Sharon Cox 2022 Nictone Intro
Sharon Cox 2022 Nictone Intro
Sharon Cox 2022 Nictone Intro
DOI: 10.1111/add.16010
1
Department of Behavioural Science and Abstract
Health, University College London, London,
UK Background and aims: Ontologies are ways of representing information that improve
2
SPECTRUM research consortium clarity and the ability to connect different data sources. This paper proposes an initial
3
Addiction Research Group, Norwich Medical version of an ontology of tobacco, nicotine and vaping products with the aim of reducing
School, University of East Anglia, Norwich, UK
4
ambiguity and confusion in the field.
Centre for Addictive Behaviours Research,
London South Bank University, London, UK Methods: Terms related to tobacco, nicotine and vaping products were identified in the
5
Department of Clinical, Educational and research literature and their usage characterised. Basic Formal Ontology was used as a
Health Psychology, University College London,
unifying upper-level ontology to describe the domain, and classes with definitions and
London, UK
6
Institute for Intelligent Interacting Systems, labels were developed linking them to this ontology. Labels, definitions and properties
Otto-von-Guericke University Magdeburg, were reviewed and revised in an iterative manner until a coherent set of classes was
Germany
agreed by the authors.
Correspondence Results: Overlapping, but distinct classes were developed: ‘tobacco-containing product’,
Sharon Cox, Department of Behavioural
‘nicotine-containing product’ and ‘vaping device’. Subclasses of tobacco-containing
Science and Health, University College
London, UK. products are ‘combustible tobacco-containing product’, ‘heated tobacco product’ and
Email: [email protected]
‘smokeless tobacco-containing product’. Subclasses of combustible tobacco-containing
Funding information product include ‘cigar’, ‘cigarillo’, ‘bidi’ and ‘cigarette’ with further subclasses including
Cancer Research UK, Grant/Award Number: ‘manufactured cigarette’. Manufactured cigarettes have properties that include
C64552/A29896; the Society for the Study of
Addiction ‘machine-smoked nicotine yield’ and ‘machine-smoked tar yield’. Subclasses of smoke-
less tobacco product include ‘nasal snuff’, ‘chewing tobacco product’, and ‘oral snuff’
with its subclass ‘snus’. Subclasses of nicotine-containing product include ‘nicotine loz-
enge’ and ‘nicotine transdermal patch’. Subclasses of vaping device included ‘electronic
vaping device’ with a further subclass, ‘e-cigarette’. E-cigarettes have evolved with a
complex range of properties including atomiser resistance, battery power, properties of
consumables including e-liquid nicotine concentration and flavourings, and the ontology
characterises classes of product accordingly.
Conclusions: Use of an ontology of tobacco, nicotine and vaping products should help
reduce ambiguity and confusion in tobacco control research and practice.
KEYWORDS
E-cigarette, nicotine, ontology, tobacco, tobacco product, vape, vaping device
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.
I N T R O D U CT I O N from using certain types of vaping device [15]. It is built into the label
that a cause of the condition is use of e-cigarettes. However, the con-
Products containing tobacco are widely used worldwide and their use dition has been found not to be caused by use of e-cigarettes per se,
has been estimated to contribute to more than 7 million deaths per but almost certainly by vaping tetrahydrocannabinol (THC)-containing
year globally [1]. There are many diverse products that differ in popu- e-liquids adulterated with vitamin E acetate [14]. The widespread con-
larity according to geographical region, demographic characteristics, flation of vaping THC with e-cigarette use in this case has led to fur-
legislation and culture. The products also differ in how they are used, ther inaccurate perceptions of the harmfulness of e-cigarettes among
how the tobacco is prepared and their harmfulness to health. Ciga- members of the public [16]. Although an ontology may not immedi-
rettes contribute to the most deaths [1]. Products containing nicotine, ately help with such issues, if scientists can be clear on the classifica-
but no other tobacco constituents are also used widely, most com- tion of products, so too may the writing of press releases, and other
monly in an attempt to stop or reduce cigarette consumption [2, 3]. types of scientific communication to the press and the public. In par-
The advent of non-tobacco nicotine-containing products, e-cigarettes ticular, the ontology may help to highlight the distinction between
and other vaping devices has added to the range of products that harmfulness that arises from products themselves and that with their
need to be considered to understand and address tobacco-related replaceable constituents such as different forms of e-liquid.
