Commentary: Cigarette dependence in menthol and non-menthol young adult cigarette smokers.

FDA's Proposed Final Rule to ban menthol cigarettes asserts that "menthol cigarettes contribute to greater nicotine dependence in youth and young adults than non-menthol cigarettes." However, none of the publications referenced included young adults. To provide empirical evidence on the subject, we examine smoking frequency and Heaviness of Smoking Index (HSI) dependence among 2,194 young adult (ages 18-25 years) menthol and non-menthol smokers from 31 online survey samples. Unpaired t-tests examined if daily smoking or the proportion of daily smokers who are low or high dependence on the HSI vary by menthol cigarette smoking status. Young adult menthol smokers were less likely to be daily smokers than young adult non-menthol smokers. There were no differences in the percentages of daily menthol and non-menthol smokers categorized as low or high dependence on the HSI. Smoking menthol cigarettes, therefore, does not appear to be associated with greater cigarette dependence among young adults than smoking non-menthol cigarettes.

Heaviness of smoking index in menthol and non-menthol smokers.

BACKGROUND: It has been hypothesized that menthol in cigarettes increases dependence. Several studies suggest that menthol and non-menthol smokers have similar or lower levels of dependence, but those studies are not without limitations. The Heaviness of Smoking Index (HSI) is a widely accepted, validated measure of cigarette dependence. OBJECTIVES: This report aims to provide further evidence regarding dependence among menthol and non-menthol smokers, as indicated by daily smoking and as measured by the HSI. METHODS: Survey data from 27,131 adult smokers were analyzed to compare the percent of menthol and non-menthol smokers who are daily smokers, and the percentage who are low or high HSI dependence. Logistic regressions were also conducted to determine if menthol use predicts daily smoking, and low or high dependence after controlling for demographic differences. RESULTS: Comparisons among weighted samples of adult smokers demonstrate that menthol smokers were consistently more likely to be non-daily smokers, more likely to be in the low dependence category, and less likely to be in the high dependence category on the HSI as compared to non-menthol smokers. Logistic regression confirmed that when controlling for age, gender, race/ethnicity, and education, relative to non-menthol smokers, menthol smokers had no difference in odds of being in the low dependence HSI category and significantly lower odds of being a daily smoker, and of being in the high dependence category. CONCLUSIONS: These analyses support the conclusion that, based on the HSI, menthol smokers are not more cigarette dependent than non-menthol smokers, and may be less dependent.

Assessing comprehension and perceptions of modified-risk information for snus among adult current cigarette smokers, former tobacco users, and never tobacco users.

INTRODUCTION: Snus, a low nitrosamine smokeless tobacco product, presents less risks to health than cigarettes. Effectively communicating such risk information could facilitate smokers switching completely to snus, thereby benefiting public health. METHODS: This study assessed comprehension and perceptions of modified-risk information regarding snus. Adult cigarette smokers, former tobacco users, and never tobacco users (N = 3,922) from a US internet panel viewed an advertisement stating that smokers who switched completely to snus could greatly reduce risk of lung cancer, respiratory disease, heart disease, and oral cancer. Respondents answered questions regarding the modified-risk information and rated perceived risks of snus relative to cigarettes and other smokeless tobacco products. RESULTS: Across the four diseases mentioned in the advertisement, most respondents (49.7%-68.6%, across tobacco user groups) understood that snus presents less risk than cigarettes but is not completely safe. Some indicated snus presents the same risk as cigarettes; this was highest for oral cancer (33.7%-42.02%) and lowest for lung cancer (15.4%-23.1%) and respiratory disease (15.6%-23.4%). Majorities understood snus is addictive (77.7%-87.9%), quitting all tobacco is the best option for smokers (83.6%-93.1%), and non-users of tobacco should not use snus (80.4%-87.8%). Only 2.1%-5.8% indicated smokers would receive a health benefit if they continued to smoke while using snus. CONCLUSIONS: The modified-risk information, conveying that snus presents less risk than cigarettes but is not completely safe, was understood by majorities of respondents. Differential risk beliefs across diseases suggest responses were shaped not only by the modified-risk information, but also by intuitions and pre-existing beliefs about tobacco products.

Assessing likelihood of product use for snus with modified-risk information among adult current cigarette smokers, former tobacco users, and never tobacco users.

