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North American Quitline Consortium
October 2015

For quick navigation, please click on the titles below of the topics featured in this month's issue of Connections
  Time-Sensitive News


NEW NAQC Resources on Medicaid, eReferral ENDS, and Calculating Quit Rates!
In the last few weeks, NAQC has released a number of important resources, as shown below. We hope that you find them to be useful!  Please note, the implementation date for the new MDS questions and the quit rate calcuations are January 1, 2016!
  • Guide for Implementing eReferral Using Certified EHRs
    This guide is a resource for quitlines and other cessation services that would like to establish referral systems with healthcare electronic health record  (EHR) systems. It provides recommended standards for implementing eReferral in a straightforward and efficient way.
  • New MDS Questions on Electronic Nicotine Delivery Systems (ENDS).
    NAQC asks quitlines to  incorporate the STANDARD MDS Intake and Follow-up questions on ENDS, as well as any OPTIONAL questions the quitline may choose, beginning January 1, 2016. This will ensure that quitline evaluations begun after January 2016 will include questions necessary for calculating the new NAQC quit rates
  • Online Medicaid Toolbox.
    The Toolbox provides building blocks for advancing your work with Medicaid! Each building block represents a specific type of activity or stage of action to advance quitlines’ activities with Medicaid and to  improve  the access of Medicaid members to cessation services.
  • Calculating Quit Rates, 2015 Update (Including Implementation Guide).
    The full paper is intended to be a stand-alone document to support efforts to produce a standard NAQC quit rate. While randomized controlled trials have established the efficacy of quitlines, quit rates can assess the effectiveness of quitlines in real-world settings, under certain conditions or with different populations. NAQC asks all quitlines to begin using the new standard calculations for evaluations that begin after January 1, 2016.
Sign-on Letter on Appropriations Issues!
In September, NAQC joined 53 other national tobacco control organizations in signing onto a coalition letter on Appropriations issuesThis letter highlights the adverse impact of the proposed  50 percent cut to CDC’s  Office on Smoking and Health in the House LHHS Appropriations bill.  The letter went to the Chair and Ranking member of the full House and Senate Appropriations committees (Representatives Rogers and Lowey and Senators Cochran and Mikulski) as well as the Chair and Ranking members of the Agriculture (Representatives Aderholt and Farr and Senators Moran and Merkley) and LHHS (Representatives Cole and DeLauro and Senators Blunt and Murray) subcommittees.  

Webinar Training  Series on eReferral - SAVE THE DATES! 
This week, NAQC hosted the second call in the Webinar Training Series on eReferral,  made possible with funding from Pfizer Independent Grant for Learning & Change, in partnership with Smoking Cessation Leadership Center. This webinar training series is intended to provide practical training on building eReferral capacity.  The slides and recordings of the past calls are available online. The dates and topics for the five webinars are: 
September 22, 2015 12:00 – 1:30 pm ET eReferral Training Webinar #1:  Meaningful Use and the Technical Approach to eReferral (recording available online)
October 13,  2015 12:00 – 1:30 pm ET eReferral Training Webinar #2:  Structure of eReferrals (recording available online)
November 10, 2015 12:00 – 1:30 pm ET eReferral Training Webinar #3: HL7 and Interoperability
December 8, 2015 12:00 – 1:30 pm ET eReferral Training Webinar #4: Message Transport and Message Delivery
June 7, 2016 12:00 – 1:30 pm ET eReferral Training Webinar #5: Refining Your eReferral System After Implementation

 Find more NAQC News in our Newsroom or go back to top.

Time-Sensitive News

Upcoming Webinar: CDC's Public Health Grand Rounds Presents: "E-cigarettes: An Emerging Pubic Health Challenge"!
On Tuesday, October 20, 2015 (1-2 pm ET), CDC will host a Public Health Grand Rounds on “E-cigarettes: An Emerging Public Health Challenge.” Speakers will include:
Brian King, PhD, MPH
Deputy Director for Research Translation, OSH/CDC
“Patterns of E-cigarette Use Among U.S. Adults and Youth”
Jonathan M. Samet, MD, MS
Distinguished Professor and Flora L. Thornton Chair, USC
“Health Consequences of Electronic Cigarettes”

John Wiesman, DrPH, MPH
Secretary of Health, State of Washington
“E-cigarettes in Washington State: On the Front Lines”
Matthew L. Myers
Campaign for Tobacco-Free Kids
“Attaining a Tobacco-Free Generation and the Emergence of E-cigarettes”
For non-CDC staff interested in viewing the session:
A live external webcast will be available.  For individuals who are unable to view the session during the scheduled time, the archived presentation will be posted 48 hours after each session.
For questions about this Grand Rounds topic:
Feel free to e-mail your questions before or during the session.
» learn more!

Find more Time-Sensitive News in our Newsroom or go back to top.

Tobacco Control

New Resources from The Behavioral Health & Wellness Program University of Colorado!
Are you working on tobacco control & cessation with partners in behavioral health? The Behavioral Health & Wellness Program University of Colorado has released two new toolkits and a series of videos for encouraging adoption of tobacco free policies and peer-support programs by behavioral health care institutions. These toolkits along with a series of short videos to assist interdisciplinary providers effectively use the 5A’s model are available at:
HUD Resources!
The U.S. Department of Housing and Urban Development is providing outstanding support for the smoke-free multifamily housing movement in the form of tools and resources. Click HERE to access a web portal with a wealth of tools and resources. Quitlines have a role to play in making services available for residents who smoke as HUD housing goes smokefree. Review the Change is in the Air action guide to learn more about how to adopt and implement a smoke-free housing policy.  
» learn more  

CDC's New Best Practices Guide on Health Equity!
New Best Practices Guide: Health Equity in Tobacco Prevention and Control, Bridgette Garrett, CDC/OSH and Stephanie Anderson, Center for Public Health Systems Science at Washington University in St. Louis. 
» learn more

New FDA Videos on the Latest Tobacco Research!
Watch Scientists Discuss the Latest Tobacco Research:  The FDA recently launched two new videos as part of a series that features scientists who are leading important tobacco regulatory research. Listen to scientists describe their research and its importance to public health.*
  • Stephen Higgins, Ph.D., discusses research on how reducing the nicotine levels in cigarettes may change smoking behaviors in vulnerable populations.
  • Suchitra Krishnan-Sarin, Ph.D., discusses research on the impact of flavors on the initiation, preference, and development of addiction to tobacco products, especially among children and adolescents.
The FDA is currently funding a broad range of important research in tobacco regulatory science, most in collaboration with the National Institutes of Health. These projects help CTP with the knowledge base for decision-making.  Watch the entire collection of 10 videos.
*The opinions in these videos reflect the views of individual researchers and not necessarily the official position of the CTP.

