Tobacco-Product Use by Adults and Youths in the United States in 2013 and 2014

Correcting misperceptions about very low nicotine cigarettes for cigarette-only smokers, dual/poly smokers, other tobacco users, and non-tobacco users

Background

The U.S. Food and Drug Administration authorized the sale and marketing of two very low nicotine cigarettes (VLNC) as modified risk tobacco products. The misperception that VLNC are healthier than regular cigarettes is common. This study explores effective message strategies to inform the public about health risks associated with VLNC use, encourage cigarette smokers to try VLNC, and prevent other tobacco users and non-users from product initiation.

Methods

Following the Reasoned Action approach, a VLNC educational message was developed based on the salient beliefs associated with behavioral intention. The message was tested in an online survey conducted in 2018, where 410 participants were randomly assigned to one of the two message conditions (no-message, VLNC message). Message effects were assessed across four tobacco-use groups (non-tobacco users, cigarette-only smokers, cigarette dual/poly smokers, other tobacco users).

Results

Compared to the no-message control, the VLNC message condition showed lower nicotine risk perception for all participants, lower misbelief in VLNC safety for non-users and cigarette-only smokers, higher belief in VLNC carcinogenicity for other tobacco users, stronger belief in second-hand smoke harm for cigarette dual/poly smokers and other tobacco users, and higher VLNC intention for cigarette-only smokers.

Conclusions

Different messages are needed for different types of tobacco users. Both cigarette smokers and other tobacco users could benefit from messages that acknowledge the non-addictiveness but emphasize the health risks of VLNC. Regulators could consider making physical harm statements a requirement for VLNC packaging and marketing. New strategies need to be explored to inform cigarette dual/poly smokers.

Trends and Disparities in Waterpipe Tobacco Smoking Among US Adolescents and Adults: PATH Study 2013-2021

Background

Waterpipe tobacco smoking (WTS) is a popular mode of nicotine delivery among young people. We examined the trends and disparities in WTS from 2013 to 2021 among US adolescents and adults.

Methods

Data were from Wave 1 (initially conducted among 32 320 adults and 13 651 adolescents) to Wave 6 (2013-2021) of the Population Assessment of Tobacco and Health Study. We assessed the weighted prevalence of ever and current (past 30-day) WTS for adults and adolescents across waves stratified by demographics.

Results

From 2013-2021 among adolescents, the prevalence of ever and current WTS decreased by 86.5% (7.4% to 1.00%; p = 0.0364) and 97.1% (1.65% to 0.05%; p = 0.0012), respectively. Despite the decreasing trends among adolescents across all waves, females had a higher prevalence of ever and current WTS compared to males (p 's < 0.001 for all trends). Hispanics had the highest prevalence of ever WTS compared to other races/ethnicities (p 's < 0.001). Adolescents aged 15-17 had a higher (except Wave 6) prevalence of ever and current WTS than 12-14 years old (p 's < 0.001). For adults, the prevalence of ever WTS increased by 27.4% (16.39% to 20.92%; p = 0.0006), and current WTS decreased by 45.5% (2.19% to 1.24%; p = 0.0012). Young adults aged 18-24 experienced increasing trends in WTS and had the highest prevalence of ever and current WTS compared to other age groups (p 's < 0.001) across all waves.

Conclusions

Our study indicates a notable decrease in adolescent WTS prevalence from 2013 to 2021 but an increase of ever WTS among adults. Demographic differences underscore disparities in WTS, calling for tailored interventions.

E-Cigarette Characteristics and Cigarette Cessation Among Adults Who Use E-Cigarettes

Importance

Population-level health outcomes associated with e-cigarettes depend in part on the association between e-cigarettes and combustible cigarette cessation. The US Food and Drug Administration has authority to regulate e-cigarette characteristics, including flavor and device type.

Objective

To investigate whether e-cigarette characteristics are associated with cigarette cessation behaviors among adults in the US population who use e-cigarettes.

Design, Setting, and Participants

This cohort study was conducted using longitudinal data collected in 2014 to 2021 by the Population Assessment of Tobacco and Health Study, a population-based, US nationally representative study. Participants were sampled from the civilian noninstitutionalized population using a 4-staged, stratified sampling design. Data were weighted and analyzed from 1985 adults ages 21 or older who smoked cigarettes daily and had used e-cigarettes in the past 30 days. Data were analyzed in May 2021 to May 2024.

Exposures

The following e-cigarette characteristics were assessed: use frequency (daily and nondaily), flavor type (tobacco, menthol or mint, sweet, and combination), device type (disposable, cartridge, and tank), and year of data collection as a proxy for the evolving e-cigarette marketplace.

Main Outcomes and Measures

The following cigarette cessation behaviors were assessed: making a cigarette quit attempt, cigarette cessation among individuals who made a quit attempt, and overall cigarette discontinuation regardless of quit attempts. Associations were evaluated between e-cigarette characteristics (assessed at baseline in 1 approach and assessed at follow-up in another approach) and cigarette cessation outcomes, controlling for demographic, cigarette smoking, and other e-cigarette use characteristics.

Results

The study sample consisted of 1985 participants representing adults in the population (mean age, 40.0 years [95% CI, 39.2-40.9 years]; 49.4% [95% CI, 46.3%-52.6%] male; 11.4% [95% CI, 9.6%-13.4%] Black, 80.7% [95% CI, 77.8%-83.3%] White, and 8.0% [95% CI, 6.3%-10.0%] other race; 9.2% [95% CI, 7.5%-11.2%] Hispanic). Daily vs nondaily e-cigarette use was associated with greater overall cigarette discontinuation rates (12.8% [95% CI, 9.1%-17.7%] vs 6.1% [95% CI, 4.8%-7.7%]; adjusted odds ratio [aOR], 2.26 [95% CI, 1.34-3.81]), and use of e-cigarettes in 2019 to 2021 vs 2014-2015 to 2015-2016 was also associated with greater overall cigarette discontinuation rates (12.0% [95% CI, 8.8%-16.0%] vs 5.3% [95% CI, 2.9%-9.3%]; aOR, 2.75 [95% CI, 1.13-6.67]). Use of menthol or mint vs tobacco flavor e-cigarettes was associated with greater overall cigarette discontinuation rates (9.2% [95% CI, 6.6%-12.8%] vs 4.7% [95% CI, 3.0%-7.1%]; aOR, 2.63 [95% CI, 1.32-5.27]) only when assessing e-cigarette use at baseline. E-cigarette device type was not associated with cigarette discontinuation rates in adjusted analyses.

Conclusions and Relevance

In this study, daily e-cigarette use and use of e-cigarettes in 2019 to 2021 were consistently associated with greater cigarette discontinuation rates. These findings suggest that research focused on e-cigarettes marketed in recent years is needed to inform product regulation and public health policy decisions.

Effects of exposure to snus marketing with versus without modified risk tobacco product claims on snus use intention and perceived harm among young adults

BACKGROUND

We tested whether snus marketing with modified risk tobacco product (MRTP) claims: (a) promotes accurate knowledge about snus's health effects in young adults and (b) encourages use intentions in only those who use combustible tobacco without attracting other young adult populations.

METHODS

A randomised between-subjects experiment was embedded in a 2020 web survey of participants from Los Angeles (aged 19-23 years). Participants viewed mass-marketed snus advertising materials with (n=1212) vs without (n=1225) US Food and Drug Administration-authorised MRTP claims. After advertising exposure, snus use intention and perceptions of snus harms relative to cigarettes or e-cigarettes were measured.

RESULTS

Advertisements with versus without MRTP claims did not affect snus use intention (18.0% vs 19.4%) but produced a higher prevalence of perceptions that snus was less harmful than cigarettes (12.6% vs 9.1%; p=0.007) and e-cigarettes (8.0% vs 5.8%; p=0.04). MRTP claim exposure effects did not differ by past 30-day e-cigarette or combustible tobacco use. Snus use intentions after marketing exposure, collapsed across MRTP claim conditions, were higher in those who did versus did not report past 30-day use of e-cigarettes (38.4% vs 14.3%; adjusted OR (95% CI) 2.95 (2.28 to 3.81); p<0.001) or combustible tobacco (44.0% vs 16.2%; adjusted OR (95% CI) 2.26 (1.62 to 3.16); p<0.001).

CONCLUSION

Although some young adults who vape or smoke may have snus use intentions, snus MRTP claims might not affect young adults' snus use intentions, regardless of whether they vape/smoke. MRTP claims might modestly increase the accuracy of perceived harms of snus relative to cigarettes while also slightly causing unsubstantiated perceptions of lower harm than e-cigarettes.

Unintended exposure to e-liquids and subsequent health outcomes among US youth and adults

This study aimed to determine the prevalence and predictors of oral, ocular, or dermal e-liquid exposure and subsequent outcomes (becoming sick, going to the hospital) in the US. We examined survey data from the Population Assessment of Tobacco and Health Study Wave 5 (2018-2019). The analytic sample included US youth (aged 12-17 years), young adults (aged 18-24 years), and older adults (aged ≥ 25 years) who reported e-cigarette use in the past 12 months. We first determined the prevalence of self-reported e-liquid exposure (in the mouth, skin, or eyes), subsequently "becoming sick" from the exposure, and "going to the hospital" after the exposure. We also examined associations between these outcomes and the device type used (refillable tank /mod system, replaceable prefilled cartridges, disposable/ other device type). E-liquid exposure was reported by 25% of youth (aged 12-17 years), 25% of young adults (aged 18-24 years), and 19% of older adults (aged≥ 25 years). Among individuals reporting e-liquid exposure, subsequent sickness was reported by 10% of youth11% of young adults, and 14% of older adults, and "going to the hospital" was reported by 3.5% of youth, 2.7% of young adults, and 6.8% of older adults. Among young adults, the use of a refillable tank /mod system was associated with higher odds of e-liquid exposure (aOR = 2.2, 95% CI = 1.2, 4.1) than the use of other device types, including disposables. The findings suggest that, at a minimum, e-cigarettes/e-liquids may need warning labels that state the risks of e-liquid exposure and packaging regulations that promote device and bottle designs that minimize e-liquid spills.

Examining Demand and Substitutability of Usual Brand Little Cigars/Cigarillos and Cigarettes in Young Adults Who Dual Use

INTRODUCTION

Cigarette and little cigar/cigarillo (LCC) dual use is popular among young people and poses a substantial health risk. What remains unclear is the abuse liability of LCCs vs. cigarettes, LCCs' substitutability for cigarettes, and the influence of flavors on the abuse liability and substitutability of LCCs.

METHODS

Sixty-five young adults (18-34 years) who dual use completed hypothetical purchase tasks to measure consumption of usual brand cigarettes and LCCs in 24 hours at increasing prices (demand), and LCC consumption at increasing cigarette prices (substitution). Three demand indices were calculated from raw data: breakpoint (price after which consumption reaches 0), Omax (maximum daily expenditure), and Pmax (price at maximum expenditure). Two indices were estimated using nonlinear mixed-effects modeling: intensity (consumption when free) and price-sensitivity (rate of decline in consumption as price increases). Substitution, and associations of flavored use with demand and substitution, were estimated using linear mixed models.

