Background: The topics “interventions for smoking cessation” as well as “embracing harm reduction through alternative nicotine products” have been referred to family doctors in different districts over the past 5 years, as part of a continuous training activity.

Material and Methods: The activity was conducted during the years 2016-2022 for health personnel in the districts of Tirana, Elbasan, Korca, Durrës, Vlora and beyond. The level of knowledge obtained was evaluated through the forms filled in by the participants. Pre-test and Post-test were two important mechanisms through which personnel was evaluated for the knowledge they had before and after training.

Results: Four hundred seventy doctors, nurses, pharmacists, participating in these training activities have been informed about “Smoking” as a public health problem. 61% women and 39% men. Considerable participation was from both rural (42%) and urban areas (58%). Based on the evaluation of the activity it was found that 72.3% of the participants stated that they upgraded the knowledge and are able to advice and offer help if a smoker wants to stop (p<0.01). The percentage of doctors who answered correctly varies from 45% to 92%.

Conclusions: It is important to increase the level of knowledge of health personnel on harm reduction as it reduces the smoking prevalence in the communities they serve among smokers who quit smoking and as well as for those smokers who do not agree to quit or cannot quit smoking by using less harmful products. Quitting smoking and harm reduction go hand in hand.

AUTHORS: Adrian Hoxha¹, Roland Shuperka², Redona Shuperka², Alba Agaraj¹, Bukurie Hysenaj¹, Artan Simaku³

AFFILIATIONS: ¹Department of Public Health, Faculty of Medicine, University of Medicine, Tirana, Albania || ²NGO “For Albania without smoking” || ³Institut of Public Health, Tirana, Albania

Background: Belarus National Household Survey 2019 found 23.7% prevalence of adult tobacco smoking (male 43.2%, female 10.7%) and 3.8% prevalence of Electronic Nicotine Delivery Systems (ENDS) consumption (males 4.2%, females 2.3%). The total amount of DALYs lost from all risk factors in the Belarus in 2019 was 2,095,967 years (smoking responsible for 26.9%) and lost from all death causes - 3,740,663 years (15.1% - smoking-related). Tobacco Atlas Belarus in 2016 shows that tobacco smoking economic burden was 4.7 B USD.

Description: Goal of the study was the evaluation of economic costs of preventable harms to public health by switching from tobacco to reduced risk nicotine products based on modeling utilizing current prevalence of smoking and of alternative products use and their impact on health research data.

Results: Recent sociological research evaluate ENDS consumption in the adult population as 17.1% (11.0% users of e-cigarettes and 6.1% users of heated tobacco products - HTPs). Raise of HTPs use associate with decrease of smoking (from 29.6 and 3.8 in 2016 to 26.7 and 6.1 in 2020, respectively). The economic benefits of implementation of Tobacco Harm Reduction (THR) in Belarus were calculated under various models (all population, 200,000 smokers and 100,000 city population) and different levels of prevented harm (70% and 30%). All population model shows decrease of all mortality up to 8.2% with saving of 4.4 M USD. Switching of 200,000 smokers to HTPs could save 5% of DALYs lost with 31.2-72.8 M USD savings per year. 100,000 city model find lost savings are 2200-5132 of DALYs and 19.0-44.2 M USD and for 9.5 M Belarus population preventable burden will be 1,805-4,199 B USD per year.

Conclusions: Current tobacco control legal regulation in Belarus should be adapted to THR approach and public health specialists should be principal advocates of switching from tobacco to ENDS.

AUTHORS: Alexei Alexandrov¹, Dmitry Ruzanov², Vitaly Pisaryk²

AFFILIATIONS: ¹Minsk Regional Clinical Center “Psychiatry-Narcology”, Minsk, Belarus || ²Republican Scientific and Practical Center for Medical Technologies, Informatization, Management and Health Economics, Minsk, Belarus

Background: The aim of study was to identify differences in groups of smokers using different tobacco delivery devices.

Material and Methods: 57 smokers were surveyed and divided into 3 groups: users of regular cigarette (RC), electronic cigarettes (EC/vapes) and heated tobacco product (HTP). No age differences were found. Research methods included a questionnaire on the use of various means of tobacco delivery, the Horn questionnaire, the Fagerström test, a scale for assessing the degree of readiness to quit smoking.

Results: The severity of nicotine addiction in 1^st group was 2.2 points, in 2^nd - 3.3, in 3^rd - 3.6 (p=0.01). The degree of willingness to quit smoking was significantly lower in EC/vapes smokers (3.4 vs 5.5 and 5.9 points in groups 1 and 3). “Support” type dominated in all groups (36.8%, 46.7%, 34.3%). This type is associated with emotional stress. On the second place was “relaxation” type, especially in the EC group (30%, p=0.003). They smoke only in comfortable conditions. In the HTP group, the “thirst” type was significantly more common (26.4%). “Reflex”, “game”, “stimulation” were less common. Transfer to HTP wasn’t recommended by doctors. 84% of RC smokers and 89.7% of persons from the HTP group combined smoking and alcohol or drinking coffee. Correlative analysis revealed a moderate direct relationship in the group of RC smokers (r=0.4).

