Studying the willingness to accept a new vaccine helps better understand the consumer behavior to formulate strategies to improve its acceptance when rolled out on a large scale. An online survey using a quota sampling covering all Malaysian states and territories was conducted. A pretested and validated questionnaire covering willingness under four hypothetical scenarios of the Dengue vaccine on a Juster scale and factors related to Dengue knowledge, vaccine, and prevention was used. By multiple linear regression, we identified the factors associated with the Dengue vaccine willingness score. The respondents’ mean age was 38.7 y (SD = 11.5). Mean willingness score for Dengue vaccine under development was highest if efficacy is 95% and no side effect was 7.9 (SD = 2.2), and an authorized Dengue vaccine if recommended by a physician was about 7.2 (SD = 2.3). The significant covariates positively associated with the willingness score were female sex, perceived susceptibility, knowledge about symptoms, beliefs about Dengue vaccination, and perceptions about Dengue prevention. In contrast, higher education, past Dengue infection, and vaccine-related concerns were negatively associated with willingness score. Our national survey indicates that willingness to accept the Dengue vaccine was positive. The positive association of perceptions toward disease susceptibility and severity, beliefs toward Dengue vaccination and preventive programs, with willingness, suggests a conducive ground for potential Dengue vaccine rollout. Public education be provided about the Dengue vaccine to address their concerns about the vaccine, and post-marketing surveillance be done.

INTRODUCTION There are reports of oral nicotine pouches (ONPs) being marketed in high-income countries. The aim of this study was to report online promotions and marketing claims about ONPs in Malaysia, which currently does not regulate nicotine pouches. METHODS We did a content analysis of ONPs sold on e-stores. We searched the terms: 'Velo', 'Zyn', 'Onz', 'nicotine pouch', and 'oral nicotine pouch' on Google Malaysia, Facebook, Reddit, TikTok, and Instagram during March-April 2024. Three trained coders independently coded the e-stores, using a codebook developed based on previous research. Visual and textual information about brands, prices, discounts, flavors, nicotine strength, and marketing claims, was collected. Results are presented in both descriptive and free text formats. RESULTS A sample of 41 e-stores was analyzed. ONP marketing was present on TikTok and e-commerce stores. Brands such as 'Velo', 'Zyn', and 'Boltbe' offered discounts, free deliveries, and an array of flavors, with nicotine strengths of 2-50 mg. All brands displayed nicotine strength (mg). Only 51% of the e-stores explicitly stated that the product contained 'nicotine', and 5% disclosed that nicotine is addictive; 41% of the stores displayed ONPs as 'tobacco-free'. About half of the e-stores had marketing claims of 'product appeal' (56%), 'convenient to use anywhere, everywhere' (46%), and 'smoking cessation' (49%). Age verifications and identification proofs were not available at all, whereas health warnings against usage by minors, non-smokers, and pregnant women, were present on only 5%. CONCLUSIONS Online marketing and sales promotions were present on e-commerce websites and some social media platforms. The range of flavors and strengths, sales promotions, marketing claims such as appeal and convenience of use, the lack of nicotine disclaimers, and age verification were noted. Surveillance of ONPs is needed to inform regulatory policy.

INTRODUCTION:Adoption patterns of electronic cigarettes and heated tobacco products (HTPs) across diverse low- and middle-income countries (LMICs) remain poorly understood. This study aimed to evaluate country-level prevalence of e-cigarettes and HTPs across five geographically diverse nations. METHODS:We analysed Global Adult Tobacco Survey microdata from Costa Rica (2022), Malaysia (2023), Mauritania (2021), Mexico (2023), and South Africa (2021). For each country, we estimated weighted prevalence and 95% CIs of awareness, ever and current use, and their distribution by cigarette smoking status. Factors associated with e-cigarette and/or HTP use in each country were explored using binary logistic regression analyses (except Mauritania). RESULTS:For e-cigarettes, weighted prevalence of awareness ranged from 22.2% (Mauritania) to 70.7% (Mexico), 'current use' from 0.4% (Mauritania) to 5.8% (Malaysia), and 'ever use' from 2.8% (Malaysia) to 10.6% (Mexico). For HTPs, weighted prevalence of 'awareness' ranged from 5.6% (Costa Rica) to 15.8% (South Africa), 'current use' from <0.1% (South Africa) to 0.2% (Mexico), and 'ever use' from 0.4% (Malaysia) to 0.9% (Mexico). Awareness and use were significantly higher among respondents with current and past smoking behaviours (p < 0.01). Reasons given for current e-cigarette use were "attractive flavors" (50-70%), "enjoyment" (53-68%), and "to quit smoking" (38-58%). Reasons for HTP use were "enjoyment" (50-80%) and "to quit smoking" (20-60%). CONCLUSIONS:E-cigarette and HTP awareness and use vary substantially across diverse low- and middle-income country contexts. This demands localised, agile surveillance and regulatory frameworks rather than a uniform, global policy approach.

