Indonesia ranks third in the number of smokers in the world after China and India. The number of smokers in Indonesia reaches 66 million (25.09%) of the total population of 263 million. Attempts in reducing the number of smokers have been continued yet still ineffective even in the last 10 years, and the number of smokers has continued to increase, especially among young people. From the medical aspect, smoking has a negative impact on health, including yellow teeth, neck cancer, lung disease, etc. The main problem that arises is that it is difficult to stop the smoking habit directly even though it has been through various efforts. This research aimed to identify and analyze the factors that caused a person to smoke, and which strategies were the most appropriate of tobacco harm reduction according to the real condition. The method used was the combination of inductive and deductive approaches. The inductive approach used the descriptive and inferential statistical analysis, based on the empirical data obtained from the respondents through questionnaires, while the deductive approach used the discussion by experts. The analysis methods used were SAST (Strategic Assumption Surfacing and Testing) and ECM (Exponential Comparison Method). The analysis results of 930 respondents and discussions by experts, involving health experts, policy makers, business actors, as well as active and passive smokers, academics and associations, showed that the main factors that cause people to become smokers were just wanted to try, and being invited by their friends, and soon after feeling good, then they got used to it. There were three factors that made them willing to quit smoking: health, economic reasons, and also family encouragement. The development of other low-risk products was an alternative to tobacco harm reduction for those who found it difficult to quit immediately (cold turkey). The most appropriate strategy to adopt tobacco harm reduction was government affirmative policy, as well as correct and complete education regarding the risks of smoking, based on scientific evidence through segmented communication by building Penta Helix collaboration and synergy involving business actors, academics, government, society, and the media.

AUTHORS: Kholil Kholil¹, Hifni Alifahmi², Ariyo Bimmo³, Muhammad-Ilham Karim³

AFFILIATIONS: ¹Faculty of Engineering, Universitas Sahid Jakarta, Indonesia || ²Postgraduate School, Universitas Sahid Jakarta, Indonesia || ³Koalisi Indonesia Bebas Tar (KABAR), Indonesia

Background: Up-to-date monitoring of combustible and non-combustible nicotine products is important for public health planning according to WHO recommendations (WHO, 2021). We aimed to assess the prevalence in the use of these products and the perceptions concerning non-combustible alternatives to cigarettes in the adult Greek population in 2022.

Material and Methods: A cross-sectional survey was conducted throughout Greece in June 2022. Random digit dialing and proportional quota sampling was used to recruit respondents, with quotas based on the NUTS I regions of Greece (N=2,004). We defined smokers, users of e-cigarettes and users of heated tobacco products (HTPs) as those who had smoked at least 100 cigarettes, used e-cigarettes at least 100 times and used at least 100 sticks in their entire lifetime, respectively. Current use was defined as use in the past 30 days.

Results: The prevalence of use of any tobacco/nicotine product in the past 30 days was 32.7% (boxed/hand-rolled cigarettes: 28.3%, cigars/cigarillos/pipes: 2.0%, e-cigarettes: 3.2%, HTPs: 4.0%). Current daily users constituted 25.4% (boxed/hand-rolled cigarettes), 0.8% (cigars/cigarillos/pipes), 2.4% (e-cigarettes) and 3.4% (HTPs) of the sample. Exclusive use of boxed/hand-rolled cigarettes, cigars/cigarillos/pipes, e-cigarettes and HTPs was reported by 24.2%, 0.4%, 1.4% and 2.3% of the participants, respectively. In the sample, 93.7% had heard about e-cigarettes and 55.9% about HTPs before the interview. Of those, 31.7% and 40.4% believed that the use of e-cigarettes and of HTPs, respectively, is less harmful than cigarettes.

Conclusions: The prevalence of cigarette smoking in 2022 in Greece was higher compared to the prevalence in 2020 in the European region (28.3% vs. 23.0%) (WHO, 2021). Boxed/hand-rolled cigarettes remain the most used form of tobacco products and a small proportion report daily or exclusive use of alternative products.