Conclusions: 1. The severity of nicotine dependence was greatest in the HTP group, and the lowest motivation to quit smoking was in the EC/vape group. “Support” was the predominant type of smoking in all groups. “Relaxation” was the prevalence in the EC/vape group, “thirst” in the HTP group. 2. Most smokers tend to combine smoking with alcohol and coffee. 3. Medical personnel are not aware of the concept of tobacco harm reduction. It is necessary to continue work in this direction.

AUTHORS: Aigul Zinnatullina, Lubov Palmova

AFFILIATION: Kazan State Medical University, Kazan, Russian Federation

Tobacco smoking is a major risk factor for oral diseases such as oral cancer and periodontitis (US Surgeon General 2014). Dental professionals have an important role to play in providing smoking cessation advice and support to their patients who smoke and in considering this risk factor when planning and providing dental treatment. The use of heat-not-burn tobacco products (HnB) is being adopted increasingly as an alternative to smoking combusted products. Peer-reviewed evidence indicates that HnB are effective nicotine delivery devices that expose users and bystanders to substantially fewer harmful and potentially harmful compounds than smoking cigarettes. The effect of HnB on oral health is not fully understood and is still debated among many scientists and clinicians.

The number of studies addressing the potential toxic effect of HnB aerosol on oral cells is limited along with the clinical studies which are still preliminary, and their sample size is limited. The long-term effects of inhaled aerosols and the potential synergistic effect of the HnB components are not known. In this short review, we review the evidence in 4 main areas: 1) basic science studies that evaluated cell lines and tissue cultures, 2) microbiological evidence from basic science and clinical research, 3) evidence from clinical studies evaluating oral health and smoking cessation (in dental settings), and 4) evidence from epidemiological studies.

There is a clear need for further well-conducted studies in this field. Those areas that have the strongest potential to benefit patients are understanding the oral health consequences in nonsmokers who initiate HnB use, establishing the effectiveness of HnB as a tobacco quit aid (especially within the dental setting), and understanding any impacts on periodontal health and oral cancer in smokers who switch to HnB.

AUTHOR: Naichia Teng

AFFILIATION: Taipei Medical University, Taiwan

Background: Our objective was to identify smoking cessation in patients with MNS in order to investigate the possibility of implementing a specialized smoking cessation assistance program or reducing the harm from tobacco smoking.

Material and Methods: An initiative group developed an online questionnaire stratified by smoking, length of service, sex, age, comorbidities, educational level, financial status, smoking cessation methods, other addictions. The survey of 556 patients treated in Prof. M.Z. Segal’s Republican Clinical Hospital of RT was conducted, among them 262 people have the status of an active smoker.

Results: The greatest percent of smokers was found among men – 89.3% of age more than 60 years old. The duration of smoking experience was more than 5 years in 81.9% of patients, and the habit manifested before 18 years in 57.6%. 67.1% of the respondents smoked more than a pack of cigarettes a day, 45% of the patients had a history of concomitant pathologies of the cardiovascular and respiratory systems. 88.2% of those surveyed had tried to quit smoking, only 14% were able to quit. A high motivation to quit smoking was found among 63% of the patients surveyed because the process of quitting smoking can be long-term and quit attempts are not always successful; this is due to the nicotine addiction of the patients. 42% of the respondents tried to quit smoking 1-2 times. 19.8% made 3 to 5 attempts to quit. 9.9% tried to quit smoking over 5 times, and 28.2% of the patients responded that they had never tried to quit smoking. 35.4% of continuing smokers had sought help from specialists to quit; of these, 7.5% had a maximum interval of more than a year without smoking. 10.7% were able to abstain from smoking for 6 to 12 months. 48.3% of respondents had a maximum interval of less than 6 months without smoking. 4.5% of the respondents answered that they decided to quit smoking because of their disease, and the maximum period of abstinence from smoking for these patients was less than 6 months. 33% of patients responded that they could not quit smoking for a single day. These patients are not motivated or cannot quit smoking. In order to minimize the toxic effects of tobacco smoking, switching to HTS can be recommended because the HTS aerosol does not contain combustion products that are potentially harmful to the body.

Conclusions: The high compliance identified indicates the need to provide patients with tobacco cessation assistance. Smoking cessation should be a component of cancer treatment. Patients who are unwilling or unable to quit completely can be advised on the concept of harm reduction.