RESULTS

Results indicated similar abuse liability for LCCs and cigarettes. Intensity was greater for cigarettes, but price-sensitivity was similar. Flavored LCC use was associated with lower price-sensitivity and greater intensity than unflavored. LCCs were significant substitutes for cigarettes, but the effect was small. Flavored use was not associated with substitution.

CONCLUSIONS

Among young adults who dual use, LCCs and cigarettes had similar abuse liability, and those who used flavored had higher demand for their LCCs. A flavored cigar ban, as well as targeted prevention and cessation services for those who smoke flavored LCCs, may be important for reducing dual use in young adults.

IMPLICATIONS

Cigarette and LCC dual use remains high among young adults. Using hypothetical purchase tasks with young adults who dual use, LCCs had abuse liability similar to cigarettes, but were only modest substitutes for cigarettes. Participants who used flavored LCCs reported greater abuse liability than those who used unflavored, but not greater substitution for cigarettes. Prevention and cessation services are needed to target LCCs in young people, particularly those smoking flavored products. A flavored cigar ban may help to reduce their demand.

Correlates of susceptibility to waterpipe tobacco smoking in young adults

INTRODUCTION

Many US young adults are susceptible to waterpipe (i.e., hookah) tobacco smoking (WTS) initiation, but research on factors associated with WTS susceptibility is limited. We examined sociodemographic, other tobacco and substance use, and attitudes and perceptions correlates of WTS susceptibility among young adults.

METHODS

Baseline data from a randomized trial testing WTS risk messages was collected in US young adults aged 18 to 30 years who never used waterpipe tobacco but were susceptible to WTS (n = 294). Extent of susceptibility to WTS was defined using the average score of a valid scale with higher scores indicating higher susceptibility. Correlates were sociodemographics, other tobacco and substance use, and attitudes and perceptions. Multiple linear regression models identified correlates of greater WTS susceptibility.

RESULTS

Participants averaged 25 (SD 3.2) years of age, 60% were male, 22% were Black non-Hispanic, 47% completed some college education, and 66% were employed. Our models consistently showed that more positive attitudes toward WTS (β = -0.08, p<0.01), lower perceived addictiveness relative to cigarettes (β = -0.09, p = 0.04), and greater perceived social acceptability of WTS (β = 0.05, p<0.01) were positively correlated with WTS susceptibility. Additionally, young adults who smoked cigarillos (β = 0.53, p<0.01), used cannabis (β = 0.14, p = 0.02), and Black non-Hispanic versus White non-Hispanic young adults (β = 0.18, p = 0.03) also had higher WTS susceptibility.

CONCLUSIONS

Findings suggest that WTS prevention efforts require multicomponent interventions including targeting subpopulations at greater risk based on race/ethnicity and other tobacco and substance use. These interventions should consider attitudes and social acceptability of WTS as modifiable targets to maximize public health benefits.

Free Radicals in Little Cigar Mainstream Smoke and the Potential Influence of Flavoring Chemicals on Free Radical Production

Implementation of the Tobacco Control Act in 2009 banned characterizing flavors in cigarettes (except menthol and tobacco), but substitution has occurred by the continued availability of alternative flavored products (i.e., flavored little cigars). Little is known about how flavorants in noncigarette tobacco products impact human health. Thus, we investigated the impact of flavorants on free radical production in the mainstream smoke of little cigars. Gas- and particulate-phase free radical yields in mainstream smoke generated from 12 commercial little cigar brands and research little cigars and cigarettes were measured via electron paramagnetic resonance spectroscopy using the International Organization of Standardization (ISO) smoking protocol. Flavorants were extracted from unsmoked little cigars and analyzed by gas chromatography-mass spectroscopy. Gas- and particulate-phase radical yields from little cigars ranged from 13.5 to 97.6 and 0.453-1.175 nmol/unit, respectively. Comparatively, research cigarettes yielded an average of 4.9 nmol gas-phase radicals/unit and 0.292 nmol particulate-phase radicals/unit. From the products, 66 flavorants were identified, with each brand containing 4-24 individual flavorants. The free radical content was strongly correlated with the number of flavorants present in each cigar (r = 0.74, p = 0.01), indicating that highly flavored little cigars may produce higher levels of toxic free radicals. The presence of the flavorant ethyl methylphenylglycidate (strawberry) was associated with >2-fold higher levels of GP radicals (p = 0.001). Our results show that free radical delivery from little cigars is greater than that from research cigarettes and provide empirical evidence for the harmfulness of flavored tobacco products. Additionally, it demonstrates that flavorants present in combustible tobacco products can influence the levels of free radicals produced. Therefore, future tobacco product standards should consider little cigars.

Longitudinal Assessment of Association Between Tobacco Use and Tobacco Dependence Among Adults: Latent Class Analysis of the Population Assessment of Tobacco and Health Study Waves 1-4

INTRODUCTION

With increasing tobacco product varieties, understanding tobacco use (TU) profiles and their associations with tobacco dependence (TD) has also become increasingly challenging.

AIMS AND METHODS

We aimed to identify TU profiles and their associations with TD over time, and to identify subgroups with high risk of TD. We included 3463 adult recent tobacco users who had complete TU and TD data across waves 1-4 of the Population Assessment of Tobacco and Health (PATH) study. We used a composite index of TD and a summed TD score from an established 16-item TD measure. We applied a latent class analysis to identify TU profiles based on participants' usage of eight common tobacco product groups at each survey wave and to check the stability of the TU profiles over time. We then used generalized estimating equations regressions to evaluate the longitudinal TU-TD association, adjusting for potential confounders.

RESULTS

We identified three distinct TU profiles that remained consistent across four survey waves: Dominant cigarette users (62%-68%), poly users with high propensity of using traditional cigarettes, e-cigarettes, and cigars (24%-31%), and dominant smokeless product users (7%-9%). Covariate-adjusted models showed that TD was significantly lower among the poly users and the dominant smokeless users, compared to that among the dominant cigarette users.

CONCLUSIONS

Both TU profiles and their associations with TD were stable over time at the population level. Poly users and smokeless product users were consistently associated with lower TD than cigarette-dominant users, suggesting the need for tailored tobacco cessation interventions for users with different TU profiles.

IMPLICATIONS

The finding of consistent TU profiles across four survey waves extends the current literature in capturing TU patterns in an evolving tobacco product landscape. The finding of the overall higher level of TD among the cigarette-dominant users compared to the other TU latent profiles (the Cig+eCig+Cigar dominant poly users and the dominant smokeless product users) can help identify high-risk groups for potential interventions. Our application of innovative statistical methods to high-quality longitudinal data from the PATH study helps improve the understanding of the dynamic TU-TD relationship over time.

National longitudinal tobacco product discontinuation rates among US youth from the PATH Study: 2013-2019 (waves 1-5)

OBJECTIVE

Determine longitudinal tobacco product discontinuation rates among youth (ages 12-17 years) in the USA between 2013 and 2019.

METHODS

The Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study, was used to determine annual/biennial rates of tobacco product discontinuation behaviours among youth across 2013-2019: (1) discontinuing product use (transition from past 30-day use to no past 30-day use), (2) attempting to quit product use and (3) discontinuing product use among those who attempted to quit. Discontinuing use was evaluated separately for cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah, smokeless tobacco and any tobacco. Attempting to quit and discontinuing use among those who attempted were each evaluated for cigarettes and ENDS. Generalised estimating equations were used to evaluate linear and non-linear trends in rates across the study period.

RESULTS

Between 2013 and 2019, biennial rates of discontinuing tobacco product use among youth increased for cigarettes from 29% to 40%, increased for smokeless tobacco from 39% to 60%, and decreased for ENDS from 53% to 27%. By 2018/2019, rates of discontinuing use among attempters were 30% for those who used ENDS and 30% for those who smoked cigarettes.

CONCLUSIONS

Findings show decreasing rates of discontinuing ENDS use among youth in the USA alongside the changing ENDS marketplace and increasing rates of discontinuing cigarette smoking and smokeless tobacco use. Findings will serve as benchmarks against which future tobacco product discontinuation rates can be compared with evaluating impacts of subsequent tobacco regulatory policies, ENDS product development and public education campaigns.

The interacting effects of depression symptoms and sweet flavoring on the rewarding and reinforcing value of cigarillo use among young adults

Background

Young adults 18-24 years old have the highest prevalence of cigarillo use, exposing young adults to comparable or higher nicotine levels and many of the same toxicants as combustible cigarettes. Identifying individual and product characteristics that increase the potential for persistent use is warranted. We sought to examine the interacting effects of depression symptoms and sweet flavoring on the rewarding and reinforcing value of cigarillo use.

Methods

86 young adults (18-24 years old, 73.3 % male, 38.4 % White, 33.7 % Black, and 27.9 % Other) completed three laboratory visits assessing the subjective rewarding value (exposure paradigm), relative reinforcing value (computerized choice task), and absolute reinforcing value (ad libitum cigarillo smoking session) of sweet-flavored versus non-flavored cigarillos. Depression symptoms were measured with the 20-item Center for Epidemiologic Studies of Depression Scale and treated as a continuous variable.

Results

General linear models with the appropriate family link tested differences in depressive symptomology for each outcome. Irrespective of flavor, greater cigarillo subjective reward was reported across increasing depressive symptomology (B=.0.03 [95%CI=0.00, 0.05], p=.017). Across symptom levels, no significant differences were observed in the subjective reward and relative and absolute reinforcing values of sweet-flavored versus non-flavored cigarillos (p's >.05).

Conclusions

Young adults with elevated depression find cigarillos more rewarding but not more reinforcing. They are not more vulnerable than young adults with lower symptom levels to sweet cigarillo flavoring. Public health prevention campaigns and tobacco product regulations aimed at preventing the initiation and escalation of young adult cigarillo use may impact young adults broadly.

Understanding American Indian tribal college student knowledge, attitudes, beliefs, and behaviors surrounding alternative tobacco products

OBJECTIVES

To examine knowledge, attitudes, beliefs, and behaviors about alternative tobacco products among American Indian tribal college students.

PARTICIPANTS

One hundred and five tribal college students.

METHODS

Focus groups, one interview, and demographic surveys.

RESULTS

Tobacco use varied across the sample with 35.2% of the participants being users of ENDS products and 29.5% were cigarette smokers. Overall, participants viewed electronic nicotine delivery systems and chewing tobacco as primary examples of alternative tobacco products and described a generational divide between alternative and conventional tobacco product use. Alternative tobacco products were not considered suitable for use in traditional contexts.

CONCLUSIONS

Previously successful cessation programs in this population have relied on cultural tailoring related to traditional tobacco use in American Indian communities. Our findings suggest that this strategy may be less effective for addressing alternative tobacco use. Reliance on the importance of family relationships may prove more impactful in future programming.