AUTHORS: Vasiliki Engeli, Vana Sypsa

AFFILIATION: Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Greece

The US FDA Modified Risk Tobacco Product Application (MRTPA) process provides a regulatory pathway by which reduced exposure or modified risk claims for a specific tobacco product can be communicated to consumers. An MRTPA must show that promulgating such communication would benefit the population as a whole, taking into account both users and non-users of tobacco products. Building on the population health impact model (PHIM) of Wissmann et al. (2021), we estimate the impact on mortality from reduced-exposure messaging for JUUL ENDS. This agent-based PHIM was used to model transitions among nine tobacco use states (e.g., smokers switching to ENDS use, never-smokers initiating with ENDS). It compared a Base Case where ENDS were already available to a Modified Case where a reduced exposure claim applied to ENDS was additionally made. Tobacco use transition rates were drawn from Wissmann et al. (2021) and based on data from PATH, NHIS/CISNET, and published studies on JUUL users. The effect of the claim on transitions was estimated from a randomized experiment assessing behavioral intentions with and without the claim. The mortality risks of tobacco use behaviors were estimated from the NHIS Linked Mortality File. The model projects a robust net population benefit over 100 years, averting tens of thousands of premature deaths and more than a quarter million life-years lost as a result of making the reduced exposure claim. Sensitivity and tipping point analyses suggest that dissemination of the reduced-exposure claim yields a population benefit under a wide array of scenarios, and only results in population harm under grossly unrealistic assumptions about its effects on initiation and switching.

AUTHORS: Nathan M. Holt¹, Changhua Zhan¹, Saul Shiffman², Ryan A. Black¹, Stacey A. McCaffrey¹

AFFILIATIONS: ¹Juul Labs, Inc. || ²Pinney Associates, Inc.

Disclosures: The analysis was sponsored by Juul Labs, Inc. Authors Holt, Zhan, Black, and McCaffrey are employed by Juul Labs, Inc. Through Pinney Associates, author Shiffman provides consulting on tobacco harm reduction to Juul Labs, Inc. on an exclusive basis.

Background: Smokers expressed less gingival inflammation and less gingival bleeding than non-smokers did. It is difficult to define a good clinical diagnosis and prompt treatment, when the symptoms are hidden in smokers. In experimental gingivitis, smokers displayed a less pronounced gingival inflammatory reaction compared to non-smokers. Today, e-cigarette or vape has become the most popular alternative tobacco product and has been said as less harmful than combustible tobacco, but no studies have been carried out to observe the gingival response of vapers during an experimental gingivitis.

Objective: To evaluate gingival response as assessed by gingival inflammation index and bleeding index during an experimental gingivitis in vapers, in comparison with smokers and non-smokers.

Material and Methods: Fifteen participants were divided into 3 groups, namely non-smokers, smokers, and vapers. Before the trial, dental cleaning was performed to reach zero plaque accumulation for each participant. Acrylic stents were custom-made to cover an area in lower jaw’s teeth. Participants were instructed to wear the stent when brushing their teeth, throughout the duration of the experimental gingivitis phase (21 days), in order to avoid brushing of the lower jaw’s teeth. Assessments performed were Plaque Index (Loe et al. 1967), Gingival Index (Loe et al. 1967), Angulated Bleeding Index (Van der Weijden et al. 1994) at the beginning of the study (H0), at 14 days (H14), and 21 days (H21) of the experimental gingivitis period. Salivary cotinine levels were confirmed by Salimetrics, ELISA at H0 and H21.

Results: During experimental gingivitis, bacterial plaque accumulated in all groups. Despite the similar amount of bacterial plaque accumulation, gingival and bleeding index of non-smokers and vapers were higher compared to smokers, while salivary cotinine levels of smokers and vapers were higher than these of non-smokers.

Conclusions: There was an obvious increase in gingival bleeding and inflammation after 21 days of experimental gingivitis in vapers who consumed e-liquid with nicotine as confirmed by salivary cotinine levels and in non-smokers, contradicting the claim from previous studies that gingival vasoconstriction by nicotine component is the cause of reduced bleeding and inflammation. Under the limitations of the present study, we observed that vapers have similar gingival responses as non-smokers, during 21 days of experimental gingivitis.

AUTHORS: Amaliya Amaliya¹, Jimmy Gunawan², Agus Susanto¹

AFFILIATIONS: ¹Department of Periodontology, Dental Faculty, Universitas Padjadjaran, Bandung, Indonesia || ²Private Practice, Periodontist, Jakarta, Indonesia

Background: Cigarette smoking has been established as a risk factor for developing metabolic syndrome (MetS), which is a common condition in Kazakhstan affecting up to a quarter of the population. The aim of this study was to analyze the long-term effects of shifting to heated tobacco products (HTP) use on the prevalence of metabolic syndrome compared to continued combustible cigarettes (CC) use in long-term smokers.