Find more Tobacco Control in our Newsroom or go back to top.

Lemaire RH, Bailey L, Leischow SJ.
Meeting the Tobacco Cessation Coverage Requirement of the Patient Protection and Affordable Care Act: State Smoking Cessation Quitlines and Cost Sharing. 
Am J Public Health. 2015 Oct 8:e1-e7. [Epub ahead of print]
We explored whether various key stakeholders considered cost sharing with state telephone-based tobacco cessation quitlines, because including tobacco cessation services as part of the required essential health benefits is a new requirement of the Patient Protection and Affordable Care Act (ACA).
We analyzed qualitative data collected from interviews conducted in April and May of 2014 with representatives of state health departments, quitline service providers, health plans, and insurance brokers in 4 US states.
State health departments varied in the strategies they considered the role their state quitline would play in meeting the ACA requirements. Health plans and insurance brokers referred to state quitlines because they were perceived as effective and free, but in 3 of the 4 states, the private stakeholder groups did not consider cost sharing. If state health departments are going to initiate cost-sharing agreements with private insurance providers, then they will need to engage a broad array of stakeholders and will need to overcome the perception that state quitline services are free.

Albert L. Siu, MD, MSPH, for the U.S. Preventive Services Task Force*
Behavioral and Pharmacotherapy Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Women: U.S. Preventive Services Task Force Recommendation Statement USPSTF Recommendation Statement for Interventions for Tobacco Smoking Cessation.
Ann Intern Med. Published online 22 September 2015 doi:10.7326/M15-2023
 Update of the 2009 U.S. Preventive Services Task Force (USPSTF) recommendation on counseling and interventions to prevent tobacco use and tobacco-related disease in adults, including pregnant women.  The USPSTF reviewed the evidence on interventions for tobacco smoking cessation that are relevant to primary care (behavioral interventions, pharmacotherapy, and complementary or alternative therapy) in adults, including pregnant women. This recommendation applies to adults aged 18 years or older, including pregnant women.

  • The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration–approved pharmacotherapy for cessation to adults who use tobacco. (A recommendation)
  • The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. (A recommendation)
  • The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women. (I statement)
  • The USPSTF concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation in adults, including pregnant women. The USPSTF recommends that clinicians direct patients who smoke tobacco to other cessation interventions with established effectiveness and safety (previously stated). (I statement)
S. René Lavinghouze, MA; Ann Malarcher, PhD; Amal Jama, MPH; Linda Neff, PhD; Karen Debrot, DrPH; Laura Whalen, MPH
Trends in Quit Attempts Among Adult Cigarette Smokers — United States, 2001–2013
Morbidity and Mortality Weekly Report. October 15, 2015.
CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) for the years 2001-2010 and 2011–2013 to provide updated state-specific trends in quit attempts among adult smokers. During 2001-2010, the proportion of adult cigarette smokers who had made a quit attempt in the past 12 months increased in 29 states and the US Virgin Islands. During 2011-2013, quit attempts increased in Hawaii and Puerto Rico and decreased in New Mexico. In 2013, past year quit attempts were reported most frequently by smokers in Puerto Rico and Guam (76.4%) and least frequently by those in Kentucky (56.2%). In every state, older smokers were generally less likely to report a past year quit attempt than were younger smokers.
The findings in this report support previous findings on variations in quit attempts among state and underscore the continued need for surveillance and evaluation of health-risk behaviors to guide preventive health care services. Variations by states in the proportion of cigarette smokers who reported having made a quit attempt in the past year might be attributed to a number of factors, including differences in population demographics; tobacco control program infrastructure, programs, and policies; and awareness, availability, accessibility, and use of smoking cessation treatments. Nationally, younger people, African Americans, and those with higher than a high-school diploma were more likely to report quit attempts in the last year than were older people, whites, and those with less education.
Eric C. Donny, Ph.D., Rachel L. Denlinger, B.S., Jennifer W. Tidey, Ph.D., Joseph S. Koopmeiners, Ph.D., Neal L. Benowitz, M.D., Ryan G. Vandrey, Ph.D., Mustafa al’Absi, Ph.D., Steven G. Carmella, B.A., Paul M. Cinciripini, Ph.D., Sarah S. Dermody, M.S., David J. Drobes, Ph.D., Stephen S. Hecht, Ph.D., Joni Jensen, M.P.H., Tonya Lane, M.Ed., Chap T. Le, Ph.D., F. Joseph McClernon, Ph.D., Ivan D. Montoya, M.D., M.P.H., Sharon E. Murphy, Ph.D., Jason D. Robinson, Ph.D., Maxine L. Stitzer, Ph.D., Andrew A. Strasser, Ph.D., Hilary Tindle, M.D., M.P.H., and Dorothy K. Hatsukami, Ph.D.
Randomized Trial of Reduced-Nicotine Standards for Cigarettes.
N Engl J Med 2015; 373:1340-1349October 1, 2015DOI: 10.1056/NEJMsa1502403
We conducted a double-blind, parallel, randomized clinical trial between June 2013 and July 2014 at 10 sites. Eligibility criteria included an age of 18 years or older, smoking of five or more cigarettes per day, and no current interest in quitting smoking. Participants were randomly assigned to smoke for 6 weeks either their usual brand of cigarettes or one of six types of investigational cigarettes, provided free. The investigational cigarettes had nicotine content ranging from 15.8 mg per gram of tobacco (typical of commercial brands) to 0.4 mg per gram. The primary outcome was the number of cigarettes smoked per day during week 6.
In this 6-week study, reduced-nicotine cigarettes versus standard-nicotine cigarettes reduced nicotine exposure and dependence and the number of cigarettes smoked. (Funded by the National Institute on Drug Abuse and the Food and Drug Administration Center for Tobacco Products; number, NCT01681875.)