Divergence in Cigarette Discontinuation Rates by Use of Electronic Nicotine Delivery Systems (ENDS): Longitudinal Findings From the United States PATH Study Waves 1-6

INTRODUCTION

We compare real-world trends in population-level cigarette discontinuation rates among adults (ages ≥21) who smoked cigarettes, by electronic nicotine delivery systems (ENDS) use.

AIMS AND METHODS

U.S nationally representative data from adults in the Population Assessment of Tobacco and Health (PATH) Study (2013/14-2021, Waves 1-6) who smoked cigarettes in the past 30 days (P30D) were analyzed (n = 13 640). The exposure was P30D ENDS use. The outcome was P30D cigarette discontinuation at biennial follow-up. Weighted trend analyses were conducted to test for differences in cigarette discontinuation trends by ENDS use.

RESULTS

Between 2013/14 and 2015/16, cigarette discontinuation rates were both 16% for those who used ENDS and for those who did not; between 2018/19 and 2021, rates were ~30% for those who used ENDS and ~20% for those who did not; the time by ENDS use interaction was significant.

CONCLUSIONS

The relationship between adults' ENDS use and cigarette discontinuation in the context of an expanded ENDS marketplace, new tobacco regulatory actions, and COVID-19 differs from the relationship in earlier years.

IMPLICATIONS

It is important for public health decisions to be informed by research based on the contemporary ENDS marketplace and circumstances.

Dual and polytobacco use disparities at the intersection of age, sex, race and ethnicity, and income among US adults. Results from the 2018-2019 TUS-CPS

Aim

We aim to describe disparities in dual and polytobacco use at the intersection of age, sex, race and ethnicity, and income.

Methods

We used the 2018-2019 Tobacco Use Supplement to the Current Population Survey to estimate the prevalence of combinations of dual (two products) and polytobacco (three or more products) use for cigarettes, e-cigarettes, cigars, and smokeless tobacco (n = 135,268). We created five mutually exclusive categories: 1) cigarettes and e-cigarettes, 2) cigarettes and cigars, 3) cigarettes and smokeless tobacco, 4) dual/polyuse without cigarettes, and 5) polyuse with cigarettes. We estimated the dual/polyuse prevalence at the intersection of age (18-34, 35-54, 55+ years), sex (male, female), race and ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic, and Non-Hispanic Other), and annual household income (<$50,000, $50,000-$99,999, ≥$100,000), resulting in 72 sociodemographic categories. We used a visualization tool that allowed for detailed characterization and identification of dual and polytobacco use disparities.

Results

Females were in three of the top four groups with the highest cigarette and e-cigarette dual use. Cigarette and cigar dual use was disproportionately high among low-income Non-Hispanic Black male adults aged 35-54 and 18-34. The highest prevalence of both polyuse with cigarettes and dual/polyuse without cigarettes was among low-income, Non-Hispanic White male adults aged 18-34 years.

Conclusion

We identified the population groups disproportionately using two or more tobacco products. This information is helpful for surveillance and for the implementation of tobacco control policies aimed at decreasing disparities in tobacco use.

National longitudinal tobacco product cessation rates among US adults from the PATH Study: 2013-2019 (waves 1-5)

OBJECTIVE

To report on longitudinal tobacco product cessation rates, by product type, among adults (ages 18+ years) in the USA between 2013 and 2019.

METHODS

The Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study was used to report on annual and biennial rates of the following three cessation behaviours across 2013-2019: (1) discontinuing tobacco product use (ie, transition from past 30-day use to no past 30-day use), (2) attempting to quit tobacco product use and (3) quitting tobacco product use among those who attempted to quit. Each cessation behaviour was evaluated separately for cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah and smokeless tobacco. Generalised estimating equations were used to evaluate linear and nonlinear trends in cessation rates across the study period.

RESULTS

Between 2013 and 2019, rates of discontinuing cigarette smoking among adults in the USA statistically increased from 16% to 18%, though these were consistently lower than rates of discontinuing use of other tobacco products. Similarly, quit attempt rates and rates of quitting among attempters increased for cigarette smokers. However, rates of discontinuing ENDS use sharply declined across the study period, from 62% to 44%.

CONCLUSIONS

Findings show that tobacco product cessation rates have been changing in recent years in the USA alongside the changing tobacco product marketplace and regulatory environment, though rates of discontinuing cigarette smoking remain relatively low. Findings can serve as a benchmark against which future cessation rates can be compared to evaluate the impacts of future tobacco regulatory policies.

Trajectories of body mass index and combustible and electronic cigarette use across adolescence: Findings from the PATH study

PURPOSE

Associations between empirically-generated body mass index (BMI) trajectories and risk of current use of combustible cigarettes and e-cigarettes across adolescence were examined using longitudinal data from the Population Assessment of Tobacco and Health (PATH) study.

METHODS

The PATH study is an ongoing annual longitudinal population-based study of adolescents. We utilized Waves 1-4 conducted from 2013 to 2017. Adolescents completed self-reported surveys of their height, weight, and current tobacco use at Waves 1-4 and their tobacco weight control beliefs at Waves 1-2.

RESULTS

Using latent growth mixture modeling, six trajectories of BMI were identified. The largest group ("normal weight increasing;" n = 4,858; 86.6 %), which was used as the comparator in subsequent analyses, consisted of adolescents ages 12-17 who were normal weight at Wave 1 with a significant increase in BMI across Waves 2--4. The "overweight early increasing," "overweight late increasing," and "obesity stable" classes had greater likelihood of current combustible cigarette use during the study compared to the "normal weight increasing class." The "overweight early increasing," "overweight late increasing," and "overweight increasing then decreasing" classes showed elevated risk for e-cigarette use during the study. Compared to those in the "normal weight increasing" class, those in the "overweight increasing then decreasing" and "obesity stable" classes had greater weight control beliefs at Wave 1 and those in the "obesity stable" class had greater weight control beliefs at Wave 2.

CONCLUSIONS

Findings highlight the importance of weight trajectories and weight control beliefs by tobacco product use across adolescence and the need for mechanistic and intervention research.

Electronic cigarette use and chest pain in US adults: Evidence from the PATH study

INTRODUCTION

Electronic cigarettes (e-cigarette) were introduced for smoking cessation/reduction but have also become popular among the youth. Although e-cigarettes contain fewer toxins than combustible cigarettes, their long-term cardiovascular and pulmonary effects remain unknown. We aimed to assess the association between self-reported chest pain and e-cigarette use.

METHODS

We analyzed data from the PATH (Population Assessment of Tobacco and Health) study wave 4 (2016-2018) and wave 5 (2018-2019). Based on questionnaires from wave 4, we categorized tobacco use as: 1) non-use, 2) exclusive e-cigarette use, 3) combustible cigarette use, and 4) dual use. Presence of established cardiovascular disease was examined at wave 4, and participants aged >40 years were asked about chest pain during wave 5. We used binary logistic regression models to determine the association between tobacco exposures and self-reported chest pain.

RESULTS

We evaluated a total of 11254 adults. The rates of chest pain were 1518 out of 7055 non-users, 49 from 208 exclusive e-cigarette users, 1192 from 3722 combustible cigarette users, and 99 out of 269 dual users. In the multivariable models adjusted for relevant covariates, combustible cigarette users (adjusted odds ratio, AOR=1.77; 95% CI: 1.56-2.01) and dual users (AOR=2.22; 95% CI: 1.61-3.05) had higher odds of reporting ever having chest pain, as well as having chest pain in the past 30 days. Conversely, exclusive e-cigarette users had similar odds of reporting chest pain compared to non-users (AOR=1.03; 95% CI: 0.69-1.54) and lower odds than combustible and dual users. In sensitivity analyses, categorizing individuals based on their reported history of cardiovascular disease, overall findings were similar.

CONCLUSIONS

Exclusive e-cigarette use is associated with a lower rate of chest pain compared to combustible cigarette use and dual use.

Adult smokers' Complete Switching Away from Cigarettes at 6, 9, and 12 Months after Initially Purchasing a JUUL e-Cigarette

Background: Electronic nicotine delivery systems (ENDS) have the potential to benefit public health if smokers completely switch from cigarettes to ENDS. Methods: A cohort of adult smokers (age ≥ 21) who purchased a JUUL Starter Kit was followed for 12 months after the initial purchase. We defined "switching" as past-30-day abstinence from smoking (even if JUUL use had stopped), and analyzed factors associated with achievement and maintenance of self-reported repeated point-prevalence switching (RPPS) at three follow-ups, i.e., no past-30-day smoking at months 6, 9, and 12. Results: RPPS was reported by 21.6% of the 12,537 evaluable smokers. Smokers with lighter smoking history and lower cigarette dependence at baseline were more likely to report RPPS. RPPS was also associated with daily use of JUUL (Month-3: OR = 2.32, 95% CI = 2.02-2.68; Month-6: OR = 1.73, 95% CI = 1.42-2.10), and with greater subjective reinforcing effects from JUUL use (assessed by the mCEQ, Month-3: OR = 1.46, 95% CI = 1.38-1.56; Month-6: OR = 1.11; 95% CI = 1.02-1.20). Even among smokers who did not meet the criteria of RPPS (i.e., who smoked at least once), 35.5% reported past 30-day point-prevalence switching on at least one follow-up, and their cigarette consumption was substantially reduced compared to baseline. Conclusions: Approximately one-fifth of adult smokers reported 30-day point-prevalence abstinence at 6, 9, and 12 months after purchasing JUUL. Greater use of JUUL and stronger subjective reinforcing effects were associated with nonsmoking, validating the potential for ENDS to substitute for smoking, with potential for positive impacts on individual and population health.

Household vaping bans and youth e-cigarette use

AIMS

The aims of this study were to measure whether household bans on vaping were associated with lower odds of youth past-month vaping when compared with (1) otherwise similar youth whose households did not have a vaping ban (using coarsened exact matching); and (2) themselves in waves when their household did not have a ban (using hybrid panel models). We used the same analytical strategies to examine cross-sectional associations between household smoking bans and adolescents' past-month cigarette smoking.

DESIGN

This was a longitudinal study using data from a nationally representative sample of youth (age 12-17 years) in the Population Assessment of Tobacco and Health Study.

SETTING

United States of America.

PARTICIPANTS

A total of 16 214 adolescents followed over 48 103 total observations (approximately three waves).

MEASUREMENTS

Measurements comprised youth past-month e-cigarette and cigarette use and parent-reported household bans on vaping and smoking. Potential confounders were prior adolescent smoking, vaping, and other nicotine product use; parent current smoking, vaping, and other nicotine use; adolescent peer e-cigarette/cigarette use; parental monitoring; and demographic characteristics.

FINDINGS

Before matching, smoking bans were associated with 46% lower odds of youth smoking [odds ratio (OR) = 0.54; 95% confidence interval (CI) = 0.41-0.70] and vaping bans with 37% lower odds of youth e-cigarette use (OR = 0.63; 95% CI = 0.50-0.80). However, households with and without bans differed significantly on all confounders before matching. After matching, household vaping bans were associated with 56% lower odds of youth vaping (OR = 0.44; 95% CI = 0.33-0.58). Results from hybrid panel models also revealed 37% lower odds of vaping in waves when youth lived in a vape-free household compared to waves when they did not (OR = 0.63; 95% CI = 0.50-0.78). Associations between smoking bans and youth smoking were not statistically significant after matching or when using hybrid panel models.