harm [2, 3]. We have also seen marketing of tobacco products that Another area of confusion and lack of clarity are the terms used
are heated, but without being fully combusted. Such a wide variety of for inclusion criteria and outcomes in the research studied. For exam-
products with such varied properties makes it essential to have clarity ple, it is common for studies to conflate tobacco use, tobacco smoking
about the type of product to which one is referring [4–6]. This paper and cigarette smoking. Therefore, randomised trials often refer to
aims to improve clarity by setting out an initial version of an ontology ‘smoking cessation’ as an outcome measure when the presumed
of products related to tobacco, nicotine and vaping with clearly meaning is cigarette smoking, tobacco smoking or even tobacco use.
defined classes and relationships between them. This may not appear to matter in cultures where cigarette smoking is
The rapid evolution of tobacco, nicotine and vaping products has the only form of smoking, but presents difficulties when attempting to
caused problems when it comes to defining and labelling these, and integrate evidence internationally as in other locations or cultures cig-
some high profile organisations have struggled to achieve logical con- arillos or other tobacco products may be more dominant.
sistency in their nomenclature [4, 6–8]. For example, the Food and Ontologies can go a long way to addressing such confusions.
Drug Association (FDA) in the United States (US), classifies e- They are formal ways of representing the world using clearly delin-
cigarettes as a ‘tobacco product’ [6, 7]. Unfortunately, this creates eated classes and their inter-relationships, taking care to ensure that
two inconsistencies. First of all, the only tobacco constituent in e- each entity is unique and unambiguously defined [17, 18]. Ontologies
cigarettes is nicotine, and nicotine replacement therapy (NRT) prod- are being used in other areas of study such as biomedicine and social
ucts are not classified as tobacco products because they are regulated science to address problems of inconsistent and confusing terminol-
as medicinal products by the Center for Drug Evaluation and Research ogy, for example, the Gene Ontology in molecular biology [19] and
(CDER). Second, many e-cigarettes do not contain nicotine or any the Behaviour Change Intervention Ontology in behavioural science
other tobacco constituent or even any psychoactive drug. The World [20]. They provide a more secure foundation for advancing the sci-
Health Organisation (WHO) similarly classifies as tobacco products ence in a given domain, linking it with other domains, and making the
ones that have no tobacco constituents [9]. Bloomberg Philanthropies, output more usable by policy makers and practitioners.
a major funder of tobacco control research, goes further in labelling e- The definitions of classes in ontologies differ from typical dictio-
cigarettes as ‘flavoured tobacco products’, which at a broad level to nary definitions. In ontologies, the definition is primary and the label is
those without specific product knowledge conflates and equates them a way of referring to that defined entity, whereas in dictionary defini-
with other types of flavoured combustible products [10]. tions the label is primary and the definition makes a claim about the
How tobacco-related products are labelled influences the conduct correct usage of the label [17]. For example, in a dictionary definition
and interpretation of scientific research. Lack of clarity around prod- one can claim that the correct meaning of the word ‘elephant’ is a
ucts has led to misunderstanding and disputes over the interpretation large pachyderm with an elongated proboscis and large ears. In fields
of data (e.g. Jarvis et al.) [11]. For example, estimates of the preva- such as addiction, there is no unique ‘true’ meaning for a given term,
lence of ‘youth tobacco use’ in the United States have been increased because different people and organisations often use the same term
by including e-cigarettes as a tobacco product, whereas headline fig- to represent different things and use different terms to represent the
ures for adult smoking prevalence have focused on cigarette smoking same thing.
and excluded cigarillos, which are very similar to cigarettes in addic- Use of ontological definitions is important because it avoids fruit-
tiveness and harmfulness [12]. This confusion has been exacerbated less discussions about the ‘true’ meaning of labels and focuses instead
by conflation of ever-use, past 30-day use and ‘current’ use [11, 13]. on identifying classes of entities that can be unambiguously defined,
Another example of confusing use of terminology is the term ‘e- whatever one chooses to call them. The label that is given to an entity
cigarette or vaping product use-associated lung injury (EVALI)’ [14]. is important, but only insofar as it allows users to make reference to
The term was adopted by the US Centers for Disease Control and entities without having to keep looking up the definition. The primacy
others to describe a clinical condition involving acute lung damage of the definition allows users from different epistemological positions
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TOWARD AN ONTOLOGY OF TOBACCO, NICOTINE AND VAPING PRODUCTS 179
to take different views about what they mean by a label as long as Addiction journal within the previous year (2019) were reviewed, and
they make it clear, which definition their preferred label relates all substantive terms were extracted and entered into a spreadsheet.
