Electronic cigarette awareness, use, and perception of harmfulness in Brazil: findings from a country that has strict regulatory requirements. / Conhecimento e uso de cigarros eletrônicos e percepção de risco no Brasil: resultados de um país com requisitos regulatórios rígidos.

Given the uncertainties regarding electronic cigarettes' (e-cigs) impact on health, in 2009 Brazil prohibited sales, importation or advertisements of these products until manufacturers are able to show they are safe and/or effective in smoking cessation. This study sought to analyze: (1) awareness of electronic cigarettes, ever-use and recent use; (2) perception of harmfulness of electronic cigarettes when compared with conventional cigarettes; and (3) correlates of awareness and perception of harmfulness. This is a cross-sectional study among Brazilian smokers (≥ 18 years) using the Wave 2 replenishment sample of the Brazilian International Tobacco Control Policy Evaluation Survey. Participants were recruited in three cities through a random-digit dialing sampling frame between October 2012 and February 2012. Among the 721 respondents, 37.4% (n = 249) of current smokers were aware of e-cigs, 9.3% (n = 48) reported having ever tried or used e-cigs and 4.6% (n = 24) reported having used them in the previous six months. Among those who were aware of e-cigs, 44.4% (n = 103) believed they were less harmful than regular cigarettes (low perception of harmfulness). "Low perception of harmfulness" was associated with a higher educational level and with having recently tried/used e-cigs. Despite restrictions to e-cigs in Brazil, 4.6% of sample smokers reported having recently used them. Health surveillance programs in Brazil and other countries should include questions on use and perceptions of e-cigs considering their respective regulatory environments.

Perspectives of key stakeholders and smokers on a very low nicotine content cigarette-only policy: qualitative study.

AIMS: To investigate views of New Zealand key stakeholders (stakeholders) and smokers on very low nicotine content (VLNC) cigarettes, and a policy mandating that only VLNC cigarettes are available for sale. METHODS: Using a semi-structured interview schedule, we interviewed 17 stakeholders and held focus groups with 21 smokers. Questions were asked about VLNC cigarettes and a VLNC cigarette-only policy. Smokers were given approximately 15 VLNC cigarettes to take home and smoke. One week after the focus groups, 17 smokers were interviewed. Data were analysed using a general inductive approach. RESULTS: Stakeholders and smokers were largely unconvinced of the value of a mandated reduction in nicotine in cigarettes. After smoking VLNC cigarettes, smokers had less interest in them but would support them being sold alongside high nicotine content (HNC) cigarettes at a much cheaper price. CONCLUSION: The government is not likely to mandate nicotine reduction in cigarettes if there is a perceived lack of support from stakeholders or smokers. However, they could make VLNC cigarettes available as an option for smokers utilising a differential tax favouring VLNC cigarettes. If this were combined with better access to nicotine containing e-cigarettes, smokers may shift away from HNC cigarettes.

Here Comes Trouble: A Career as a Tobacco Control Activist.

Dr Glantz is Professor of Medicine in the Division of Cardiology, the Truth Initiative Distinguished Professor of Tobacco Control, and Director of the Center for Tobacco Control Research and Education at the University of California, San Francisco School of Medicine. He obtained a BSc in aerospace engineering from the University of Cincinnati in 1969 and an MSc and PhD in applied mechanics from Stanford University. He is the author of 4 books, including The Cigarette Papers and Primer of Biostatistics He is also a member of the University of California, San Francisco Cardiovascular Research Institute and Institute for Health Policy Studies and Co-leader of the University of California, San Francisco Comprehensive Cancer Center Tobacco Program. He was elected to the Institute of Medicine in 2005.

Regulations and policies regarding e-cigarettes.

Electronic cigarettes (e-cigarettes) are a growing public health concern because of a dramatic increase in use by adolescents and the uncertainty of potential health impacts. These health concerns and lack of an established federal regulatory scheme have led many local and state governments to address the regulatory void for e-cigarettes by incorporating them into the statutory definition of tobacco or by passing laws specific to the use of e-cigarettes. In August 2016, the US Food and Drug Administration issued a final rule deeming e-cigarettes within their authority; providing uniform requirements like premarket approval applications, Harmful and Potentially Harmful Constituents reporting, and warning labels; and establishing 18 years as a minimum age of purchase. Although the impact on the public's health remains uncertain, regulations and laws governing e-cigarettes continue to develop. This review highlights the available data regarding safety and public health impacts of e-cigarettes and details the status of US regulations and policies affecting their sale and use. Cancer 2017;123:3007-14. © 2017 American Cancer Society.