CONCLUSIONS

Household vaping bans appear to be associated with lower odds of past-month vaping among US adolescents, compared with similar youth whose households did not have a ban and to themselves in waves when their households did not have a ban.

Social Ecological Influences on Nicotine/Tobacco Use Among Gender-Varying and Gender-Stable Adolescents and Adults in the USA

BACKGROUND AND PURPOSE

Our study examined individual-, interpersonal-, community-, and policy-level associations with nicotine/tobacco use among gender-varying and gender-stable U.S. individuals.

METHODS

Data from Waves 2-4 (2014/15-2016/18) of the Population Assessment of Tobacco and Health (n = 33,197 U.S. adolescents and adults aged ≥14 years) and state-level gender minority policy data were used. Using multivariable logistic regression, the odds of past-30-day nicotine/tobacco use at W4 were estimated as a function of gender stability/variability, psychological distress, number of tobacco products used by family/friends, anti-tobacco marketing exposure, and change in gender minority-related policies from 2015 to 2017.

RESULTS

Gender-varying individuals had higher odds of nicotine/tobacco use compared with gender-stable individuals (AOR range = 1.7-2.3, p < .01). In the overall sample, positive change in gender minority policy protections (tallied from medium to high) was associated with lower odds of any nicotine/tobacco, other tobacco, and poly-tobacco use (AOR = 0.8, p < .05) compared to states with no change in their negative policies. Anti-tobacco marketing exposure was associated with lower odds of any tobacco, cigarette, e-cigarette, and poly-tobacco use compared with those who had no anti-tobacco marketing exposure (AOR = 0.9, p < .05). Higher psychological distress (AOR range = 1.7-2.4, p < .001) and an increasing number of tobacco products used by family/friends (AOR range = 1.1-1.3, p < .001) were associated with increased odds of nicotine/tobacco use.

CONCLUSIONS

Multilevel prevention and intervention strategies are needed to reduce the risk of nicotine/tobacco use among gender-varying and gender-stable individuals.

Prevalence of Tobacco Products' Use and Associated Factors Among Adolescents in Morocco: A Systematic Review

Introduction

Tobacco use is the major preventable cause of premature death worldwide, responsible for about 8 million deaths per year, mostly in low- and middle-income countries, such as Morocco. Adolescents' tobacco use is a matter of concern, because early initiation increases the risk of becoming a lifelong user. There exists a notable gap in the synthesis of evidence concerning tobacco use among Moroccan adolescents. Thus, the purpose of this study was to provide a comprehensive view of the prevalence of tobacco products' use and associated factors among adolescents in Morocco.

Methods

We systematically searched PubMed, Scopus, Web of Science and ScienceDirect for relevant studies reporting prevalence rates of tobacco products' use among Moroccan adolescents, published until June 2024, using inclusion and exclusion criteria in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Additional searches were completed on other sources to reach unpublished reports. The Joanna Briggs Institute Critical Appraisal Checklist was used to assess the quality of included studies.

Results

After the final screening, 22 papers met the inclusion criteria. Life-time prevalence of tobacco use ranged from 7.8% to 20.4% for cigarettes smoking, from 10.6% to 21.9% for waterpipe, from 7.9% to 9.1% for chewing tobacco and from 9.2% to 12.4% for snuff. The last 12-month prevalence of cigarette smoking was comprised between 6.9% and 10.8%. As for the prevalence of current use, ranges of (1.8%-16.4%) and (4.9%-8.4%) were noted for cigarettes and waterpipe, respectively. The most commonly highlighted risk factors for tobacco use included male sex, older age, having friends or family members who use tobacco and low perception of risk associated with tobacco use.

Conclusion

Our findings reveal an alarming situation of tobacco use among Moroccan adolescents. Therefore, it is crucial that all stakeholders engage in concerted efforts to develop and implement evidence-based preventive interventions among early adolescents.

Association of non-daily hookah tobacco smoking and cardiovascular disease-related exposure biomarkers among U.S. users: The Population Assessment of Tobacco and Health Study

Hookah smoking has grown to become a global tobacco epidemic. While cigarette smoking is a well-established cardiovascular disease (CVD) risk factor, the CVD risks of hookah smoking are unknown, particularly among regular U.S. adult hookah users who are predominantly non-daily users. Herein, we examined the association between hookah smoking and biomarkers of CVD risk among regular exclusive hookah smokers (n = 75), compared to regular exclusive cigarette smokers (n = 1773), dual hookah and cigarette smokers (n = 43) and never tobacco users (n = 757), using data from a nationally representative sample of adults from the Population Assessment of Tobacco and Health Study (2013-2014). Whereas 84% of cigarette smokers reported daily use, only 8% of hookah smokers reported daily use, with more than a third reporting monthly use. Adjusting for age and sex and as compared to exclusive cigarette smokers, exclusive hookah smokers had significantly lower geometric mean concentrations in serum sICAM-1 and urinary F2-isoprostane (p < 0.05). Although not statistically significant, a signal of increased oxidative stress was observed among hookah smokers as compared to never tobacco users (urinary F2-isoprostane). CVD-related harm biomarkers appear to be lower among hookah smokers than cigarette smokers. These findings represent patterns of hookah smoking predominantly shared among adult U.S. users who report non-daily occasional use and do not reflect solitary, daily use as is common in the Middle East. Future studies with longer exposure and longitudinal hookah use are warranted to explore the association between hookah smoking and CVD risk.

Cigarette and e-cigarette use trajectories and prospective prescription psychotherapeutic drug misuse among adolescents and young adults

OBJECTIVE

This study aimed to determine the potential longitudinal impact of different cigarette and e-cigarette use trajectories among people aged 10-24 on prescription drug misuse of psychotherapeutic drugs.

METHODS

Data came from waves 1-5 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2019; n = 14,454). Group-based trajectory modeling identified groups of adolescents and young adults based on cigarette and e-cigarette use across the five waves. Weighted logistic regression models were fit to examine the association of group membership with two outcomes at all waves: 1) misuse of opioids, sedatives, and/or tranquilizers, and 2) misuse of Ritalin and/or Adderall, adjusting for background characteristics.

RESULTS

Five trajectory groups emerged: (1) non-use (77.7 %); (2) early-onset cigarette use with reducing use (4.6 %); (3) ever-increasing e-cigarette use (6.1 %); (4) stable dual use of cigarettes and e-cigarettes (3.2 %); and (5) accelerating dual use of cigarettes and e-cigarettes (8.4 %). In comparison to the non-use group, all other groups had significantly higher odds of misuse of opioids, tranquilizers, and/or sedatives and all but the early-onset cigarette use with reducing use group had significantly higher odds of misuse of Ritalin and/or Adderall by the end of wave 5.

DISCUSSION

Patterns of cigarette and e-cigarette use in adolescent and young adult populations may serve as important indicators for concurrent and prospective prescription psychotherapeutic drug misuse. Findings highlight the need for cigarette and e-cigarette use prevention, harm reduction, and/or cessation efforts among adolescents and young adults.

The Burden and Correlates of Waterpipe (Hookah) Smoking among Adolescents and Youth: A Systematic Review

BACKGROUND

This systematic review evaluated the available medical literature on the prevalence and trends of waterpipe tobacco smoking among adolescents and youth in jurisdictionally representative populations.

METHODS

PubMed, Embase, and Scopus were searched for relevant studies from inception until 31 December 2022 that reported the burden of waterpipe smoking among adolescents and youth (10-24 years of age). We extracted qualitative data on the demographic characteristics, burden, and correlates of waterpipe smoking (PROSPERO ID: CRD42022310982).

RESULTS

A total of 2,197 articles were screened and 62 were included in the analysis. The majority (29) of the studies was from the United States of America and there were no studies from the south-east Asian region. The prevalence of ever waterpipe smoking among the 10-24 years age group was noted to be 18.16% (95% CI, 18.03-18.29). The prevalence of current (30-day) waterpipe smoking was 6.43% (95% CI, 6.34-6.50). The age of initiation of waterpipe smoking was variable. The prevalence of waterpipe smoking was higher among males, among those who belong to the high- and middle-income groups, and among university students. The common risk factors of waterpipe smoking included cigarette smoking, alcohol, and substance use. Waterpipe smoking resulted in increased susceptibility to the use of conventional forms of tobacco (e.g. smoking) among those who were never smokers.

CONCLUSION

Waterpipe smoking usage was significantly high among adolescents and young adults. Developing regulatory guidelines for water-pipe smoking, surveillance of its use, intervention, and specific policy frameworks may be considered a public health priority.

Effect of sweet flavouring on the rewarding and reinforcing value of cigarillo use among young adults

INTRODUCTION

Cigarillos dominate the US cigar market, and young adults largely drive use. While young adults prefer flavoured to non-flavoured cigarillos, especially those flavoured to taste like fruit or other sweets, the factors that underlie this preference have received little attention. We sought to determine if key indicators of abuse liability, the rewarding and reinforcing effects, are greater for sweet versus non-flavoured cigarillos.

METHODS

Young adults (18-24 years old) completed three laboratory visits assessing the subjective rewarding value (exposure paradigm), relative reinforcing value (computerised choice task) and absolute reinforcing value (ad libitum cigarillo smoking session) of sweet-flavoured versus non-flavoured cigarillos. General linear regression models were fit with the appropriate family link for each outcome measure.

RESULTS

Young adults rated sweet-flavoured cigarillos as more rewarding (estimated marginal mean (EMM) =4.52, 95% CI 4.00 to 5.03) than the non-flavoured cigarillo (EMM=3.31, 95% CI 2.80 to 3.83; B=1.20, 95% CI 0.80 to 1.60, p<0.001). The reinforcing value of sweet-flavoured cigarillos, measured by break point, was higher relative to non-flavoured cigarillos (6.34 out of 10), especially among young adults with a preference for flavoured cigarillos (B=1.94, 95% CI 0.71 to 3.18, p=0.003). Young adults took 1.9 times the number of puffs (35.75 vs 19.95) from sweet-flavoured cigarillos compared with non-flavoured cigarillos (Rate Ratio =1.94, 95% CI 1.30 to 2.90, p<0.001).

CONCLUSIONS

Sweet flavouring increases the abuse liability of cigarillos among young adults as reflected in greater liking, motivation to use and actual use. Banning sweet flavouring in cigarillos may diminish their use in young adults.Trial registration number CT.gov (NCT05092919).

Do Tobacco Companies Have an Incentive to Promote "Harm Reduction" Products?: The Role of Competition

INTRODUCTION

Some cigarette companies have started to talk about replacing cigarettes with less harmful alternatives, which might include nicotine vaping products (NVPs), heated tobacco products (HTPs), and oral nicotine delivery products. We consider market competition as a primary driver of whether cigarette companies follow through on their stated intentions.

