misleading terms in order to reduce smokers' misperceptions regarding product risks.

Effects of a Fact Sheet on beliefs about the harmfulness of alternative nicotine delivery systems compared with cigarettes.

BACKGROUND: This study explored the value of providing information in a Fact Sheet to correct misperceptions about the relative harmfulness of nicotine replacement products (NRT) and smokeless tobacco (ST), when compared to cigarette smoking. METHODS: Four convenience samples from different countries (Australia, UK, Sweden and USA) were surveyed concerning their beliefs about the relative harmfulness of smokeless tobacco and NRT. Study participants were given the Fact Sheet that explained that nicotine, as used by consumers, is not particularly harmful and explained why. They were resurveyed one week later regarding their beliefs about the relative harmfulness of smokeless tobacco and NRT and future intentions to use the products. RESULTS: In all four samples knowledge increased by similar amounts and beliefs regarding the lower harmfulness of smokeless tobacco increased. However, misconceptions remained common and responses to belief measures were not always consistent. Likelihood of use of ST increased in all four samples after exposure to the Fact Sheet, but interest in NRT use only increased in the US sample. CONCLUSIONS: A Fact Sheet such as this one can help address misconceptions about NRT and smokeless tobacco, at least in the short term. However, as is true of most educational interventions, exposure to a single educational session is not sufficient to overcome misperceptions that smokers have about the relative harmfulness of oral versus combustible forms of nicotine delivery.

The decline of menthol cigarette smoking in Australia, 1980-2008.

INTRODUCTION: Concerns have been expressed that menthol cigarettes are highly conducive to uptake and hence function as "starter cigarettes" for adolescents. There is strong evidence for this in the United States. If menthol cigarettes are critical to uptake for some adolescents, they might be expected to remain popular among adolescents independent of promotional activity. We analyzed trends in the market share of menthol brands in Australia among both adolescents and adults to provide further insights into the determinants of menthol cigarette smoking. METHODS: We used the Australian Secondary Students Alcohol and Drug Survey (1984-2008), the Smoking and Health Survey (1980-1998), and the International Tobacco Control Four Nations Survey (2002-2008) to estimate market share of brands. Measures were reported use of all menthol brands for adults and use of the Alpine brand for adolescents. RESULTS: Menthol smoking was much more popular among female smokers of all age groups in the early 1980s. During the 1980s and 1990s, use declined markedly in the 18-29 age groups, while remaining relatively stable among older smokers. Use of Alpine declined markedly among adolescents in the 1980s and 1990s. However, during this period, Alpine remained more popular among experimenting than regular smokers. CONCLUSIONS: Both Alpine and other menthol brands are now primarily "older women's cigarettes" in Australia. The trends in declining popularity among younger smokers suggest that targeted marketing plays a major role in determining menthol brand market share. Alpine has played a role as a "starter" cigarette in Australia but that role has decreased markedly since the 1980s. Within the Australian context, "light/mild" brands may have taken over the role of easier-to-smoke cigarettes that attract experimenting smokers.

The acceptability of nicotine containing products as alternatives to cigarettes: findings from two pilot studies.

BACKGROUND: This study aimed to explore issues that might impact on the acceptability and feasibility of offering smokers nicotine containing products either to quit nicotine use altogether by using as a short term means of quitting cigarettes or as a longer term substitute. METHOD: Two small pilot studies, one in the UK (n = 34) involving face to face contact and direct provision of the product, the other in Australia (n = 31) conducted remotely with products sent in the mail. RESULTS: Nicotine lozenges were the most popular products, but significant minorities liked a smokeless product more. Use stimulated interest in quitting, and although many failed to use all the products provided, most were interested in future use, more often to help quit than as a planned long-term substitute. CONCLUSIONS: These studies indicate an untapped interest in the use of substitutes to reduce the harmfulness of smoking. Studies of this sort do not inhibit interest in quitting nicotine altogether, and may facilitate it. The greater the range of products on offer, the more smokers are likely to try a product to quit.