A Risk Assessment Matrix for Public Health Principles: The Case for E-Cigarettes.

Besides nicotine replacement therapies, a realistic alternative for smoking cessation or for smoking substitution may come from electronic cigarettes (ECs), whose popularity has been steadily growing. As for any emerging behaviour associated with exposure to inhalational agents, there is legitimate cause for concern and many health organizations and policy makers have pushed for restrictive policy measures ranging from complete bans to tight regulations of these products. Nonetheless, it is important to reframe these concerns in context of the well-known harm caused by cigarette smoking. In this article, we discuss key public health principles that should be considered when regulating ECs. These include the concept of tobacco harm reduction, importance of relative risk and risk continuum, renormalization of smoking, availability of low-risk product, proportionate taxation, and reassessment of the role of non-tobacco flavours. These public health principles may be systematically scrutinized using a risk assessment matrix that allows: (1) to determine the measure of certainty that a risk will occur; and (2) to estimate the impact of such a risk on public health. Consequently, the ultimate goal of responsible ECs regulation should be that of maximizing the favourable impact of these reduced-risk products whilst minimizing further any potential risks. Consumer perspectives, sound EC research, continuous post-marketing surveillance and reasonable safety and quality product standards should be at the very heart of future regulatory schemes that will address concerns while minimizing unintended consequences of ill-informed regulation.

Lung cancer specialist physicians' attitudes towards e-cigarettes: A nationwide survey.

OBJECTIVES: Despite a sharp increase in e-cigarette use, there is debate about whether e-cigarettes are a viable alternative for harm reduction, and the forms that regulation should take. Healthcare providers can be effective in offering guidance to patients and their families and shaping regulatory policy. We described lung cancer specialists' attitudes toward e-cigarettes and its regulation. METHODS: We undertook a nationwide survey of pulmonologists, thoracic surgeons, medical and radiological oncologists who are members of Korean Association for Lung Cancer. Survey items included beliefs and attitudes toward e-cigarettes, attitudes toward e-cigarette regulation and preparedness on discussing e-cigarettes with their patients. RESULTS: Most respondents believed that e-cigarettes are not safer than conventional tobacco cigarettes (75.7%) or smokeless tobacco (83.2%), and feared that discussing e-cigarettes with the patients would encourage use (65.4%). They did not consider it a smoking cessation treatment (78.3%), and thus would not recommend it to smokers who do not want to quit (82.2%) or who failed to quit with conventional smoking cessation treatment (74.1%). Most respondents supported all examples of e-cigarette regulations, including the safety and quality check (97.8%), warning label (97.8%), advertisement ban (95.1%), restriction of flavoring (78.4%), minimum purchasing age (99.5%), and restriction of indoor use (94.6%). Most learned about e-cigarettes from media and advertisements, or conversation with patients rather than through professional scientific resources, and reported discomfort when discussing e-cigarette with patients. CONCLUSION: Lung cancer specialist physicians in Korea doubt the safety of e-cigarette and use of e-cigarette as smoking cessation treatment, and supported strict regulation. However, only 20% reported that they obtained information on e-cigarettes from the scientific literature and many lacked adequate knowledge based on scientific evidence, suggesting the need for better preparedness. Nevertheless, the views of professionals revealed from our study could help to develop clinical guidelines and regulatory guidance.

E-cigarettes: An update on considerations for the otolaryngologist.

PURPOSE: We provide an update in the literature and national regulations regarding electronic cigarettes with special attention to the pediatric population. BACKGROUND: Electronic nicotine delivery systems (ENDS) are handheld battery operated devices that vaporize nicotine-containing liquids for inhalation. Use of these products has dramatically increased over the last several years, particularly among the youth. ENDS are being marketed with advertising techniques and flavors which appeal to the adolescent and young adult population. More reports of accidental pediatric exposures are being documented, as are suicides from abuse of liquid nicotine. Federal regulation has only now become required of these devices. CONCLUSION: Use of e cigarettes among adolescents increases each year. Government oversight is needed to protect our children from the re-normalization of tobacco. Otolaryngologists should be prepared to counsel their patients and families regarding the latest in ENDS use.

Support for electronic cigarette regulations among California voters.

Policies regulating the sale and use of electronic cigarettes (e-cigarettes) vary widely within the USA and worldwide. We assessed support for four proposed policies among a representative sample of California voters (N=1002) and identified latent classes of voters who were likely to support or oppose various policies. Findings showed support for prohibiting e-cigarette use where smoking is banned (70%), taxing e-cigarettes (74%), licensing e-cigarette retailers (74%), and restricting flavourings (57%). Correlates of policy support included smoking status, political orientation, age group and California region. The latent class analysis revealed three classes of voters: Policy Supporters (predominantly college-educated, higher-income, liberal non-smokers), Policy Opposers (predominantly low-educated, low-income, conservative smokers), and Swing Voters (intermediate levels of education, income, and smoking, conservative). Findings provide information to inform segmented state-based communication campaigns regarding regulation of e-cigarettes. If policymakers want to enact prohibitive state-level policies, Opposers and Swing Voters may be important constituents to target.

