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February, 2020:

Integrating Social Dynamics Into Modeling Cigarette and E-Cigarette Use



The use of electronic cigarettes (e-cigarette) offers potential to facilitate cigarette smoking cessation, yet potentially increases risk of cigarette smoking initiation. This relationship has been primarily modeled in mathematical ways that often do not represent real-world complexities, which could inform decisions regarding local prevention programs or policies. Aims. To develop a model of cigarette and e-cigarette use that combines current research on tobacco use and incorporates real-world geographic and demographic data. Method. We used a platform for developing agent-based models with demographic information representative of the population in Pennsylvania. We developed three models of cigarette and e-cigarette use. The primary outcome for each was the total number of users for cigarette, e-cigarette, and total nicotine. The first model applied current cigarette and e-cigarette data, the second tested the effect of implementing a program of e-cigarette education and policies, and the third considered a social contagion factor, where local schools functioned as a transmission vector. Results. The baseline and social contagion models found an overall decline in cigarette use but an increase in e-cigarette and total nicotine use. The education/policies model had declines in all categories. Sensitivity analysis suggested the importance of nuanced e-cigarette/cigarette interactions when modeling tobacco use.


Public health campaigns that focus on reducing youth e-cigarette usage can have a large effect. Social contagion should be strongly considered when studying e-cigarette spread. Conclusion. Targeted public health campaigns focused on reducing school prevalence of e-cigarette use may be particularly valuable.

Historical Perspective of Proactive and Reactive Regulations of E-cigarettes to Combat Nicotine Addiction


Cigarettes and electronic cigarettes (e-cigarettes) are major sources of exposure to nicotine, an addictive chemical. Although these products are being regulated by the Food and Drug Administration (FDA) under the Tobacco Control Act, specifications about the nicotine content in these products have not been established yet. In e-cigarettes, nicotine concentration ranges from 0 to > 50mg/mL, and the recent e-cigarette devices provide control to change nicotine flux for higher nicotine delivery. Due to the lack of robust regulations in manufacturing, distribution and marketing, e-cigarettes have already infiltrated the market with youth appealing flavors and devices. As a result, the country is facing a youth epidemic of e-cigarette use. The unregulated nicotine levels in both cigarettes and e-cigarettes can lead to repeated and overexposure of nicotine to youth which can lead to the addiction and detrimental effects on their cognitive functions. Over the past decade, the corrective measures being taken by the FDA for cigarette and e-cigarette regulations also should focus on nicotine exposure levels. Before it is too late to prevent youth from lifetime addiction to nicotine, it is important to address the issues of nicotine concentration, nicotine flux and the e-cigarette device regulations while offering adults with smoking disorder less harmful alternatives to cigarettes.

Response to Britton et al.

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A rational approach to e-cigarettes – challenging ERS policy on tobacco harm reduction

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New Zealand moves to ban vaping ads, sales to minors

(Reuters) – New Zealand’s government said on Sunday it will introduce laws banning all advertisements of e-cigarettes and the sale of such products to people under 18 in a move to regulate a market that has been under pressure globally.

A string of vaping-related deaths and illnesses tied to e-cigarettes, which allow users to inhale nicotine vapor, often flavored, without smoking, have been reported in the United States, leading to lawsuits and restrictions.

The New Zealand bill, posted on the health ministry’s website, also seeks to ban e-cigarettes and smokeless tobacco in smoke-free areas, restrict who can sell them and give the government the powers to recall or suspend vaping products.

“We are making sure that we are protecting our kids but at the same time ensuring that smokers who want to use vaping as a quit tool still have access to those products,” Associate Health Minister Jeny Salesa told state-owned TVNZ.

Although the number of people smoking has steadily fallen in New Zealand, according to official data, nearly one in eight adults, or close to half a million people, are regular cigarette smokers.

The government said in the bill, which will be proposed to parliament on Monday, that it “acknowledges” that vaping and smokeless tobacco products are less harmful than smoking and the bill would exempt vaping products from some of the provisions that apply to tobacco products.

“(The bill) enables all retailers to display products in-store, in contrast to requirements that require tobacco products to be out of the public’s sight,” the government said.

In the United States, the Trump administration earlier this year banned some popular e-cigarette flavours to curb rising teenage use of vaping products, allowing only menthol and tobacco flavours to remain on the market.

The New Zealand government came short of prohibiting flavours, but the bill limits general stores, such as convenience outlets, to selling only three flavours: tobacco, mint and menthol.

“Flavors may be used to attract children and young people to vape or use smokeless tobacco products, however, they also seem to be an important factor in supporting smokers to switch,” the government said in the bill.

The lungs: how they work, what the coronavirus does to them, and the effects of smoking and asthma

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Tobacco smoke exposure reduction strategies – do they work?



Many children experience tobacco smoke exposure (TSE) and parents may take preventive measures to reduce TSE. The study goal is to assess if these strategies are associated with lower cotinine values, an objective biological measure of TSE.