AUTHORS: Sufiia Safina, Aigul Fayrushina

AFFILIATION: GAUZ, Kazan, Republic of Tatarstan, Russian Federation

Cigarette smoking is a risk factor for several diseases such as cancer, cardiovascular disease (CVD), and chronic obstructive pulmonary diseases (COPD), however, the underlying factors are not fully understood. Alternative nicotine products with reduced risk potential (RRPs) including heated tobacco products (HTPs) and e-cigarettes have recently emerged as a viable alternative to cigarettes, that may contribute to the overall strategy of tobacco harm reduction due to the significantly lower levels of toxicants and potentially harmful constituents in these products’ emissions as compared to cigarette smoke. Assessing the effects of RRPs on biological responses is important to demonstrate the potential value of RRPs towards tobacco harm reduction. Here, we evaluated the inflammatory and signaling responses of human lung epithelial cells to aqueous aerosol extracts (AqE) generated from the 1R6F reference cigarette, the glo™ HTP, and the Vuse ePen 3 e-cigarette using multiplex analysis of 37 inflammatory and phosphoprotein markers. Cellular exposure to the different RRPs and 1R6F AqEs resulted in distinct response profiles with 1R6F being the most biologically active followed by glo™ and ePen 3. 1R6F activated stress-related and pro-survival markers c-JUN, CREB1, p38 MAPK and MEK1 and led to the release of IL-1α. glo™ activated MEK1 and decreased IL-1β levels, whilst ePen 3 affected IL-1β levels but had no effect on the signaling activity compared to untreated cells. Our results demonstrated the reduced biological effect of RRPs and suggest that targeted analysis of inflammatory and cell signaling mediators is a valuable tool for the routine assessment of RRPs.

AUTHORS: Nikos Tsolakos¹, Linsey E. Haswell², Fabio Miazzi², Emma Bishop², David Smart², Asier Antoranz¹, Vaia Pliaka¹, Angeliki Minia¹, Leonidas G. Alexopoulos^1,3, Marianna Gaca², Damien Breheny²

AFFILIATIONS: ¹Protavio Ltd, Agia Paraskevi, Attiki, Greece || ²B.A.T. (Investments) Limited, Southampton, UK || ³Biomedical Systems Laboratory, School of Mechanical Engineering, National Technical University of Athens, Greece

Background: Tobacco smoking is a major public health problem throughout the world, especially for young adults. While smoking prevalence has a decrease among developed countries, for other countries it is still an increasing risk factor for public health. The study describes the prevalence of different forms of smoking, and the correlates of current smoking.

Material and Methods: The study enrolled a total of 336 students from Tirana Medical University who fulfilled an anonymous self-administered online questionnaire regarding tobacco and e-cigarettes smoking during the year 2022.

Results: Sixty four percent of respondents reported ever smoking whereas the overall prevalence of daily cigarette smoking was 10.5% accounting for 22% of males and only 2.4% of the females with a higher prevalence for those aged 21–23 years (44%). The mean age of starting smoking was 15.3 (±4.6) years with a range 11-17 years old. Only 6% of current smokers use e-cigarettes and vaping devices. Older participants were more likely to report smoking more cigarettes/day. Only 5.8% reported to discuss in family about the harm from smoking. In logistic regression analysis older age, living away from home, smoking by family and close friends, a lower level of parents’ education and exposure to tobacco promotion were predictors of current smoking status. Only 35% of students have tried to quit smoking.

Conclusions: The results of this study provide interesting insights on smoking among students and can be used to help develop an effective health promotion program to prevent smoking among university students.

AUTHORS: Adrian Hoxha¹, Roland Shuperka², Artan Simaku^2,3

AFFILIATIONS: ¹Faculty of Medicine, Tirana Medical University, Albania || ²National Association of Public Health of Albania || ³Institute of Public Health, Tirana, Albania

Adverse outcome pathways (AOPs) are simple linear or branching paths representing a sequence of molecular, cellular, tissue, and organ level perturbations (or “key events”). They are triggered by the interaction between a particular compound and a cellular component (identified as the “molecular initiating event”) that precedes an adverse outcome (AO) at the organism or population level. AOPs integrate data from alternative test methods in line with the “3R” paradigm (to refine, reduce, and replace laboratory animals) and serve the development of new predictive tools for hazard assessment.

Here, we took advantage of the AOP 411 that describes how increased oxidative stress, reduced ciliary beat frequency (CBF) and reduced mucociliary clearance (MCC) sequentially lead to decreased lung function to develop mathematical models reflecting the relationships between key events and allowing the quantification of AO prediction.

As a case study, we evaluated the potential risk of impaired lung function associated with tobacco heating system (THS) use compared with cigarette smoking, by using data from a series of in vitro studies on the THS, employing advanced human tissue culture models, and by mapping them in the AOP 411. Our new quantitative AOP (qAOP) predicted a 48.7% reduced risk of decreased CBF based on measurement of oxidative stress indicators and 18.4% reduced risk of decreased MCC based on measurement of CBF in THS aerosol compared with cigarette smoke-exposed cultures.

Finally, modeling based on human MCC data predicted a 79.3% reduced risk of decreased lung function in heated tobacco product switchers compared with smokers. In summary, the development and use of this new qAOP may be a potent alternative to evaluate the risk of decreased lung function in the context of tobacco harm reduction while waiting for long-term clinical studies and epidemiological data.

AUTHORS: Carole Mathis, Alain Sewer, Florian Calvino, Karsta Luettich, Anita Iskandar, Marja Talikka

AFFILIATION: R&D, Philip Morris International