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Economic evaluation of tobacco control policies is common in high-income settings and mainly focuses on cigarette smoking. Evidence suggests that increasing the excise tax of tobacco products is a consistently effective tool for reducing tobacco use and is an efficient mechanism for increasing government revenues. However, less research has been conducted in low/middle-income countries where other tobacco forms are common. This paper presents insights from our work on the economics of waterpipe tobacco smoking conducted in the Eastern Mediterranean Region where waterpipe smoking originated and is highly prevalent. The specific areas related to economics of waterpipe smoking considered herein are: price elasticity, taxation, government revenue, expenditure and healthcare costs. This paper aims to provide practical guidance for researchers investigating the economics of waterpipe tobacco with potential implications for other novel tobacco products. We present lessons learnt across five thematic areas: data, demand, taxes, equity and health modelling. We also highlight knowledge gaps to be addressed in future research. Research implications include designing comprehensive assessment tools that investigate heterogeneity in waterpipe smoking patterns; accounting for cross-price elasticity of demand with other tobacco products; exploring the change in waterpipe tobacco smoking in response to a tax increase and analysing the equity impact of waterpipe tobacco control interventions.

IntroductionDespite the high prevalence of waterpipe tobacco smoking in the Eastern Mediterranean region, evidence supporting its fiscal measures is limited. We modelled the impact of waterpipe tobacco-specific excise taxes on consumption, government revenue and premature deaths averted in Jordan, Lebanon and Palestine.MethodsWe developed a simulation model using country-specific and market share-specific price, consumption and price elasticity data from WHO, UN Comtrade and nationally representative surveys. We modelled increases to specific excise taxes to meet a 35.9% tax burden on 20 g of waterpipe tobacco in Lebanon and Jordan, in line with the global average, and to double government revenues from excise duties in Palestine, which has surpassed this average.ResultsSpecific excise tax was raised by $1.14 ($0.18–$1.32) in Jordan, $2.41 ($0.03–$2.44) in Lebanon (alongside removal of ad valoremtaxes) and $2.39 ($1.72–$4.11) in Palestine per 20 g of waterpipe tobacco. Government revenue increased by $126.3 million in Jordan, $53.8 million in Lebanon and $162.4 million in Palestine while waterpipes smoked decreased by 32.4% in Jordan, 71.0% in Lebanon and 16.3% in Palestine. The corresponding numbers of premature deaths averted annually were approximately 162 000; 1 000 000; and 52 000.DiscussionIncreases in waterpipe tobacco-specific excise taxes substantially reduce smoking and increase government revenue and averted premature deaths in Jordan, Lebanon and Palestine. This has positive implications for both public health and financing and should be considered a policy priority.