Zhang L, Malarcher A, Babb S, Mann N, Davis K, Campbell K, Schauer G, Alexander R, Debrot K, and Rodes R
The Impact of a National Tobacco Education Campaign on State-Specific Quitline Calls.
American Journal of Health Promotion 2015:doi:10.4278/ajhp.140825-QUAN-427.

The purpose of the study was to evaluate ads from the first federally funded national tobacco education campaign, Tips From Former Smokers (Tips), on state-specific quitline calls. The study concluded that the Tips campaign significantly increased calls to quitlines for almost all the states. These findings highlight the effectiveness of national tobacco media campaigns for reaching state audiences. Tips campaign exposure was measured by gross rating points (GRPs). Nationally, every 100 Tips GRPs per week, at the market level, was associated with an average of 45 additional quitline calls in a given area code. Tips GRPs were associated with significant increases in quitline calls in 46 states and the District of Columbia. Of the 46 states and DC, 11 experienced effects significantly larger than the national average and 5 experienced significantly smaller effects.

Jennifer L. Pearson, Cassandra A. Stanton, Sarah Cha, Raymond S. Niaura, George Luta, Amanda L. Graham. 
E-Cigarettes and Smoking Cessation: Insights and Cautions From a Secondary Analysis of Data From a Study of Online Treatment-Seeking Smokers. 
Nicotine Tob Res (2015) 17 (10): 1219-1227. doi: 10.1093/ntr/ntu269 First published online: December 26, 2014
Evidence from observational studies regarding the association between electronic cigarette (e-cigarette) use and cessation is mixed and difficult to interpret. Utilizing 2 analytic methods, this study illustrates challenges common in analyses of observational data, highlights measurement challenges, and reports associations between e-cigarette use and smoking cessation. Data were drawn from an ongoing web-based smoking cessation trial. The sample was comprised of 2,123 participants with complete 3-month follow-up data. Logistic regression models with and without entropy balancing to control for confounds were conducted to evaluate the association between e-cigarette use and 30-day cigarette smoking abstinence.
At follow-up, 31.7% of participants reported using e-cigarettes to quit in the past 3 months. E-cigarette users differed from nonusers on baseline characteristics including cigarettes per day, Fagerström score, quit attempt in the past year, and previous use of e-cigarettes to quit. At follow-up, e-cigarette users made more quit attempts and employed more cessation aids than smokers who did not use e-cigarettes to quit. E-cigarette use was negatively associated with abstinence after adjustment for baseline characteristics; however, the association was not significant after additional adjustment for use of other cessation aids at 3 months. The magnitude and significance of the estimated association between e-cigarette use and cessation in this study were dependent upon the analytical approach. Observational studies should employ multiple analytic approaches to address threats to validity. Future research should employ better measures of patterns of and reasons for e-cigarette use, frequency of e-cigarette use, and concurrent use of cessation aids.

Lila J. Finney Rutten, Kelly D. Blake, Amenah A. Agunwamba, Rachel A. Grana, Patrick M. Wilson, Jon O. Ebbert, Janet Okamoto, Scott J. Leischow.
Use of E-Cigarettes Among Current Smokers: Associations Among Reasons for Use, Quit Intentions, and Current Tobacco Use.
Nicotine Tob Res (2015) 17 (10): 1228-1234. doi: 10.1093/ntr/ntv003 First published online: January 14, 2015
Research has documented growing availability and use of e-cigarettes in the United States over the last decade. We conducted a national panel survey of current adult cigarette smokers to assess attitudes, beliefs, and behaviors relating to e-cigarette use in the United States (N = 2,254).
Among current cigarette smokers, 20.4% reported current use of e-cigarettes on some days and 3.7% reported daily use. Reported reasons for e-cigarette use included: quit smoking (58.4%), reduce smoking (57.9%), and reduce health risks (51.9%). No significant differences in sociodemographic characteristics between e-cigarette users and nonusers were observed. Prior quit attempts were reported more frequently among e-cigarette users (82.8%) than nonusers (74.0%). Intention to quit was reported more frequently among e-cigarette users (64.7%) than nonusers (46.8%). Smokers intending to quit were more likely to be e-cigarette users than those not intending to quit (odds ratio [OR] = 1.90, CI =1.36–2.65). Those who used e-cigarettes to try to quit smoking (OR = 2.25, CI = 1.25–4.05), reduce stress (OR = 3.66, CI = 1.11–12.09), or because they cost less (OR = 3.42, CI = 1.64–7.13) were more likely to report decreases in cigarette smoking than those who did not indicate these reasons. Smokers who reported using e-cigarettes to quit smoking (OR = 16.25, CI = 8.32–31.74) or reduce stress (OR = 4.30, CI = 1.32–14.09) were significantly more likely to report an intention to quit than those who did not indicate those reasons for using e-cigarettes. Nearly a quarter of smokers in our study reported e-cigarettes use, primarily motivated by intentions to quit or reduce smoking. These findings identify a clinical and public health opportunity to re-engage smokers in cessation efforts.

Deepa R. Camenga, MD, MHS, Dana A. Cavallo, PhD, Grace Kong, PhD, Meghan E. Morean, PhD, Christian M. Connell, PhD, Patricia Simon, PhD, Sandra M. Bulmer, PhD, Suchitra Krishnan-Sarin, PhD
Adolescents’ and Young Adults’ Perceptions of Electronic Cigarettes for Smoking Cessation: A Focus Group Study.
Nicotine Tob Res (2015) 17 (10):1235-1241.doi: 10.1093/ntr/ntv020

Research has shown that adults perceive that electronic cigarettes (e-cigarettes) are effective for smoking cessation, yet little is known about adolescents and young adults’ perceptions of e-cigarettes for quitting cigarette smoking. This study describes middle, high school, and college students’ beliefs about, and experiences with, e-cigarettes for cigarette smoking cessation. We conducted 18 focus groups (n = 127) with male and female cigarette smokers and nonsmokers in 2 public colleges, 2 high schools, and 1 middle school in Connecticut between November 2012 and April 2013. Participants discussed cigarette smoking cessation in relation to e-cigarettes. Verbatim transcripts were analyzed using thematic analysis.
All participants, regardless of age and smoking status, were aware that e-cigarettes could be used for smoking cessation. College and high school participants described different methods of how e-cigarettes could be used for smoking cessation: (a) nicotine reduction followed by cessation; (b) cigarette reduction/dual use; and (c) long-term exclusive e-cigarette use. However, overall, participants did not perceive that e-cigarette use led to successful quitting experiences. Participants described positive attributes (maintenance of smoking actions, “healthier” alternative to cigarettes, and parental approval) and negative attributes (persistence of craving, maintenance of addiction) of e-cigarettes for cessation. Some college students expressed distrust of marketing of e-cigarettes for smoking cessation. Adolescent and young adult smokers and nonsmokers perceive that there are several methods of using e-cigarettes for quitting and are aware of both positive and negative aspects of the product. Future research is needed to determine the role of e-cigarettes for smoking cessation in this population.