INTRODUCTION:We aimed to estimate the prevalence of cigarette smoking, e-cigarette, and heated tobacco product use behaviors and their associated factors among adult Malaysians. METHODS:A cross-sectional online survey was conducted in December 2024 among a nationally representative sample of 1000 adult Malaysians (≥18 years). We used a questionnaire adapted from the Global Adult Tobacco Survey. Binary logistic regression analyses were performed to identify factors associated with tobacco and nicotine product use. RESULTS:The overall prevalence of current smoking was 28.6% (95% CI: 25.8-31.4), with a mean age of smoking initiation of 21.5 years. Awareness of e-cigarettes was high (92.4%), with 14.6% (95% CI: 12.5-17.0) and 13.4% (95% CI: 11.4-15.8) reporting current daily and non-daily use, respectively. Fewer respondents were aware of heated tobacco products (HTPs, 548.5%), with 4.5% (95% CI: 3.4-6.1) and 10.0% (95% CI: 8.2-12.1) reporting current daily and non-daily use, respectively. Current smoking (AOR=44.19; 95% CI: 24.78-78.81 for e-cigarettes; AOR=31.0; 95% CI: 13.58-73.57 for HTPs), male sex, younger age, and exposure to advertisements were significantly associated with e-cigarette and HTP use. A smoke-free home environment was a protective factor against e-cigarette (AOR=0.44; 95% CI: 0.24-0.80) and HTP use (AOR=0.27; 95% CI: 0.13-0.55). CONCLUSIONS:Continued surveillance of nicotine product use is essential. Tobacco control measures under the new Public Health Act should include specific regulations for e-cigarettes and heated tobacco products, particularly targeting younger populations.

With increasing global travel, pre-travel care is essential for safe travel. This study aimed to describe pre-travel health advice and medical services offered by general practitioners (GPs) in Malaysia. This was a descriptive cross-sectional survey conducted among private GPs in Malaysia. Private clinics were initially randomly selected from the Ministry of Health registry in proportion to state distribution. However, the final sample consisted of self-selected respondents who voluntarily completed the survey, and this may introduce selection bias. Data were collected via self-administered online questionnaire and analysed using descriptive statistics, Fisher’s Exact, ANOVA, and Kruskal Wallis tests. 131 GPs responded (response rate: 20.89

Understanding health behavior using the Health Belief Model (HBM) helps formulate strategies to improve the willingness, thereby increasing the acceptance of pneumococcal vaccination among the elderly. We aimed to assess the willingness to receive the pneumococcal vaccine and associated factors to inform pneumococcal vaccination policy for the elderly in Malaysia. We surveyed 402 elderly (60 years and above) selected from 14 Pusat Aktiviti Warga Emas (PAWE; Senior Citizen Activity Centers) in Klang Valley, Malaysia. Using a questionnaire, we gathered information on respondents' sociodemographic characteristics, self-reported knowledge of pneumococcal diseases, behavioral determinants using the HBM, trust in healthcare, trust in vaccines, and willingness to receive the pneumococcal vaccine. The mean age was 66.4 years (SD = 5.6). Only 29% had received at least one dose of pneumococcal vaccine, almost all of whom (93%) had received it before the Hajj or Umrah pilgrimage of Muslims. Mean willingness score was 8.20 (95% CI 8.01-8.39). Multiple linear regression analysis showed that elderly individuals were more willing to receive the pneumococcal vaccine if they perceived the disease as severe, had fewer barriers to vaccination, were influenced by prompts or encouragement to take action, and had greater trust in healthcare providers and the vaccine itself. The survey found low coverage for pneumococcal vaccination. Our findings suggest that improving information about pneumococcal disease, its severity, and the pneumococcal vaccine through health care providers to the elderly and their families would improve willingness to uptake the pneumococcal vaccine.