to. This in turn means that a field can achieve wider convergence These terms were separated into those that were generic
around a set of definitions even in areas where the use of specific (of relevance to the broader scientific domain) and those that were
labels is disputed. In ontologies, the concept of ‘namespace’ is used specific to the addiction domain. The resulting list of terms was
to uniquely specify the ontology to which a given label belongs, and merged with that arising from the workshop to create a master list of
within each ontology unique unambiguous identifiers specify entities. entities of relevance for the domain, with a flag to indicate those that
Therefore, if people want to use a term such as ‘dependence’ in dif- were specific to the e-cigarette domain in particular as opposed to
ferent ways, they just need to specify the namespace and unique those that were relevant for addiction in general, but not directly for
identifier for the term they are using to make clear what it is referring the e-cigarette domain (e.g. measures of alcohol dependence).
to. Each entity can then have different and potentially overlapping The top-down step, which proceeded concurrently, involved an
labels and synonyms to reflect different communities of usage. iterative process of attempting to identify sub-domains of entities
The Society for the Study of Addiction has sponsored the initial referred to in addiction papers. The results of this process will be
development of an Addiction Ontology (namespace: AddictO) that reported elsewhere; for the current paper we note that one of the
can be applied across the whole addiction domain [21]. As part of this, sub-domains was labelled ‘product’ and this included all entities relat-
and with additional funding from Cancer Research United Kingdom ing to products referred to in the addiction literature, including addic-
(UK) we are developing an E-Cigarette Ontology (E-CigO) to include tive products such as tobacco-related products and alcoholic
all entities relating to e-cigarettes and their study, which includes beverages, chemicals such as nicotine and alcohol and devices con-
tobacco, nicotine and vaping products [4]. This paper reports the structed to ingest chemicals.
development of a part of E-CigO concerning tobacco and nicotine The authors of this paper represent the core team who were
products and vaping devices. The aim was to arrive at a set of defini- responsible for curating the entities collected through the above pro-
tions and labels that could be used to unambiguously characterise cesses and seeking agreement on what should be included or edited
these products and show how they relate to each other. If this ontol- ready for inclusion. Each team member focused on a specific area to
ogy becomes widely used it should improve research and practice in develop and sought feedback from the team at weekly meetings (held
this area. online) over a 2-year period. This process allowed the team to system-
atically work through the entities by domain and agree on (i) whether
the entity should be included, (ii) its position with the ontology,
METHODS (iii) label and definition. We sought a majority consensus before
including entities, if we could not seek agreement or the scope was
Data sources for ontology development beyond our group’s expertise, we would seek input from an expert in
that area or refer to other ontologies—although this only happened on
The E-CigO project was initiated with a webinar [22] hosted by Can- a few occasions. J.H. was responsible for ontology expertise, consis-
cer Research UK (CRUK) in March 2019 (live event attended by 60 tency checks and assigning identifiers through automated processes.
individuals including academics, policy makers and stop smoking advi- Figure 1 presents the workflow of the ontology from the point of
sors/trainers). A subsequent in-person meeting was held at University agreed entity inclusion onward.
College London in May 2019 hosted by S.C., R.W., C.N. and J.H.,
attended by 50 individuals with an academic and/or policy interest
in nicotine and tobacco research, and 10 domain experts (representa- Use of Basic Formal Ontology as the upper level
tion from United Kingdom, United States and Europe, covering areas: ontology
policy, practice, research methods, public health, epidemiology, basic
science and toxicology and special populations) who presented key A hierarchy of classes is a key feature of ontologies. As one goes up
areas of divergence within their specialist field. During these presen- the hierarchy to more and more general classes, it is important for
tations the initial scope and range of terminology relevant for the e- interoperability to connect up as far as possible with a single coherent
cigarette research domain was collected (by R.W.) and further devel- set of upper-most classes shared across domains. Most ontologies in
oped through a snowball technique by group participation with those biological sciences link to a single upper level ontology called Basic
in attendance on the day. This initial workshop-based scoping exercise Formal Ontology (BFO) [23]. This was the upper-level ontology cho-
led to 700 terms being collated across the different aspects of e- sen for AddictO and E-CigO. An explanation of this and information
cigarette research and informed the main structure of the categorisa- about BFO can be found in our recently published paper [24].