Dimitra Kale, Hazel M. Gilbert, Stephen Sutton
Are Predictors of Making a Quit Attempt the Same as Predictors of 3-month Abstinence From Smoking? Findings From a Sample of Smokers Recruited for a Study of Computer-tailored Smoking Cessation Advice in Primary Care Addiction.
Addiction. Volume 110, Issue 10, pages 1653–1664, October 2015
The aim of the study was to identify predictors of quit attempts and of 3-month abstinence from cigarette smoking using secondary analysis of data gathered for a two-armed randomized controlled trial with 6-month follow-up. A total of 4397 participants who completed the 6-month follow-up. Participants were categorized on self-reported smoking behaviour at 6-month follow-up as non-attempters (n = 2664), attempted quitters (n = 1548) and successful quitters (n = 185). Demographic characteristics, smoking history and nicotine dependence, cognitive and social–environmental factors measured at baseline were examined as potential predictors of quit attempts and 3-month abstinence. Univariate predictors of quit attempts included commitment [odds ratio (OR) = 11.64, 95% confidence interval (CI) = 8.30–16.32], motivation (OR = 2.10, 95% CI = 1.98–2.22) and determination to quit (OR = 1.94, 95% CI = 1.83–2.05). Successful quitting was associated with being married (OR = 1.51, 95% CI = 1.11–2.05), lower social deprivation (OR = 0.47, 95% CI = 0.30–0.74), higher reading level (OR = 1.62, 95% CI = 1.19–2.21) and lower nicotine dependence (OR = 0.42, 95% CI = 0.29–0.62). Health problems related to smoking and previous quit attempts for 3 months or longer predicted both. In the multivariate analysis, the significant predictors of making a quit attempt were; later stage of readiness to quit (OR = 5.38, 95% CI = 3.67–7.89), motivation (OR = 1.48, 95% CI = 1.34–1.62) and determination to quit (OR = 1.16, 95% CI = 1.05–1.29) and health problems related to smoking (OR = 1.44, 95% CI = 1.18–1.75). For 3-month abstinence, the only significant predictor was not having health problems related to smoking (OR = 0.50, 95% CI = 0.29–0.83). While high motivation and determination to quit is necessary to prompt an attempt to quit smoking, demographic factors and level of nicotine dependence are more important for maintaining abstinence.

Sheryl L. Silfen, Jisung Cha, Jason J. Wang, Thomas G. Land, and Sarah C. Shih.  
Patient Characteristics Associated With Smoking Cessation Interventions and Quit Attempt Rates Across 10 Community Health Centers With Electronic Health Records.
American Journal of Public Health: October 2015, Vol. 105, No. 10, pp. 2143-2149.
We used electronic health record (EHR) data to determine rates and patient characteristics in offering cessation interventions (counseling, medications, or referral) and initiating quit attempts. Ten community health centers in New York City contributed 30 months of de-identified patient data from their EHRs.
Of 302,940 patients, 40% had smoking status recorded and only 34% of documented current smokers received an intervention. Women and younger patients were less likely to have their smoking status documented or to receive an intervention. Patients with comorbidities that are exacerbated by smoking were more likely to have status documented (82.2%) and to receive an intervention (52.1%), especially medication (10.8%). Medication, either along (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.5, 2.3) or combined with counseling (OR = 1.8; 95% CI = 1.5, 2.3), was associated with high quit attempts compared with no intervention. Data from EHRs demonstrated underdocumentation of smoking status and missed opportunities for cessation interventions. Use of data from EHRs can facilitate quality improvement efforts to increase screening and intervention delivery, with the potential to improve smoking cessation rates.

Sharon E. Cummins, Shiushing Wong, Erika Bonnevie, Hye-ryeon Lee, Cynthia J. Goto, Judy McCree Carrington, Carrie Kirby, and Shu-Hong Zhu.  
A Multistate Asian-Language Tobacco Quitline: Addressing a Disparity in Access to Care. 
American Journal of Public Health: October 2015, Vol. 105, No. 10, pp. 2150-2155.
We conducted a dissemination and implementation study to translate an intervention protocol for Asian-language smokers from an efficacy trial into an effective and sustainable multistate service.
Three state tobacco program (in California, Colorado, and Hawaii) promoted a multistate cessation quitline to 3 Asian –language-speaking communities: Chinese, Korean, and Vietnamese. The California quitline provided counseling centrally to facilitate implementation. Three more states joined the program during the study period (January 2010 – July 2012). We assessed the provision of counseling, quitting outcomes and dissemination of the program.
A total of 2004 smokers called for the service, with 88.3% opting for counseling. Among those opting for counseling, the 6-month abstinence rate (18.8%) was similar to results of the earlier efficacy trail (16.4%). The intervention protocol, based on an efficacy trial, was successfully translated into a multistate service and further disseminated. This project paved that way for the establishment of a national quitline for Asian-language speakers, which serves as an important strategy to address disparities in access to care.
Kristin Voigt, DPhil
Smoking Norms and the Regulation of E-Cigarettes.
American Journal of Public Health: October 2015, Vol. 105, No. 10, pp. 1967-1972.
Electronic nicotine delivery systems (ENDS) – commonly called e-cigarettes – are at the center of a polarized debate. How should they be regulated? Central to this debate is the concern that e-cigarettes could lead to the renormalization of smoking and that the regulation of ENDS should therefore be modeled on the regulation of conventional cigarettes.
I argue that arguments based on the renormalization of smoking can lend support to restrictions on marketing of ENDS, but that such arguments are problematic when used to justify restrictions on where ENDS can be used.
The debate has been insufficiently sensitive to the ethical complexities of attempts to manipulate social norms to change health behaviors; these complexities must also inform the debate about ENDS and their regulation.