Introduction Data on e-cigarette (EC) and heated tobacco product (HTP) use and the reasons for their use are useful for policy making. We report comparable nationally representative estimates of EC and HTP use and their associated factors.Aims and Methods Global Adult Tobacco Survey data from Indonesia (2021), Kazakhstan (2019), and the Philippines (2021) were analyzed. The weighted prevalence rates and 95% CI of EC and HTP awareness, current use, and ever use, and their distribution by cigarette smoking status were calculated. Binary logistic regression analyses assessed socioeconomic, and tobacco control factors associated with EC and HTP use.Results The prevalence (%) of EC awareness, ever use and current use were 48.7-69.4, 3.6-8.8, and 1.9-3.0, respectively. The prevalence(%) of HTP awareness, ever use and current use were 2.7-21.7, 0.2-2.1, and 0.1-1.2, respectively. The main reasons for EC and HTP use were attractive flavors(45.8%-73.9%), less harmful than smoking(23.0%-70.1%), and enjoyment(40.8%-76.7%). Avoiding going back to smoking(0.9%-54.4%) and quitting smoking(19.4%-49.8%) were less frequently cited reasons (except in the Philippines). EC/HTP use was associated with younger age, higher education and wealth, current/past smoking, exposure to information about the dangers of tobacco use, and advertisements about tobacco products and smoke-free rules at home.Conclusions The prevalence of EC and HTP use was higher among younger men with higher education and wealth, and current/past smoking. EC and HTP use should be closely monitored. Regulations to restrict the widespread marketing and sales of EC and HTP are needed to prevent the escalation of their use.Implications The population-level data provide the benchmark for future monitoring use of e-cigarettes and HTPs and identify population subgroups for future surveillance in low- and middle-income countries. The association of EC/HTP use with tobacco control-related factors provides leads for policies that should be formulated and implemented to regulate the product contents, marketing, and sales of EC and HTP.

Malaysia recently introduced new tobacco regulations such as the sale, advertising, and promotion of all smoking products, including e-cigarettes and vapes in October 2024. We report the qualitative results of mixed-methods research to assess public opinion and perspectives on the implementation of tobacco control measures in Malaysia. Semi-structured interviews were conducted from November 2024-January 2025 using an interview guide. The guide was refined through discussion among the researchers and piloted on one individual. The interviews were conducted via online software, either in English or in Bahasa Melayu, according to the interviewee’s choice. The transcripts generated were edited and translated into English if needed. Thematic analysis was performed according to the methods of Braun and Clarke. New themes were identified and refined during the study. Member checking was performed. Nine individuals were interviewed. The themes identified were participants ‘opinions about current tobacco control strategies; current challenges in implementing these strategies; suggestions for addressing these challenges; the impact of removing liquid nicotine from the list of controlled substances, such as opium, cannabis, psychotropic substances, etc.; and measures to curb growing e-cigarette use and vaping. The participants supported the tobacco control strategies, but the lack of dedicated personnel to implement these strategies was a challenge. Different suggestions to address these issues have been provided. The action of removing nicotine from the list was regarded unfavourably, and participants wanted tighter regulation of e-cigarettes and vapes. Efforts to raise awareness were mentioned. This study identified the enforcement of smoke-free policies, curbing illicit trade, as some challenges in implementing tobacco control measures. Public views and suggestions may provide new approaches to strengthening tobacco control and regulation of e-cigarette use. Not applicable.

Poor knowledge of smoking-related diseases is a major concern as smoking is associated with an increasing trend in smoking-related illnesses globally and in Malaysia. Our study aimed to investigate the knowledge of smoking tobacco, smoking behaviour, nicotine use, willingness to quit smoking, and level of stress, anxiety, and depression among current and former smokers in the Klang Valley of Malaysia. A cross-sectional study was conducted online from March 2023 to January 2024, using a structured, validated questionnaire. Individuals with a history of active or previous smoking and living in the Klang Valley region of Malaysia were included using a convenience sampling technique. The study instrument consisted of six sections with 56 questions using varying response types, to collect the data. Out of 395 respondents, the majority were male (n = 326; 82.5