Banning flavors in e-cigarettes and other tobacco products may decrease their use. To examine how current users of flavored e-cigarettes might react to a ban on flavored e-cigarettes when: (i) menthol flavor is banned together with other flavors, or (ii) this ban on e-cigarettes is combined with a ban on menthol cigarettes and flavored cigars. A national cross-sectional survey of 2,347 current users of flavored e-cigarettes was conducted in May 2022. For each hypothetical ban scenario, respondents reported if they would quit all tobacco product use, continue to use e-cigarettes with no flavor or flavors that were not banned, or switch to alternative tobacco products. Multinomial logistic regressions were used to estimate the associations between responses and ban scenarios, adjusting for tobacco use and demographic variables.If e-cigarettes with any flavors except menthol and tobacco were banned, the majority of current e-cigarette users would keep using e-cigarettes with no flavor or tobacco and menthol flavor. When menthol flavor was added to a ban, a greater proportion of respondents would quit all tobacco use; however, more would also switch to cigarettes or cigars. When menthol cigarettes and flavored cigars were added to a ban, those who used menthol flavor only would be less likely to switch to cigarettes and cigars.Among current e-cigarette users, the harm reduction (i.e., from quitting all use) from a ban on flavored e-cigarettes, particularly if menthol is also banned, may be outweighed by the harm increases (i.e., switching to cigarettes or cigars, or other products that are more harmful than using e-cigarettes). A concurrent ban on menthol cigarettes and flavored cigars would secure more certain net reductions to public health harms from e-cigarette use and smoking.For current flavored e-cigarette users, the harm reduction (i.e., from quitting all use) from a ban on flavored e-cigarettes, particularly if menthol is also banned, may be outweighed by the harm increases (i.e., switching to cigarettes or cigars, or other products that are more harmful than using e-cigarettes).Banning flavors in e-cigarettes and other tobacco products has the potential to decrease their use. We examined how current users of flavored e-cigarettes might react to several hypothetical ban scenarios. We found that if e-cigarettes with any added flavors except tobacco or menthol were banned, the majority of current e-cigarette users would keep using non-flavored e-cigarettes or those with flavors that were not banned. When menthol flavor was added to a ban, a greater proportion of respondents would quit all tobacco use, however, more would also switch to cigarettes or cigars. When menthol cigarettes and flavored cigars were added to a ban, those who used menthol-flavor e-cigarettes only would be less likely to switch to cigarettes and cigars. Our study indicated that among current e-cigarette users, the harm-reduction resulting from a ban on flavored e-cigarettes, particularly when menthol was banned (i.e., from users quitting all use), may be outweighed by the harm increases (i.e., switching to cigarettes or cigars, or other products that are more harmful than using e-cigarettes). Concurrently banning menthol cigarettes and flavored cigars would secure more certain net harm reductions.

IntroductionThis study examines how current smokers using menthol cigarettes or flavoured cigars, and current users of flavoured e-cigarettes may respond to three hypothetical flavour-ban scenarios: (1) banning only menthol cigarettes and flavoured cigars; (2) also banning e-cigarettes with any non-tobacco flavours except menthol; and (3) also banning e-cigarettes with any non-tobacco flavours, including menthol.MethodsRecruited from mTurk, respondents were asked if they would quit all tobacco-nicotine use or continue or start using products that were still legally available. The patterns of responding to each ban scenario, for both flavoured smokers and users of non-tobacco flavoured e-cigarettes, were summarised. Multinomial logistic regressions were used to estimate associations between demographics, smoking or e-cigarette use status and reactions to a ban.ResultsA ban on menthol cigarettes and flavoured cigars would lead to 12%–20% of flavoured smokers trying to quit all tobacco use and 32%–52% switching to non-flavoured smoking, with the remaining switching to e-cigarettes or other products. Compared with a ban on only menthol cigarettes and flavoured cigars, also banning flavoured e-cigarettes would increase the likelihood of quitting all tobacco-nicotine use (OR=2.58) but also increase the likelihood of switching to non-flavoured smoking (OR=1.74).ConclusionsOur results indicate that a ban on menthol cigarettes and flavoured cigars would decrease smoking. However, it is unclear if adding a ban of menthol e-cigarettes would lead to additional benefits because without menthol e-cigarettes as an alternative, some smokers and e-cigarette users may switch to non-flavoured tobacco smoking, rather than quit all tobacco use.

This study aimed to characterize the cervical cancer diagnosis experience of Kenyan women undergoing treatment for cervical cancer. We analyzed qualitative interviews with 29 women living in rural Kenya who were currently undergoing cervical cancer treatment at Machakos Cancer Care and Research Centre at Machakos Level 5 Referral Hospital in eastern Kenya. Semistructured qualitative interviews were conducted in Kiswahili and English and then de-identified and translated to English during transcription. The main themes generated were identified through an inductive approach to determine how women experienced cervical cancer symptoms and their process of navigating healthcare. Three themes emerged from the qualitative interviews: (1) delaying seeking care, (2) misinterpreting or misdiagnoses, and (3) grappling with the costly diagnosis process. Women misattributed early signs of cervical cancer to benign conditions. Women sought care only after experiencing severe symptoms. When they sought care, women reported facing lengthy and costly screening processes before receiving a cervical cancer diagnosis. There is a need to educate women on the early symptoms of cervical cancer and to increase the institutional capacity and availability of cervical cancer screening resources in healthcare facilities.