Assessing the knowledge of all-terrain vehicle safety for children among Alabama pediatricians.

BACKGROUND: Since 1987, the American Academy of Pediatrics (AAP) has had a policy regarding the use of all-terrain vehicles (ATVs) by children, which calls for pediatricians to educate families regarding the dangers of ATV use and to give recommendations for safety. Given the high incidence of ATV-related injuries in Alabama, our objective was to determine if pediatricians in our state are educating patients on ATV hazards and safety. METHODS: All general pediatricians in Alabama who are members of the AAP were asked to complete a survey distributed through e-mail using Survey Monkey® (Survey Monkey Palo Alto, Calif). Data were entered into Microsoft® Excel (Microsoft Corporation Redmond, Wash). RESULTS: Of the 353 general pediatricians in Alabama, 104 responded. Forty-one percent of the respondents were not aware that there is an AAP policy. Of the 59% who knew of the policy, 36% correctly identified the age limit recommendations. Forty-eight percent said that they routinely give anticipatory guidance regarding ATV use. Of them, 63% gave age recommendations younger than stated in the AAP policy. In addition, only 52% of them recommend helmet use, 5% recommend use of reflective clothing, 35% discourage passenger riding, and 8% encourage ATV training classes. Respondents who had patients treated for ATV-related injuries were more likely to give anticipatory guidance than those who had not had patients treated (χ² = 5.3; P = 0.02; odds ratio, 3.9 [95% confidence interval, 1.2-13.6]). Respondents who practice in rural areas were more likely not to give anticipatory guidance than those who practice in urban areas (χ² = 2.1; P = 0.14; odds ratio, 2.9 [95% confidence interval, 0.8-5.4]). CONCLUSIONS: Many general pediatricians in a state where ATV use is popular are not familiar with the current AAP policy and do not routinely follow its guidelines. Given the high incidence of ATV-related injuries and the complexities of general practice, exploring multiple methods to modify risk-taking ATV behavior is warranted.

Impact of the removal of misleading terms on cigarette pack on smokers' beliefs about 'light/mild' cigarettes: cross-country comparisons.

AIM: This paper examines how smokers' beliefs about 'light/mild' cigarettes in Australia, Canada and the United Kingdom were affected by the removal of misleading 'light/mild' terms from packs. DESIGN, SETTING AND PARTICIPANTS: The data come from the first seven waves (2002-09) of the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey, an annual cohort telephone survey of adult smokers in Canada, the United States, the United Kingdom and Australia (21 613 individual cases). 'Light' and 'mild' descriptors were removed in 2003 in the United Kingdom, in 2006 in Australia and in 2007 in Canada. We compare beliefs about 'light' cigarettes both before and after the bans, with those of smokers in the United States serving as the control condition. MEASURES: Smokers' beliefs about 'light' cigarettes were assessed using a set of statements rated on a five-point 'agree'-'disagree' scale. FINDINGS: The proportions of respondents reporting misperceptions about light cigarettes declined between 2002 and 2009 in all four countries. There were marked temporary reductions in reported misperceptions in the United Kingdom and Australia, but not in Canada, following the removal of 'light/mild' descriptors. CONCLUSIONS: Removal of 'light/mild' descriptors and tar, nicotine and carbon monoxide yield information from cigarette packs is insufficient to effectively eliminate false beliefs. The combination of alternative descriptors and design features that produce differences in taste strength and harshness, independent of actual intakes, are sufficient to produce or sustain the same misbeliefs.

Divergence between strength indicators in packaging and cigarette engineering: a case study of Marlboro varieties in Australia and the USA.