AIMS AND METHODS

We focus on the behavior of cigarette companies in the United States. We compare competition in the pre- and post-2012 time periods, analyze the impact of the growth in NVPs on smoking prevalence and cigarette company profits, and examine the potential future role of competition.

RESULTS

Since 2006, consumers have broadened their use of non-combustible nicotine delivery products (NCNDPs) to include, inter alia, NVPs, HTPs, and oral nicotine pouches. U.S. cigarette companies have acquired major stakes in each of these product categories which corresponds to a period of rapidly declining adult smoking prevalence, especially among younger adults (ages 18-24 years). The shifting dynamics of the nicotine product marketplace are also reflected in cigarette company stock prices. While cigarette companies are likely to promote HTPs and nicotine delivery products over NVPs, their incentives will be directly related to competition from independent firms, which in turn will depend on government regulation.

CONCLUSIONS

Although cigarette companies will back alternatives to combusted tobacco when threatened by competition, the prospects for their lasting conversion to NCNDPs will depend on the extent of such competition, which will be influenced by government regulation of tobacco products.

IMPLICATIONS

Regulations that limit competition from independent firms while also protecting cigarette company profits risk slowing or even reversing recent declines in smoking, especially among youth and young adults. Regulations that reduce the appeal and addictiveness of combusted tobacco products, such as higher cigarette taxes or a reduced nicotine standard, will encourage smokers to quit and/or switch to less harmful non-combusted forms of tobacco. The regulation of non-combustible nicotine delivery products and cigarettes should be proportionate to their relative risks, so that smokers have incentives to switch from combustibles to safer alternatives, and cigarette companies have incentives to promote safer products.

Do alternative tobacco products induce less adverse respiratory risk than cigarettes?

RATIONALE

Due to the relatively short existence of alternative tobacco products, gaps exist in our current understanding of their long-term respiratory health effects. We therefore undertook the first-ever side-by-side comparison of the impact of chronic inhalation of aerosols emitted from electronic cigarettes (EC) and heated tobacco products (HTP), and combustible cigarettes (CC) smoke.

OBJECTIVES

To evaluate the potential differential effects of alternative tobacco products on lung inflammatory responses and efficacy of vaccination in comparison to CC.

METHODS

Mice were exposed to emissions from EC, HTP, CC, or air for 8 weeks. BAL and lung tissue were analyzed for markers of inflammation, lung damage, and oxidative stress. Another group was exposed for 12 weeks and vaccinated and challenged with a bacterial respiratory infection. Antibody titers in BAL and sera and pulmonary bacterial clearance were assessed.

MAIN RESULTS

EC- and HTP-aerosols significantly augmented lung immune cell infiltrates equivalent to that achieved following CC-exposure. HTP and CC significantly increased neutrophil numbers compared to EC. All products augmented numbers of B cells, T cells, and pro-inflammatory IL17A+ T cells in the lungs. Decreased lung antioxidant activity and lung epithelial and endothelial damage was induced by all products. EC and HTP differentially augmented inflammatory cytokines/chemokines in the BAL. Generation of immunity following vaccination was impaired by EC and HTP but to a lesser extent than CC, with a CC > HTP > EC hierarchy of suppression of pulmonary bacterial clearance.

CONCLUSIONS

HTP and EC-aerosols induced a proinflammatory pulmonary microenvironment, lung damage, and suppressed efficacy of vaccination.

Tobacco retailer density and smoking behaviour: how are exposure and outcome measures classified? A systematic review

INTRODUCTION

To date only a limited number of reviews have focused on how exposure and outcome measures are defined in the existing literature on associations between tobacco retailer density ('density') and smoking behaviour ('smoking'). Therefore this systematic review classified and summarised how both density and smoking variables are operationalised in the existing literature, and provides several methodological recommendations for future density and smoking research.

METHODS

Two literature searches between March and April 2018 and April 2022 were conducted across 10 databases. Inclusion and exclusion criteria were developed and keyword database searches were undertaken. Studies were imported into Covidence. Cross-sectional studies that met the inclusion criteria were extracted and a quality assessment was undertaken. Studies were categorised according to the density measure used, and smoking was re-categorised using a modified classification tool.

RESULTS

Large heterogeneity was found in the operationalisation of both measures in the 47 studies included for analysis. Density was most commonly measured directly from geocoded locations using circular buffers at various distances (n = 14). After smoking was reclassified using a smoking classification tool, past-month smoking was the most common smoking type reported (n = 26).

CONCLUSIONS

It is recommended that density is measured through length-distance and travel time using the street network and weighted (e.g. by the size of an area), or by using Kernel Density Estimates as these methods provide a more accurate measure of geographical to tobacco and e-cigarette retailer density. The consistent application of a smoking measures classification tool, such as the one developed for this systematic review, would enable better comparisons between studies. Future research should measure exposure and outcome measures in a way that makes them comparable with other studies.

IMPLICATIONS

This systematic review provides a strong case for improving data collection and analysis methodologies in studies assessing tobacco retailer density and smoking behaviour to ensure that both exposure and outcome measures are clearly defined and captured. As large heterogeneity was found in the operationalisation of both density and smoking behaviour measures in the studies included for analysis, there is a need for future studies to capture, measure and classify exposure measures accurately, and to define outcome measures in a manner that makes them comparable with other studies.

Examining smoking and vaping behaviors, expectancies, and cessation outcomes between bisexual and heterosexual individuals

Prior research indicates bisexual individuals have higher smoking and vaping rates and heightened vulnerability to negative health outcomes. Thus, we compared adult bisexual (n = 294) and heterosexual (n = 2412) participants enrolled in a smoking cessation trial on baseline smoking and vaping use behaviors, motivations, and expectancies/beliefs as well as follow-up smoking and vaping status. This is a secondary analysis of a large randomized controlled trial testing a smoking cessation intervention for dual users of combustible and electronic cigarettes (e-cigarettes) in the United States. Self-reported 7-day point prevalence smoking and vaping abstinence were collected at 3-, 12-, and 24-month assessments. Bisexual and heterosexual participants did not differ in sociodemographic variables or baseline smoking and vaping history and behavior. We found significant differences among bisexual and heterosexual individuals in smoking and vaping beliefs/expectancies. Specifically, bisexual participants expressed overall greater positive expectancies regarding smoking and vaping, such as smoking and vaping to reduce negative affect and stress. There were no differences in smoking at any follow-up assessment. Only at 3 months were bisexual individuals more likely to be abstinent from vaping and less likely to be dual users than heterosexual individuals. Despite similar smoking and vaping status over time, bisexual individuals reported greater positive expectancies regarding smoking and vaping. Our findings revealed few targets for tailoring cessation interventions to bisexual individuals; thus, it is possible that there may be greater utility in targeting the disparities in prevalence (i.e., via prevention efforts).

Multiple Tobacco Product Use Among Youth E-Cigarette Users: National Youth Tobacco Survey, 2020

PURPOSE

Limited information exists on multiple tobacco product use, particularly among youth. This study assessed the prevalence of current youth use of e-cigarettes with other tobacco products and their associated characteristics using 2020 National Youth Tobacco Survey data.

METHODS

Prevalence estimates were calculated for current e-cigarette users, by multiple tobacco product use status and product combination. Demographic characteristics, e-cigarette use behaviors, age at first combustible tobacco use, and tobacco dependence symptoms were compared between current users of both e-cigarettes and combustible tobacco (dual users) and current exclusive e-cigarette users.

RESULTS

In 2020, 61.1% of all current e-cigarette users reported exclusive e-cigarette use, and 38.9% used e-cigarettes with other tobacco products. Among those who used e-cigarettes with other tobacco products, 85.0% used combustible tobacco, with cigarettes being the most commonly used other tobacco product. Compared with current exclusive e-cigarette users, higher proportions of dual users reported the following: frequent e-cigarette use; obtaining e-cigarettes from gas stations, persons other than a family member/friend, vape shops, or the internet; and having any tobacco dependence symptoms. Among dual users, 31.2% reported first combustible product use after e-cigarette initiation, and 34.3% reported first combustible product use prior to e-cigarette initiation.

DISCUSSION

Approximately four in 10 youth current e-cigarette users reported using multiple tobacco products, with a majority using combustible tobacco. Frequent e-cigarette use and tobacco dependence symptoms were more prevalent among dual users of e-cigarettes and combustible tobacco.

[Vaping and vaping-associated lung injury: A review]

Vaping, i.e. the use of electronic nicotine/other substances delivery systems, increases a risk of vaping-associated lung injury. The review describes clinical manifestation, methods of diagnosis and diagnostic criteria, treatment of patients with this disease as well as risk stratification of vapers and approaches to their management based on Worchester classification and clinical guidance. The pathogenetic mechanisms of vaping-associated lung injury have been analyzed.

E-cigarette awareness and use, among adult residents in Shanghai, China

INTRODUCTION

The widespread popularity of e-cigarettes is considered an important public health concern. However, only some studies have investigated the prevalence of e-cigarette use in Shanghai, China. Research on the perceived harmfulness of e-cigarettes and public support for e-cigarette regulations in China is limited. This study aimed to estimate e-cigarette awareness, prevalence, and associated factors among adults in Shanghai, China.

METHODS

This study used data from a representative survey conducted in Shanghai, China, in 2019. The survey was conducted at 64 surveillance points in Shanghai, China, using a multistage, stratified, cluster-randomized sampling design, recruiting community-based Chinese adults aged ≥15 years. Based on the principles outlined in the Global Adult Tobacco Survey (GATS) China Project, data were collected by conducting face-to-face interviews in households. Of the 3200 selected households, 3060 people completed the individual survey. The overall response rate was 97.4%.

RESULTS

In all, 72.3% of the respondents had heard of e-cigarettes. The respondents who had used e-cigarettes at some point in their life, used them in the last 12 months, and used them currently were 5.8%, 2.6%, and 1.3%, respectively. Among adult residents who had heard of e-cigarettes, 38.2% thought they were less harmful than traditional cigarettes. The respondents who perceived e-cigarettes as more harmful than traditional cigarettes were less likely to have ever used e-cigarettes (AOR=0.2; 95% CI: 0.1-0.5, p=0.0015) and more likely to support incorporating e-cigarettes into the regulation of smoking control (AOR=3.9; 95% CI: 1.8-8.6, p=0.0008).

CONCLUSIONS

Our findings reveal that the awareness about e-cigarettes was high, and the prevalence of e-cigarette use was similar to the findings from previous studies in China. The harmful perception of e-cigarettes warrants further attention from public health practitioners.