BACKGROUND:The density and distribution of Human Resources for Health (HRH) are critical to achieving universal health coverage. We aimed to study temporal trends in HRH density and state-wise inequalities in Malaysia, 2010-2022. METHODS:We obtained state-wise data on HRH (doctors, dentists, pharmacists, nurses, and assistant medical officers) from the Ministry of Health (MOH), and estimates of mid-year population, the human development index (HDI), and Gross National Income (GNI) from the Department of Statistics Malaysia. We estimated trends in HRH density per 10,000 population. Inequalities in HRH density were measured using absolute and relative gaps, and slope index inequality (SII) and concentration index (CI) across the states are ranked high, middle, and low. For geographic inequalities, we estimated absolute and relative dissimilarity indices and the Theil index. RESULTS:HRH density increased from 43.77 to 77.65 at an annual rate of change (ARC) of 4.89%. In absolute terms (SII), HRH density in states ranked by HDI and GNI was higher for doctors (9.77) and nurses (7.44), and in relative terms (CI), however, pharmacists (9.62), doctors (8.48), and dentists (6.30) had higher inequalities between the states, indicating higher concentration in higher-ranked states. To attain distributive equality across the states, about 13% of current doctors, nurses, and dentists, and 11% of pharmacists need to be redistributed. CONCLUSION:HRH numbers and density increased across the states. Inequalities analyses showed that HRH are concentrated in higher-ranked states. Our report provides leads and directions for policymakers to achieve an equitable distribution of HRH, essential for achieving Universal Health Coverage.

Childhood drowning is a major cause of morbidity and mortality with significant economic and social implications, especially in low- and middle-income countries. Despite this, there is a lack of good-quality epidemiological data on childhood drowning. We report the epidemiology of fatal and non-fatal unintentional childhood drowning in Malaysia between the years 2000 and 2022. Data about childhood drowning were obtained from a hospital-based registry gathered by the National Health Informatics Centre, the Ministry of Health, Malaysia. Child population data were downloaded from the Malaysian Census. Overall incidence rates (IRs), case fatality rates (CFRs), and IR and CFR by age, sex, race, and region were calculated. Binary logistic regression was used to determine the factors associated with fatality. Between the years 2000 and 2022, a total of 4247 cases of drowning were reported. IR was significantly higher among children aged 0-9, boys, Bumiputera, and the East Coast and Borneo regions. Overall CFR was 3.7%. Age, year of hospitalization, and Bumiputera were associated with CFR. The site of drowning was unspecified in 84% of cases, while for those recorded, natural water sources and swimming pools accounted for most sites. While the annual incidence of drowning has remained nearly constant throughout the years, the fatality rate has increased between 2010 and 2022. Our report provides leads for further research data requirements to understand childhood drowning epidemiology better and improve preventive measures.

Indigenous people often have poor health due to a lack of access to health care. We studied healthcare-seeking behaviors and associated factors of Orang Asli populations living in remote hilly areas of Peninsular Malaysia. A house-to-house survey was done in 11 of 28 randomly selected villages. A sample of 225 Adults aged 18 years and above were interviewed about healthcare-seeking behavior for an episode of illness 30 days before the survey date. Factors associated with appropriate healthcare-seeking behavior as determined by binary logistic regression analyses. More than a third of the Orang Asli adults (88/225) did not consult any healthcare provider (39%) for which ‘illness does not need treatment’ or ‘not sick enough’ (22%) and no transportation (12%) were the main reasons. Being of older age (aOR 0.95, 95%CI 0.9, 0.98), income higher than 500 Malaysian Ringgits per month (aOR 2.35, 95%CI 1.04, 5.39), perception of illness as ‘severe’(aOR 54.79 95% CI 12.61, 239.9), and closer distance of health facility (aOR 0.86 95% CI 0.81, 0.93) were associated with appropriate healthcare-seeking behavior. Health promotion campaigns are needed to improve awareness about common illnesses and improve care-seeking behavior.