INTRODUCTION: Switching from cigarettes to snus by smokers unlikely to quit would be expected to benefit overall population health, with any potential benefit needing to be weighed against potential harms from snus use by tobacco non-users and smokers likely to quit. This study evaluates likelihood of snus use among tobacco users and non-users provided modified-risk information. METHODS: An online sample of 11,302 U.S. adults was randomized to view advertisements for snus that either provided modified-risk information or only described snus. Intent to purchase ratings were converted to projected purchase (use) rates using an empirically derived algorithm. RESULTS: Projected product use for snus was significantly higher among current smokers than former or never tobacco users (p < 0.0001) for both the modified-risk and control information. A significant interaction effect between information and tobacco user group (p < 0.0001) indicated the modified-risk information differentially increased projected use among smokers (8.2% vs. 6.9%), with much lower projections for both the test and control information among former (1.2%) and never tobacco users (0.4%). Among never users, projected use was highest among those susceptible to smoking. These findings were generally similar for young adults, ages 18-24. Smokers expecting to quit who viewed modified-risk information had lower projected use (4.2%) than those not expecting to quit (8.7%). CONCLUSIONS: Results suggest that providing modified-risk information for snus is unlikely to increase use among those not using tobacco. Interest in snus was greatest among current smokers who would benefit by switching to snus as communicated in the modified-risk advertisement.

Assessing Recall and Recognition for Important Safety Information in Digital Promotion for Pharmaceutical Products: Implications for Website Design.

BACKGROUND: To date, there has been little research with digital direct-to-consumer (DTC) communication regarding pharmaceutical products (eg, product websites), so this study was designed to measure perception and recall of Important Safety Information (ISI) in websites viewed on desktops and smartphone devices. METHODS: A quantitative survey was conducted with 1600 self-identified asthma patients. Participants viewed 1 of 4 mocked-up websites for a fictitious asthma product in either a desktop or smartphone format that varied in the way in which risk information was presented and accessed. The "websites" were embedded in survey software that enabled behavior to be tracked and facilitated presentation of questions designed to assess memory and user experience. RESULTS: Statistically significant differences in likelihood of interacting with, and memory of, the ISI were observed across the 4 different presentation formats-2 typical of existing website formats and 2 representing alternative formats-for both desktop and smartphone media. The traditional formats consistently outperformed the alternative formats overall, but when analyses are restricted to the subset of participants who view ISI, elements of one of the alternative formats proved to be superior. CONCLUSIONS: Digital presentation of different formats of risk information has a significant effect on recall and recognition of ISI associated with pharmaceutical products, and the interactive nature of digital material adds a layer of complexity to assessing the performance of the various formats.

A comparison of preferences for two GLP-1 products--liraglutide and exenatide--for the treatment of type 2 diabetes.

OBJECTIVE: To use time trade-off (TTO) to compare patient preferences for profiles of two glucagon-like peptide (GLP-1) products for the treatment of type 2 diabetes (liraglutide and exenatide) that vary on four key attributes - efficacy (as measured by hemoglobin A(1C)), incidence of nausea, incidence of hypoglycemia, and dosing frequency (QD vs. BID) - and measure the contribution of those attributes to preferences. METHODS: A total of 382 people with T2DM were recruited to participate in an internet-based survey consisting of a series of health-related questions, a conjoint exercise and a set of time trade-off items. In the conjoint exercise, respondents were presented with eight pairs of hypothetical GLP-1 profiles, and completed a time-tradeoff exercise for each pair. RESULTS: The product profile representing liraglutide was preferred by 96% of respondents and resulted in significantly higher health utilities (0.038) than the product profile representing exenatide (0.978 vs. 0.94, p < 0.05). Estimated preference scores from the conjoint analysis revealed that efficacy measured by hemoglobin A(1C) is the most important attribute, followed by nausea, hypoglycemia, and dosing schedule. LIMITATIONS: On-line participants may not represent 'typical' type 2 diabetes patients, and brief product profiles represented results from clinical trials, not clinical practice CONCLUSION: Based on the four attributes presented, patients prefer liraglutide over exenatide. Preference is based on superior efficacy and less nausea more than less hypoglycemia and once-daily dosing.