BackgroundWaterpipe tobacco smoking rates in the Eastern Mediterranean region are among the highest worldwide, yet little evidence exists on its economics. Estimates of demand elasticities for tobacco products are largely limited to cigarettes. This study aimed to estimate own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco products in Lebanon, Jordan and Palestine.MethodsA volumetric choice experiment was conducted using nationally representative household surveys. The choice experiment elicited respondents’ stated purchases of eight cigarette and waterpipe tobacco product varieties by hypothetically varying prices. Data were analysed using zero-inflated Poisson models that yielded demand elasticity estimates of cigarette and waterpipe tobacco consumption.ResultsThe study included 1680 participants in Lebanon (50% female), 1925 in Jordan (44.6% female) and 1679 in Palestine (50% female). We found the demand for premium cigarettes to be price elastic (range, −1.0 to −1.2) across all three countries, whereas the demand for discount cigarettes was less elastic than premium cigarettes in Lebanon (−0.6) and Jordan (−0.7) and more elastic in Palestine (−1.2). The demand for premium waterpipe tobacco was highly elastic in Lebanon (−1.9), moderately elastic in Jordan (−0.6) and inelastic in Palestine (0.2). The cross-price elasticity between cigarettes and waterpipe tobacco was near zero, suggesting that the two products are not considered to be close substitutes by consumers.ConclusionsThese results serve as a strong evidence base for developing and implementing fiscal policies for tobacco control in the Eastern Mediterranean region that address cigarettes and waterpipe tobacco products.

IntroductionTo understand the impact of e-cigarette devices, flavours, nicotine levels and prices on adult e-cigarette users’ choices among closed-system and open-system e-cigarettes, cigarettes and heated tobacco products (HTPs).MethodsOnline discrete choice experiments were conducted among adult (≥18 years) e-cigarette users (n=2642) in August 2020. Conditional logit regressions were used to assess the relative impact of product attributes and the interactions between product attributes and user characteristics, with stratified analyses to examine differences by smoking status and primarily used e-cigarette device and flavour.ResultsOn average, participants preferred non-tobacco and non-menthol flavours most, preferred open-system over closed-system e-cigarettes and preferred regular nicotine level over low nicotine level. However, the preference varied by demographics, smoking status and the primarily used e-cigarette device and flavour. The differences in preference among products/devices were larger than the difference among flavours or nicotine levels. Participants who primarily used closed-system e-cigarettes exhibited similar preferences for closed-system and open-system e-cigarettes, but those who primarily used open-system e-cigarettes preferred much more open-system over closed-system e-cigarettes. HTP was the least preferred product, much lower than cigarettes in general, but participants living in states where IQOS is being sold had similar preferences to cigarettes and HTPs.ConclusionsPeople are unlikely to switch to another product/device because of the restriction of flavour or nicotine level. If non-tobacco and non-menthol flavours were banned from open-system e-cigarettes, users may switch to menthol flavour e-cigarettes. Intervention strategies should be tailored to specific groups.

LKB1 loss of function is one key oncogenic event in lung cancer. Clinical data suggest that LKB1 loss of function is associated with patients’ smoking status. The responsible ingredients and molecular mechanisms in tobacco for LKB1 loss of function, however, are not defined. In this study, we reported that NNAL, a major metabolite of a tobacco-specific carcinogen NNK, induces LKB1 phosphorylation and its loss of function via the β-AR/PKA signaling pathway in an isomer-dependent manner in human lung cancer cells. NNAL exposure also resulted in enhanced lung cancer cell migration and chemoresistance in an LKB1-dependent manner. A 120-day NNAL exposure in lung cancer cells, mimicking its chronic exposure among smokers, resulted in more prominent LKB1 phosphorylation, cell migration, and chemoresistance even in the absence of NNAL, indicating the long-lasting LKB1 loss of function although such an effect eventually disappeared after NNAL was removed for two months. These observations were confirmed in a lung cancer xenograft model. More importantly, human lung cancer tissues revealed elevated LKB1 phosphorylation in comparison to the paired normal lung tissues. These results suggest that LKB1 loss of function in human lung cancer could be extended to its phosphorylation, which may be mediated by NNAL from tobacco smoke in an isomer-dependent manner via the β-AR/PKA signaling pathway.