OBJECTIVES: To investigate how the tobacco industry is adapting to regulatory action in accordance with provisions of the Framework Convention on Tobacco Control that targets misleading packaging and labelling. To relate the packaging and labelling of new cigarette varieties to their construction and performance. METHODS: The principal design features and tar, nicotine and carbon monoxide yields of the Marlboro 'brand family' in Australia were measured and compared with those of the US equivalents. RESULTS: Marlboro Red and Blue/Medium, could not be differentiated in preliminary tests in Australia, but were different in the USA. However, yield testing showed Marlboro Blue/Medium did not have lower tar and nicotine yields in either country, indeed being higher in Australia. CONCLUSIONS: Colour can be used to market cigarettes as 'milder', independently of ISO yields and 'Light'/'Mild' descriptors. Banning of 'Light' and 'Mild' brand descriptors may be inadequate to end belief in less harmful cigarettes so long as the tobacco industry remains free to engineer 'mildness' and to use colours, other descriptors and design features to characterise varieties it wants to market as 'milder'.

Effect of differing levels of tobacco-specific nitrosamines in cigarette smoke on the levels of biomarkers in smokers.

BACKGROUND: Smokers are exposed to significant doses of carcinogens, including tobacco-specific nitrosamines (TSNA). Previous studies have shown significant global differences in the levels of TSNAs in cigarette smoke because of the variation in tobacco blending and curing practices around the world. METHODS: Mouth-level exposure to 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) measured in cigarette butts and urinary concentrations of its major metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) were examined among 126 daily smokers in four countries over a 24-hour study period. RESULTS: As mouth-level exposure of NNK increased, the urinary NNAL increased even after adjustment for other covariates (beta = 0.46, P = 0.004). The relationship between mouth-level exposure to nicotine and its salivary metabolite, cotinine, was not statistically significant (beta = 0.29, P = 0.057), likely because of the very limited range of differences in mouth-level nicotine exposure in this population. CONCLUSIONS: We have shown a direct association between the 24-hour mouth-level exposure of NNK resulting from cigarette smoking and the concentration of its primary metabolite, NNAL, in the urine of smokers. Internal dose concentrations of urinary NNAL are significantly lower in smokers in countries that have lower TSNA levels in cigarettes such as Canada and Australia in contrast to countries that have high levels of these carcinogens in cigarettes, such as the United States. IMPACT: Lowering the levels of NNK in the mainstream smoke of cigarettes through the use of specific tobacco types and known curing practices can significantly affect the exposure of smokers to this known carcinogen.

ITC "spit and butts" pilot study: the feasibility of collecting saliva and cigarette butt samples from smokers to evaluate policy.

INTRODUCTION: Large-scale epidemiological surveys have frequently relied upon clinic-based sample collection to incorporate biological data, which can be costly and result in nonrepresentative data. Collecting samples in a nonclinical setting (i.e., through postal mail or at the subject's home) offers an alternative option that is minimally invasive and can be incorporated into large population-based studies. OBJECTIVES: (a) To assess the feasibility of collecting biological data from a cohort of smokers in the International Tobacco Control (ITC) study, through the mail and in the home; (b) to examine whether participants are representative of the population under consideration; and (c) to evaluate how the added burden of providing biomarker samples might impact subsequent participation in a follow-up survey. METHODS: Participants were asked to provide a saliva sample and five cigarette butts from cigarettes smoked on a single day, using standardized procedures. Sample collection kits were mailed to a random sample of 400 daily cigarette smokers who were involved in the 2006 annual ITC Four Country (United Kingdom, United States, Canada, and Australia) telephone survey and agreed to participate in sample collection. A random sample of 179 daily smokers who participated in a face-to-face ITC survey in Mexico and Uruguay and agreed to participate in sample collection were also asked to provide samples. RESULTS: Samples were collected from 96% of invited participants in the face-to-face surveys and 52% of participants in the telephone survey. The added burden of the sample collection did not reduce survey retention rates. Participants who initially agreed to participate in the sample collection were more likely to participate in the subsequent survey than participants who were not asked or declined to participate (odds ratio [OR] = 1.28; 95% CI = 1.01-1.62, p = .021). Further, those who provided samples were also more likely to participate in the subsequent survey than those who did not (OR = 2.78; 95% CI = 1.71-4.52, p < .001). DISCUSSION: Collecting saliva and cigarette butt samples from a group of smokers is feasible, yields a representative sample, and the added participant burden does not reduce subsequent survey response rates.