Heated Tobacco Products: Insights into Composition and Toxicity

Heated tobacco products (HTPs) are novel products that allow users to inhale nicotine by heating (350 °C) reconstituted tobacco rather than combustion (900 °C) as in conventional cigarettes. HTP sticks containing reconstituted tobacco come in various flavours such as menthol, citrus, etc., like electronic cigarette liquids. Thus, the composition of HTP aerosol will also vary according to the flavouring agents added. Overall, the content of toxic chemicals in HTP aerosol appears to be lower than in cigarette smoke. However, the concentrations of more than twenty harmful and potentially harmful constituents have been reported to be higher in HTP aerosol than in cigarette smoke. Further, several toxic compounds not detected in cigarette smoke are also reported in HTP aerosol. Thus, the risks of HTP use remain unknown. Most of the available data on the composition and health effects of mainstream HTP aerosol exposure are generated by the tobacco industry. Few independent studies have reported short-term pathophysiological effects of HTP use. Currently available HTP toxicity data are mainly on the pulmonary and cardiovascular systems. Moreover, there are no long-term toxicity data and, therefore, the claims of the tobacco industry regarding HTPs as a safer alternative to traditional combustible cigarettes are unsubstantiated. Furthermore, HTP aerosol contains the highly addictive substance nicotine, which is harmful to the adolescent brain, developing foetuses, pregnant women, and also adults. Hence, comprehensive studies addressing the safety profiling related to long-term HTP use are warranted. With this background, the following review summarizes the current state of knowledge on HTP toxicity on four broad lines: composition of mainstream HTP aerosol compared to traditional combustible cigarette smoke, biomarkers of HTP exposure, health effects of HTP exposure, and the harm reduction aspect.

Youth Use of e-Cigarette Flavor and Device Combinations and Brands Before vs After FDA Enforcement

Importance

The US Food and Drug Administration's Center for Tobacco Products (CTP) prioritized its enforcement efforts against nontobacco, nonmenthol (ie, sweet)-flavored cartridge e-cigarettes in February 2020. Within-person e-cigarette initiation, continuation, and switching behaviors among youth are unknown following CTP's prioritized enforcement efforts.

Objective

To describe transitions in youths' e-cigarette flavor/device combination use, brand use, nicotine use, and frequency of use following CTP's e-cigarette enforcement prioritization.

Design, Setting, and Participants

The US population-based, nationally representative Population Assessment of Tobacco and Health cohort study included data collected in 2019 and 2021 from youth aged 12 to 17 years. The data were analyzed from February to June 2023.

Exposure

e-cigarette use (past 30 days), flavor/device combination used, brand used, nicotine use, and frequency of use.

Main Outcomes and Measures

Transitions in e-cigarette use, flavor/device combination used, brand used, nicotine use, and frequency of use between 2019 and 2021 among 9088 youth aged 12 to 17 years in 2019; prevalence of e-cigarette use, flavor/device combination used, and brand used in 2019 (n = 8771) and 2021 (n = 5574) among youth aged 14 to 17 years in each year.

Results

The 2019 sample included 8771 youth. The population of those aged 12 to 17 years was 49.0% female (95% CI, 48.7%-49.3%) and 51.0% male (95% CI, 50.8%-51.3%). Participants were 15.4% Black (95% CI, 15.0%-15.7%), 24.1% Hispanic (95% CI, 23.9%-24.4%), 75.9% non-Hispanic (95% CI, 75.6%-76.1%), 69.1% White (95% CI, 68.5%-69.8%), and 15.5% another race (95% CI, 14.9%-16.1%). Among youth ages 12 to 17 years who did not use e-cigarettes in 2019, 531 (6.5%) initiated use in 2021 (95% CI, 5.9%-7.1%); among them, 415 (76.8%) initiated with a combination other than a sweet cartridge (95% CI, 72.2%-80.8%). Among youth ages 12 to 17 who used e-cigarettes in 2019, 360 (47.8%) continued use in 2021 (95% CI, 44.0%-51.1%). Continuation rates were similar for those who used sweet-cartridge e-cigarettes (144 [51.5%]; 95% CI, 45.7%-57.3%) and those who used other combinations (204 [47.6%]; 95% CI, 42.8%-52.4%) in 2019. Among those who continued e-cigarette use in 2021, 121 (84.0%) of those who used sweet-cartridge e-cigarettes in 2019 switched to a different combination (95% CI, 77.0%-89.2%). Overall, among youth who used e-cigarettes in 2021, 177 (53%) used a sweet-disposable combination, 32 (11%) used a sweet-cartridge, and no individual brand was used by more than 10%.

Conclusions and Relevance

The results of this longitudinal cohort study of youth in the US suggest that most youth who initiated or continued e-cigarette use in 2021 used flavor/device combinations that were excluded from CTP's enforcement priorities. Restrictions and enforcement efforts that only cover a subset of products may be ineffective at preventing youth flavored e-cigarette use.

Correlates of motivation to quit waterpipe tobacco smoking among US young adults: implications for cessation interventions

Waterpipe tobacco smoking is a public health concern that poses many of the same health risks as cigarette smoking, especially among young adults-a subpopulation characterized by the highest prevalence of waterpipe tobacco smoking. Nevertheless, it remains understudied relative to other forms of tobacco use. We examined sociodemographic, behavioral and cognitive factors associated with young adults' motivation to quit waterpipe smoking using a theory-informed approach. We completed a secondary analysis of baseline data on waterpipe tobacco smoking beliefs and behavior collected from 349 US young adults aged 18-30 years. We analyzed sociodemographics, tobacco use and cessation behaviors and perceptions, and theory-related constructs associated with motivation to quit waterpipe tobacco smoking using linear regression. Overall, participants reported low motivation (mean = 2.68, SD = 1.56, scale range 1-7) and high self-efficacy (mean = 5.12, SD = 1.79) to quit waterpipe tobacco smoking. In multivariable analysis, prior quit attempts (β = 1.10, P < 0.01), greater perceived risks of waterpipe tobacco smoking (β = 0.42, P < 0.01) and increasingly negative attitudes toward waterpipe tobacco smoking (β = 0.29, P < 0.01) were associated with higher motivation to quit. These findings highlight the importance of those factors as potential cessation determinants. These findings can help guide the development and refinement of interventions targeting young adult waterpipe tobacco smoking.

Investigating the association of traditional and non-traditional tobacco product use with subclinical and clinical cardiovascular disease: The Cross-Cohort Collaboration-Tobacco working group rationale, design, and methodology

While the impact of combustible cigarette smoking on cardiovascular disease (CVD) is well-established, the longitudinal association of non-traditional tobacco products with subclinical and clinical CVD has not been fully explored due to: 1) limited data availability; and 2) the lack of well-phenotyped prospective cohorts. Therefore, there is the need for sufficiently powered well-phenotyped datasets to fully elucidate the CVD risks associated with non-cigarette tobacco products. The Cross-Cohort Collaboration (CCC)-Tobacco is a harmonized dataset of 23 prospective cohort studies predominantly in the US. A priori defined variables collected from each cohort included baseline characteristics, details of traditional and non-traditional tobacco product use, inflammatory markers, and outcomes including subclinical and clinical CVD. The definitions of the variables in each cohort were systematically evaluated by a team of two physician-scientists and a biostatistician. Herein, we describe the method of data acquisition and harmonization and the baseline sociodemographic and risk profile of participants in the combined CCC-Tobacco dataset. The total number of participants in the pooled cohort is 322782 (mean age: 59.7 ± 11.8 years) of which 76% are women. White individuals make up the majority (73.1%), although there is good representation of other race and ethnicity groups including African American (15.6%) and Hispanic/Latino individuals (6.4%). The prevalence of participants who never smoked, formerly smoked, and currently smoke combustible cigarettes is 50%, 36%, and 14%, respectively. The prevalence of current and former cigar, pipe, and smokeless tobacco is 7.3%, 6.4%, and 8.6%, respectively. E-cigarette use was measured only in follow-up visits of select studies, totaling 1704 former and current users. CCC-Tobacco is a large, pooled cohort dataset that is uniquely designed with increased power to expand knowledge regarding the association of traditional and non-traditional tobacco use with subclinical and clinical CVD, with extension to understudied groups including women and individuals from underrepresented racial-ethnic groups.

Objective and perceived measures of tobacco marketing are uniquely associated with cigar use

BACKGROUND

Few studies have examined associations between perceived and objective exposure to tobacco marketing and cigar use, which is the second most commonly used tobacco product by youth.

METHODS

We used Geographic Ecological Momentary Assessment data over 14 days from youth aged 16-20 years (n=83 participants, n=948 observations; 34% past month users of any tobacco product) in eight city areas in California. Tobacco outlets in study cities were visited by trained observers to record outlet Global Positioning System (GPS) point locations and outdoor tobacco marketing. We assessed daily perceived exposure to tobacco marketing within participants' activity spaces; daily objective exposure to tobacco outlets with outdoor marketing within 50 m of activity space polylines (number of outlets and time spent near outlets) and daily cigar use excluding and including blunts.

RESULTS

Controlling for demographics and baseline tobacco use, results from mixed logistic regression models showed that greater perceived exposure to tobacco marketing was positively associated with higher odds of cigar use each day, excluding blunts (adjusted odds ratios (aOR): 2.00; 95% CI 1.03 to 3.87) and including blunts (aOR: 1.87; 95% CI 1.26 to 2.77). Also, exposure to a greater number of tobacco outlets with outdoor marketing was associated with higher odds of cigar use each day, excluding blunts (aOR: 1.34; 95% CI 1.01 to 1.78), but not including blunts.

CONCLUSIONS

Tobacco control efforts should consider both perceived and objective exposure to tobacco marketing and unique associations with blunt use to prevent cigar use.

Public Perceptions and Discussions of Premium Cigars on Reddit

Introduction

While premium cigars have similar addictive, toxic, and carcinogenic constituents as other cigars and cigarettes, about 1% of the US adults reported premium cigar use from 2010 to 2019. This study aimed to understand public perceptions and discussions of premium cigars on Reddit, one of the most popular social media platforms.

Methods

Using keywords such as "premium cigar", we extracted 2,238 Reddit posts from Reddit Archive between July 2019 and June 2021. Among them, 1,626 posts were related to premium cigars. By employing the inductive approach, we manually coded each Reddit post on premium cigars to understand public perceptions and discussions of premium cigars by summarizing them into different topics and subtopics.

Results

Longitudinal analysis showed that the number of Reddit posts on premium cigars increased since June 2020. Content analysis showed that among Reddit posts related to premium cigars, the most popular topic is "Information sharing" (75.72%), in which Reddit users shared their perceptions about premium cigars, asked for advice, and provided some recommendations about premium cigars. Over one-quarter of posts (27.17%) are sharing user experiences of premium cigars (such as taste). Nearly one-fifth (18.99%) of posts are discussing the affordability of premium cigars. In addition, 7.87% of posts are discussing legal/policy issues related to premium cigars, and 6.82% of posts are related to the health risks of premium cigars compared to cigarettes.

Conclusions

Public perceptions including misperceptions, user experiences, and affordability related to premium cigars have been actively discussed on Reddit.