Low-value care exposes patients to ineffective, costly, and potentially harmful care. In endocrinology, low-value care practices are common in the care of patients with highly prevalent conditions. There is an urgent need to move past the identification of these practices to an active process of de-implementation. However, clinicians, researchers, and other stakeholders might lack familiarity with the frameworks and processes that can help guide successful de-implementation. To address this gap and support the de-implementation of low-value care, we provide a summary of low-value care practices in endocrinology and a primer on the fundamentals of de-implementation science. Our goal is to increase awareness of low-value care within endocrinology and suggest a path forward for addressing low-value care using principles of de-implementation science.

Cigarette smoking is the leading preventable cause of death and illness in the United States. We tested the usability, acceptability, and efficacy of a smartphone‐based contingency management treatment to promote cessation. We used a nonconcurrent multiple‐baseline design. Participants (N= 14) provided breath carbon monoxide (CO) samples by using a CO meter that was connected to the user's smartphone. An app (mMotiv8) housed on participants' smartphones automatically captured pictures of the CO sampling procedure to validate the end user's identity, and it prompted submissions via a push message delivered to participants' smartphones. Participants earned a $10 incentive for daily abstinence, which was added to a reloadable debit card. Overall, 4% of the CO samples were negative during baseline, and 89% were negative during treatment. Self‐reported usability and acceptability were high, and 85% of the prompted samples were submitted. A smartphone intervention could be scalable and reduce the health consequences and costs associated with cigarette smoking, particularly in rural and low‐income populations.

AbstractAimsTo evaluate the quality and content of free smoking cessation apps and assess their adherence to the US Public Health Service guideline for treating tobacco use and dependence.MethodsIn total 180 apps were downloaded from the App Store and Google Play Store in January 2018; the top-ranking 30 apps were retrieved for the search terms: ‘smoking cessation’, ‘quit smoking’, ‘stop smoking’. Technical quality was rated using the Mobile Application Rating Scale (MARS) and by assessing other characteristics, behavioral change strategies and adherence to the 5As.Results/findingsA total 67 free-to-download apps were identified for full review (n= 40 from the Apple App Store and n= 27 from the Google Play Store). The average MARS score was 16.2/19.0: Engagement (3.3/5.0), Functionality (4.4/5.0), Aesthetics (4.0/5.0), and Information (2.6/5.0). Overall, 43 apps allowed sharing, 12 allowed for an app community, and five required a password. The following features were observed: assessment (n= 51), feedback (n= 38), information/education (n= 45), monitoring (n= 52), and goal setting (n= 23). Significant differences were found among apps adhering to the 5As: Ask (n= 44), Advise (n= 54), Assess (n= 30), Assist (n= 62), and Arrange (n= 0).ConclusionsGiven the growth in smoking cessation apps, future efforts should focus on improving their technical quality and adherence to the 5As.

4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone (commonly known as NNK) is one of the most prevalent and potent pulmonary carcinogens in tobacco products that increases the human lung cancer risk. Kava has the potential to reduce NNK and tobacco smoke-induced lung cancer risk by enhancing urinary excretion of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL, the major metabolite of NNK) and thus reducing NNK-induced DNA damage. In this study, we quantified N-glucuronidated NNAL (NNAL-N-gluc), O-glucuronidated NNAL (NNAL-O-gluc), and free NNAL in the urine samples collected before and after 1-week kava dietary supplementation. The results showed that kava increased both NNAL-N-glucuronidation and O-glucuronidation. Since NNAL-N-glucuronidation is dominantly catalyzed by UGT2B10, its representative single-nucleotide polymorphisms (SNPs) were analyzed among the clinical trial participants. Individuals with any of the four analyzed SNPs appear to have a reduced basal capacity in NNAL-N-glucuronidation. Among these individuals, kava also resulted in a smaller extent of increases in NNAL-N-glucuronidation, suggesting that participants with those UGT2B10 SNPs may not benefit as much from kava with respect to enhancing NNAL-N-glucuronidation. In summary, our results provide further evidence that kava enhances NNAL urinary detoxification via an increase in both N-glucuronidation and O-glucuronidation. UGT2B10 genetic status has not only the potential to predict the basal capacity of the participants in NNAL-N-glucuronidation but also potentially the extent of kava benefits.