BackgroundInquiring conservative Asian women about their menopausal symptoms is often challenging in crowded primary healthcare clinics. Furthermore, the subject matter is culturally sensitive to most Malaysian women. Hence, the translation of MQ6 into Malay is crucial to enable self-administration, eliminating the necessity for interviewers and mitigating potential respondent shyness.MethodsThe Menopause Quick 6 (MQ6) questionnaire was translated into the Malay language with an addition of an item, henceforth termed MQ6 (M). Forward and backward translation was performed. Face and content validity were conducted. MQ6 (M) was self-administered to 400 women aged between 40 and 60 attending six primary healthcare clinics in Malaysia. To ascertain the reliability for MQ6 (M), corrected Item-Total Correlation, Squared Multiple Correlation, Cronbach's Alpha if the Item is Deleted, and Kuder-Richardson Reliability Coefficients (KR20). Exploratory factor analysis was done to determine its' construct validity.ResultsThe outcome of the validation was satisfactory. By the Lawshe method, the content validity ratios ranged from 0.6 to 1.0 and the content validity index was 0.914. The Internal consistency for MQ6(M) Cronbach's alpha was 0.711 while Kuder-Richardson Reliability Coefficients KR20 was 0.676. Factor loading of all four items is above 0.70, indicating a well-defined structure. Whereas factor loading for three items fell within the range of 0.50-0.69 indicating a practically significant threshold for a new questionnaire.ConclusionMQ6 (M) has acceptable reliability and construct validity to be considered as a self-administered screening tool in primary care clinics in Malaysia.

Background Marketing and sales of e-cigarettes are unregulated in Malaysia. We analyzed content displayed on e-cigarette retailer websites to identify marketing claims, promotional strategies, and product details in the year 2022. Methods We analyzed 30 Malaysia-based retailer websites using a mixed methods approach. Data were extracted as the frequency of occurrences of marketing claims, presence of regulatory information, product types, and flavors of e-juice as per a predefined codebook based on published literature. We also extracted textual details published on the websites about marketing claims, and slogans. Results Most retailer websites provided contact information and physical store addresses (83%) but only half had ‘click through’ age verification (57%) that seldom needed any identification proof for age (3%). Marketing claims were related to health (47%), smoking cessation (37%), and modernity/trend (37%) and none had health warnings. Promotional strategies were discounts (80%). starter kits (57%) and email subscriptions (53%). Product types displayed were rechargeable (97%) and disposable (87%) devices and e-liquids (90%) of an array of flavors (> 100). Nicotine presence, its concentration, and “nicotine is an addictive chemical” were displayed in 93%, 53%, and 23% of websites respectively. Conclusion Surveillance of content displayed online on e-cigarette retailer websites and regulation of online marketing and sales should be implemented by the Ministry of Health, Malaysia. Such measures are needed to prevent access to, and initiation of e-cigarette use among the youth and adults who do not smoke.

We report prevalence estimates of single, dual, and poly tobacco product use and the associated factors in 18 Global Adult Tobacco Survey (GATS) countries (2015–2021). We computed the number of tobacco products currently consumed (daily or non-daily) by survey participants using GATS microdata. County-level weighted prevalence rates of single, dual (any two), and poly (more than two) tobacco product users were calculated. Demographic, socioeconomic, and tobacco control-related factors associated with single, dual, and poly use were tested using multi-level multinomial regression analyses. Single (4.3–31.5

INTRODUCTION The increasing use of e-cigarettes among the youth is a public health problem that needs surveillance. We report changes in e-cigarette use, cigarette smoking, and 'dual use' among youth in 10 countries. METHODS Global Youth Tobacco Surveys from Georgia, Iraq, Italy, Latvia, Montenegro, Paraguay, Peru, Qatar, Romania, and San Marino were analyzed. Changes in prevalence of 'awareness of e-cigarettes', 'ever use' (even tried a few puffs) and 'current use' (during last 30 days) of e-cigarettes and cigarette smoking, and 'dual use' (both e-cigarette and cigarette smoking) between baseline (2013/2014) and most recent (2017-2019 ) surveys were estimated. RESULTS 'Awareness of e-cigarettes' and 'ever e-cigarette use' significantly increased (p<0.001). 'Ever e-cigarette use' was highest in Italy, 93% (95%CI 90.9, 94.4). 'Current e-cigarette use' significantly (p<0.05) increased by >50% in most countries. During the most recent surveys, 'current e-cigarette' use was >10% in five countries Italy (18.3%) and Latvia (18.5%) being the highest. Cigarette smoking significantly declined in Italy, Latvia, Peru, and San Marino (p<0.05) but remains unchanged in other countries. 'Dual use' (both electronic and conventional cigarettes) significantly increased in all countries (p<0.001). During the most recent surveys 'dual use' was highest in Italy (10%, 95%CI 8.1, 12.2) and Latvia (8.6%, 95%CI 7.2, 10.2). Youth aged 14 and ≥ 15 years the smokers, were more likely to be e-cigarette users. CONCLUSIONS Awareness and use of e-cigarettes and 'dual use' among youth have increased. Closer monitoring of tobacco use among youths and comprehensive tobacco control policies inclusive of e-cigarettes are needed. IMPLICATIONS Secondary data analyses of serial Global Youth Tobacco Surveys in 10 countries showed that both awareness of e-cigarette and e-cigarette use has increased among school-going youth aged 13-15 years. A concurrent increase in 'dual use' of e-cigarettes and cigarette smoking during the last 30 days in all 10 countries indicates continued cigarette smoking in the absence of e-cigarettes due to the common risk construct of tobacco product use. Results call for continued surveillance of both e-cigarettes and cigarette smoking among school-going youth. Comprehensive tobacco control measures inclusive of e-cigarettes should be implemented to reduce tobacco use among the youth.