Material and Methods: A cohort of 1200 participants (400 HTP and 800 CC) aged 40-59 years with a minimum of 10 pack-year smoking history were recruited and followed for 36 months. Data on demographic, medical history, smoking habits, etc. was collected. International Diabetes Federation was used as MetS definition. Specifically, subjects were considered to have MetS if they had had central obesity [waist circumference (WC) >94 cm in males and >80 cm in females for Caucasian; >90 cm in males and >80 cm in females for Asians] plus two and more of the following criteria: (1) hypertriglyceridemia, ≥150 mg/dL; (2) reduced HDL cholesterol, <40 mg/dL in males and <50 mg/dL in females; (3) high blood pressure, ≥130/85 mm Hg; (4) raised fasting plasma glucose, ≥100 mg/dL. Chi-squared test were used to compare the frequency of MetS between visits (baseline, 12-, 24-, and 36-months).

Results: The prevalence of MetS was 35% in CC and HTP users at baseline. Over the observed period (36-months) the prevalence of MetS significantly decreased for HTP users from 35% to 28% (P=0.03), compared to 35% to 30% (P=0.32) decrease in CC users. The prevalence of reduced HDL cholesterol and raised fasting plasma glucose components decreased for both CC and HTP users, whereas central obesity and high blood pressure components significantly decreased for HTP users only (P=0.003 and P=0.03 respectively).

Conclusions: This study demonstrated that while both CC and HTP users experienced decrease in the prevalence of MetS components, HTP users experienced decreases in a larger number of MetS components. The results of this study suggest that HTP might be a less deleterious alternative compared to CC in people with long history of CC use and who cannot quit smoking.

AUTHORS: Almaz Sharman, Irina Yermakova, Elmira Erenchina, Gulnara Tyulebekova, Aisulu Bekzhanova

AFFILIATION: Clinical Research Unit, Academy of Preventive Medicine, Almaty, Republic of Kazakhstan

Acknowledgments: This study is supported with resources and the use of facilities at the Academy of Preventive Medicine and Synergy Group Kazakhstan. The project is partially funded by a grant from Philip Morris International (IIS.PMI.2016.001). Nor the Academy nor any authors of this abstract are affiliated with the Philip Morris International. This funder had no involvement in the study conduct, data analysis, and writing of this abstract.

Background: Tobacco harm reduction (THR) aims to reduce the health burden of cigarettes by encouraging smokers to switch to using alternative tobacco or nicotine products. Nicotine pouches (NPs) are smokeless, tobacco-free, oral products that may be beneficial as part of a THR strategy.

Objective: This 2-center, cross-sectional confinement study conducted in Denmark and Sweden aimed to determine whether biomarkers of exposure (BoEs) to tobacco toxicants and biomarkers of potential harm (BoPHs) in exclusive users of NPs show favorable differences compared with current smokers.

Methods: Participants were healthy NP users (target n=100) and current, former, or never smokers (target n=40 each), as confirmed by urinary cotinine and exhaled carbon monoxide concentrations. During a 24-hour confinement period, participants were asked to use their usual product (NP or cigarette) as normal, and BoEs/BoPHs were measured in blood and 24-hour urine samples, with compliance determined using anabasine, anatabine, and N-(2-cyanoethyl)valine. BoEs/BoPHs were compared between NP users and current, former, and never smokers. Urinary total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (BoE to nicotine-derived nitrosamine ketone) and urinary 8-epi-prostaglandin F2α type III, exhaled nitric oxide, blood carboxyhemoglobin, white blood cell count, soluble intercellular adhesion molecule-1, and high-density lipoprotein cholesterol (BoPHs) were evaluated as primary outcomes. Other measures include urinary 11-dehydrothromboxane B2, forced expiratory volume, carotid intima-media thickness, self-reported quality of life, and oral health.

Results: The results of this study were received mid-2022 and will be published late 2022 to early 2023.

Conclusions: The results of this study will provide information on toxicant exposure and biomarkers associated with the development of smoking-related diseases among users of NPs compared with smokers, as well as on the potential role of NPs in THR.

AUTHORS: David Azzopardi, Linsey E. Haswell, Justin Frosina, Michael McEwan, Nathan Gale, Jesse Thissen, Filimon Meichanetzidis, George Hardie
AFFILIATION: Research and Development, B.A.T. (Investments) Limited, Southampton, United Kingdom