Pancreatic ductal adenocarcinoma (PDAC) is currently the third-leading cause of cancer-related death in the United States. African Americans (AAs) with PDAC have worse survival in comparison to other racial groups. The COVID-19 pandemic caused significant stress to the healthcare system. We aim to evaluate the pandemic's impact on already known disparities in newly diagnosed patients with PDAC in Florida.

BackgroundThe US Food and Drug Administration (FDA) has regulatory authority to use inserts to communicate with consumers about harmful and potentially harmful constituents (HPHCs) in tobacco products; however, little is known about the most effective manner for presenting HPHC information.MethodsIn a discrete choice experiment, participants evaluated eight choice sets, each of which showed two cigarette packages from four different brands and tar levels (high vs low), accompanied by an insert that included between-subject manipulations (ie, listing of HPHCs vs grouping by disease outcome and numeric values ascribed to HPHCs vs no numbers) and within-subject manipulations (ie, 1 of 4 warning topics; statement linking an HPHC with disease vs statement with no HPHC link). For each choice set, participants were asked: (1) which package is more harmful and (2) which motivates them to not smoke; each with a ’no difference' option. Alternative-specific logit models regressed choice on attribute levels.Results1212 participants were recruited from an online consumer panel (725 18–29-year-old smokers and susceptible non-smokers and 487 30–64-year-old smokers). Participants were more likely to endorse high-tar products as more harmful than low-tar products, with a greater effect when numeric HPHC information was present. Compared with a simple warning statement, the statement linking HPHCs with disease encouraged quit motivation.ConclusionsNumeric HPHC information on inserts appears to produce misunderstandings that some cigarettes are less harmful than others. Furthermore, brief narratives that link HPHCs to smoking-related disease may promote cessation versus communications that do not explicitly link HPHCs to disease.

Numerous epidemiological accounts suggest that waterpipe smoking (aka hookah, shisha, narghile) has become a global phenomenon, especially among youth. The alarming spread of waterpipe and accumulating evidence of its addictive and harmful effects represent a new threat in the global fight to limit tobacco-related morbidity and mortality. In response to waterpipe's alarming trends, major public health and tobacco control organisations have started or are considering systematic collection of data about waterpipe smoking to monitor its trends and assess its harmful effects in different societies. Such plans require coordination and agreement on epidemiological measurement tools that reflect the uniqueness of this tobacco use method, and at the same time allow comparison of waterpipe trends across time and place, and with other tobacco use methods. We started a decade ago our work to develop standardised measures and definitions for the assessment of waterpipe smoking in epidemiological studies. In this communication, we try to expand and update these assessment tools in light of our increased knowledge and understanding of waterpipe use patterns, its context and marketing, as well as the need for evidence-guided policies and regulations to curb its spread. We have assembled for this purpose a group of leading waterpipe researchers worldwide, and worked through an iterative process to develop the suggested instruments and definitions based on what we know currently about the waterpipe epidemic. While the suggested measures are by no means comprehensive, we hope that they can provide the building blocks for standard and comparable surveillance of waterpipe smoking globally.

Access to substance use disorder (SUD) treatment remains a significant issue in the United States. Telehealth has potential for increasing access to services; however, it is underutilized in SUD treatment compared to mental health treatment. This study uses a discrete choice experiment (DCE) to examine stated preferences for telehealth (videoconferencing, text-based + video, text only) versus in-person SUD treatment (community-based, in-home) and the attributes (location, cost, therapist choice, wait time, evidence-based practices) most important when choosing between modalities. Subgroup analyses are reported about preference differences based on type of substance and substance use severity.