Mark V. Avdalovic, MD, MAS; Susan Murin, MD, FCCP
POINT: Does the Risk of Electronic Cigarettes Exceed Potential Benefits? YES.
Chest. 2015; 148(3):580-582. Doi:10.1378/chest. 15-0538
The use of electronic cigarettes (e-cigarettes) continues to dramatically increase, and the debate over their safety and appropriate use has heated up in parallel. We as pulmonary clinicians are called upon to advise our patients and others about e-cigarettes, which presents challenges given the current limitations of the data upon which our advice should be based. What do we say?
There is no evidence that e-cigarettes are safe, and there is some evidence that they may in fact be harmful, both through introducing new young users to nicotine addiction and through direct effects upon the lung. It took decades for the medical community to recognize, prove, and accept that cigarettes are a major health hazard; we should not make the same error with e-cigarettes. We risk losing hard-won ground in the battle on smoking through the so-called “renormalization” of smoking that may attend the uncritical acceptance of e-cigarettes, and that is a stated goal of the e-cigarette industry. Additional research to fully understand the health effects of e-cigarettes, including among dual users of e-cigarettes and traditional cigarettes, is needed. Harm-reduction arguments are only valid if we can objectively document an overall reduction in harm, at both the individual and population levels, and at present we cannot. When patients come to us and ask for guidance about the use of e-cigarettes they are expecting a response informed by data. The limited data we have at present do not demonstrate benefits exceeding known risks.

Holly R. Middlekauff, MD.
COUNTERPOINT: Does the Risk of Electronic Cigarettes Exceed Potential Benefits? NO.
Chest. 2015; 148(3):582-584. Doi10.1378/chest. 15-0540.
Although the medical community is unanimous in its wish to limit or even eliminate tobacco smoking, the role of electronic cigarettes (e-cigarettes) in this process has been controversial.1 Will e-cigarettes be part of the solution by harm reduction, and are e-cigarettes really less harmful? Or will e-cigarettes contribute to the problem by serving as a gateway to tobacco cigarettes? As we are debating, regulations are being issued—and challenged. Unfortunately, due to a paucity of data, the calls for regulations in some cases sound alarmist.2 Certainly contributing to the strong opposition roused by the e-cigarette is our well-founded distrust of anything associated with the $85 billion US combusted-cigarette industry. Tobacco cigarette smoke is responsible for approximately 480,000 deaths/y in the United States. Approximately 18% of adult Americans smoke, a number which has not significantly decreased for a decade, despite antismoking campaigns, high cigarette taxes, and smoke-free policies. The position argued here is that an emotion-based, rather than evidenced-based, response to e-cigarettes may lead to a premature and scientifically unjustified rejection of a potentially beneficial means to reduce the enormous adverse health effects of tobacco cigarettes.
Ryan Ramanujam, Anna-Karin Hedström, Ali Manouchehrinia, Lars Alfredsson, Tomas Olsson, Matteo Bottai, Jan Hillert.
Effect of Smoking Cessation on Multiple Sclerosis Prognosis.
JAMA Neurol. Published online September 08, 2015. doi:10.1001/jamaneurol.2015.1788
Smoking tobacco is a well-established risk factor for multiple sclerosis (MS), a chronic inflammatory disorder of the central nervous system usually characterized by bouts and remissions and typically followed by a secondary progressive (SP) course. However, it is not clear whether smoking after diagnosis is detrimental. The objective was to determine whether smoking after MS diagnosis is associated with a change in time to SP disease.
Design, Setting, and Participants:  Cross-sectional study of patients with prevalent MS who smoked at diagnosis (n = 728) taken from the Genes and Environment in Multiple Sclerosis Study, which consists of patients from the Swedish National MS Registry. The study entrance date was at time of first-year smoking. The study was conducted between November 2008 and December 2011, with patient environmental data collected from November 2009 to March 2011 via questionnaire. Study participants were from all counties in Sweden diagnosed as having MS at the time of the Genes and Environment in Multiple Sclerosis Study and registered in the Swedish National MS Registry. Patients with MS with relapsing-remitting disease course or SP were included. These patients’ conditions were diagnosed according to the McDonald criteria and the patients responded to recruitment letters with detailed questionnaires.
The optimized model illustrated that each additional year of smoking after diagnosis accelerated the time to conversion to SPMS by 4.7% (acceleration factor, 1.047; 95% CI, 1.023-1.072; P < .001). Kaplan-Meier plots demonstrated that those who continued to smoke continuously each year after diagnosis converted to SPMS faster than those who quit smoking, reaching SP disease at 48 and 56 years of age, respectively. This study provides evidence that continued smoking is associated with an acceleration in time to SPMS and that those who quit fare better. Therefore, we propose that patients with MS should be advised to stop smoking once a diagnosis has been made, not only to lessen risks for comorbidities, but also to avoid aggravating MS-related disability.

Donna M. Buchanan, Suzanne V. Arnold, Kensey L. Gosch, Philip G. Jones, Lance S. Longmore, John A. Spertus, Sharon Cresci.
Association of Smoking Status With Angina and Health-Related Quality of Life After Acute Myocardial Infarction.
Circulation: Cardiovascular Quality and Outcomes. 2015; 8: 493-500
Smoking cessation after acute myocardial infarction (AMI) decreases the risk of recurrent AMI and mortality by 30% to 50%, but many patients continue to smoke. The association of smoking with angina and health-related quality of life (HRQOL) after AMI is unclear. Patients in 2 US multicenter AMI registries (n=4003) were assessed for smoking and HRQOL at admission and 1, 6, and 12 months after AMI. Angina and HRQOL were measured with the Seattle Angina Questionnaire and Short Form-12 Physical and Mental Component Scales. At admission, 29% never had smoked, 34% were former smokers (quit before AMI), and 37% were active smokers, of whom 46% quit by 1 year (recent quitters). In hierarchical, multivariable, regression models that adjusted for sociodemographic, clinical and treatment factors, never and former smokers had similar and the best HRQOL in all domains. Recent quitters had intermediate HRQOL levels, with angina and Short Form-12 Mental Component Scale scores similar to never smokers. Persistent smokers had worse HRQOL in all domains compared with never smokers and worse Short Form-12 Mental Component Scale scores than recent quitters. Smoking after AMI is associated with more angina and worse HRQOL in all domains, whereas smokers who quit after AMI have similar angina levels and mental health as never smokers. These observations may help encourage patients to stop smoking after AMI.