IntroductionMonitoring changes in cessation behaviors and cessation assistance is critical for policymaking.MethodsWe analyzed two rounds (2009-2014 and 2015-2021) of Global Adult Tobacco Surveys in 13 countries. We estimated the quit ratio, quit attempt, and utilization of cessation assistance. The availability of cessation services was obtained from World Health Organization reports. We calculated absolute and relative changes in quit ratio, quit attempt, and cessation assistance. We assessed socio-economic determinants of cessation behaviors by binary logistic regression analyses on pooled data.ResultsIn all countries during both rounds smoking prevalence was 7.6-33.8%, the quit ratio was 0.15-0.54%, and the quit attempt was 17.7-52.8%. Quit ratio improved in Indonesia by 100% but declined in Turkey by 56%. Quit attempts increased in Indonesia (31.9%), Mexico (16.9%) and China (15.9%) but decreased in Turkey (140.4%), Vietnam (43.1%), and Romania (62.4%). In both rounds, using at least one method was 12.5-99.8% while the WHO-recommended method was 4.1-88.4%. In both rounds "try to quit without any assistance" and "other methods" were the most frequently reported cessation assistance. Nicotine replacement therapy (0.2-25.3%) was frequently used as recommended cessation assistance. Nicotine replacement therapy was available in most countries but not quitline and support services.ConclusionLimited progress was made in smoking cessation behaviors and cessation assistance in most countries. Health education to improve demand for smoking cessation and availability of evidence-based, low-cost smoking cessation assistance including quit-smoking may improve quit ratios in the population.

Background Nicotine dependence, factors associated with dependence, and self-reported side effects among people who use e-cigarettes are scarce in developing countries. Methods A sample of 302 persons who currently use e-cigarettes was recruited from discussion forums on Reddit, Facebook, and the forum ‘lowyat’. The online Google form survey collected data on demographics, e-cigarette use, and the reasons, for cigarette smoking, Fagerstorm Test for Nicotine Dependence adapted for e-cigarettes (eFTND), and side effects experienced. Results The mean age was 25.5 years (6.5), 60.6% were males and 86% had higher education. About 47% were using e-cigarettes only, 27.8% were currently using dual products (both electronic and conventional cigarettes), and 25.2% had also smoked cigarettes in the past. ‘ Less harmful than cigarettes’ (56.3%), ‘ because I enjoy it’ (46.7%), and ‘ it has a variety of flavors (40.4%) were the common reasons for e-cigarette use. The mean eFTND score was 3.9 (SD = 2.2), with a median of four side effects (IQR 3–6), sore or dry mouth/throat (41.4%), cough 33.4%, headache (20.5%), dizziness (16.2%) were commonly reported side effects. eFTND score and side effects were higher among persons using dual products. By multiple linear regression analysis, males (β = 0.56 95% CI 0.45, 1.05, p = 0.033), dual-use (β = 0.95 95% CI 0.34, 1.56, p < 0.003), and use of nicotine-containing e-cigarettes (β = 0.66 95% CI 0.07, 1.25 p = 0.024) had higher eFTND score. Conclusion Our findings of the study call for the placement of disclaimers about possible nicotine addiction and side effects of e-cigarette products.