Patients with lung cancer: Are electronic cigarettes harmful or useful?

E-cigarettes remain controversial because the scientific evidence of short term and long term effects on tolerance and the health value of a switch from tobacco to e-cigarettes is contested and controversial. Nevertheless the quality of e-cigarettes and e-liquids has improved. The main ingredients, propylene glycol, vegetable glycerine and nicotine are pharmaceutical-grade quality in most e-liquids. Flavors are almost all food grade. The high quality of ingredients has decreased the presence of impurities in e-liquids. The emissions of e-cigarettes do not contain solid particles or carbon monoxide. Nitrosamine content is at least one hundred times lower than in tobacco smoke. E-cigarette emissions in normal use do not contain any harmful constituents at significant levels except nicotine. UK public health authorities have stated that e-cigarette use is likely to be at least 95% less toxic than cigarette use. There are benefits from having a well-regulated legal market. In countries where e-liquid containing nicotine is not allowed, "do-it-yourself" liquids are common and have handling risks and may sometimes contain toxic impurities. Though e-cigarettes should never be assumed safe products for non-smokers, for smokers, the e-cigarette is at least 20 times less dangerous than the cigarette. Tobacco cessation specialists in countries where nicotine containing e-cigarettes are available increasingly provide counselling for e-cigarette use to stop smoking or to reduce smoking at the request of patients. Based on current knowledge, for patients with lung or other forms of cancer who would otherwise continue to smoke, e-cigarettes offer an alternative way to quit smoking while they undergo medical treatment.

E-Cigarettes and Potential Implications for Plastic Surgery.

The use of tobacco-based products, most notably cigarettes, is related directly to wound healing problems and poorer outcomes in plastic surgery. Current abstracts have highlighted the potential complications from nicotine, specifically following plastic surgery in patients who choose to smoke. Recently, products that use electricity to vaporize liquid nitrogen have been gaining popularity. New rules were recently proposed that would give the federal government authority over electronic cigarettes. However, the health-related issues surrounding e-cigarettes are still largely unknown or misunderstood. These issues also extend to their impact on surgical procedures, notably their effect on plastic surgical procedures that rely heavily on the vascularity of either the host wound bed or the replacement tissue.

Identification of Vape Shops in Two North Carolina Counties: An Approach for States without Retailer Licensing.

Stores that sell electronic nicotine delivery systems (ENDS) as their primary product are a new phenomenon and often termed "vape shops". While vape shops are now regulated by state and federal agencies, not all states maintain lists of vape shops in operation. Standard ways of identifying tobacco retailers through off-premise alcohol permits and business listing services may not identify vape shops. We used four online business listing services (i.e., Google Maps, ReferenceUSA, YellowPages.com, Yelp) to identify vape shops in two counties in North Carolina (NC). In one county, we also assessed four vaping web sites. We drove primary and secondary roads to physically validate the identified stores and attempt to identify stores not listed online. To assess the accuracy of the online searches, we calculated sensitivity and positive predictive values (PPVs). This research was conducted in spring and summer 2016 and identified 28 vape shops online. We confirmed 16 vape shops (seven in Pitt County, NC, USA, and nine in Durham County, NC, USA). Online searches ranged in sensitivity, 62.5%-81.3%, and PPVs ranged from 73.3% to 92.3%. Because of the range of sensitivity found among the business listing services, state policymakers should consider uniform licensing requirements for vape and tobacco retailers to more easily track retailers and ensure compliance with regulations.

Electronic Cigarettes: Questions in the Mist.

In many parts of the world, electronic cigarettes (ECs) are marketed as a tool to assist users in attempts to quit smoking and are perceived to be a safer alternative to tobacco cigarettes. Numerous studies have suggested ECs may not be effective in achieving this goal and that the illusive "safety" of ECs can be enticing to consumers. The composition of the liquid solutions vaporized by these devices has not been fully disclosed and may not contain the actual advertised ingredients in the fractions reported. As this market has developed largely outside the oversight of an appropriate regulatory body, we are left to evaluate how ECs as a form of nicotine replacement therapy fit in the existing regulatory framework of conventional cigarettes and what the role of nicotine is in our society.