Brian A. Primack, MD, PhD; Samir Soneji, PhD; Michael Stoolmiller, PhD; Michael J. Fine, MD, MSc; James D. Sargent, MD
Progression to Traditional Cigarette Smoking After Electronic Cigarette Use Among US Adolescents and Young Adults.
 JAMA Pediatr. Published online September 08, 2015. doi:10.1001/jamapediatrics.2015.1742
Electronic cigarettes (e-cigarettes) may help smokers reduce the use of traditional combustible cigarettes. However, adolescents and young adults who have never smoked traditional cigarettes are now using e-cigarettes, and these individuals may be at risk for subsequent progression to traditional cigarette smoking.
In this longitudinal cohort study, a national US sample of 694 participants aged 16 to 26 years who were never cigarette smokers and were attitudinally nonsusceptible to smoking cigarettes completed baseline surveys from October 1, 2012, to May 1, 2014, regarding smoking in 2012-2013. They were reassessed 1 year later. Analysis was conducted from July 1, 2014, to March 1, 2015. Multinomial logistic regression was used to assess the independent association between baseline e-cigarette use and cigarette smoking, controlling for sex, age, race/ethnicity, maternal educational level, sensation-seeking tendency, parental cigarette smoking, and cigarette smoking among friends. Sensitivity analyses were performed, with varying approaches to missing data and recanting.
Among the 694 respondents, 374 (53.9%) were female and 531 (76.5%) were non-Hispanic white. At baseline, 16 participants (2.3%) used e-cigarettes. Over the 1-year follow-up, 11 of 16 e-cigarette users and 128 of 678 of those who had not used e-cigarettes (18.9%) progressed toward cigarette smoking. In the primary fully adjusted models, baseline e-cigarette use was independently associated with progression to smoking (adjusted odds ratio [AOR], 8.3; 95% CI, 1.2-58.6) and to susceptibility among nonsmokers (AOR, 8.5; 95% CI, 1.3-57.2). Sensitivity analyses showed consistent results in the level of significance and slightly larger magnitude of AORs. In this national sample of US adolescents and young adults, use of e-cigarettes at baseline was associated with progression to traditional cigarette smoking. These findings support regulations to limit sales and decrease the appeal of e-cigarettes to adolescents and young adults. 

Jennifer B. Unger.
E-Cigarettes: Introducing New Complexities and Controversies to the Field of Nicotine and Tobacco Research.
Nicotine Tob Res (2015) 17 (10): 1185-1186. doi: 10.1093/ntr/ntv186  
For decades, there has been nearly unanimous agreement among researchers that tobacco is harmful to health, that current smokers should quit, and that non-smokers should not start smoking.1 The introduction of e-cigarettes has brought new debates to the scientific community. As described by Hitchman,2 the field has not yet achieved consensus about whether or not e-cigarettes help smokers quit. The answer to this question likely depends on numerous factors, including the characteristics of the people attempting to quit,3 the characteristics of the electronic nicotine delivery system (ENDS) they choose,2 and the definition of cessation used in the study. Indeed, when we as researchers debate this issue, it is often unclear whether we are all using the same definition of cessation. Does cessation include the replacement of combustible cigarettes with long-term use of less harmful e-cigarettes? Or does cessation mean complete and permanent abstinence from nicotine? One’s definition of cessation is somewhat ideological, determined in part by whether one believes that the long-term use of nicotine without combustion is dangerous or not (for the individual as well as for bystanders breathing nearby and for youth observing behaviors that they might later imitate). This is still an empirical question …

Robert C. McMillen, Mark A. Gottlieb, Regina M. Whitmore, Jonathan P. Winickoff, Johnathan D. Klein.
Trends in Electronic Cigarette Use Among U.S. Adults: Use is Increasing in Both Smokers and Nonsmokers.
Nicotine Tob Res (2015) 17 (10): 1195-1202. doi: 10.1093/ntr/ntu213
We assessed trends in use of electronic cigarettes among U.S. adults, demographic predictors of use, and smoking status of current electronic cigarette users. Mixed-mode surveys were used to obtain representative, cross-sectional samples of U.S. adults in each of 4 years.
Sample sizes for 2010, 2011, 2012, and 2013 were 3,240, 3,097, 3,101, and 3,245, respectively. Ever use of electronic cigarettes increased from 1.8% (2010) to 13.0% (2013), while current use increased from 0.3% to 6.8%, p < .001. Prevalence of use increased significantly across all demographic groups. In 2013, current use among young adults 18–24 (14.2%) was higher than adults 25–44 (8.6%), 45–64 (5.5%), and 65+ (1.2%). Daily smokers (30.3%) and nondaily smokers (34.1%) were the most likely to currently use e-cigarettes, compared to former smokers (5.4%) and never-smokers (1.4%), p < .001. However, 32.5% of current electronic cigarette users are never- or former smokers. There has been rapid growth in ever and current electronic cigarette use over the past 4 years. Use is highest among young adults and current cigarette smokers. Although smokers are most likely to use these products, almost a third of current users are nonsmokers, suggesting that e-cigarettes contribute to primary nicotine addiction and to renormalization of tobacco use. Regulatory action is needed at the federal, state, and local levels to ensure that these products do not contribute to preventable chronic disease.