tion of the domain into modules, of which ‘products’, the subject of In brief, BFO distinguishes two broad classes of entity: continu-
the present article, was one. ants (things that continue to exist as individuals over a period of time,
This scoping phase was followed by both top-down and bottom- such as objects and their attributes) and occurrents (things that take
up steps to progress the ontology development. In the bottom-up place or happen in time, such as processes). Within continuants, BFO
step, a sample of the first 100 abstracts that were published in the distinguishes between ‘independent continuants’ such as objects and
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180 COX ET AL.
regions that have a physical presence and ‘dependent continuants’ which it belongs), synonyms (alternative words or phrases used for
such as qualities and dispositions that are attributes that have no sep- this class, which do not have to be unique), comment (an elaboration
arate existence beyond the things they are attributes of. ‘Qualities’ and explanation of the definition if needed), curator note
are attributes such as age and mass that are fully manifested in the (an explanation if needed of the choices made in arriving at the label
things they are attributes of. Dispositions are attributes such as addic- or definition) and curation status (a label to indicate whether the
tiveness and harmfulness that are more complex in that they are only entity was still being worked on or was agreed).
conditionally manifested in certain contexts; they involve the poten- The terms identified for inclusion were entered as labels into
tial for something to occur under certain conditions. A third important spreadsheets for each of the subdomains and the project team dis-
type of dependent continuant, that is not in BFO but is closely linked cussed and revised the labels, definitions and other fields until agree-
to it, is the ‘information content entity’. These are entities that pro- ment was reached within the team. If there was a suitable entity that
vide information about things (e.g. ‘grams of tobacco’ provides infor- could be used from an existing ontology, this was imported; otherwise
mation, using a unit of measurement, about an amount of tobacco). an entity was created. This is an ongoing process. Ontologies grow
Tracing all the classes in the ontology being developed to classes organically as new entities and relationships are added. Computer pro-
in BFO provides a basis for linking them to other ontologies that use grams were written using the ROBOT tool to convert the spreadsheet
BFO. In addition, AddictO and E-CigO are developed using the techni- representation into the standard format for ontologies, Web Ontology
cal standards advocated by the Open Biological and Biomedical Ontol- Language (OWL) [26].
ogy (OBO) Foundry [25], which enable direct re-use of ontology Figure 1 shows the workflow for each class in the ontology, start-
content across ontologies, avoiding duplication of effort. For example, ing with a label and a preliminary definitions and proposed parent
classes representing chemicals such as nicotine do not have to be class. At this stage the class would be given a unique ID and its cura-
defined anew in AddictO, but can be imported from the Chemical tion status would be ‘Proposed’. Next, it would be discussed within
Entities of Biological Interest (ChEBI) ontology, which adopts the the team (all authors named above) and other information added as
same technical standards. required, such as an informal definition, a comment to help interpret
the definition and a curator note if required to explain to users why a
particular definition or label was used. These fields would be reviewed
Process of ontology development and revised until there was agreement within the team. The curation
status would then be changed to ‘Discussed’. There would be one fur-
A spreadsheet template was created with fields for all the properties ther chance to review and amend before the curation status would be
of the entities and metadata about them. These included: ID (a unique changed to ‘Published’. At this point, an automated process would
identifier for the entity), label (a word or phrase representing the transfer all the information for the class in the spreadsheet to the
entity that is unique within the ontology), definition (an ontological Qeios publishing platform where it would be published as a definition
definition of the entity specifying the parent class that it belongs to and assigned a digital object identifier (doi). Once the class was pub-
and features that distinguish this class from others in the parent class lished on Qeios, there was an opportunity for anyone to comment
) [17], informal definition (a less technical definition if required), logical publicly. Revisions could then be made and documented in response
definition (a formal expression defining the class in terms of a combi- to those comments and an updated definition published on Qeios.
