Who is using heated tobacco products and what are the implications for public health? Find out in today's featured Science Lab session from Dr Konstantinos Farsalinos.
Transcription:
00:05 - 00:45
[Summer Hanna]
Dr. Konstantinos Farsalinos. He's a physician and senior researcher specializing in public health at the Universities of Patras and West Attica in Greece. He has conducted extensive research on smoking, tobacco harm reduction, and vaping since 2011, publishing over 100 studies and presenting in more than 80 conferences. He's authored the first systematic review on safety and risk profile of e-cigarettes in 2014 and the first book published by Elsevier. His research was influential in shaping the EU's regulatory framework in vaping, and today he will share patterns of heated tobacco product use and biochemically verified smoking status among customers of dedicated HTP stores.
00:45 - 06:00
[Video]
Hello everyone. Today I will present a study titled Patterns of Heated Tobacco Product Use and Biochemically Verified Smoking Status Among Customers of Dedicated HTP Stores. No funding was provided for this study. If we want to address the public health impact of heated tobacco products, we need to look at whether they promote smoking cessation, so if they are used by smokers in order to substitute for smoking, whether they could perpetuate smoking by being attractive to non-smokers or by making former smokers relapse back to smoking. And in that respect, it is imperative to look at patterns of use and the characteristics of users of HDP products. So the study was conducted in two out of the five available at that time dedicated heated tobacco product stores in Athens, Greece. And the purpose of this study was to identify the user characteristics. the HCP use patterns, and of course the smoking history, but also the current smoking status of HCP users, with the latter being biochemically objectively verified by measuring exhaled carbon monoxide on site. The study included 373 participants, of whom 113 were current smokers, so dual users, while the rest were former smokers. The only criterion for study inclusion was that they were visiting the stores in order to buy products for their own use. So all of them were by definition HTTP users. Seven participants, that is 1.9% of the study sample, were never smokers who were using HTPs and they will be analyzed separately. Concerning the demographic characteristics, there were only minor differences between current and former smokers in household economic status. Gender, age distribution were identical. Now on the smoking history and patterns of use of HTP products between the two groups. There were no differences in the smoking duration between groups or in their smoking dependence as assessed using the first item of the Fagerstrom test of cigarette dependence. So the smoking characteristics between former smokers and in that case we were talking about the past of smoking history and current smokers was similar. Current smokers reported a substantial 50% reduction in the number of cigarettes smoked daily after initiating HTP use. Concerning the smoking history and smoking characteristics of the two groups, the smoking duration and consumption before HTP use initiation was similar between groups. While minor statistically significant differences were observed in dependence on smoking as assessed by the Fagerstrom test of cigarette dependence, specifically the first item which addresses time since waking to using the first cigarette. Concerning the patterns of HTP use, former smokers were using HTPs for longer period and they were more likely to use them daily compared to occasional. Concerning harm perceptions for HTPs, both groups classified HTPs as less or substantially less harmful than smoking in the vast majority of cases. A substantial proportion, about 10% in the whole sample reported that they didn't know what was the harm of HTPs compared to tobacco cigarettes. Finally, a very small proportion classified HTPs as absolutely harmless. We performed a logistic regression analysis, so a multivariate analysis, in order to identify factors associated with being a former smoker. Only two factors showed statistical significance. Using HTPs daily compared to occasionally, and the duration of HTP use, which specifically showed that for every month of additional duration of HTP use, the odds of being a former smoker were increased by about 6%. Now, on the 7 participants, that is 1.9% of the whole sample, who reported they had never smoked and they were using HTPs, more than half of them were using HTPs occasionally rather than daily, and importantly, None of them became a current smoker, both in terms of their self-report, but also by measuring exhaled carbon monoxide, in which case all of them had less than 3 ppm. So to conclude, the vast majority of HTP users who go to specialized stores to get the products were current or former smokers, so people with a smoking history. A substantial proportion, about 69%, reported being former smokers, and that was objectively verified by measuring exhaled carbon monoxide. Use by never smokers was quite uncommon, less than 2% of the whole study sample. So it seems that in this sample of users visiting dedicated DHP stores to get the products, the main drive is to reduce or stop smoking. Of course, more studies, particularly longitudinal studies, are needed to examine the smoking cessation potential of HTPs, but also in general their public health impact, a major part of which depends on how the products are used and why the products are used by consumers. Thank you very much.
06:05 - 06:07
[Summer Hanna]
Dr. Farsalinos, if you'd like to add any further comments.
06:07 - 06:43
[Konstantinos Farsalinos]
Not really. We did the study in 2019. At that time, there were only, this is IQOS flagship stores. In Greece, there were only five stores available in Athens only. So we chose two of them, and we had the researcher on site, so the interviews were all performed on site, as well as the measurements of exhaled carbon monoxide. And the recruitment was also on site. The recruitment was every customer visiting the store while the researcher was present in the store was invited to participate.
06:53 - 06:58
[Summer Hanna]
Any questions from the floor?