Jessica M. Yingst, Susan Veldheer, Shari Hrabovsky, Travis T. Nichols, Stephen J. Wilson, Jonathan Foulds.
Factors Associated With Electronic Cigarette Users’ Device Preferences and Transition From First Generation to Advanced Generation Devices.
Nicotine Tob Res (2015) 17 (10):1242-1246.doi: 10.1093/ntr/ntv052First published online: March 5, 2015

Electronic cigarettes (e-cigs) are becoming increasingly popular but little is known about how e-cig users’ transition between the different device types and what device characteristics and preferences may influence the transition. Four thousand four hundred twenty-one experienced e-cig users completed an online survey about their e-cig use, devices, and preferences. Participants included in analysis were ever cigarette smokers who used an e-cig at least 30 days in their lifetime and who reported the type of their first and current e-cig device and the nicotine concentration of their liquid. Analyses focused on transitions between “first generation” devices (same size as a cigarette with no button) and “advanced generation” devices (larger than a cigarette with a manual button) and differences between current users of each device type.
Most e-cig users (n = 2603, 58.9%) began use with a first generation device, and of these users, 63.7% subsequently transitioned to current use of an advanced generation device. Among users who began use with an advanced generation device (n = 1818, 41.1%), only 5.7% transitioned to a first generation device. Seventy-seven percent of current advanced generation e-cig users switched to their current device in order to obtain a “more satisfying hit.” Battery capabilities and liquid flavor choices also influenced device choice. E-cig users commonly begin use with a device shaped like a cigarette and transition to a larger device with a more powerful battery, a button for manual activation and a wider choice of liquid flavors.

Raul E. Martinez, MS, Steven Dhawan, Walton Sumner, MD, Brent J. Williams, PhD
On-Line Chemical Composition Analysis of Refillable Electronic Cigarette Aerosol—Measurement of Nicotine and Nicotyrine.
Nicotine Tob Res (2015) 17 (10):1263-1269.doi: 10.1093/ntr/ntu334
Electronic cigarettes (e-cigs) generate aerosols that users inhale. Analyses of e-liquids inconsistently report nicotyrine, a nicotine analog that could impede nicotine metabolism, raising questions about nicotyrine formation. E-cig aerosols were analyzed on-line using a Thermal Desorption Aerosol Gas Chromatograph. Three e-liquids were tested: an unflavored solution in propylene glycol (PG); an unflavored solution in PG and vegetable glycerin (VG), and a flavored solution in PG and VG. A heating duration experiment determined the nicotyrine to nicotine ratio (NNR) in particle phase as a function of the duration of e-cig activation. An aging experiment determined the NNR in e-liquids and aerosols as a function of time since initial exposure to air and storage condition.
Nicotine and nicotyrine were quantified in all 3 e-liquids and aerosols. Duration of e-cig activation was inversely related to NNR (NNR = 0.04 with 3-s activation, 0.26 with 0.5 s). Aging influenced both e-liquid NNR and aerosol NNR. On average, the e-liquid NNR increased from 0.03 at 11 days after opening to 0.08 after 60 days. For similar heating durations, aerosol NNR increased from 0.05 at 11 days to 0.23 after 60 days. Storage conditions had little effect on NNR. E-cig aerosols have variable nicotyrine quantities. Aerosol NNR depends on vaping technique and time elapsed since the e-liquid was exposed to air. It is hypothesized that aerosolized nicotyrine could facilitate nicotine absorption, inhibit the metabolism of nicotine, and reduce a user’s urge to smoke.

Joseph G. Lisko, MS, Hang Tran, MS, Stephen B. Stanfill, MS, Benjamin C. Blount, PhD and Clifford H. Watson, PhD
Chemical Composition and Evaluation of Nicotine, Tobacco Alkaloids, pH, and Selected Flavors in E-Cigarette Cartridges and Refill Solutions.
Nicotine Tob Res (2015) 17 (10):1270-1278.doi: 10.1093/ntr/ntu279
Electronic cigarette (e-cigarette) use is increasing dramatically in developed countries, but little is known about these rapidly evolving products. This study analyzed and evaluated the chemical composition including nicotine, tobacco alkaloids, pH, and flavors in 36 e-liquids brands from 4 manufacturers. We determined the concentrations of nicotine, alkaloids, and select flavors and measured pH in solutions used in e-cigarettes. E-cigarette products were chosen based upon favorable consumer approval ratings from online review websites. Quantitative analyses were performed using strict quality assurance/quality control validated methods previously established by our lab for the measurement of nicotine, alkaloids, pH, and flavors.
Three-quarters of the products contained lower measured nicotine levels than the stated label values (6%–42% by concentration). The pH for e-liquids ranged from 5.1–9.1. Minor tobacco alkaloids were found in all samples containing nicotine, and their relative concentrations varied widely among manufacturers. A number of common flavor compounds were analyzed in all e-liquids. Free nicotine levels calculated from the measurement of pH correlated with total nicotine content. The direct correlation between the total nicotine concentration and pH suggests that the alkalinity of nicotine drives the pH of e-cigarette solutions. A higher percentage of nicotine exists in the more absorbable free form as total nicotine concentration increases. A number of products contained tobacco alkaloids at concentrations that exceed U.S. pharmacopeia limits for impurities in nicotine used in pharmaceutical and food products.

Article: Congress Must Not Weaken Nation’s Fight Against Tobacco!
"While the United States has made tremendous progress in reducing smoking, tobacco use continues to take an enormous toll not just on the nation’s health, but on its finances as well. 

Tobacco use is still the leading preventable cause of death, claiming the lives of more than 480,000 Americans each year and sickening millions more.        
Less well known is the fact that smoking costs the nation about $170 billion in annual healthcare expenditures, about 60 percent of which is paid by taxpayers through government programs such as Medicare and Medicaid. According to a December 2014 study in the American Journal of Preventive Medicine, smoking-related diseases each year account for 9.6 percent of Medicare expenditures, 15.2 percent of Medicaid expenditures and nearly a third of expenditures from other federal government-sponsored insurance programs. 

Given tobacco’s huge health and financial toll, including on the federal budget, it is good news that the federal government in recent years has taken several strong steps to accelerate progress against tobacco use. "
» learn more
Italia V. Rolle, PhD; Sara M. Kennedy, MPH; Israel Agaku, DMD; Sherry Everett Jones, PhD, JD; Rebecca Bunnell, ScD; Ralph Caraballo, PhD; Xin Xu, PhD; Gillian Schauer, MPH; Tim McAfee, MD
Cigarette, Cigar, and Marijuana Use Among High School Students — United States, 1997–2013
Morbidity and Mortality Weekly Report. October 15, 2015
CDC analyzed data from the 1997–2013 national Youth Risk Behavior Surveys (YRBS) among U.S. non-Hispanic white (white), non-Hispanic black (black), and Hispanic students in grades 9–12 to examine trends in the prevalence of current 1) exclusive cigarette or cigar use, 2) exclusive marijuana use, and 3) any use of the three products. CDC further examined the prevalence of current marijuana use among current users of cigarettes or cigars. During 1997–2013, significant linear decreases occurred in exclusive cigarette or cigar use; however, significant linear increases occurred in exclusive marijuana use. Any cigarette, cigar, or marijuana use significantly decreased overall and among all sex and racial/ethnic subgroups during the study period, whereas marijuana use among cigarette or cigar users increased significantly among all sex and racial/ethnic subgroups. Significant nonlinear trends in exclusive marijuana use and marijuana use among cigarette or cigar users also were identified among black and Hispanic students. Increased exclusive marijuana use and use of marijuana among cigarette or cigar users could undermine success in reducing tobacco use among youths. Closer collaboration between public health professionals to address prevention of tobacco and marijuana use might be beneficial in the development of evidence-based policies and programs to prevent tobacco and marijuana use.