nation of other classes), a URL for a link to a source of the definition The Addiction Ontology under development is available for
(e.g. Wikipedia) if there was one, parent class (the broader class to download in the OWL language from http://addictovocab.org/
13600443, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/add.16010 by Cochrane Romania, Wiley Online Library on [26/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
TOWARD AN ONTOLOGY OF TOBACCO, NICOTINE AND VAPING PRODUCTS 181
F I G U R E 2 Major classes of tobacco and related products included in the Addiction Ontology. Each rounded box in the Figure represents a
class in the ontology, whereas arrows represent relationships between classes. Black unlabelled arrows represent taxonomic (hierarchical)
relationships; other relationships are labelled with the relationship type: ‘has part’ and its inverse ‘part of’ represent parthood relationships,
‘contains’ represents inclusion, ‘has disposition’ captures the relationship between a thing and the dispositional properties or attributes it has
(properties that are only realized in certain contexts), and ‘inheres in’ captures the inverse relationship between a property or attribute and the
thing it is a property or attribute of.
addicto.owl and the spreadsheets can be downloaded from the open cases they contain neither nicotine or tobacco, or indeed a psychoac-
source project repository at http://github.com/addicto-org/addiction- tive substance of any kind.
ontology. Classes that are under consideration or have been discussed Entities that the US FDA calls ‘tobacco products’ had to be con-
or published can be explored at https://addictovocab.org/. Classes sidered as a separate class because of the inconsistencies in the defi-
that have been agreed within the team are published on the Qeios nition. This class is not included in Table 1 or Fig. 2, but can be found
publishing platform (www.qeios.com/) with a doi, which makes it easy on Qeios (www.qeios.com/read/VMLSA4.4). Although this definition
to refer to them in articles using the standard crossref bibliographic has been developed for purposes of regulation in the United States,
referencing system (www.crossref.org). This paper reports only the its potential for causing confusion means that it is better avoided in
major classes and relationships. scientific discourse unless the purpose is to refer specifically to the
regulatory status of a product in the United States.
To define tobacco-containing products, we have to define
RESULTS tobacco and assign it a parent class. An obvious parent class would be
‘psychoactive substance’, but biomedical ontologies typically do not
The tobacco and related products and their properties use psychological or biological effects of chemicals as their primary
basis for classification of substances because these are complex and
Figure 2 shows the major classes identified in the ontology and links context-specific attributes. Therefore, ‘nicotine’ in the CHEBI ontol-
these to classes in the BFO via another ontology called the Products ogy is classed according to its chemical structure. Another reason for
Life Cycle Ontology (PLCO). The PLCO provides a way of linking not using psychological or biological effects in the primary classifica-
tobacco products to other kinds of products [27]. tion is that any chemical or substance may have many such actions.
Table 1 provides definitions of the entities and shows their parent Nicotine is not only psychoactive, it has effects on the cardiovascular
classes. Full details of all the AddictO and E-CigO classes can be found and many other body systems. Therefore, we used commodity as the
using the Qeios URL provided in the table. parent for tobacco and product for the parent for tobacco product.
AddictO distinguishes tobacco-containing products as products The ontology subdivides tobacco-containing product classes into
that consist of or include tobacco that are distinct from nicotine- combustible tobacco-containing products, heated tobacco products
containing products that in turn are distinguished from vaping devices. and smokeless tobacco-containing products. This is to reflect the most
This upper-level distinction is essential to ensure consistency and clar- common upper-level division of these classes of product in common
ity in the use of terms. Therefore, although nicotine transdermal usage. It also captures some empirical distinctions. Combustion of
patches may contain nicotine, they do not contain tobacco, although tobacco creates additional toxins that increase their harmfulness to
they are used to ingest a chemical, nicotine, which is usually (but not health. Combustible products are also designed for users to inhale the
always) found in tobacco. Similarly vaping devices cannot be classified smoke, which offers both the potential for increased harm because of
as either nicotine- or tobacco-containing products because in many toxic chemicals coming into contact with the large and delicate tissues
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182 COX ET AL.
TABLE 1 Major classes of tobacco and related products and their properties.
TABLE 1 (Continued)
Chewing tobacco product An oral tobacco-containing product that is Oral tobacco-containing www.qeios.com/read/
manufactured to be chewed. product 810RFA.3
Nasal snuff A smokeless tobacco-containing product Smokeless nicotine-containing www.qeios.com/read/
that is formed of dry finely-ground product T2DP55
tobacco and is ingested by a person
into the nasal cavity.
Oral snuff An oral tobacco-containing product that is Oral tobacco-containing www.qeios.com/read/
composed mainly or exclusively of product 6NCMYS.2
moist, ground or powdered tobacco
that is processed to make it suitable
for use by a person placing it in the
mouth between the gum and the
cheek.