IMPORTANCE: Since 2001, there has been a rapid adoption of positron emission tomography (PET) for diagnosis and American Joint Committee on Cancer (AJCC) staging of head and neck cancer (HNC) without data describing improved clinical outcomes. OBJECTIVE: To determine the association between increased use of PET and stage and/or survival for patients with HNC in the managed care environment. DESIGN, SETTING, AND PARTICIPANTS: Adult patients diagnosed as having HNC (n = 958) from 2000 to 2008 at 4 integrated health systems were identified via tumor registries linked to administrative data. The AJCC stage distribution, patient and treatment characteristics, and survival between pre-PET era (2000-2004) vs PET era (2005-2008) and use of PET vs no use of PET during the PET era were compared. The AJCC stages were categorized to represent localized (stage I or II), locally advanced (stage III, IVA, or IVB), and metastatic (stage IVC) disease. INTERVENTIONS: Treatments were determined by billing codes for surgery, radiation treatment, and chemotherapy. MAIN OUTCOMES AND MEASURES: The primary outcome for this study was the use of PET. Secondary outcomes included treatment received and 2-year survival. A logit model estimated the effects of PET on diagnosis of locally advanced disease. Kaplan-Meier estimates described overall survival differences between PET and non-PET. Cox regression evaluated the association of PET on survival in patients with locally advanced disease. RESULTS: An association between PET and locally advanced disease was found (odds ratio, 2.86 [95% CI, 1.90-4.29) (P < .001). Two-year overall survival for patients with locally advanced disease with and without PET was 52% and 32%, respectively (P = .004), but there was no difference for all stages (P = .69). On Cox proportional hazard regression, PET had no association with survival in patients with locally advanced disease (hazard ratio, 1.208 [95% CI, 0.778-1.877]) (P = .40). CONCLUSIONS AND RELEVANCE: The increasing use of PET among patients with HNC is associated with a greater number of patients with higher-stage disease and a dilution of the population with higher-stage disease with patients who have a better prognosis. Thus, the improved survival in patients with locally advanced disease likely reflects selection bias and stage migration. Further research on PET use among patients with HNC is necessary to determine if it results in improved treatment for individual patients.

Little is known about the medical care resources devoted to diagnosing and treating cancer-related symptoms before a definitive cancer diagnosis. Previous research using SEER-Medicare data to measure incremental costs and utilization associated with cancer started with the date of diagnosis. We hypothesized that health care use increases before diagnosis of a new primary cancer.

Introduction:Acute GVHD (aGVHD) contributes to poor outcomes and increased healthcare resource utilization (HRU) after allogeneic stem cell transplantation (allo-HCT). However, HRU and the economic burden of aGVHD based on severity of the disease and organ involvement is not well characterized. We examined the HRU, cost and mortality associated with aGVHD severity from initial hospitalization (index admission) up to 100 days post allo-HCT.

•Severe acute graft-versus-host disease (grade III-IV aGVHD) was significantly associated with higher total health resource utilization (HRU), economic burden and inferior survival post allogeneic stem cell transplantation (HCT).•Lower gastrointestinal (GI) involvement irrespective of the grade of aGVHD was associated with higher HRU, cost and mortality compared with aGVHD without lower GI involvement•Effectively mitigating severe aGVHD may improve survival and substantially reduce HRU and costs of HCT.

Comparative effectiveness research (CER) can make important contributions to the transformation of US health care by filling gaps left by tightly controlled clinical trials. However, without comprehensive and comparable data that reflect the diversity of the US health-care system, CER’s value will be diminished. We document the limits of observational CER by examining the age at diagnosis, disease stage, and select measures of health-care use among individuals diagnosed with incident cancer aged 65 or older from four large health maintenance organizations (HMOs) relative to seniors identified through the linked Surveillance, Epidemiology, and End Results (SEER)–Medicare data for the period 1999–2007. Aged individuals in the HMOs were younger, diagnosed at earlier stages, and more likely to receive care in inpatient settings than individuals in the linked SEER–Medicare data. These differences highlight the need for comprehensive and comparable datasets that reflect the diversity of US health care to support CER that can inform health-care reform in the United States.