Catherine G. Corey, MSPH; Bridget K. Ambrose, PhD; Benjamin J. Apelberg, PhD; Brian A. King
Flavored Tobacco Product Use Among Middle and High School Students — United States, 2014.
MMWR / October 2, 2015 / Vol. 64 / No. 38
In 2014, millions of middle- and high-school students were exposed, through inhalation or oral absorption, to nicotine and harmful constituents from tobacco products. A substantial proportion of this exposure was due to use of flavored tobacco products. Sustained efforts to implement proven tobacco control policies and strategies are necessary to prevent all forms of tobacco use, including flavored tobacco products, among U.S. youth. In 2014, among middle and high school students, 1.58 million e-cigarette users, 1.02 million hookah users, and 910,000 cigar smokers used flavored varieties of these products within the past 30 days. Among past-30-day tobacco users, 70.0 percent reported using at least one flavored tobacco product; 63.5 percent of cigar smokers, 63.3 percent of e-cigarette users, and 60.6 percent of hookah users reported using flavored varieties of these tobacco products in the past 30 days. There is growing concern that widely marketed flavored tobacco products may appeal to youth and could be contributing to recent increases in the use of tobacco products, including e-cigarettes and hookah, among youth

Linda J. Neff, PhD; René A. Arrazola, MPH; Ralph S. Caraballo, PhD; Catherine G. Corey, MSPH; Shanna Cox, MSPH; Brian A. King, PhD; Conrad J. Choiniere, PhD; Corinne G. Husten, MD
Frequency of Tobacco Use Among Middle and High School Students — United States, 2014.
 MMWR / October 2, 2015 / Vol. 64 / No. 38
Preventing youths from initiating the use of any tobacco product is important to tobacco-use prevention and control strategies in the United States. Monitoring the frequency and patterns of tobacco use among middle- and high-school students, including the use of two or more tobacco products, is important to inform evidence-based interventions to prevent and reduce all forms of tobacco use. Among current or past-30-day tobacco users in high school, frequent use (>20 days during the preceding 30 days) was most prevalent among smokeless tobacco users (42.0 percent), followed by cigarette smokers (31.6 percent), e-cigarette users (15.5 percent), and cigar smokers (13.1 percent). A similar pattern was observed for students who used tobacco on all of the past 30 days. Among current users in middle school, frequent use was greatest among smokeless tobacco users (29.2 percent), followed by cigarette smokers (20.0 percent), cigar smokers (13.2 percent) and e-cigarette users (11.8 percent). Current use of two or more types of tobacco products was common, even among students who used the following tobacco products 1–5 days during the preceding 30 days: 77.3 percent for cigar smokers, 76.9 percent for cigarette smokers, 63.4 percent for smokeless tobacco users, and 54.8 percent for e-cigarettes users.

Sean Semple, Andrew Apsley, Tengku Azmina Ibrahim, Stephen W Turner, John W Cherrie. 
Fine Particulate Matter Concentrations in Smoking Households: Just How Much Secondhand Smoke do you Breathe in if you Live with a Smoker Who Smokes Indoors? 
Using data on fine particulate matter less than 2.5 μm (PM2.5) concentrations in smoking and non-smoking homes in Scotland to estimate the mass of PM2.5 inhaled by different age groups. Data from four linked studies, with real-time measurements of PM2.5 in homes, were combined with data on typical breathing rates and time-activity patterns. Monte Carlo modelling was used to estimate daily PM2.5 intake, the percentage of total PM2.5 inhaled within the home environment and the percentage reduction in daily intake that could be achieved by switching to a smoke-free home.
Median (IQR) PM2.5 concentrations from 93 smoking homes were 31 (10–111) μg/m3 and 3 (2–6.5) μg/m3 for the 17 non-smoking homes. Non-smokers living with smokers typically have average PM2.5 exposure levels more than three times higher than the WHO guidance for annual exposure to PM2.5 (10 μg/m3). Fine particulate pollution in Scottish homes where smoking is permitted is approximately 10 times higher than in non-smoking homes. Taken over a lifetime many non-smokers living with a smoker inhale a similar mass of PM2.5 as a non-smoker living in a heavily polluted city such as Beijing. Most non-smokers living in smoking households would experience reductions of over 70% in their daily inhaled PM2.5 intake if their home became smoke-free. The reduction is likely to be greatest for the very young and for older members of the population because they typically spend more time at home.
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October 31- November 4, 2015: APHA Annual Meeting Registration is Open!
Join thousands of you peers in Chicago, Oct. 31-Nov. 4, to discuss public health’s biggest challenges, exchange information and share best practices.  Learn more here.

April 18-20, 2016: 8th National Summit on Smokeless and Spit Tobacco!
Who Should Attend:

  • Local, state and federal tobacco prevention and control administrators
  • Tobacco program staff
  • Public health educators and policy professionals
  • Health care professionals and providers including physicians, nurses and clinic managers
  • Tobacco treatment specialists
  • Scientists
  • Dentists, dental hygienists and dental assistants
  • Higher education staff
  • Students
  • School and youth-serving agencies and youth advocates

Learn more here

April 25-26, 2016: Reduce Tobacco Use Conference! 
The Virginia Foundation for Health Youth and Prevention Connections will host the 12th Reduce Tobacco Use Conference to be held April 25-26, 2016 in Arlington, VA. A call for abstracts to secure conference presenters has gone out, with a submission deadline of October 23, 2015. Learn more here.

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