Cigarillo A cigar that is short and thin with Cigar www.qeios.com/read/
wrapping that is tobacco or tobacco- SNP7WR
based paper.
Manufactured cigarette A cigarette that is manufactured in a Cigarette www.qeios.com/read/
factory. XJ63ZR
Hand-rolled cigarette A cigarette whose parts have been Cigarette www.qeios.com/read/
purchased separately and assembled 7UZ5V7
by hand or using a device for single
assembly.
Types of nicotine-containing products
Oral nicotine-containing product A nicotine-containing product that is Nicotine-containing product www.qeios.com/read/
manufactured to be held in the mouth 6IVS58
or chewed so that nicotine is absorbed
through the buccal mucosa.
Nasal nicotine-containing product A nicotine-containing product that is Nicotine-containing product www.qeios.com/read/
manufactured to enable users to GSE0NT
ingest nicotine through the nasal
mucosa.
Iinhaled nicotine-containing product A nicotine-containing product that is Nicotine-containing product www.qeios.com/read/
manufactured to enable users to draw XE3EUB
a nicotine-containing vapour into the
respiratory tract so that nicotine can
be absorbed through the lining of this
tract.
Transdermal nicotine-containing A nicotine-containing product that is Nicotine-containing product www.qeios.com/read/
product manufactured to be attached to the J10IA5
skin so that nicotine can be absorbed
through the skin.
Types of e-cigarette
E-cigarette An electronic vaping device that is hand Electronic vaping device www.qeios.com/read/
held and produces for inhalation an 0WX80U
aerosol formed by heating an e-liquid
using a battery-powered heating coil.
Nicotine-containing e-cigarette An e-cigarette whose e-liquid contains E-cigarette www.qeios.com/read/
nicotine. H51NZN
E-cigarette open system An e-cigarette in which all of the main E-cigarette www.qeios.com/read/
components are interchangeable. ROMCLB.2
E-cigarette pod device An e-cigarette that has as a part a E-cigarette www.qeios.com/read/
replaceable e-cigarette pod. G3SA5I.2
E-cigarette closed system An e-cigarette in which none of the main E-cigarette www.qeios.com/read/
components is interchangeable. 6CURTR.2
(Continues)
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184 COX ET AL.
TABLE 1 (Continued)
TABLE 1 (Continued)
E-cigarette battery power A e-cigarette battery disposition to E-cigarette battery disposition www.qeios.com/read/
transfer electrical energy in a circuit 24QQDS
containing an atomiser.
E-cigarette atomiser resistance An e-cigarette atomiser quality that is the E-cigarette atomiser quality www.qeios.com/read/
opposition of its circuit to the flow of ZIM0VV
current in that circuit.
Note: Ontological definitions can seem technical and are sometimes not easy to read. Informal definitions are being added to AddictO Vocab to address
this; however, informal definitions should always be read only alongside the formal definition and not in isolation to avoid the risks associated with
ambiguity. Some internet browsers direct users to the Qeios landing page and not directly to the definition.
*Major classes are not always informative because they cover a variety of products.
of the lungs and upper airways, and more rapid ingestion of nicotine, vaping device, but they do contain tobacco and so it was judged that
which is the primary psychoactive compound in tobacco. it would be best to classify them as tobacco-containing products.
Combustible tobacco-containing products come in many forms. Smokeless tobacco-containing products come in many forms that
The ontology, based on common usage, distinguishes between cigars are distinguished in common usage by their intended route of admin-
(including cigarillos) whose outer covering is made from tobacco, ciga- istration: primarily oral versus nasal. They can also be distinguished by
rettes (whose outer covering is made from a thin paper), and bidi the way that the tobacco used in them is processed because this has
(which are like small cigarettes except that their outer covering could implications for their harmfulness. Snus is processed in a way that
be made from paper or a processed plant leaf). It is important to note results in very low concentrations of tobacco-specific nitrosamines
that beyond this distinction in terms of components, the classes of and this is reflected in their low carcinogenicity relative to, for exam-
combustible tobacco-containing products provide little information on ple, chewing tobacco of the kind used in the United States. However,
attributes of interest, particularly harmfulness and addictiveness. as with combustible tobacco, this broad classification is of limited use
This severely restricts the value of relying on these classes per se for policy and clinical decision-making and needs to be supplemented
as a basis for clinical or policy decisions. For example, cigarillos of the by information about specific attributes of individual products.