06:58 - 07:25
[Riccardo Polosa]
Konstantinos. I noticed the range of the former smokers were quite wide, from five to 24 years of being former smokers. So that indicates that some former smokers, long-standing former smokers, were going to the Icos shop to buy Icos, probably because they felt the urge to avoid relapse back into smoking. What do you think?
07:25 - 09:06
[Konstantinos Farsalinos]
I didn't mention the data, but it was asked by a reviewer, that's why. We had a question among former smokers, how did you manage to quit smoking? Because Ricardo is right that there may be cases of former smokers who have quit long before initiating HTP use, and HTPs may be used as a relapse back to nicotine use or in preventing relapsing to smoking. So from this sample of former smokers, 90% reported that they had quit with the help of HTPs. So 90% of them were probably quitters that quit after initiating HTP use. The rest is 10%, so it's about 25 subjects, if I remember well. Some of them reported they had quit with using other methods by themselves with NRTs, but very small numbers. I mentioned all of this in the paper, which is in proofreading. It's already been accepted, so it will be published very soon. in the next few days. We gave them a list of options from quitting by yourself with medication, with NRTs, even in cigarettes, and they were able to choose more than one option. So we gave them the possibility to choose everything they used to help them quit smoking. But 90% were most likely, based on this question, people who used HTPs and subsequently quit smoking. Although, I mean, take this cautiously because it's not a longitudinal study. It's a cross-sectional study. But this question helps to address the limitations of the cross-sectional design.
09:10 - 09:17
[Yusuff Adebayo Adebisi]
Based on how the participants were recruited, do you think selection bias is a major problem in that study?
09:18 - 11:53
[Konstantinos Farsalinos]
selection bias is a serious issue because we went to a dedicated store which means that they get different experience they get different communication and time for the staff to communicate whatever they want to communicate about the product so by definition their customers there receive more attention than going to other places but in 2019 These dedicated stores or online orders from the company were the only ways of getting devices, IQOS devices, in Greece. There were other sales points to buy tobacco sticks, but not devices. After that, I mean today, the availability of heated tobacco products in Greece is everywhere. Everywhere. I mean, there are even electronics stores, chain stores, with many shops all over Greece, that sell heated tobacco products. They have a sales point inside the store and they only sell heated tobacco products. So now it's a different story. In that case, one was the availability, of course, of the devices, but the second is that You know, we did the study on-site, so you can't do an on-site study outside a kiosk, for example, and have people, you know, standing up, having a questionnaire lasting 15, maybe 20 minutes, depending on the smoking history, and also measuring exhaled carbon monoxide. You need a more controlled environment in order to support such a study design. It's not an online questionnaire. It's not a phone call, computer-assisted telephone interview or anything like that. So the design and our willingness to objectively assess the smoking status, by definition, confined the method through which we could do the study. We needed to have a more confined and more controlled space to do it. Of course, we're not saying that the smoking cessation efficacy of HTPs is 67%. Definitely, that's not the answer. And we couldn't measure the smoking cessation efficacy. There is no doubt that many, many, many people have tried HTPs or e-cigarettes or whatever other product and have failed. The 67% being former smoker does not mean that 67% of people who try HTP products are going to quit. That can't be addressed with such a design.
11:58 - 11:58
[Summer Hanna]
Okay, well...
11:59 - 12:30
[Marewa Glover]
Yeah, you say at the end about needing a longitudinal study, and then after my presentation, you would need to follow people for quite a long time. So you had former smokers, and you said nearly, well, I think it was 97%, had quit formally. Native. Native. Yeah, with using HTP. So there's a transition and a back and forth pattern that happens there as well, isn't there? Oh, definitely. And then, so how long would you need to follow people up?
12:30 - 13:26
[Konstantinos Farsalinos]
Well, I think that... As long as you follow them, you will see transitions happening. I think at some point, probably after the first year, former smokers usually don't relapse in such a high extent compared to the first year of making the switch. But it would be interesting to follow them up for a period similar to yours, three or four years, and look at what's happening. What is interesting is look at dual users. You will see a lot of transitions. In former smokers, I think that after the first year, where you will definitely see probably a lot of transition and changing behaviors, I expect them to stabilize and to have a consistent behavior afterwards, whether it's a relapse back to smoking or maintaining their smoke-free status. But we need to do that. Yeah, I agree. It's just...
13:27 - 13:31
[Gabriel Oke]
Just out of curiosity, why did you pick those two out of the five?
13:32 - 14:00
[Konstantinos Farsalinos]
Randomly, we had three researchers. We randomly chose three out of the five. We didn't have more to spread them throughout all the stores. But all the flagship stores were of the same size and they were in very large populated areas in the capital. But there was no issue, no real difference in attendance and visits to these tours.
14:01 - 14:13
[Summer Hanna]
Great. Well, I want to thank our speakers today for their time and their contributions and the dialogue here with everyone. With that, we'll break for lunch and thank you again very much for your participation.