Post-consumption waterpipe tobacco waste as an unrecognized source of toxic metal(loid)s leachates into aquatic environments

Waterpipe is a common form of tobacco smoking, and recently, its use has been increasing globally. Therefore, concern arises regarding the large quantity of post-consumption waterpipe tobacco waste produced and released into the environment and which can contain high levels of dangerous pollutants such as toxic meta(loid)s. This study reports the concentrations of meta(loid)s in waste from fruit-flavoured and traditional tobacco smoking as well as the release rate of these pollutants from waterpipe tobacco waste into three types of water. These include distilled water, tap water, and seawater and contact times ranging from 15 min to 70 days. The mean concentration levels of Ʃmetal(loid)s in waste samples of Al-mahmoud, Al-Fakher, Mazaya, Al-Ayan brands and traditional tobacco brands were 212 ± 92.8, 198 ± 94.4, 197 ± 75.7, 214 ± 85.8 and 40.6 ± 16.1 μg/g, respectively. The concentration levels of Ʃmetal(loid)s in fruit-flavoured tobacco samples were significantly higher than for traditional tobacco samples (p < 0.05). It was found that waterpipe tobacco wastes leached toxic metal(loid)s into different water samples with similar trends. In addition distribution coefficients showed that most metal(loid)s are highly likely to enter the liquid phase. The concentration levels of these pollutants (except Ni and As) in deionized water and tap water exceeded the surface fresh water standards for sustaining aquatic life during long contact time (up to 70 days). In seawater, concentration levels of Cu and Zn exceeded the recommended standards for maintaining aquatic life in the sea. Therefore, due to the possibility of contamination by soluble metal(loid)s through disposal of waterpipe tobacco waste in wastewater, there is concern that these toxic chemicals might enter the human food chain. Appropriate regulatory measures for disposal of waterpipe tobacco waste are necessary to prevent environmental pollution due to discarded wastes into aquatic ecosystems.

Polycyclic aromatic hydrocarbon (PAH) leachates from post-consumption waterpipe tobacco waste (PWTW) into aquatic environment- a primary study

Post-consumption waterpipe tobacco waste (PWTW) is an unrecognized type of hazardous waste that is produced and released in large quantities into the aquatic environment. It may contain high amounts of various pollutants including PAH, and to date, there has been no research on the potential for contamination by PAH from PWTW leaching into aquatic environments. In this study, the concentrations of PAH via PWTW of fruit-flavored and traditional tobacco leachate into three water types, including distilled water (DW), tap water (TW) and sea water (SW) at different contact times were evaluated. There were significantly higher concentration levels of ƩPAH in waters with leachates from fruit-flavored PWTW than traditional tobacco (P-value<0.05). The concentration levels of ƩPAH in DW, TW and SW at a total contact time of two months ranged from 0.13 to 3.51, 0.12 to 3.63 and 0.11-3.64 μg/L, respectively. Lower molecular weight PAH such as naphthalene (Naph), acenaphthylene (Acen) and fluorine (Flu) were detected in leachates immediately after a short contact time of 15 min. Higher molecular weight PAH including benzo [a]anthracene (BaA), benzo [b]fluoranthene (BbF), benzo [k]fluoranthene (BkF), chrysene (Chr), and benzo [a]pyrene (BaP) were detected after one month contact time, while indeno [1,2,3-cd] pyrene (Indp), benzo [ghi]perylene (BghiP) and dibenz [a,h]anthracene (DahA) were only observed at the contact time measurement of two months. By adding sodium azide as an antimicrobial agent and chemical preservative to SW samples, higher concentrations of PAH including IP, DahA and BghiP were observed. The concentration levels of PAH in water samples after two months contact time were higher than water quality standards provided by the World Health Organization (WHO) and other international organizations.

Use of Electronic Nicotine Delivery Systems or Cigarette Smoking After US Food and Drug Administration-Prioritized Enforcement Against Fruit-Flavored Cartridges

Importance

The Center for Tobacco Products (CTP) of the US Food and Drug Administration prioritized its enforcement efforts against non-tobacco-, non-menthol- (fruit-) flavored cartridge electronic nicotine delivery systems (ENDS) in February 2020.

Objective

To evaluate adults' use of ENDS and cigarette smoking following the CTP's prioritized enforcement efforts against fruit-flavored cartridge ENDS.

Design, Setting, and Participants

In this population-based, nationally representative US cohort study, data were collected from the Population Assessment of Tobacco and Health Study from December 2018 to November 2019 (hereafter referred to as 2019) and/or from September 2020 to December 2020 (Adult Telephone Survey, hereafter referred to as 2020). Adults (aged ≥21 years) who used ENDS in the past 30 days and smoked cigarettes in the past 30 days or quit smoking cigarettes in the past year (n = 3173) were evaluated. Data were analyzed from January 1, 2022, to May 2, 2023.

Exposure

ENDS flavor-device combinations used.

Main Outcomes and Measures

Outcome measures were cross-sectional prevalence of ENDS flavor-device combinations used in 2019 (n = 2654) and 2020 (n = 519) and longitudinal transitions in cigarette smoking (cessation [no smoking in the past 30 days in 2020 among those who smoked in 2019; n = 876] and relapse [smoking in the past 30 days in 2020 among those who recently quit in 2019; n = 137]) as a function of ENDS flavor-device combination used in 2019.

Results

The sample in 2019 included 2654 individuals (55% male [95% CI, 53%-58%]). Among those who used ENDS and smoked cigarettes, fruit-flavored cartridge ENDS use decreased from 13.9% (95% CI, 12.1%-15.9%) in 2019 to 7.9% (95% CI, 5.1%-12.1%) in 2020 (P = .01), whereas fruit-flavored disposable ENDS use increased from 4.0% (95% CI, 3.1%-5.1%) in 2019 to 14.5% (95% CI, 11.6%-18.0%) in 2020 (P < .001). Patterns were similar among those who recently quit smoking. Neither cigarette cessation nor relapse rates differed between those who used ENDS that were vs were not prioritized for enforcement efforts (cessation: 23.4% [95% CI, 18.1%-29.7%] vs 26.4% [95% CI, 22.4%-30.8%]; adjusted odds ratio, 1.12; 95% CI, 0.57-2.21; relapse: 32.7% [95% CI, 17.1%-53.4%] vs 29.8% [95% CI, 20.3%-41.3%]; adjusted odds ratio, 0.96; 95% CI, 0.24-3.84).

Conclusions and Relevance

In this nationally representative US cohort study of adults who smoked cigarettes and used ENDS, fruit-flavored cartridge ENDS use was nearly halved between 2019 and 2020. Cigarette cessation and relapse rates did not differ between those who used ENDS targeted by CTP and those who used other ENDS.

Longitudinal transitions in e-cigarette and cigarette use among US adults: prospective cohort study

Background

To support tobacco control efforts, this study sought to characterize longitudinal transitions in use of electronic nicotine delivery systems (ENDS) and cigarettes.

Methods

Participants were nationally representative samples of 53,729 US adults from Waves 3-5 (2015-2019) of the Population Assessment of Tobacco and Health Study. We examined behavioral transitions (initiation, relapse, progression, and cessation) in ENDS and cigarette use across waves. Weighted generalized estimating equation models adjusted for sociodemographic variables.

Findings

Of never ENDS users at baseline, an estimated 1.7% reported initiating ENDS use by follow-up. Of former ENDS users, an estimated 12.1% relapsed into ENDS use. Of periodic ENDS users at baseline, 13% progressed to established ENDS use. Of baseline current ENDS users, 46.3% discontinued ENDS use. The corresponding transitions for cigarette smoking were 1.6% (initiation), 4.8% (relapse), 21.1% (progression), and 14% (discontinuation). Adults aged 18-24 (vs. older age), Hispanics (vs. non-Hispanic white), and past 12-month cannabis users were more likely to initiate ENDS or cigarettes (all p < 0.05). Having any internalizing mental health symptoms increased the odds of ENDS initiation, while externalizing symptoms increased the odds of cigarette initiation. Those who perceived nicotine as very harmful (vs. none/low harm) were more likely to discontinue ENDS. Current cigarette users (vs. non-users) at baseline were more likely to initiate, relapse, or discontinue ENDS (all p < 0.05) and vice versa.

Interpretation

We observed high changeability in ENDS and cigarette use among US adults over time. In absolute terms, ENDS use grew, while smoking fell. Tobacco control programs should focus on priority populations, including young adults and people with internalizing and externalizing mental health symptoms.

Funding

National Institutes of Health, R01-CA246606-01A1, R01-DA048390.

Comparison of a Tobacco-Specific Carcinogen in Tobacco Cigarette, Electronic Cigarette, and Dual Users

BACKGROUND

4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) is known as a lung carcinogen. The objective of this study was to investigate associations of urine NNAL concentrations and smoking status.

METHODS

This was a cross-sectionally designed study based on data from the 2016-2018 Korean National Health and Nutrition Examination Survey. A total of 2,845 participants were classified into past-smoker, electronic cigarette (e-cigar) only, dual-user, and cigarette only smoker groups. All sampling and weight variables were stratified and analysis was conducted accounting for the complex sampling design. Analysis of covariance was used to compare the geometric mean of urine NNAL concentrations and log-transformed urine NNAL level among smoking status with weighted survey design. Post hoc paired comparisons with Bonferroni adjustment was performed according to smoking status.

RESULTS

The estimated geometric mean concentrations of urine NNAL were 1.974 ± 0.091, 14.349 ± 5.218, 89.002 ± 11.444, and 117.597 ± 5.459 pg/mL in past-smoker, e-cigar only, dual-user, and cigarette only smoker groups, respectively. After fully adjusting, log-transformed urine NNAL level was significantly different among groups (P < 0.001). Compared with the past-smoker group, e-cigar only, dual-user, and cigarette only smoker groups showed significantly higher log-transformed urine NNAL concentrations in post hoc test (all P < 0.05).

CONCLUSION

E-cigar only, dual-user, and cigarette only smoker groups showed significantly higher geometric mean concentrations of urine NNAL than the past-smoker group. Conventional cigarette, dual users, and e-cigar users can potentially show harmful health effects from NNAL.

Point-of-Sale Health Communication Campaigns for Cigarillos and Waterpipe Tobacco: Effects and Lessons Learned from Two Cluster Randomized Trials

Many adolescents and young adults hold erroneous beliefs that cigarillos and waterpipe tobacco (WT) are safer than cigarettes, contributing to use. Communication campaigns can correct misperceptions and increase risk beliefs. We tested point-of-sale (POS) communication campaigns focused on chemical exposure for cigarillos and WT. We conducted two cluster randomized trials at 20 gas stations with convenience stores (10 stores for cigarillos, 10 for WT) in North Carolina between June and November 2017. Within each trial, stores were randomly assigned to either the intervention (campaign messages displayed) or a no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 adolescents and young adults (ages 16-25) per store, at baseline and follow-up. There were 978 participants (mean age = 20.9 years) in the cigarillo trial, and 998 participants (mean age = 21.0 years) in the WT trial. Rates of campaign exposure were low (26% for cigarillos; 24.3% for WT). The cigarillo campaign increased knowledge that ammonia is in cigarillo smoke (p < .01). There were also significant increases in knowledge about ammonia and cyanide in cigarillo smoke and arsenic in WT smoke (p < .05) in the sub-sample who reported exposure to the campaign. No differences were found in outcome expectancies, product attitudes, worry about chemical exposure, or behavioral intentions in either campaign. Garnering attention for communication campaigns in saturated POS environments, often dominated by tobacco advertising, is challenging. Our study demonstrates the feasibility of anti-tobacco campaigns at the POS and points to several lessons learned for future POS campaigns.