type widely used in the United States are classified as cigars, but in There are a very large number of smokeless tobacco-containing
terms of harmfulness and addictiveness have much more in common products in use around the world and we are working with experts to
with cigarettes than with large panatella cigars because of key attri- include as many of these as possible in the ontology. This is work in
butes that influence the way they are used [28]. In particular, the progress and will be reported separately.
smoke is readily inhaled into the lungs and they are cheap and conve- Nicotine-containing products vary by route of nicotine absorp-
nient to use. tion, intended method of administration, rate of nicotine absorption,
An important distinction between types of cigarettes is between and nicotine dose. In common usage products are classified by their
manufactured cigarettes and hand-rolled cigarettes. This distinction intended route of administration: oral-buccal (held in the mouth or
is important because the former can be characterised in terms of chewed), oral-alimentary (swallowed), pharyngeal-pulmonary (inhaled),
machine-smoked nicotine yield, machine-smoked tar yield, and nasal (sniffed or placed in the nasal cavity) and transdermal (attached
machine smoked carbon monoxide yield, whereas the latter cannot. to the skin).
The latter are typically much less expensive than the former. Note Tobacco-containing products are typically, although not necessar-
that machine-smoked yields of cigarettes bear very little relation ily, nicotine-containing products, but many nicotine-containing prod-
to the amount of nicotine, tar and carbon monoxide that users ucts are not tobacco-containing products. The route of administration
typically obtain from them because of compensatory puffing and provides some information about the rate of nicotine absorption that
inhalation patterns [29]. Nevertheless, they need to be represented can be expected with transdermal being the slowest and pharyngeal-
in the ontology because they are often referred to in research and pulmonary being the fastest. This in turn may provide information on
policy. their addictiveness [30]. However, individual products may differ con-
A separate major class had to be created for heated tobacco siderably in these attributes so class membership cannot be used defi-
products such as iQos. This is because, although it has been claimed nitely for this inference. It should also be noted that the route of
that there is no combustion, they produce carbon monoxide, which administration can allow inferences to be drawn about the rate of nic-
indicates that the temperature attained does lead to some combus- otine absorption. For example, the transdermal route produces slower
tion. Moreover, they cannot be considered combustible tobacco- absorption than the buccal route, which provides slower absorption
containing products because the tobacco stick that is heated is not than the nasal route, which provides slower absorption than the pul-
consumed by the heat. They could potentially be considered as a monary route [30].
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186 COX ET AL.
Vaping devices can be further classified according to whether the makes in-roads to achieving this. The definitions are published on
heat needed to vaporise the material is provided electronically or Qeios and readers are invited to comment.
through combustion. Therefore, we can identify electronic vaping Adopting the terms and definitions in the ontology should help to
device and a subclass of this, the e-cigarette. Not all vaping devices avoid researchers and policymakers confusing vaping with e-cigarette
are electronic and not all electronic vaping devices are e-cigarettes. use, cigarette smoking with tobacco smoking and nicotine use with
Moreover, not all e-liquids used in e-cigarettes contain nicotine. For tobacco use. However, this will not happen overnight and there is a
the reasons above, when describing use of these devices it is essential role for journals and research funders to foster good practice.
to make distinctions between the different products. Researchers can immediately begin to use the ontology by using
the labels in their research reports and referring to the definitions in
Qeios. Journals and research funders can begin to set standards when
E-cigarettes and their properties it comes to use of terminology to help ensure clarity. Researchers and
practitioners can also join the ongoing discussion about the terms and
E-cigarettes have evolved rapidly and the terminology used to label definitions and develop expertise in ontologies to improve and extend
them is variable and often imprecise. The major distinctions appear to the ontology.
be between devices that have no replaceable components (e-cigarette Work is currently underway to extend the ontology to the wide
closed systems) and those that have replaceable components: the bat- range of smokeless tobacco-containing products in use around the
tery, atomiser (that heats the e-liquid), the tank (liquid container) or world. There is also ongoing work to define and label e-cigarette com-
the e-liquid. There are also e-cigarette pod devices in which the atom- ponents, and to use the ontology of products to define tobacco and
iser and e-liquid container form a single part (the pod), which can be nicotine use behaviours [4].