Families admitted to Children’s Hospital Colorado from 2014-2018 who screened positive for TSE were invited to participate in a tobacco smoking cessation/reduction program. Caregivers were consented and asked about demographics, beliefs around smoking, and strategies to reduce TSE. Child urine samples were collected, tested for cotinine levels, and analyzed using geometric means. Bi-variable comparisons and multivariable linear regression were completed using SAS v9.4.


213 children (81.4%) are included in this analysis. The median ages of children and parents were 4 and 32 years. 57% of children were male, 36% were Hispanic, and 55% were white. 56% of parents had at least some college education and 69% had an annual income less than $50K. The median daily cigarettes smoked per day was 10. 88% reported using at least one type of protective measure to prevent TSE and 90% believed they protect other household members from TSE. None of the strategies had a significant relationship with lower cotinine levels on bi-variable or multivariable analyses.


Parental strategies to decrease TSE did not result in lower cotinine levels. Many measures are not evidence-based and do not protect children. Parent’s clothing and homes may create a reservoir for nicotine. Education should focus on exposure elimination and cessation rather than protective measures.

The Philip Morris Campaign to Popularize “Heat Not Burn” Tobacco

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Inside the Philip Morris campaign to ‘normalize’ a tobacco device

(Reuters) – At Germany’s Bambi Awards for the media industry in November, celebrities posed for red-carpet photos against a backdrop of established luxury brands. Alongside the likes of Mercedes-Benz and Swiss watchmaker Chopard was a newer name: IQOS, a “reduced risk” heated-tobacco device sold by cigarette maker Philip Morris International Inc.

Across Europe, Asia and South America, the tobacco firm has affixed the IQOS brand to music festivals and art exhibits. The company also markets through IQOS lounges at mountainside resorts in the Pyrenees and in fashionable neighborhoods of Rome. Throughout Europe, it has partnered with “IQOS friendly” bars and restaurants – closed to cigarettes but open to IQOS.

Such promotions are part of a wide-ranging “normalization” strategy by Philip Morris (PM.N) to scrub its image as a purveyor of cancer-causing cigarettes and present its new smoking alternatives as youthful, upscale lifestyle products, according to a ten-month study by tobacco researchers at Stanford University, who shared it exclusively with Reuters before its release on Friday. The marketing strategy mimics that of tobacco companies in the mid-20th century, when they started associating cigarettes with Hollywood and high society.

“Philip Morris, as a company name, is somewhat of a pariah,” said Robert Jackler, a professor who led the study and heads Stanford’s Research into the Impact of Tobacco Advertising. “IQOS is an attempt to sanitize their product line.”

The Stanford researchers said their study was spurred in part by a May 2019 Reuters investigation that found Philip Morris had used young online personalities, including a 21-year-old woman in Russia, to promote IQOS. The company’s internal marketing standards prohibit it from using youth-oriented celebrities or “models who are or appear to be under the age of 25.” The Reuters report prompted the company to acknowledge it had violated its own policy and to suspend its use of social media influencers.

The Stanford study found that, although the company suspended its “most visible” social-media influencer programs, IQOS marketing continues to stray substantially from its corporate standards on youth-oriented marketing.

“Its use of youth-oriented social media channels, trendy pop music festivals and celebrity influencers are mis-aligned with their commitment to exclusive ‘adult smoker’ targeting,” the Stanford report concluded.

Philip Morris declined to answer detailed questions from Reuters on its IQOS marketing strategy and the Stanford findings, saying it did not have access to the full report. “However, we doubt that there is anything PMI could say or do that Dr. Jackler, and others who criticize our scientific commitment and smoke-free vision, would ever find satisfactory.”

The IQOS device is central to the firm’s efforts to overhaul its image through such initiatives as its “unsmoke” campaign, which promotes such “smoke-free” alternatives as a way to accelerate the shift away from cigarettes. The device heats up but does not burn packages of ground-up tobacco, which resemble small cigarettes, to create a nicotine-filled aerosol that is similar to that produced by e-cigarettes, which heat flavored liquid nicotine.

At this year’s Davos World Economic Forum in Switzerland – a gathering of some of the world’s richest people – Philip Morris set up an “Unsmoke your mind” lounge, where panelists argued against regulations preventing “truth in marketing” by tobacco firms looking to promote smoking alternatives.

IQOS is sold in about 50 countries, including the United States through a partnership with U.S. Marlboro maker Altria Group Inc. The two companies pledged to regulators that they would market the device only to adult smokers, showing sample advertisements of adults conservatively dressed in business attire.

But in other markets across the world, the Stanford study said, Philip Morris uses “coaches” and “ambassadors” to market IQOS. In Romania and Russia, employment agencies recruit attractive women as young as 19 to market IQOS, according to job postings mentioned in the Stanford report and reviewed by Reuters.

Instagram postings for Be Like Me, a Romanian marketing agency, show young women posing with the IQOS device in recent months, often wearing robe-like uniforms in malls. The Instagram account for RBT Group, a staffing agency in Russia that markets IQOS, similarly shows photos of attractive young women in front of IQOS signs or posing with other “coaches.”

Be Like Me and RBT Group could not be reached for comment.

