摘要：Objectives. We provided estimates of noncombustible tobacco product (electronic nicotine delivery systems [ENDS]; snus; chewing tobacco, dip, or snuff; and dissolvables) use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use. Methods. We assessed awareness of, prevalence of, purchase of, harm perceptions of, and reasons for using noncombustible tobacco products among 1487 current and former smokers from 8 US designated market areas. We used adjusted logistic regression to identify correlates of noncombustible tobacco product use. Results. Of the sample, 96% were aware of at least 1 noncombustible tobacco product, but only 33% had used and 21% had purchased one. Noncombustible tobacco product use was associated with being male, non-Hispanic White, younger, and more nicotine dependent. Respondents used noncombustible tobacco products to cut down or quit cigarettes, but only snus was associated with a higher likelihood of making a quit attempt. Users of noncombustible tobacco products, particularly ENDS, were most likely to endorse the product as less harmful than cigarettes. Conclusions. Smokers may use noncombustible tobacco products to cut down or quit smoking. However, noncombustible tobacco product use was not associated with a reduction in cigarettes per day or cessation. The use of noncombustible tobacco products has increased rapidly in recent years 1–3 and may continue to rise in response to restrictions such as smoke-free indoor air laws and rising cigarette taxes. 4–8 Noncombustible tobacco products can be grouped into 2 broad categories—aerosolized products such as e-cigarettes, or more accurately termed electronic nicotine delivery systems (ENDS), which deliver nicotine primarily through vapor inhalation that mimics smoking a traditional cigarette, 9 and smokeless tobacco products such as chew, dip, or snuff; snus; and dissolvables, which deliver nicotine via oral mucosal absorption. 10 These products are marketed to appeal to unique target audiences, 9,11–13 such as smokers and young adults, and vary in levels of harmful constituents. 9 Noncombustible tobacco products are a critical part of the tobacco industry’s strategy to navigate the changing tobacco product landscape. Phillip Morris 14,15 and RJ Reynolds 16 have announced their intent to develop and market noncombustible tobacco products as part of a shift to reduced harm products. 17 In some cases, noncombustible tobacco products have been used to expand the appeal of established cigarette brands to a broader spectrum of consumers, as with RJ Reynolds’s Camel Snus product. 18 Most ENDS are marketed and sold independently; however, this is changing with Lorillard’s acquisition of blu eCigs in 2012 19,20 and the recent launches of RJ Reynolds’s Vuse digital vapor cigarettes 21,22 and Altria’s MarkTen e-cigarettes. 23 Noncombustible tobacco product awareness and prevalence vary by product. In 2010, approximately 40% of adults reported awareness of e-cigarettes, 24,25 rising to nearly 60% in 2011 25 ; awareness approached 75% among current and former smokers in 2010 to 2011. 26 Between 1.8% and 3.4% of the adult general population has tried an e-cigarette, 24,25,27,28 including up to 21.2% of current smokers. 25,26 More than 40% of adults have heard of snus, 29 5% have tried the product, 29 and 1.4% are current users. 30 Awareness of dissolvables is low (10%), and use is even lower (0.5%). 29 Noncombustible tobacco product use is highest among young adults 26,31 and smokers. 24,27,28 Although use of noncombustible tobacco products could potentially reduce harm associated with smoking if they replace cigarettes, 32,33 some studies suggest that current smokers who use noncombustible tobacco products do not reduce combustible use and may delay cessation. 12,34–37 For example, a study by Wetter et al. 38 found that dual users of smokeless tobacco products and cigarettes were less likely to quit than were either smokeless tobacco product or cigarette users alone. This is of concern given the rising rates of dual use; a recent study reported that 30% of young adults who smoke cigarettes use at least 1 other tobacco product. 31 Dual use is more prevalent among men, 39,40 those of lower socioeconomic status, 39,41 and youths and young adults. 35,41,42 Studies show that most users (65%–85%) perceive ENDS as less harmful than cigarettes, 24,26,43 and 40% to 50% perceive snus and dissolvables as equally harmful as cigarettes. 29 Few studies have examined reasons for use; one study of visitors to ENDS and smoking cessation Web sites found that nearly 85% used ENDS because they believed that they were less toxic than tobacco; other responses included use of ENDS to deal with cravings or withdrawal, to quit smoking, and to save money. 43 Focus group research has shown that adults associate snus and dissolvables with historic images of chewing tobacco, 34,44 express skepticism that the products are safer than cigarettes, 34 do not view them as substitutes for cigarettes, 34,44 and express concern about the user’s lack of control of nicotine ingestion relative to cigarettes. 44 By contrast, young adults expressed positive perceptions of snus, dissolvables, and ENDS, in part because of a willingness to experiment with new products and because they are available in flavors. 45 With the ever-changing tobacco marketplace and the tobacco companies’ commitment to the development and promotion of noncombustible tobacco products, surveillance is critical. This study built on previous research to provide current estimates of noncombustible tobacco product use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.