replaced by one with a similar design. It is important to note that the ontology definitions presented
Another important distinguishing feature is the use of flavourings here are based on the product characteristics and what they are
in the e-liquid. The large number of combinations of features that may designed to do by the manufacturer. That is, although an e-cigarette
be important when characterising the effects of e-cigarette use means may be used by a sub-community for purposes other than vaping nic-
that it is better to characterise e-cigarettes by specific features than otine (e.g vaping illicit substances [30]) the products were not
by broad classes. designed for this purpose. Indeed, in this case, it is actually clearer for
The resistance of the atomiser, power rating of the battery, nico- the reader if they understand that another substance has been used
tine concentration of the e-liquid and choice of flavourings appear to within an e-cigarette for purposes that the product was not designed
be important features that should be represented. Figure 2 and for, rather than trying to shape the definition of a device to accommo-
Table 1 show the proposed classes for use with e-cigarettes. The date all the possibly diverging ways it is being used in practice. Prob-
Addiction Ontology specifies that e-cigarettes have as parts batteries, lems arise when researchers create their own labels for products
atomisers and e-liquid containers, which contain e-liquid, and then (e.g. alternative nicotine delivery systems [ANDS]) or are vague as to
specifies the properties of these. This provides a systematic way of the product characteristics.
capturing the complexity of the differing properties of e-cigarettes, However, for completeness and to make the resource useful and
which in turn can provide a basis for gathering data on these proper- searchable we include product synonyms. Synonyms provide a useful
ties. More classes that capture different variants of e-cigarettes can searchable point of reference, but the primary product label should be
be found on AddictO Vocab (addictovocab.org). used wherever possible. This is because synonyms (e.g. vape as a syn-
Given the varied ways in which tobacco products are labelled in onym for e-cigarette), although familiar to some researchers, are often
research reports and policy documents, the proposed ontology based on colloquialisms and do not reflect the object as either it truly
includes synonyms for some of the classes. Synonyms do not have to is or how the manufacturer designed the product to be used. As men-
be unique, but provide a way of searching the ontology for classes tioned before, within this ontology synonyms are not always exact
based on colloquial terms. These synonyms can be found in AddictO equivalences, because they may also offer the ontology user the
Vocab. opportunity to see how the product is being broadly referred to even
if those terms are ambiguous. An example of a synonym that is not an
exact equivalence is e-cigarette and electronic nicotine delivery
DISCUSSION device (END). A further example of a synonym that is a colloquial term
is when referring to e-cigarette use as ‘non-cigarette tobacco use’
Creating an ontology of tobacco and related products involves making [31]. This expression is factually incorrect as e-cigarette use is not
important distinctions between classes that, although they may be tobacco use, but could nevertheless be included within the ontology
related in practice, have to be treated as separate. Tobacco-containing as a synonym connected to the class ‘e-cigarette use’.
products cannot logically include nicotine-containing products, and Retroactively, the ontology can be used to synthesise previously
vaping devices are a separate class. Each of these classes has sub- published data, to understand how findings in relation to different
classes that need to be distinguished from each other in research products align, depending on how the products are described (if at all),
reports and policy documents. The ontology proposed in this paper fit within these categories and where errors with the published data
13600443, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/add.16010 by Cochrane Romania, Wiley Online Library on [26/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
TOWARD AN ONTOLOGY OF TOBACCO, NICOTINE AND VAPING PRODUCTS 187
may exist. For example, in reviews of the literature on product use Conceptualization; formal analysis; funding acquisition; investigation;
and health impacts it is important to separate the different types of e- project administration. Kirstie Soar: Data curation; formal analysis;
cigarette and tobacco product, before it is possible to draw integrated investigation; project administration. Janna Hastings: Conceptualiza-
conclusions about their respective health impacts. The ontology, tion; data curation; formal analysis; funding acquisition; investigation;
therefore, provides a vital resource for systematic reviews, living methodology; project administration; resources; software;
reviews, meta-synthesis and literature scoping reviews. visualization.
Limitations of the organisation of definitions in an ontological
structure need to be acknowledged. Tobacco, nicotine and vaping ORCID
research is a broad field encompassing many products that are contin- Sharon Cox https://orcid.org/0000-0001-8494-5105
uously evolving. The taxonomy presented here is not complete and it Robert West https://orcid.org/0000-0001-6398-0921
is possible that because of the limitations of our scoping exercises Caitlin Notley https://orcid.org/0000-0003-0876-3304
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