Other Instagram accounts with the “IQOS” name, including one called “iqostyle.arm,” based in Armenia, continue to show young women posing with the IQOS in what appear to be professional photographs. One photo on that account from last July – two months after Philip Morris said it had suspended all influencer marketing – showed Nika Shuvalova, a 22-year-old Ukrainian model, posing in a swimsuit on a boat with an IQOS.

Shuvalova could not be reached for comment.

A message sent to the “iqostyle.arm” Instagram account was returned by someone calling themselves Tiko, who said the IQOS postings were a “hobby” and that he had not been paid by Philip Morris.

The stakes for Philip Morris are huge: The company invested $6 billion in developing “smoke-free” products such as IQOS in hopes of staving off a trend of declining global cigarette sales. In 2018, company CEO Andre Calantzopoulos told shareholders that it hoped to receive about 40% of its revenue – nearly $20 billion – from “reduced risk” products by 2025.

Internal Philip Morris documents underscore the importance of its larger strategy: “Make ‘normalization’ a PMI priority and imbed this mindset into the organization,” read an internal company document from 2014, reviewed by Reuters as part of a 2017 investigation. The document also cited “the threats posed by PMI/industry de-normalization” – such as lobbying bans and exclusions from international treaties and trade agreements – “and the need to reverse this trend to drive future growth.”

The Stanford researchers pointed to wide-ranging company efforts to associate IQOS with fashion, art and popular culture in a way that cigarette brands such as Marlboro have been unable to do, given changing social attitudes and laws around the world that prohibit such advertising and promotions.

IQOS has been present at events such as Germany’s Bambi Awards – which honor stars in TV and film, sports, art and music – as well as that country’s Playboy Playmate of the Year Awards.

Philip Morris worked with British sculptor Alex Chinneck on a dramatic installation at the 2019 Milan Design Week. The work depicted the facade of an old, two-story building being unzipped like a pair of jeans – meant to signify the IQOS “notion of opening the future,” the sculptor said in an interview with FAD magazine. A representative of Chinneck confirmed the partnership.

The company also worked with distinguished industrial designer Karim Rashid to create an installation at the previous year’s Milan Design Week. In an interview with website, Rashid described his installation, showing two faces meeting one another, as similar to the IQOS, which he called “an intimate device that speaks to forward-thinking and original expression.” A representative of Rashid said he was unavailable for an interview on Thursday.

The company has also sought to distinguish IQOS from smoking through partnerships with restaurants, bars and salons who designate themselves as “IQOS friendly” spaces, where cigarettes are banned but the IQOS device is allowed. The Stanford researchers found evidence of hundreds of “IQOS friendly” establishments in places such as the Czech Republic, Ukraine, Romania and Japan.

Philip Morris did not respond to questions about its business relationships with the establishments that promote the device and display its branding.

The Stanford researchers and other experts say such policies undermine public smoking laws and encourage dual use of cigarettes and alternative devices. Many users will continue smoking outdoors, but turn to e-cigarettes or IQOS where they are permitted indoors. Such switching can “deepen nicotine addiction and make cessation less probable,” the Stanford report said.

The brand also had a presence at a Tel Aviv University student music festival last year – where the minimum age for entrance was 16, and where a video showed young IQOS staff at a pop-up booth.

At a launch party for IQOS in Albania last year, a performer in an elaborate white sequined dress did an interpretive dance on stage with an IQOS, while another performer attached to wires performed acrobatic moves in the air while playing a violin.

“They’re trying very hard to resurrect the glory era of smoking, where it was glamorous and sophisticated and stylish,” Jackler said. “It’s about associating it with all the good things in life.”

Increases in Secondhand Smoke After Going Smoke-Free

An Assessment of the Impact of a Mandated Smoke-Free Housing Policy



The 12-month impact of federally mandated smoke-free housing (SFH) policy adoption (July 2018) was assessed using two markers of ambient secondhand smoke (SHS): airborne nicotine and particulate matter at the 2.5-micrometer threshold (PM2.5).


We measured markers of SHS in Norfolk, VA from December 2017 to December 2018 in six federally subsidized multi-unit public housing buildings. Multi-level regression was used to model the following comparisons: (1) the month immediately before SFH implementation versus the month immediately after, and (2) December 2017 versus December 2018.


There was a 27% reduction in indoor PM2.5 and a 32% reduction in airborne nicotine in the first month after SFH adoption, compared to the month prior to adoption. However, there was a 33% increase in PM2.5 and a 25% increase in airborne nicotine after 12 months.


US Department of Housing and Urban Development (HUD)-mandated SFH can reduce SHS in multi-unit housing. However, SFH could also plausibly increase indoor smoking. Policy approaches adopted by individual properties or housing authorities—for example, property-wide bans versus allowing designated smoking areas—could be driving this potential unintended consequence.


Successful implementation of SFH by public housing authorities in response to the HUD rule requires ongoing attention to implementation strategies. In this sense, SFH likely differs from other policies that might be seen as less intrusive. Long-term success of SFH will depend on careful policy implementation, including plans to educate and support housing authority staff, inform and engage residents, and build effective partnerships with community agencies.