Varenicline Mitigates the Increased Risk of Pseudoarthrosis Associated with Nicotine

BACKGROUND CONTEXT

High serum nicotine levels increase the risk of non-union after spinal fusion. Varenicline, a pharmaceutical adjunct for smoking cessation, is a partial agonist designed to displace and outcompete nicotine at its receptor binding site, thereby limiting downstream activation. Given its mechanism, varenicline may have therapeutic benefits in mitigating non-union for active smokers undergoing spinal fusion.

PURPOSE

To compare fusion rate and fusion mass characteristics between cohorts receiving nicotine, varenicline, or concurrent nicotine and varenicline after lumbar fusion.

STUDY DESIGN

Rodent non-instrumented spinal fusion model.

METHODS

Sixty eight-week-old male Sprague-Dawley rats weighing approximately 300 grams underwent L4-5 posterolateral fusion (PLF) surgery. Four experimental groups (control: C, nicotine: N, varenicline: V, and combined: NV [nicotine and varenicline]) were included for analysis. Treatment groups received nicotine, varenicline, or a combination of nicotine and varenicline delivered through subcutaneous osmotic pumps beginning two weeks before surgery until the time of sacrifice at age 14 weeks. Manual palpation testing, microCT imaging, bone histomorphometry, and biomechanical testing were performed on harvested spinal fusion segments.

RESULTS

Control (p=0.016) and combined (p=0.032) groups, when compared directly to the nicotine group, demonstrated significantly greater manual palpation scores. The fusion rate in the control (93.3%) and combined (93.3%) groups were significantly greater than that of the nicotine group (33.3%) (p=0.007, both). Biomechanical testing demonstrated greater Young's modulus of the fusion segment in the control (17.1 MPa) and combined groups (34.5 MPa) compared to the nicotine group (8.07 MPa) (p<0.001, both). MicroCT analysis demonstrated greater bone volume fraction (C:0.35 vs N:0.26 vs NV:0.33) (p<0.001, all) and bone mineral density (C:335 vs N:262 vs NV:328 mg Ha/cm³) (p<0.001, all) in the control and combined groups compared to the nicotine group. Histomorphometry demonstrated a greater mineral apposition rate in the combined group compared to the nicotine group (0.34 vs 0.24 μm/day, p=0.025).

CONCLUSION

In a rodent spinal fusion model, varenicline mitigates the adverse effects of high nicotine serum levels on the rate and quality of spinal fusion.

CLINICAL SIGNIFICANCE

These findings have the potential to significantly impact clinical practice guidelines and the use of pharmacotherapy for active nicotine users undergoing fusion surgery.

The first nicotine product tried is associated with current multiple nicotine product use and nicotine dependence among a nationally representative sample of U.S. youths

This study examines the demographic factors associated with youths' first product tried (i.e., cigarettes, e-cigarettes, cigars, hookah, or smokeless tobacco). This study also evaluates whether the first product tried is associated with future nicotine product use (i.e., no use, single product use, and multiple product use) and nicotine dependence. Participants were 1999 youths (ages 12-17 years) who had ever tried a nicotine product and completed the Population Assessment of Tobacco Health study's Wave 1 (2013-2014) and Wave 4 (2016-2018) assessments. Two separate multinomial logistic regression models examined the association between 1) demographic factors and the first product tried at Wave 1 and 2) the first product tried at Wave 1 and past-30-day product use status at Wave 4. A two-part multivariable model examined the association between the first product tried and nicotine dependence, with part 1 modeling the presence (or absence) of any symptom of dependence and part 2 modeling the degree of dependence among those with any symptom of dependence. The first product tried was associated with sex, race, urbanicity, and parent education. First trying smokeless tobacco (vs. e-cigarettes) was associated with a greater likelihood of multiple product use (vs. no use and vs. single product use). Regarding the degree of nicotine dependence (n = 713), first trying smokeless tobacco (vs. e-cigarettes) was associated with higher nicotine dependence scores among those with any symptom of dependence. Youths who first try smokeless tobacco (vs. e-cigarettes) may be at higher risk for future multiple product use and more symptoms nicotine dependence. Research should explore tailored interventions for smokeless tobacco users.

Messaging to prevent and reduce young adults' waterpipe tobacco smoking: A randomized trial

INTRODUCTION

More than 10% of U.S. young adults have smoked waterpipe tobacco in the past month and >25% of those who have never smoked are susceptible. We tested messages designed to prevent and reduce waterpipe tobacco smoking (WTS).

METHODS

In 2020, we recruited 830 U.S. young adults (18-30 years) who had never smoked waterpipe tobacco and were susceptible or currently smoked waterpipe tobacco for an online study. We randomized participants to intervention messages about the risks of WTS or control messages unrelated to tobacco. Participants had up to four message exposures over 12 weeks and completed two-, four-, and six-month follow-ups. Outcomes were WTS initiation and curiosity (susceptible never smokers), WTS frequency, cessation, motivation to quit (those who currently smoked), and WTS risk perceptions.

RESULTS

Intervention messages increased perceived addictiveness of WTS at two months (β = 0.27; 95% CI: 0.11, 0.43) in susceptible never smokers. There were no significant intervention effects in those who currently smoked. Exploratory analyses among intervention participants showed that higher dose of message exposure decreased WTS initiation at six months in susceptible never smokers (RR = 0.68; 95% CI: 0.48, 0.96) and decreased WTS frequency (IRR = 0.84; 95% CI: 0.73, 0.97) and increased cessation (RR = 1.31; 95% CI: 1.07, 1.59) at six months in those who smoked.

CONCLUSIONS

Although the WTS intervention messages had few significant effects on outcomes overall, a higher dose of message exposure affected behavioral outcomes in the intervention arm. Findings highlight the need to identify effective message content and optimal message dose, especially for digital media campaigns.

Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults

BACKGROUND

The US Food and Drug Administration requires six text-only warnings for cigar products, including cigarillos. Research has demonstrated the superiority of pictorial over text-only cigarette warnings, yet the relative effectiveness of pictorial warnings for cigarillos has not been examined. We examined the impact of pictorial cigarillo warnings compared with text-only warnings.

METHODS

Data were collected from a nationally representative sample of US young adult (18-29) cigarillo users and susceptible non-users. Participants were randomised to one of three experimental conditions: text-only or one of two pictorial conditions (combined for analyses). For each warning, we assessed negative emotional reactions, cognitive elaboration (ie, thinking about cigarillo risks) and perceived message effectiveness (PME).

RESULTS

Participants (N=661) were 46.5% female, 64.7% white and 21.9% Hispanic; 34.1% reported past 30-day cigarillo use; 41.4% were lifetime users (excluding past 30-day use); and 24.4% were susceptible non-users. Pictorial warnings elicited more negative emotional reactions and higher PME than text-only warnings (p values<0.01), with interactions showing the largest effects for past 30-day users (emotional reactions: d=0.99, PME: d=0.63). For cognitive elaboration, there was no main effect of warning type, but an interaction revealed effects for past 30-day users (p<0.05, d=0.46).

CONCLUSIONS

Pictorial cigarillo warnings elicited greater negative emotional reactions and PME compared with text-only warnings. These effects and the effects on cognitive elaboration were strongest for past 30-day users. Our findings extend research on cigarette warnings to cigarillos, demonstrating that pictorial warnings are superior to text-only warnings for cigarillos in eliciting beneficial responses.

The Effects of Oral Nicotine Pouch Packaging Features on Adult Tobacco Users' and Non-Users' Product Perceptions

BACKGROUND

Oral nicotine pouches (ONPs) are novel products that are marketed as "tobacco-free" alternatives to cigarettes and smokeless tobacco (ST). This study examined the effects of ONP packaging features on adult tobacco users' and non-users' product perceptions.

MATERIALS AND METHODS

Adult tobacco users (cigarettes, ST, and dual cigarette/ST) and non-users (total N = 301) viewed ONP pack images in a 4 × 3 × 2 between-subject experiment testing the effects of the displayed flavor (cool mint, coffee, dark frost, and smooth), nicotine concentration (none displayed on the package, 3 mg, and 6 mg), and addiction warning label (yes or no). The outcomes were perceived substitutability of ONPs for cigarettes and ST and perceived risks. We modeled the effects of tobacco user status and the experimental factors on these outcomes.

RESULTS

All tobacco user groups perceived ONPs to be significantly less harmful and less addictive than non-users. There were significant effects of nicotine concentration on perceived risks. Compared to packages that did not display nicotine concentration, packages displaying 6 mg nicotine concentration produced significantly lower perceived harm (β = -0.23, 95% CI -0.44, -0.02), perceived addictiveness (β = -0.28, 95% CI -0.51, -0.05), risk appraisals of harm (β = -0.50, 95% CI -0.88, -0.12) and risk appraisals of addictiveness (β = -0.53, 95% CI -0.95, -0.11).

CONCLUSIONS

The study findings demonstrate that the nicotine concentration displayed on ONP packaging can affect adults' perceptions of ONPs. Further research on the effects of ONP packaging features emphasizing nicotine (e.g., "tobacco free" nicotine claims) on tobacco users and non-users is needed to assess their potential public health impact.

Differences in cessation attempts and cessation methods by race/ethnicity among US adult smokers, 2016-2018

BACKGROUND

Advice to quit smoking and cessation patterns vary by race/ethnicity in the United States. This study aims to provide the up-to-date prevalence of quit advice, quit attempts and use of smoking cessation methods (particularly e-cigarettes) by race/ethnicity among US adult smokers.

METHODS

We used data from Wave 4 (2016-2018) of the Population Assessment of Tobacco and Health (PATH) Study. Using past-12-month and current adult cigarette smokers (n = 9,272), we conducted multivariable models to examine the association between race/ethnicity and advice to quit and quit attempts. Further, using a subset of those who made quit attempts (n = 5,046), we examined the use of smoking cessation methods, including e-cigarettes, by race/ethnicity, controlling for associated factors.

RESULTS

Compared to Non-Hispanic [NH] White smokers, Hispanic smokers were less likely to receive quit advice (aPR [95 % CI] = 0.88 [0.78, 1.00]), but more likely to make quit attempts (1.14 [1.06, 1.23]). NH Black smokers (vs. NH Whites) were more likely to receive quit advice (1.06 [1.00, 1.12]) and more likely to make quit attempts (1.22 [1.15, 1.29]). NH Black smokers (vs. NH Whites) were more likely to use behavioral treatment (e.g., counseling) (1.84 [1.22, 2.77]). Hispanic smokers were less likely to use e-cigarettes to quit smoking than Whites (0.48 [0.33, 0.71]) and use pharmacotherapy (0.62 [0.44, 0.88]).

CONCLUSIONS

We found different patterns in cessation attempts and cessation methods by race/ethnicity among US adult smokers. Efforts to eliminate disparities must increase access and use of proven cessation therapies for these groups.